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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073400100
Report Date: 01/24/2024
Date Signed: 01/24/2024 10:16:29 AM

Document Has Been Signed on 01/24/2024 10:16 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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:HOLY SHEPHERD COMMUNITY PRESCHOOLFACILITY NUMBER:
073400100
ADMINISTRATOR:KOEPER, SUSANFACILITY TYPE:
850
ADDRESS:433 MORAGA WAYTELEPHONE:
(925) 254-3429
CITY:ORINDASTATE: CAZIP CODE:
94563
CAPACITY: 53TOTAL ENROLLED CHILDREN: 53CENSUS: DATE:
01/24/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Claire PetersonTIME COMPLETED:
10:30 AM
NARRATIVE
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On 01/24/2024 at 9:15 AM Licensing Program Analyst (LPA) A. Curry conducted an unannounced case management inspection to follow up regarding lead testing at the facility. LPA met with director, Claire Peterson, to explain the purpose of today's visit. The director indicated the facility tested their drinking water for lead contamination, but was unable to provide documentation during today's visit (See 809D). The director stated she will submit the required lead packet to Licensing as soon as possible. The lead packet includes the lead test results, LIC 9275 form, LIC 9276 form, and facility sketch that identifies the outlets that were tested.

Exit interview conducted, appeal rights were given, and report was reviewed with the Director, Claire Peterson.

SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Ashley Curry
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2024
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 01/24/2024 10:16 AM - It Cannot Be Edited


Created By: Ashley Curry On 01/24/2024 at 09:37 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: HOLY SHEPHERD COMMUNITY PRESCHOOL
FACILITY NUMBER: 073400100

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/23/2024
Section Cited

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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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This requirement was not met as evidence by:
The licensee did not comply with the section cited above by providing documentation that shows the lead testing was completed prior to January 1, 2023, which poses a potential risk to health & safety of children in care.
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LPA requested lead documentation on multiple occassions, but did not receive it.
The director indicated the testing was completed and she will submit lead packet as soon as possible.

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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: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024


LIC809 (FAS) - (06/04)
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