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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408052
Report Date: 04/06/2022
Date Signed: 04/06/2022 12:10:45 PM


Document Has Been Signed on 04/06/2022 12:10 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:SINAI NURSERY SCHOOLFACILITY NUMBER:
434408052
ADMINISTRATOR:IFAT KANTOROVITCHFACILITY TYPE:
850
ADDRESS:1532 WILLOWBRAE AVENUETELEPHONE:
(408) 264-8486
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:60CENSUS: 34DATE:
04/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:22 AM
MET WITH:Ifat KantorovitchTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janette Cruz, conducted an unannounced case management inspection and met with Ifat Kantorovitch, Director. LPA informed Director that purpose of visit is to discuss Lead Sampling Testing conducted on 11/05/2021. Census was taken, LPA observed 34 children with 10 staff supervising. LPA informed Director that the testing of water supply in Sites A & N indicated an Action Level Exceedance, hence, water from these two sites is deemed not safe to drink or be used for food preparation due to elevated levels of lead. Director provided LPA with water sampling report dated 12/03/2021 from Pace Analytical Environmental Sciences that indicated results on both sites A & N are above 5ppb.

Director stated that she will have the sink on both sites fixed and have the water supply retested by a certified external water sampler within 30 days and before use. Director immediately made the affected water outlets with elevated levels of lead inaccessible for use. Director also stated that water from these two sites would also be turned off until it can be replaced or repaired. In addition, Director stated that the facility was not using the two affected water fountains due to COVID. Director stated that facility does not do any food preparation in the facility since they do not offer any food or snacks. Director stated that facility is using the faucets and water fountains inside the classrooms for drinking.

Based on LPA's record review and observation, the following violation 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.

Exit interview was completed and Appeal Rights were discussed with Ifat Kantorovich.

A NOTICE OF SITE VISIT WAS ISSUED AND POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022
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 04/06/2022 12:10 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: SINAI NURSERY SCHOOL
FACILITY NUMBER: 434408052

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/20/2022
Section Cited

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101238(a)Buildings and Grounds
(a) 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. This requirement was not met as evidenced by:
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Based on observations, interview and record review, the CCC Lead Sampling report for the facility indicated that water from two outlet sites have elevated lead greater than 5ppb which poses a potential health and safety or Personal 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: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022
LIC809 (FAS) - (06/04)
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