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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415729
Report Date: 03/08/2023
Date Signed: 03/08/2023 05:01:57 PM

Document Has Been Signed on 03/08/2023 05:01 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:ESTRELLA FAMILY SERVICES @ GARDNERFACILITY NUMBER:
434415729
ADMINISTRATOR:KRISTINE NGUYENFACILITY TYPE:
850
ADDRESS:611 WILLIS AVENUETELEPHONE:
(408) 269-7827
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 80TOTAL ENROLLED CHILDREN: 80CENSUS: DATE:
03/08/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Kristine NguyenTIME COMPLETED:
03:15 PM
NARRATIVE
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 Licensing Program Analyst (LPA), Kassandra Medrano, conducted an unannounced case management inspection in response to a completed lead testing on 1/11/2023 resulting in an exceedance level of 8.3 on faucet “h”. Faucet “H” is located in room 3. LPA met with the Director, Kristine Nguyen, and explained the nature of today's inspection.
Prior to today’s inspection, Community Care Licensing received notification of the lead exceedances by the water program.
Preceding the arrival of LPA Medrano, the fountain that has been found in exceedance has been replaced and re-tested by CRWA. On 3/2/2023 the facility received a passing result.

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

Type B deficiency was cited, exit interview conducted, and a copy of this report was given and reviewed with the Director, Kristine Nguyen. 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: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2023
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 03/08/2023 05:01 PM - It Cannot Be Edited


Created By: Kassandra Medrano On 03/08/2023 at 03:11 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: ESTRELLA FAMILY SERVICES @ GARDNER
FACILITY NUMBER: 434415729

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2023
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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Director to send documentation of remediation as well as retesting with a passing level.
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This exceedance levels found in Bubbler "H" was found with 8.3ppb. 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: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023


LIC809 (FAS) - (06/04)
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