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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274410749
Report Date: 07/30/2024
Date Signed: 07/30/2024 02:35:47 PM

Document Has Been Signed on 07/30/2024 02:35 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:SHORELINE PRE-SCHOOLFACILITY NUMBER:
274410749
ADMINISTRATOR/
DIRECTOR:		KRISTA CHAWINGAFACILITY TYPE:
850
ADDRESS:2500 GARDEN ROADTELEPHONE:
(831) 641-0209
CITY:MONTEREYSTATE: CAZIP CODE:
93940
CAPACITY: 36TOTAL ENROLLED CHILDREN: 36CENSUS: 0DATE:
07/30/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Keith KruegerTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
NARRATIVE
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Licensing Program Analyst (LPA), Elizabeth Larios, met with Operations Pastor, Keith Krueger, and explained purpose of visit to follow-up on water lead testing conducted for the facility. LPA was admitted into the facility by Keith and requested Keith to identify faucet with Action Level Exceedance (value of 6.0 parts per billion or greater).

During today's inspection LPA Larios requested and obtained the following documents; LPA received the following documents during visit from Keith: Post-Testing Sampling Documents; Self-Certification (LIC9275) completed by Certified External Water Sampler, Sampling Checklist Form (LIC9276), and Facility Sketch (LIC999) labeled with locations of water outlets.



Water sample was conducted by Cal Rural Water (CRWA) on 7/11/2023 and the report indicated that faucet "C" had Action Level Exceedance value of 6.0. The faucet is located in the classroom bathroom sink and is one of the faucets for hand washing. The facility has remediated faucet "C" by fully replacing faucet on 3/15/2023. Keith states that the facility completed the 30 second flushes four time per day for 21 days on faucet "C" until retesting was done. Keith states retesting was done on 7/11/2023 and has a Action Level Exceedance value of 6.0. Keith states sink faucet "C" is currently made accessible for hand washing only. LPA observed that the faucet is accessible and observed notices above sink that state the following, "notice sink for hand washing only and do not drink the water". LPA also observed cabinet below sink faucet is locked to avoid someone turning water back on. The sinks faucets are not used for drinking water, but solely as a hand washing station. The center provides bottle drinking water for the children. Keith confirmed sink faucet "C" is shutoff & and water source is close during today's inspection. Upon review of documents provided It was determined that (CRWA) labeled the sink faucets incorrectly (sink faucet "C" should be sink faucet "D"). Keith will be contacting (CRWA) to have documents corrected. LPA requested for corrected documents to be submitted to the department and uploaded.

Exit interview conducted and report was reviewed with the Operations Pastor, Pastor Krueger.

As a result of todays inspection, a deficiency was cited, see 809-D.

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: Joel Segura
LICENSING EVALUATOR NAME: Elizabeth Larios
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2024
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 07/30/2024 02:35 PM - It Cannot Be Edited


Created By: Elizabeth Larios On 07/30/2024 at 01:49 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SHORELINE PRE-SCHOOL
FACILITY NUMBER: 274410749

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/06/2024
Section Cited
CCR
101700.3(b)(1)

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Lead Testing Written Directives (b)(1) a result with values of 5.5 parts per billion or greater shall be deemed an Action Level Exceedance (ALE).

This requirement is not met as evidenced by:
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The facility has completely replaced faucet "C" and retested and did not resloved the water lead ALE result. The facility shall contacting (CRWA) to label the sink faucets correctly. Facility shall either cap off/, replace, or retest faucet "C"and notify Licensing once it has been
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After water lead testing was completed, the facility had faucet (C) located in the classroom bathroom sink with an Action Level Exceedance of 6.0, which poses a potenial risk to the health, safety, and personal rights of children in care.
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completed by submitting plan of correction by POC due date 08/06/2024.

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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:Joel Segura
LICENSING EVALUATOR NAME:Elizabeth Larios
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


LIC809 (FAS) - (06/04)
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