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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013420947
Report Date: 10/19/2023
Date Signed: 10/19/2023 01:11:24 PM


Document Has Been Signed on 10/19/2023 01:11 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:CHILD UNIQUE MONTESSORI SCHOOL, THEFACILITY NUMBER:
013420947
ADMINISTRATOR:ACKER, CINDYFACILITY TYPE:
850
ADDRESS:1400 - 6TH STTELEPHONE:
(510) 521-0595
CITY:ALAMEDASTATE: CAZIP CODE:
94501
CAPACITY:75CENSUS: 14DATE:
10/19/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
12:01 PM
MET WITH:Cindy AckerTIME COMPLETED:
01:15 PM
NARRATIVE
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On 10/19/2023 at 11:15 AM Licensing Program Analysts (LPAs) Catherine Fernandes and Brittany Crass conducted an unannounced case management inspection regarding a lead exceedance at the facility. LPAs met with the owner Cindy Acker and explained the purpose of today's inspection. Present in care were 14 preschoolers and six additional staff members.

The facility tested its drinking water for lead contamination on 08/8/2023 and water fountain D located outside on the left side of the bathroom exceeded the acceptable amount of lead allowed at a childcare facility with a result of 24 ppb. 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 water fountain D-sink (middle spout).

Water testing results identified with Action Level Exceedance as defined in WD section 101700.3 are not deemed safe to drink (See 809D for deficiency being cited today). The director was advised and place the faucet out of service and inoperable by the water being shut off at wall and placed a "not in use" sign on on the fountain. Results were given to parents of children in care and director has provided the required documents to the LPAs while at the center.


See 809D for deficiency being cited today

Exit interview conducted with Cindy Acker

Appeal Rights and Report was provided.

Notice of Site Visit provided and must remain posted for 30 days.

SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 873-6408
LICENSING EVALUATOR NAME: Catherine FernandesTELEPHONE: (510) 725-7002
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
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 10/19/2023 01:11 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: CHILD UNIQUE MONTESSORI SCHOOL, THE
FACILITY NUMBER: 013420947

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2023
Section Cited

101700.3(b)(1)

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Lead Testing Written Directive: A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. This requirement has not been met as evidenced by:
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The center has be made the water fountain inoperable by shutting off the water supply to the entire fountain and placing a "not in use sign".
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Based on center records one spout in the water fountain tested above 5.5 ppb which poses a potential risk to the health and safety of the children in care.
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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: Mayla MendozaTELEPHONE: (510) 873-6408
LICENSING EVALUATOR NAME: Catherine FernandesTELEPHONE: (510) 725-7002
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
LIC809 (FAS) - (06/04)
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