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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073400249
Report Date: 11/14/2022
Date Signed: 11/14/2022 01:17:15 PM

Document Has Been Signed on 11/14/2022 01:17 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
BAY AREA-CC OAKLAND, 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: 58DATE:
11/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Marilyn DossTIME COMPLETED:
01:31 PM
NARRATIVE
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On Monday, November 14, 2022 at 9:58 AM, Licensing Program Analyst (LPA) Caroline Colson met with Marilyn Doss, Center Director, for an unannounced Case Management inspection. Tana Reed, Site Administrator, arrived during the inspection. There are 58 children and 19 staff members. An incident occurred when a child left an area of the classroom to go into the bathroom located within the classroom. There were Federal Head Start monitors present and on a facility tour. The child left his assigned area without adult supervision to go into the bathroom alone. A monitor saw the child enter the bathroom to wash hands and exit the bathroom.

Please See LIC 809 D for Deficiency
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Caroline Colson
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/14/2022 01:17 PM - It Cannot Be Edited


Created By: Caroline Colson On 11/14/2022 at 11:12 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: CONTRA COSTA CO. HEAD START - BALBOA CDC
FACILITY NUMBER: 073400249

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/14/2022
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision

(1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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BY POC DUE DATE: Licensee will have all staff in the classroom watch the Care/Supervision video on the Community Care Licensing website and provide a summary.
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During a classroom tour, a monitor observed a child walk into the bathroom to wash hands and exit without any adult supervision. This poses a 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: 11/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2022


LIC809 (FAS) - (06/04)
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