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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013415189
Report Date: 01/17/2023
Date Signed: 01/17/2023 11:32:41 AM

Document Has Been Signed on 01/17/2023 11:32 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:KIDDO LAND LEARNING CENTERFACILITY NUMBER:
013415189
ADMINISTRATOR:MOON CHIAFACILITY TYPE:
850
ADDRESS:46280 BRIAR PLACETELEPHONE:
(510) 490-7311
CITY:FREMONTSTATE: CAZIP CODE:
94539
CAPACITY: 61TOTAL ENROLLED CHILDREN: 61CENSUS: 27DATE:
01/17/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Moon ChiaTIME COMPLETED:
11:35 AM
NARRATIVE
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On January 17, 2022, License Program Analyst (LPA) Melanie Otsuji met with Director Moon Chia for an UNANNOUNCED CASE MANAGEMENT INSPECTION for Lead Testing Results. Present for today's inspection was the Director, 9 staff members and 27 preschool aged children. The facility operates Monday - Friday from 8:30 AM - 6:00 PM.

LPA and Director toured the facility and LPA obtained photos of the faucets that have exceeded 5.5 ppb. It was indicated that an area exceeded the Action Level established by the state for lead exposure. A Plan of correction was discussed with the Director. This facility is being given a TYPE B citation (see 809-D) The two faucets that exceeded the Action Level are faucets D (adult bathroom hand washing sink) & E (sink used for washing items)

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, Moon Chia.

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2023
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 01/17/2023 11:32 AM - It Cannot Be Edited


Created By: Melanie Otsuji On 01/17/2023 at 10:54 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: KIDDO LAND LEARNING CENTER
FACILITY NUMBER: 013415189

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/17/2023
Section Cited
HSC
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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Director is to have water outlets (D and E) repaired and/or replaced. Once outlets have been repaired/replaced, Director is to obtain a follow up water sample following Written Directives, Section 101705.

Follow Up sample shall be done prior to 2/17/2023 if possible. Director is to keep LPA
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This requirement is not met as evidenced by:
Based on record review, facility had 2 outlets of water test 5.5 ppb or greater (neither of which are used for drinking water/food preparation), which is a potential health and safety risk to persons in care.
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up to date on repair/replacement and testing progress.

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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:Wynn Norona
LICENSING EVALUATOR NAME:Melanie Otsuji
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023


LIC809 (FAS) - (06/04)
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