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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410503906
Report Date: 11/02/2023
Date Signed: 11/02/2023 11:15:55 AM


Document Has Been Signed on 11/02/2023 11:15 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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:CHILDRENS PLACE, THEFACILITY NUMBER:
410503906
ADMINISTRATOR:BAKSA, KATALINFACILITY TYPE:
850
ADDRESS:1336 ARROYO AVENUETELEPHONE:
(650) 595-1910
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY:36CENSUS: 29DATE:
11/02/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Katalin BaksaTIME COMPLETED:
11:30 AM
NARRATIVE
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On 11/02/23, at 9:00AM, Licensing Program Analyst (LPA) Maria Olguin-Leon conducted an unannounced, case management inspection for the Action Level Exceedance (ALE) of Lead in Child Care Center's water. LPA met with Assistant Director, Heather Baumrucker, Director Katalin Baksa arrived at approx. 9:20AM. LPA explained the purpose of the visit and conducted a tour of facility and kitchen where lead exceedance faucet was located. Present today were 29 children and 5 staff.

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 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 and Regional Office received the ALE report from the Vendor with contradicting results. It was determined test results for this facility 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 fixture is not for drinking or for food preparation. The fixture affected is D (15) and is located in the church kitchen.

The facility was not initially cited for the ALE during annual visit on 09/19/2023 due to clarification on conflicting information in the executive summary page and actual results from the fixture of water exceedance. Due to updated guidance regarding the Written Directives for Lead Testing detailed in PIN 21-21.1-CCP, the facility must be cited for the ALE. However, the facility has replaced both faucets and replaced pipes under sink with copper pipes soldered with lead free joints. Copper pipes were replaced as far as plumber was able to reach. The affected fixture will be retested within the next two week. Citation was given today and POC was developed.

See next page for deficiencies cited today.

This report was reviewed and signed by Director, Katalin Baksa.

This notice of Site visit was provided to the Director and must remain posted for 30 days.
SUPERVISOR'S NAME: Marie RodriguezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Maria Olguin-LeonTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023
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 11/02/2023 11:15 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: CHILDRENS PLACE, THE
FACILITY NUMBER: 410503906

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/04/2023
Section Cited

100700.3

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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 had the affected fixtures replaced and piping underneath sink was removed and replaced with new copper piping on 10/23/23. Fixtures will be retested in a couple of weeks and test results submitted to Regional Office.
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Based on results received from the certified water samplers, the facility exceeded 5.4 ppb of lead in their water source. 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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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: Marie RodriguezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Maria Olguin-LeonTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023
LIC809 (FAS) - (06/04)
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