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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073400495
Report Date: 07/17/2023
Date Signed: 07/17/2023 03:43:17 PM

Document Has Been Signed on 07/17/2023 03:43 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. CHILD START - LOS NOGALES CENTERFACILITY NUMBER:
073400495
ADMINISTRATOR:SHAWN POWERSFACILITY TYPE:
850
ADDRESS:321 ORCHARD DRIVETELEPHONE:
(925) 427-8531
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 40TOTAL ENROLLED CHILDREN: 8CENSUS: 4DATE:
07/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Entesar (Sarah) EbeidTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cherie Acosta conducted an unannounced Case Management visit in regards to a self reported incident. LPA met with Entesar (Sarah) Ebeid. Ms. Ebeid is temporarily over seeing this site until a new director is hired. There were 4 staff and 4 children present during the visit.

An incident occurred on 6/26/23 were a child received a burn on her thumb. A teacher was putting away a glue gun and a child needed help putting away a nap mat. While holding the glue gun, the teacher went to assist the child. The child accidentally touched the hot glue gun and received a burn. The facility self reported this incident to Community Care Licensing (CCL).

See attached 809-D for deficiency cited today.
Exit interview and report reviewed with Entesar (Sarah) Ebeid.
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: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2023
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 07/17/2023 03:43 PM - It Cannot Be Edited


Created By: Cherie Acosta On 07/17/2023 at 03:11 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. CHILD START - LOS NOGALES CENTER
FACILITY NUMBER: 073400495

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/24/2023
Section Cited
CCR
101223(a)(2)

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Personal Rights. The licensee shall ensure that each child is accorded the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs
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Entesar (Sarah) Ebeid stated that staff have received training on safe practices. It is agreed that proof of training will be submitted to CCL by 7/24/23.
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This requirement was not met as evidenced by: a child in care was accidently burned by a hot glue gun which poses a potential risk to the health and safety of children in care
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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: 07/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023


LIC809 (FAS) - (06/04)
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