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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274400369
Report Date: 08/31/2023
Date Signed: 08/31/2023 10:58:57 AM

Document Has Been Signed on 08/31/2023 10:58 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:KING CITY COOPERATIVE NURSERY SCHOOLFACILITY NUMBER:
274400369
ADMINISTRATOR:MILLER, TANYAFACILITY TYPE:
850
ADDRESS:508 NORTH SECOND STREETTELEPHONE:
(831) 385-3577
CITY:KING CITYSTATE: CAZIP CODE:
93930
CAPACITY: 15TOTAL ENROLLED CHILDREN: 15CENSUS: 9DATE:
08/31/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Tanya MillerTIME COMPLETED:
11:00 AM
NARRATIVE
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On 08/31/2023 at 10:00 AM, Licensing Program Analysts (LPAs) Susy Cervantes and Fermin Campos-Jaramillo, met with director, Tanya Miller, 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 was one staff and one parent with 9 children in care.

Initial Lead testing was conducted by Adviro on 08/09/2023. Facility submitted that there is an exceedance of 24 (ppb) in the outdoor faucet by the main door entrance (Faucet F on facility sketch). Director stated the faucet has not been used in years and they plan to cap off the faucet.

LPA Cervantes was emailed the Self-Certification form (LIC 9275), Sampling Checklist form (LIC 9276), and the updated facility sketch (LIC 999).

Type B deficiency was cited during today's visit. Director 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 director, Tanya Miller. 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: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023
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 08/31/2023 10:58 AM - It Cannot Be Edited


Created By: Susy Cervantes On 08/31/2023 at 10:32 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: KING CITY COOPERATIVE NURSERY SCHOOL
FACILITY NUMBER: 274400369

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2023
Section Cited

101700.3(b)(1)

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Lead Testing Written Directives (b)(1) a result 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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Director stated they will cap off the water faucet. Director will send proof of correction to the San Jose Regional Office by close of business on September 29, 2023.
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Based on record review: LPA observed Faucet F has an exceedance of 24 ppb which poses a potential risk to the heakth, safety, and personal rights of the children in care.
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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: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


LIC809 (FAS) - (06/04)
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