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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270710410
Report Date: 07/06/2023
Date Signed: 07/06/2023 11:10:19 AM


Document Has Been Signed on 07/06/2023 11:10 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:NO. MONTEREY CO. UNIFIED SCH. DIST. PRESCHOOLFACILITY NUMBER:
270710410
ADMINISTRATOR:MARGARITA PALACIOSFACILITY TYPE:
850
ADDRESS:17719 PESANTE ROADTELEPHONE:
(831) 663-6129
CITY:PRUNEDALESTATE: CAZIP CODE:
93907
CAPACITY:44CENSUS: 8DATE:
07/06/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Kristina TorresTIME COMPLETED:
11:15 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 Coordinator of Early Learning Programs Kristina Torres, and explained the nature of today's inspection to her.

During today's inspection LPA Macias requested 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. Sample D exceedance level is 9.6, E is 6.8, F is 5.8, and G is 15.8. The center provides filtered drinking water for the children, as well as nutrition services.

The Director will identify the four locations of the lead exceedance and ensure children are unable to access the water source. The water source will be labeled and or shut off.

The Child Care Center's plan of correction shall include notification to all parents or guardians, that includes what steps the licensee has taken and any additional steps that will be taken to correct the deficiency, including steps to either permanently cease use of the outlets for drinking and food preparation or remediate by replacing the outlets, and the time frame for completion.

Type B deficiency cited, exit interview conducted, and a copy of this report was reviewed with the Coordinator of Early Learning Programs Kristina Torres. 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: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023
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 07/06/2023 11:10 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: NO. MONTEREY CO. UNIFIED SCH. DIST. PRESCHOOL
FACILITY NUMBER: 270710410

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/21/2023
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 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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Sample D exceedance level is 9.6, E is 6.8, F is 5.8, and G is 15.8. This poses a potential risk to the Health, Safety, or Personal Rights of children in care.
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The Director will identify the location of the lead exceedance and ensure children are unable to access the water source. The water source will be labeled and or shut off. The Director will submit a letter outlining the drinking water procedure by the POC date.

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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: 07/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2