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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430706089
Report Date: 11/10/2022
Date Signed: 11/10/2022 03:59:22 PM

Document Has Been Signed on 11/10/2022 03:59 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:CAMPBELL CHRISTIAN EARLY CHILDHOOD CENTERFACILITY NUMBER:
430706089
ADMINISTRATOR:KATHY HARMONFACILITY TYPE:
850
ADDRESS:1075 WEST CAMPBELL AVE.TELEPHONE:
(408) 370-4900
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY: 116TOTAL ENROLLED CHILDREN: 79CENSUS: 59DATE:
11/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Kathy HarmonTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA), James Santos conducted an unannounced case management inspection today and met with Director, Kathy Harmon. The case management inspection is in response to a lead testing completed with exceedance levels. The positive lead finding test results was self reported to Community Care Licensing (CCL) on 11/7/2022.

Per report, the lead exceedance result was found on a drinking fountain located in the playground area. Prior to today's visit, the drinking fountain was removed and capped the water and waste line and is no longer used. The center provides filtered drinking water for the children in the classrooms and outside area.

During today's inspection, LPA observed that the identified drinking fountain is no longer operational.

A deficiency has been cited. See attached 809D page. Exit interview conducted with Director, Kathy Harmon. A copy of this report and appeal rights were reviewed and provided.



NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: James G Santos
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2022
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 11/10/2022 03:59 PM - It Cannot Be Edited


Created By: James G Santos On 11/10/2022 at 12:44 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: CAMPBELL CHRISTIAN EARLY CHILDHOOD CENTER
FACILITY NUMBER: 430706089

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2022
Section Cited

101700.3(b)(1)

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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:
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Prior to today's inspection, the drinking fountain was removed and capped the water and waste line and is no longer used.

*CORRECTED
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The exceedance level found at a drinking fountain located in Building 1 on the playgound area.
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:Joel Segura
LICENSING EVALUATOR NAME:James G Santos
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022


LIC809 (FAS) - (06/04)
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