233006150-1-12-2023-01-CC-ASTR-CMZPAY-20230112100930

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 233006150
Report Date: 01/12/2023
Date Signed: 01/12/2023 10:09:48 AM

Document Has Been Signed on 01/12/2023 10:09 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:	TALMAGE STATE PRESCHOOL		FACILITY NUMBER:	233006150
ADMINISTRATOR:	CHIRIBOGA, PAM		FACILITY TYPE:	850
ADDRESS:	2240 OLD RIVER ROAD		TELEPHONE:	(707) 467-5091
CITY:	UKIAH	STATE: CA	ZIP CODE:	95482
CAPACITY:	27	CENSUS: 11	DATE:	01/12/2023
TYPE OF VISIT:	Case Management - Lead Testing/Exceedance	UNANNOUNCED	TIME BEGAN:	09:12 AM
MET WITH:	Pamela "Pam" Chiriboga		TIME COMPLETED:	10:05 AM

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On 01/12/23, Licensing Program Analyst (LPA), Amy Strother conducted a case management tele-inspection with Director, Pam Chiriboga (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, "D" an outdoor drinking fountain had a reading of 6.1 ppb. All other sources of water tested below the allowable level of 5.0 ppb.

The Department received an email from Kristin Hills (A1), Director of Early Learning and Care, Educational Services for Mendocino County Office of Education on 11/30/22 stating that the facility has discontinued use of faucet “D” and plan to permanently remove the drinking fountain fixture.

LPA obtained the following documents from A1 via email on 12/12/22 and 12/16/22; 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 11/30/22 and a photo of sample site “D”. On 01/04/23 LPA Strother emailed a copy of the lead report from the California State Water Resource Control Board to A1. On 01/11/23 LPA Strother requested and photos identifying all water outlets labeled and corresponding to the Facility Sketch (LIC 999).

During today’s visit, LPA verified that the test results were posted and that Sample site “D” was made inoperable. The facility has permanently removed faucet "D" by capping it off. D1 stated that children in care are receiving drinking water from water pitchers filled from faucets inside and reusable cups, both indoors and outdoors.

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: 01/12/2023

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)

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Document Has Been Signed on 01/12/2023 10:09 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: TALMAGE STATE PRESCHOOL	FACILITY NUMBER: 233006150
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	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 permanently removed drinking faucet "D" from service by way of capping it off. Clearing the deficiency. LPA has a photo of the capped off faucet.
	8 9 10 11 12 13 14	Based on record review, the facility had one faucet (Site “D”) that exceeded that allowable levels of lead in the water (6.1 ppb). This is a potential health and safety risk to children in care.	8 9 10 11 12 13 14	D1 stated that children in care are receiving drinking water from water pitchers filled from faucets inside and reusable cups, both indoors and outdoors. D1 stated parents have been notified of the lead exceedance and that the faucet has been removed from use.
	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: 01/12/2023

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)

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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: TALMAGE STATE PRESCHOOL	FACILITY NUMBER: 233006150
	VISIT DATE: 01/12/2023

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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, Pam Chiriboga.

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 Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy Strother	TELEPHONE: (707) 588-5077
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)

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