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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434406757
Report Date: 03/15/2023
Date Signed: 03/15/2023 03:40:29 PM

Document Has Been Signed on 03/15/2023 03:40 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:KIDANGO MEYER CENTERFACILITY NUMBER:
434406757
ADMINISTRATOR:CAROLYN LOAYZAFACILITY TYPE:
850
ADDRESS:1824 DAYTONA DRIVETELEPHONE:
(408) 258-9129
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY: 22TOTAL ENROLLED CHILDREN: 22CENSUS: 15DATE:
03/15/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Raquel RiveraTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Janette Cruz and Cynthia Tamayo conducted an unannounced case management inspection and met with Raquel Rivera, Teacher. LPAs explained the purpose of today’s inspection is to follow-up lead testing completed on 9/15/22 that indicated a water outlet found to have Action Level Exceedance (ALE) of 52 parts per billion (ppb). Census was taken, LPAs observed 15 children with total of three staff supervising. LPAs reviewed the water sample summary and requested Raquel to identify water outlet “C" located in Room 80. LPAs informed Raquel that results of water testing indicated ALE, hence, water from outlet "C" is not safe to drink or be used for food preparation due to elevated levels of lead.

LPAs observed that plastic bag is placed over the affected outlet "C" making it inaccessible for use. Raquel stated that the remediation process had started and water faucet "C" was replaced on 3/6/23. Raquel stated that there is no water re-sampling scheduled at this time. The facility is conducting proper procedures and flushing out water in preparation for water retesting tentatively scheduled for 04/03/23. The facility is currently using a Brita water filter that is refilled via water outlet "D" for the staff and children for drinking purposes, until the results clear retesting.

LPAs obtained the following facility documents during todays inspection: Self-Certification (LIC9275) completed by Certified External Water Sampler, Sampling Checklist Form (LIC9276), Facility Sketch (LIC999) labeled with locations of water outlets that were tested and water testing summary conducted by Alpha Analytical Laboratories Inc. on 10/27/22.

As a result of this inspection, Type B deficiency was cited on the following page.
Exit interview conducted and Appeal Rights was discussed with Teacher, Raquel Rivera.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2023
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 03/15/2023 03:40 PM - It Cannot Be Edited


Created By: Janette Cruz On 03/15/2023 at 02:37 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: KIDANGO MEYER CENTER
FACILITY NUMBER: 434406757

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2023
Section Cited

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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Licensee will submit a written plan of action by POC due date 04/14/23 showing proof of remediation (plumbing/repair of outlet) and water retested within 30 days before use for drinking. Licensee will have bottled waters available on site.
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Based on observation and record review, the Lead Sampling Report conducted on 09/15/22 indicated that water outlet "C" had elevated lead of 52 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:Diana Stephenson
LICENSING EVALUATOR NAME:Janette Cruz
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2023


LIC809 (FAS) - (06/04)
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