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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 233002483
Report Date: 10/20/2023
Date Signed: 10/20/2023 09:39:07 AM


Document Has Been Signed on 10/20/2023 09:39 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:NCO HEAD START - CHILD DEV. CTR. - NOKOMISFACILITY NUMBER:
233002483
ADMINISTRATOR:ANNA CRUMPLERFACILITY TYPE:
850
ADDRESS:499 WASHINGTON AVE.TELEPHONE:
(707) 462-2671
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:60CENSUS: DATE:
10/20/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Judy BaugusTIME COMPLETED:
09:55 AM
NARRATIVE
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On 10/20/23 at 9:10 am, Licensing Program Analyst (LPA), Robert Maciel made a case management inspection and met with Administrator Judy Buagus. 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 faucets tested above the allowable level (5 ppb) of lead in the water:

Faucet “A” – children's outdoor drinking fountain, 30ppb
Faucet “J” – children's outdoor drinking fountain, 7.2ppb

The staff have made the faucets inaccessible by placing a bucket bound with caution tape over the faucet. Children in care are receiving drinking water from individual water bottles provided by the facility.

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 Judy Baugus. Appeal Rights were given.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert MacielTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023
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 10/20/2023 09:39 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: NCO HEAD START - CHILD DEV. CTR. - NOKOMIS
FACILITY NUMBER: 233002483

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2023
Section Cited

101700.3(b)(2)

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Licensees shall maintain a lead value at or below the Action Level of 5 ppb in all outlets subject to the testing requirements of these Written Directives, for the health and safety of children in care.
This requirement was not met as evidenced by:
On 7/26/23, licensee failed to maintain a lead
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On 10/12/23, LPA Maciel was sent proof of remediation for followup testing performed on 9/27/23 which revealed both faucets tested within the allowable lead levels.
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value at or below the Action Level for water lead testing resulting with values of 5.5 ppb or greater for faucet "A" and faucet "J". Water testing results identified with Action Level Exceedance as defined in WD section 101700.3. are not deemed safe to drink. 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: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert MacielTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023
LIC809 (FAS) - (06/04)
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