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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073402613
Report Date: 11/14/2022
Date Signed: 11/14/2022 01:23:06 PM


Document Has Been Signed on 11/14/2022 01:23 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
BAY AREA-CC OAKLAND, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:CONTRA COSTA CO. HEAD START - BALBOA CDCFACILITY NUMBER:
073402613
ADMINISTRATOR:DOSS, MARILYNFACILITY TYPE:
830
ADDRESS:1001 - SOUTH 57TH STTELEPHONE:
(510) 374-7025
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY:38CENSUS: 8DATE:
11/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Marilyn DossTIME COMPLETED:
01:37 PM
NARRATIVE
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On Monday, November 14, 2022 at 9:58 AM, Licensing Program Analyst (LPA) Caroline Colson met with Marilyn Doss, Center Director, for an unannounced Case Management Inspection. Tana Reed, Site Administrator, arrived during the inspection. There are 8 Infant/Toddlers and 9 staff members present. An incident occurred when an infant walked into the kitchen after a teacher didn't close the door all the way. There were Federal Head Start monitors present and on a facility tour. A monitor informed the teacher that an infant went into the kitchen without adult supervision. A teacher immediately went into the kitchen and removed the infant. The teacher closed the door behind her and the infant.

Please See LIC 809 D for Deficiency
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-2724
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 725-7008
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2022
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 11/14/2022 01:23 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
BAY AREA-CC OAKLAND, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612


FACILITY NAME: CONTRA COSTA CO. HEAD START - BALBOA CDC
FACILITY NUMBER: 073402613

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/14/2022
Section Cited

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Responsibility for Providing Care and Supervision for Infants
Each infant shall be constantly supervised and under direct visual observation and supervision by a staff person at all times.
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During a classroom tour, a monitor observed an infant walk into the kitchen without any adult supervision. This poses a potential health and safety risk to children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are 250.00 per violation and $100 per day until corrected.

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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) 292-2724
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 725-7008
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2022
LIC809 (FAS) - (06/04)
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