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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004812
Report Date: 10/20/2023
Date Signed: 10/20/2023 03:17:26 PM

Document Has Been Signed on 10/20/2023 03:17 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:PRIMARY SCHOOL, THEFACILITY NUMBER:
414004812
ADMINISTRATOR:EASTER, KYNDALFACILITY TYPE:
850
ADDRESS:2086 CLARKE AVENUETELEPHONE:
(650) 396-2779
CITY:EAST PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY: 98TOTAL ENROLLED CHILDREN: 92CENSUS: 73DATE:
10/20/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:ECE Dean, Tajmah Martin, Director of Operations and Integration, Nathalie Carvajal, and Dean of Operations, Reyna NietoTIME COMPLETED:
01:30 PM
NARRATIVE
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On October 20th, 2023, at approximately 11:50 AM, Licensing Program Analyst (LPA) Tapia-Mandujano conducted an unannounced, case management inspection for the Action Level Exceedance (ALE) of Lead in Child Care Center's water in concurrent with other inspections. LPA met with ECE Dean, Tajmah Martin, Director of Operations and Integration, Nathalie Carvajal, and Dean of Operations, Reyna Nieto.

Present in the facility are 12 staff supervising a total of 73 preschool age children. Facility operates in Classrooms #3,4,5,6,7, and 12. Facility is within teacher child ratio during today's inspections. All staff are fingerprint cleared and associated. LPA inspected classrooms for Health and Safety Hazards.

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 04/12/2023. 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 that were affected replaced and even added a filter system in faucets that were affected and in all ECE classrooms (#3, 4,5, 6,7, and 12). Facility was proactive and tested the entire building faucets for lead. The faucets that exceeded 5.5ppb in lead were Classrooms #1 (Faucet A), #2 (Faucets C &D), and the Staff break room (Faucet Q); all rooms which are not occupied for the preschool program. All faucets in Classrooms #3, 4, 5, 6,7, and 12 did not exceed in lead.

Due to the exceedance of 5.5ppb in Classrooms #1, #2, and staff room and testing of lead not being done by the due date of January 1st, 2023, deficiencies were given. Please refer to LIC 809D for citation. Appeal rights will be provided.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with ECE Dean, Tajmah Martin, Director of Operations and Integration, Nathalie Carvajal, and Dean of Operations, Reyna Nieto.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2023
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 10/20/2023 03:17 PM - It Cannot Be Edited


Created By: Leslit Tapia-Mandujano On 10/20/2023 at 01:18 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: PRIMARY SCHOOL, THE
FACILITY NUMBER: 414004812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2023
Section Cited

100700(c)(1)

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100700(c)(1): A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.

This requirement is not met as evidenced by:
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Director emailed proof of lead testing being done on April 12th, 2023.

Deficiency will be cleared.
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Based on record review, the facility did not comply with the section cited above as the Lead testing was not done until April 12th, 2023 after the required due date of January 1st, 2023, which posed a potential health, safety or personal rights risk to persons in care.
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Type B
11/20/2023
Section Cited
10700.3(b)(2)

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101700.3 California Lead Action Level at Child Care Centers: (b)(2): "Licensee shall maintain a lead value at or below the Action Level of 5.5ppb 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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The facility has since replace the fixtures affected and will be flushing the water fixture until they are retested with a certified water sampler.

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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 In classrooms #1, #2, and Staff Room. Once received, 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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Facility will provide the new test results to LPA no later than 11/20/2023.
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:Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023


LIC809 (FAS) - (06/04)
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