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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210105096
Report Date: 10/19/2023
Date Signed: 10/19/2023 01:27:21 PM

Document Has Been Signed on 10/19/2023 01:27 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:TWIN CITIES COMMUNITY PRESCHOOLFACILITY NUMBER:
210105096
ADMINISTRATOR:JOHNSTONE, MAUREEN D.FACILITY TYPE:
850
ADDRESS:56 MOHAWK AVENUETELEPHONE:
(415) 924-3150
CITY:CORTE MADERASTATE: CAZIP CODE:
94925
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 12DATE:
10/19/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
12:52 PM
MET WITH:Maureen JohnstoneTIME COMPLETED:
01:45 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. LPA met with director, Maureen Johnstone. LPAs explained the purpose of the visits and was given a tour of the facility.
Present in facility are 12 children, with 3 staff members, including the director.

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 November 4, 2022. 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 C (19) is a water fountain located in the play yard. According to the director, the water fountain has been removed prior to April 20, 2023. LPAs observed that there was no outdoor water fountain during the visit, confirming that the affected fixture was permanently removed. The facility is also using other sources of water, sinks that passed the tests, for food preparation and water ingestion or refill.

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, Maureen Johnstone.

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 01:27 PM - It Cannot Be Edited


Created By: Nathan Garcia On 10/19/2023 at 01:06 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: TWIN CITIES COMMUNITY PRESCHOOL
FACILITY NUMBER: 210105096

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 permanently removed the affected outdoor water fountain prior to ALE case management visit. LPA was notified by the director on April 20, 2023 that the fixture was removed, with an attached photo of where the fixture used to be.
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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 posed a potential health, safety, or personal rights risk to persons in care.
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Deficiency will be issued and cleared during the same visit on 10/19/23.

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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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