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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412429
Report Date: 10/19/2022
Date Signed: 10/19/2022 12:05:14 PM


Document Has Been Signed on 10/19/2022 12:05 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:KIDANGO MEADOWFAIRFACILITY NUMBER:
434412429
ADMINISTRATOR:YADIRA RIOSFACILITY TYPE:
850
ADDRESS:2696 SOUTH KING ROADTELEPHONE:
(408) 353-0680
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY:30CENSUS: 9DATE:
10/19/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Rios, YadiraTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Almaraz, conducted an unannounced case management inspection in response to a lead testing completed with exceeded levels. Due to COVID- 19 precautionary measures were taken, licensing staff present during inspection wore appropriate personal protective equipment. The positive lead finding was self reported to Community Care Licensing (CCL). LPA met with the Director Rios, Yadira and explained the nature of today's inspection to her.

Prior to today's inspection the facility self reported by submitting an unusual incident report, Self-Certification LIC 9275, Sampling Checklist Form LIC 9276, Facility Sketch LIC 999, fully labeled with locations of all water outlets, and full lead report. The lead exceedance readings were found in one exterior fountain. Previous to the arrival of LPA Almaraz the affected fountain was capped off from the water sources and no longer used. The center provides filtered drinking water and cups for the children while outside. Director states the water fountain/s have not been used since before the COVID 19 pandemic.

During today's inspection LPA Almaraz observed that the water sources where the lead was located is no longer operational. Director discussed cutting off water supply from drinking fountain. LPA referred Director to regulation 101239.2 (a)" Drinking water from a noncontaminating fixture or container shall be readily available both indoors and in the outdoor activity area". (3) Bottled water or portable containers will be allowed provided that: (A The water and containers are kept free of contamination.(B) Bottled water containers are secured to prevent tipping and breaking.

Type B deficiency cited, exit interview conducted, and a copy of this report was reviewed with the Director. Appeal rights were reviewed and provided.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE CENTER, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.

SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Araceli AlmarazTELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
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 10/19/2022 12:05 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: KIDANGO MEADOWFAIR
FACILITY NUMBER: 434412429

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2022
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 section 101700.3 (b)(1), 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 exceedances level found:
exterior fountain hose G value 12 ug/L note/s: P-02, C-04. This poses a potential risk to the Health, Safety, or Personal Rights of children in care.
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fully labeled with locations of all water outlets, and full lead report. Prior to the arrival of LPA the affected fountain was capped off from the water source and no longer used. Plumber will replace fixtures in two weeks. Teachers will flush for 30 seconds 4 times a day for three weeks. Another sample tested mid November. Results will be sent to LPA.

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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: Araceli AlmarazTELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
LIC809 (FAS) - (06/04)
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