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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274410787
Report Date: 09/20/2023
Date Signed: 09/20/2023 11:35:14 AM

Document Has Been Signed on 09/20/2023 11:35 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:M.A.O.F. GONZALES EARLY LEARNING CENTERFACILITY NUMBER:
274410787
ADMINISTRATOR:TERESA HOLLEYMANFACILITY TYPE:
850
ADDRESS:225 ELKO STREETTELEPHONE:
(831) 675-2764
CITY:GONZALESSTATE: CAZIP CODE:
93926
CAPACITY: 34TOTAL ENROLLED CHILDREN: 34CENSUS: 13DATE:
09/20/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Juana CamachoTIME COMPLETED:
11:35 AM
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On 09/20/2023 at 11:00 AM, Licensing Program Analysts (LPAs) Susy Cervantes, met with director, Juana Camacho, for a case management visit in regards to the lead testing results submitted by the facility and explained the reason for the visit to them. Present was 4 staff with 13 children in care.

Initial Lead testing was conducted by Terra Environmental on 11/04/2022. Facility submitted that there is an exceedance of 17.5 (ppb) in the classroom #1 drinking fountain (Faucet A on facility sketch). Report stated the faucet has been removed and no further testing was required.

LPA Cervantes received the Self-Certification form (LIC 9275), Sampling Checklist form (LIC 9276), and the updated facility sketch (LIC 999).

Type B deficiency was cited during today's visit. Director was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date will result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made. Exit interview conducted and report was reviewed with the director, Juana Camacho. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2023
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 09/20/2023 11:35 AM - It Cannot Be Edited


Created By: Susy Cervantes On 09/20/2023 at 11:22 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: M.A.O.F. GONZALES EARLY LEARNING CENTER
FACILITY NUMBER: 274410787

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/21/2023
Section Cited

101700.3(b)(1)

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Lead Testing Written Directives (b)(1) a result 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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Based on water lead testing report, faucet has been removed and no further testing is needed. Deficiency cleared during today's visit.
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Based on record review: LPA observed Faucet A has an exceedance of 17.5 ppb which poses a potential risk to the heakth, safety, and personal rights of the children 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:Mary Segura
LICENSING EVALUATOR NAME:Susy Cervantes
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023


LIC809 (FAS) - (06/04)
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