010210783-10-21-2020-52-CC-CCHS-BW46KS-20201207195315

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 010210783
Report Date: 10/21/2020
Date Signed: 10/21/2020 12:14:26 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/15/2020 and conducted by Evaluator Renee Reed

PUBLIC

COMPLAINT CONTROL NUMBER: 52-CC-20201015101736

FACILITY NAME:	RESURRECTION LUTHERAN PRESCHOOL		FACILITY NUMBER:	010210783
ADMINISTRATOR:	COLLINS. SHARON		FACILITY TYPE:	850
ADDRESS:	7557A AMADOR VALLEY BOULEVARD		TELEPHONE:	(925) 829-5487
CITY:	DUBLIN	STATE: CA	ZIP CODE:	94568
CAPACITY:	80	CENSUS: 23	DATE:	10/21/2020
		UNANNOUNCED	TIME BEGAN:	09:22 AM
MET WITH:	Wazhma Masarweh		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Physical Plant

INVESTIGATION FINDINGS:

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On 10/21/2020 at approximately 9:25 AM, LPA Reed, LPA Clayton, LPA Dacanay-Breaux and LPM Charles, met with Wazhma Masarweh, Director & Admin Assistant Amy Collins, for an Unannounced Complaint Investigation filed against the preschool component. LPA's and LPM toured the facility with the director and Admin. Assistant ins, for a Health and Safety inspection. Present during the inspection was 7 staff personnel and 23 preschoolers.

The facility has four Preschool rooms: The Owl, The Bees, The Tigers and the Superstars. LPM and LPA Reed toured the Owl Room and Superstars. LPA Clayton and LPA Dacanay-Breaux toured the The Tigers and Bees rooms.
LPM and LPA observed a towel dispenser above the rolling paint cart, LPM moved the cart to observe damaged dry wall & exposed water valve and pvc piping. We also, observed a piece of flooring was missing. It was revealed a sink had been removed due to a water leakage.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Renee Reed	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 52-CC-20201015101736

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: RESURRECTION LUTHERAN PRESCHOOL	FACILITY NUMBER: 010210783
	VISIT DATE: 10/21/2020

NARRATIVE

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Based on LPA and LPM observation and interview which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations; Title 22, Division 12, Chapter 1, Article 7, Physical Environment, Code 101238 (a) is being cited on the attached LIC 9099-D . During this inspection a type 'B' violation was cited .

The Complaint report was read to the Center Director Wazhma Masarweh, & Admin Assistant Amy Collins. Exited interview was conducted, appeals rights explained and notice of cite visit was issued.

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Renee Reed	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 52-CC-20201015101736

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: RESURRECTION LUTHERAN PRESCHOOL	FACILITY NUMBER: 010210783
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/21/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/18/2020 Section Cited CCR 101238(a)	1 2 3 4 5 6 7	101238 (a) Buildings and Grounds - The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors.	1 2 3 4 5 6 7	On or before 11/18/2020 the facility is to have sink re-installed, dry wall repaired & checked, for dry rot and/or mildew. Also, the surrounding floor area will be repaired. Director will forward pictures of repairs of the sink and flooring to LPA's email.
	8 9 10 11 12 13 14	LPA observed in The Owl room, sink had been removed and drywall was damaged with exposed black pvc piping.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Renee Reed	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2020

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020

LIC9099 (FAS) - (06/04)

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