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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490111334
Report Date: 10/04/2022
Date Signed: 10/04/2022 09:12:46 AM


Document Has Been Signed on 10/04/2022 09:12 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:MARK WEST EXTENDED CHILD CAREFACILITY NUMBER:
490111334
ADMINISTRATOR:JASON RIGGSFACILITY TYPE:
840
ADDRESS:4600 LAVELLE ROADTELEPHONE:
(707) 526-4066
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:126CENSUS: 0DATE:
10/04/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Reachel Coburn TIME COMPLETED:
09:30 AM
NARRATIVE
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On 10/03/2022 at 8:30am, Licensing Program Analyst (LPA), Sebastian Phouthavong made a case management inspection and met with Director, Rachel Coburn. 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 kitchen sink tested above the allowable level (5 ppb) of lead in the water: Sample Sites, Kitchen sink, 39.400 ppb. All other sources of water tested below the allowable level of 5.0ppb.

The staff have made the kitchen sink inaccessible by temporarily taping up the sink, so children have no way of using it. Children in care are receiving drinking water from bottled water and can able to use the other rooms for water. The director stated the fixer has been replaced on 09/24/2022 and is required to be checked on and have the sink running for a certain amount of time every day for 30 days before retesting the sink. The facility plans to retest once completed.

The facility will submit 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). 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, Rachel Coburn.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Sebastian PhouthavongTELEPHONE: 707-588-5056
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2022
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 10/04/2022 09:12 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: MARK WEST EXTENDED CHILD CARE
FACILITY NUMBER: 490111334

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/04/2022
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 one faucet (Site "A") that exceeded that allowable levels of lead in the water (39.400 ppb) This is a potential health and safety risk to children in care.
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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: 10/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2022
LIC809 (FAS) - (06/04)
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