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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710433
Report Date: 10/17/2022
Date Signed: 10/17/2022 11:33:04 AM

Document Has Been Signed on 10/17/2022 11:33 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:BOWERS STATE/DISTRICT PRESCHOOLFACILITY NUMBER:
430710433
ADMINISTRATOR:ROSIE FLORESFACILITY TYPE:
850
ADDRESS:2755 BARKLEY AVENUETELEPHONE:
(408) 423-1117
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY: 87TOTAL ENROLLED CHILDREN: 35CENSUS: 29DATE:
10/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Frances O'Brien & Pushpa WewegamaTIME COMPLETED:
11:45 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
Licensing Program Analysts (LPAs), Marilou Monico and Elizabeth Berumen, conducted an unannounced Case Management inspection. LPAs met with teachers, Frances O'Brien and Pushpa Wewegama, and explained the purpose of the inspection. LPAs reviewed water sample summary and requested Frances to identify faucets F, G, & H with reported Lead Action Level Exceedance of 5.5 parts per billion (ppb) or greater. LPAs observed that faucets F and G are located in Room 26 and faucet H is in Room 27. LPAs observed that the faucets are covered with plastic. Pushpa states that the facility has not used faucets F, G, and H since August 31, 2022.

LPA obtained the following facility documents during today's inspection: 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 08/13/22 indicated the following:
1) Faucet "F-Drinking Fountain Room 26" has Lead Action Level Exceedance value of 24 ppb.
2) Faucet "G-Sink Faucet Room 26 Kitchen" has Lead Action Level Exceedance value of 6.6 ppb.
3) Faucet "H-Drinking Fountain Room 27 Kitchen" has Lead Action Level Exceedance of 32 ppb.

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

Exit interview conducted and report was reviewed with teacher, Frances O'Brien.


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: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2022
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 10/17/2022 11:33 AM - It Cannot Be Edited


Created By: Marilou Monico On 10/17/2022 at 09:47 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: BOWERS STATE/DISTRICT PRESCHOOL
FACILITY NUMBER: 430710433

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2022
Section Cited

101700.3(b)(1)

1
2
3
4
5
6
7
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:
1
2
3
4
5
6
7
The faucets are covered with plastic and currently not being used. The children are using bottled water to refill their individual water container.

The facility to submit a new water
sample test results to Licensing that is within the reporting limits by 11/17/22.
8
9
10
11
12
13
14
Based on record review, the Lead Sampling Report in three (3) identified faucets: F, G, & H had elevated lead above 5.5 ppb. This poses a potential risk to the health, safety, or personal rights of children 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:Joel Segura
LICENSING EVALUATOR NAME:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2