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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013417784
Report Date: 06/20/2023
Date Signed: 06/20/2023 01:35:31 PM


Document Has Been Signed on 06/20/2023 01:35 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:EAST BAY ACADEMY, INC.FACILITY NUMBER:
013417784
ADMINISTRATOR:MARGARIDA WONGFACILITY TYPE:
850
ADDRESS:1011 7TH AVENUETELEPHONE:
(510) 267-0788
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY:113CENSUS: 41DATE:
06/20/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Cuicui Ma/ Jennifer WongTIME COMPLETED:
04:00 PM
NARRATIVE
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On 06/20/2023 at 12:30 PM Licensing Program Analyst (LPA) A. Curry conducted an unannounced case management inspection in regards to the lead testing at the facility. LPA met with Lead Teacher/ Supervisor Cui Cui Ma to explain the purpose of today's inspection. LPA also spoke with Lead Teacher/ Administrator, Jennifer Wong, via telephone. The Administrator indicated the lead testing was completed, but was not able to provide documentation that shows the testing was done (See 809D).
SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Ashley CurryTELEPHONE: 510-566-1562
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
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 06/20/2023 01:35 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: EAST BAY ACADEMY, INC.
FACILITY NUMBER: 013417784

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/07/2023
Section Cited
CCR
100700(C)(1)

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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.
This requirement is not evidence by:
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Jennifer Wong indicated the testing was completed, but could not provide any documentation that shows the lead testing was done.
By 07/07/2023 send lead packet to LPA, which includes lead test results, facility sketch, LIC 9275 form, and LIC 9276 form.
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Based on interviews and record review the licensee did not comply with the section cited above by ensuring the facility is able to provide documentation that shows the lead testing was completed.
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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: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
LIC809 (FAS) - (06/04)
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