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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490100475
Report Date: 09/16/2022
Date Signed: 09/16/2022 03:57:58 PM


Document Has Been Signed on 09/16/2022 03:57 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:CROSS & CROWN LUTHERAN PRESCHOOLFACILITY NUMBER:
490100475
ADMINISTRATOR:MC CARTHY, MANDYFACILITY TYPE:
850
ADDRESS:5474 SNYDER LANETELEPHONE:
(707) 795-7863
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:70CENSUS: 12DATE:
09/16/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Mandy McCarthyTIME COMPLETED:
12:01 PM
NARRATIVE
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On 09/16/2022, Licensing Program Analyst (LPA), Y.Yang made a case management inspection and met with Director, Mandy McCarthy. 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 faucets tested above the allowable level (5.0 ppb) of lead in the water: Sample Sites, "A", classroom A's faucet had a reading of 30.0ppb, "B" the indoor bathroom water faucet had a reading of 22.0ppb, "C", classroom C's water faucet had a reading of 5.7ppb, and "E", the children's outdoor bathroom E water faucet had a reading of 9.5ppb. All other sources of water tested below the allowable level of 5.0ppb.

The facility temporarily removed the faucets from service by turning off the water supply and taping up the faucets so children have no way of using it. Children in care are receiving drinking water from individual tumblers from home that staff refill from faucets inside the facility as needed and children are receiving bottled water.

The Center Director submitted the External Water Sampling Self-Certification Form (LIC 9275), Child Care Center Sampling Checklist Form (LIC 9276) and Facility Sketch/Floor Plan (LIC 999) to LPA.

The following deficiency is being cited (see LIC 809D). Appeal Rights was 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 the Director, Mandy McCarthy.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022
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 09/16/2022 03:57 PM - 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: CROSS & CROWN LUTHERAN PRESCHOOL
FACILITY NUMBER: 490100475

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2022
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 four faucets (Sites "A", "B", "C", and "E") that exceeded that allowable levels of lead in the water (30.0 ppb, 22.0ppb, 5.7ppb and 9.5ppb, respectively). This is a potential health and safety risk to children in care
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receive drinking water from bottled water and from other available faucets at the center. The facility will be replacing the faucet and will have the water retested three weeks later and send results to CCL by 11/15/22.

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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: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022
LIC809 (FAS) - (06/04)
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