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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073400249
Report Date: 05/06/2022
Date Signed: 05/06/2022 01:35:48 PM

Document Has Been Signed on 05/06/2022 01:35 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:CONTRA COSTA CO. HEAD START - BALBOA CDCFACILITY NUMBER:
073400249
ADMINISTRATOR:DOSS, MARILYNFACILITY TYPE:
850
ADDRESS:1001 S. 57TH STREETTELEPHONE:
(510) 374-7025
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY: 140TOTAL ENROLLED CHILDREN: 140CENSUS: 37DATE:
05/06/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:28 AM
MET WITH:Marilyn DossTIME COMPLETED:
01:50 PM
NARRATIVE
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On Friday, May 6, 2022, Licensing Program Analyst (LPA) Caroline Colson met with Tana Reed, Site Administrator I, and Marilyn Doss, Site Administrator III for an unannounced case management inspection at 10:28 AM. A self reported unusual incident was received in our office. During today's investigation, video recordings showed that a staff member physically moved a child who was laying on a mat multiple times. During one of these transitions, the child fell off the mat.

The attached type B deficiency is being cited today and must be corrected by the due date. Appeal Rights was given. Exit interview was conducted.

Please See LIC 809 D for deficiency
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Caroline Colson
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2022
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 05/06/2022 01:35 PM - It Cannot Be Edited


Created By: Caroline Colson On 05/06/2022 at 12:15 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: CONTRA COSTA CO. HEAD START - BALBOA CDC
FACILITY NUMBER: 073400249

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/06/2022
Section Cited
CCR
101223(a)

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Personal Rights
To be accorded dignity in his/her personal relationships with staff and other persons.
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BY POC DUE DATE
Licensee will conduct a Personal Rights training for the entire child care center. Each staff member will submit a written summary of the training.
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This requirement was not met as evidenced by video recordings that a staff member physically moved a child who was laying on a mat and fell to the floor. This poses an potential health and safety risk to children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250.00 per violation and $100 per day until corrected.

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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:Mayla Mendoza
LICENSING EVALUATOR NAME:Caroline Colson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022


LIC809 (FAS) - (06/04)
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