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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490102646
Report Date: 12/12/2022
Date Signed: 12/12/2022 03:59:40 PM

Document Has Been Signed on 12/12/2022 03:59 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:BETH AMI COMMUNITY NURSERY SCHOOLFACILITY NUMBER:
490102646
ADMINISTRATOR:DREZNER, CARENFACILITY TYPE:
850
ADDRESS:4676 MAYETTE AVENUETELEPHONE:
(707) 360-3030
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 75TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
12/12/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:44 PM
MET WITH:Caren DreznerTIME COMPLETED:
04:15 PM
NARRATIVE
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On 12/12/22, Licensing Program Analyst (LPA), Amy Strother made a case management inspection and met with Director, Caren Drezner (D1). The inspection was made in response to water lead testing results received from the facility. The test results showed that the following faucet tested above the allowable level 5.0 parts per billion (ppb) of lead in the water: Sample Site, "P" the sink in the currently vacant classroom #12/13 had a reading of 11 parts per billion (ppb). All other sources of water tested below the allowable level of 5.0 ppb. D1 stated that faucet "P" is used for hand-washing only and not for drinking water or food preparation.

Upon notification on 12/1/22, the facility removed the faucet from service by placing caution tape around the faucet and sink with a sign that reads, “Don’t Use”. A photo documenting the sink as inaccessible was received by LPA on 12/01/22. Children in care are receiving drinking water from individual water bottles from home that staff refill from faucet "H" located in the kitchen, as needed.

LPA obtained the following documents during the visit, from D1; External Water Sampling Self-Certification Form (LIC 9275), Child Care Center Sampling Checklist Form (LIC 9276) and Facility Sketch/Floor Plan (LIC 999).
D1 emailed LPA photos of all water outlets tested during today's visit.

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 the Director, Caren Drezner.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2022
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 12/12/2022 03:59 PM - It Cannot Be Edited


Created By: Amy Strother On 12/12/2022 at 03:16 PM
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: BETH AMI COMMUNITY NURSERY SCHOOL
FACILITY NUMBER: 490102646

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/12/2023
Section Cited

101700.3(b)(1)

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101700.3(b)(1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
This requirement was not met as evidenced by:
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LPA observed that the facility has temporarily removed the affected faucet “P” from service by way of a sign and caution tape. D1 stated that the facility plans to either replace faucet “P” and retest or cap off water flow to faucet “P” and send photos to LPA when capped or send new test results.
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Based on record review, the facility had one faucet (Site “P”) that exceeded that allowable levels of lead in the water (11 ppb). 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:Alexis Hollon
LICENSING EVALUATOR NAME:Amy Strother
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022


LIC809 (FAS) - (06/04)
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