<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483001838
Report Date: 05/17/2023
Date Signed: 05/17/2023 12:48:37 PM

Document Has Been Signed on 05/17/2023 12:48 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:KINDERCARE LEARNING CENTERFACILITY NUMBER:
483001838
ADMINISTRATOR:FIELDS, DONJEFACILITY TYPE:
850
ADDRESS:35 ROTARY WAYTELEPHONE:
(707) 557-3007
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 72; 72TOTAL ENROLLED CHILDREN: 67CENSUS: 53DATE:
05/17/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Justice Willis - Assistant Center DirectorTIME COMPLETED:
01:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 05/17/2023, Licensing Program Analyst (LPA), M. Augustin made a case management inspection and met with Assistant Center Director, Justice Willis. 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 (5.5 ppb) of lead in the water: Sample site, "A", is a sink located in the hallway outside the "Infant classroom", had a reading of 19.8 ppb and Sample site, “D”, is a hand washing station that is located in the “kitchen” had a reading of 6.3 ppb, and Sample site, “G”, is located in a preschool classroom; had a reading of 12.0 ppb. All other sources of water that were tested had a reading below the allowable level of 5.5ppb.

The facility temporarily removed the faucet from service by turning off the water supply, taping up the sink, and/or by posting a sign by the faucet. The Assistant Center Director notified all staff members regarding the faucet and instructed staff to not use the faucet. Children in care are receiving drinking water from other drinking sources such as a large jug container that is filled with five gallon filtered water that is located at the center. Assistant Center Director reported that twelve five gallons of filtered water is delivered to the facility bi-weekly.

On 12/06/22, the Center Director submitted 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 LPA.

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 Assistant Center Director, Justice Willis.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 05/17/2023 12:48 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 05/17/2023 at 11:33 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: KINDERCARE LEARNING CENTER
FACILITY NUMBER: 483001838

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/17/2023
Section Cited

101700.3(b)(1)

1
2
3
4
5
6
7
California’s Action Level for lead in water at Child Care Centers -, "A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance."
1
2
3
4
5
6
7
The facility previously posted a "Do not use this water source" sign on each site, intends to inform all teachers, maitenance previously turned off the water sites, an outside vendor/plumber will be contacted to remedy the situation, and the sites would be retested for lead by 06/17/23. Assistant Center Director stated she would submit the plumber's report
8
9
10
11
12
13
14
Based on record review, facility faucet (Site “A, D & G”) exceeded the allowable levels of lead in the water, testing respectively at 19.8 ppb, 6.3 ppb & 12.0 ppb. This is a potential health and safety risk to children in care.
8
9
10
11
12
13
14
showing the repair to the sites, and the POC will be submitted via mail, email or fax.

Email: melchisedeck.augustin@dss.ca.gov
Fax: 707-588-5099

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2