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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 213001036
Report Date: 10/02/2023
Date Signed: 10/02/2023 01:21:49 PM


Document Has Been Signed on 10/02/2023 01:21 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:CITY OF SAN RAFAEL - PICKLEWEED P/SFACILITY NUMBER:
213001036
ADMINISTRATOR:VELARDE, MARIAFACILITY TYPE:
850
ADDRESS:40 CANAL STREETTELEPHONE:
(415) 485-3101
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY:44CENSUS: 32DATE:
10/02/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
12:39 PM
MET WITH:Maria VelardeTIME COMPLETED:
01:45 PM
NARRATIVE
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On 10/2/23 at approximately 12:30 PM, Licensing Program Analysts (LPAs) Nathan Garcia and Jonathan Tse conducted an unannounced, case management inspection for the Action Level Exceedance (ALE) of Lead in Child Care Center's water. LPAs met with the director, Maria Velarde. LPA explained the purpose of the visits and was given a tour of the facility.
Present in facility are 32 children, present with 7 staff members.

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 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 10/18/2022. 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 water fountain/kitchen fixture is not for drinking and or currently out of order. Per director, the affected fixture B (16) has been replaced on 3/9/2023 and the facility is waiting for the water samplers to update the portal to schedule a retest appointment. On July 14, 2023, the director asked for a status update on their test but the director was advised to check the portal. LPAs observed that fixture B is located in the Bumblebee classroom. The facility is using other sources of water, sink that passed the tests, for food preparation and water ingestion to refill the Brita pitchers.

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

* See next page for deficiencies cited today

This report was reviewed and signed by Director, Maria Velarde.

This report and notice of Site visit and appeal rights were provided to the licensee and must remain posted for 30 days.

SUPERVISOR'S NAME: Daniel J OquendoTELEPHONE: (650) 379-9023
LICENSING EVALUATOR NAME: Nathan GarciaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2023
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 10/02/2023 01:21 PM - 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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: CITY OF SAN RAFAEL - PICKLEWEED P/S
FACILITY NUMBER: 213001036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/02/2023
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 facility replaced the affected fixture on 3/9/23. The facility is waiting for the retest schedule from the certified water samplers. Once the new results are available, the facility will forward them to LPA for review.
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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. Once received, the facility took immediate and proper actions to remediate the fixtures.
This poses a potential health, safety, or personal rights risk to persons in care.
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The director will update the LPA for the retest schedule and results will be forwarded once available.

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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 OquendoTELEPHONE: (650) 379-9023
LICENSING EVALUATOR NAME: Nathan GarciaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2