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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700505
Report Date: 11/29/2023
Date Signed: 11/29/2023 01:36:55 PM

Document Has Been Signed on 11/29/2023 01:36 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:KIDS KONNECT INFANT CARE & PRESCHOOLFACILITY NUMBER:
015700505
ADMINISTRATOR:DAVIS, SHABRIESEFACILITY TYPE:
830
ADDRESS:1600 BANCROFT AVENUETELEPHONE:
(510) 305-7857
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 22TOTAL ENROLLED CHILDREN: 22CENSUS: 19DATE:
11/29/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
12:16 PM
MET WITH:director, Shabriese DavisTIME COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jyoti Saini met with Director Shabriese Davis to conduct a Case Management inspection for the Lead Testing results at this facility. In addition to the director, 19 children and six staff members are present today. The facility operates Monday - Friday from 7:00 am to 5:30 pm.

LPA Inspected the facility for health and safety. It was concluded that one outlet in room #8 exceeded the Action Level established by the state for exposure.LPA obtained photos of the faucet that have exceeded 5.5 ppb. LPA discussed a Plan of Correction, and received documentation for the post-testing requirements during the inspection. Find the attached deficiency (LIC 809-D)

A notice of site visit was given and must remain posted for 30 days.

Appeal Rights were given.

An exit interview was conducted, and the report was reviewed with the Director, Shabriese Davis.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jyoti Saini
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2023
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 11/29/2023 01:36 PM - It Cannot Be Edited


Created By: Jyoti Saini On 11/29/2023 at 12:29 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: KIDS KONNECT INFANT CARE & PRESCHOOL
FACILITY NUMBER: 015700505

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
12/07/2023
Section Cited

101700.3(b)(1)

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101700.3(b)(1)A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
This requirement is not met as evidenced by:
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The facility has already developed an alternative plan to provide safe drinking to the children in care. LPA received a written directive stating that the facility uses a Brita jug and filtered 5-gallon water dispenser.
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 Based on record review, the facility has one outlet in room #8 that have an ALE of 5.5ppb 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:Wynn Norona
LICENSING EVALUATOR NAME:Jyoti Saini
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2023


LIC809 (FAS) - (06/04)
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