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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414000798
Report Date: 11/07/2023
Date Signed: 11/07/2023 03:08:49 PM


Document Has Been Signed on 11/07/2023 03:08 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 MONTESSORIFACILITY NUMBER:
414000798
ADMINISTRATOR:TINA PROZELLFACILITY TYPE:
850
ADDRESS:15 - 14TH AVENUETELEPHONE:
(650) 571-5095
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY:21CENSUS: 18DATE:
11/07/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Assistant Director, Wendy WongTIME COMPLETED:
03:25 PM
NARRATIVE
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On 11/7/2023, at approximately 1:10PM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced case management visit regarding an Action Level Exceedance (ALE) with the lead in the Child Care Center's water. LPA was granted entry to the facility by Assistant Director, Wendy Wong. LPA explained the purpose of the visit. Present in the facility are 5 staff and 18 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 initially tested its water for lead on 11/5/2022, and therefore is in compliance with the testing requirement.

The facility received the initial ALE report from the Vendor on 12/14/2022. Test results for one fixture in this facility exceeded a higher level of parts per billion (ppb) allowed, 5.5 ppb, fixture A (26.0). Fixture A is a sink in the kitchen, and is primarily for staff use. The facility had replaced the filter for the fixture and sampled the water again on 7/15/2023. The facility received the ALE report from the Vendor on 9/13/2023, and fixture A tested at 6.5ppb, above the the level allowed. Per Assistant Director, the facility has retested the fixture again on 10/18/2023 and received results on 11/6/2023. LPA acquired a copy of the lead testing results and verified that fixture A did not have any lead detected. 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 equivalent to 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 action level exceedance of fixture A. The deficiency will be cleared once the lab uploads test results to the lead sampling database. LPA advised that lead testing results and LIC forms 9275, 9276 and 999 should be posted.

This report was reviewed and signed by Assistant Director, Wendy Wong.
A Notice of Site Visit was given and must be posted for thirty days.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan TseTELEPHONE: (650) 464-4927
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 03:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 MONTESSORI
FACILITY NUMBER: 414000798

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

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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 has taken action to remediate the fixture by retesting twice. The facility received lab results from an ELAP certified laboratory and the fixture is now compliant with WD 101700.3(b)(2).
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Based on record review of the water sampling database, the facility was not in compliance with the above as of the initial water results uploaded on 12/14/2022. This posed a potential health, safety, or personal rights risk to persons in care.
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The deficiency cited today will be cleared once the results are uploaded onto the water sampling portal by the laboratory.

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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 ZebilaTELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan TseTELEPHONE: (650) 464-4927
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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