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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002350
Report Date: 10/20/2022
Date Signed: 10/20/2022 10:39:11 AM


Document Has Been Signed on 10/20/2022 10:39 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:UCSF KIRKHAM CDC (PS)FACILITY NUMBER:
384002350
ADMINISTRATOR:NANCY TRINH COSTANTIELLOFACILITY TYPE:
850
ADDRESS:10 KIRKHAM STREETTELEPHONE:
(415) 664-1217
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94143
CAPACITY:93CENSUS: 43DATE:
10/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Natasha Lau & Kulsimranjit KaurTIME COMPLETED:
10:35 AM
NARRATIVE
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On October 20, 2022 at approximately 8:35am, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, case management inspection to UCSF Kirkham for the Action Level Exceedance (ALE) of Lead in child Care Center's water. LPA's visit also included closure of a complaint investigation. LPA met with instructional coach, Kulsimranjit Kaur, and interim health and safety director, Natasha Lau, and explained the purpose of the visit.

Present at facility are 12 staff members (including instructional coach and interim health and safety director) and 43 enrolled children. Facility is licensed to operate out of 6 classrooms. Program is currently operating out of 4 of the 6 classrooms: Stingray, Otter, Sea Turtle and Starfish. Classrooms not currently in use: Seahorse and Jellyfish.

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 instructional coach and interim health and safety 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 07/27/2022. 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 and sinks tested. Facility has shut down faucets and sinks with exceeded levels of lead, by placing signs and coverings, that indicate fixtures are currently out of order. The facility took action to contact the facility's management to repair and replace the fixtures, and have installed water filters. Facility also continues to flush and run water fixtures 4 times a day, daily. Per regional manager, retesting with certified water sampler will be conducted in November.

LPA obtained the copies of the External Water Sampler Self-Certification Form (LIC9275), Child Care Center Sampling Checklist (LIC9276), Facility Sketch (LIC999), and a copy of an email of the checklist for running the water after the repair.

* See next page for deficiency cited today

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with instructional coach, Kulsimranjit Kaur, and interim health and safety director, Natasha Lau.
SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina QuimboTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022
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 10/20/2022 10:39 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: UCSF KIRKHAM CDC (PS)
FACILITY NUMBER: 384002350

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2022
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 observation, interview and record review, the facility did not ensure to maintain a level to be under 5.5 ppb at fixtures used for drinking and food prepration. 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: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina QuimboTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022
LIC809 (FAS) - (06/04)
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