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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010206137
Report Date: 01/19/2024
Date Signed: 01/19/2024 02:48:25 PM

Document Has Been Signed on 01/19/2024 02:48 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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:OUSD - HARRIET TUBMANFACILITY NUMBER:
010206137
ADMINISTRATOR:REED, VONZELEFACILITY TYPE:
850
ADDRESS:800-33RD STREETTELEPHONE:
(510) 654-7890
CITY:OAKLANDSTATE: CAZIP CODE:
94608
CAPACITY: 72TOTAL ENROLLED CHILDREN: 72CENSUS: DATE:
01/19/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Lawrence GotancoTIME COMPLETED:
03:00 PM
NARRATIVE
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On 01/19/2024 at 11:45 AM Licensing Program Analyst (LPA) A. Curry conducted an unannounced case management inspection to follow up on a lead exceedance at the facility. LPA met with Site Principal, Lawrence Gotanco, to explain the purpose of today's visit. The facility tested their drinking water for lead contamination on 08/04/2022 and 11/15/2023. The licensee failed to maintain a lead value at or below the Action Level for water lead testing resulting with values of 5.5ppb or greater for outlets F, K, and P. Water testing results identified with Action Level Exceedance as defined in WD section 101700.3 are not deemed safe to drink (See 809D). During today's visit LPA verified that all three outlets were made inaccessible to children in care by having the water turned off and a bag placed over each outlet with an exceedance.

Exit interview conducted, appeal rights were given, and report was reviewed with the Site Principal, Lawrence Gotanco.

SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Ashley Curry
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2024
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 01/19/2024 02:48 PM - It Cannot Be Edited


Created By: Ashley Curry On 01/19/2024 at 01:07 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: OUSD - HARRIET TUBMAN
FACILITY NUMBER: 010206137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/19/2024
Section Cited
CCR
101700(b)(2)

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Licensee shall maintain a lead value at or below the Action Level of 5.5 ppb in all outlets subject to the testing requirements of these Written Directives, for the health and safety of children in care.

This requirement is not met as evidence by:
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By 02/19/2024 the facility must permanently remove or repair and retest each outlet that exceeded.
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Based on interview and record review the licensee did not comply with the section cited above as outlets F, K, and P exceeded the acceptable amount of lead allowed in a child care center, which poses a potential Health and Safety risk to persons in care.
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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:Loretta Dyson
LICENSING EVALUATOR NAME:Ashley Curry
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024


LIC809 (FAS) - (06/04)
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