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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001029
Report Date: 11/03/2023
Date Signed: 11/03/2023 04:30:28 PM


Document Has Been Signed on 11/03/2023 04:30 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:SAN CARLOS-BELMONT AFTER SCHOOL-HEATHER SITEFACILITY NUMBER:
414001029
ADMINISTRATOR:DASKALAKIS, EVEFACILITY TYPE:
840
ADDRESS:2757 MELENDYTELEPHONE:
(650) 591-1997
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY:105CENSUS: 62DATE:
11/03/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Director, Kenny MeadeTIME COMPLETED:
04:45 PM
NARRATIVE
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On 11/3/2023, at approximately 3:45PM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced case management visit regarding an Action Level Exceedance (ALE) related to lead water testing. LPA was granted entry to the facility by Director Kenny Meade. LPA explained the purpose of the visit. Present were 8 staff and 62 school-age children. The facility is located on Heather Elementary School grounds.

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 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 their initial ALE report from the Vendor on May 25, 2023. Test results for this facility exceeded a higher level of parts per billion (ppb) allowed, 5.5 ppb. There was one fixture that tested above the threshold, fixture A(75.0ppb). Per Director, the water to the fixture has been turned off and it is currently non-operational.

According to Director, the fixture has not been used for over three years. The facility has notified the San Carlos School District of the need to remove the affected fixture.

See LIC809-D for deficiencies cited today.

This report was reviewed and signed by Site Director, Kenny Meade.

A Notice of Site Visit was provided to the Director and must remain posted for 30 days.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan TseTELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023
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 11/03/2023 04:30 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: SAN CARLOS-BELMONT AFTER SCHOOL-HEATHER SITE
FACILITY NUMBER: 414001029

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/10/2023
Section Cited
HSC
1597.17(a)(1)

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(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.

This requirement is not met as evidenced by:
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The facility has tested for lead on 5/18/2023.
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Based on record review, LPA confirmed that the facility did not test for lead until 5/18/2023.
This posed a potential health, safety, or personal rights risk to persons in care.
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This deficiency will cited and cleared on the same of visit, 11/3/2023.
Type B
12/04/2023
Section Cited
101700.3

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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 Director will contact the school district to obtain a plan of action from the school district regarding the modification of school property (Fixture A).
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Upon record review of the water sampler datebase, LPA confirmed that one water fixture had an exceedance. The water fixture has not been remediated as of 11/3/2023,
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The facility will submit a plan of action and other related correspondence by the due date, 12/4/2023.
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: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023
LIC809 (FAS) - (06/04)
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