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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010213705
Report Date: 10/13/2022
Date Signed: 10/13/2022 03:12:19 PM

Document Has Been Signed on 10/13/2022 03:12 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:GAN SAMEACH NURSERY SCHOOLFACILITY NUMBER:
010213705
ADMINISTRATOR:JACOB, ANNIEFACILITY TYPE:
850
ADDRESS:42000 PASEO PADRE PARKWAYTELEPHONE:
(510) 651-5833
CITY:FREMONTSTATE: CAZIP CODE:
94539
CAPACITY: 22TOTAL ENROLLED CHILDREN: 22CENSUS: 8DATE:
10/13/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Annie JacobTIME COMPLETED:
03:30 PM
NARRATIVE
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On October 13, 2022, License Program Analyst (LPA) Melanie Otsuji met with Director Annie Jacob for an UNANNOUNCED CASE MANAGEMENT INSPECTION for Lead Testing Results. Present for today's inspection was the Director, an additional staff member and 8 preschool aged children. The facility operates Monday - Friday from 8:00 AM - 6:00 PM.

LPA and Director toured the facility and LPA obtained photos of the faucets that have exceeded 5.5 ppb. It was indicated that an area exceeded the Action Level established by the state for lead exposure. A Plan of correction was discussed with the Director. This facility is being given a TYPE B citation (see 809-D) The facility has covered the drinking fountains making them inoperable. Facility is in the process of hiring someone to have the fountains removed.

A notice of site visit was given and must remain posted for 30 days. Appeal Rights provided. Exit interview conducted and report was reviewed with the Director, Annie Jacob.

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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 10/13/2022 03:12 PM - It Cannot Be Edited


Created By: Melanie Otsuji On 10/13/2022 at 01:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: GAN SAMEACH NURSERY SCHOOL
FACILITY NUMBER: 010213705

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/13/2022
Section Cited
HSC
101700.3(b)(1)

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101700.3(b)(1) Lead Testing Written Directive-
A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
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Director shall have a contractor remove the water outlets and submit proof of removal of all water outlets which have tested 5.5 ppb or greater by 11/13/2022. LPA observed the water to the affected outlets have been turned off and made inoperable
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This requirement is not met as evidenced by:
Based on record review, facility had 3 outlets of water test 5.5 ppb or greater (two of which are located outside of the preschool grounds), which is a potential health and safety risk to persons in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.

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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:Wynn Norona
LICENSING EVALUATOR NAME:Melanie Otsuji
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022


LIC809 (FAS) - (06/04)
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