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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423117
Report Date: 09/06/2023
Date Signed: 09/06/2023 12:07:35 PM

Document Has Been Signed on 09/06/2023 12:07 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:BOULEVARD ACADEMYFACILITY NUMBER:
013423117
ADMINISTRATOR:LI, WAN BINGFACILITY TYPE:
850
ADDRESS:468 BOULEVARD WAYTELEPHONE:
(510) 832-0132
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
09/06/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Wan Bing LiTIME COMPLETED:
02:00 PM
NARRATIVE
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On 09/06/2023 at 11:30 AM Licensing Program Analysts (LPAs) A. Curry and S. Blue conducted an unannounced case management inspection in regards to the lead testing at the facility. LPA met with director, Wan Bing Li, to explain the purpose of today's visit. The director indicated the facility did not test the water for lead contamination prior to the deadline of 01/01/2023. The director stated the facility is in the process of testing the drinking water and water used to prepare food for lead contamination.

The director was advised to review PIN 21-21.1-CCP for more information on lead testing of water for Child care Centers.

Exit interview conducted, appeal rights were given, and report was reviewed with the director Wan Bing Li.

SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Ashley Curry
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2023
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 09/06/2023 12:07 PM - It Cannot Be Edited


Created By: Ashley Curry On 09/06/2023 at 11:48 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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: BOULEVARD ACADEMY
FACILITY NUMBER: 013423117

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/06/2023
Section Cited
HSC
1596.16(a)(1)

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(1) A licensed child day care center... constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.
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By 10/06/2023 the licensee will schedule an appointment with a certified water sampler to test the water supply for lead. Please send proof of appointment to LPA.
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This requirement is not met as evidence by:

Based on interview and record review the licensee did not comply with the section cited above by ensuring the day care center water was tested for lead prior to the deadline of 01/01/2023.
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Once testing is completed, please submit the lead test packet to LPA, which includes lead test results, facility sketch, LIC 9275 form, and LIC 9276 form

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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:Loretta Dyson
LICENSING EVALUATOR NAME:Ashley Curry
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2023


LIC809 (FAS) - (06/04)
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