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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004942
Report Date: 11/16/2023
Date Signed: 11/16/2023 12:55:49 PM

Document Has Been Signed on 11/16/2023 12:55 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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SHARMILA MONTESSORI HOUSE OF CHILDRENFACILITY NUMBER:
414004942
ADMINISTRATOR:SHARMILA FERNANDO, MARYFACILITY TYPE:
850
ADDRESS:3300 ALPINE ROAD, UNIT BTELEPHONE:
(650) 362-3320
CITY:PORTOLA VALLEYSTATE: CAZIP CODE:
94028
CAPACITY: 61TOTAL ENROLLED CHILDREN: 61CENSUS: 21DATE:
11/16/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:26 AM
MET WITH:Moderage Shamin PereraTIME COMPLETED:
01:05 PM
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On November 16, 2023, Licensing Program Analyst (LPA) Garcia conducted an unannounced, case management inspection for the Action Level Exceedance (ALE) of Lead in Child Care Center's water. LPA met with owner Moderage Shamin Perera. LPA explained the purpose of the visits and was given a tour of the facility.
Present in facility are 21 children, with 5 staff members.

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 October 7, 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. The affected fixtures are A(8), B(10), and C(13) parts per billion (ppb) of lead. Per director, fixture A and C are sinks located in the classrooms. Fixture B is garden hose used for watering plants or any outdoor water play. LPA also observed that the facility uses water services for food preparation and drinking.

LPA obtained the copies of the External Water Sampler Self-Certification Form (LIC9275), Child Care Center Sampling Checklist (LIC9276), Facility Sketch (LIC999), sent in an email to the LPA.

* See next page for deficiencies cited today

This report was reviewed and signed by Owner, Moderage Shamin Perera.

This notice of Site visit was 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: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023
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 11/16/2023 12:55 PM - It Cannot Be Edited


Created By: Nathan Garcia On 11/16/2023 at 12:27 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: SHARMILA MONTESSORI HOUSE OF CHILDREN
FACILITY NUMBER: 414004942

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/18/2023
Section Cited

101700.3

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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 affected fixtures will be remediated and retested. The facility will update LPA for scheduled retest date and results will be forwarded to LPA for verification.
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Based on results received from the certified water samplers, the facility exceeded 5.4 ppb of lead in their water source. This pose a potential health, safety, or personal rights risk to persons in care.
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The facility will notify LPA of the retest results by set due date.

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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: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023


LIC809 (FAS) - (06/04)
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