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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417307
Report Date: 07/12/2023
Date Signed: 07/12/2023 09:59:53 AM

Document Has Been Signed on 07/12/2023 09:59 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:NEIGHBORHOOD CHRISTIAN PRESCHOOLFACILITY NUMBER:
434417307
ADMINISTRATOR:JULIE KENNEDYFACILITY TYPE:
850
ADDRESS:2315 CANOAS GARDEN AVENUETELEPHONE:
(408) 639-6376
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 96TOTAL ENROLLED CHILDREN: 61CENSUS: 37DATE:
07/12/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Julie KennedyTIME COMPLETED:
10:15 AM
NARRATIVE
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Licensing Program Analyst (LPA), Kassandra Medrano, conducted an unannounced case management inspection in response to a completed lead testing on 6/9/2023 which resulted in four action level exceedances within the facility of 12 ppb, 9.4 ppb ,8.2 ppb,and 7.9 ppb. LPA met with the Director, Julie Kennedy, and Rebecca Daugherty, Operations, and explained the nature of today's inspection. Facility stated they were not aware that they had an exceedance. LPA explained that an exceedance is classified as 5.5.ppb or greater.

Prior to today’s inspection, Community Care Licensing received notification of the lead exceedances by the water program. Facility is using main faucets that received clearances for their only source of drinking water. Prior to the testing all faucets were replaced, and the facility is in the process of replacing all the piping through out the facility no matter the lead exceedance.
The water sample conducted by California Rural Water Association (CRWA) on 6/9/2023, indicated the following:
1) Sink "I" located in room 113, has Lead Action Level Exceedance value of 12 ppb.
2) Sink"C" located within room 117, has Lead Action Level Exceedance of 9.4 ppb.
3) Sink "E" located in room 115, has Lead Action Level Exceedance of 8.2 ppb.
4) Sink "F", located in room 114 has Lead Action Level Exceedance of 7.9 ppb.
Prior to inspection LPA obtained the following documents:
1.Self-Certification (LIC9275)
2.Sampling Checklist Form (LIC9276)
3.Facility Sketch LIC 999 (fully labeled with locations of all water outlets)
4. Full lead report from water program

Type B deficiency was cited, exit interview conducted, and a copy of this report was given and reviewed with the Director, Julie Kennedy. Appeal rights were reviewed and provided.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE CENTER, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2023
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 07/12/2023 09:59 AM - It Cannot Be Edited


Created By: Kassandra Medrano On 07/12/2023 at 09:42 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: NEIGHBORHOOD CHRISTIAN PRESCHOOL
FACILITY NUMBER: 434417307

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/14/2023
Section Cited

101700.3(b)(1)

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Lead Testing Written Directives section 101700.3 (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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During inspection LPA observed new piping being placed into all the classrooms as well as the classrooms that had lead exceedances had jugs of filtered water. LPA and director agreed to scheduling the resampling of faucets as well as sending over new results once completed.
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The exceedance levels found in “I” sink was 12 ppb and in bubbler "C" sink was 9.4 ppb. Bubbler "E" was found with 8.2 ppb and Bubbler "F" was found with 7.9 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:Diana Stephenson
LICENSING EVALUATOR NAME:Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023


LIC809 (FAS) - (06/04)
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