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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700512
Report Date: 12/14/2023
Date Signed: 12/14/2023 12:13:07 PM

Document Has Been Signed on 12/14/2023 12:13 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:SAFARI KID - IRVINGTONFACILITY NUMBER:
015700512
ADMINISTRATOR:KIRAN, GOWRIFACILITY TYPE:
850
ADDRESS:41811 BLACOW ROADTELEPHONE:
(510) 573-4871
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 105TOTAL ENROLLED CHILDREN: 105CENSUS: 69DATE:
12/14/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Gowri KiranTIME COMPLETED:
12:20 PM
NARRATIVE
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On December 14th, 2023, at approximately 10:25am, Licensing Program Analyst (LPA) April Wright conducted a Case Management inspection due to the center's lead testing results. LPA met with the facility representative Gowri Kiran. Present during inspection were 69 preschool/toddler age children and 10 staff personnel. LPA toured the facility for health and safety inspection.

LPA discussed with the Facility Representative that Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010 to test their drinking water for lead contamination between January 1, 2020 and January 1, 2023, and then every 5 years after the date of the first test. Health and Safety (HSC) Code section 1597.16 authorizes the Department to implement and administer procedures for lead testing at CCCs through written instructions until it adopts regulations under the Administrative Procedure Act. LPA discussed with the Facility Representative of the PIN 21-21-CCP - Release of the Written Directives for Lead Testing of Water in Licensed Child Care Centers Per AB 2370 https://cdss.ca.gov/Portals/9/CCLD/PINs/2021/CCP/PIN-21-21-CCP.pdf

Fixtures E & F (Outside playground water fountains) Samples #22L0906-05 and 22L0906-06 had a Lead Action Level of Exceedance Response of more than 5.5 ppb. Per Facility Representative, the fixtures were have not be in use since Covid (February 2020) and these fountains were closed off/covered and labeled "not in use". LPA observed the fixtures are closed off/covered and not accessible to children in care. Owner will have fountains removed and advise LPA when it has been completed.

See LIC 809-D for deficiencies cited during today's inspection. Appeal rights provided. Exit interview was conducted with the Facility Representative/Owner Gowri Kiran. A notice of site visit was provided and must be posted for 30 days.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: April Wright
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2023
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 12/14/2023 12:13 PM - It Cannot Be Edited


Created By: April Wright On 12/14/2023 at 11:47 AM
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: SAFARI KID - IRVINGTON
FACILITY NUMBER: 015700512

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/19/2024
Section Cited
HSC
101700.3(b)(2)

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101700.3(b)(2) 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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LPA confirmed the Plan of Correction and advised Owner to submit proof of permanent removal of the faucets will be emailed to LPA Wright no later than January 22nd, 2024.
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Fixtures E & F (Outside playground water fountains) Samples #22L0906-05 and 22L0906-06 had a Lead Action Level of Exceedance Response of more than 5.5 ppb, which poses a potential health, safety and personal rights risk to children 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:Chandra Charles
LICENSING EVALUATOR NAME:April Wright
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023


LIC809 (FAS) - (06/04)
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