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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416983
Report Date: 01/18/2023
Date Signed: 01/18/2023 05:57:53 PM

Document Has Been Signed on 01/18/2023 05:57 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:GILROY HEAD STARTFACILITY NUMBER:
434416983
ADMINISTRATOR:EVA SUAREZFACILITY TYPE:
850
ADDRESS:9300 WREN AVENUETELEPHONE:
(669) 212-8692
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: 0DATE:
01/18/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
02:53 PM
MET WITH:Martha MoralesTIME COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Case Management- Lead Testing/Exceedance inspection. LPA met with Martha Morales, Site Director, and explained the reason for the inspection. The facility had a result of 5.5ppb.

During today's inspection, LPA inspected the kitchen sink, which had an exceedance. LPA observed that there are 5 gallon water jugs by the sink and a sign that states to not use the water. Facility is using the water jugs to prepare food.

Site Director stated that they replaced the outlet and will be doing longer flush duration. Facility has another test scheduled for 01/19/2023. Site Director stated that a copy of the test results will be sent to Licensing upon receipt.



As a result of this inspection, a Type B citation was issued . Exit interview was conducted and report was reviewed with Site Supervisor Martha Morales. A notice of site visit has been issued 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: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2023
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 01/18/2023 05:57 PM - It Cannot Be Edited


Created By: Samantha Yip On 01/18/2023 at 03:07 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: GILROY HEAD START
FACILITY NUMBER: 434416983

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/17/2023
Section Cited

101700.3(b)(1)

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Lead Testing Written Directives. A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
This requirement is not met as evident by:
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Facility replaced the outlet of the sink and has a test scheduled for 01/19/2023.
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The kitchen sink had a result of 5.5 ppb, which poses a potential health and safety risk to 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:Joel Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2023


LIC809 (FAS) - (06/04)
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