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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430706092
Report Date: 10/25/2022
Date Signed: 10/25/2022 12:13:42 PM


Document Has Been Signed on 10/25/2022 12:13 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:CHANDLER TRIPP HEAD STARTFACILITY NUMBER:
430706092
ADMINISTRATOR:TAFOYA, VICKIFACILITY TYPE:
850
ADDRESS:780 THORNTON WAYTELEPHONE:
(408) 573-4894
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:40CENSUS: 8DATE:
10/25/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:09 AM
MET WITH:Dee VoTIME COMPLETED:
12:25 PM
NARRATIVE
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Licensing Program Analyst (LPA), Marilou Monico, conducted an unannounced Case Management Inspection. LPA met with Site Director, Dee Vo, and explained the purpose of the inspection. LPA reviewed water sample summary and requested Dee to identify Faucets "A, E, and I" with reported Action Level Exceedance of 5.5 parts per billion (ppb) or greater. Faucet "A" is located in Room 1, Faucet "E" is in the kitchen, and Faucet "I" is in Room 2. LPA observed that the faucets were taped and not being used.

The following documents were submitted by the facility to Licensing on October 21, 2022:
1)Self-Certification (LIC9275) completed by Certified External Water Sampler
2) Sampling Checklist Form (LIC9276)
3) Facility Sketch (LIC999) labeled with locations of water outlets that were tested.

The water sample conducted by Adviro on October 14, 2022 indicated the following:
1) Faucet "A-Drinking Faucet Room 1" has Action Level Exceedance value of 17 ppb.
2) Faucet "E-Kitchen Prep Kitchen" has Action Level Exceedance value of 16 ppb.
3) Faucet "I-Drinking Faucet Room 2" has Action Level Exceedance of 14 ppb.

As a result of this inspection, Type B deficiency was cited on the following page.

Exit interview conducted and report was reviewed with Site Director, Dee Vo.



A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
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 10/25/2022 12:13 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: CHANDLER TRIPP HEAD START
FACILITY NUMBER: 430706092

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/28/2022
Section Cited

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Lead Testing Written Directives - a result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. 

This requirement is not met as evidenced by:
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Based on record review, the Lead Sampling Report in three (3) identified faucets: A, E, & I have elevated lead above 5.5 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: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
LIC809 (FAS) - (06/04)
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