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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010212475
Report Date: 09/30/2025
Date Signed: 09/30/2025 11:55:17 AM

Document Has Been Signed on 09/30/2025 11:55 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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:OAKLAND HEAD START - SAN ANTONIOFACILITY NUMBER:
010212475
ADMINISTRATOR/
DIRECTOR:		JIMINEZ, LOURDESFACILITY TYPE:
850
ADDRESS:2228 EAST 15TH STREETTELEPHONE:
(510) 535-5639
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY: 24TOTAL ENROLLED CHILDREN: 16CENSUS: 15DATE:
09/30/2025
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Jiminez, LourdesTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
NARRATIVE
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On 09/30/2025 at 10:40 AM Licensing Program Analyst (LPA) Mario Caro conducted an unannounced case management inspection to follow up regarding the lead testing at the facility. LPA met with the Director, Lourdes, Jiminez, to explain the purpose of today's inspection. Present during todays inspection were 3 additional staff and 15 pre school aged children in care.

Do to the reporting of a lead exceedance for the faucets in the children's bathroom, adult bathroom, and the kitchen sink a type B citation was cited during todays visit. See 809-D. The facility replaced all three faucets and retested the fixtures, but the lead levels are still above 5.5 ppb. The facility made the three water fixtures inoperable while they are taking further measures to resolve the issue.

The director was advised to review PIN 21-21-CCP for more information on lead testing of water for Child care Centers.

Exit interview conducted, appeal rights were given, and report was reviewed with the director Lourdes Jiminez.

NAME OF LICENSING PROGRAM MANAGER: Mayla Mendoza
NAME OF LICENSING PROGRAM ANALYST: Mario Caro
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/30/2025 11:55 AM - It Cannot Be Edited


Created By: Mario Caro On 09/30/2025 at 11:20 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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: OAKLAND HEAD START - SAN ANTONIO
FACILITY NUMBER: 010212475

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/30/2025
Section Cited

101700.3(b)(1)

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101700.3 California Lead Action Level at Child Care Centers, 101700.3 (b)(1) that states “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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The facility will follow up with their program operation manager to reduce the lead levels in the affected faucets, and will submit documentation showing that lead is no longer present in concentrations over the action level of 5 parts per billion by POC date 10/30/25. Facility may submit documents via email at Mario.Caro@dss.ca.gov.
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Based on record review, the Facility did not comply with the section cited above because Facility failed to maintain a lead value at or below the Action Level for water lead testing which posed a potential health, safety or personal rights risk to persons 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.
Mayla Mendoza
NAME OF LICENSING PROGRAM MANAGER:
Mario Caro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2025


LIC809 (FAS) - (06/04)
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