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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380500491
Report Date: 03/17/2023
Date Signed: 03/17/2023 04:39:27 PM

Document Has Been Signed on 03/17/2023 04:39 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 BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:PACIFIC PRIMARYFACILITY NUMBER:
380500491
ADMINISTRATOR:TURNER, LYNN RFACILITY TYPE:
850
ADDRESS:1500 GROVE STREETTELEPHONE:
(415) 346-0906
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94117
CAPACITY: 80TOTAL ENROLLED CHILDREN: 80CENSUS: 73DATE:
03/17/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Ilsa Miller and Natalie KaretTIME COMPLETED:
04:55 PM
NARRATIVE
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On March 17, 2023 at 1:30 PM, Licensing Program Analyst (LPA) April Cowan conducted an unannounced, case management inspection for the Action Level Exceedance (ALE) of Lead in Child Care Center's water. LPA met with the executive and site directors, Ilsa Miller and Natalie Karet respectively.. The purpose of the inspection was explained.

Present in facility is directors and 22 staff with 73 children in care.

LPA discussed the new Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018 requires the Lead Testing of water in the Child Care Center with the site director during the inspection. All Child Care Centers 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.

The facility received the ALE report from the Vendor on 12/23/2022. Test results for this facility that exceeded a higher level of parts per billion (ppb) allowed, 5.5 ppb. The facility was proactive in getting facility faucets tested and putting signs indicating that the water sink fixture are not for drinking and is currently out of order.

The facility took action to contact licensed plumbers to make repairs, and replace the fixture. Directors are waiting their selected plumber to respond to their request for service. Once the faucets are installed, the facility will be flushing the fixtures as instructed by the certified water samplers. The facility will be scheduling a retest with the certified water samplers three weeks after the flush has been done. Directors state they last reached out to the plumber on (3/15/23) to follow up. If there is no response, they will reach out to another plumber who can do the repairs. The facility is using filtered water for drinking currently. The facility is planning to utilize the affected fixtures once they are repaired.

See next page for deficiency cited today
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: April Cowan
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023
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 03/17/2023 04:39 PM - It Cannot Be Edited


Created By: April Cowan On 03/17/2023 at 04:25 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PACIFIC PRIMARY
FACILITY NUMBER: 380500491

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2023
Section Cited

101700.3(b)(1)

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101700.3 California Lead Action Level at Child Care Centers (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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The facility has included signs and will replace the fixtures affected and will be flushing the water fixture until they are retested by a certified water sampler.

Director will provide the new test results to LPA no later than 5/17/23.
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Based on results received from the certified water samplers, the facility exceeded 5.5 ppb of lead in their water source.
This 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:Garfield Leung
LICENSING EVALUATOR NAME:April Cowan
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2023


LIC809 (FAS) - (06/04)
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