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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 283009663
Report Date: 02/15/2023
Date Signed: 02/15/2023 10:09:11 AM

Document Has Been Signed on 02/15/2023 10:09 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:LITTLE IVY PRESCHOOLFACILITY NUMBER:
283009663
ADMINISTRATOR:KAYLEE ANDRESFACILITY TYPE:
850
ADDRESS:2201 PINE STREETTELEPHONE:
(707) 257-1185
CITY:NAPASTATE: CAZIP CODE:
94559
CAPACITY: 45TOTAL ENROLLED CHILDREN: 45CENSUS: 35DATE:
02/15/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Teacher, Angie MacielTIME COMPLETED:
10:15 AM
NARRATIVE
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On 02/15/2023, Licensing Program Analyst (LPA), Sebastian Phouthavong made a case management inspection and met with Staff, Angie Maciel. 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: Sample Site B had a reading of 10.00 ppb. All other sources of water tested below the allowable level of 5.0 ppb.

During today’s inspection, LPA observed the drinking fountain to be already covered and typed off making it inaccessible to day care children. The facility is providing a water jug and children have individual bottles for potable water. Staff stated the facility plans to permanently remove the drinking fountain from the premises and cap the drinking fountain making it not useable. Staff stated Owner, Alex Myers is the lead person handling the Lead simple situation.

During today’s inspection LPA requested the Child Care Center Sampling Checklist Form (LIC 9276) and Facility Sketch/Floor Plan (LIC 999). LPA requested that the facility provide the External Water Sampling Self-Certification Form (LIC 9275) and photos of all water outlets labeled and corresponding to the Facility Sketch (LIC 999).

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 Staff, Angie Maciel

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2023
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 02/15/2023 10:09 AM - It Cannot Be Edited


Created By: Sebastian Phouthavong On 02/15/2023 at 09:14 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: LITTLE IVY PRESCHOOL
FACILITY NUMBER: 283009663

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2023
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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Facility has made Site “B” inaccessible and to notified all parents or guardians of the lead testing results. The facility will submit an LIC 9275, LIC 9276, and Facility Sketch.
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Based on record review, the facility had one faucet (Site “B”), that exceeded that allowable levels of lead in the water (10 ppb). This is a potential health and safety risk to children in care.
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Staff stated Site “B” will remove the drinking fountain from the premises and will submit proof by picture once completed and required forms to sebastian.phouthavong@dss.ca.gov by 03/15/23.

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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: 02/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2023


LIC809 (FAS) - (06/04)
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