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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 213001939
Report Date: 10/19/2023
Date Signed: 10/19/2023 10:53:54 AM

Document Has Been Signed on 10/19/2023 10:53 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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:C.A.M. (CFS) HAMILTON (PS)FACILITY NUMBER:
213001939
ADMINISTRATOR:LOMBARDI KELSEYFACILITY TYPE:
850
ADDRESS:5520 NAVE DRIVETELEPHONE:
(415) 883-3791
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY: 80TOTAL ENROLLED CHILDREN: 80CENSUS: 37DATE:
10/19/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:Alida LeonTIME COMPLETED:
11:15 AM
NARRATIVE
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On October 19, 2023, Licensing Program Analysts (LPAs) Garcia and Tse conducted an unannounced, case management inspection for the Action Level Exceedance (ALE) of Lead in Child Care Center's water. The case management inspection for the ALE was in conjunction with School Age facility #210111538. LPA met with site director, Alida Leon. LPAs explained the purpose of the visits and was given a tour of the facility.
Present in facility are 37 children, present with 11 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 11/5/2022. 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 barricaded and or made the affected fixture out of order. LPA Garcia met with Facilities manager on Februaury 7, 2023 during an earlier lead case management visit and showed that the affected fixture E (10) is a water fountain outside that has been removed and capped off.

The facility was not initially cited for the action level exceedance during the lead case management visit on February 7,2023. Due to updated guidance on the written directives in the PIN 21-21.1-CCP, the facility will be cited for the action level exceedance of the fixture. However, the facility has removed the affected fixture before the lead case management visit and the citation given today will be cleared on the same day.

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

* See next page for deficiencies cited today

This report was reviewed and signed by Site Director, Alida Leon .

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: 10/19/2023
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 10:53 AM - It Cannot Be Edited


Created By: Nathan Garcia On 10/19/2023 at 10:28 AM
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: C.A.M. (CFS) HAMILTON (PS)
FACILITY NUMBER: 213001939

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/20/2023
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 had the affected fixture permanently removed prior to another lead case management visit dated February 7,2023. The citation given today will be cleared.
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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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Type B violation will be cleared on the same day.

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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: 10/19/2023
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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