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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434404912
Report Date: 05/12/2022
Date Signed: 05/12/2022 12:39:36 PM


Document Has Been Signed on 05/12/2022 12:39 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:ROSEMARY PRESCHOOLFACILITY NUMBER:
434404912
ADMINISTRATOR:HEATHER ELSTONFACILITY TYPE:
850
ADDRESS:401 WEST HAMILTON AVENUETELEPHONE:
(408) 341-7127
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:180CENSUS: 81DATE:
05/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Heather ElstonTIME COMPLETED:
12:50 PM
NARRATIVE
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Licensing Program Analyst (LPA), James Santos conducted an unannounced case management inspection visit today and met with Director. Heather Elston. LPA informed Director that purpose of visit which was to discuss the Lead Sampling Testing conducted at the center on 4/16/2022. The Lead Testing Analysis report was sent to CCL by the Director on 5/5/2022. Per report, the testing of water supply on three (3) faucets located in the Rosemary Elementary kitchen and a faucet located in the Occupational Therapy (Rm H) indicated an Action Level Exceedance, hence, water from this faucet is deemed not safe to drink or be used for food preparation due to elevated levels of lead. The water sampling report dated 4/16/2022 from Moore Twining Associates, Inc. indicated results on the identified Sites are above the reporting limit of 5ppb.

LPA inspected the identified faucets. Per discussion with the Director, the identified faucets will be replaced, then follow the 3 week conditioning protocol and have the water supply retested by a certified external water sampler before use. Per Director, all preschool food preparation is currently being conducted in their district central kitchen, and also the food are being delivered pre-packaged and pre-washed.

Director will send the new water sample test results to CCL after the testing is completed.

Based on record review, a deficiency is being cited in accordance with California Code of Regulations, Title 22, Division 12, Chapter 3, Section 101238 (a) Buildings and Grounds. See attached 809D. Appeal rights were reviewed and a provided.


NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: James G SantosTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
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 05/12/2022 12:39 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: ROSEMARY PRESCHOOL
FACILITY NUMBER: 434404912

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2022
Section Cited

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Buildings and Grounds:
The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors.
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This requirement is not met as evidenced by:
Based on record review, the CCC Lead Sampling report for the facility indicated that water from the identified four (4) faucets have elevated lead above 5ppb which poses a potential health and safety or 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: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: James G SantosTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2