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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415238
Report Date: 03/23/2023
Date Signed: 03/23/2023 03:35:18 PM


Document Has Been Signed on 03/23/2023 03:35 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:ABC PLAY SCHOOLFACILITY NUMBER:
434415238
ADMINISTRATOR:SHU CHEN PANFACILITY TYPE:
850
ADDRESS:3000 SOUTH BASCOM AVENUETELEPHONE:
(408) 645-6239
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:35CENSUS: 33DATE:
03/23/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Jia Yi & Shu Chen PanTIME COMPLETED:
03:45 PM
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Licensing Program Analysts (LPAs) Mel Matos and Ashley Lopez conducted an unannounced case management inspection to discuss the lead water testing and Action Level Exceedance (ALE) levels. LPAs met with Jia Yi, Licensee representative, and Shu Chen Pan, director, and explained purpose of today's inspection to them.

Jia Yi states that she has another licensed preschool, located at 14834 Leigh Ave, San Jose, CA 95124 (Creative Beginnings Preschool - #434417014) that was tested on November 2, 2022. Jia Yi states that this Facility has yet to be tested. Jia Yi provided a copy of the lead testing report done by Adviro on November 2, 2022 for the other licensed Facility noted above.

LPAs advised Jia Yi to notify the lead testing company (Adviro) to submit a corrected lead water testing report to the California Water Board. Jia Yi states that she will submit a copy of the corrected lead testing report to LPA Ashley Lopez once that has been completed.

Jia Yi states that she will request lead water testing of this Facility once the corrected lead water testing report has been completed.

Exit interview conducted and report was reviewed with the Licensee representative, Jia Yi.

No deficiencies issued during today's inspection.

A Notice of Site Visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023
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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