233003554-1-10-2023-01-CC-ASTR-CMXUE6-20230110143036

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 233003554
Report Date: 01/10/2023
Date Signed: 01/10/2023 02:31:59 PM

Document Has Been Signed on 01/10/2023 02:31 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	SMALL WONDERS PRESCHOOL		FACILITY NUMBER:	233003554
ADMINISTRATOR:	JESSICA ACEVES		FACILITY TYPE:	850
ADDRESS:	1056 NORTH BUSH STREET		TELEPHONE:	(707) 463-5217
CITY:	UKIAH	STATE: CA	ZIP CODE:	95482
CAPACITY:	24	CENSUS: 9	DATE:	01/10/2023
TYPE OF VISIT:	Case Management - Lead Testing/Exceedance	UNANNOUNCED	TIME BEGAN:	01:34 PM
MET WITH:	Jessica Aceves		TIME COMPLETED:	02:40 PM

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On 01/10/23, Licensing Program Analyst (LPA), Amy Strother conducted a case management tele-inspection with Director, Jessica Aceves (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 parts per billion (ppb) of lead in the water: Sample Site, "A" a hand washing sink faucet had a reading of 5.6 ppb, Sample Site “C”, a drinking fountain, had a reading of 9.4 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 stating that the facility plans to replace faucet “A” and remove faucet “C” from the facility.

LPA obtained the following documents from A1 via email on 12/12/22; 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 notifying them of the lead exceedances. On 01/04/23 LPA Strother emailed a copy of the lead report from the California State Water Resource Control Board to A1. On 01/10/23 LPA requested and received photos identifying all water outlets labeled and corresponding to the Facility Sketch (LIC 999) from A1 via email.

During today’s tele-visit, LPA verified that the test results were posted and observed that sample site “A” was made inaccessible to children in care. D1 stated that the faucet of sample site "A" was replaced on 11/27/22, is being flushed and is scheduled for re-testing in late January. LPA observed sample site "B" to be capped off and removed from service.

Continue on LIC809-C

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy Strother	TELEPHONE: (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)

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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: SMALL WONDERS PRESCHOOL	FACILITY NUMBER: 233003554
	VISIT DATE: 01/10/2023

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D1 stated that children in care are receiving drinking water from individual water bottles from home that staff refill from the refrigerator water dispenser (sample site "B") inside the facility as needed, stating that if a child does not have a water bottle they are provided with a disposable cup of water, using a water pitcher filled from the refrigerator water dispenser.

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, Jessica Aceves.

D1’s signature was not recorded on this LIC809, LIC809-C or LIC809-D; however, D1 was provided with a copy of 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 Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy Strother	TELEPHONE: (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)

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Document Has Been Signed on 01/10/2023 02:31 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SMALL WONDERS PRESCHOOL	FACILITY NUMBER: 233003554
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	1 2 3 4 5 6 7	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:	1 2 3 4 5 6 7	LPA observed that the facility has made faucet “A" inaccessible and sample site "B" has been capped off and permanently removed. D1 stated that the facility replace faucet “A”, is flushing it and will retest, submitting results to amy.strother@dss.ca.gov by 02/10/23.
	8 9 10 11 12 13 14	Based on record review, the facility had two faucets (Site “A” and “C”) that exceeded that allowable levels of lead in the water (5.6 and 9.4 ppb). This is a potential health and safety risk to children in care.	8 9 10 11 12 13 14	D1 stated children in care are receiving drinking water from individual water bottles from home or disposable cups refilled/filled from the refrigerator water dispenser. Parents have been notified of the lead exceedance and plans for remediation.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy Strother	TELEPHONE: (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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