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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710174
Report Date: 10/18/2022
Date Signed: 10/18/2022 11:37:03 AM


Document Has Been Signed on 10/18/2022 11:37 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:DE ANZA COLLEGE CHILD DEVELOPMENT CENTERFACILITY NUMBER:
430710174
ADMINISTRATOR:NAOKO NANCY HARADAFACILITY TYPE:
850
ADDRESS:21250 STEVENS CREEK BLVD.TELEPHONE:
(408) 864-5795
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:217CENSUS: 68DATE:
10/18/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:21 AM
MET WITH:Maritza FuentesTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA), Marilou Monico, conducted an unannounced Case Management inspection. LPA observed that the front door of the facility was locked. A sign was posted by the door to contact any of the three individuals listed. LPA contacted Director, Naoko Harada. Naoko indicated that she is out of the office. LPA explained to her the purpose of the inspection and asked her if someone in the facility has access to the documents needed for the inspection such as Self-Certification (LIC9275) completed by Certified External Water Sampler, Sampling Checklist Form (LIC9276), and Facility Sketch (LIC999) labeled with locations of water outlets that were tested. Naoko stated that she is the only one who has those documents. LPA reviewed the water sample summary and asked Naoko to identify faucet "G" with reported Lead Action Level Exceedance of 5.5 parts per billion (ppb) or greater. Naoko stated that faucet "G" is the staff's faucet located in Room 26.

LPA met with Administrative Assistant, Maritza Fuentes. LPA was accompanied by Maritza to check Room 26. LPA observed that the staff's faucet is not labelled. Staff in Room 26 indicated that they are only using the staff's faucet to wash their hands. LPA observed filtered water container in the classroom. Martiza stated that they use filtered water from the kitchen's faucet for drinking as well as food preparation purposes. LPA observed three faucets available for the children and another faucet in the kitchen. During the inspection, Maritza covered the staff's faucet with plastic and placed a "Do Not Use" sign.

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

Exit interview conducted and report was reviewed with Administrative Assistant, Maritza Fuentes.



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: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2022
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 10/18/2022 11:37 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: DE ANZA COLLEGE CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 430710174

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/18/2022
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 was not met as evidenced by:
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The Lead Sampling Report in one identified faucet has 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: 10/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2022
LIC809 (FAS) - (06/04)
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