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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173009608
Report Date: 08/17/2023
Date Signed: 08/17/2023 12:02:27 PM


Document Has Been Signed on 08/17/2023 12:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:NCO HEAD START CDC-LAKEPORT CENTERFACILITY NUMBER:
173009608
ADMINISTRATOR:GARCIA, LETICIAFACILITY TYPE:
850
ADDRESS:864 & 868 LAKEPORT BLVDTELEPHONE:
(707) 263-8213
CITY:LAKEPORTSTATE: CAZIP CODE:
95453
CAPACITY:20CENSUS: 7DATE:
08/17/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH: Leticia GarciaTIME COMPLETED:
12:00 PM
NARRATIVE
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On 08/17/2023, Licensing Program Analyst (LPA), Sebastian Phouthavong made a case management inspection and met with Site Supervior, Leticia Garcia . The inspection was made in response to water lead testing results received from the facility. The test results showed that the following simples tested above the allowable level 5.0 parts per billion (ppb) of lead in the water: Sample Site "F" had a reading of 6.2 ppb and Sample Site "F30” had a reading of 15 ppb. All other sources of water tested below the allowable level of 5.0 ppb.

During today’s inspection, LPA observed Simple Site "F" & Simple Site “F30”, the outdoor water fountains to be covered with tape and a buckets, making inaccessible to daycare children. Site Supervisor stated there is currently uncontaminated drinking water available to children as of water jug and individual cups. Child Development Supervisor, Hyechong Froschl stated the water fountains will be replaced and retested. Child Development Supervisor, Hyechong Froschl further stated the water fountains have not been use since before COVID 19. The facility will update LPA of the results.

The facility has submit the External Water Sampling Self-Certification Form (LIC 9275), Child Care Center Sampling Checklist Form (LIC 9276) and Facility Sketch/Floor Plan (LIC 999) to CCL.

The following deficiency is being cited (see LIC 809D). Appeal Rights were provided. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with Site Supervisor,Leticia Garcia.

SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Sebastian PhouthavongTELEPHONE: 707-588-5056
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/17/2023 12:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: NCO HEAD START CDC-LAKEPORT CENTER
FACILITY NUMBER: 173009608

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/17/2023
Section Cited

101700.3(b)(1)

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101700.3(b)(1) A result with values of 5.0 ppb or greater shall be deemed an Action Level Exceedance.
This requirement was not met as evidenced by:
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The facility will replace the water fountain and retest. The facility will then submit documentation resluts of the retest by 09/17/2023.
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Based on record review, facility water fountains (Site "F" & Site “F30”) exceeded the allowable levels of lead in the water, testing at 15 ppb. This is a potential health and safety risk to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Sebastian PhouthavongTELEPHONE: 707-588-5056
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023
LIC809 (FAS) - (06/04)
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