<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444410610
Report Date: 03/16/2023
Date Signed: 03/16/2023 11:46:27 AM


Document Has Been Signed on 03/16/2023 11:46 AM - 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:COMMUNITY BRIDGES FAIRGROUNDS CHILD DEV CENTERFACILITY NUMBER:
444410610
ADMINISTRATOR:AMY RATHERFACILITY TYPE:
850
ADDRESS:2667 EAST LAKE AVENUETELEPHONE:
(831) 786-9621
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY:45CENSUS: 15DATE:
03/16/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
10:54 AM
MET WITH:Rosalba TorresTIME COMPLETED:
11:56 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs), Cortney Nelson and Farida Raja, met with Site Director, Rossy Torres, and explained purpose of visit, to follow-up on water lead testing conducted for the facility. Upon arrival, LPAs toured the facility and located faucet "F" with reported Action Level Exceedance (value of 5.5 parts per billion or greater).

LPA Nelson received the following lead testing document via email from Licensee, Lisa Hindman Holbert: Sampling Checklist Form (LIC9276), Facility Sketch (LIC999) labeled with locations of water outlets, and water lead test result.

LPAs reminded that the Self-Certification (LIC9275) completed by Certified External Water Sampler needs to be submitted.

Water sample conducted by Monterey Bay Analytical Services on 12/9/2022 indicated faucet "F" had an Action Level Exceedance (ALE) value of 61.4. LPA's observed that the faucet is located outside the facility, in the outdoor play area near the sandbox. LPAs requested that the facility submit plan of correction for faucet "F" to ensure that it is not used for food preparation or children's drinking water.

Exit interview conducted and report was reviewed with the Site Director, Rossy Torres.

As a result of todays inspection, a deficiency was cited, see 809-D.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney NelsonTELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2023
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 03/16/2023 11:46 AM - 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: COMMUNITY BRIDGES FAIRGROUNDS CHILD DEV CENTER
FACILITY NUMBER: 444410610

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
03/24/2023
Section Cited

101700.3(b)(1)

1
2
3
4
5
6
7
101700.3 Lead Testing Written Directives (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:
1
2
3
4
5
6
7
The Licensee will submit a written declaration regarding plan of action for facuet "F" to ensure that it is not used for food preparation or children's drinking water.
8
9
10
11
12
13
14
After water lead testing was completed, the facility had one faucet (F) located in the outdoor preschool play area with an Action Level Exceedance of 61.4, which poses a potential risk to the health, safety, and personal rights of children in care.
8
9
10
11
12
13
14
The Licensee will additionally submit the External Water Sampler Self-Certification Form (LIC9275) by 3/24/2023. A blank copy was provided to the Site Director during today's inspection.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Cortney NelsonTELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2