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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270709776
Report Date: 10/17/2022
Date Signed: 10/17/2022 11:45:20 AM

Document Has Been Signed on 10/17/2022 11:45 AM - 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:CATALYST KIDS - KING CITY MIGRANTFACILITY NUMBER:
270709776
ADMINISTRATOR:PATRICIA REYESFACILITY TYPE:
830
ADDRESS:440 JAYNE STREETTELEPHONE:
(831) 385-4005
CITY:KING CITYSTATE: CAZIP CODE:
93930
CAPACITY: 22TOTAL ENROLLED CHILDREN: 22CENSUS: 10DATE:
10/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Gabriela GonzalezTIME COMPLETED:
12:00 PM
NARRATIVE
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On 10/17/2022 at 10:40 AM, Licensing Program Analyst (LPA) Susy Cervantes, met with administrator, Gabriela Gonzalez, for a case management visit in regards to the lead testing results submitted by the facility and explained the reason for the visit to them. Present were 5 staff with 10 children in care.

Facility submitted that there is an exceedance of about 10 (ppb) in the infant drinking fountain. Administrator stated the faucets were fixed immediately and facility staff were asked to turn on the water every day for 30 seconds and to log it, LPA observed facility staff have been logging when they open the water faucet. Administrator stated the water sampling company will be returning this Thursday and Friday (10/20 and 10/21) to test the water again. Administrator stated the water fountain is not being used at this time and will be used pending upcoming test results.

Type B deficiency was cited during today's visit. Administrator was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date will result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made. Exit interview conducted and report was reviewed with the administrator, Gabriela Gonzalez. 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
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2022
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 10/17/2022 11:45 AM - It Cannot Be Edited


Created By: Susy Cervantes On 10/17/2022 at 11:31 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: CATALYST KIDS - KING CITY MIGRANT
FACILITY NUMBER: 270709776

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
10/17/2022
Section Cited

101700.3(b)(1)

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101700.3(b)(1)
Testing results with fractional ppb readings of 0.5 ppb or greater shall be rounded up to the nearest whole number, before comparing to the Action Level. A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
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Facility repaired faucets and are currently not being used.
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Facility submitted that there is an exceedance of about 10 (ppb) in the infant drinking fountain.
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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:Mary Segura
LICENSING EVALUATOR NAME:Susy Cervantes
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022


LIC809 (FAS) - (06/04)
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