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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 233008828
Report Date: 12/20/2022
Date Signed: 12/20/2022 11:01:29 AM


Document Has Been Signed on 12/20/2022 11:01 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:NCO HEAD START - CHILD DEV. CTR. - PEACH TREE CTR.FACILITY NUMBER:
233008828
ADMINISTRATOR:JOHNS, DEANNFACILITY TYPE:
850
ADDRESS:425A ORCHARD AVENUETELEPHONE:
(707) 463-8600
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:56CENSUS: 45DATE:
12/20/2022
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Deann JohnsTIME COMPLETED:
11:15 AM
NARRATIVE
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On 12/20/22, Licensing Program Analyst (LPA), Amy Strother made a case management inspection and met with Site Supervisor, Deann Johns (S1). The inspection was made in response to water lead testing results received from the facility. The test results showed that the following faucet tested above the allowable level 5.0 parts per billion (ppb) of lead in the water: Sample Site, "C" had a reading of 9.6 ppb. All other sources of water tested below the allowable level of 5.0 ppb.

During a phone call on 12/07/22, S1 informed LPA that Sample Site “C” is an adult sink in the classroom used for cleaning and staff hand washing, not for drinking water or food prep. S1 stated that the sink was made inaccessible on 11/28/22 when they became aware that it tested in exceedance for lead. S1 stated that the sink faucet and hose connection at Site “C” has been replaced and is currently in the process of being flushed prior to re-testing. During today's visit, LPA observed that Site "C" has been made inaccessible. S1 stated that children from disposable water cups.

On 12/15/22 facility representative submitted the Facility Sketch/Floor Plan (LIC 999), Child Care Center Sampling Checklist Form (LIC 9276), a photo of sample site “C” showing how it was made inaccessible, with yellow caution tape and a sign that reads, “Do Not Use” on red paper and 8 pages of documents from the laboratory that completed the testing. LPA has requested that the following documentation be submitted; External Water Sampling Self-Certification Form (LIC 9275), and photos of all water outlets labeled and corresponding to the Facility Sketch (LIC 999).

The following deficiency is being cited (see LIC 809D). Appeal Rights were provided. A notice of site visit was given 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 Site Supervisor, Deann Johns .

SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022
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 2


Document Has Been Signed on 12/20/2022 11:01 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: NCO HEAD START - CHILD DEV. CTR. - PEACH TREE CTR.
FACILITY NUMBER: 233008828

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/20/2023
Section Cited

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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:
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LPA observed that the facility has temporarily removed the affected sink faucet “C” from service by way of a sign and caution tape. S1 stated that the facility has replaced the sink faucet, connecting hose and are currently in the process of flushing it in preparation for re-testing.
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Based on record review, facility faucet (Site “C”) exceeded the allowable levels of lead in the water, testing at 9.6 ppb. This is a potential health and safety risk to children in care.
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S1 stated that the test results of the re-test will be sent to LPA, once received. S1 will notify all parents or guardians about what has been done, to remediate the outlet and how drinking water is provided to children.

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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: 12/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022
LIC809 (FAS) - (06/04)
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