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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422420
Report Date: 05/24/2023
Date Signed: 05/24/2023 12:42:28 PM


Document Has Been Signed on 05/24/2023 12:42 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:LA PLAZITA PRESCHOOL IIIFACILITY NUMBER:
013422420
ADMINISTRATOR:LOPEZ, ETELVINAFACILITY TYPE:
850
ADDRESS:3616 - 3636 35TH AVE.TELEPHONE:
(510) 857-7309
CITY:OAKLANDSTATE: CAZIP CODE:
94619
CAPACITY:110CENSUS: 94DATE:
05/24/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Etelvina LopezTIME COMPLETED:
12:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lisa Dyer arrived at the facility to conduct an unannounced Case Management inspection to follow up on results received regarding lead testing/exceedance. LPA met with Director Etelvina Lopez. There were 94 children and 11 staff present.

The facility completed the required lead testing of water outlets.

One outlet was found to be in exceedance of the Action Level of 5 ppb. The facility took action and made the outlet inaccessible to children. The facility completed and submitted all required documents to Licensing, and posted the test results in the facility. All families will be notified of the test results with a letter this week. LPA inspected the outlet. A sign has been placed to advise that the water is not safe for drinking.

The facility understands that they are unable to use the outlet until they receive additional test results, and the Action Level is 5 ppb or below.

See LIC 809-D for a deficiency being cited today. No other deficiencies are being cited.

An exit interview was conducted with Etelvina Lopez. A copy of this report, Notice of Site Visit, and Appeal Rights were given to the director. The facility was reminded to post the Notice of Site Visit for 30 days.

SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Phyllis DyerTELEPHONE: (510) 725-7006
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023
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 05/24/2023 12:42 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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612


FACILITY NAME: LA PLAZITA PRESCHOOL III
FACILITY NUMBER: 013422420

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
06/24/2023
Section Cited
CCR
101700.3(b)(1)

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101700.3 California Lead Action Level at Child Care Centers (b) Testing results with fractional ppb readings of 0.5 ppb or greater shall be rounded up to the nearest whole number, before comparing to the Action Level. (1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
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The facility closed off the outlet. A sign was placed on the unit.
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This requirement has not been met as evidenced by the lead testing results received, indicating that one outlet in the facility had results in exceedance of the 5 ppb Action Level. This poses a potential risk to the children in care.
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Facility director states the outlet will not be used. Per CCL regulations, the outlet cannot be used for drinking until the Action Level is determined to be 5 ppb or below.

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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 DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Phyllis DyerTELEPHONE: (510) 725-7006
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023
LIC809 (FAS) - (06/04)
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