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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421992
Report Date: 06/01/2023
Date Signed: 06/01/2023 10:53:09 AM


Document Has Been Signed on 06/01/2023 10:53 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:CAPE - FREDERIKSONFACILITY NUMBER:
013421992
ADMINISTRATOR:CERVANTES, CELIAFACILITY TYPE:
850
ADDRESS:7243 TAMARACK DRIVETELEPHONE:
(925) 443-3434
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY:24CENSUS: 9DATE:
06/01/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH: director, Celia CervantesTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Jyoti Saini met with Director, Ceila Cervantes to conduct a Case Management inspection for the Lead Testing results at this facility. In addition to the director, there are 9 children, and 2 staff members present today. The facility operates Monday - Friday from 9:00am to 3:30pm.

LPA inspected the facility for health and safety. It was concluded that one outlet exceeded the Action Level that was established by the state for exposure, however that faucet with an exceedance of ALE has never been used for drinking or food preparation.

To correct the exceedance, the facility has already replaced the water outlet and in process of rescheduling retesting. LPA obtained photos of the faucet that has exceeded 5.5 ppb. LPA obtained the documentation for the post-testing requirements.



A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Director, Celia Cervantes.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jyoti SainiTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023
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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