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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173000114
Report Date: 10/26/2023
Date Signed: 10/26/2023 09:32:33 AM

Document Has Been Signed on 10/26/2023 09:32 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:NCO HEAD START - PEARL CENTERFACILITY NUMBER:
173000114
ADMINISTRATOR:MEDEROS, JODYFACILITY TYPE:
850
ADDRESS:14521 PEARL AVE.TELEPHONE:
(707) 994-6045
CITY:CLEARLAKESTATE: CAZIP CODE:
95422
CAPACITY: 17TOTAL ENROLLED CHILDREN: 14CENSUS: 11DATE:
10/26/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Site Supervisor, Jody MederosTIME COMPLETED:
09:45 AM
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On 10/26/2023 at 8:45am, Licensing Program Analyst (LPA), Sebastian Phouthavong made a case management inspection and met with Site Supervisor, Jody Mederos. 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 parts per billion (ppb) of lead in the water: Simple Site “A” – playground drinking fountain, 13.000ppb and Simple Site "A30"- part of playground fountain, 5.200ppb.

The staff have made the playground drinking fountain inaccessible by placing tight fitted bucket over it and posting a sign not to used. Children in care are receiving drinking water from water dispenser pitcher and individual cups. Site Supervisor stated the drinking fountain is being checked and in the process of receiving a retest.

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). 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 Site Supervisor, Jody Mederos.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2023
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 10/26/2023 09:32 AM - It Cannot Be Edited


Created By: Sebastian Phouthavong On 10/26/2023 at 09:01 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: NCO HEAD START - PEARL CENTER
FACILITY NUMBER: 173000114

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/27/2023
Section Cited

101700.3(b)(2)

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101700.3(b)(2) Licensees shall maintain a lead value at or below the Action Level of 5 ppb in all outlets subject to the testing requirements of these Written Directives, for the health and safety of children in care.
This requirement was not met as evidenced by:
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The facility has made drinking fountain temporarily inaccessible by covering it, and children receive drinking water fromwater dispenser pitcher and individual cups. Development Supervisor, Hyechong Froschl stated the water line and will retest again.
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The facility failed to maintain a lead value at or below the Action Level for water lead testing resulting with values of 5 ppb or greater for the drinking fountain. Itis not deemed safe to drink. This is a potential health and safety risk to children in care.
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Retesting documents will be submitted within once completed to CCL by 11/27/2023.

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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 Lepori
LICENSING EVALUATOR NAME:Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023


LIC809 (FAS) - (06/04)
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