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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013415181
Report Date: 08/03/2023
Date Signed: 08/03/2023 12:26:35 PM


Document Has Been Signed on 08/03/2023 12:26 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:OUSD - MARTIN LUTHER KING CDCFACILITY NUMBER:
013415181
ADMINISTRATOR:SLOCUM AM/SLOCUM PMFACILITY TYPE:
850
ADDRESS:960-A TENTH STREETTELEPHONE:
(510) 874-7759
CITY:OAKLANDSTATE: CAZIP CODE:
94607
CAPACITY:75CENSUS: 0DATE:
08/03/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Nemiya MooreTIME COMPLETED:
02:00 PM
NARRATIVE
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On 08/03/2023 at 11:45 AM Licensing Program Analyst (LPA), A. Curry conducted an unannounced case management inspection to follow up regarding a lead exceedance at the facility. LPA met with lead teacher, Neymiya Moore, to explain the purpose of today's inspection. The licensee failed to maintain a lead value at or below the Action Level for water lead testing resulting with values of 5.5ppb or greater for outlet i. Water testing results identified with Action Level Exceedance as defined in WD section 101700.3 are not deemed safe to drink (See 809D). The facility tested its drinking water for lead contamination on 09/14/2022 and outlets Faucet Room 2 Sink and Faucet Room 3 sink 2 exceeded the acceptable amount of lead allowed at a child care facility. The facility retested its drinking water for lead contamination on 05/05/2023 and outlet i in Room 3 has a lead exceedance. The lead teacher indicated Building and Grounds are in the process of remediating the lead exceedance. The lead teacher was advised to place a bag over the sink to make it inoperable and place a "Do not use" sign next to the sink.

Exit interview conducted, appeal rights were given, and report was reviewed with lead teacher, Neymiya Moore.
SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Ashley CurryTELEPHONE: 510-566-1562
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 08/03/2023 12:26 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: OUSD - MARTIN LUTHER KING CDC
FACILITY NUMBER: 013415181

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/07/2023
Section Cited
CCR
101700.3

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Licensee 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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By 08/07/2023 the facility will make the sink with a lead exceedance inoperable by placing a bag over it and by placing a "Do Not Use" sign next to the sink.
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Based on interview and record review the licensee did not comply with the section cited above as outlet i exceeded the acceptable amount of lead allowed in a child care center, which poses a potential Health and Safety risk to persons in care.
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LPA will follow up with the facility at a later time to see if the sink will be permanently removed or repaired.

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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: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Ashley CurryTELEPHONE: 510-566-1562
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
LIC809 (FAS) - (06/04)
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