POTTER VALLEY STATE PRESCHOOL

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25On 01/10/23, Licensing Program Analyst (LPA), Amy Strother conducted a case management tele-inspection with Director, Jaime Vonfeldt (D1). Due to severe winter storms with high wind and flooding the Department has approved a virtual inspection. D1 agreed to conduct the visit using FaceTime with LPA for the Tele-Inspection. 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 water faucets tested above the allowable level (5.0 ppb) of lead in the water: Sample Site, "D" an outdoor drinking fountain had a reading of 83 parts per billion (ppb). All other sources of water tested below the allowable level of 5.0 ppb. LPA Strother received an email from Kristin Hills (A1), Director of Early Learning and Care, Educational Services for Mendocino County Office of Education on 01/03/23. A1 stated in the email that the facility is closed for winter break until 01/09/23, and will immediately discontinue use of the drinking fountain “D”, by covering it or shutting off the water supply and posting an “out of order” sign next to it upon return. A1 stated in the email that the facility plans to replace the drinking faucet, flush and retest. LPA obtained the following documents from A1 via email on 01/03/22; External Water Sampling Self-Certification Form (LIC 9275), Child Care Center Sampling Checklist Form (LIC 9276) and Facility Sketch/Floor Plan (LIC 999), a copy of the lab report, and a copy of the letter given to parents or authorized representatives of children in care, dated 01/03/22 and photos identifying all water outlets labeled and corresponding to the Facility Sketch (LIC 999). On 01/04/22 LPA Strother emailed a copy of the lead report from the California State Water Resource Control Board to A1. During today’s tele-visit, LPA verified that the test results were posted and that Sample site “D” was made inoperable and inaccessible to children in care, observing a plastic bag covering the drinking fountain. The bag hand a hand written sign, stating "Do Not Use". D1 stated that children in care are receiving drinking water from the indoor fountain "B" while inside and either individual water bottles from home or water from kitchen sink "A" poured into disposable cups while outside. Continue on LIC809-C SUPERVISORS NAME: Alexis Hollon LICENSING EVALUATOR NAME: Amy Strother LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2023 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2023 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 3 FACILITY NAME: POTTER VALLEY STATE PRESCHOOLFACILITY NUMBER: 233001045 VISIT DATE: 01/10/2023 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 26 27 28 29 30 31 32The following deficiency is being cited (see LIC 809D). Appeal Rights were provided via email. A notice of site visit was given via email 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, Jaime Vonfeldt. D1’s signature was not recorded on this LIC809, LIC809-C or LIC809-D; however, D1 was provided with a copy of the LIC809, LIC809-C and LIC809-D; and D1’s confirmation of read receipt is on file. The report was also emailed to A1. SUPERVISORS NAME: Alexis Hollon LICENSING EVALUATOR NAME: Amy Strother LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2023 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2023 FACILITY NAME: POTTER VALLEY STATE PRESCHOOL FACILITY NUMBER: 233001045 DEFICIENCY INFORMATION FOR THIS PAGE: VISIT DATE: 01/10/2023 Deficiency Type POC Due Date / Section NumberDEFICIENCIESPLAN OF CORRECTIONS(POCs) Type B 02/10/2023 Section Cited 101700.3(b)(1) 1 2 3 4 5 6 7A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. This requirement was not met as evidenced by: 1 2 3 4 5 6 7LPA observed that the facility has temporarily removed the affected faucet “D” from service by way of a sign and cover and water shut off. D1 stated that the facility plans to replace the faucet, flush it and retest, submitting results by 02/10/23 to amy.strother@dss.ca.gov 8 9 10 11 12 13 14Based on record review, the facility had one faucet (Site “D”) that exceeded that allowable levels of lead in the water (83 ppb). This is a potential health and safety risk to children in care.8 9 10 11 12 13 14D1 stated that children in care are receiving dri

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25On 01/10/23, Licensing Program Analyst (LPA), Amy Strother conducted a case management tele-inspection with Director, Jaime Vonfeldt (D1). Due to severe winter storms with high wind and flooding the Department has approved a virtual inspection. D1 agreed to conduct the visit using FaceTime with LPA for the Tele-Inspection. 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 water faucets tested above the allowable level (5.0 ppb) of lead in the water: Sample Site, "D" an outdoor drinking fountain had a reading of 83 parts per billion (ppb). All other sources of water tested below the allowable level of 5.0 ppb. LPA Strother received an email from Kristin Hills (A1), Director of Early Learning and Care, Educational Services for Mendocino County Office of Education on 01/03/23. A1 stated in the email that the facility is closed for winter break until 01/09/23, and will immediately discontinue use of the drinking fountain “D”, by covering it or shutting off the water supply and posting an “out of order” sign next to it upon return. A1 stated in the email that the facility plans to replace the drinking faucet, flush and retest. LPA obtained the following documents from A1 via email on 01/03/22; External Water Sampling Self-Certification Form (LIC 9275), Child Care Center Sampling Checklist Form (LIC 9276) and Facility Sketch/Floor Plan (LIC 999), a copy of the lab report, and a copy of the letter given to parents or authorized representatives of children in care, dated 01/03/22 and photos identifying all water outlets labeled and corresponding to the Facility Sketch (LIC 999). On 01/04/22 LPA Strother emailed a copy of the lead report from the California State Water Resource Control Board to A1. During today’s tele-visit, LPA verified that the test results were posted and that Sample site “D” was made inoperable and inaccessible to children in care, observing a plastic bag covering the drinking fountain. The bag hand a hand written sign, stating "Do Not Use". D1 stated that children in care are receiving drinking water from the indoor fountain "B" while inside and either individual water bottles from home or water from kitchen sink "A" poured into disposable cups while outside. Continue on LIC809-C SUPERVISORS NAME: Alexis Hollon LICENSING EVALUATOR NAME: Amy Strother LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2023 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2023 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 3 FACILITY NAME: POTTER VALLEY STATE PRESCHOOLFACILITY NUMBER: 233001045 VISIT DATE: 01/10/2023 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 26 27 28 29 30 31 32The following deficiency is being cited (see LIC 809D). Appeal Rights were provided via email. A notice of site visit was given via email 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, Jaime Vonfeldt. D1’s signature was not recorded on this LIC809, LIC809-C or LIC809-D; however, D1 was provided with a copy of the LIC809, LIC809-C and LIC809-D; and D1’s confirmation of read receipt is on file. The report was also emailed to A1. SUPERVISORS NAME: Alexis Hollon LICENSING EVALUATOR NAME: Amy Strother LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2023 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2023 FACILITY NAME: POTTER VALLEY STATE PRESCHOOL FACILITY NUMBER: 233001045 DEFICIENCY INFORMATION FOR THIS PAGE: VISIT DATE: 01/10/2023 Deficiency Type POC Due Date / Section NumberDEFICIENCIESPLAN OF CORRECTIONS(POCs) Type B 02/10/2023 Section Cited 101700.3(b)(1) 1 2 3 4 5 6 7A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. This requirement was not met as evidenced by: 1 2 3 4 5 6 7LPA observed that the facility has temporarily removed the affected faucet “D” from service by way of a sign and cover and water shut off. D1 stated that the facility plans to replace the faucet, flush it and retest, submitting results by 02/10/23 to amy.strother@dss.ca.gov 8 9 10 11 12 13 14Based on record review, the facility had one faucet (Site “D”) that exceeded that allowable levels of lead in the water (83 ppb). This is a potential health and safety risk to children in care.8 9 10 11 12 13 14D1 stated that children in care are receiving dri

Type B citation - potential risk if not corrected