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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416145
Report Date: 04/07/2023
Date Signed: 04/07/2023 10:22:28 AM

Document Has Been Signed on 04/07/2023 10:22 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:KIDANGO ANDREW HILLFACILITY NUMBER:
434416145
ADMINISTRATOR:MAI TONFACILITY TYPE:
850
ADDRESS:3200 SENTER ROADTELEPHONE:
(408) 928-5211
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY: 27TOTAL ENROLLED CHILDREN: 27CENSUS: 10DATE:
04/07/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Angelica GalvanTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA), Harsimran Kaur, conducted an unannounced case management inspection in response to a completed lead testing. which resulted in two action level exceedances within the facility of 8.2 ppb and 6.9 ppb. LPA met with the Director, Angelica Galvan 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 Kaur, both the fountains that have been found in exceedance have been taped off and are not being used. Facility is using filtered water for their only source of drinking water and children use their own individual drinking cups/bottles.
The water sample conducted by California Rural Water Association (CRWA) on 11/01/22, indicated the following:
1) Water bubbler and sink named "J" located in room has Lead Action Level Exceedance value of 8.2 ppb.
2) Water bubbler and sink named "G" located in staff restroom has Lead Action Level Exceedance of 6.9 ppb.

LPA has requested the following documents during today’s inspection Director to send via email:
1.Self-Certification (LIC9275)
2.Sampling Checklist Form (LIC9276)
3.Facility Sketch LIC 999 (fully labeled with locations of all water outlets)
4. Full lead report from water program

Type B deficiency was cited, exit interview conducted, and a copy of this report was given and reviewed with the Facility Representative, Angelica Galvan. 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: Harsimran Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2023
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 04/07/2023 10:22 AM - It Cannot Be Edited


Created By: Harsimran Kaur On 04/07/2023 at 09:30 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: KIDANGO ANDREW HILL
FACILITY NUMBER: 434416145

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2023
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, Angelica Galvan stated that they will remediate the exceedances and contact Alpha to retest. Director stated she will send documentation of remidation as well as retesting.
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This exceedance levels found in “J” bubbler and sink was 8.2 ppb and in bubbler and sink "G" was 6.9 ppb. 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:Harsimran Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023


LIC809 (FAS) - (06/04)
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