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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010211857
Report Date: 10/27/2022
Date Signed: 10/27/2022 02:55:29 PM


Document Has Been Signed on 10/27/2022 02:55 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 STE 1102
OAKLAND, CA 94612



FACILITY NAME:EXTENDED DAY CHILD CARE - WALNUT GROVEFACILITY NUMBER:
010211857
ADMINISTRATOR:NATALIE GLYNNFACILITY TYPE:
840
ADDRESS:5199 BLACK AVENUETELEPHONE:
(925) 846-5519
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY:120CENSUS: 17DATE:
10/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Natalie GlynnTIME COMPLETED:
03:15 PM
NARRATIVE
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On October 27, 2022 at approximately 1:45 PM Licensing Program Analysts Lorraine Dacanay Breaux and Russ Haderer for an Unannounced Case Management Visit for Lead Testing Result at Extended Day Child Care for the inspection were Director and four (4) staff. The census was seventeen (17) children. The facility operates Monday - Friday 7:00 AM - 6:00 PM.

LPAs and Director toured the facility and LPAs obtained photos of the faucets in the kitchen and bathrooms.A plan of correction was discussed with the Director and the facility has submitted the documentation for the post-testing requirements. This facility is being given a Type B citation for California Code of Regulations, Title 22, Division 12 Chapter 1 Regulation number: 101238(a) Buildings and Grounds. (Please see 809D page for citation and Plan of correction details).

A copy of this report was provided. A notice of site visit was given and appeal rights. Exit interview conducted and report was reviewed with the with Director Natalie Glynn.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Lorraine Dacanay-BreauxTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
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 10/27/2022 02:55 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 STE 1102
OAKLAND, CA 94612


FACILITY NAME: EXTENDED DAY CHILD CARE - WALNUT GROVE
FACILITY NUMBER: 010211857

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2022
Section Cited

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101238(a) Buildings and Grounds (a) 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 visitor. This requirement is not met as evidenced by:
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Based on Lead Testing Samples the facility has multiple water faucets with lead level exceeding 0.5ppb. This is an potential risk to Health and Safety or Personal RIghts to persons in care.
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The facility will have the bathroom facuets replaced on November 1, 2022. The kitchen facuet is on back order and will be replaced as soon it becomes available.

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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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Lorraine Dacanay-BreauxTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
LIC809 (FAS) - (06/04)
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