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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073402755
Report Date: 01/18/2023
Date Signed: 01/18/2023 11:37:23 AM


Document Has Been Signed on 01/18/2023 11:37 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
BAY AREA-CC OAKLAND, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:W.C.C.U.S.D. - RIVERSIDE SCHOOLFACILITY NUMBER:
073402755
ADMINISTRATOR:DUVIVIER, HANNAHFACILITY TYPE:
850
ADDRESS:1300 AMADOR ST., ROOM 6TELEPHONE:
(510) 231-1570
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY:24CENSUS: 21DATE:
01/18/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
10:04 AM
MET WITH:Anna WirsigTIME COMPLETED:
11:51 AM
NARRATIVE
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On Wednesday, January 18, 2023 10:04 AM, Licensing Program Analyst (LPA) Caroline Colson met with Anna Wirsig, Head Teacher, for a case management inspection for Lead Testing Results. Demi Branch, Early Learning Program Supervisor and Olanrewaju Ajayi, Early Learning Program Preschool Coordinator. There are 21 preschool children and 3 staff members including head teacher. A tour of the facility was conducted. Test Results were obtained. It was concluded that there is one faucet located behind the director's desk that has elevated lead levels established by an certified independent water sampler.

Please See LIC 809 D for Deficiency

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Olanrewaju Ajayi, Early Learning Program Preschool Coordinator.
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-2724
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 725-7008
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2023
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 01/18/2023 11:37 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
BAY AREA-CC OAKLAND, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612


FACILITY NAME: W.C.C.U.S.D. - RIVERSIDE SCHOOL
FACILITY NUMBER: 073402755

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/20/2023
Section Cited

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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.
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BY POC DUE DATE: Licensee repaired the faucet but will need to have it reinspected for new results.
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Based on record review, the licensee did not comply with the section cited above which poses a potential health and safety risk to persons in care.
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Failure to correct will result in a $100.00 per day civil penalty until corrected. Repeat violations are 250.00 per violation and $100.00 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: 01/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2023
LIC809 (FAS) - (06/04)
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