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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430701361
Report Date: 03/07/2023
Date Signed: 03/07/2023 12:18:12 PM


Document Has Been Signed on 03/07/2023 12:18 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 JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:ACTION DAY NURSERYFACILITY NUMBER:
430701361
ADMINISTRATOR:JILL MILLERFACILITY TYPE:
850
ADDRESS:2146 LINCOLN AVENUETELEPHONE:
(408) 266-8952
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:154CENSUS: 151DATE:
03/07/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:08 AM
MET WITH:Jamie FergusonTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Kassandra Medrano, conducted an unannounced case management inspection in response to a completed lead testing on 12/12/2022 which resulted in two action level exceedances within the facility of 11 ppb and 10 ppb. LPA met with the Regional Director (RD), Jamie Ferguson, and explained the nature of today's inspection.
Prior to today’s inspection, Community Care Licensing received notification of the lead exceedances by the water program. Preceding the arrival of LPA Medrano, both the fountains that have been found in exceedance have been taped off and are not being used. Facility is using filtered Brita water for their only source of drinking water and children use their own individual drinking cups/bottles.
The water sample conducted by California Rural Water Association (CRWA) on 12/12/2022, indicated the following:
1) Water bubbler and sink named "C" located in room 14 has Lead Action Level Exceedance value of 11 ppb.
2) Water bubbler and sink named "E" located in room 12 has Lead Action Level Exceedance of 10 ppb.

LPA has requested the following documents during today’s inspection RD to send via email:
1.Self-Certification (LIC9275)
2.Sampling Checklist Form (LIC9276)
3.Facility Sketch LIC 999 (fully labeled with locations of all water outlets)
4. Full lead report from water program

Type B deficiency was cited, exit interview conducted, and a copy of this report was given and reviewed with the Facility Representative, Jamie Ferguson. Appeal rights were reviewed and provided.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE CENTER, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Kassandra MedranoTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/07/2023 12:18 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 JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: ACTION DAY NURSERY
FACILITY NUMBER: 430701361

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/07/2023
Section Cited

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Lead Testing Written Directives section 101700.3 (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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Regional Director, Jamie Ferguson stated that they will remediate the exceedances and contact CRWA to retest. Jamie stated she will send documentation of remidation as well as retesting.
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This exceedance levels found in “C” bubbler and sink was 11 ppb and in bubbler and sink "E" was 10 ppb. This poses a potential risk to the Health, Safety, or Personal Rights of children 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: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Kassandra MedranoTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023
LIC809 (FAS) - (06/04)
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