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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410519010
Report Date: 12/04/2023
Date Signed: 12/04/2023 03:21:57 PM

Document Has Been Signed on 12/04/2023 03:21 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:CSSF REC DEPT-SPRUCE AFTER SCHOOL REC PROGRAMFACILITY NUMBER:
410519010
ADMINISTRATOR:ELISIA ESPINOZAFACILITY TYPE:
840
ADDRESS:501 SPRUCE AVENUE, RM. B3TELEPHONE:
(650) 873-0924
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: 19DATE:
12/04/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Site Supervisor, Kim Morrison TIME COMPLETED:
03:25 PM
NARRATIVE
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On 12/4/2023, at approximately 2:25PMM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced case management visit regarding an Action Level Exceedance (ALE) due to lead in the Child Care Center's water. LPA was granted entry to the facility by Site Supervisor, Kim Morrison. LPA explained the purpose of the visit. Present during the visit were three staff and 19 school-age children. The facility is in compliance with teacher-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 Assistant 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 initially tested for lead on 12/15/2022 and is in compliance with testing requirements.

The facility received the initial ALE report from the Vendor on 12/22/2022. Test results for one fixture in this facility exceeded a higher level of parts per billion (ppb) allowed, 5.5 ppb, fixture B(7.5). The facility had children bring water bottles from home and provided store bought water to refill those bottles. Fixture B was relabeled as Fixture A and subsequently retested. Fixture A then tested at 3.2ppb, below the ALE. All other fixtures tested below the threshold and are in compliance with the Written Directives detailed in PIN 21-21.1-CCP.

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 facility will be cited for the ALE of fixture B. LPA advised that lead testing results and LIC forms 9275, 9276 and 999 should be posted.

See LIC809-D for deficiency cited and cleared today.
This report was reviewed and signed by Site Director, Kim Morrison.
A Notice of Site Visit was given and must be posted for thirty days.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2023
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 12/04/2023 03:21 PM - It Cannot Be Edited


Created By: Jonathan Tse On 12/04/2023 at 02:43 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: CSSF REC DEPT-SPRUCE AFTER SCHOOL REC PROGRAM
FACILITY NUMBER: 410519010

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/04/2024
Section Cited

101700.3(b)(2)

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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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Fixture B was replaced and retested under the ALE on 5/24/2023. The facility is now in compliance with WD 101700.3(b)(2).
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Based on record review of the lead sampling database, the facility was not in compliance with the above as of 12/22/2022. This posed a potential health, safety, or personal rights risk to persons in care.
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This deficiency will be cited and cleared the same day of the visit, 12/4/2023.

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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:Jonathan Tse
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2023


LIC809 (FAS) - (06/04)
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