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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434400282
Report Date: 08/09/2023
Date Signed: 08/11/2023 08:40:50 AM

Document Has Been Signed on 08/11/2023 08:40 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:MONTICELLO CHILD DEVELOPMENT CENTERFACILITY NUMBER:
434400282
ADMINISTRATOR:JHUN, CELENAFACILITY TYPE:
850
ADDRESS:3401 MONROE STREETTELEPHONE:
(408) 261-0494
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY: 111TOTAL ENROLLED CHILDREN: 111CENSUS: 56DATE:
08/09/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Celena JhunTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst(LPA) Anna Morales conducted a Case Management- Lead Testing/Exceedance visit and met with Director Celena Jhun. LPA, also, spoke to Trinh Trinh on the telephone to discuss the purpose of the visit.

LPA was informed that the first Lead Sample test was conducted on 5/8/23 in 21 areas. Level Exceedance(ALE) were found in two locations: SL-W03 Guppy Room-Right Side Fountain=26.4 and in SL-W15 Kids Castle-Left Side Fountain=11.8. LPA was informed that all of the drinking faucets were removed. Directors stated that the children bring their own water bottles and have access to refills( by filter water).

During today's inspection LPA Morales obtained the following documents; Self-Certification LIC9275, Sampling Checklist Form LIC9276, Facility Sketch LIC 999, fully labeled with locations of all water outlets, and full lead report.

During today's inspection, LPA requested verification of passing lead test results for the above outlets' that was retested on 7/25/23. LPA toured the facility and observed that all of the drinking faucets were removed.

A Type B deficiency was issued during visit, exit interview conducted, and a copy of this report was reviewed with the Director Celena Jhun. 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: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2023
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 08/11/2023 08:40 AM - It Cannot Be Edited


Created By: Anna Morales On 08/09/2023 at 03:39 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: MONTICELLO CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 434400282

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2023
Section Cited

101700.3(b)(1)

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Lead Testing Written Directives 101700.3 (b)(1), a result with values 5.5 ppb or greater shall be deemed an Action Level Exceedance. This requirement was met as evidenced by:
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Facility removed all Drinking Faucets from the premises. Children bring their own water bottles and have access to refills from Filter water from the Facility. Director to submit proof of non-ALE results for all outlets by the POC date.
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Lead testing conducted on 5/8/23 showed ALE on 2 outlets in the facility. This posed a potential risk to 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: 08/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023


LIC809 (FAS) - (06/04)
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