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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417014
Report Date: 05/03/2023
Date Signed: 05/03/2023 02:39:08 PM

Document Has Been Signed on 05/03/2023 02:39 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:CREATIVE BEGINNINGS PRESCHOOLFACILITY NUMBER:
434417014
ADMINISTRATOR:HUIMIN XUFACILITY TYPE:
850
ADDRESS:14834 LEIGH AVENUETELEPHONE:
(408) 391-6535
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 40TOTAL ENROLLED CHILDREN: 36CENSUS: 30DATE:
05/03/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Atorin CarkhochTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Oscar Huang, conducted an unannounced case management inspection in response to a lead testing completed with an exceedance level. LPA met with Director, Atorin Carkhoch and Licensee Representative, Jia Yi, and explained the nature of today's inspection to them.

During today's inspection LPA Huang obtained the following documents; Self-Certification LIC9275, Sampling Checklist Form LIC9276, Facility Sketch LIC 999, fully labeled with locations of all water outlets, and full lead report. The lead exceedance readings was found from backyard playground drinking fountain of 45 ppb. LPA Huang conducted a tour to backyard which was no longer in service since March/2020 according to them. Children bring their own water bottle when play outside. LPA observed that the drinking faucet was covered by plastic paper.

Atroin and Jie stated the lead testing was conducted on November 1 & 2, 2022, but the result was mistakenly on to the wrong facility as they have two sites. Atorin anf Jie stated that their plan is to remove the fountain and shutoff the water source. Once the project is complete, they will send the picture along with the statement for Plan of Correction.

Type B deficiency cited, exit interview conducted, and a copy of this report was reviewed with the Director, Atorin Carkhoch. 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: Gladys Kuizon
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2023
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 05/03/2023 02:39 PM - It Cannot Be Edited


Created By: Yangcheng Huang On 05/03/2023 at 02:16 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: CREATIVE BEGINNINGS PRESCHOOL
FACILITY NUMBER: 434417014

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/03/2023
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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During today's inspection LPA Huang obtained the following documents; Self-Certification LIC9275, Sampling Checklist Form LIC9276, Facility Sketch LIC 999, fully labeled with locations of all water outlets, and full lead report.
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This exceedance level found in the
play yard drinking fountin was 45ppb. This poses a potential risk to the Health, Safety, or Personal Rights of children in care.
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The drinking water fountain located in playground was covered by plastic paper and no longer in use. The facility to fix the lead exceedance, and pass the test or to remove the fountain.

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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:Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023


LIC809 (FAS) - (06/04)
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