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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380500086
Report Date: 10/12/2023
Date Signed: 10/12/2023 10:58:24 AM

Document Has Been Signed on 10/12/2023 10:58 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 BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:JCCSF BROTHERHOOD WAY PRESCHOOLFACILITY NUMBER:
380500086
ADMINISTRATOR:EDNA VAKNINFACILITY TYPE:
850
ADDRESS:655 BROTHERHOOD WAYTELEPHONE:
(415) 333-4289
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94132
CAPACITY: 116TOTAL ENROLLED CHILDREN: 116CENSUS: 75DATE:
10/12/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Theresa ArroyoTIME COMPLETED:
11:00 AM
NARRATIVE
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On 10/12/23, Licensing Program Analyst (LPA) Van conducted an unannounced case management inspection for the Action Level Exceedance (ALE) of Lead in the Child Care Center's water. LPAs met with ECE Business manager Theresa Arroyo. Present in the facility are 75 children, present with 18 staff members.

LPA discussed the new Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018 requires the Lead Testing of water in the Child Care Center with the site director during the inspection. All Child Care Centers that are located in buildings constructed before January 1, 2010, must have their water tested and post the results by January 1, 2023, and every 5 years after the date of the first testing.

The facility received the ALE report from the Vendor on 04/11/2023 and a subsequent report on 09/21/23.
Test results for this facility exceeded the higher level of parts per billion (ppb) allowed at 5.5 ppb. The facility was proactive in getting facility faucets tested and putting signs indicating that the water fountain/kitchen fixture is not for drinking or is currently out of order. Per Business manager, the affected fixture C, E, and e-30 are not being used for any kind of water ingestion or food preparation. The facility uses other sources of water that passed the lead water testing for food preparation and water ingestion. The facility has asked the children to bring their own water bottles from home. The bottles are replenished by using water from water services and a dispenser available for water ingestion and food preparation.

LPA obtained copies of the External Water Sampler Self-Certification Form (LIC9275), Child Care Center Sampling Checklist (LIC9276), Facility Sketch (LIC999), and copy of the lead water testing results during the visit.

See LIC 809D on the next page for the deficiency cited today.

This report and notice of Site visit and appeal rights were provided to the licensee and must remain posted for 30 days.
Garfield Leung
Brendon Van
DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2023
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 10/12/2023 10:58 AM - It Cannot Be Edited


Created By: Brendon Van On 10/12/2023 at 10:46 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: JCCSF BROTHERHOOD WAY PRESCHOOL
FACILITY NUMBER: 380500086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/13/2023
Section Cited

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101700.3 California Lead Action Level at Child Care Centers (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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Based on results received from the certified water samplers, the facility exceeded 5.5 ppb of lead in their water source. Once received, the facility immediately took proper actions to remediate the fixtures. This poses a potential health, safety, or personal rights risk to persons 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:Garfield Leung
LICENSING EVALUATOR NAME:Brendon Van
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023


LIC809 (FAS) - (06/04)
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