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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274410749
Report Date: 03/02/2023
Date Signed: 03/02/2023 12:51:04 PM


Document Has Been Signed on 03/02/2023 12:51 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 JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:SHORELINE PRE-SCHOOLFACILITY NUMBER:
274410749
ADMINISTRATOR:KRISTA CHAWINGAFACILITY TYPE:
850
ADDRESS:2500 GARDEN ROADTELEPHONE:
(831) 641-0209
CITY:MONTEREYSTATE: CAZIP CODE:
93940
CAPACITY:36CENSUS: 21DATE:
03/02/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Krista ChawingaTIME COMPLETED:
01:00 PM
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 Krista Chawinga, 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 sun room classroom (#1122) sinks outside of the restroom. The sinks are not used for drinking water, but solely as a hand washing station. The classroom affected will refrain from using the sinks. The sinks shall be marked and the water source shut off. The center provides filtered drinking water for the children.

The Director shutoff/ closed the water source of both affected sinks during today's inspection.


Type B deficiency cited, exit interview conducted, and a copy of this report was reviewed with the Director Krista Chawinga. 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: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2023
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 03/02/2023 12:51 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 JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: SHORELINE PRE-SCHOOL
FACILITY NUMBER: 274410749

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/03/2023
Section Cited

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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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This exceedance level found in the
main entrance drinking fountain was 39. This poses a potential risk to the Health, Safety, or Personal Rights of children in care.
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The water fountains were disconnected from the water source and no longer used. The center provides filtered drinking water for the children. The Director shall submit a plan on how the facility will move forward 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: 03/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2023
LIC809 (FAS) - (06/04)
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