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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410500408
Report Date: 11/16/2023
Date Signed: 11/16/2023 10:56:30 AM

Document Has Been Signed on 11/16/2023 10:56 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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:KIRK HOUSE PRESCHOOLFACILITY NUMBER:
410500408
ADMINISTRATOR:CONNELL, KATHYFACILITY TYPE:
850
ADDRESS:1148 JOHNSON STREETTELEPHONE:
(650) 323-8667
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY: 44TOTAL ENROLLED CHILDREN: 44CENSUS: 18DATE:
11/16/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Kathy ConnellTIME COMPLETED:
11:10 AM
NARRATIVE
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On November 16, 2023, Licensing Program Analyst (LPA) Garcia conducted an unannounced, case management inspection for the Action Level Exceedance (ALE) of Lead in Child Care Center's water. LPA met director Kathy Connell. LPA explained the purpose of the visit and was given a tour of the facility.
Present in facility are 18 children, with 5 staff members, including the director.

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 November 10, 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 putting signs indicating that the water fountain/kitchen fixture is not for drinking and or currently out of order. Per director, the affected fixture H (7.2) is a water fountain attached to the sink. According to the director, the water fountain has been permanently removed during the Winter break of 2022. LPA observed that there is a cap in place of where the water fountain used to be. Fixture I(7.2) is also a water fountain next to fixture H. It was entered into the database as an ALE but further review by LPA Garcia shows on the report by Adviro that fixture I is actually at 4.7 ppb of lead in water, which is not an Action Level Exceedance and is within the threshold.

LPA obtained emailed copies of the External Water Sampler Self-Certification Form (LIC9275), Child Care Center Sampling Checklist (LIC9276), Facility Sketch (LIC999).

* See next page for deficiencies cited today and will also be cleared on the same day.

This report was reviewed and signed by Director, Kathy Connell.

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

SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Nathan Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023
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 11/16/2023 10:56 AM - It Cannot Be Edited


Created By: Nathan Garcia On 11/16/2023 at 10:42 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: KIRK HOUSE PRESCHOOL
FACILITY NUMBER: 410500408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/15/2023
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 had fixture H permanently removed in December 2022 and fixture I is not an Action Level Exceedance (ALE). based on the report, it is at 4.7 ppb of lead. and it was incorrectly entered into the database at 7.2 ppb.
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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 posed a potential health, safety, or personal rights risk to persons in care.
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Deficiency will be cited and cleared on the same visit.

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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:Daniel J Oquendo
LICENSING EVALUATOR NAME:Nathan Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023


LIC809 (FAS) - (06/04)
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