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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493008692
Report Date: 02/12/2024
Date Signed: 02/12/2024 02:19:05 PM

Document Has Been Signed on 02/12/2024 02:19 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:4CS FLOWERY PRESCHOOLFACILITY NUMBER:
493008692
ADMINISTRATOR:SANFILIPPO, AMBERFACILITY TYPE:
850
ADDRESS:17600 SONOMA HWY.TELEPHONE:
(707) 935-4244
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 0DATE:
02/12/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
01:57 PM
MET WITH:Amber SanfilippoTIME COMPLETED:
02:25 PM
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On 02/12/2024, Licensing Program Analyst (LPA), Mindy Mohr made a case management inspection and met with Site Supervisor, Amber Sanfilippo. The inspection was made in response to water lead testing results received from the facility. The test results showed that the following samples tested above the allowable level 5.5 parts per billion (ppb) of lead in the water: Sample Site B had a reading of 8.700 ppb. All other sources of water tested below the allowable level of 5.5 ppb.

During today’s inspection, LPA observed the water faucet originally used for drinking was removed completely and had a cover over the original faucet hole.

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 Site Supervisor, Amber Sanfalippo.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melinda Mohr
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2024
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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