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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102822
Report Date: 10/04/2023
Date Signed: 10/04/2023 12:58:41 PM

Document Has Been Signed on 10/04/2023 12:58 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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:HAWTHORNE NURSERY SCHOOLFACILITY NUMBER:
210102822
ADMINISTRATOR:GISLADOTTIR, HRUNDAFACILITY TYPE:
850
ADDRESS:145 ROCK HILL DRIVETELEPHONE:
(415) 435-9757
CITY:TIBURONSTATE: CAZIP CODE:
94920
CAPACITY: 45TOTAL ENROLLED CHILDREN: 45CENSUS: 15DATE:
10/04/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:57 AM
MET WITH:Hrunda GisladottirTIME COMPLETED:
01:20 PM
NARRATIVE
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On 10/4/23 at approximately 12:00 PM, Licensing Program Analyst (LPA) Nathan Garcia conducted an unannounced, case management inspection for the Action Level Exceedance (ALE) of Lead in Child Care Center's water. LPA met with the director, Hrunda Gisladottir. LPA explained the purpose of the visits and was given a tour of the facility.
Present in facility are 15 children, present with 3 staff members.

LPA discussed the new Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018 requires the Lead Testing of water in the Child Care Center with the site director during the inspection. All Child Care Centers that are located in buildings constructed before January 1, 2010, must have their water tested and post the results by January 1, 2023, and every 5 years after the date of the first testing.

The facility received the ALE report from the Vendor on October 29, 2022. Test results for this facility that exceeded a higher level of parts per billion (ppb) allowed, 5.5 ppb. The facility was proactive in getting facility faucets tested and putting signs indicating that the water fountain/kitchen fixture is not for drinking and or currently out of order. Per director, the affected fixture B (6.1) is located in a church kitchen next door but is outside of the day care area. The facility was not initially cited for the action level exceedance during the annual inspection on June 28, 2023 due to the location of the affected fixture. Ultimately, the fixture was still tested and has an action level exceedance, therefore the facility will be cited for the fixture being above the 5.5ppb of lead in water threshold. The facility is using other sources of water, sinks that passed the tests, for food preparation and water ingestion. According to the director, the facility will continue not using the fixture even after the fixture has been replaced and retested.

LPA obtained the copies of the External Water Sampler Self-Certification Form (LIC9275), Child Care Center Sampling Checklist (LIC9276), Facility Sketch (LIC999), in an email to the LPA.

* See next page for deficiencies cited today

This report was reviewed and signed by Director, Hrunda Gisladottir .

This notice of Site visit was provided to the licensee and must remain posted for 30 days.

SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Nathan Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2023
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 10/04/2023 12:58 PM - It Cannot Be Edited


Created By: Nathan Garcia On 10/04/2023 at 12:36 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HAWTHORNE NURSERY SCHOOL
FACILITY NUMBER: 210102822

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/06/2023
Section Cited

101700.3

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101700.3 California Lead Action Level at Child Care Centers (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 will contact the church next door to replace the faucet and have it retested by the certified water samplers. The director will update the LPA for any progress with the remediation.
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Based on results received from the certified water samplers, the facility exceeded 5.4 ppb of lead in their water source. Once received, the facility took immediate and proper actions to remediate the fixtures.
This poses a potential health, safety, or personal rights risk to persons in care.
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The facility will also continue to not use the affected fixture as it is not part of their day care facility. The facility is using other sources of water that passed the tests.

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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:Daniel J Oquendo
LICENSING EVALUATOR NAME:Nathan Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023


LIC809 (FAS) - (06/04)
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