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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005617
Report Date: 10/04/2023
Date Signed: 10/04/2023 02:44:15 PM

Document Has Been Signed on 10/04/2023 02:44 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:GROVE PRESCHOOL AT KOL SHOFAR, THEFACILITY NUMBER:
214005617
ADMINISTRATOR:BARBONI, KATHERINEFACILITY TYPE:
850
ADDRESS:215 BLACKFIELD DRIVETELEPHONE:
(415) 388-1818
CITY:TIBURONSTATE: CAZIP CODE:
94920
CAPACITY: 105TOTAL ENROLLED CHILDREN: 105CENSUS: 40DATE:
10/04/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
01:37 PM
MET WITH:Katherine BarboniTIME COMPLETED:
03:00 PM
NARRATIVE
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On 10/4/23 at approximately 1:30 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, Katherine Barboni. LPA explained the purpose of the visits and was given a tour of the facility.
Present in facility are 40 children, present with 10 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 August 17, 2022 for the initial test and the retest was done on November 8 2023. 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 initially labeled as O (5.83) is located in the sensory room adult sink. The second retest, the samplers labeled it as fixture A (14). According to the director, the facility had a home lead water test done recently and LPA advised that will not suffice requirements for water lead testing. The facility is using other sources of water, sinks that passed the tests, for food preparation and water ingestion.

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, Katherine Barboni .

This notice of Site visit was provided to the director 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.

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Document Has Been Signed on 10/04/2023 02:44 PM - It Cannot Be Edited


Created By: Nathan Garcia On 10/04/2023 at 02:28 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: GROVE PRESCHOOL AT KOL SHOFAR, THE
FACILITY NUMBER: 214005617

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 certified water samplers to do a third retest of the fixture. Once the retest results are available, the director will notify LPA and forward the results for review.
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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 testing and results shall be submitted by set due date.

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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


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