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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422420
Report Date: 11/02/2023
Date Signed: 11/02/2023 06:13:59 PM

Document Has Been Signed on 11/02/2023 06:13 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:LA PLAZITA PRESCHOOL IIIFACILITY NUMBER:
013422420
ADMINISTRATOR:LOPEZ, ETELVINAFACILITY TYPE:
850
ADDRESS:3616 - 3636 35TH AVE.TELEPHONE:
(510) 857-7309
CITY:OAKLANDSTATE: CAZIP CODE:
94619
CAPACITY: 110TOTAL ENROLLED CHILDREN: 110CENSUS: 12DATE:
11/02/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
04:35 PM
MET WITH:Etelvina (Lupe) LopezTIME COMPLETED:
06:15 PM
NARRATIVE
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On 11/2/23 at 5:40pm, Licensing Program Manager (LPM) Loretta Dyson conducted an unannounced case management inspection to follow up on results received indicating a lead exceedance for an outlet at the facility. LPM met with Etelvina (Lupe) Lopez. There were 12 children and 5 additional staff also present.

The facility completed the required lead testing of water outlets in the facility. One outlet was found to be in exceedance of the Action Level of 5 ppb. The outlet is located outside the facility in the garden area, on the left side. Etelvina (Lupe) Lopez stated that the outlet has only ever been used to water plants. The capped off the outlet source so no water can come from it. The facility completed and submitted all required documents to Community Care Licensing and posted the test results in the facility.

See LIC 809D for a deficiency being cited today. An exit interview was conducted with Etelvina (Lupe) Lopez, and a copy of this report, Notice of Site Visit, and appeal rights were emailed to the facility. 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: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2023
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 11/02/2023 06:13 PM - It Cannot Be Edited


Created By: Loretta Dyson On 11/02/2023 at 05:22 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: LA PLAZITA PRESCHOOL III
FACILITY NUMBER: 013422420

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/01/2023
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 Action Level Exceedance.
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As a permanent solution, the facility has capped off the outlet, so that no water can come from it.
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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 health and safety of 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: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023


LIC809 (FAS) - (06/04)
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