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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173009810
Report Date: 10/11/2022
Date Signed: 10/11/2022 10:16:31 AM


Document Has Been Signed on 10/11/2022 10:16 AM - 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:LAKEPORT CHRISTIAN CENTER PS/DAYCAREFACILITY NUMBER:
173009810
ADMINISTRATOR:MARY PAARSCHFACILITY TYPE:
840
ADDRESS:455 SOUTH FORBES STREETTELEPHONE:
(707) 262-5520
CITY:LAKEPORTSTATE: CAZIP CODE:
95453
CAPACITY:18CENSUS: 0DATE:
10/11/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Michele WalkerTIME COMPLETED:
10:30 AM
NARRATIVE
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On 10/11/2022 at 9:00am, Licensing Program Analyst (LPA), Sebastian Phouthavong made a case management inspection and met with Staff, Michele Walker. The inspection was made in response to water lead testing results received from the California State Water Resource Control Board. The test results showed that the following faucet tested above the allowable level (5 ppb) of lead in the water: Sample Sites, Kitchen sink, 5.7 ppb. All other sources of water tested below the allowable level of 5.0ppb.

During today's inspection, LPA observed no children in care and toured the facility inside and out. The staff members have made the kitchen sink inaccessible by temporarily locking the room and having a closed sign on the door. Staff members stated the room as not currently in use and has not have plane to reopen as soon. Children in care are receiving drinking water from bottled water and a water dispenser. The facility will submit a plan to a plan to completely resolve the situation, ensuring the safety of the children in care.

The facility will 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 LPA.

The following deficiency is being cited (see LIC 809D). 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 the Staff, Michele Walker.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Sebastian PhouthavongTELEPHONE: 707-588-5056
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022
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 10/11/2022 10:16 AM - 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: LAKEPORT CHRISTIAN CENTER PS/DAYCARE
FACILITY NUMBER: 173009810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2022
Section Cited

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101700.3(b)(1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
This requirement was not met as evidenced by:
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Based on record review, the facility had one faucet (Site "A") that exceeded that allowable levels of lead in the water (5.7 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: 10/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022
LIC809 (FAS) - (06/04)
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