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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 233001045
Report Date: 01/10/2023
Date Signed: 01/10/2023 09:36:15 AM


Document Has Been Signed on 01/10/2023 09:36 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:POTTER VALLEY STATE PRESCHOOLFACILITY NUMBER:
233001045
ADMINISTRATOR:VONFELDT, J.FACILITY TYPE:
850
ADDRESS:10401 MAIN STREETTELEPHONE:
(707) 743-2704
CITY:POTTER VALLEYSTATE: CAZIP CODE:
95469
CAPACITY:39CENSUS: 16DATE:
01/10/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
08:44 AM
MET WITH:Jamie VonfeldtTIME COMPLETED:
09:40 AM
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On 01/10/23, Licensing Program Analyst (LPA), Amy Strother conducted a case management tele-inspection with Director, Jaime Vonfeldt (D1). Due to severe winter storms with high wind and flooding the Department has approved a virtual inspection. D1 agreed to conduct the visit using FaceTime with LPA for the Tele-Inspection. 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 water faucets tested above the allowable level (5.0 ppb) of lead in the water: Sample Site, "D" an outdoor drinking fountain had a reading of 83 parts per billion (ppb). All other sources of water tested below the allowable level of 5.0 ppb.

LPA Strother received an email from Kristin Hills (A1), Director of Early Learning and Care, Educational Services for Mendocino County Office of Education on 01/03/23. A1 stated in the email that the facility is closed for winter break until 01/09/23, and will immediately discontinue use of the drinking fountain “D”, by covering it or shutting off the water supply and posting an “out of order” sign next to it upon return. A1 stated in the email that the facility plans to replace the drinking faucet, flush and retest.

LPA obtained the following documents from A1 via email on 01/03/22; External Water Sampling Self-Certification Form (LIC 9275), Child Care Center Sampling Checklist Form (LIC 9276) and Facility Sketch/Floor Plan (LIC 999), a copy of the lab report, and a copy of the letter given to parents or authorized representatives of children in care, dated 01/03/22 and photos identifying all water outlets labeled and corresponding to the Facility Sketch (LIC 999). On 01/04/22 LPA Strother emailed a copy of the lead report from the California State Water Resource Control Board to A1.

During today’s tele-visit, LPA verified that the test results were posted and that Sample site “D” was made inoperable and inaccessible to children in care, observing a plastic bag covering the drinking fountain. The bag hand a hand written sign, stating "Do Not Use". D1 stated that children in care are receiving drinking water from the indoor fountain "B" while inside and either individual water bottles from home or water from kitchen sink "A" poured into disposable cups while outside.

Continue on LIC809-C

SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: POTTER VALLEY STATE PRESCHOOL
FACILITY NUMBER: 233001045
VISIT DATE: 01/10/2023
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The following deficiency is being cited (see LIC 809D). Appeal Rights were provided via email. A notice of site visit was given via email 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 Director, Jaime Vonfeldt.

D1’s signature was not recorded on this LIC809, LIC809-C or LIC809-D; however, D1 was provided with a copy of the LIC809, LIC809-C and LIC809-D; and D1’s confirmation of read receipt is on file.

The report was also emailed to A1.

SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/10/2023 09:36 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: POTTER VALLEY STATE PRESCHOOL
FACILITY NUMBER: 233001045

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2023
Section Cited

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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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LPA observed that the facility has temporarily removed the affected faucet “D” from service by way of a sign and cover and water shut off. D1 stated that the facility plans to replace the faucet, flush it and retest, submitting results by 02/10/23 to amy.strother@dss.ca.gov
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Based on record review, the facility had one faucet (Site “D”) that exceeded that allowable levels of lead in the water (83 ppb). This is a potential health and safety risk to children in care.
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D1 stated that children in care are receiving drinking water from the indoor fountain "B" inside and either individual water bottles from home or water from kitchen sink "A" poured into disposable cups outside. Parents have been notified of the lead exceedance and plans for remediation.

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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: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2023
LIC809 (FAS) - (06/04)
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