<meta name="robots" content="noindex">
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: 113TOTAL ENROLLED CHILDREN: 43CENSUS: 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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
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).
Loretta Dyson
Ashley Curry
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


Created By: Ashley Curry On 06/20/2023 at 01:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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

1
2
3
4
5
6
7
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:
8
9
10
11
12
13
14
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.
8
9
10
11
12
13
14

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:Loretta Dyson
LICENSING EVALUATOR NAME:Ashley Curry
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)
Page: 2 of 2