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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004787
Report Date: 09/26/2022
Date Signed: 09/26/2022 11:52:31 AM

Document Has Been Signed on 09/26/2022 11:52 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:UMC PRESCHOOL-BURLINGAMEFACILITY NUMBER:
414004787
ADMINISTRATOR:ARLETTE E. & VIKKI G.FACILITY TYPE:
850
ADDRESS:1443 HOWARD AVENUETELEPHONE:
(650) 347-6432
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 34DATE:
09/26/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:49 AM
MET WITH:Vikki GomezTIME COMPLETED:
11:45 AM
NARRATIVE
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On September 26, 2022 at approximately 10:30am, 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, Vikki Gomez. The purpose of the inspection was explained.

Present in facility are 34 children, present with 9 staff members and 9 parent volunteers.

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 8/12/2022. 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. The facility took action to contact the facility's management to repair and replace the fixture. Per director, the certified plumber is scheduled to visit on 9/28/22 and order the necessary parts. Once the faucet or filter is installed, the facility will be flushing the fixture for three weeks as instructed by the certified water samplers. The facility director will contact Cal Rural today, 9/26/22 to get an appointment for a retest. The facility has always asked the children to bring their own water from home and the bottles are replenished by using filtered water or store bought bottled water, as needed. The facility also sent letters to families about their Lead water results and their plan of action. LPA received a copy of this letter.

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.

* 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: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2022
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 09/26/2022 11:52 AM - It Cannot Be Edited


Created By: Nathan Garcia On 09/26/2022 at 11:04 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: UMC PRESCHOOL-BURLINGAME
FACILITY NUMBER: 414004787

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2022
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 included signs and will replace the fixtures affected and will be flushing the water fixture until they are retested with a certified water sampler by 10/31/2022.

Director will provide the new test results to LPA no later than 10/31/2022.
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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: 09/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2022


LIC809 (FAS) - (06/04)
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