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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430701981
Report Date: 03/07/2023
Date Signed: 03/07/2023 10:40:26 AM

Document Has Been Signed on 03/07/2023 10:40 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 JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:WOODHAVEN PRESCHOOL AT WILLOW GLEN UMCFACILITY NUMBER:
430701981
ADMINISTRATOR:SMITH, SUSANFACILITY TYPE:
850
ADDRESS:1420 NEWPORT AVENUETELEPHONE:
(408) 294-6072
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 48TOTAL ENROLLED CHILDREN: 75CENSUS: 36DATE:
03/07/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Susan SmithTIME COMPLETED:
11:00 AM
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 12/24/2022 which resulted in four action level exceedances within the facility of 12 ppb, 11 ppb ,9.3 ppb,and 8.5 ppb. LPA met with the Director, Susan Smith, and explained the nature of today's inspection. Facility stated they were not aware that they had an exceedance. LPA explained that an exceedance is classified as 5.5.ppb or greater.
Prior to today’s inspection, Community Care Licensing received notification of the lead exceedances by the water program. During the inspection of LPA Medrano, allthe fountains that have been found in exceedance have been taped off and are cannot being used. Facility is using main faucets that received clearances for their only source of drinking water. Facility is in the process
The water sample conducted by California Rural Water Association (CRWA) on 12/13/2022, indicated the following:
1) Water Bubbler"B" located in room 104, the Pre- K 1 classroom has Lead Action Level Exceedance value of 12 ppb.
2) Water Bubbler "S" located within outside, in between play yards has Lead Action Level Exceedance of 11 ppb.
3) Water Bubbler "H" located in room 103, the Pre-K 2 classroom has Lead Action Level Exceedance of 9.3 ppb.
4) Water Bubbler"O" located within thr preschool room, near the bathroom has Lead Action Level Exceedance of 8.5 ppb.

LPA has requested the following corrected documents during today’s inspection and was sent via email:
1.Self-Certification (LIC9275)
2.Sampling Checklist Form (LIC9276)
3.Facility Sketch LIC 999 (fully labeled with locations of all water outlets)
4. Full lead report from water program

Type B deficiency was cited, exit interview conducted, and a copy of this report was given and reviewed with the Director, Susan Smith. 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: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2023
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 03/07/2023 10:40 AM - It Cannot Be Edited


Created By: Kassandra Medrano On 03/07/2023 at 10:00 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: WOODHAVEN PRESCHOOL AT WILLOW GLEN UMC
FACILITY NUMBER: 430701981

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/07/2023
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
During inspection faclity has taped off the bubblers found with exceedances. Facility will be in contact with CRWA for remediation. Facility has purchased new bubblers, director has agreed to send documentation of completion as well as new sampling.
8
9
10
11
12
13
14
This exceedance levels found in “B” bubbler was 12 ppb and in bubbler "S" was 11 ppb. Bubbler "H" was found with 9.3ppb and Bubbler "O" was found with 8.5ppb. 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: 03/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023


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