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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490111526
Report Date: 11/29/2022
Date Signed: 11/29/2022 10:07:30 AM


Document Has Been Signed on 11/29/2022 10:07 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:HEAD START - SONOMA VALLEYFACILITY NUMBER:
490111526
ADMINISTRATOR:SHURA, JOHNICEFACILITY TYPE:
850
ADDRESS:17600 SONOMA HWY, ROOM #5.4TELEPHONE:
(707) 996-5464
CITY:BOYES HOT SPRINGSSTATE: CAZIP CODE:
95416
CAPACITY:20CENSUS: 0DATE:
11/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Doug Pettit - Facilities ManagerTIME COMPLETED:
10:07 AM
NARRATIVE
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On 11/29/2022 at 9:45 AM, Licensing Program Analyst (LPA), Fernandes-Goes made a case management inspection and met with Community Action Partnership - Facilities Manager, Doug Pettit. The inspection was made in response to water lead testing results received by facility contacting Department and California State Water Resource Control Board. The test results showed that the following faucets tested above the allowable level (5 ppb) of lead in the water: Sample Site, "001A - A", 17.0 ppb and Sample Site, "002A - B", 11.0 ppb – Head Start Classroom.

The CAP of Sonoma Doug Pettit - Facilities Manager have made the faucet inaccessible by posting a “Do not use until removed by sampler” posting on the sink and removing the sink from service and children are not able to access it. However; the facility has been empty since May, 2022. Facility plan is to run the water daily for a week and then retest. If the testing fails again facility plan is to replace the 2 faucets in question with new faucet, run water through the faucets 4 times daily for 3 weeks prior to retesting. In addition, Doug Pettit stated that the faucet will be replaced and retested by POC date and has submitted plans regarding how that will be accomplished. Facility hasn't posted testing results and/or notified parents or guardians due to the fact that no children are attending this Head Start at this time.

The CAP of Sonoma Doug Pettit has provided the External Water Sampling Self-Certification Form (LIC 9275), Child Care Center Sampling Checklist Form (LIC 9276), pictures, 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 CPA of Sonoma, Doug Pettit

SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
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 11/29/2022 10:07 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: HEAD START - SONOMA VALLEY
FACILITY NUMBER: 490111526

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/28/2022
Section Cited

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101700.3(b)(1) A result with values of 5.1 ppb or greater shall be deemed an Action Level Exceedance.
This requirement was not met as evidenced by:
Based on record review, the
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facility had 2 faucets (Site "A" & "B") that exceeded that allowable levels of lead in the water (17 & 11ppb). This is a potential health and safety risk to children in care.
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Facility has been empty since May, 2022. Facility plan is to run the water daily for a week and then retest. If the testing fails again facility plan is to replace the 2 faucets in question with new faucet, run water through the faucets 4 times daily for 3 weeks prior to retesting. In addition, Doug Pettit stated that the faucet will be replaced and retested by POC date of 12/28/22

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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: Carla Fernandes-GoesTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2022
LIC809 (FAS) - (06/04)
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