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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210111538
Report Date: 10/19/2023
Date Signed: 10/19/2023 11:04:09 AM


Document Has Been Signed on 10/19/2023 11:04 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 BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:C.A.M (CFS) HAMILTON (SA)FACILITY NUMBER:
210111538
ADMINISTRATOR:LOMBARDI KELSEYFACILITY TYPE:
840
ADDRESS:5520 NAVE DRIVETELEPHONE:
(415) 883-4385
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY:47CENSUS: 0DATE:
10/19/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Site Manager, Alida LeonTIME COMPLETED:
11:15 AM
NARRATIVE
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On 10/19/23, at 10:05AM, Licensing Program Analysts (LPAs) Tse and Garcia conducted an unannounced, case management inspection for the Action Level Exceedance (ALE) of Lead in Child Care Center's water. LPA met with Site Manager, Alida Leon. LPAs explained the purpose of the visit. This Case Management visit for the ALE was carried out in conjunction with Preschool Facility #213001939.

LPAs 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 Manager 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 November 5th, 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 putting signs indicating that the fixture is not for drinking and/or currently out of order. Per Manager, the affected fixture C (10) is a water fountain located outside one of the classrooms.

The facility was not initially cited for the ALE during the case management visit on 2/7/2023 due to the affected fixture being blocked off and made unavailable for use. Due to updated guidance regarding the Written Directives for Lead Testing detailed in PIN 21-21.1-CCP, the facility must be cited for the ALE. However, the facility has removed the affected fixture completely and the citation given today will be cleared on the same day.

See next page for deficiencies cited today.

This report was reviewed and signed by Site Manager, Alida Leon.
A Notice of Site Visit was provided to the Site Manager and must remain posted for 30 days.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan TseTELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
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 10/19/2023 11:04 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: C.A.M (CFS) HAMILTON (SA)
FACILITY NUMBER: 210111538

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/20/2023
Section Cited

101700.3(b)(1)

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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 facility took immediate and proper actions to remediate the fixture by removing it completely from facility grounds. The deficiency cited today will be cleared.
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Based on results received from the certified water samplers, the facility exceeded 5.5 ppb of lead in a water fixture.
This posed a potential health, safety, or personal rights risk to persons in care.
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Type-B deficiency will cleared on the same day.

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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: Ali ZebilaTELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan TseTELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
LIC809 (FAS) - (06/04)
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