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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493006287
Report Date: 11/08/2022
Date Signed: 12/07/2022 03:31:04 PM

Document Has Been Signed on 12/07/2022 03:31 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:LA PETITE ACADEMY - PRESCHOOL/WINDSORFACILITY NUMBER:
493006287
ADMINISTRATOR:JAMIE POMAFACILITY TYPE:
850
ADDRESS:9451 SOUTH BROOKS ROADTELEPHONE:
(707) 838-0549
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 92TOTAL ENROLLED CHILDREN: 96CENSUS: 71DATE:
11/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:39 PM
MET WITH:Jamie PomaTIME COMPLETED:
01:47 PM
NARRATIVE
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This is an amended report. On 11/08/2022, Licensing Program Analyst (LPA), Y.Yang made a case management inspection and met with Director, Jamie Poma. 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 (5.0 ppb) of lead in the water: Sample Site, "G", located in the "Two's Class", had a reading of 11.0ppb. On 12/07/22, LPA Yang made a follow up case management visit to the facility in response to updated water lead testing results from the California State Water Resource Control Board. The test results showed that the following faucet tested above the allowable level (5.0 ppb) of lead in the water: Sample Site, "A", a drinking fountain located in the hallway, had a reading of 5.8ppb. All other sources of water that were tested had a reading below the allowable level of 5.0ppb.

The facility temporarily removed the faucets from service by turning off the water supply, taping up the sink, and/or by posting a sign by the faucets. The center director notified all staff members regarding the faucet and instructed staff to not use the faucets. Children in care are receiving drinking water from individual tumblers from home and from other drinking fountains located at the center.

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 Center Director, Jamie Poma.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Yang Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
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 12/07/2022 03:30 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 12/07/2022 03:24 PM


Created By: Yang Yang On 11/08/2022 at 12:57 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: LA PETITE ACADEMY - PRESCHOOL/WINDSOR
FACILITY NUMBER: 493006287

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/07/2023
Section Cited
CCR
101238(a)

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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. This requirement was not met as evidenced by:

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The center director has made the faucets temporarily inaccessible by shutting the water off, taping up the sink(s), and posting "do not use" signs. Children will be provided drinking water from water tumblers from home and drinking fountains located at the center. The Center Director stated that the faucet at "Site G" has been replaced and will be retested. "Site A" will be replaced and retested at a later date as well. The Center Director stated that she will submit the retesting documents within 2 weeks of the completed sampling to CCLD.
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Based on record review, the facility had two faucets "Site G" and "Site A" that exceeded that 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:Yang Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2022


LIC809 (FAS) - (06/04)
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