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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380504419
Report Date: 10/31/2023
Date Signed: 10/31/2023 11:00:43 AM

Document Has Been Signed on 10/31/2023 11:00 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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SFUSD-JEFFERSON EARLY EDUCATION SCHOOL-PRESCHOOLFACILITY NUMBER:
380504419
ADMINISTRATOR:LIN, MARYFACILITY TYPE:
850
ADDRESS:1350 - 25TH AVENUETELEPHONE:
(415) 759-2852
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94122
CAPACITY: 56TOTAL ENROLLED CHILDREN: 56CENSUS: 21DATE:
10/31/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:59 AM
MET WITH:Ivy LauTIME COMPLETED:
11:15 AM
NARRATIVE
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On October 31, 2023, Licensing Program Analysts (LPAs) Garcia and Tso conducted an unannounced, case management inspection for the Action Level Exceedance (ALE) of Lead in Child Care Center's water. LPAs met with secretary Mei Huang and later joined by Ivy Lau. LPAs explained the purpose of the visit and was given a tour of the facility.
There were 21 children and 7 teachers present. There were also parents on site for the Halloween parade.

LPAs 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 June 11, 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 fountain/kitchen fixture is not for drinking and or currently out of order. Per staff, the affected fixture B (5.9) is a kitchen sink. According to the director, the faucet has been replaced and retested on September 10, 2022. LPAs observed that there was a new fixture where the affected fixture used to be and based on the retest results show 1.1 ppb for fixture B, which is below the 5.4 ppb threshold.

LPAs obtained emailed copies of the External Water Sampler Self-Certification Form (LIC9275), Child Care Center Sampling Checklist (LIC9276), Facility Sketch (LIC999), during the visit.

* See next page for deficiencies cited today and will also be cleared on the same day.

This report was reviewed and signed by lead teacher, Ivy Lau.

This notice of Site visit was provided to the Director and must remain posted for 30 days.

SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Nathan Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2023
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 10/31/2023 11:00 AM - It Cannot Be Edited


Created By: Nathan Garcia On 10/31/2023 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SFUSD-JEFFERSON EARLY EDUCATION SCHOOL-PRESCHOOL
FACILITY NUMBER: 380504419

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/01/2023
Section Cited

101700.3

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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 had affected fixture 'B' replaced and retested on September 10, 2022. The retest results show for that fixture is 1.1ppb of lead. The facility remediated the fixture before the visit.
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Based on results received from the certified water samplers, the facility exceeded 5.4 ppb of lead in their water source. This posed a potential health, safety, or personal rights risk to persons in care.
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Deficiency cited and cleared on the same visit, 10/31/2023.

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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:Daniel J Oquendo
LICENSING EVALUATOR NAME:Nathan Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023


LIC809 (FAS) - (06/04)
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