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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417135
Report Date: 02/26/2025
Date Signed: 02/26/2025 01:43:18 PM

Document Has Been Signed on 02/26/2025 01:43 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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:TESSELLATIONS CHILDREN'S CENTERFACILITY NUMBER:
434417135
ADMINISTRATOR/
DIRECTOR:		STEPHANIE HOLSONFACILITY TYPE:
850
ADDRESS:1170 YORKSHIRE DRIVETELEPHONE:
(650) 260-4409
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY: 36TOTAL ENROLLED CHILDREN: 33CENSUS: DATE:
02/26/2025
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:03 AM
MET WITH:Stephanie HolsonTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marilou Monico conducted an unannounced Case Management- Lead Testing/Exceedance inspection. LPA met with Site Director, Stephanie Holson, and explained the reason for the inspection. LPA reviewed the water sample summary and requested Stephanie to identify Sinks "E", "G" & "H" with reported Action Level Exceedance of lead that is 5.5 parts per billion (ppb) or greater. There were eight sinks that were tested, however it was not identified on the facility sketch the locations of Sinks "E", "G" and "H" and other outlets that were tested.

LPA toured the facility. LPA observed eight sinks . Site Director stated that they are using one sink for food preparation and the children use the drinking fountain in the playground. During the inspection, the custodian disconnected the water supply in both the food preparation sink and drinking fountain. Site Director placed a "Do Not Use This Sink" sign in both sinks. Stephanie stated that she will purchase bottled water to be used for drinking and food preparation effective immediately.

The following documents were submitted to analyst during today's inspection:
1) Sampling Checklist Form (LIC9276)
3) Facility Sketch (LIC999)
4) Water Sample Summary

As a result of this inspection, a Type B citation was issued.

Exit interview was conducted and report was reviewed with Site Director, Stephanie Holson.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2025
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 02/26/2025 01:43 PM - It Cannot Be Edited


Created By: Marilou Monico On 02/26/2025 at 01:01 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: TESSELLATIONS CHILDREN'S CENTER
FACILITY NUMBER: 434417135

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/07/2025
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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Stephanie stated that she will purchase bottled water to be used for drinking and food preparation effective immediately. Stephanie stated that she will submit a written plan of correction by 03/07/25 and get all the eight outlets retested as soon as possible.
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Sinks "E", "G" and "H" had a result of greater than 5.5 pbb. 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:Gladys Kuizon
LICENSING EVALUATOR NAME:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2025


LIC809 (FAS) - (06/04)
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