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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073400249
Report Date: 01/07/2025
Date Signed: 01/07/2025 01:44:19 PM

Document Has Been Signed on 01/07/2025 01:44 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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:CONTRA COSTA CO. HEAD START - BALBOA CDCFACILITY NUMBER:
073400249
ADMINISTRATOR/
DIRECTOR:		DOSS, MARILYNFACILITY TYPE:
850
ADDRESS:1001 S. 57TH STREETTELEPHONE:
(510) 374-7025
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY: 140TOTAL ENROLLED CHILDREN: 92CENSUS: 62DATE:
01/07/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Marilyn DossTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cherie Acosta and Kayla Merchant conducted an unannounced visit in regards to two self reported incidents. LPAs met with Site Supervisor Marilyn Doss.

During the visit LPAs conducted interviews, reviewed documents and viewed video footage.
Facility reported that a staff inappropriately handled a child by grabbing the child by the arm. There were no injuries reported.
Staff involved in the incident no longer works for Contra Costa Head Start.

The attached type A violation is cited today and must be corrected by the due date. Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. All parents/guardians must sign an acknowledgement form of proof of receiving this report (LIC9224). The LIC 9224 must be placed in the child's file to be reviewed by licensing.

Exit interview and report reviewed with Marilyn Doss.
Notice of Site Visit was provided and must be posted for 30 days.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Cherie Acosta
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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 01/07/2025 01:44 PM - It Cannot Be Edited


Created By: Cherie Acosta On 01/07/2025 at 01:05 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: 01/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/08/2025
Section Cited
CCR
101223(a)(3)

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Personal Rights-The licensee shall ensure that each child is accorded the following personal rights:
To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental
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Site Supervisor shall create a written plan of action to ensure there are no further incidents. A copy of the plan shall be submitted to CCL by 1/8/25.
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 abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This requirement was not met as eviendenced by: Staff grabbed a child by the arm which is an immediate risk to the health and safety of children in care.
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Proof that the child's parent was notified of the incident shall also be provided to CCL by 1/8/25

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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:Sherelle Johnson
LICENSING EVALUATOR NAME:Cherie Acosta
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2025


LIC809 (FAS) - (06/04)
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