<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444403570
Report Date: 11/09/2022
Date Signed: 11/09/2022 09:44:21 AM

Document Has Been Signed on 11/09/2022 09:44 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: 31TOTAL ENROLLED CHILDREN: 21CENSUS: 16DATE:
11/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Crissy RoubalTIME COMPLETED:
10:05 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Cortney Nelson, met with Site Supervisor, Crissy Roubal, and explained purpose of today's visit, to follow-up on lead water testing and Action Level Exceedance (ALE) for one (1) faucet (F).

During previous visit on 10/14/2022, an executive summary for water testing conducted at Holy Cross Preschool stated that no exceedances (ALE) were found. A follow-up summary from California Rural Water Association (CRWA) indicated that an ALE of 5.8 was measured for faucet "F" and indicated steps to be taken to flush the faucet. The original executive summary provided to the facility was incorrectly reported due to CRWA using federal lead water limits rather than state required limits.

The Site Supervisor states that faucet "F" has been capped at the source by Cimarellis Laurel Plumbing Co. on 11/2/2022 and the drinking fountain will no longer be used as a source of drinking water. LPA observed that the fixture has been re-purposed as a planter box and is now filled with succulents. Children will now be provided drinking water from water bottles when outside and the water from faucet "F" will only be used for watering the garden as needed.

An Action Exceedance Level is a value of 5.5 parts per billion or greater and faucet "F" reported an ALE of 5.8 during initial testing on 7/21/2022. The Site Supervisor received a follow-up report and faucet "F" is no longer being used by the preschool for drinking and has been removed from the facility. Site Supervisor additionally states that the drinking fountain with ALE (faucet F) has not been used by children since March 2020.

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

As a result of todays inspection, a deficiency was cited, see 809-D.

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: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/09/2022 09:44 AM - It Cannot Be Edited


Created By: Cortney Nelson On 11/09/2022 at 09:21 AM
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: HOLY CROSS PRESCHOOL
FACILITY NUMBER: 444403570

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
11/09/2022
Section Cited

101700.3(b)(1)

1
2
3
4
5
6
7
101700.3 Lead Testing Written Directives (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:
1
2
3
4
5
6
7
The facility plans to make faucet "F" inaccessible to the children and will be providing drinking water from water bottles while outside.
8
9
10
11
12
13
14
After water testing was completed, the facility had one faucet (F) located in the outdoor preschool play area with an Action Level Exceedance of 5.8 which poses a potential risk to the health, safety, and personal rights of children in care.
8
9
10
11
12
13
14
POC cleared during todays visit.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Cortney Nelson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2