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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004486
Report Date: 03/08/2024
Date Signed: 03/08/2024 09:43:33 AM

Document Has Been Signed on 03/08/2024 09:43 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:LITTLE ANGELS JAPANESE PRESCHOOLFACILITY NUMBER:
384004486
ADMINISTRATOR:HIRAI, HISAMIFACILITY TYPE:
850
ADDRESS:2545 JUDAH STREETTELEPHONE:
(415) 564-6123
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94122
CAPACITY: 12TOTAL ENROLLED CHILDREN: 4CENSUS: 3DATE:
03/08/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Hisami HiraiTIME COMPLETED:
10:00 AM
NARRATIVE
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On March 08, 2024, at approximately 8:30am, Licensing Program Analyst (LPA) Ly conducted an Unannounced Case Management - Lead Testing Visit at and met with Site Director, Hisami Hirai during the visit. Purpose of the inspection was explained. There were the Director and her husband caring for 3 children during today's visit. Per Director, facility has 4 children enrolled in the program. Facility operating days and hours are Monday - Friday 9:00am - 3:00pm.

On this day, LPA verified with Director that facility has not done lead testing on water. Per Director, facility only offer purified bottle water to the children. Based on interview and record review, facility did not conduct lead test or request attestation/waiver by January 01, 2023, poses a potential health and safety risk to persons in care. Type B violation is being cited on this day in accordance with the California Health & Safety Code, see LIC 809D.

A copy of this report and appeal rights were discussed and left with Director whose signature on this form confirm receipt of these reports. Notice of Site Visit was posted. Notice to remain posted for 30 days. For updates on Licensing information, go to CCL website: www.ccld.ca.gov. For Provider Information Notice: ccld.ca.gov/PG5098.htm
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Winnie Ly
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2024
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 03/08/2024 09:43 AM - It Cannot Be Edited


Created By: Winnie Ly On 03/08/2024 at 09:05 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: LITTLE ANGELS JAPANESE PRESCHOOL
FACILITY NUMBER: 384004486

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/08/2024
Section Cited
HSC
1597.16(a)(1)

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(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.

This requirement is not met as evidenced by:
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Per Director, facility only offer purified water bottle to the children. Director will submit request for attestation/waiver to be exempt from lead testing.
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Based on interview and record review, the facility did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
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Request for attestation/waiver need to be submitted by due date 04/08/2024.

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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:Winnie Ly
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024


LIC809 (FAS) - (06/04)
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