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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412705
Report Date: 03/22/2023
Date Signed: 03/22/2023 12:31:30 PM

Document Has Been Signed on 03/22/2023 12:31 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:QUEEN OF APOSTLES SCHOOLFACILITY NUMBER:
434412705
ADMINISTRATOR:PAUL, SOPHIAFACILITY TYPE:
850
ADDRESS:4950 MITTY WAYTELEPHONE:
(408) 252-3659
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY: 40TOTAL ENROLLED CHILDREN: 40CENSUS: 5DATE:
03/22/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Sophia PaulTIME COMPLETED:
01:05 PM
NARRATIVE
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On 03/09/2023, Licensing Program Analyst (LPA) Pete Hernandez, met with Director, Sophia Paul, for a case management Lead Testing/ Exceedance visit in regards to the lead testing results submitted by the facility and explained the reason for the visit to them. Present were 3 staff with 5 children in care.

Facility submitted that there is an exceedance of about 5.7 (ppb) sample (C) faucet located in the sink of pre-k room in the back area. Director stated that the above have been disabled and will not be used. Director stated that the above have been disabled and will not be used until repaired and passes retesting.. Retesting has not been requested yet because they are waiting for the faucet to be replaced by the the school first. The facility uses water for the staff and children from other faucets that have passed lead safety testing of 5.5 (ppb) or less.

Type B deficiency was cited during today's visit. Director was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date will result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made. Exit interview conducted and report was reviewed with the Director, Sophia Paul,

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: Gladys Kuizon
LICENSING EVALUATOR NAME: Pietro Hernandez
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 03/22/2023 12:31 PM - It Cannot Be Edited


Created By: Pietro Hernandez On 03/22/2023 at 12:13 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: QUEEN OF APOSTLES SCHOOL
FACILITY NUMBER: 434412705

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2023
Section Cited

101700.3(b)(1)

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101700.3(b)(1)
Testing results with fractional ppb readings of 0.5 ppb or greater shall be rounded up to the nearest whole number, before comparing to the Action Level. A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. This requirement is not met as evidenced by:
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By the POC date 5/12/2023: Licensee will have the repair completed and retesting performed. Licensee shall provide proof of repair and retest rwesults submitted to CCLD.
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Facility submitted that there is an exceedance of about 5.7 (ppb) sample (C) faucet located in the sink of pre-k room in the back area.This poses a potential risk to the children.
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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:Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2023


LIC809 (FAS) - (06/04)
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