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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013417788
Report Date: 11/28/2023
Date Signed: 11/28/2023 03:54:30 PM

Document Has Been Signed on 11/28/2023 03:54 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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:NORTHERN LIGHT SCHOOLFACILITY NUMBER:
013417788
ADMINISTRATOR:SHERIN AMEERDEENFACILITY TYPE:
850
ADDRESS:3710 DORISA AVENUETELEPHONE:
(510) 957-0570
CITY:OAKLANDSTATE: CAZIP CODE:
94605
CAPACITY: 30TOTAL ENROLLED CHILDREN: 18CENSUS: 17DATE:
11/28/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Evelyn TorresTIME COMPLETED:
04:00 PM
NARRATIVE
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On 11/28/23 at 2:30pm, Licensing Program Manager (LPM) Loretta Dyson arrived at the center for an unannounced case management inspection. LPM met with Evelyn Torres and Maryam Nazari, the teachers at the facility. There were 17 children and 1 additional staff also present.

The facility completed the required lead testing of water outlets, and outlet B was found to be in exceedance of the Action Level of 5 ppb. The outlet is located outside of the preschool classroom, inside of the main school building. Staff advised that the outlet is not accessible to children. The facility was provided a copy of the test results and it was posted during the inspection. The facility plans to have the faucet replaced and the outlet retested. The facility understands that they are unable to use the outlet until they receive the test results, and the Action Level is 5 ppb or below.

See LIC 809D for a deficiency being cited today. No other deficiencies are being cited today. An exit interview was conducted with Maryam Nazari, and a copy of this report, Notice of Site Visit, and appeal rights were provided. The facility was reminded to have the Notice of Site Visit posted for 30 days.
SUPERVISORS NAME: Diane Perez
LICENSING EVALUATOR NAME: Loretta Dyson
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2023
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 11/28/2023 03:54 PM - It Cannot Be Edited


Created By: Loretta Dyson On 11/28/2023 at 03:05 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: NORTHERN LIGHT SCHOOL
FACILITY NUMBER: 013417788

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/28/2023
Section Cited
CCR
101700.3(b)(1)

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101700.3 California Lead Action Level at Child Care Centers (b) Testing results with fractional ppb readings of 0.5 ppb or greater shall be rounded up to the nearest whole number, before comparing to the Action Level. (1) A result with values of 5.5 ppb or greater shall be deemed an
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The facility is working on replacing the faucet, and will submit proof of the new test results, with Action Level at 5ppb or below, by 12/28/23.
The facility understands that they cannot use the outlet until the Action Level is determined to be 5 ppb or below.
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Action Level Exceedance.
This requirement has not been met as evidenced by the lead testing results received, indicating that two outlets in the facility had results in exceedance of the 5 ppb Action Level. This poses a potential risk to the children 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:Diane Perez
LICENSING EVALUATOR NAME:Loretta Dyson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023


LIC809 (FAS) - (06/04)
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