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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010210145
Report Date: 12/19/2023
Date Signed: 12/19/2023 02:51:32 PM

Document Has Been Signed on 12/19/2023 02:51 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:CHILD UNIQUE MONT. SCHOOLFACILITY NUMBER:
010210145
ADMINISTRATOR:MASCORRO, MARISELAFACILITY TYPE:
850
ADDRESS:2212 PACIFIC AVE.TELEPHONE:
(510) 521-1030
CITY:ALAMEDASTATE: CAZIP CODE:
94501
CAPACITY: 20TOTAL ENROLLED CHILDREN: 8CENSUS: 7DATE:
12/19/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
12:22 PM
MET WITH:Miesha LampkinsTIME COMPLETED:
02:50 PM
NARRATIVE
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On 12/19/2023 at 12:22 PM, Licensing Program Analysts (LPAs) Catherine Fernandes and Janai McClain conducted an unannounced case management inspection regarding a lead exceedance at the facility. LPAs met with the Director Miesha Lampkins and explained the purpose of today's inspection. Present in care were seven preschoolers and two additional staff members.

The facility tested its drinking water for lead contamination on 08/8/2023 and B1 (the backyard hose) has exceeded the acceptable amount of lead allowed at a childcare facility with a result of 14.0ppb. The licensee failed to maintain a lead value at or below the Action Level for water lead testing resulting with values of 5.5ppb or greater for water sources B1.


Water testing results identified with Action Level Exceedance as defined in WD section 101700.3 are not deemed safe to drink (See 809D for deficiency being cited today). The C1 sink in primary two classroom has been turned off from the water supply and the senor for the sink is covered and stated it is not being used. E1 is outside and connected to a hose and the portable hand washing sink, the sink is unplugged from the water outlet. The director has provided the required documents to the LPAs while at the center.


See 809D for deficiency being cited today

Exit interview conducted with Miesha Lampkins

Appeal Rights and Report was provided.

Notice of Site Visit provided and must remain posted for 30 days.

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Catherine Fernandes
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2023
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 12/19/2023 02:51 PM - It Cannot Be Edited


Created By: Catherine Fernandes On 12/19/2023 at 02:34 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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CHILD UNIQUE MONT. SCHOOL
FACILITY NUMBER: 010210145

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/27/2023
Section Cited

101700.3(b)(1)

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Lead Testing Written Directive: A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. This requirement has not been met as evidenced by:
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Center will retest the water supply and come up with a plan to resolve the lead exceedance.

*Center removed the water source, POC cleared today
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Based on center records water supply B1 (hose in the backyard) tested above 5.5 ppb which poses a potential risk to the health and safety of the 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:Mayla Mendoza
LICENSING EVALUATOR NAME:Catherine Fernandes
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023


LIC809 (FAS) - (06/04)
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