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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444414387
Report Date: 10/18/2022
Date Signed: 10/18/2022 11:40:20 AM


Document Has Been Signed on 10/18/2022 11:40 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:ROSEBUD PLAYGARDENFACILITY NUMBER:
444414387
ADMINISTRATOR:HAILEY VILLA-BRIGHTMANFACILITY TYPE:
850
ADDRESS:2190 EMPIRE GRADETELEPHONE:
(831) 425-0519
CITY:SANTA CRUZSTATE: CAZIP CODE:
95060
CAPACITY:14CENSUS: 8DATE:
10/18/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:03 AM
MET WITH:Hailey Villa-BrightmanTIME COMPLETED:
11:52 PM
NARRATIVE
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Licensing Program Analyst (LPA), Cortney Nelson, met with Program Director, Hailey Villa-Brightman, and explained purpose of visit- to follow-up on water lead testing conducted for the facility. Upon arrival, LPA toured the facility and requested Program Director identify faucet with Action Level Exceedance (value of 5.5 parts per billion or greater).

LPA received the following documents during todays inspection: Self-Certification (LIC9275) completed by Certified External Water Sampler, Sampling Checklist Form (LIC9276), and Facility Sketch (LIC999) labeled with locations of water outlets.

Water sample conducted by McCampbell Analytical, Inc. indicated faucet A located in the kitchen sink had Action Level Exceedance value of 6.9. The facility has remediated the faucet by making it inaccessible to children and have completely removed the faucet from use. Program Director states that the entire faucet was replaced with a new one and that the faucet will be retested after 21 days of flushing and is scheduled for 10/28/2022. Another drinking faucet located in the kitchen sink is being used for drinking water and washing until faucet A can be retested again. Retesting of the water lead levels will be submitted to the Department upon completion.

Exit interview conducted and report was reviewed with the Program Director, Hailey Villa-Brightman.

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: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2022
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 10/18/2022 11:40 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: ROSEBUD PLAYGARDEN
FACILITY NUMBER: 444414387

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
10/19/2022
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 has made the faucet inaccessible to children and has stopped using water from it for washing. Program Director states that 21 day flush is being completed and faucet will be retested 10/28/2022.
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After water testing was completed, the facility had one faucet (A) located in the kitchen sink with an Action Level Exceedance of 6.9.
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The facility will submit lead water testing results for faucet "A" once testing has been completed.

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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: 10/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2022
LIC809 (FAS) - (06/04)
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