233004086-1-12-2023-01-CC-ASTR-CMZRGZ-20230112120134

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 233004086
Report Date: 01/12/2023
Date Signed: 01/12/2023 12:02:15 PM

Document Has Been Signed on 01/12/2023 12:02 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:	PEACHLAND STATE PRESCHOOL		FACILITY NUMBER:	233004086
ADMINISTRATOR:	MENDOZA, ANITA		FACILITY TYPE:	850
ADDRESS:	12300 ANDERSON VALLEY WAY		TELEPHONE:	(707) 895-2761
CITY:	BOONVILLE	STATE: CA	ZIP CODE:	95415
CAPACITY: 99	TOTAL ENROLLED CHILDREN: 18	CENSUS: 0	DATE:	01/12/2023
TYPE OF VISIT:	Case Management - Lead Testing/Exceedance	UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Anita Mendoza		TIME COMPLETED:	12:10 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

On 01/12/23, Licensing Program Analyst (LPA), Amy Strother conducted a case management tele-inspection with Director, Anita Mendoza (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, "B" an indoor drinking fountain had a reading of 69 (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 01/03/22 stating that the faucet has been made inaccessible. A1’s email further stated that Fixture B will be replaced with a certified low-lead fixture, with a plan to schedule retesting for the replaced fixture.

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 12/05/22. On 01/04/23 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. Photos were received on 01/12/23.

During today’s tele-visit, LPA verified that the test results were posted and that Sample site “B” was made inaccessible to children in care . D1 stated that children in care are receiving drinking water from individual water bottles from home that staff can refill from faucet "A" inside the facility as needed. Disposible cups are provided for any children without a water bottle.

Continue on LIC809-C

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

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: PEACHLAND STATE PRESCHOOL	FACILITY NUMBER: 233004086
	VISIT DATE: 01/12/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

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, Anita Mendoza.

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.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 01/12/2023 12:02 PM - It Cannot Be Edited

Created By: Amy Strother On 01/12/2023 at 10:50 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PEACHLAND STATE PRESCHOOL	FACILITY NUMBER: 233004086
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/12/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/12/2023 Section Cited 101700.3(b)(1)	1 2 3 4 5 6 7	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:	1 2 3 4 5 6 7	LPA observed that the facility has temporarily removed the affected faucet “B” from service by way of a a plastic cover. D1 stated that the facility has replaced the faucet "B" and is currently in the process of flushing the new faucet. The facility plans to retest, submitting results by 02/12/23 to amy.strother@dss.ca.gov.
	8 9 10 11 12 13 14	Based on record review, the facility had one faucet (Site “B”) that exceeded the allowable levels of lead in the water (69 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 that staff refill from faucet "A" inside the facility as needed or from paper cups. D1 stated families have been notified of 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

LICENSING EVALUATOR NAME:

Amy Strother

LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3