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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490101798
Report Date: 01/06/2023
Date Signed: 03/16/2023 01:03:17 PM


Document Has Been Signed on 03/16/2023 01:03 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:SPRING HILL MONTESSORIFACILITY NUMBER:
490101798
ADMINISTRATOR:HAMIDI, SHAHARAZADFACILITY TYPE:
850
ADDRESS:825 MIDDLEFIELD DRTELEPHONE:
(707) 763-9222
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY:107CENSUS: 59DATE:
01/06/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Hamidi Shaharazad & Karen SheehanTIME COMPLETED:
01:00 PM
NARRATIVE
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On 01/06/2023, Licensing Program Analyst (LPA), Sebastian Phouthavong made a case management inspection and met with Director, Hamidi Shaharazad and Site Supervisor, Karen Sheehan. The inspection was made in response to water lead testing results received from the facility. The test results showed that the following simples tested above the allowable level 5.0 parts per billion (ppb) of lead in the water: Sample Site, "A" had a reading of 8.0 ppb and Sample Site, "B" had a reading of 9.0 ppb. All other sources of water tested below the allowable level of 5.0 ppb.

During today’s inspection, LPA observed the both drinking fountains to be temporarily blocked off by means of caution tape and covers over them, making it inaccessible children in care. For the drinking fountain outside, the director stated the facility intend to remove parts of the fountain or remove the whole fountain of the location and turning off the valve, making it unusable. For the Water fountain inside a classroom, the Site Supervisor stated the facility intend to “Cap off” the fountain, making it enclosed and turning off the valve, making it unusable.

On 01/04/2023, the facility has 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 CCL.

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, Karen Sheehan.

SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Sebastian PhouthavongTELEPHONE: 707-588-5056
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023
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 03/16/2023 01:03 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: SPRING HILL MONTESSORI
FACILITY NUMBER: 490101798

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/06/2023
Section Cited

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101700.3(b)(1) A result with values of 5.0 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 drinking fountains “Site A” and “Site B” from service by way of a covers and caution tape. Site Supervisor stated that the facility plans to remove parts of water fountains for the 1st drinking fountain and capping off the 2nd drinking fountain, making both making it unusable.
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Based on record review, facility drinking fountains (Site “A” and Site “B”) exceeded the allowable levels of lead in the water, testing at 8 ppb and 9ppb. This is a potential health and safety risk to children in care.
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Site Supervisor stated the facility plans to turn off the value for both drinking fountains as well.

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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: Sebastian PhouthavongTELEPHONE: 707-588-5056
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023
LIC809 (FAS) - (06/04)
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