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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070215161
Report Date: 10/13/2022
Date Signed: 10/13/2022 10:38:34 AM


Document Has Been Signed on 10/13/2022 10:38 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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:LA PETITE ACADEMY, INC.FACILITY NUMBER:
070215161
ADMINISTRATOR:DAVIS, GRETAFACILITY TYPE:
840
ADDRESS:3891 LAKESIDE DRIVETELEPHONE:
(510) 222-3070
CITY:RICHMONDSTATE: CAZIP CODE:
94806
CAPACITY:28CENSUS: 56DATE:
10/13/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Greta M.Shelby-DavisTIME COMPLETED:
10:45 AM
NARRATIVE
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On 10/13/22 Licensing Program Analyst (LPA) Monica Mathur met with Director, Greta Shelby-Davis to conduct a Case Management inspection for the Lead Testing results at La Petite Academy Inc..

LPA conducted an inspection and toured the premises with Greta. It was indicated that there were at least 2 water outlets that exceeded the Action Level established by the State for exposure. Director states the faucets have been replaced, children were using those faucets to wash hands only and did not drink out of it. Facility does not prepare meals using those faucets. LPA discussed a Plan of Correction and facility will submit the documentation for the post-testing requirements. Director states re-testing is scheduled to be done end October 2022.

Facility will submit to CCLD the following, no later than 10/17/22:


1. External Water Sampler Self-Certification Form (LIC 9275)
2. Child Care Center Sampling Checklist Form (LIC 9276)
3. Facility Sketch LIC999 marking faucets with exposure
4. Photos of faucets replaced
5. a written plan on how facility is ensuring safe water availability.
6. Documentation of re-testing - when results become available.

There is potential risk to health and safety of children in care, therefore deficiency is cited from the California Code of Regulations, Title 22 (See LIC 809-D). A Notice of Site Visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Director, Greta Shelby-Davis.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
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 10/13/2022 10:38 AM - 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: LA PETITE ACADEMY, INC.
FACILITY NUMBER: 070215161

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2022
Section Cited

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101238 Buildings and Grounds (a)The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors. This requirement is not met as evidenced by
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Based on Lead Testing Samples the facility has 2 water faucets with lead exposure. This is a potential risk to Health & Safety or Personal Rights risk to persons in care
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 Faciilty has replaced the faucets and is scheduled to re-test. By 11/14/22 Facility will provide all documentation for lead results when they become available in end October 2022.

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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: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
LIC809 (FAS) - (06/04)
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