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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408229
Report Date: 11/06/2023
Date Signed: 11/06/2023 03:27:47 PM

Document Has Been Signed on 11/06/2023 03:27 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:GAN B'NAI SHALOM AT CONGREGATION B'NAI SHALOMFACILITY NUMBER:
073408229
ADMINISTRATOR:MEDWIN, MARLAFACILITY TYPE:
830
ADDRESS:74 ECKLEY LANETELEPHONE:
(925) 933-7633
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94596
CAPACITY: 18TOTAL ENROLLED CHILDREN: 18CENSUS: 9DATE:
11/06/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Stuart KirschTIME COMPLETED:
04:00 PM
NARRATIVE
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On 11/6/23 Licensing Program Analysts (LPAs) Monica Mathur and Brindha Govindasamy conducted an unannounced Case Management inspection and met with Executive Director, Stuart Kirsch to conduct a follow up inspection for the Lead Testing results at the center.

It was determined that one outlet which was tested exceeded the Action Level established by the State for exposure. It is located in the Director's Office and Stuart stated it was not used by children for drinking or food preparation. The faucet has been rendered out of service and the office staff has not been using the outlet since exceedance.

Under California State's Written Directives on lead exceedance, any tested outlet that results in exceedance poses/posed a potential risk. Center must follow a remediation process of either replacing the faucet and re-testing again; or permanently removing it. Deficiency is cited on 809-D.

Exit interview conducted and report was reviewed with Executive Director, Stuart Kirsch. A Notice of Site Visit was given and must remain posted for 30 days..

SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2023
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 11/06/2023 03:27 PM - It Cannot Be Edited


Created By: Monica Mathur On 11/06/2023 at 01:53 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: GAN B'NAI SHALOM AT CONGREGATION B'NAI SHALOM
FACILITY NUMBER: 073408229

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2023
Section Cited

101700.3(b)(2)

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Licensees shall maintain a lead value at or below the Action Level of 5 ppb in all outlets subject to the testing requirements of these Written Directives, for the health and safety of children in care. This requirement is not met as evidenced by:
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By POC due date 12/6/23 Director agreed to send a written plan of remediation,ensure outlet is either replaced and re-tested, or permanently removed.
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An outlet in the Office tested positive for lead. This posed a potential risk.
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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:Monica Mathur
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023


LIC809 (FAS) - (06/04)
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