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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430700603
Report Date: 10/03/2023
Date Signed: 10/03/2023 03:31:36 PM


Document Has Been Signed on 10/03/2023 03:31 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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:ST TIMOTHY'S PRESCHOOLFACILITY NUMBER:
430700603
ADMINISTRATOR:STACEY SULLIVANFACILITY TYPE:
850
ADDRESS:2094 GRANT ROADTELEPHONE:
(650) 967-4724
CITY:MOUNTAIN VIEWSTATE: CAZIP CODE:
94040
CAPACITY:22CENSUS: 10DATE:
10/03/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Stacey SullivanTIME COMPLETED:
03:50 PM
NARRATIVE
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On 10/03/2023 Licensing Program Analyst (LPA) Melanie Otsuji conducted a Case Management - Lead Testing/Exceedance Inspection. LPA met with the Director, Stacey Sullivan. LPA was provided a tour of the facility inside and out. Also present during today's visit were 3 additional staff members and 10 preschool aged children.

LPA discussed to the Director that Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010 to test their drinking water for lead contamination between January 1, 2020 and January 1, 2023, and then every 5 years after the date of the first test. Health and Safety (HSC) Code section 1597.16 authorizes the Department to implement and administer procedures for lead testing at CCCs through written instructions until it adopts regulations under the Administrative Procedure Act. LPA discussed to the Director of the PIN 21-21-CCP - Release of the Written Directives for Lead Testing of Water in Licensed Child Care Centers Per AB 2370 https://cdss.ca.gov/Portals/9/CCLD/PINs/2021/CCP/PIN-21-21-CCP.pdf

Sample ID 430700603 D - Sink Faucet_Kitchen had a Lead Action Level of Exceedance Response of more than 5.5 ppb. The Director stated they have not utilized the sink since COVID started. It was previously utilized for food preparation. Facility maintenance staff stated that valves will be replaced and water will be retested. LPA confirmed the Plan of Correction with the Director.

Please see LIC 809D page for the citation.

Appeal rights provided. Exit interview was conducted with Director, Stacey Sullivan
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Melanie OtsujiTELEPHONE: (510) 341-5559
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023
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 10/03/2023 03:31 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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: ST TIMOTHY'S PRESCHOOL
FACILITY NUMBER: 430700603

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/03/2023
Section Cited
HSC
101700.3(b)(1)

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101700.3(b)(1) Lead Testing Written Directive-
A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
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Facility maintenance staff stated valves are being replaced on the main water line (found within the garden). Spouts will be retested. Director will send LPA an email once retesting has occurred.
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This requirement is not met as evidenced by:
Based on record review, facility has 1 outlet of water test 5.5 ppb or greater (located outside of preschool grounds), which is a potential health and safety risk to persons in care.
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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: Wynn NoronaTELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Melanie OtsujiTELEPHONE: (510) 341-5559
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023
LIC809 (FAS) - (06/04)
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