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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010213903
Report Date: 12/20/2023
Date Signed: 12/20/2023 09:04:42 AM

Document Has Been Signed on 12/20/2023 09:04 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 SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:MONTESSORI SCHOOL AT WASHINGTON AVENUEFACILITY NUMBER:
010213903
ADMINISTRATOR:YOUSSEF, MARIANFACILITY TYPE:
850
ADDRESS:14795 WASHINGTON AVENUETELEPHONE:
(510) 357-8432
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY: 111TOTAL ENROLLED CHILDREN: 66CENSUS: 10DATE:
12/20/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Karina Estevez- Head TeacherTIME COMPLETED:
09:15 AM
NARRATIVE
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On 12/20/2023, Licensing Program Analyst (LPA) Briana Plumboy conducted a Case Management - Lead Testing/Exceedance Inspection. LPA met with Head Teacher Karina Estevez. Also present during today's visit were 3 additional staff members and 10 preschool aged children.

LPA discussed to the teacher that Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010 to test their drinking water for lead contamination between January 1, 2020 and January 1, 2023, and then every 5 years after the date of the first test. Health and Safety (HSC) Code section 1597.16 authorizes the Department to implement and administer procedures for lead testing at CCCs through written instructions until it adopts regulations under the Administrative Procedure Act. LPA discussed to the Director of the PIN 21-21-CCP - Release of the Written Directives for Lead Testing of Water in Licensed Child Care Centers Per AB 2370 https://cdss.ca.gov/Portals/9/CCLD/PINs/2021/CCP/PIN-21-21-CCP.pdf

The department was notified of a lead exceedance which exceeded the Action Level (ALE) established by the state for lead exposure. The faucet was replaced and per teacher not in use. Re-testing has been completed and PASSED.

See LIC 809-D for deficiency cited during today's inspection.

Exit interview conducted with the facility representative Karina Estevez. A notice of site visit was provided and must be posted for 30 days. Appeal Rights provided and discussed.

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Briana Plumboy
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2023
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 is an Amendment of Original Document on 01/25/2024 04:51 PM


Created By: April Wright On 12/20/2023 at 08:48 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: MONTESSORI SCHOOL AT WASHINGTON AVENUE
FACILITY NUMBER: 010213903

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/21/2023
Section Cited

101700.3(b)(1)

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101700.3(b)(1) Lead Testing Written Directive-
A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
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A sample was retaken after repairs were made and the center PASSED the lead sampling.
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This requirement is not met as evidenced by:
Based on record review, facility had at least 1 outlet of water test 5.5 ppb or greater which posed a potential health and safety 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.
SUPERVISOR'S NAME:Chandra Charles
LICENSING EVALUATOR NAME:April Wright
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023


LIC809 (FAS) - (06/04)
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