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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417077
Report Date: 11/02/2023
Date Signed: 11/02/2023 05:30:51 PM

Document Has Been Signed on 11/02/2023 05:30 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:MARIPOSAS PRESCHOOLFACILITY NUMBER:
434417077
ADMINISTRATOR:VANESSA VALDEZFACILITY TYPE:
850
ADDRESS:16900 DE WITT AVENUETELEPHONE:
(408) 209-4648
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 51TOTAL ENROLLED CHILDREN: 4CENSUS: 4DATE:
11/02/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Vanessa ValdezTIME COMPLETED:
02:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Case Management- Lead Testing/Exceedance inspection. LPA met with Licensee Vanessa Valdez and explained the reason for the inspection. The purpose of this inspection is Faucet B- Drinking Fountain by Building 2 had a result of 5.7ppb. Present during today's inspection were Licensee and four children.

LPA inspected Faucet B. Licensee stated that the children bring their own water bottles and have a water cooler for children to refill their water bottles. Licensee stated that she will cover the drinking fountain and send proof to Licensing by 11/03/2023.

Licensee stated that they will get it fixed and retested. Upon completion of it being retested, Licensee will send LIC 999, LIC 9275, LIC 9776, and test results.

As a result of this inspection, a Type B citation will be issued. Exit interview conducted and report was reviewed with Licensee Vanessa Valdez. A notice of site visit has been issued and must remain posted for 30 days.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2023
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 11/02/2023 05:30 PM - It Cannot Be Edited


Created By: Samantha Yip On 11/02/2023 at 02:30 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: MARIPOSAS PRESCHOOL
FACILITY NUMBER: 434417077

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/01/2023
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 evidenced by:
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By POC 12/01/2023, Licensee stated that she will fix the faucet and get it retested. Licensee submit proof to Licensing.
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Faucet B had a result of 5.7 ppb. This 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: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023


LIC809 (FAS) - (06/04)
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