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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700009
Report Date: 01/11/2023
Date Signed: 01/11/2023 06:55:27 PM


Document Has Been Signed on 01/11/2023 06:55 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
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108



FACILITY NAME:TSUMIKIFACILITY NUMBER:
376700009
ADMINISTRATOR:MIHO TAKAHASHIFACILITY TYPE:
850
ADDRESS:4811 MOUNT ETNA DRIVETELEPHONE:
(858) 571-7000
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY:40CENSUS: 0DATE:
01/11/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
06:45 PM
MET WITH:Maasa Ishikawa.TIME COMPLETED:
07:15 PM
NARRATIVE
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On 1/11/23 at 6:45 PM, Licensing Program Analyst (LPA) Adrian Mangina conducted an unannounced Case Management inspection, for reported Lead Exceedance. LPA Mangina met with Teacher/Assistant Director Director, Maasa Ishikawa. No daycare children were present. Facility was within ratio & capacity. LPA interviewed staff and examined the faucets deemed an Action Level Exceedance. Facility provided facility sketch and required forms (LIC 9275/9276) to Department on 12/19/22.

Faucets and drinking fountains reported with 5.5 ppb or greater lead exceedance levels were as follows:

Kitchen faucet (c) 12.00 ppb

Facility Representative reported, the faucet in exceedance was covered to prevent use. Facility Representative Stated that prior to lead testing children had been drinking bottled water provided by Sparkletts for at least 12 years. In addition, the kitchen has three sinks and sink faucet in exceedance was in a sink that was used as a utility sink for wringing out towels and was never used for drinking water. All staff have been informed not to use the faucets for drinking water or food preparation. Faucet was replaced 1/7/23 and will be tested after required flushing four times per day for the next three weeks.

See LIC809-D for Type B deficiency cited.

Exit interview conducted and report was reviewed with the facility representative, Maasa Ishikawa. A copy of PIN 21-21-CCP was provided. A notice of site visit was given and must remain posted for 30 days..

SUPERVISOR'S NAME: Renesha AskewTELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Adrian L ManginaTELEPHONE: (619) 629-6197
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2023
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 01/11/2023 06:55 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
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108


FACILITY NAME: TSUMIKI
FACILITY NUMBER: 376700009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/08/2023
Section Cited

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A licensed child day care center...that is located in a building...constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years...
This requirement is not met as evidenced by:
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Facility represenative reported, the faucet in exceedance was replaced on 1/7/23 and it is being flushed 4 times a day for per protocol and will be tested again in 3 weeks. In the meantime, Children continue to drink bottled water and sink is blocked from use.
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Based on water testing results and interviews, facility tested over the Action Level Exceedance level at 1 kitchen faucet. This poses a potential health, safety or personal rights risk to 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: Renesha AskewTELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Adrian L ManginaTELEPHONE: (619) 629-6197
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2023
LIC809 (FAS) - (06/04)
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