<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410509197
Report Date: 11/27/2023
Date Signed: 11/27/2023 03:14:58 PM

Document Has Been Signed on 11/27/2023 03:14 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:PENINSULA TEMPLE SHOLOM PRESCHOOLFACILITY NUMBER:
410509197
ADMINISTRATOR:STECKLEY, ALLISONFACILITY TYPE:
850
ADDRESS:1655 SEBASTIAN DRIVETELEPHONE:
(650) 697-2279
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 164TOTAL ENROLLED CHILDREN: 164CENSUS: 74DATE:
11/27/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Assistant Director, Leslie WeinsteinTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/27/2023, at approximately 2:45PM, 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 Assistant Director, Leslie Weinstein. LPA explained the purpose of the visit. Present during the visit were 18 staff and 74 children. The facility is in compliance with staff-child ratios.

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 Assistant 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 1/7/2023 and was not in compliance with the testing requirement.

The facility received the initial ALE report from the Vendor on 1/7/2023. Test results for one fixture in this facility exceeded a higher level of parts per billion (ppb) allowed, 5.5 ppb, fixture R(6.2). The fixture is a sink located in a classroom. Per Assistant Director, the facility provided an alternative water source via a bubbler that did not have an exceedance and sampled the fixture again on 3/31/2023. The facility received the ALE report from the Vendor on 4/18/2023, with Fixture R testing below 1.0ppb. The fixture is below the threshold for an 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 fixtures E and H. The deficiency will be cleared the same day of the visit because the fixture has retested below the threshold. LPA advised that lead testing results and LIC forms 9275, 9276 and 999 should be posted.
See LIC809-D for deficiency cited and cleared today.
This report was reviewed and signed by Assistant Director, Leslie Weinstein.
A Notice of Site Visit was given and must be posted for thirty days.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE: DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/27/2023
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 11/27/2023 03:14 PM - It Cannot Be Edited


Created By: Jonathan Tse On 11/27/2023 at 03:07 PM
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: PENINSULA TEMPLE SHOLOM PRESCHOOL
FACILITY NUMBER: 410509197

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/27/2023
Section Cited

101700.3(b)(2)

1
2
3
4
5
6
7
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:
1
2
3
4
5
6
7
The facility took steps to remediate the fixtures by providing an alternative water source that did not have an exceedance and retesting the fixture on 3/31/2023. The fixtures then tested below the ALE level and are now in compliance.
8
9
10
11
12
13
14
Based upon record review, the facility had one fixture (R) that tested above the Action Level of 5ppb. This posed a potential health, safety, or personal rights risk to persons in care.
8
9
10
11
12
13
14
This deficiency will be cited and cleared the same day of the visit, 11/7/2023.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 Zebila
LICENSING EVALUATOR NAME:Jonathan Tse
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2