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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004132
Report Date: 11/07/2023
Date Signed: 11/07/2023 11:22:53 AM


Document Has Been Signed on 11/07/2023 11:22 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:ALL FIVE @ BELLE HAVEN (PS)FACILITY NUMBER:
414004132
ADMINISTRATOR:CAROL THOMSENFACILITY TYPE:
850
ADDRESS:415 IVY DRIVETELEPHONE:
(650) 387-8268
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY:60CENSUS: 37DATE:
11/07/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Director, Carol ThomsenTIME COMPLETED:
11:40 AM
NARRATIVE
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On 11/7/2023, at approximately 10:50AM, 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 Director, Carol Thomsen. LPA explained the purpose of the visit. Present in the facility are 7 staff and 37 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 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 9/10/2022, before the deadline.

The facility received the ALE report from the Vendor on 9/23/2022. Test results for one fixture in this facility exceeded a higher level of parts per billion (ppb) allowed, 5.5 ppb, fixture E (12.0). Fixture E is a sink in the staff kitchen, and is primarily for staff use. Per Director, the fixture was tested in the case that it may have to be used for children's dishes. As the sink was relatively new, the facility flushed the sink for a longer period of time prior to the second sampling of the fixture on 12/22/2022. The facility received the ALE report from the Vendor on 2/3/2023, and fixture E tested at 4.8ppb, below the the level allowed. All other fixtures tested below the threshold are in compliance with the Written Directives detailed in PIN 21-21.1-CCP.

Due to updated guidance on the written directives in the PIN 21-21.1-CCP, the facility will be cited for the action level exceedance of fixture E. However, because the facility had retested the fixture and results show that it is now currently below the threshold of 5.5ppb, the citation will be cleared the same day of the visit. LPA advised that lead testing results should be posted.

See LIC809-D for deficiency cited today.
This report was reviewed and signed by Director, Carol Thomsen.
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: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023
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 11/07/2023 11:22 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: ALL FIVE @ BELLE HAVEN (PS)
FACILITY NUMBER: 414004132

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/07/2023
Section Cited

101700.3(b)(2)

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(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 had taken steps to properly flush the fixture before the retest on 12/2/2022 and the fixture tested at 4.8ppb, below the Action Level of 5ppb.
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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 9/23/2022. 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 the visit.

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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: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023
LIC809 (FAS) - (06/04)
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