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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408781
Report Date: 07/12/2023
Date Signed: 07/12/2023 02:39:05 PM

Document Has Been Signed on 07/12/2023 02:39 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:KIDDIE ACADEMY OF SAN JOSEFACILITY NUMBER:
434408781
ADMINISTRATOR:MARIE NUNEZFACILITY TYPE:
850
ADDRESS:521 WEST CAPITOL EXPRESSWAYTELEPHONE:
(408) 978-1500
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 98TOTAL ENROLLED CHILDREN: 98CENSUS: 73DATE:
07/12/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
01:12 PM
MET WITH:Marie NunezTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Harsimran Kaur, met with site Director, Marie Nunez, and explained purpose of today's visit- to follow-up on water lead testing conducted for the facility. Upon arrival, LPA toured the facility and requested director identify the faucet with Action Level Exceedance (ALE)- a value of 5.5 parts per billion or greater.

Water lead testing was conducted on March 2022 and indicated that kitchen faucet (used for cooking) located in the preschool classroom had an ALE of 6.7. The faucet has been fully replaced and is currently being used for cooking. Drinking water is being provided by gallon bottles located in the classrooms. LPA requested that the facility update Licensing when a retest date has been confirmed for faucet and advised that the results be submitted once retesting is completed.

The facility has submitted required documentation for water lead testing and LPA requested that the following documents are submitted by 08/11/2023:

-Self-Certification completed by Certified External Water Sampler (LIC9275)


-Sampling Checklist Form (LIC9276)
-Facility Sketch (LIC999) with faucets clearly labeled with water lead testing letters
-Water lead test results

Exit interview conducted and report was reviewed with the Site Supervisor, Marie Nunez.

As a result of todays inspection, a deficiency was cited, see 809-D.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Harsimran Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2023
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 07/12/2023 02:39 PM - It Cannot Be Edited


Created By: Harsimran Kaur On 07/12/2023 at 01:35 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: KIDDIE ACADEMY OF SAN JOSE
FACILITY NUMBER: 434408781

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/11/2023
Section Cited

101700.3(b)(1)

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101700.3 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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The facility fully replaced faucet and Results for lead retesting should be submitted upon completion.

LPA requested the facility update Licensing on the date water lead retesting is scheduled.
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After water lead testing was completed, the facility had one faucet located in the kitchen with an Action Level Exceedance of 6.7, which poses a potential risk to the health, safety, and personal rights of children in care.
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Additionally, all required documentation (LIC9275, LIC9276, LIC999, water lead test results) should be submitted to the Department 08/11/23

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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:Harsimran Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023


LIC809 (FAS) - (06/04)
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