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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 354413128
Report Date: 09/20/2023
Date Signed: 09/20/2023 11:54:55 AM


Document Has Been Signed on 09/20/2023 11:54 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:ASJUSD/SAN JUAN MI ESCUELITA PRESCHOOLFACILITY NUMBER:
354413128
ADMINISTRATOR:FABIOLA VALADEZFACILITY TYPE:
850
ADDRESS:100 NYLAND DRIVETELEPHONE:
(831) 623-4538
CITY:SAN JUAN BAUTISTASTATE: CAZIP CODE:
95045
CAPACITY:24CENSUS: 15DATE:
09/20/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Margarita Carrillo-GaitanTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Deanna Villagrana conducted an unannounced case management inspection to discuss the lead water testing and Action Level Exceedance (ALE) for water faucets within the Facility. LPA met with Margarita Carrillo-Gaitan, director, and explained purpose of today's inspection to her.

The lead testing was completed by CRWA, on May 2, 2023. An Action Exceedance Level is a value of 5.5 parts per billion or greater. Water faucet for sink A located in school kitchen reported an ALE of 8.8 parts per billion.

Margarita states that sink is not used for preparation of food. LPA advised Margarita that faucet either needed to be replaced or capped off. If water faucet is replaced, then it must be retested.


Exit interview conducted and report was reviewed with the Director, Margarita Carrillo-Gaitan. The following Type B deficiency is cited on the attached page (LIC 809-D). Copy of appeal rights was provided to Margarita prior to the conclusion of today's inspection.

Notice of site visit was issued and must remain posted for 30 days.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/20/2023 11:54 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: ASJUSD/SAN JUAN MI ESCUELITA PRESCHOOL
FACILITY NUMBER: 354413128

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2023
Section Cited

101700.3(b)(1)

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Lead Testing Written Directives (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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Margarita Carrillo-Gaitan stated she will contact the district to either have the faucet in sink A capped off or replaced and understands if it is replaced, it must re-tested.
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Water faucet for sink A located in school kitchen, reported an ALE of 8.8 parts per billion. This poses a potential risk to the health, safety, and personal rights of children in care.
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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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023
LIC809 (FAS) - (06/04)
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