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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073400249
Report Date: 09/21/2022
Date Signed: 09/21/2022 12:59:19 PM

Document Has Been Signed on 09/21/2022 12:59 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: 67DATE:
09/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Tana ReedTIME COMPLETED:
01:13 PM
NARRATIVE
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On Wednesday, September 21, 2022 at 10:15 AM, Licensing Program Analyst (LPA) Caroline Colson met with Tana Reed, Site Supervisor I, for an unannounced case management inspection for Lead Testing Results. There are 67 children and 12 staff members present. A tour of the facility was conducted. Pictures were taken. Documentation was obtained. It was concluded that there are two faucets that have elevated lead levels established by an certified independent water sampler.

Please See LIC 809 for Deficiency

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Tana Reed, Site Supervisor.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Caroline Colson
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2022
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 09/21/2022 12:59 PM - It Cannot Be Edited


Created By: Caroline Colson On 09/21/2022 at 12:22 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: CONTRA COSTA CO. HEAD START - BALBOA CDC
FACILITY NUMBER: 073400249

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2022
Section Cited
CCR
101700.3(b)(1)

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Lead Testing Written Directive
A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
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BY POC DUE DATE: Licensee will have a contractor to fixed both faucets and send a post-testing report.
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Based on record review, the licensee did not comply with the section cited above which poses a potential health and safety risk to persons in care.
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Failure to correct will result in a $100.00 per day civil penalty until corrected. Repeat violations are 250.00 per violation and $100.00 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: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022


LIC809 (FAS) - (06/04)
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