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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013415043
Report Date: 02/03/2023
Date Signed: 02/03/2023 02:24:11 PM

Document Has Been Signed on 02/03/2023 02:24 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 STE 1102
OAKLAND, CA 94612
FACILITY NAME:OUR SAVIOR LUTHERAN EARLY CHILDHOOD DEV. CTR.FACILITY NUMBER:
013415043
ADMINISTRATOR:ANNAMARIE BUYERFACILITY TYPE:
850
ADDRESS:1385 SO. LIVERMORE AVENUETELEPHONE:
(925) 455-5437
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 97TOTAL ENROLLED CHILDREN: 97CENSUS: 16DATE:
02/03/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Ryann NessTIME COMPLETED:
02:20 PM
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On February 3 , 2023, Licensing Program Analyst (LPA) Simerjit Kaur conducted a case management inspection due to the center's lead testing results. LPA met with Administrator Ryann Ness. Present during the inspection, were 16 children and 5 staff members present.

The department was notified that water faucets “A” located in the preschool age Room 1/ "Rising Stars" classroom, have elevated lead levels that have exceeded 5.5 ppb. This exceeds the Action Level (ALE) established by the state for lead exposure. Per Administrator Ryann Ness, the faucet is immediately closed off and work order has been placed to replace the faucet. LPA observed today the faucet is closed and not in use. LPA also observed posting of lead testing results.

See LIC809D for deficiency cited during today's inspection.



Exit interview conducted with Administrator Ryann Ness. A notice of site visit was provided and must be posted for 30 days.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Simerjit Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2023
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 02/03/2023 02:24 PM - It Cannot Be Edited


Created By: Simerjit Kaur On 02/03/2023 at 01:58 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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: OUR SAVIOR LUTHERAN EARLY CHILDHOOD DEV. CTR.
FACILITY NUMBER: 013415043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/03/2023
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 (ALE)
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LPA observed the 1 water outlet have been closed in Room 1. Administrator Ryann Ness is advised to submit re-test results to LPA by due date of 03/03/23.
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This requirement is not met as evidenced by:
Based on record review, the facility has 1 outlets ("A" in Room 1) that have an ALE of ppb or greater, which poses 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:Jason Jang
LICENSING EVALUATOR NAME:Simerjit Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2023


LIC809 (FAS) - (06/04)
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