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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270710407
Report Date: 07/30/2024
Date Signed: 07/30/2024 09:57:59 AM

Document Has Been Signed on 07/30/2024 09:57 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 JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:ROOSEVELT PRESCHOOLFACILITY NUMBER:
270710407
ADMINISTRATOR/
DIRECTOR:		MARY RANDALLFACILITY TYPE:
850
ADDRESS:120 CAPITOL STREETTELEPHONE:
(831) 753-5645
CITY:SALINASSTATE: CAZIP CODE:
93901
CAPACITY: 23TOTAL ENROLLED CHILDREN: 23CENSUS: 0DATE:
07/30/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH: Densie Noel TIME VISIT/
INSPECTION COMPLETED:
10:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Andrea Cortez, conducted an unannounced case management inspection to discuss a water lead testing complaint. LPA met with Program Coordinator (PC) Denise Noel and explained the purpose for the inspection. At 8:40am, LPA and PC conducted a tour of the facility. On May 9th 2024 water testing was done by Monterey Bay Analytical Services. According to the analysis lead testing was not included their sample.

LPA observed the center closed however, the school year starts August 8 2024. PC will insure bottle water will be provide to the children until test is completed and results are submitted to the department. Lunches are provide by the Salinas School District (SSD).

The following documents were explained to PC during today's inspection:
1) External Water Sampler Self-Certification Form (LIC9275).
2) Childcare Center Sampling Checklist Form (LIC9276).
3) Facility Sketch (LIC999) labeled with locations of water outlets that were tested.

Type B deficiency was cited and exit interview conducted

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Andrea Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2024
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 07/30/2024 09:57 AM - It Cannot Be Edited


Created By: Andrea Cortez On 07/26/2024 at 04:19 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ROOSEVELT PRESCHOOL
FACILITY NUMBER: 270710407

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
08/29/2024
Section Cited
HSC
1597.16(a)(1)

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(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.
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The Licensee shall schedule water lead testing for the facility and submit results to the department by 8/30/24. LPA advised submitting facility sketch (LIC999) with tested faucets indicated, LIC9275, and LIC9276. LPA to email PIN 21-21.1-CCP and certified water sampler list to Licensee.
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Based on record review and interview, the licensee did not comply with the section cited above as the facility has not completed water lead testing for faucets used for drinking water/food prep, which poses a potential health, safety or personal rights risk to persons in care.
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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:Gladys Kuizon
LICENSING EVALUATOR NAME:Andrea Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/30/2024 09:57 AM - It Cannot Be Edited


Created By: Andrea Cortez On 07/30/2024 at 09:37 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ROOSEVELT PRESCHOOL
FACILITY NUMBER: 270710407

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/30/2024
Section Cited
HSC
1597.16(a)(1)

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(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.
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The Licensee shall schedule water lead testing for the facility and submit results to the department by 8/30/24. LPA advised submitting facility sketch (LIC999) with tested faucets indicated, LIC9275, and LIC9276. LPA to email PIN 21-21.1-CCP and certified water sampler list to Licensee.
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Based on insepction the licensee did not comply with the section cited above as the facility has not completed water lead testing for faucets used for drinking water/food prep, which poses a potential health, safety or personal rights risk to persons in care.
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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:Gladys Kuizon
LICENSING EVALUATOR NAME:Andrea Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


LIC809 (FAS) - (06/04)
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