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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010083
Report Date: 02/09/2023
Date Signed: 02/09/2023 05:23:39 PM

Document Has Been Signed on 02/09/2023 05:23 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:ACHIEVERSFACILITY NUMBER:
493010083
ADMINISTRATOR:HEATHER PETERSFACILITY TYPE:
850
ADDRESS:573 SUMMERFIELD ROADTELEPHONE:
(707) 539-6232
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 90TOTAL ENROLLED CHILDREN: 55CENSUS: 50DATE:
02/09/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Heather PetersTIME COMPLETED:
10:30 AM
NARRATIVE
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On 02/09/23, Licensing Program Analyst (LPA), Amy Strother made a case management inspection and met with Director, Heather Peters (D1). 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 "C" a child size sink faucet, tested with elevated levels of lead, testing at 65 parts per billion (ppb). All other sources of water tested below the allowable level of 5.0 ppb.

During today’s inspection D1 removed the faucet "C" from service by turning the water off under the sink, placing a bag over the faucet and placing an "out of order" sign on a tray that rests over the sink. Children in care are receiving drinking water from individual water bottles from home that staff refill from water faucets. D1 stated that water bottles will no longer be refilled from faucet "C" and will only use faucets "A", "B" or "D" - "F" as needed, until faucet "C" can be remediated.

During today’s inspection LPA requested and received the Child Care Center Sampling Checklist Form (LIC 9276) and Facility Sketch/Floor Plan (LIC 999). LPA requested that D1 provide the External Water Sampling Self-Certification Form (LIC 9275) and photos of all water outlets labeled and corresponding to the Facility Sketch (LIC 999).

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 Director, Heather Peters.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2023
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 02/09/2023 05:23 PM - It Cannot Be Edited


Created By: Amy Strother On 02/09/2023 at 04:12 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: ACHIEVERS
FACILITY NUMBER: 493010083

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/09/2023
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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D1 has made faucet “C” inaccessible and has posted the lead testing results. D1 stated faucet "C" will be replaced, flushed and retested submitting results to amy.strother@dss.ca.gov by 03/09/23 .
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Based on record review, the facility had one faucet (Site “C”), that exceeded that allowable levels of lead in the water (65 ppb). This is a potential health and safety risk to children in care.
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 D1 stated children in care are receiving drinking water from individual water bottles from home that staff will refill from faucets "A", "B" or "D" - "F" as needed, until faucet "C" is remediated. D1 will notify parents or authorized representatives of the lead exceedance and plans for remediation.

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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: 02/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023


LIC809 (FAS) - (06/04)
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