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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384001376
Report Date: 11/13/2023
Date Signed: 11/13/2023 10:45:16 AM

Document Has Been Signed on 11/13/2023 10:45 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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SERRA PRESCHOOL, THEFACILITY NUMBER:
384001376
ADMINISTRATOR:MARYBETH CODYFACILITY TYPE:
850
ADDRESS:7 FUNSTON AVENUETELEPHONE:
(415) 561-2200
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94129
CAPACITY: 47TOTAL ENROLLED CHILDREN: 47CENSUS: 41DATE:
11/13/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Victoria DudleyTIME COMPLETED:
10:45 AM
NARRATIVE
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On November 13, 2023, Licensing Program Analysts (LPA)Tso met with the Director, Marybeth Cody and Assistant Director,Victoria Dudley (Directors). The purpose of inspection was explained and was for an
unannounced, case management inspection for the Action Level Exceedance (ALE) of Lead in Child Care Center's water. LPA was given a tour of the facility. Present in the facility was 7 staff, 1 Aide and 2 directors supervising 41 children.

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 January 11, 2023. Test results for this facility that exceeded a higher level of parts per billion (ppb) allowed, 5.5 ppb. The affected fixture is, fixture A (6.4). The Director proactively replace the faucet of fixture A for retest.

The affected fixture A, were retested on February 23, 2023, with a reading of 1.5 ppb. Per the updated guidance on written directives in PIN 21-21.1-CCP, facility will be cited for the actionable level exceedance of the fixtures. As the retested results had not been updated into the system. LPA reminded the Director to follow up with laboratory to upload into the system. Once the Director is notified the completion of uploading the retest results into the system, Director would email LPA to check at the system for clearance of Plan of Correction.

LPA obtained copies of the External Water Sampler Self-Certification Form (LIC9275), Child Care Center Sampling Checklist (LIC9276), Facility Sketch (LIC999), have been sent to the department by email.

* See next page for deficiencies cited today

This report was reviewed and signed by Director, Marybeth Cody.

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

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Man Tso
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2023
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 11/13/2023 10:45 AM - It Cannot Be Edited


Created By: Man Tso On 11/13/2023 at 10:10 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: SERRA PRESCHOOL, THE
FACILITY NUMBER: 384001376

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/12/2023
Section Cited
CCR
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 retested the affected fixture on 2/13/23. It reads 1.5 ppb, which is lowered than the Action Level Exceedance. As the retested results had not been updated into the system.
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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 poses a potential health, safety, or personal rights risk to persons in care.
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 Once the Director is notified the completion of uploading the retest results into the system, the Director would email LPA to check at the system for clearance of Plan of Correction.


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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:Ali Zebila
LICENSING EVALUATOR NAME:Man Tso
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2023


LIC809 (FAS) - (06/04)
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