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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434410805
Report Date: 12/14/2023
Date Signed: 12/14/2023 01:08:07 PM


Document Has Been Signed on 12/14/2023 01:08 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:T'ENNA PRESCHOOL AT THE OSHMAN FAMILY JCCFACILITY NUMBER:
434410805
ADMINISTRATOR:MYKENZIE BUSSERFACILITY TYPE:
850
ADDRESS:3921 FABIAN WAYTELEPHONE:
(650) 223-8788
CITY:PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY:250CENSUS: DATE:
12/14/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Mykenzie BusserTIME COMPLETED:
01:25 PM
NARRATIVE
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On 12/14/23, at 11:15 am Licensing Program Analyst (LPA) Michael Mathew conducted a Case Management - Lead Testing/Exceedance Visit. LPA met with the Director Mykenzie Busser and advised her the purpose of the inspection. LPA was provided a tour of the facility inside and out. There were 167 children in care and 48 staff at the time of the inspection.

LPA discussed to the Director that Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010 to test their drinking water for lead contamination between January 1, 2020 and January 1, 2023, and then every 5 years after the date of the first test. Health and Safety (HSC) Code section 1597.16 authorizes the Department to implement and administer procedures for lead testing at CCCs through written instructions until it adopts regulations under the Administrative Procedure Act. LPA discussed to the Director of the PIN 21-21-CCP - Release of the Written Directives for Lead Testing of Water in Licensed Child Care Centers Per AB 2370 https://cdss.ca.gov/Portals/9/CCLD/PINs/2021/CCP/PIN-21-21-CCP.pdf

Sample ID ABCEFGHIJKLMNOPQRSTUVWXYZ and sample ID AA,BB,CC,DD,EE,FF,GG,HH,II,JJ,KK,LL,MM,NN,OO,PP, and PP30 where tested and result came in on 12/5/22 and sample ID J and O had a Lead Action Level of Exceedance Response of more than 5.5ppb. The Director stated that once they received the report faucet where shut off and disconnected water source and will be using alternative sources that passed in the classroom. LPA confirmed the Plan of Correction with the Director.

Please see LIC 809D page for the citation. LPA generated a Proof of Correction Clearance Letter and provided a copy to the Director.
Appeal rights provided. Exit interview was conducted with the Director Mykenzie Busser
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Michael MathewTELEPHONE: 510-292-8297
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
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 12/14/2023 01:08 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: T'ENNA PRESCHOOL AT THE OSHMAN FAMILY JCC
FACILITY NUMBER: 434410805

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/14/2023
Section Cited
CCR
101700.3(b)(1

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101700.3(b)(1)A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
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LPA confirmed the Plan of Correction Facility shut off and disconnected water source.
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Sample ID J and O had a Lead Action Level of Exceedance Response of more than 5.5ppb. This poses a potential health, safety and personal rights risk to 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: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Michael MathewTELEPHONE: 510-292-8297
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
LIC809 (FAS) - (06/04)
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