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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073400254
Report Date: 10/19/2022
Date Signed: 03/07/2023 11:41:30 AM

Document Has Been Signed on 03/07/2023 11:41 AM - 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 - LAVONIA ALLEN CENTERFACILITY NUMBER:
073400254
ADMINISTRATOR:DORIS STEPHENSFACILITY TYPE:
850
ADDRESS:94 1/2 MEDANOS AVENUETELEPHONE:
(925) 427-8270
CITY:BAY POINTSTATE: CAZIP CODE:
94565
CAPACITY: 48TOTAL ENROLLED CHILDREN: 17CENSUS: 15DATE:
10/19/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jessie Black TIME COMPLETED:
04:15 PM
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THIS IS AN AMENDED REPORT

On 10/19/22 at 1:30 PM Licensing Program Analyst (LPA) Michelle Sutton conducted an unannounced Case Management inspection about two unusual incidents self reported by the Center on 9/26/22 and 10/12/22. LPA met with assistant director Jessie Black and explained the purpose of today's inspection.

LPA conducted staff interviews and observed the facility. The Children's Roster and Personnel Report LIC500 were obtained. For incident reported on 10/12/22 although the incident was reported by the facility, the facility is currently still conducting their own investigation there for no deficiency is cited. For incident reported on 9/26/22, video footage was provided to The Regional Manager Diane Perez which determined that there was no lack of supervision in care. The Type-B cited on 12/21/22 has been overturned during the appeal process.

There are no deficiencies cited as of today. Exit interview conducted and report was reviewed with the site supervisor Ligia Ortiz.

SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Michelle Sutton
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2023
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 Has Been Signed on 03/07/2023 11:42 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/27/2023 03:39 PM


Created By: Michelle Sutton On 10/19/2022 at 03:36 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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CONTRA COSTA CO. HEAD START - LAVONIA ALLEN CENTER
FACILITY NUMBER: 073400254

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2022
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:Sherelle Johnson
LICENSING EVALUATOR NAME:Michelle Sutton
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023


LIC809 (FAS) - (06/04)
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