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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073400249
Report Date: 05/10/2023
Date Signed: 05/10/2023 04:59:20 PM

Document Has Been Signed on 05/10/2023 04:59 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
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: 0DATE:
05/10/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
04:18 PM
MET WITH:Kimberly VegasTIME COMPLETED:
05:15 PM
NARRATIVE
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On Wednesday, May 10, 2023 at 4:18 PM, Licensing Program Analyst (LPA) Caroline Colson met with Kimberly Vega, Comprehensive Services Assistant Manager, for an unannounced case management inspection for Lead Testing Results. There are no children or staff present. Documentation will be sent via email. It was concluded that there are two faucets that have elevated lead levels established by an certified independent water sampler.

Please See LIC 809 D 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 Kimberly Vega, Facility Representative.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Caroline Colson
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2023
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 is an Amendment of Original Document on 07/17/2023 04:57 PM


Created By: Mayla Mendoza On 05/10/2023 at 04:39 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
BAY AREA-CC OAKLAND, 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: 05/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed




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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:Diane Perez
LICENSING EVALUATOR NAME:Mayla Mendoza
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023


LIC809 (FAS) - (06/04)
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