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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173003602
Report Date: 01/30/2023
Date Signed: 01/30/2023 09:34:09 AM

Document Has Been Signed on 01/30/2023 09:34 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:KELSEYVILLE EARLY CONNECTIONFACILITY NUMBER:
173003602
ADMINISTRATOR:BURGOYNE, SAJEANNEFACILITY TYPE:
850
ADDRESS:5065 KONOCTI ROADTELEPHONE:
(707) 279-6745
CITY:KELSEYVILLESTATE: CAZIP CODE:
95451
CAPACITY: 50TOTAL ENROLLED CHILDREN: 50CENSUS: 23DATE:
01/30/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Sajeanne BurgoyneTIME COMPLETED:
09:50 AM
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On 01/30/2023, Licensing Program Analyst (LPA), Sebastian Phouthavong made a case management inspection and met with Site Supervisor, Sajeanne Burgoyne. The inspection was made in response to water lead testing results received from the facility. The test results showed that the following simples tested above the allowable level 5.0 parts per billion (ppb) of lead in the water: One sample Site had a reading of 6.0 ppb and another had a reading of 9.0 ppb. All other sources of water tested below the allowable level of 5.0 ppb. Prior to visit, Child Development Program Director, Megan Handy and Operations and Emergency Services Director, Robert Young notified LPA of the lead testing and as submitted the facility’s plan of correction 01/25/2023.

During today’s inspection, LPA observed the drinking fountain to be already shutoff and was removed from the premise. Site Supervisor stated the water fountain has been turned off as of March 2020 due to COVID 19 and the water fountain was removed on 01/24/2023. LPA observed at the kitchen sink has been replaced. Site Supervisor stated the sink is not currently in use till finding out if itis fully operational and safe to use.

On 01/24/2023, 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). 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 Site Supervisor, Sajeanne Burgoyne

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2023
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 01/30/2023 09:34 AM - It Cannot Be Edited


Created By: Sebastian Phouthavong On 01/30/2023 at 09:13 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: KELSEYVILLE EARLY CONNECTION
FACILITY NUMBER: 173003602

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2023
Section Cited

101700.3(b)(1)

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101700.3(b)(1) A result with values of 5.0 ppb or greater shall be deemed an Action Level Exceedance. This requirement was not met as evidenced by:
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The water fountain has been removed and the kitchen sink has been replaced. Site Supervisor stated she will notify LPA once the kitchen sink is fully operational and safe to use by 02/28/2023.
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Based on record review, facility drinking fountains and kitchen sink exceeded the allowable levels of lead in the water, testing at 6 ppb and 9ppb. 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 Lepori
LICENSING EVALUATOR NAME:Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2023


LIC809 (FAS) - (06/04)
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