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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410509769
Report Date: 12/04/2023
Date Signed: 12/04/2023 11:47:27 AM


Document Has Been Signed on 12/04/2023 11:47 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:CSSF REC DEPT-SIEBECKER CENTERFACILITY NUMBER:
410509769
ADMINISTRATOR:ALENI CAPAZFACILITY TYPE:
850
ADDRESS:510 ELM COURTTELEPHONE:
(650) 875-6979
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:55CENSUS: 36DATE:
12/04/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Supervisor, Diana GonzalezTIME COMPLETED:
12:00 PM
NARRATIVE
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On 12/4/2023, at approximately 11:15AM, 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 Supervisor, Diana Gonzalez. LPA explained the purpose of the visit. Present during the visit were six staff and 36 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 received the initial ALE report from the Vendor on 11/10/2022. Test results for one fixture in this facility exceeded a higher level of parts per billion (ppb) allowed, 5.5 ppb, fixture B(6.2). Fixture B was a water fountain located in the children's restroom. Per Supervisor, the fountain had not been used since 2019. The facility had children bring water bottles from home and provided water from other fixtures that did not have exceedances. LPA observed that the fixture has been removed. 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 B. 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 Supervisor, Diana Gonzalez.
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: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2023
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 12/04/2023 11:47 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: CSSF REC DEPT-SIEBECKER CENTER
FACILITY NUMBER: 410509769

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/04/2024
Section Cited

101700.3(b)(2)

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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 has since removed the fixture. LPA observed during the visit that the fixture has been removed.
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Based upon record review, the facility had one fixture (B) that tested above the Action Level of 5ppb. This posed a potential health, safety, or personal rights risk to persons in care.
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This deficiency shall be cleared the same day of the visit, 12/4/2023.

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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: Ali ZebilaTELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan TseTELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2023
LIC809 (FAS) - (06/04)
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