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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380503900
Report Date: 02/15/2023
Date Signed: 02/15/2023 02:41:42 PM


Document Has Been Signed on 02/15/2023 02:41 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
PENINSULA CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:YMCA OF SF., MISSION BRANCH, MISSION PRESCHOOLFACILITY NUMBER:
380503900
ADMINISTRATOR:ALVAREZ, KATIAFACILITY TYPE:
850
ADDRESS:4080 MISSION STREETTELEPHONE:
(415) 586-6900
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY:42CENSUS: 33DATE:
02/15/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Kari Lee TIME COMPLETED:
03:00 PM
NARRATIVE
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On 2/15/23 at approximately 1:40PM, Licensing Program Analyst (LPA) Nathan Garcia conducted an unannounced, case management inspection for the Action Level Exceedance (ALE) of Lead in Child Care Center's water. LPA met with the Executive Director, Kari Lee. The purpose of the inspection was explained.

Present in facility are 33 children, present with 6 staff members during nap time.

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 12/29/2022. Test results for this facility that exceeded a higher level of parts per billion (ppb) allowed, 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 and or currently out of order. Per director, the facility had a retest on 1/16/23 to have a secondary retest due to incorrect testing procedures. LPA reviewed the second retest and the results are: fixture E(13), F(3.7) and G(2.4). Fixture E still has an exceedance and the plumbers have replaced the affected fixtures on the weekend of 2/4/23. The facility director contacted the certified water samplers to schedule for a third retest. LPA advised director to keep the department updated on the status of the fixtures. The facility has asked the children to bring their own water from home and the bottles are replenished by using water from unaffected or filtered fixtures, as needed. The facility also uses Alhambra water services for water ingestion and food preparation.

LPA obtained the copies of the External Water Sampler Self-Certification Form (LIC9275), Child Care Center Sampling Checklist (LIC9276), Facility Sketch (LIC999), in an email to the LPA. LPA obtained hard copy of the lead water testing results as well.

* See next page for 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.
SUPERVISOR'S NAME: Daniel J OquendoTELEPHONE: (650) 379-9023
LICENSING EVALUATOR NAME: Nathan GarciaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2023
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 02/15/2023 02:41 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
PENINSULA CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: YMCA OF SF., MISSION BRANCH, MISSION PRESCHOOL
FACILITY NUMBER: 380503900

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2023
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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The facility has included signs and replaced the fixtures affected and will be flushing the water fixture until they are retested with a certified water sampler by 03/31/2023.

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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 took immediate and proper actions to remediate the fixtures.
This poses a potential health, safety, or personal rights risk to persons in care.
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Director will provide the new test results to LPA no later than 03/31/2023.

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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: Daniel J OquendoTELEPHONE: (650) 379-9023
LICENSING EVALUATOR NAME: Nathan GarciaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2023
LIC809 (FAS) - (06/04)
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