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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010213410
Report Date: 02/10/2023
Date Signed: 02/10/2023 11:44:00 AM

Document Has Been Signed on 02/10/2023 11:44 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:HACIENDA CHILD DEVELOPMENT CENTERFACILITY NUMBER:
010213410
ADMINISTRATOR:IMELDA ACOSTAFACILITY TYPE:
850
ADDRESS:4671 CHABOT DRIVETELEPHONE:
(925) 463-2885
CITY:PLEASANTONSTATE: CAZIP CODE:
94588
CAPACITY: 136TOTAL ENROLLED CHILDREN: 136CENSUS: 40DATE:
02/10/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Imelda AcostaTIME COMPLETED:
12:00 PM
NARRATIVE
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On February 10, 2023 Licensing Program Analyst (LPA) Lorraine Dacanay Breaux conducted an Unannounced Case Management Visit/Lead Testing Exceedance. LPA met with the Director, Imelda Acosta and explained the nature of the visit today. LPA conducted an inspection and inspected the facility for health and safety. Present for today's visit was 10 staff and 40 children in care. The facility operates from Monday - Friday from 7:30 AM - 6:00 PM. (Due to COVID the hours are from 8:30 AM - 5:30 PM).

On August 27, 2022 a lead test sample was drawn for 20 water locations in the facility. The department was notified that four water faucets in Room 2, 6, 1D and 5, have elevated lead levels that have exceeded 5.5 ppb. This exceeds the Action Level (ALE) established by the state for lead exposure.Values greater than 5.5 ppb is deemed an Action Level Exceedance and requires the issuance of a deficiency and a Plan of Correction.

Per Director, due to low enrollment Classrooms 2 and 6 are not being used at this time. Per Director, Classrooms 1D and 5 the sink/facets are only used for washing hands and supplies, there is another small sink within the classroom that passed testing. This facility does not provide meals (only snacks) and/or cooks at the facility (parents supply) and parents supply the children's water bottles, the facility refills with filtered water as needed through out the day.

Upon arrival to review the test results, LPA viewed a plan of correction and the lead testing results posted in a public area. Per director, the president has informed all parents of the test results and received a copy of the plan of action.

In addition to the above, a Type B deficiency and plan of correction was documented and issued today, see LIC809D. A notice of site visit was given and must remain posted for 30 days. Appeal Rights provided. Exit interview conducted and report was reviewed with the director Imelda Acosta.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Lorraine Dacanay-Breaux
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2023
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
Document Has Been Signed on 02/10/2023 11:44 AM - It Cannot Be Edited


Created By: Lorraine Dacanay-Breaux On 02/10/2023 at 11:06 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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: HACIENDA CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 010213410

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/10/2023
Section Cited
CCR
101238(a)

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101238 Buildings and Grounds
(a) The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors.
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 A Plan of Correction is already in placed, two facuets are covered with "Do not use" sign posted. The parents supplies water bottles and facility refills as needed. New faucets are ordered to replace the existing ones. Due to low enrollment 2 of the classrooms are not in use. (Room 6 & 2)
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This requirement was not met as evidenced by: Based on lead testing results. Based on lead testing results, 4 (four) faucets tested have lead levels exceeding 5.5ppb which poses a potential Health and Safety risk to children in care.
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Director must submit proof to LPA via email the results once the facucets pass testing. The documentation must be submitted to LPA no later than 03/10/2023.
Email: Lorraine.Dacanay-Breaux@dss.ca.gov

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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:Chandra Charles
LICENSING EVALUATOR NAME:Lorraine Dacanay-Breaux
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023


LIC809 (FAS) - (06/04)
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