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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710174
Report Date: 10/20/2022
Date Signed: 10/20/2022 10:46:29 AM

Document Has Been Signed on 10/20/2022 10:46 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:DE ANZA COLLEGE CHILD DEVELOPMENT CENTERFACILITY NUMBER:
430710174
ADMINISTRATOR:NAOKO NANCY HARADAFACILITY TYPE:
850
ADDRESS:21250 STEVENS CREEK BLVD.TELEPHONE:
(408) 864-5795
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY: 217TOTAL ENROLLED CHILDREN: 73CENSUS: 68DATE:
10/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Naoko HaradaTIME COMPLETED:
10:55 AM
NARRATIVE
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[This report replaces the Facility Evaluation Report (LIC 809) - Case Management Inspection dated 10/18/22].

Licensing Program Analyst (LPA), Marilou Monico, conducted an unannounced Case Management Inspection. LPA met with Director, Naoko Harada, and explained the purpose of the inspection. LPA reviewed water sample summary and requested Naoko to identify faucet "G" with reported Action Level Exceedance of lead that is 5.5 parts per billion (ppb) or greater. LPA observed that faucet "G" is located in Building 2, same building as Rooms 26 and 27. LPA observed that faucet "G" is covered with plastic with a "Do Not Use" sign. Naoko stated that the children are using bottled water and filtered water from the kitchen's sink located in their classrooms for drinking purposes. Naoko stated that meals and snacks are catered to the center from an outside vendor, Chefables.

The following documents were submitted to Licensing: Self-Certification (LIC9275) completed by Certified External Water Sampler, Sampling Checklist Form (LIC9276), and Facility Sketch (LIC999) labeled with locations of water outlets that were tested.

The water sample conducted by California Rural Water Association (CRWA) on 07/29/22 indicated the following:
1) Faucet "G-Sink Faucet Kitchen Near Room 26" has Action Level Exceedance value of 7.3 ppb..

As a result of this inspection, Type B deficiency was cited on the following page.

Exit interview conducted and report was reviewed with Director, Naoko Harada.


A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2022
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 10/20/2022 10:46 AM - It Cannot Be Edited


Created By: Marilou Monico On 10/20/2022 at 10:12 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: DE ANZA COLLEGE CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 430710174

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2022
Section Cited

101700.3(b)(1)

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Lead Testing Written Directives - 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 faucet was covered with plastic with a "Do Not Use" sign.

The facility to submit a new water
sample test result to Licensing that is within the reporting limits by 11/21/22.
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The Lead Sampling Report in one identified faucet has elevated lead above 5.5 ppb. This poses a potential risk to the health, safety, or personal rights of children 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:Joel Segura
LICENSING EVALUATOR NAME:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022


LIC809 (FAS) - (06/04)
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