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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 283010138
Report Date: 03/05/2024
Date Signed: 03/05/2024 01:01:48 PM

Document Has Been Signed on 03/05/2024 01:01 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:HOPPER CREEK MONTESSORIFACILITY NUMBER:
283010138
ADMINISTRATOR:ELIZABETH FOSTERFACILITY TYPE:
850
ADDRESS:2141 2ND STREETTELEPHONE:
(707) 231-8768
CITY:NAPASTATE: CAZIP CODE:
94559
CAPACITY: 35TOTAL ENROLLED CHILDREN: 20CENSUS: 16DATE:
03/05/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Brenna Roth (Licensee) & Tamara KinmanTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA), Melchisedeck Augustin made an unannounced Plan of Correction (POC) visit and initially met with Licensee (LS), Brenna Roth for the purpose of obtaining signatures on several amended reports and to follow up on outstanding deficiencies that were respectively due on 02/12/24 and 02/29/24. On 01/29/24, the facility was cited a type B deficiency for not complying with Health and Safety (HSC) 1597.16(a)(1) which mandated the facility to test its waters used for drinking and preparing food for lead contamination level if its building was constructed before January 1, 2010, between January 1, 2020, but no later than January 1, 2023. Furthermore, the facility was cited a type B deficiency for not furnishing complete records for C1-C7. According to LS, she did not know about Written Directives section 101700 (PIN 21-21.1-CCP) which required certain facilities to test its water sites for lead contamination, LS confirmed the facility had not scheduled an appointment for a Lead Sampling Technician to test its water for lead contamination; and LS claimed she recently found out about the requirements to test the facility’s water for lead during a prior licensing visit on 01/29/24. LS stated the children brought their own cups and the facility had an outsourced vendor that delivered several thirty gallons water supply to install in a cooler, however; the staff used the water from the kitchen sink to wash off fruits provided to the children.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For childcare center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP). LPA referred Brenna Roth to the Department website for lead: Lead Toxicity Prevention and Water Testing Information. (Continue to LIC 809-C)

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2024
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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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: HOPPER CREEK MONTESSORI
FACILITY NUMBER: 283010138
VISIT DATE: 03/05/2024
NARRATIVE
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Additionally, on 02/15/24, the facility was cited two type A deficiencies as a result of substantiated complaint allegations which alleged the facility did not comply with requirements of children’s personal rights of California Code of Regulations (CCR) 101223(a)(2) and 101223(a)(3). During today’s visit, report which cited a type A was posted on the parent board near the front entrance. LPA counted sixteen children in the care of LS, Designated Center Director (CD) and one staff; and LPA did not witness any violation(s) of children’s personal rights. The Department contacted the Lead Sampling vendor via telephone who confirmed they were answering their phones during their operational hours, and they were accepting and scheduling appointments to test for lead contamination. LPA also reached out to the facility’s assigned analyst which confirmed the facility did not submit a POC and the POC remains outstanding, and according to Department records the facility did not have results for lead contamination level(s). LPA had a subsequent discussion with the Facility Representative who agreed to contact the lead sampling vendor to schedule an appointment to have its water site(s) tested, and according to the Representative, she would ensure the facility submitted evidence to show an appointment was successfully scheduled by 03/15/24. LPA assessed a civil penalty of $500 because LS did not correct deficiency by the POC due date.

LPA reviewed seven children’s (C1-C7) records at 9:45am which revealed C1-C7's record contained signed Acknowledgement of Receipt of Licensing Reports (LIC 9224), however; several children’s records were incomplete. C1 was missing Child’s Preadmission Health History (LIC 702) and Admission Agreement (AD), C2’s Immunization Record (IR) was transcribed on the incorrect CDPH 286 form, C3 was missing LIC 701 and IR, C4’s IR did not contain identifiable characters, C5 was missing AD & LIC 701 & LIC 702, C6 AD is incomplete and missing LIC 701; and C7 was missing a full AD.

Exit interview conducted and report was reviewed with the Facility Representative, Tamara Kinman. 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. The following violation of the California Code of Regulations, Title 22; Division 12, were observed during today’s visit. See LIC 809-D. Appeal Rights were provided.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
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Document Has Been Signed on 03/05/2024 01:01 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 03/05/2024 at 11:28 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: HOPPER CREEK MONTESSORI
FACILITY NUMBER: 283010138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2024
Section Cited
CCR
101221(a)

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(a) The licensee shall ensure that a separate, complete and current record for each child is maintained in the child care center.

This requirement is not met as evidenced by: Based on LPA's review of seven children's records which revealed C1-C7's records were missing various required licensing forms and were incomplete.
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Center Director stated she would review each child's record and ensure the children's records were complete. The Director stated she would notify the Department and submit evidence to prove she completed her review of and corrected the children's records. Director stated she would submit her Plan of Correction to the Department by 03/15/24 via mail, email or fax.
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This poses a potential health, safety and or personal rights risk to the children in care.
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Email: Melinda.Mohr@dss.ca.gov

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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:Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024


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