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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009803
Report Date: 01/19/2023
Date Signed: 01/19/2023 09:58:59 AM

Document Has Been Signed on 01/19/2023 09:58 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:EARLY HEAD START-COOKFACILITY NUMBER:
493009803
ADMINISTRATOR:LISA GROCOTTFACILITY TYPE:
830
ADDRESS:2480 SEBASTOPOL ROADTELEPHONE:
(707) 535-3315
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
01/19/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Lisa GrocottTIME COMPLETED:
10:10 AM
NARRATIVE
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On 01/19/23, Licensing Program Analyst (LPA), Amy Strother made a case management inspection and met with Community Action Partnership – Director of Head Start, Lisa Grocott (D1). This facility is currently on inactive status, effective 08/01/22, therefore no children are present. The inspection was made in response to water lead testing results received from the California State Water Resource Control Board. The test results showed that the following faucets tested above the allowable level 5.0 parts per billion (ppb) of lead in the water: Sample Site “E”, a handwashing faucet in the classroom had a reading of 18 ppb and sample site “F” another hand washing faucet in the classroom, a reading of 12 ppb.

On 01/05/23 Facilities Manager, Doug Pettit (M1) submitted the testing results to LPA Strother via email, stating that he is currently working on replacing the two faucets, with plans of re-testing. Due to the facilities current inactive status, no children have access to faucets. Facility hasn't posted testing results and/or notified parents or guardians due to the fact that no children are enrolled or attending at this time.

On 01/12/23 LPA Strother received the following documents in an email from M1; External Water Sampling Self-Certification Form (LIC 9275), Child Care Center Sampling Checklist Form (LIC 9276), and Facility Sketch/Floor Plan (LIC 999). On 01/12/23 LPA Strother emailed a copy of the lead report from the California State Water Resource Control Board to D1 and M1, requesting photos identifying all water outlets labeled and corresponding to the Facility Sketch (LIC 999) be submitted within one week, as required. On 01/17/23 LPA received the requested photos.

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 Head Start Director, Lisa Grocott.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2023
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 01/19/2023 09:58 AM - It Cannot Be Edited


Created By: Amy Strother On 01/19/2023 at 09:43 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: EARLY HEAD START-COOK
FACILITY NUMBER: 493009803

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
02/19/2023
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 no children were present and the facility is currently inactive. D1 stated that the facility has ordered replacement faucets, will replace, flush and retest, submitting results to LPA at amy.strother@dss.ca.gov by 02/19/23.
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Based on record review, the facility had two faucets (Site “E” and “F”) that exceeded that allowable levels of lead in the water (18 and 12 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: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023


LIC809 (FAS) - (06/04)
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