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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004138
Report Date: 04/04/2024
Date Signed: 04/04/2024 03:36:28 PM

Document Has Been Signed on 04/04/2024 03:36 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:THOMAS EDISON ELEMENTARY SCHOOLFACILITY NUMBER:
414004138
ADMINISTRATOR/
DIRECTOR:		ZIMIGA, LISAFACILITY TYPE:
850
ADDRESS:1267 SOUTHGATE AVENUETELEPHONE:
(650) 991-1250
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 24TOTAL ENROLLED CHILDREN: 21CENSUS: 4DATE:
04/04/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Geraldine MalunayTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On April 4, 2024 at approximately 3:30pm, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, case management visit. LPA met with site supervisor, Geraldine Mulunay, and explained the purpose of the visit. Present during visit included 4 preschool children with site supervisor and 1 teaching staff.

Preschool program operates at Thomas Edison Elementary in KB classroom only. Children have access to drinking water at facility through a water pitcher that is refilled in classroom through a sink or water fountain.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care
Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.

Facility completed lead water testing March 9, 2024, past the testing due date of January 1, 2023. Water fixture tested is below the 5.5ppb threshold.

LPA referred facility representative to the Department website for lead: Toxicity Prevention and Water Testing Information.

Facility is being cited a Type B citation for completing lead water testing requirement after due date. Water fixture tested is below the 5.5ppb threshold. Deficiency will be cleared on this date.

A notice of site visit was given and must remain posted for 30 days. Appeal Rights were also provided.

Exit interview conducted and report was reviewed with the facility representative, Geraldine Malunay.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2024
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 04/04/2024 03:36 PM - It Cannot Be Edited


Created By: Catrina Quimbo On 04/04/2024 at 03:22 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: THOMAS EDISON ELEMENTARY SCHOOL
FACILITY NUMBER: 414004138

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

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HSC 1597.16(a)(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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Facility completed lead water testing March 9, 2024. Water fixture tested is below the 5.5ppb threshold. Deficiency cleared on same date.
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Based on interview and record review, the licensee did not comply with the section cited above by not completing lead testing by January 1, 2023 which poses a potential health, safety or personal rights risk to persons in care.
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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:Marie Rodriguez
LICENSING EVALUATOR NAME:Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024


LIC809 (FAS) - (06/04)
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