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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710458
Report Date: 12/14/2022
Date Signed: 12/15/2022 09:04:30 AM

Document Has Been Signed on 12/15/2022 09:04 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:HUGHES STATE PRESCHOOLFACILITY NUMBER:
430710458
ADMINISTRATOR:ADRIANA SALASFACILITY TYPE:
850
ADDRESS:4949 CALLE DE ESCUELATELEPHONE:
(408) 423-1518
CITY:SANTA CLARASTATE: CAZIP CODE:
95054
CAPACITY: 44TOTAL ENROLLED CHILDREN: 44CENSUS: 11DATE:
12/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Joanie NellisTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA), Anna Morales conducted an unannounced Case Management inspection. LPA met with Site Supervisor Joanie Nellis and explained the purpose of the inspection. LPA reviewed water sample summary and requested to identify the kitchen drinking faucet in Room 25 (with reported Lead Action Level Exceedance of 5.5 parts per billion (ppb) or greater. Joanie stated that Classroom 25 ( DISTRICT PRESCHOOL) has been closed (approximately in 2020),and it is unknown when it will be re-opened..

Staff (S1) from Hughes Elementary came to ROOM 25 to unlocked the door. Staff (S1) states that the drinking fountain in the Kitchen (R)had been replaced approximately on Monday, December 12, 2022.

On November 7,2022, 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 11/15/2022 indicated the following:
1) Faucet- -Drinking Fountain Room- Kitchen(R) has Lead Action Level Exceedance value of 82 ppb.
As a result of this inspection, Type B deficiency was cited on the following page. Exit interview conducted and report was reviewed with Director Joanie Nellis.

Due to Technical difficulties, LPA was unable to leave a copy of this report with Joanie Nellis. LPA will submit once return to the office.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2022
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 12/15/2022 09:04 AM - It Cannot Be Edited


Created By: Anna Morales On 12/14/2022 at 09:28 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: HUGHES STATE PRESCHOOL
FACILITY NUMBER: 430710458

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/16/2023
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. 

This requirement was not met as evidenced by:
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CLASSROOM 25 (District Preschool) is closed and the children have not been using the classroom for approximately two years. Children are using their own individual water container Site Supervisor Nellis states that they(children) use the water from Classroom 37, or from the water fountain outside in the playground to refill their individual water container if needed.
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Based on record review, the Lead Sampling Report in one (1) identified faucet in Room 25, Kitchen(R) 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: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022


LIC809 (FAS) - (06/04)
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