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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270709281
Report Date: 06/13/2023
Date Signed: 06/13/2023 10:10:02 AM


Document Has Been Signed on 06/13/2023 10:10 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:ST. ANGELA'S PRESCHOOLFACILITY NUMBER:
270709281
ADMINISTRATOR:HEATHER DIAZFACILITY TYPE:
850
ADDRESS:136 8TH STREETTELEPHONE:
(831) 372-3555
CITY:PACIFIC GROVESTATE: CAZIP CODE:
93950
CAPACITY:88CENSUS: 31DATE:
06/13/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Heather DiazTIME COMPLETED:
10:10 AM
NARRATIVE
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Licensing Program Analyst (LPA), Joe Macias, conducted an unannounced case management inspection in response to a lead testing completed with an exceedance level. LPA met with the Director Heather Diaz, and explained the nature of today's inspection to her.

During today's inspection LPA Macias requested and obtained the following documents; Self-Certification LIC9275, Sampling Checklist Form LIC9276, Facility Sketch LIC 999, fully labeled with locations of all water outlets, and full lead report. The lead exceedance readings were found in the Seahorse classroom in the kitchen sink faucet, as well as the tide pool multipurpose room sink faucet. Both water sources are not utilized by the children. The center provides filtered drinking water for the children, as well as nutrition services.

During today's inspection LPA Macias observed that the affected sinks are not in use, and are labeled. The posting reads lead exceedance found, this faucet is not to be used for consumption. The Director shared that the faucets will be replaced and retested to ensure the safety of the water source.

Type B deficiency cited, exit interview conducted, and a copy of this report was reviewed with the Director Heather Diaz. 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.

SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Joseph MaciasTELEPHONE: (408) 334-8320
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2023
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 06/13/2023 10:10 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 JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: ST. ANGELA'S PRESCHOOL
FACILITY NUMBER: 270709281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2023
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 today's inspection LPA Macias requested and obtained the following documents; Self-Certification LIC9275, Sampling Checklist Form LIC9276, Facility Sketch LIC 999, fully labeled with locations of all water outlets, and full lead report.
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The lead exceedance readings were found in the Seahorse classroom (D-12)in the kitchen sink faucet, as well as the tide pool multipurpose room (B-6.8) sink faucet. This poses a potential risk to the health, safety, and personal rights of the children in care.
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During today's inspection LPA Macias observed that the affected sinks are not in use, and are labeled. The posting reads lead exceedance found, this faucet is not to be used for consumption. The Director shared that the faucets will be replaced and retested to ensure the safety of the water source.

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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: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Joseph MaciasTELEPHONE: (408) 334-8320
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2