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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415300
Report Date: 03/12/2024
Date Signed: 03/12/2024 01:50:34 PM

Document Has Been Signed on 03/12/2024 01:50 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:ENGENIUS LEARNING CENTER @ BOOKSIN ELEMENTARYFACILITY NUMBER:
434415300
ADMINISTRATOR:IKEMOTO, DOUGFACILITY TYPE:
840
ADDRESS:1590 DRY CREEK ROADTELEPHONE:
(408) 785-1599
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 150TOTAL ENROLLED CHILDREN: 176CENSUS: 0DATE:
03/12/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
01:24 PM
MET WITH:Doug Ikemoto and David WalterTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Cortney Nelson and Mandeep Kaur, met with Site Director, Doug Ikemoto, and Assistant Site Director, David Walter, and explained purpose of visit- to follow-up on water lead testing conducted for the facility. Upon arrival, LPAs toured the facility and requested facility representatives identify faucet with Action Level Exceedance (value of 5.5 parts per billion or greater).

LPA received the following documents via email from Doug on 2/28/2024: Self-Certification (LIC9275) completed by Certified External Water Sampler, Sampling Checklist Form (LIC9276), and Facility Sketch (LIC999) labeled with locations of water outlets.

Water sample was conducted by Adviro on 2/26/2024 and the report indicated that faucet "A" had Action Level Exceedance value of 5.6. The faucet is located inside of the portable on the left side of the building. The facility has remediated faucet "A" by turning off the water valve temporarily until retesting can be completed and it is currently made inaccessible to children. LPA observed that the faucet is taped off and has an "Out of Service" sign on it. Doug and David state that faucet will be retested and they will submit retesting results to Licensing upon completion. They are currently working with the school district for the retesting to be completed and are unsure when the retesting will be completed. LPA requested that Doug and David let Licensing know when they have a confirmed date for the faucet retesting.

Exit interview conducted and report was reviewed with the Site Director, Doug Ikemoto, and Assistant Site Director, David Walter.

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: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2024
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 03/12/2024 01:50 PM - It Cannot Be Edited


Created By: Cortney Nelson On 03/12/2024 at 01:39 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: ENGENIUS LEARNING CENTER @ BOOKSIN ELEMENTARY
FACILITY NUMBER: 434415300

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/12/2024
Section Cited

101700.3(b)(1)

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Lead Testing Written Directives (b)(1) a result with values of 5.5 parts per billion or greater shall be deemed an Action Level Exceedance (ALE).

This requirement was not met as evidenced by:
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The facility has shut off the water valve for Faucet A and is planning to get it rested.
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After water lead testing was completed, the facility had one faucet (A) located in the left room of the portable with an Action Level Exceedance of 5.6, which poses a potential risk to the health, safety, and personal rights of children in care.
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The facility will notify Licensing when the restesting has been scheduled for faucet A and will submit water lead testing results when completed. The faucet will remain inaccessible to children until retesting completed.

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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:Joel Segura
LICENSING EVALUATOR NAME:Cortney Nelson
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024


LIC809 (FAS) - (06/04)
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