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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004670
Report Date: 11/16/2023
Date Signed: 11/16/2023 03:56:40 PM

Document Has Been Signed on 11/16/2023 03:56 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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:PALCARE (TIDEPOOLS)FACILITY NUMBER:
414004670
ADMINISTRATOR:KIESSELBACH, LISAFACILITY TYPE:
830
ADDRESS:1001 CALIFORNIA DRIVETELEPHONE:
(650) 787-5477
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 32TOTAL ENROLLED CHILDREN: 32CENSUS: 11DATE:
11/16/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
03:03 PM
MET WITH:Tina HardleyTIME COMPLETED:
04:15 PM
NARRATIVE
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On November 16, 2023, Licensing Program Analyst (LPA) Garcia conducted an unannounced, case management inspection for the Action Level Exceedance (ALE) of Lead in Child Care Center's water. LPA met with director, Tina Hardley. LPA explained the purpose of the visit and was given a tour of the facility.
Present in facility are 11 children, with 5 staff members.

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 received the first ALE report from the Vendor on December 22, 2022. Test results for this facility that exceeded a higher level of parts per billion (ppb) allowed, 5.5 ppb. The facility was proactive in getting facility faucets tested and putting signs indicating that the water fountain/kitchen fixture is not for drinking and or currently out of order. The affected fixture is B(5.9), which is a sink faucet located in the staff lounge, used by adults. The facility replaced and retested the fixture on January 6, 2023 with the results at B(26) and after 30 seconds of flush at 7 parts per billion (ppb). The third retest was done with new pipes and filters installed and the results from the February 28, 2023 retest is less than 1 (ppb) of lead for fixture 'B'. The facility were/are using other water sources for food preparation, and water ingestion.

The facility was not initially cited for the action level exceedance during the lead case management visit on February 2, 2023. Due to updated guidance on the written directives in the PIN 21-21.1-CCP, the facility will be cited for the action level exceedance of the fixture. However, the facility has removed the affected fixture before the lead case management visit and the citation given today will be cleared on the same day.

LPA obtained hard copies of the External Water Sampler Self-Certification Form (LIC9275), Child Care Center Sampling Checklist (LIC9276), Facility Sketch (LIC999).

* See next page for deficiencies cited today and will also be cleared on the same day.

This report was reviewed and signed by Director, Tina Hardley.

This notice of Site visit was provided to the Director and must remain posted for 30 days.

SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Nathan Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023
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 11/16/2023 03:56 PM - It Cannot Be Edited


Created By: Nathan Garcia On 11/16/2023 at 03:39 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: PALCARE (TIDEPOOLS)
FACILITY NUMBER: 414004670

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/15/2023
Section Cited

101700.3

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101700.3 California Lead Action Level at Child Care Centers (b)(1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.

This requirement was not met as evidenced by:
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The facility had the fixture replaced, flushed and retested on February 28, 2023. The retest results show below 5 ppb of lead for fixture 'B'. Facility had remediated the affected fixture before the visit.
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Based on results received from the certified water samplers, the facility exceeded 5.4 ppb of lead in their water source. This posed a potential health, safety, or personal rights risk to persons in care.
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Deficiency will be cited and cleared on the same visit, 11/16/2023.

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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:Daniel J Oquendo
LICENSING EVALUATOR NAME:Nathan Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023


LIC809 (FAS) - (06/04)
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