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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004813
Report Date: 11/07/2023
Date Signed: 11/07/2023 02:57:05 PM

Document Has Been Signed on 11/07/2023 02:57 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:PACIFIC RIM INTERNATIONAL SCHOOLFACILITY NUMBER:
414004813
ADMINISTRATOR:CHEUNG, CHRISTINIAFACILITY TYPE:
850
ADDRESS:2600 CAMPUS DRIVETELEPHONE:
(650) 685-1881
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 120TOTAL ENROLLED CHILDREN: 120CENSUS: 28DATE:
11/07/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Rita TangTIME COMPLETED:
03:00 PM
NARRATIVE
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On November 7, 2023, Licensing Program Analysts (LPAs) Luis Gomez and Man Tso met with director, Rita Tang. Purpose of inspection was explained and was for an unannounced, case management inspection to cite for the Action Level Exceedance (ALE) of Lead in Child Care Center's water. Present in facility was director and 6 staff supervising 28 children during the napping time. LPAs inspected facility for health and safety hazards.

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 ALE report from the Vendor on March 29, 2023. Test results for this facility that exceeded a higher level of parts per billion (ppb) allowed, 5.5 ppb. The affected fixture, fixture F, tested (6.6); fixture V, tested (6.1); and fixture W, tested (8.3). Fixtures F, V and W are located at the pre-school program.

The affected fixture F, V and W, were retested on September 2, 2023, with a reading of < 1ppb. Per the written directives in PIN 21-21.1-CCP, facility will be cited for the actionable level exceedance of the fixtures.

LPA obtained the copies of the External Water Sampler Self-Certification Form (LIC9275), Child Care Center Sampling Checklist (LIC9276), Facility Sketch (LIC999), has been sent to the department by email.

* See next page for deficiencies cited today

This report was reviewed and signed by Director, Rita Tang.

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

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Man Tso
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)
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Document Has Been Signed on 11/07/2023 02:57 PM - It Cannot Be Edited


Created By: Man Tso On 11/07/2023 at 02:16 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: PACIFIC RIM INTERNATIONAL SCHOOL
FACILITY NUMBER: 414004813

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2023
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 retested the affected fixture on 9/2/23. It reads < 1 ppb, which is lowered than the Action Level Exceedance.

Deficiency has been cleared.

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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 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:Ali Zebila
LICENSING EVALUATOR NAME:Man Tso
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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