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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372000300
Report Date: 10/17/2022
Date Signed: 06/29/2023 01:22:46 PM

Document Has Been Signed on 06/29/2023 01:22 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
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:KENSINGTON COMMUNITY CHURCH PRE-SCHOOLFACILITY NUMBER:
372000300
ADMINISTRATOR:ADRIANA DICARLOFACILITY TYPE:
850
ADDRESS:4773 MARLBOROUGH DRIVETELEPHONE:
(619) 280-1610
CITY:SAN DIEGOSTATE: CAZIP CODE:
92116
CAPACITY: 44TOTAL ENROLLED CHILDREN: 53CENSUS: 27DATE:
10/17/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Adriana DiCarloTIME COMPLETED:
12:00 PM
NARRATIVE
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On 10/17/22 at 9:55am, Licensing Program Analyst (LPA), Martha Malane conducted an unannounced case management inspection for the Action Level Exceedance (ALE) of lead detected in facility water fixtures. LPA met with Director, Adriana DiCarlo. The purpose of the inspection was explained, and facility was toured. Present in facility were 27 children and five (5) staff members.

LPA discussed the new Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, which requires the testing of water for lead in Child Care Centers (CCCs) with facility director during the inspection. Per AB 2370, all CCCs 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.

LPA obtained copies of the External Water Sampler Self-Certification Form (LIC9275), Child Care Center Sampling Checklist (LIC9276) Facility Sketch (LIC999), on 7/18/22.

On 9/1/22 the Department received notification from the State Water Resources Control Board (SWRCB), Division of Drinking Water (DDW). The SWRCB report indicated the facility was inspected and samples were collected on 7/8/22. The outlets/fixtures reported with 5.5 ppb or greater lead exceedance levels were as follows:

A – Drinking fountain, 3 and 4-year-old playground, currently not in use
C – Drinking fountain, teacher workroom next to children’s restroom, currently not in use
E – Drinking fountain, downstairs next to 4-year-old classroom, currently not in use

Facility no longer utilizes the drinking fountains located on the playground, in the teacher workroom or downstairs next to 4-year-old classroom. Facility turned off the water and placed a ‘do not use’ sign on the drinking fountains. Facility provides water for children via bottled water.
See LIC809C continuation... This is an amended version of a report dated 10/17/22.
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Martha Malane
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: KENSINGTON COMMUNITY CHURCH PRE-SCHOOL
FACILITY NUMBER: 372000300
VISIT DATE: 10/17/2022
NARRATIVE
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Grant funding will be available for testing and remediation of lead to the Child Care Centers that qualify. To make a determination of eligibility, refer to PIN 21-04-CCP. For Lead Testing and Prevention Information, including additional resources please visit https://www.cdss.ca.gov/inforesources/child-care-licensing/water-testing-information.

An exit interview conducted with Director, Adriana DiCarlo. 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.

This is an amended version of a report dated 10/17/22.
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Martha Malane
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/29/2023 01:23 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/17/2023 07:32 PM


Created By: Martha Malane On 10/17/2022 at 10:41 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
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: KENSINGTON COMMUNITY CHURCH PRE-SCHOOL
FACILITY NUMBER: 372000300

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
11/17/2022
Section Cited

101700.3(b)(1)

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101700.3 California Lead Action Level at Child Care Centers. (b) Testing results with fractional ppb readings of 0.5 ppb or greater shall be rounded up to the nearest whole number, before comparing to the Action Level. (1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
This requirement is not met as evidenced by:
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The facility made the outlets that tested with an ALE out of service and posted appropriate signage. Director stated they will repair the impacted outlets. Fixtures are to be retested by a certified water sampler and a follow-up water sample must be taken following the protocol outlined in Written Directives, Section 101705.
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Based on record review, the licensee did not comply with the directive above, as three (3) outlets used for drinking and/or food preparation tested with an Action Level Exceedance (ALE). This poses a potential Health and Safety risk to children in care.
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Director stated that children in care will be provided with alternative potable water, by using bottled water, while waiting to repair the outlets and fixtures. Director stated parents will be notified of the lead exceedances via email. Director stated the POC will be provided to the San Diego Regional Office no later than 11/16/22. This is an amended version of a report dated 10/17/22.

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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:Tulam Vu
LICENSING EVALUATOR NAME:Martha Malane
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022


LIC809 (FAS) - (06/04)
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