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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434400031
Report Date: 05/03/2023
Date Signed: 05/05/2023 10:20:33 AM

Document Has Been Signed on 05/05/2023 10:20 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 JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:SANTA CLARA CHRISTIAN PRESCHOOLFACILITY NUMBER:
434400031
ADMINISTRATOR:RACHEL EATONFACILITY TYPE:
850
ADDRESS:3421 MONROE STREETTELEPHONE:
(408) 246-5423
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY: 75TOTAL ENROLLED CHILDREN: 75CENSUS: 66DATE:
05/03/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Principal Stuart NiceTIME COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analysts (LPA), Anna Morales, conducted an unannounced Case Management inspection. LPA met with Principal Stuart Nice. LPA reviewed water sample summary and requested the Principal to identify sink faucet in Room 15 with reported Lead Action Level Exceedance of 5.5 parts per billion (ppb) or greater. LPA observed that sink faucet in Room 15 is covered with plastic.

LPA obtained the following facility documents during today's inspection: 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.

The water sample conducted by California Rural Water Association (CRWA) on 03/25/23 indicated the following
1) Faucet D- Sink Faucet in Room 15 has Lead Action Level Exceedance value of 7.0 ppb.

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

Exit interview conducted and report was reviewed with Principal Stuart Nice



A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
Gladys Kuizon
Anna Morales
DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2023
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 05/05/2023 10:20 AM - It Cannot Be Edited


Created By: Anna Morales On 05/03/2023 at 03:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SANTA CLARA CHRISTIAN PRESCHOOL
FACILITY NUMBER: 434400031

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/05/2023
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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Based on record review, the Lead Sampling Report in one(1) identified faucet: Room 15, D, Sink Faucet had 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:Gladys Kuizon
LICENSING EVALUATOR NAME:Anna Morales
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023


LIC809 (FAS) - (06/04)
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