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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410500240
Report Date: 11/17/2023
Date Signed: 11/17/2023 02:57:22 PM

Document Has Been Signed on 11/17/2023 02:57 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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:FIRST PRESBYTERIAN CHURCH PRESCHOOLFACILITY NUMBER:
410500240
ADMINISTRATOR:CORPUZ, ANGELINA VFACILITY TYPE:
850
ADDRESS:1500 EASTON DRIVETELEPHONE:
(650) 342-8326
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 80TOTAL ENROLLED CHILDREN: 80CENSUS: 2DATE:
11/17/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Angelina CorpuzTIME COMPLETED:
03:10 PM
NARRATIVE
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On November 17, 2023, Licensing Program Analysts (LPA)Tso met with director, Angelina Corpuz. The purpose of inspection was explained and was for an unannounced, case management inspection for the Action Level Exceedance (ALE) of Lead in Child Care Center's water. LPA was given a tour of the facility. Present in the facility was the director and 1 staff supervising 2 children during the napping time. The facility is in compliance with staff-child ratios.

LPA 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 October 26, 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 replaced the affected fixtures. The affected fixtures are, fixture D (7.9), fixture F (6.5), fixture G (400), fixture H (5.7), J (5.6) and K (8).

The affected fixtures D, F, G, H and K were retested on August 14, 2023, with the readings of <1ppb, except fixture G with a reading of 1 ppb. However, no record is found for fixture J. LPA observed and per the director, the fixtures K & J are in the next-door church which is not the center areas. The Director also stated that since September 2023, the center had not provided hot lunch. So the fixture J is no longer used by the center. Per Written Directives 101700.3(b)(2), licensees shall maintain a lead value at or below 5ppb in all outlets subject to testing requirements for the health and safety of children in care. The Written Directives are included in HSC 1597.16 and are specific guidelines for facilities to adhere to regarding lead water testing. Due to updated guidance on the written directives in PIN 21-21.1-CCP, the facility will be cited for the ALE of fixtures. Although the facility is cited for the ALE,the citation was cleared on today's visit and in compliance since 8/14/23.

* See next page for deficiencies cited today
This report was reviewed and signed by Director, Angelina Corpuz. This notice of Site visit was provided to the Director and must remain posted for 30 days.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Man Tso
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2023
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 11/17/2023 02:57 PM - It Cannot Be Edited


Created By: Man Tso On 11/17/2023 at 02:11 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: FIRST PRESBYTERIAN CHURCH PRESCHOOL
FACILITY NUMBER: 410500240

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/01/2023
Section Cited
HSC
1597.16

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WD101700.3(b)(2) Licensees shall maintain a lead value at or below the Action Level of 5 ppb in all outlets subject to the testing requirements of these Written Directives, for the health and safety of children in care.

This requirement was not met as evidenced by:
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The facility took steps to remediate by replacing the affected fixtures and retesting the fixtures on 8/14/2023. The fixtures were then tested below the ALE level and is now in compliance.

This deficiency was cited and cleared at the same day of the visit, 11/17/2023.
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Based upon record review, the facility had the fixtures that tested above the Action Level of 5ppb. This posed a potential health, safety, or personal rights risk to persons 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:Ali Zebila
LICENSING EVALUATOR NAME:Man Tso
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023


LIC809 (FAS) - (06/04)
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