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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002201
Report Date: 03/06/2024
Date Signed: 03/06/2024 04:10:26 PM


Document Has Been Signed on 03/06/2024 04:10 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 BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:FACESSF - MASONIC PRESCHOOLFACILITY NUMBER:
384002201
ADMINISTRATOR:KAREN LAMFACILITY TYPE:
850
ADDRESS:1101 MASONIC AVENUETELEPHONE:
(415) 355-0210
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94117
CAPACITY:71CENSUS: 71DATE:
03/06/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Kim WongTIME COMPLETED:
04:20 PM
NARRATIVE
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On 3/6/2024, at approximately 3:45PM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced case management visit regarding an Action Level Exceedance (ALE) due to lead in the Child Care Center's water. LPA was granted entry to the facility by Senior Program Director, Kim Wong. LPA explained the purpose of the visit.

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 Senior Program 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 initially tested its water for lead on 11/23/2022 and was in compliance with the testing requirement.

The facility received the initial ALE report from the Vendor on 12/14/2022. Test results for one fixture in this facility exceeded a higher level of parts per billion (ppb) allowed, 5.5 ppb, fixture C(6.7). Fixture C is a kitchen sink in Classroom 1. The facility provided water from other fixtures that did not have exceedances and sampled the fixtures again on 3/28/2023. The facility received the second lead sampling report from the Vendor on 4/18/2023, with Fixture C testing at 4.6ppb, below the ALE. All other fixtures tested below the threshold and are in compliance with the Written Directives detailed in PIN 21-21.1-CCP.

Per Written Directives 101700.3(b)(2), licensees shall maintain a lead value at or below 5ppb in all outlets subject to testing requirements for the health and safety of children in care. Due to updated guidance on the written directives in PIN 21-21.1-CCP, the facility will be cited for the ALE of fixture C. LPA advised that lead testing results and LIC forms 9275, 9276 and 999 should be posted.
See LIC809-D for deficiency cited and cleared on the same day of the visit, 3/6/2024.
This report was reviewed and signed by Director, Kim Wong.
A Notice of Site Visit was given and must be posted for thirty days.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan TseTELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
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 03/06/2024 04:10 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 BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: FACESSF - MASONIC PRESCHOOL
FACILITY NUMBER: 384002201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/05/2024
Section Cited

101700.3(b)(2)

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(2) Licensees shall maintain a lead value at or below the Action Level of 5 ppb in all outlets subject to the testing requirements of these Written Directives, for the health and safety of children in care.

This requirement was not met as evidenced by:
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The facility had replaced the fixture and retested it on 3/28/2023, with results below 5.4ppb. The citation will be cleared on the same day.
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Based on record review, the facility had one ALE in one fixture (C) which posed a potential risk to the health, safety, or personal rights of 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: Ali ZebilaTELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan TseTELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
LIC809 (FAS) - (06/04)
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