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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700581
Report Date: 08/30/2023
Date Signed: 08/30/2023 03:01:24 PM

Document Has Been Signed on 08/30/2023 03:01 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:KIDANGO LORENZO MANORFACILITY NUMBER:
015700581
ADMINISTRATOR:BANFAL, SABEETAFACILITY TYPE:
850
ADDRESS:18250 BENGAL AVENUETELEPHONE:
(510) 509-1716
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 6DATE:
08/30/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Chloris CamachoTIME COMPLETED:
03:20 PM
NARRATIVE
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On August 30, 2023 at 2:00 PM., Licensing Program Analyst (LPA) Elimika Woods conducted a Case Management inspection due to the center's lead testing results. LPA met with the facility representative, Chloris Camacho. There were six preschool age children and one additional staff member present for the visit.

The department was notified that one (1) water fountain sink located on the inside of classroom (c) has elevated lead levels that have exceeded 5.5 ppb. This exceeds the Action Level (ALE) established by the state for lead exposure. Per director Chloris Camacho, the faucet was immediately closed off and will be replaced and retested. Director is working with Alpha Analytical Laboratories Inc to determine a retesting date. LPA observed today the sink faucet is closed off and not in use. LPA also observed posting of lead testing results.

See LIC 809-D for deficiencies cited during today's inspection.

Exit interview conducted with the facility representative Chloris Camacho. A notice of site visit was provided and must be posted for 30 days.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Elimika Woods
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2023
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 08/30/2023 03:01 PM - It Cannot Be Edited


Created By: Elimika Woods On 08/30/2023 at 02:19 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: KIDANGO LORENZO MANOR
FACILITY NUMBER: 015700581

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2023
Section Cited

101700.3(b)(1)

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101700.3(b)(1)-Lead Testing Written Directive- A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance (ALE)
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LPA observed the sink faucet has been closed off and not in use. Director is advised to submit re-test results to LPA by due date of 9/30/2023. If due date cannot be met Director is to contact LPA with an update.
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This requirement is not met as evidenced by: Based on record review and observation, the facility has a sink on the inside of the building (c) that have an ALE of 5.5 ppb or greater, 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:Chandra Charles
LICENSING EVALUATOR NAME:Elimika Woods
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023


LIC809 (FAS) - (06/04)
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