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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421386
Report Date: 08/18/2023
Date Signed: 08/18/2023 01:49:44 PM

Document Has Been Signed on 08/18/2023 01:49 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:UCB - CLARK KERR CAMPUS CHILDRENS CENTERFACILITY NUMBER:
013421386
ADMINISTRATOR:DARRELL WHITACREFACILITY TYPE:
830
ADDRESS:2900 DWIGHT WAY, BLDG. #5TELEPHONE:
(510) 642-0582
CITY:BERKELEYSTATE: CAZIP CODE:
94720
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 0DATE:
08/18/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Boris AlvaradoTIME COMPLETED:
01:56 PM
NARRATIVE
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On August 18, 2023 at 9:13am Licensing Program Analyst (LPA), Indira Loza conducted a case management inspection to follow up on a lead exceedance at the facility. LPA met with Assistant Boris Alvarado, to explain the purpose of today's inspection. The facility failed to maintain a lead value at or below the Action Level for water lead testing resulting with values of 5ppb or greater for the outlet labeled "C" in the children's classroom which had a level of 50ppb. Water testing results identified with Action Level Exceedance as defined in WD section 101700.3 are not deemed safe to drink or to be used in food preparation. During today's visit, LPA verified the water outlet was made inoperable. Assistant Alvarado was advised to place a sign on the faucet that indicates it is not to be used.

See LIC809-D for Type B deficiency.

Report was reviewed with Assistant Boris Alvarado.

Appeal Rights and Report was provided.

Notice of Site Visit must remain posted for 30 days.

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2023
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 08/18/2023 01:49 PM - It Cannot Be Edited


Created By: Indira Loza On 08/18/2023 at 12:53 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: UCB - CLARK KERR CAMPUS CHILDRENS CENTER
FACILITY NUMBER: 013421386

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/18/2023
Section Cited

101700.3

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Licensee shall maintain a lead value at or below the Action Level of 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 was not met as evidenced by:
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The Director shall decide whether the faucet will be remediated or if they choose to permanently disable the faucet from being used in the future and make arrangements for the next steps. These arrangement shall be made and in the process of being complete no later than September 18, 2023.
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Based on record review it was determined that faucet "C" had an exceedance of 50ppb which poses a potential risk to the Health and Safety of children in care.
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The Director shall email all progress made to the LPA by Spetember 18, 2023

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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 Mendoza
LICENSING EVALUATOR NAME:Indira Loza
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2023


LIC809 (FAS) - (06/04)
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