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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 233008824
Report Date: 06/24/2022
Date Signed: 11/29/2022 02:07:06 PM

Document Has Been Signed on 11/29/2022 02:07 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:GREENWOOD PRESCHOOLFACILITY NUMBER:
233008824
ADMINISTRATOR:JOHNSTON, JULIANNEFACILITY TYPE:
850
ADDRESS:5700 HIGHWAY 1TELEPHONE:
(707) 877-3361
CITY:ELKSTATE: CAZIP CODE:
95432
CAPACITY: 15TOTAL ENROLLED CHILDREN: 15CENSUS: 0DATE:
06/24/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:52 AM
MET WITH:Jessica Ballard - DirectorTIME COMPLETED:
11:45 AM
NARRATIVE
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**Amended** This report has been amended due to correct and missing information needed.
On 06/24/2022 at 11:00 am, Licensing Program Analyst (LPA), Mary Trinh made a case management inspection and met with Maintenance, Travis Yolles. 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 faucet tested above the allowable level (5 ppb) of lead in the water: Sample Site, "C" – staff bathroom, 8.0 ppb.
The Maintenance have made the faucet inaccessible and children have no way of using it by shutting the water off on drinking fountain and placing bag over drinking fountain. There are no children in care as the center is closed.
The following deficiency is being cited (see LIC 809D). 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 Maintenance, Travis Yolles.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2022
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 06/24/2022 04:46 PM - It Cannot Be Edited


Created By: Mary Trinh On 06/24/2022 at 11:22 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: GREENWOOD PRESCHOOL
FACILITY NUMBER: 233008824

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/24/2022
Section Cited
HSC
101238(a)

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Type B - 101238(a) - Buildings and Grounds 101238(a) The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors.
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Maintanance has made the drinking fountain temporarily inaccessible by shutting the water off, and placing bag over drinking fountain. The school district will determine if the faucet will be replaced and retested or permanently removed by POC date and will submit plans regarding how that will be accomplished by July 24, 2022.
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This requirement was not met as evidenced by:
Based on record review, the facility had 1 drinking fountain that exceeded the allowable levels of lead in the water. 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:Mary Trinh
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022


LIC809 (FAS) - (06/04)
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