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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 233003489
Report Date: 01/20/2023
Date Signed: 01/20/2023 10:47:16 AM


Document Has Been Signed on 01/20/2023 10:47 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:UKIAH UNIFIED PRESCHOOL VILLAGE-PRESCHOOLFACILITY NUMBER:
233003489
ADMINISTRATOR:LEONI, SARAHFACILITY TYPE:
850
ADDRESS:1100 NORTH BUSH STREETTELEPHONE:
(707) 468-3302
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:30CENSUS: 12DATE:
01/20/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Shelley Hicks TIME COMPLETED:
10:55 AM
NARRATIVE
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On 01/20/23, Licensing Program Analyst (LPA), Amy Strother made a case management inspection and met with Site Supervisor, Shelley Hicks (D1). 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 faucet tested above the allowable level 5.0 parts per billion (ppb) of lead in the water: Sample Site, "F" an outdoor drinking fountain, had a reading of 5.8 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 12/12/22 containing the following documents; External Water Sampling Self-Certification Form (LIC 9275), Child Care Center Sampling Checklist Form (LIC 9276) and Facility Sketch/Floor Plan (LIC 999), and a copy of the letter given to parents or authorized representatives of children in care, informing them of the lead testing results, and a photo of the faucet made inaccessible to children. On 01/12/23 LPA Strother emailed a copy of the lead report from the California State Water Resource Control Board to A1, requesting photos identifying all water outlets labeled and corresponding to the Facility Sketch (LIC 999) be submitted within one week, as required. On 01/12/23 LPA received the requested photos.

During today’s visit, LPA verified that the test results were posted and that Sample site “F” was made inaccessible to children in care. A1 stated that faucet “F” has been replaced, is in the process of being flushed and will be retested on 02/04/23. D1 stated that children in care are receiving drinking water from a container filled from kitchen faucet "C" and paper cups.

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 the Site Supervisor, Shelley Hicks.

SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
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 01/20/2023 10:47 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: UKIAH UNIFIED PRESCHOOL VILLAGE-PRESCHOOL
FACILITY NUMBER: 233003489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/20/2023
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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LPA observed that the facility has temporarily removed the affected faucet “F” from service by way of a plastic cover. A1 stated that the facility has replaced the faucet, is flushing it, with a plan to retest on 02/04/23, submitting test results to LPA at amy.strother@dss.ca.gov by 02/20/23.
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Based on record review, the facility had one faucet (Site “F”) that exceeded that allowable levels of lead in the water (5.8 ppb). This is a potential health and safety risk to children in care.
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 D1 stated children in care are receiving drinking water from a container filled from kitchen faucet "C" and paper cups. Testing results have been posted and families have been notified of the 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: 01/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
LIC809 (FAS) - (06/04)
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