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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010200334
Report Date: 01/17/2024
Date Signed: 01/17/2024 01:16:07 PM

Document Has Been Signed on 01/17/2024 01:16 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:JOHN KNOX CO-OP PRESCHOOLFACILITY NUMBER:
010200334
ADMINISTRATOR:JAMES, LESLIEFACILITY TYPE:
850
ADDRESS:7421 AMARILLO ROADTELEPHONE:
(925) 828-2887
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: 26DATE:
01/17/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Director, Leslie JamesTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jyoti Saini met with Director Leslie James to conduct a Case Management inspection for the Lead Testing results at this facility. In addition to the director, 26 children, six staff, and four co-op parents are present today.

LPA inspected the facility for health and safety. It was concluded that three outlets (one faucet and two drinking fountains) exceeded the Action Level that was established by the state for exposure. The faucet (C) in room #C is not yet part of the license. The facility has permanently removed the playground's water fountain(D) and water fountain in room#B(A), which had a lead exceedance, and the facility is also in the process of rescheduling and retesting the Room#C faucet for potential use. LPA obtained photos of the faucet that exceeded 5.5 ppb. LPA received the documentation for the post-testing requirements.

See the attached deficiency LIC809-D.

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

An exit interview was conducted, and the report was reviewed with the Director, Leslie James
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jyoti Saini
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2024
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 01/17/2024 01:16 PM - It Cannot Be Edited


Created By: Jyoti Saini On 01/17/2024 at 12:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: JOHN KNOX CO-OP PRESCHOOL
FACILITY NUMBER: 010200334

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/01/2024
Section Cited

101700.3(b)(1)

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101700.3(b)(1)A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
This requirement is not met as evidenced by:
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The facility has permanently removed the playground's water fountain(D) and water fountain in room#B(A) since 12/2022. The facility is also in the process of rescheduling and retesting the Room#C faucet for potential use.
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Licensee failed to maintain a lead value at or below the Action Level for water lead testing with values of 5.5 ppb or greater for outlet A,C,D. Water testing results identified with Action Level Exceedance as defined in WD section 101700.3. are not deemed safe to drink.”
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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:Wynn Norona
LICENSING EVALUATOR NAME:Jyoti Saini
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024


LIC809 (FAS) - (06/04)
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