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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 121374840
Report Date: 05/27/2022
Date Signed: 05/27/2022 11:28:22 AM

Document Has Been Signed on 05/27/2022 11:28 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
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:HEAD START - JEFFERSONFACILITY NUMBER:
121374840
ADMINISTRATOR:ROBERTS, DONNAFACILITY TYPE:
850
ADDRESS:914 B STREETTELEPHONE:
(707) 441-9020
CITY:EUREKASTATE: CAZIP CODE:
95501
CAPACITY: 20TOTAL ENROLLED CHILDREN: 20CENSUS: 0DATE:
05/27/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Abraxas LaytonTIME COMPLETED:
12:00 PM
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On May 27, 2022 at 8:30 am Licensing Program Analyst (LPA) Snow went to the administrative office for NORTHCOAST CHILDREN'S SERVICES located at 1266 9th street in Arcata to meet with Abraxas Layton. 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 (5.5 ppb) of lead in the water.
E & F (8.5 ppb & 9.9 ppb) both kitchen sinks failed the first test, plan to replace fixtures. Currently turned off. There is another kitchen sink fixture D that is being used to prepare food.
A & A-30 (10 ppb & 16 ppb) are the same drinking fountain; replaced the fixture, Failed retest. Is turned off until fixed.
B, C & G (28 ppb, 6.8 ppb, 6.3 ppb) are all inaccessible to children; they are faucets in the community center building that houses the facility but are not accessible to children & are not within the licensed area; they are permanently inaccessible to children.
Children in care are receiving drinking water from pitchers & cups.

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 facility representative, Abraxas Layton.
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Jaime Snow
LICENSING EVALUATOR SIGNATURE: DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2022
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 05/27/2022 11:28 AM - It Cannot Be Edited


Created By: Jaime Snow On 05/27/2022 at 09:48 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: HEAD START - JEFFERSON
FACILITY NUMBER: 121374840

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
06/27/2022
Section Cited
CCR
101238(a)

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The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors. This requirement was not met as evidenced by:
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The licensee agrees to submit an LIC 9275 and LIC 9276 by 6/27/22. The licensee has made the faucets temporarily inaccessible by shutting them off. The licensee plans to replace and retest the faucet . Retesting documents will be submitted within 2 weeks of the completed sampling.
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Based on record review, the facility had 7 faucets that exceeded that allowable levels of lead in the water. This is a potential health and safety risk to children in care.
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Faucet A, A30 (same fixture) &
F & E require retesting.
(B, C & G are not acessable to children and not in the licensed portion of the community center)

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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:Erin Virrueta
LICENSING EVALUATOR NAME:Jaime Snow
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022


LIC809 (FAS) - (06/04)
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