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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010210187
Report Date: 11/30/2023
Date Signed: 11/30/2023 05:32:12 PM


Document Has Been Signed on 11/30/2023 05:32 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:ALA COSTA CTR. FOR THE DEVELOPMENTALLY DISABLEDFACILITY NUMBER:
010210187
ADMINISTRATOR:PEREIRA, MICHAEL A.FACILITY TYPE:
840
ADDRESS:1300 ROSE STREETTELEPHONE:
(510) 527-2550
CITY:BERKELEYSTATE: CAZIP CODE:
94702
CAPACITY:58CENSUS: 20DATE:
11/30/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Michael PereiraTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Diana Campos conducted an unannounced case management inspection in regards to three faucets at the facility having lead exceedance.
Facility had the water tested 12/03/22. It was found that two faucets in the boys bathroom, identified as faucets 2 and 3, and one faucet in the girls bathroom identified as faucet 7 had lead that exceeded the acceptable amount of lead allowed in a child care center. The faucets identified have not been used for cooking or drinking water. Children bring their food from home and the facility provides a snack. The faucet used for cooking water (faucet 8H) did not test with lead exceedance. The faucets that had lead exceedance have not been replaced yet. The facility will have the faucets repaired and water retested. Director agrees to notify LPA of the repair and retest date and send LPA the results of the testing.

Notice of Site Visit was provided and must be posted for 30 days.

Exit interview conducted and report reviewed with Executive Director Michael Pereira.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana CamposTELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
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 11/30/2023 05:32 PM - It Cannot Be Edited

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: ALA COSTA CTR. FOR THE DEVELOPMENTALLY DISABLED
FACILITY NUMBER: 010210187

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2023
Section Cited

101700.3(b)(2)

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100700.3 (b)(2) that states “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.
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Facility shall submit by the POC date a plan of action on when and how the faucets will be repaired to correct the lead exceedance and subsequently retested for lead values.
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This requirement was not met as evidenced by: Licensee failed to maintain a lead value at or below the Action Level for water lead testing. This 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 JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana CamposTELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
LIC809 (FAS) - (06/04)
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