CSSF REC DEPT-SIEBECKER CENTER

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25On 12/4/2023, at approximately 11:15AM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced case management visit regarding an Action Level Exceedance (ALE) due to lead in the Child Care Center's water. LPA was granted entry to the facility by Supervisor, Diana Gonzalez. LPA explained the purpose of the visit. Present during the visit were six staff and 36 children. The facility is in compliance with staff-child ratios. LPA discussed the new Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018 requires the Lead Testing of water in the Child Care Center with the Assistant Director during the inspection. All Child Care Centers that are located in buildings constructed before January 1, 2010, must have their water tested and post the results by January 1, 2023, and every 5 years after the date of the first testing. The facility received the initial ALE report from the Vendor on 11/10/2022. Test results for one fixture in this facility exceeded a higher level of parts per billion (ppb) allowed, 5.5 ppb, fixture B(6.2). Fixture B was a water fountain located in the children's restroom. Per Supervisor, the fountain had not been used since 2019. The facility had children bring water bottles from home and provided water from other fixtures that did not have exceedances. LPA observed that the fixture has been removed. All other fixtures tested below the threshold and are in compliance with the Written Directives detailed in PIN 21-21.1-CCP. Per Written Directives 101700.3(b)(2), licensees shall maintain a lead value at or below 5ppb in all outlets subject to testing requirements for the health and safety of children in care. Due to updated guidance on the written directives in PIN 21-21.1-CCP, the facility will be cited for the ALE of fixture B. LPA advised that lead testing results and LIC forms 9275, 9276 and 999 should be posted. See LIC809-D for deficiency cited and cleared today. This report was reviewed and signed by Supervisor, Diana Gonzalez. A Notice of Site Visit was given and must be posted for thirty days. SUPERVISORS NAME: Ali Zebila LICENSING EVALUATOR NAME: Jonathan Tse LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2023 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2023 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 FACILITY NAME: CSSF REC DEPT-SIEBECKER CENTER FACILITY NUMBER: 410509769 DEFICIENCY INFORMATION FOR THIS PAGE: VISIT DATE: 12/04/2023 Deficiency Type POC Due Date / Section NumberDEFICIENCIESPLAN OF CORRECTIONS(POCs) Type B 01/04/2024 Section Cited 101700.3(b)(2) 1 2 3 4 5 6 7Licensees shall maintain a lead value at or below the Action Level of 5 ppb in all outlets subject to the testing requirements of these Written Directives, for the health and safety of children in care. This requirement was not met as evidenced by:1 2 3 4 5 6 7The facility has since removed the fixture. LPA observed during the visit that the fixture has been removed. 8 9 10 11 12 13 14Based upon record review, the facility had one fixture (B) that tested above the Action Level of 5ppb. This posed a potential health, safety, or personal rights risk to persons in care.8 9 10 11 12 13 14This deficiency shall be cleared the same day of the visit, 12/4/2023. 1 2 3 4 5 6 71 2 3 4 5 6 7 1 2 3 4 5 6 71 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:Ali Zebila LICENSING EVALUATOR NAME:Jonathan Tse LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2023 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2023

Type B citation - potential risk if not corrected

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25On 12/4/2023, at approximately 11:15AM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced case management visit regarding an Action Level Exceedance (ALE) due to lead in the Child Care Center's water. LPA was granted entry to the facility by Supervisor, Diana Gonzalez. LPA explained the purpose of the visit. Present during the visit were six staff and 36 children. The facility is in compliance with staff-child ratios. LPA discussed the new Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018 requires the Lead Testing of water in the Child Care Center with the Assistant Director during the inspection. All Child Care Centers that are located in buildings constructed before January 1, 2010, must have their water tested and post the results by January 1, 2023, and every 5 years after the date of the first testing. The facility received the initial ALE report from the Vendor on 11/10/2022. Test results for one fixture in this facility exceeded a higher level of parts per billion (ppb) allowed, 5.5 ppb, fixture B(6.2). Fixture B was a water fountain located in the children's restroom. Per Supervisor, the fountain had not been used since 2019. The facility had children bring water bottles from home and provided water from other fixtures that did not have exceedances. LPA observed that the fixture has been removed. All other fixtures tested below the threshold and are in compliance with the Written Directives detailed in PIN 21-21.1-CCP. Per Written Directives 101700.3(b)(2), licensees shall maintain a lead value at or below 5ppb in all outlets subject to testing requirements for the health and safety of children in care. Due to updated guidance on the written directives in PIN 21-21.1-CCP, the facility will be cited for the ALE of fixture B. LPA advised that lead testing results and LIC forms 9275, 9276 and 999 should be posted. See LIC809-D for deficiency cited and cleared today. This report was reviewed and signed by Supervisor, Diana Gonzalez. A Notice of Site Visit was given and must be posted for thirty days. SUPERVISORS NAME: Ali Zebila LICENSING EVALUATOR NAME: Jonathan Tse LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2023 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2023 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 FACILITY NAME: CSSF REC DEPT-SIEBECKER CENTER FACILITY NUMBER: 410509769 DEFICIENCY INFORMATION FOR THIS PAGE: VISIT DATE: 12/04/2023 Deficiency Type POC Due Date / Section NumberDEFICIENCIESPLAN OF CORRECTIONS(POCs) Type B 01/04/2024 Section Cited 101700.3(b)(2) 1 2 3 4 5 6 7Licensees shall maintain a lead value at or below the Action Level of 5 ppb in all outlets subject to the testing requirements of these Written Directives, for the health and safety of children in care. This requirement was not met as evidenced by:1 2 3 4 5 6 7The facility has since removed the fixture. LPA observed during the visit that the fixture has been removed. 8 9 10 11 12 13 14Based upon record review, the facility had one fixture (B) that tested above the Action Level of 5ppb. This posed a potential health, safety, or personal rights risk to persons in care.8 9 10 11 12 13 14This deficiency shall be cleared the same day of the visit, 12/4/2023. 1 2 3 4 5 6 71 2 3 4 5 6 7 1 2 3 4 5 6 71 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:Ali Zebila LICENSING EVALUATOR NAME:Jonathan Tse LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2023 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2023