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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414000446
Report Date: 12/04/2023
Date Signed: 12/04/2023 02:07:56 PM


Document Has Been Signed on 12/04/2023 02:07 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:PFS- CLUB LEO J. RYAN (SA)FACILITY NUMBER:
414000446
ADMINISTRATOR:ZEYNEP BASAKFACILITY TYPE:
840
ADDRESS:1200 MILLER AVENUETELEPHONE:
(650) 952-6848
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:100CENSUS: 0DATE:
12/04/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Site Manager, Zeynep BasakTIME COMPLETED:
02:10 PM
NARRATIVE
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On 12/4/2023, at approximately 1:05PM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced case management visit regarding an Action Level Exceedance (ALE) with the lead in the Child Care Center's water. LPA was granted entry to the facility by Site Manager, Zeynep Basak. LPA explained the purpose of the visit. Present in the facility are 2 staff and 0 children.

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 Site Manager 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 11/15/2022, and therefore is in compliance with the testing requirement.

The facility received the initial ALE report from the Vendor on 11/23/2022. Test results for two fixtures in this facility exceeded a higher level of parts per billion (ppb) allowed, 5.5 ppb, fixtures L (6.2) and N (8.9). Fixture L is a faucet that was not in use at the time of testing. Fixture N is a fountain located in Room 4. The facility had flushed the fixtures and sampled the water again on 1/31/2023. The facility received the ALE report from the Vendor on 2/6/2023, and fixture N (relabeled as A) tested at 6.6ppb. Fixture L (relabeled as B) tested at 5.2ppb. The facility had retested fixture A again on 3/16/2023 and received results on 3/22/2023. Fixture A tested at 6.7ppb. Per Site Manager, the facility had retested the fixture on 7/6/2023 and received results on 7/14/2023. LPA acquired a copy of the lead testing results and verified that fixture A did not have any lead detected. LPA observed that lab results were not uploaded to the Lead Sampling Database. 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. The deficiency will be cleared once the lab uploads test results to the lead sampling database. LPA advised that lead testing results and LIC forms 9275, 9276 and 999 should be posted.

This report was reviewed and signed by Site Manager, Zeynep Basak.
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 02:07 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: PFS- CLUB LEO J. RYAN (SA)
FACILITY NUMBER: 414000446

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.
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The facility has since added a lead filter to the affected fixture (A) and retested it on 7/6/2023. Fixture A does not have any lead detected and is now in compliance with the Written Directives. The facility shall contact the lab about uploading results onto the lead sampling database and forward correspondence to LPA until results are uploaded.
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Based on record review of the water sampling database, the facility was not in compliance with the above as of the initial water results uploaded on 11/23/2022. This posed a potential health, safety, or personal rights risk to persons in care.
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The deficiency cited today shall be cleared once results are uploaded onto the lead sampling database, by set due date of 1/4/2024.

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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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