<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430700114
Report Date: 03/23/2023
Date Signed: 03/23/2023 05:34:59 PM

Document Has Been Signed on 03/23/2023 05:34 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 JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:CARTER AVENUE CHRISTIAN PRESCHOOL AND DAYCAREFACILITY NUMBER:
430700114
ADMINISTRATOR:RACHEL SAYREFACILITY TYPE:
850
ADDRESS:5303 CARTER AVENUETELEPHONE:
(408) 265-3580
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY: 60TOTAL ENROLLED CHILDREN: 27CENSUS: 21DATE:
03/23/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Rachel SayreTIME COMPLETED:
03:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Kassandra Medrano, conducted an unannounced case management inspection in response to a completed lead testing on 1/14/2023 resulting in an exceedance level of 7.9. LPA met with the Director, Rachel Sayre, and explained the nature of today's inspection.
Prior to today’s inspection, the facility self reported to the department by sending in the full lead report, as well as plan for facility while they await replacement of the fixture that has exceeded the limit. The lead exceedance reading was found in the sink faucet "E" in “Room 2”. Preceding the arrival of LPA Medrano, facility has discontinued use of the sink for potable water use.

Prior to inspection, LPA has obtained the following documents:
1.Self-Certification LIC9275,
2.Sampling Checklist Form LIC9276
3.Facility Sketch LIC 999 (fully labeled with locations of all water outlets)

Type B deficiency was cited, exit interview conducted, and a copy of this report was given and reviewed with the Director, Rachel Sayre. Appeal rights were reviewed and provided.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE CENTER, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2023
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 03/23/2023 05:35 PM - It Cannot Be Edited


Created By: Kassandra Medrano On 03/23/2023 at 02:59 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: CARTER AVENUE CHRISTIAN PRESCHOOL AND DAYCARE
FACILITY NUMBER: 430700114

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/24/2023
Section Cited

101700.3(b)(1)

1
2
3
4
5
6
7
Lead Testing Written Directives section 101700.3 (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:
1
2
3
4
5
6
7
Director has stated that they have stopped using the faucet.
8
9
10
11
12
13
14
This exceedance level found in “E” sink, found in room 2 was 7.9 ppb This poses a potential risk to the Health, Safety, or Personal Rights of children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Diana Stephenson
LICENSING EVALUATOR NAME:Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2