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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002634
Report Date: 11/29/2023
Date Signed: 11/29/2023 09:56:54 AM

Document Has Been Signed on 11/29/2023 09:56 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:SBPSD ALLEN ELEMENTARY SCHOOL & PRESCHOOLFACILITY NUMBER:
414002634
ADMINISTRATOR:MCGINN, PAUAHIFACILITY TYPE:
850
ADDRESS:500 ACACIA AVENUETELEPHONE:
(650) 624-3158
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 84TOTAL ENROLLED CHILDREN: 84CENSUS: 16DATE:
11/29/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Director, Pauahi McGinnTIME COMPLETED:
10:10 AM
NARRATIVE
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On 11/29/2023, at approximately 8:30AM, 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 Site Supervisor, Regina Quintana. LPA explained the purpose of the visit. Present during the visit were four staff and 16 children. The facility is in compliance with staff-child ratios. Director Pauahi McGinn arrived during the visit.

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 Assistant 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 7/12/2023 and was not in compliance with the testing requirement.

The facility received the initial ALE report from the Vendor on 7/28/2023. Test results for two fixtures in this facility exceeded a higher level of parts per billion (ppb) allowed, 5.5 ppb, fixtures H(8.6) and J(26.0). Fixture H is located in Classroom 3H and Fixture J Is located in Classroom 6H. The facility had children bring water bottles from home and provided water from other fixtures that did not have exceedances, and sampled the fixtures again on 9/13/2023. The facility received the ALE report from the Vendor on 10/3/2023, with Fixture J testing below 1.0ppb. Fixture H retested at 9.8ppb. The facility continues to provide bottled water and water from alternative sources without an exceedance. The facility plans to replace Fixture H and install a lead filter. 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. Due to updated guidance on the written directives in PIN 21-21.1-CCP, the facility will be cited for the ALE of fixture H. LPA advised that lead testing results and LIC forms 9275, 9276 and 999 should be posted.
See LIC809-D for deficiency cited today.
This report was reviewed and signed by Director, Pauahi McGinn.
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: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2023
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 11/29/2023 09:56 AM - It Cannot Be Edited


Created By: Jonathan Tse On 11/29/2023 at 09:23 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: SBPSD ALLEN ELEMENTARY SCHOOL & PRESCHOOL
FACILITY NUMBER: 414002634

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2023
Section Cited

101700.3(b)(2)

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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 fixtures by providing an alternative water source that did not have an exceedance and retesting the fixtures on 9/13/2023. The facility is replacing the fixture and installing a lead filter. The facility shall retest the fixture that tested above the ALE and submit lead sampling results, LIC9275, LIC9276, and LIC999 to LPA.
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Based upon record review, the facility had two fixtures (H and J) 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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Facility shall submit lead testing results, LIC9275, LIC9276, and LIC999 to LPA by POC due date, 12/29/2023.

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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:Ali Zebila
LICENSING EVALUATOR NAME:Jonathan Tse
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2023


LIC809 (FAS) - (06/04)
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