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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434403523
Report Date: 03/08/2023
Date Signed: 03/08/2023 11:31:49 AM


Document Has Been Signed on 03/08/2023 11:31 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:KINDERCARE LEARNING CENTERFACILITY NUMBER:
434403523
ADMINISTRATOR:AMANDA HERNANDEZFACILITY TYPE:
830
ADDRESS:1155 EAST ARQUES AVENUETELEPHONE:
(408) 245-3276
CITY:SUNNYVALESTATE: CAZIP CODE:
94085
CAPACITY:73CENSUS: 50DATE:
03/08/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Amanda "Mandy" HernandezTIME COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analyst (LPA), Mel Matos conducted an unannounced case management inspection to discuss the lead water testing and Action Level Exceedance (ALE) for two water faucets within the Facility. LPA met with Amanda "Mandy" Hernandez, director, and explained purpose of today's inspection to her.

The lead testing was completed by Clinical Lab of San Bernardino, Inc on December 10, 2022. An Action Exceedance Level is a value of 5.5 parts per billion or greater. Two water faucets, Fixture I (Toddler 2 room I Faucet) reported an ALE of 17 parts per billion and
Fixture H (Infant 3 room H Faucet) reported an ALE of 12 parts per billion.

Mandy states that both water faucets were removed from service and drinking water is being provided only from faucets and drinking fountains that have tested below the ALE value of 5.5 parts per billion. Mandy states that both faucets have been replaced and are currently being flushed out before retesting can be completed.

Mandy agreed to submit the Self-Certification form (LIC 9275), Sampling Checklist form (LIC 9276) and updated Facility Sketch (LIC 999) to update the Facility file.

Exit interview conducted and report was reviewed with the Director, Amanda "Mandy" Hernandez. The following Type B deficiency is cited on the attached page (LIC 809-D). Copy of appeal rights was provided to Mandy prior to the conclusion of today's inspection.

Notice of site visit was issued and must remain posted for 30 days.

SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023
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 03/08/2023 11:31 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: KINDERCARE LEARNING CENTER
FACILITY NUMBER: 434403523

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
04/07/2023
Section Cited

101700.3(b)(1)

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Lead Testing Written Directives (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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Director states that both water faucets were removed from service and drinking water is being provided only from faucets and drinking fountains that have tested below the ALE value of 5.5 parts per billion.
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Fixture I (Toddler 2 room I Faucet) reported an ALE of 17 parts per billion & Fixture H (Infant 3 room H Faucet) reported an ALE of 12 parts per billion. This poses a potential risk to the health, safety, and personal rights of children in care.
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Director states that both faucets have been replaced and are currently being flushed out before retesting can be completed. Mandy agreed to submit the results of the follow up testing to LPA Matos by April 7, 2023.

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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: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023
LIC809 (FAS) - (06/04)
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