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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430703788
Report Date: 01/19/2023
Date Signed: 01/20/2023 03:17:51 PM

Document Has Been Signed on 01/20/2023 03:17 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:BRIARWOOD CHILDREN'S CENTER/STATE PRESCHOOLFACILITY NUMBER:
430703788
ADMINISTRATOR:STEPHANIE MASCIOCCHIFACILITY TYPE:
850
ADDRESS:1940 TOWNSEND AVE.,RMS25,26&27TELEPHONE:
(408) 423-1321
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY: 88TOTAL ENROLLED CHILDREN: 88CENSUS: DATE:
01/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Whitney LuckancTIME COMPLETED:
12:10 PM
NARRATIVE
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Licensing Program Analyst (LPA), Anna Morales conducted an unannounced Case Management inspection. LPA met with Acting Site Supervisor Whitney Lukanc, and explained the purpose of the inspection. LPA reviewed water sample summary and requested staff to identify Drinking Fountain In Room 25, 27 and in 30. with reported Lead Action Level Exceedance of 5.5 parts per billion (ppb) or greater.

LPA observed that the Drinking Fountains is located in Rooms 26,27 and in 30. LPA observed that the Drinking Fountains are covered with plastic. These fountains have been closed off from student and staff access. Room 30 is not being used and inaccessible to the children ( the classroom is locked).

On November 22,2022, LPA obtained the following facility documents: Self-Certification (LIC9275) completed by Certified External Water Sampler, Sampling Checklist Form (LIC9276), and Facility Sketch (LIC999) labeled with locations of water outlets that were tested. The water sample conducted by California Rural Water Association (CRWA) on 11/19/2022 indicated the following:

1) Faucet- -Drinking Fountain Room- 25, FOUNTAIN BUBBLER has Lead Action Level Exceedance value of 27 ppb.,
2) Faucet- Drinking Fountain Room- 27, FOUNTAIN BUBBLER has Lead Action Level Exceedance value of 22 ppb.
3) Faucet- Drinking Fountain Room- 30, FOUNTAIN BUBBLER has Lead Action Level Exceedance value of 5.2 ppb.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2023
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 01/20/2023 03:17 PM - It Cannot Be Edited


Created By: Anna Morales On 01/19/2023 at 10:04 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: BRIARWOOD CHILDREN'S CENTER/STATE PRESCHOOL
FACILITY NUMBER: 430703788

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/23/2023
Section Cited
CCR
101700.3(b)(1)

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Lead Testing Written Directives - a result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. 
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The fountains are covered with plastic and currently not being used. The children are bringing their own water bottles and they have access to a refill water station if needed..
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Based on record review, the Lead Sampling Report in three identified Drinking Fountain/ Bubbler in Room 25, 27,and 30 had elevated lead above 5.5 ppb. This poses a potential risk to the health, safety, or personal rights of children 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:Gladys Kuizon
LICENSING EVALUATOR NAME:Anna Morales
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: BRIARWOOD CHILDREN'S CENTER/STATE PRESCHOOL
FACILITY NUMBER: 430703788
VISIT DATE: 01/19/2023
NARRATIVE
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As a result of this inspection, Type B deficiency was cited on the following page. Exit interview conducted and report was reviewed with Whitney Lukanc.

NOTICE OF SITE VISIT WAS ISSUED. DIRECTOR WAS INFORMED TO POST THE NOTICE IN A VISIBLE LOCATION OF THE DAY CARE FOR A PERIOD OF 30 DAYS.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC809 (FAS) - (06/04)
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