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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410518055
Report Date: 03/22/2024
Date Signed: 03/22/2024 02:31:11 PM

Document Has Been Signed on 03/22/2024 02:31 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:J.S.D. STATE PRESCHOOLFACILITY NUMBER:
410518055
ADMINISTRATOR:ZIMIGA, LISAFACILITY TYPE:
850
ADDRESS:631 HANOVER ST., RM. 1 & 2TELEPHONE:
(650) 991-1258
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY: 104TOTAL ENROLLED CHILDREN: 80CENSUS: 0DATE:
03/22/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Lisa ZimigaTIME COMPLETED:
02:45 PM
NARRATIVE
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On March 22, 2024 at approximately 1:25pm, Licensing Program Analysts (LPAs) Catrina Quimbo and Diana Alvarado, conducted an unannounced case management visit in regards to Action Level Exceedance (ALE) of lead in facility's water. LPAs met with principal, Lisa Zimiga, and explained the purpose of the visit. During visit, no children were present as children were away on a field trip.

Drinking water is available to children, both indoors and outdoors, with filtered water pitchers and accessible drinking fountains. Water pitcher is refilled on site through classroom sinks and/or drinking fountains.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care
Centers (CCCs) constructed before January 1, 2010, to test their water (used for
drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.

The facility completed lead water testing March 9, 2024. Facility tested water fixtures located in classrooms and water fountains in the outdoor area, used for drinking purposes. Classroom fixtures were within the parts per billion (ppb) threshold. 2 water fountains (labeled M and N) in the outdoor area (located outside classroom 5) test results exceeded a higher level of ppb allowed, 5.5ppb.

The facility was proactive in getting facility faucets tested and putting signs indicating that the water fountain is not for drinking and is currently out of order. The facility took action to contact the facility's management to repair and replace the fixtures. Per principal, fixtures will be replaced and retested by a certified water sampler.

During visit, LPAs obtained copies of facility sketch (LIC999) and lead testing report. LPA to verify the child care center sampling checklist (LIC9276) and external water sampler self-certification form (LIC9275) have also been submitted.

Facility was issued a Type B citation for lead level exceedances. A plan of correction was discussed with principal.

Exit interview conducted and report was reviewed with principal, Lisa Zimiga.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2024
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 03/22/2024 02:31 PM - It Cannot Be Edited


Created By: Catrina Quimbo On 03/22/2024 at 02:08 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: J.S.D. STATE PRESCHOOL
FACILITY NUMBER: 410518055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/22/2024
Section Cited

101700.3(b)(1)

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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 has posted a sign that indictaes affected water fixture is not currently in use. Affected water fixtures will be replaced and retested.
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Based on observation, interview and record review, 2 water fixtures on site exceeded 5.5ppb. 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:Marie Rodriguez
LICENSING EVALUATOR NAME:Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


LIC809 (FAS) - (06/04)
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