<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490111657
Report Date: 11/16/2022
Date Signed: 11/16/2022 04:20:49 PM


Document Has Been Signed on 11/16/2022 04:20 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:BRUSH CREEK MONTESSORI SCHOOLFACILITY NUMBER:
490111657
ADMINISTRATOR:SUSAN MORRELLFACILITY TYPE:
850
ADDRESS:1569 BRUSH CREEK ROADTELEPHONE:
(707) 539-7980
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY:78CENSUS: 18DATE:
11/16/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:22 PM
MET WITH:Susan MorrellTIME COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/16/22, Licensing Program Analyst (LPA), Amy Strother made a case management inspection and met with Director, Susan Morrell (D1). 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 Site, "J", an outdoor sink faucet tested with elevated levels of lead, testing at 7.4 parts per billion (ppb), outdoor faucet "P" tested at 10 ppb, and outdoor faucet "Q30" tested at 72 pbb. All other sources of water tested below the allowable level of 5.0 ppb.

The facility removed the faucet "J", “P” and “Q30” from service on 10/31/22, the day they received notification of the Action Level Exceedance (ALE). The faucets were made inaccessible by placing plastic bags over the faucets and taping, along with a sign stating, "Do Not Use". Faucet "Q30" was permanently removed from service on 11/13/22, by way of a plumber capping off the pipe. D1 stated that the plumber will return to cap off faucets "J" and "P" once the materials needed are acquired, stating it's expected to be completed next week. D1 stated, the children never used faucets, "J", “P” and “Q30” for drinking water or for food preparation, only for handwashing or water play activities. Children in care are receiving drinking water from individual water bottles from home that staff refill from faucets inside the classrooms if needed. During today's visit LPA verified that faucets "J", “P” and “Q30” are no longer accessible to children in care.

The Center Director, D1 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 on 10/17/22.

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 the Director, Susan Morrell.

SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
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 11/16/2022 04:20 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: BRUSH CREEK MONTESSORI SCHOOL
FACILITY NUMBER: 490111657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2022
Section Cited

1
2
3
4
5
6
7
A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.




8
9
10
11
12
13
14
Based on record review, the facility had three faucets (Site “J”, Site “P” and Site “Q30”) that exceeded that allowable levels of lead in the water (7.4, 10 and 72 ppb). This is a potential health and safety risk to children in care.
8
9
10
11
12
13
14
D1 stated she will have the plumber cap off Sites "J" and "P" by 12/16/22, and send photos of the capped off Sites to LPA Strother.
amy.strother@dss.ca.gov

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2