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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010364
Report Date: 05/25/2023
Date Signed: 05/25/2023 02:41:41 PM

Document Has Been Signed on 05/25/2023 02:41 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:LITTLE MONARCHS PRESCHOOLFACILITY NUMBER:
493010364
ADMINISTRATOR:TEETER, ZOEFACILITY TYPE:
850
ADDRESS:3267 AIRWAY DRIVETELEPHONE:
(707) 479-5577
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 57TOTAL ENROLLED CHILDREN: 57CENSUS: 5DATE:
05/25/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Zoe TeeterTIME COMPLETED:
02:55 PM
NARRATIVE
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On 05/22/2023, Licensing Program Analysts (LPAs), Sebastian Phouthavong and Robert Maciel made a case management inspection and met with Administrator, Zoe Teeter. 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, "A” had a reading of 9.8 ppb. All other sources of water tested below the allowable level of 5.0 ppb.

During today’s inspection, LPA observed Simple Site “A”, the kitchen sink’s faucet temporarily removed and currently not in use. Administrator stated the facility is currently providing drinkable water to the children by water bottles and individual cups. Administrator stated the faucet will be replaced and will be flushing out the sink for 30 days before retesting. The facility plans to use the kitchen sink for washing hands.

The facility will submit the External Water Sampling Self-Certification Form (LIC 9275), Child Care Center Sampling Checklist Form (LIC 9276) and Facility Sketch/Floor Plan (LIC 999) to CCL.

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 Administrator, Zoe Teeter.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2023
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 05/25/2023 02:41 PM - It Cannot Be Edited


Created By: Sebastian Phouthavong On 05/25/2023 at 02:25 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: LITTLE MONARCHS PRESCHOOL
FACILITY NUMBER: 493010364

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/25/2023
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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 LPA observed Simple Site “A”, the kitchen sink’s faucet temporarily removed and currently not in use. Administrator stated the faucet will be replaced and will be flushing out the sink for 30 days before retesting. Adminstrator will notify CCL of 2nd test by email: sebastian.phouthavong@dss.ca.gov
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Based on record review, facility kitchen sink (Site “A”) exceeded the allowable levels of lead in the water, testing at 9.8 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:Leslie Lepori
LICENSING EVALUATOR NAME:Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2023


LIC809 (FAS) - (06/04)
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