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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274415302
Report Date: 05/23/2023
Date Signed: 05/23/2023 02:21:23 PM


Document Has Been Signed on 05/23/2023 02:21 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 JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:SEASIDE CHILD DEVELOPMENT CENTERFACILITY NUMBER:
274415302
ADMINISTRATOR:ROBINSON, NITTAYAFACILITY TYPE:
850
ADDRESS:1450 ELM AVENUETELEPHONE:
(831) 392-3456
CITY:SEASIDESTATE: CAZIP CODE:
93955
CAPACITY:244CENSUS: 173DATE:
05/23/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
12:57 PM
MET WITH:Nittaya RobinsonTIME COMPLETED:
02:40 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 Nittaya Robinson, 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. The lead exceedance sample D reading was 5.7. The center provides filtered drinking water for the children, as well as nutrition services.

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.

Type B deficiency cited, exit interview conducted, and a copy of this report was reviewed with the Director NIttaya Robinson. 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: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023
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 05/23/2023 02:21 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 JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: SEASIDE CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 274415302

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2023
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 5.7. 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: 05/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023
LIC809 (FAS) - (06/04)
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