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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 233004397
Report Date: 01/10/2023
Date Signed: 01/10/2023 12:04:25 PM


Document Has Been Signed on 01/10/2023 12:04 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:LAYTONVILLE STATE PRESCHOOLFACILITY NUMBER:
233004397
ADMINISTRATOR:GOLIGHTLY, NANCYFACILITY TYPE:
850
ADDRESS:150 RAMSEY ROADTELEPHONE:
(707) 984-6123
CITY:LAYTONVILLESTATE: CAZIP CODE:
95454
CAPACITY:60CENSUS: DATE:
01/10/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:16 AM
MET WITH:Misty FrostTIME COMPLETED:
12:13 PM
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On 01/10/23, Licensing Program Analyst (LPA), Amy Strother conducted a case management tele-inspection with Director, Misty Frost (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" a sink faucet in room #12 with a reading of 8.7 ppb, Sample Site “C” a drinking fountain in room #12 had a reading of 55 ppb and Sample Site “D” a drinking fountain in room #11 had a reading of 39 ppb. All other sources of water tested (Sample Site “A”) 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 facility has discontinued use of faucets “B”, “C” and “D” and have begun to notify families of the testing results.

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 sites “B”, “C” and “D” were made inaccessible to children in care by way of plastic bag covers with sign stating "Do Not Use". D1 stated that children in care are receiving drinking water from individual water bottles from home that staff can refill from store bought bottled water provided by the school district. D1 stated if a child forgets their water bottles a disposable cup with the bottled water is provided.

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: LAYTONVILLE STATE PRESCHOOL
FACILITY NUMBER: 233004397
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, Misty Frost .

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: 3 of 3
Document Has Been Signed on 01/10/2023 12:04 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: LAYTONVILLE STATE PRESCHOOL
FACILITY NUMBER: 233004397

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 faucets “B”, “C” and “D” from service by way of a sign and plastic cover. D1 stated that the facility plans to replace sink faucet "B", flush it and retest, submitting results to amy.strother@dss.ca.gov by 02/10/23. D1 stated that drinking faucets "C" and "D" will be capped off and will submit photos of the completed work as documentation.
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Based on record review, the facility had three faucets (Site “B”, “C” and “D”) that exceeded that allowable levels of lead in the water (8.7, 55, and 39 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 individual water bottles from home or disposable cups that staff (re)fill from bottled water. Parents have been notified of the lead exceedance and plans for remediation via a letter.

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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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