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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434407594
Report Date: 10/18/2022
Date Signed: 10/18/2022 09:36:48 AM

Document Has Been Signed on 10/18/2022 09:36 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:GRACE PRESCHOOLFACILITY NUMBER:
434407594
ADMINISTRATOR:KRISTY CURRIEFACILITY TYPE:
850
ADDRESS:111 CHURCH STREETTELEPHONE:
(408) 354-7163
CITY:LOS GATOSSTATE: CAZIP CODE:
95030
CAPACITY: 69TOTAL ENROLLED CHILDREN: 71CENSUS: 55DATE:
10/18/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Kristy CurrieTIME COMPLETED:
09:50 AM
NARRATIVE
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On October 18th, 2022 at 8:30 am, Licensing Program Analyst (LPA), Kassandra Medrano, conducted an unannounced case management inspection in response to a completed lead testing resulting in an exceedance level of 6.3. LPA met with the Director, Kristy Currie, and explained the nature of today's inspection.
Prior to today’s inspection, the facility self reported to the department by sending in the full lead report, as well as documentation of the replacement of the fixture that has exceeded the limit. The lead exceedance reading was found in the drinking fountain in “Room 1”. Preceding the arrival of LPA Medrano, the water fountain was disconnected and repaired by a plumber. Facility has submitted the documentation the water program has requested in order to conduct the corrective action sampling. Facility is currently waiting for a re-testing of the fountain that has been repaired.

LPA has requested and obtained the following documents via email during todays inspection:
1.Self-Certification LIC9275,
2.Sampling Checklist Form LIC9276
3.Facility Sketch LIC 999 (fully labeled with locations of all water outlets)

Type B deficiency was cited, exit interview conducted, and a copy of this report was given and reviewed with the Director, Kristy Currie. 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: Diana Stephenson
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2022
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 10/18/2022 09:36 AM - It Cannot Be Edited


Created By: Kassandra Medrano On 10/18/2022 at 08:38 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: GRACE PRESCHOOL
FACILITY NUMBER: 434407594

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
11/18/2022
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 facility self-reported by submitting an unusual incident report, the facility immediately stopped use of fountain and had it repaired on 09/01/2022.
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This exceedance level found in “Room 1” drinking fountain was 6.3. 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:Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2022


LIC809 (FAS) - (06/04)
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