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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001575
Report Date: 02/03/2023
Date Signed: 02/03/2023 12:08:56 PM

Document Has Been Signed on 02/03/2023 12:08 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
PENINSULA CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:CITY OF PACIFICA - SUNSET RIDGE CHILDREN'S CENTERFACILITY NUMBER:
414001575
ADMINISTRATOR:CYNTHIA USSERYFACILITY TYPE:
850
ADDRESS:340 INVERNESSTELEPHONE:
(650) 738-7465
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 5DATE:
02/03/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Cynthia UsseryTIME COMPLETED:
12:30 PM
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On 2/3/23 at 11:25 AM, Licensing Program Analyst (LPA) Nathan Garcia conducted an unannounced, case management inspection for the Action Level Exceedance (ALE) of Lead in Child Care Center's water. LPA met with the Site Director, Cynthia Ussery. The purpose of the inspection was explained.

There were 5 children and 3 teachers present during inspection.

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 10/17/2022. 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 barricaded and or made the affected fixture out of order. Per director, they are coordinating with the school district and their Program Manager, Tracy Gilbert regarding the plans for this particular sink. The children are currently bringing water from home and is refilled through filtered Brita pitchers from unaffected fixtures or providing purchased bottled water, as needed.

Director will keep the department updated on their plans for the affected sink fixture B (20) ppb.

LPA obtained the copies of the External Water Sampler Self-Certification Form (LIC9275), Child Care Center Sampling Checklist (LIC9276), Facility Sketch (LIC999), in an email to the LPA. LPA obtained copy of the lead water testing results as well.

* See next page for deficiency cited today

This report and notice of Site visit and appeal rights were provided to the licensee and must remain posted for 30 days.
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Nathan Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2023
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 02/03/2023 12:08 PM - It Cannot Be Edited


Created By: Nathan Garcia On 02/03/2023 at 11:46 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: CITY OF PACIFICA - SUNSET RIDGE CHILDREN'S CENTER
FACILITY NUMBER: 414001575

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/03/2023
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 will remediate the fixture until they are retested with a certified water sampler by 03/3/2023.

Director will provide the new test results to LPA no later than 03/3/2023.
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Based on results received from the certified water samplers, the facility exceeded 5.5 ppb of lead in their water source. Once recieved, the facility took immediate and proper actions to remediate the fixtures.
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:Daniel J Oquendo
LICENSING EVALUATOR NAME:Nathan Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2023


LIC809 (FAS) - (06/04)
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