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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274415293
Report Date: 10/14/2022
Date Signed: 10/14/2022 01:03:19 PM

Document Has Been Signed on 10/14/2022 01:03 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 JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:AVONDALE EARLY EDUCATION CENTERFACILITY NUMBER:
274415293
ADMINISTRATOR:LUALEMANA, ROXANNEFACILITY TYPE:
850
ADDRESS:1405 LA SALLE AVENUETELEPHONE:
(831) 899-4757
CITY:SEASIDESTATE: CAZIP CODE:
93955
CAPACITY: 127TOTAL ENROLLED CHILDREN: 127CENSUS: DATE:
10/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Ghennay WoodsTIME COMPLETED:
01:10 PM
NARRATIVE
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Licensing Program Analyst (LPA), Joe Macias, conducted an unannounced case management inspection in response to a lead testing completed with exceedances levels. The positive lead finding was self reported to Community Care Licensing (CCL). LPA met with the Director Ghennay Woods, and explained the nature of today's inspection to her.

Prior to today's inspection the facility self reported by submitting an unusual incident report, Self-Certification LIC9275, Sampling Checklist Form LIC9276, Facility Sketch LIC 999, fully labeled with locations of all water outlets, and full lead report. The lead exceedance readings were found in three exterior hoses. Preceding the arrival of LPA Macias the three affected hoses were capped off from the water sources and no longer used. The center provides filtered drinking water and cups for the children while outside.

During today's inspection LPA Macias observed that the three water sources were no longer operational.

Type B deficiency cited, exit interview conducted, and a copy of this report was reviewed with the Director Ghennay Woods. Appeal rights were reviewed and provided.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE CENTER, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Joseph Macias
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2022
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 10/14/2022 01:03 PM - It Cannot Be Edited


Created By: Joseph Macias On 10/14/2022 at 12:41 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: AVONDALE EARLY EDUCATION CENTER
FACILITY NUMBER: 274415293

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2022
Section Cited

101700.3(b)(1)

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Lead Testing Written Directives section 101700.3 (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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Prior to today's inspection the facility self reported by submitting an unusual incident report, Self-Certification LIC9275, Sampling Checklist Form LIC9276, Facility Sketch LIC 999, fully labeled with
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The exceedances level found:
exterior hose AA 42, exterior hose CC 6, exterior hose EE 14.
This poses a potential risk to the Health, Safety, or Personal Rights of children in care.
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locations of all water outlets, and full lead report. Preceding the arrival of LPA Macias the three affected hoses were capped off from the water sources and no longer used.

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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:Joseph Macias
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022


LIC809 (FAS) - (06/04)
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