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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 283008506
Report Date: 10/14/2022
Date Signed: 10/14/2022 10:19:49 AM


Document Has Been Signed on 10/14/2022 10:19 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:A PLACE OF MY OWNFACILITY NUMBER:
283008506
ADMINISTRATOR:MEGAN LYLEFACILITY TYPE:
850
ADDRESS:2590 FIRST STREETTELEPHONE:
(707) 224-8667
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:52CENSUS: 0DATE:
10/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Shannon Daniels, DirectorTIME COMPLETED:
10:35 AM
NARRATIVE
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On 10/14/2022 at 09:00am, Licensing Program Analyst (LPA), Kevin O'Connell made a case management inspection and met with Facility Representative, Shannon Daniels.
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 outlets/faucets tested above the allowable level (5.5 ppb) of lead in the water:
Drinking fountain in Preschool hallway "A30" - 8.300 ppb
The staff have made the drinking fountain inaccessible by:
Wrapping the drinking fountain in a plastic bag and posting a sign stating " Do not use until removed by sampler- failure to comply will negatively impact ongoing lead sampling work required by California State Law".
The facility just uncovered this drinking fountain in September for use a few weeks prior to testing. This fountain was shut down during Covid.
The children bring water from home and facility has used filtered water for many years to refill drinking water.

The church Executor Pastor/ facility administrator, Darlene Valencia stated that the water to the fountain will be turned off today, 10/14/22 and a determination to either remove or replace and retest will be made within the next week.
The facility will update CCL when they receive news on the determination.

The following deficiency is being cited (see LIC 809D). 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 the Facilities Director, Shannon Daniels.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Kevin O'ConnellTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
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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Document Has Been Signed on 10/14/2022 10:19 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: A PLACE OF MY OWN
FACILITY NUMBER: 283008506

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/11/2022
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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Based on record review, the facility had 1 drinking fountain in the hallway that exceeded the allowable levels of lead in the water (8.3 ppb). This is a potential health and safety risk to children in care.
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and children bring their own water and receive drinking water from a filtered water dispenser which was tested. The facility manager will either remove or replace and have retested, notify,
and send results to CCL by 11/11/22.
kevin.oconnell@dss.ca.gov

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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: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Kevin O'ConnellTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
LIC809 (FAS) - (06/04)
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