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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372000501
Report Date: 12/14/2022
Date Signed: 12/14/2022 01:28:26 PM

Document Has Been Signed on 12/14/2022 01:28 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:SAN CARLOS UNITED METHODIST WEEKDAY PRESCHOOLFACILITY NUMBER:
372000501
ADMINISTRATOR:WENDY KOZAFACILITY TYPE:
850
ADDRESS:6554 COWLES MOUNTAIN BOULEVARDTELEPHONE:
(619) 464-4335
CITY:SAN DIEGOSTATE: CAZIP CODE:
92119
CAPACITY: 122TOTAL ENROLLED CHILDREN: 122CENSUS: DATE:
12/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Wendy KozaTIME COMPLETED:
01:35 PM
NARRATIVE
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On 12/14/22, Licensing Program Analyst (LPA), Tyra Block conducted an unannounced Case Management Inspection to follow up on the lead testing result for one of the water fountains at the facility with an Action Level Exceedance. LPA met with the director, Wendy Koza. There were 61 children, 12 staff and the cook present.

Water outlet reported with 5.5 ppb or greater lead exceedance level:

Drinking Fountain- Sample ID-C located in outdoor hall area (10 Ug/L or ppb)

LPA observed the outside fountain was removed (9/19/22) subsequent to being made inaccessible/ off-limits to everyone 2020 due to COVID-19. All other fountains and water outlets tested within an acceptable level with no lead exceedance. Parents will be notified by letter and results provided.

See LIC 809D for Type B deficiency cited during today's visit.

An exit interview was conducted with facility representative, Wendy Koza. A copy of this report was provided along with a Notice of Site Visit that must be posted for 30 days.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Tyra Block
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2022
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 12/14/2022 01:28 PM - It Cannot Be Edited


Created By: Tyra Block On 12/14/2022 at 01:04 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
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: SAN CARLOS UNITED METHODIST WEEKDAY PRESCHOOL
FACILITY NUMBER: 372000501

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2022
Section Cited

101700.3(b)(1)

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Written Directive: A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. This requirement was met as evidenced by:
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Faciity representative, Wendy Koza, provided LPA with written plan of correction and stated she will provide a letter to parents to notify of lead results and action taken. LPA observed the fountain was removed and was provided notice along with photo 9/19/22 . Director stated a copy of parent notice with lead results will be provided by POC due date of 12/16/22.
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Based on documentation reviewed, observation, and interview the facility had 1 water fountain with an ALE of 10 ppb. It was located in the outdoor hallway and has been inaccessible to daycare children since 2020. This posed a potential health, safety, and personal rights risk to 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:Tashima Daniel
LICENSING EVALUATOR NAME:Tyra Block
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022


LIC809 (FAS) - (06/04)
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