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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102819
Report Date: 10/19/2023
Date Signed: 10/19/2023 12:14:51 PM

Document Has Been Signed on 10/19/2023 12:14 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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:GOOD SHEPHERD LUTHERAN SCHOOLFACILITY NUMBER:
210102819
ADMINISTRATOR:JESSICA MCINTYREFACILITY TYPE:
850
ADDRESS:1180 LYNWOOD DRIVETELEPHONE:
(415) 897-2510
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 122TOTAL ENROLLED CHILDREN: 122CENSUS: 33DATE:
10/19/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:34 AM
MET WITH:Lisa HermannTIME COMPLETED:
12:40 PM
NARRATIVE
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On October 19, 2023, Licensing Program Analysts (LPAs) Garcia and Tse conducted an unannounced, case management inspection for the Action Level Exceedance (ALE) of Lead in Child Care Center's water. LPAs met with director, Lisa Hermann. LPAs explained the purpose of the visit and was given a tour of the facility.
Present in facility are 33 children, present with 7 staff members.

LPAs discussed the new Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018 requires the Lead Testing of water in the Child Care Center with the site director during the inspection. All Child Care Centers that are located in buildings constructed before January 1, 2010, must have their water tested and post the results by January 1, 2023, and every 5 years after the date of the first testing.

The facility received the ALE report from the Vendor on May 16, 2023. Test results for this facility that exceeded a higher level of parts per billion (ppb) allowed, 5.5 ppb. The facility was proactive in getting facility faucets tested and putting signs indicating that the water fountain/kitchen fixture is not for drinking and or currently out of order. Per director, the affected fixture AL (10) is a water fountain located in the lower hallway. The other fixture C (6.5) is another hallway water fountain located in the chapel hall. The facility is also using other sources of water, sinks that passed the tests, for food preparation and water ingestion or refill. According to the director, the water fountains were replaced and retested on July 11, 2023 and passed the test for C(4.8) and AL (<1), per database.

LPA obtained the copies of the External Water Sampler Self-Certification Form (LIC9275), Child Care Center Sampling Checklist (LIC9276), Facility Sketch (LIC999), in an email to the LPA.

* See next page for deficiencies cited today and will also be cleared on the same day.

This report was reviewed and signed by Director, Lisa Hermann .

This notice of Site visit was provided to the licensee and must remain posted for 30 days.

SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Nathan Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
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 10/19/2023 12:14 PM - It Cannot Be Edited


Created By: Nathan Garcia On 10/19/2023 at 11:59 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: GOOD SHEPHERD LUTHERAN SCHOOL
FACILITY NUMBER: 210102819

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/20/2023
Section Cited

101700.3

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101700.3 California Lead Action Level at Child Care Centers (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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The facility got their water sources tested for lead contamination on May 16, 2023 and had an exceedance for fixtures C(6.5) and AL(10). The facility then remediated/replaced the affected fixtures and got retested on July 11, 2023 and passed the retest showing below the threshold for both affected fixtures.
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Based on results received from the certified water samplers, the facility exceeded 5.4 ppb of lead in their water source. Once received, the facility took immediate and proper actions to remediate the fixtures.
This poses a potential health, safety, or personal rights risk to persons in care.
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The citation given today will be cleared on the same visit.

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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:Daniel J Oquendo
LICENSING EVALUATOR NAME:Nathan Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


LIC809 (FAS) - (06/04)
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