<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001585
Report Date: 02/03/2023
Date Signed: 02/03/2023 10:48:47 AM

Document Has Been Signed on 02/03/2023 10:48 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
PENINSULA CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:CITY OF PACIFICA-CABRILLO CHILDREN'S CTR.-SCH AGEFACILITY NUMBER:
414001585
ADMINISTRATOR:LISA MENCONIFACILITY TYPE:
840
ADDRESS:601 CRESPI DR., PORT. 1, 2,&3TELEPHONE:
(650) 738-9251
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY: 108TOTAL ENROLLED CHILDREN: 108CENSUS: 0DATE:
02/03/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Marina Yakubovich TIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 2/3/23 at 9:00 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 arrived at the site and the program was not operating during arrival. LPA contacted Eva Tong and got a hold of site coordinator who's on the way to the site. Per Eva, the license is for school aged children and they don't normally operate during school hours. LPA met with the Site Director, Marina Yakubovich. The purpose of the inspection was explained.

No children or teachers present in facility 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 10/19/2022. 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 currently out of order. Per director, they coordinated with the school district to have the fixtures E and F sink removed permanently. The children are currently bringing water from home and is refilled through filtered Brita pitchers from unaffected fixtures, as needed.

Once the sink is permanently removed, director will send a picture for confirmation to the department.

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)
Page: 1 of 2
Document Has Been Signed on 02/03/2023 10:48 AM - It Cannot Be Edited


Created By: Nathan Garcia On 02/03/2023 at 10:27 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-CABRILLO CHILDREN'S CTR.-SCH AGE
FACILITY NUMBER: 414001585

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)

1
2
3
4
5
6
7
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:
1
2
3
4
5
6
7
Per director, they have coordinated with the school district facilities to remove the sink permanently. The children are currently using bottled water for ingestion.

The facility will send confirmation of the sink removal no later than 03/3/2023
8
9
10
11
12
13
14
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.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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)
Page: 2 of 2