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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444403570
Report Date: 10/14/2022
Date Signed: 10/14/2022 10:28:16 AM


Document Has Been Signed on 10/14/2022 10:28 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:HOLY CROSS PRESCHOOLFACILITY NUMBER:
444403570
ADMINISTRATOR:PATANO, PATRICIAFACILITY TYPE:
850
ADDRESS:170 A HIGH STREETTELEPHONE:
(831) 425-1782
CITY:SANTA CRUZSTATE: CAZIP CODE:
95060
CAPACITY:31CENSUS: 6DATE:
10/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Crissy RoubalTIME COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA), Cortney Nelson, met with Site Supervisor, Crissy Roubal, and explained purpose of visit- to follow-up on water lead testing conducted for Holy Cross Preschool. Upon arrival, LPA reviewed water sample summary and requested Crissy identify faucet "F" with reported Action Level Exceedance (value of 5.5 parts per billion or greater).

LPA obtained the following facility documents during todays inspection: Self-Certification (LIC9275) completed by Certified External Water Sampler, Sampling Checklist Form (LIC9276), and Facility Sketch (LIC999) labeled with locations of water outlets that were tested.

The water sample conducted by California Rural Water Association (CRWA) on 7/21/2022 indicated that faucet "F- Outdoor Drinking Fountain" had Action Level Exceedance value of 5.8 when tested at 7:10AM. The drinking fountain was flushed by water sampler, Peter Xiong, and was retested at 7:15AM. No lead was detected in the second water sample from the drinking fountain. Executive summary of exceedances for the facility states that there were "no exceedances found." Site Supervisor additionally states that she flushed and covered all faucets prior to the water sample inspection.

Crissy states that the facility has not used the outdoor drinking fountain (faucet- F) since the start of the pandemic and LPA observed that the drinking fountain is covered and inaccessible to children.

Exit interview conducted and report was reviewed with the Site Supervisor, Crissy Roubal.

As a result of todays inspection, no deficiencies were cited. Further evaluation will be conducted for final water exceedance level verification.

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.

SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney NelsonTELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
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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