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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 233008824
Report Date: 11/29/2022
Date Signed: 11/29/2022 02:13:12 PM


Document Has Been Signed on 11/29/2022 02:13 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:GREENWOOD PRESCHOOLFACILITY NUMBER:
233008824
ADMINISTRATOR:JOHNSTON, JULIANNEFACILITY TYPE:
850
ADDRESS:5700 HIGHWAY 1TELEPHONE:
(707) 877-3361
CITY:ELKSTATE: CAZIP CODE:
95432
CAPACITY:15CENSUS: 0DATE:
11/29/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Jessica Ballard - DirectorTIME COMPLETED:
02:12 PM
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On 11/29/2022 at 1:30 PM, Licensing Program Analyst (LPA), Fernandes-Goes made a case management inspection and met with Director, Jessica Ballard. The unannounced visit was conducted to amend report dated 6/24/22 and to acquire documentation still needed due to test results showed that the following faucets tested above the allowable level (5 ppb) of lead in the water: Sample Site, "C" – staff bathroom, 8.0 ppb.

The Center Preschool Program Director Kristin Hills provided the External Water Sampling Self-Certification Form (LIC 9275), Child Care Center Sampling Checklist Form (LIC 9276), pictures, and Facility Sketch/Floor Plan (LIC 999) to the Department on 7/6/22 and 10/2022. Proof of test results from HB&T Environmental Cia results is being requested for May 2022 to be submitted to the Department by December 5, 2022.

In addition, facility Director Jessica stated that faucet has been retested and is waiting for results at this time which will be provided as soon as it is completed. Center communicated testing results to families and staff and will post testing results in the front gate for parents and families to view.

Retesting was conducted on October 2022 by HB&T Environmental Cia.

Exit interview conducted and report was reviewed with Director, Jessica Ballard.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
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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