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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410505801
Report Date: 11/07/2023
Date Signed: 11/07/2023 04:26:06 PM

Document Has Been Signed on 11/07/2023 04:26 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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SAN MATEO PARENT'S NURSERY SCHOOLFACILITY NUMBER:
410505801
ADMINISTRATOR:MIE NAKAMURAFACILITY TYPE:
850
ADDRESS:1732 MONTE DIABLO AVETELEPHONE:
(650) 347-1955
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 38TOTAL ENROLLED CHILDREN: 38CENSUS: 14DATE:
11/07/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Mie NakamuraTIME COMPLETED:
04:40 PM
NARRATIVE
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On 11/7/2023, at approximately 3:40PM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced case management visit regarding an Action Level Exceedance (ALE) due to lead in the Child Care Center's water. LPA was granted entry to the facility by Director, Mie Nakamura. LPA explained the purpose of the visit. Present during the visit were three staff and 14 children. The facility is in compliance with staff-child ratios.

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 initially tested its water for lead on 5/12/2023 and was not in compliance with the testing requirement.

The facility received the initial ALE report from the Vendor on 5/18/2023. Test results for two fixtures in this facility exceeded a higher level of parts per billion (ppb) allowed, 5.5 ppb, fixtures E(26.0) and H(11.0). Both fixtures are hand washing sinks in bathrooms that are for use by children. Per Director, the facility added filters to the hand washing sinks and sampled the fixtures again on 8/30/2023. The facility received the ALE report from the Vendor on 10/18/2023, with Fixture E testing at 0.43 ppb and Fixture H testing at 0.73 ppb. Both fixtures are below the threshold for an ALE. All other fixtures tested below the threshold and are in compliance with the Written Directives detailed in PIN 21-21.1-CCP.

Per Written Directives 101700.3(b)(2), licensees shall maintain a lead value at or below 5ppb in all outlets subject to testing requirements for the health and safety of children in care. The Written Directives are included in HSC 1597.16, and are specific guidelines for facilities to adhere to regarding lead water testing. Due to updated guidance on the written directives in PIN 21-21.1-CCP, the facility will be cited for the ALE of fixtures E and H. The deficiency will be cleared the same day of the visit because the fixtures have retested below the threshold. LPA advised that lead testing results and LIC forms 9275, 9276 and 999 should be posted.

This report was reviewed and signed by Director, Mie Nakamura.
A Notice of Site Visit was given and must be posted for thirty days.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/07/2023 04:26 PM - It Cannot Be Edited


Created By: Jonathan Tse On 11/07/2023 at 03:55 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: SAN MATEO PARENT'S NURSERY SCHOOL

FACILITY NUMBER: 410505801

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/07/2023
Section Cited
HSC
1597.16(a)(1)

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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 was not met, as evidenced by:
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The facility tested for lead on 5/12/2023.
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Based upon record review, the facility did not test for lead until 5/12/2023. This posed a potential health, safety, or personal rights risk to the persons in care.
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The facility is now in compliance with lead testing and the deficiency will cleared the same day of the visit, 11/7/2023.
Type B
12/07/2023
Section Cited
HSC1597.16

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WD101700.3(b)(2) Licensees shall maintain a lead value at or below the Action Level of 5 ppb in all outlets subject to the testing requirements of these Written Directives, for the health and safety of children in care.

This requirement was not met as evidenced by:
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The facility took steps to remediate the hand washing fixtures by installing lead filters and retesting the fixtures on 8/30/2023. The fixtures then tested below the ALE level and are now in compliance.
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Based upon record review, the facility had two fixtures (E and H) that tested above the Action Level of 5ppb. This posed a potential health, safety, or personal rights risk to persons in care.
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This deficiency will be cited and cleared the same day of the visit, 11/7/2023.
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:Jonathan Tse
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023


LIC809 (FAS) - (06/04)
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