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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002878
Report Date: 11/15/2023
Date Signed: 11/15/2023 04:33:58 PM


Document Has Been Signed on 11/15/2023 04:33 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-BAYSHORE MIDWAY CDC (INF)FACILITY NUMBER:
414002878
ADMINISTRATOR:PAUL BIGGSFACILITY TYPE:
830
ADDRESS:45 MIDWAY DRIVETELEPHONE:
(415) 330-1717
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY:24CENSUS: 1DATE:
11/15/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Site Manager, Paul BiggsTIME COMPLETED:
04:35 PM
NARRATIVE
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On 11/15/2023, at approximately 3:55PM, 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 Site Manager, Paul Biggs. LPA explained the purpose of the visit. Present during the visit were 1 staff and 1 infant. 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 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 initially tested its water for lead on 11/9/2022 and was in compliance with the testing requirement.

The facility received the initial ALE report from the Vendor on 11/17/2022. Test results for one fixture in this facility exceeded a higher level of parts per billion (ppb) allowed, 5.5 ppb, fixture E(6.2). The fixture is a faucet in the infant classroom. Per Director, the facility stopped using the faucet and the adjacent water fixture. The facility provided water from fixtures that did not have any ALEs. The facility retested on 1/31/2023 and received the second ALE report from the Vendor on 2/6/2023, with fixture E being re-labeled as fixture A. Fixture A is now at 3.4ppb, under 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. The Written Directives are included in HSC 1597.16, and are specific guidelines for facilities to adhere to regarding lead water testing. Due to updated guidance on the written directives in PIN 21-21.1-CCP, the facility will be cited for the ALE of fixture E. The deficiency will be cleared the same day of the visit because the fixtures have retested below the threshold. 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, Paul Biggs.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan TseTELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
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 11/15/2023 04:33 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-BAYSHORE MIDWAY CDC (INF)
FACILITY NUMBER: 414002878

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2023
Section Cited
HSC
1597.16

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WD101700.3(b)(2) 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 was proactive in remediating the fixture and had replaced it for retesting on 11/28/2022. The remediated fixture then tested below the ALE, at 3.4ppb.
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Upon record review of the water sampling database, LPA confirmed that there was an exceedance for Fixture E(6.2ppb). This is over the acceptable threshold for lead, 5.4ppb. This posed a potential health, safety, or personal rights risk to persons in care.
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This deficiency will be cited and cleared the same day of visit, 11/15/2023.

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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: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2