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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444410610
Report Date: 10/19/2023
Date Signed: 10/23/2023 09:29:12 AM


Document Has Been Signed on 10/23/2023 09:29 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/23/2023 09:18 AM

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

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Licensing Program Analyst (LPA), Cortney Nelson, met with Site Director, Rosalba Torres, and explained purpose of visit, to follow-up on Action Level Exceedance for faucet "F." Upon arrival, LPA was admitted into the facility by staff member, Esmeralda.

Water lead test conducted by Monterey Bay Analytical Services on 12/9/2022 indicated faucet "F" had an Action Level Exceedance (ALE) value of 61.4 ppb (parts per billion). LPA observed that the faucet is located outside the facility, in the outdoor play area near the sandbox during case management visit conducted on 3/16/2023.

The facility appealed the citation and the appeal was received by the San Jose Regional Office on 6/9/2023. The appeal was originally accepted, as the faucet tested was a hose and the facility indicated that it was incorrectly tested, as it is not used for drinking water or food prep. The appeal was rescinded on 9/7/2023, indicating that if a faucet is sampled for lead, the facility is acknowledging that the faucet is used for food preparation or drinking water. A letter was provided indicating the rescinded appeal and advised that a report will be issued to reissue the citation for lead exceedance of faucet "F." A plan of correction that meets the Written Directives shall be submitted by the facility.

LPA advised that faucet "F" shall be capped to prevent use or the faucet shall be replaced and retested for lead. LPA observed during today's visit that faucet "F" has been capped and is no longer in use. There is a "Do Not Use" sign placed over the capped water line to prevent future use.

As a result of today's inspection, a deficiency has been cited, see LIC809-D.

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

A NOTICE OF SITE VISIT WAS GIVEN AND MUST BE POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney NelsonTELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
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 10/19/2023 10:39 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 EED FAIRGROUNDS CENTER
FACILITY NUMBER: 444410610

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2023
Section Cited

101700.3(b)(1)

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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:
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The facility was advised that faucet "F" shall be made inaccessible for use and POC shall be to cap the faucet or replaced it and retest for lead, in order to remain in compliance with the Written Directives.
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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 ppb, which poses a potential risk to the health, safety, and personal rights of children in care.
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Plan of correction (POC) for faucet "F" to be submitted to the Department by 11/1/2023.

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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: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney NelsonTELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
LIC809 (FAS) - (06/04)
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