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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483002019
Report Date: 08/04/2022
Date Signed: 08/04/2022 11:44:48 AM


Document Has Been Signed on 08/04/2022 11:44 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:HEAD START - TABORFACILITY NUMBER:
483002019
ADMINISTRATOR:MC CAFFREY, KRISTINFACILITY TYPE:
850
ADDRESS:83 TABOR AVENUETELEPHONE:
(707) 427-6133
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:44CENSUS: 0DATE:
08/04/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Center Director Kim RobinsonTIME COMPLETED:
11:45 AM
NARRATIVE
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On 08/04/2022 at 09:09am, Licensing Program Analyst (LPA), Elpidia Hernandez Torres made a case management inspection and met with Director, Kim Robinson. The inspection was made in response to water lead testing results received from the California State Water Resource Control Board. The site was sampled on 06/03/2022, and analysis on 06/15/2022. The test results showed that the following faucets tested above the allowable level (5 ppb) of lead in the water: Faucet "C" - Tabor 2, "sink", 8.900 ppb The staff have made the faucet inaccessible by closing off the room to children. This classroom is not in use and has not been used since 5/27/2022 when summer break started. The faucet was replaced on 6/20/2022 per the recommendations of the water test company. The faucet was re-sampled on 7/23/2022 and the facility will update Community Care Licensing when they receive the results. They plan to reopen the facility on 8/15/2022 for fall classes.

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 Director Kim Robinson
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Elpidia Hernandez TorresTELEPHONE: (707) 771-5568
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
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 08/04/2022 11:44 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: HEAD START - TABOR
FACILITY NUMBER: 483002019

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/13/2022
Section Cited

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Buildings and Grounds 101238(a) The child care center shall be
clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors. This requirement was not met as evidenced by. . .
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. . . based on record review, the facility had 1 faucet that exceeded that allowable levels of lead in the water. This is a potential health and safety risk to children in care.
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Retesting documents will be submitted within 3 weeks of the completed sampling-08/13/22 to LPA Hernandez Torres via mail, email or fax at;
Elpidia.Hernandez-Torres@dss.ca.gov
Fax: 707-588-5099
Mail: 1450 Neotomas Ave Suite 100
Santa Rosa, Ca 95405

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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: Elpidia Hernandez TorresTELEPHONE: (707) 771-5568
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
LIC809 (FAS) - (06/04)
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