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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410500322
Report Date: 11/07/2023
Date Signed: 11/07/2023 01:09:10 PM

Document Has Been Signed on 11/07/2023 01:09 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:HOPE LUTHERAN PRESCHOOLFACILITY NUMBER:
410500322
ADMINISTRATOR:TRACY SIRIFACILITY TYPE:
850
ADDRESS:600 WEST 42ND AVENUETELEPHONE:
(650) 345-8438
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 27TOTAL ENROLLED CHILDREN: 27CENSUS: 11DATE:
11/07/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Tracy SiriTIME COMPLETED:
01:15 PM
NARRATIVE
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On November 7, 2023, Licensing Program Analysts (LPAs) Luis Gomez and Man Tso met with director, Tracy Siri. Purpose of inspection was explained and was for an unannounced, case management inspection to cite for the Action Level Exceedance (ALE) of Lead in Child Care Center's water. Present in facility was director and two staff supervising 11 children. LPAs inspected facility for health and safety hazards.

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 July 19, 2022. Test results for this facility that exceeded a higher level of parts per billion (ppb) allowed, 5.5 ppb. Facility was proactive in getting facility faucets retested and barricaded, putting fixture out of order. The affected fixture, fixture C, tested (5.6).

The affected fixture C (drinking fountain) was retested on December 15, 2022, with a reading of 5.1ppb. Per the written directives in the PIN 21-21.1-CCP, facility will be cited for the action level exceedance of the fixture.

LPA obtained the copies of the External Water Sampler Self-Certification Form (LIC9275), Child Care Center Sampling Checklist (LIC9276), Facility Sketch (LIC999), have been sent in an email to the LPA.

* See next page for deficiencies cited today

This report was reviewed and signed by Director, Tracy Siri.

This notice of Site visit was provided to the licensee and must remain posted for 30 days.

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Man Tso
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2023
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 11/07/2023 01:09 PM - It Cannot Be Edited


Created By: Man Tso On 11/07/2023 at 12:35 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: HOPE LUTHERAN PRESCHOOL
FACILITY NUMBER: 410500322

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2023
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 was retested the affected fixture on 12/15/22. It reads 5.1ppb which is lowered than the Action Level Exceedance.

Deficiency has been cleared.
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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. This poses 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: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023


LIC809 (FAS) - (06/04)
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