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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700744
Report Date: 12/19/2023
Date Signed: 12/19/2023 11:37:47 AM

Document Has Been Signed on 12/19/2023 11:37 AM - 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:PRIMARY SCHOOL-BAY AREA, THEFACILITY NUMBER:
015700744
ADMINISTRATOR:PLETZ, ASHLEYFACILITY TYPE:
850
ADDRESS:750 FARGO AVENUETELEPHONE:
(773) 870-1607
CITY:SAN LEANDROSTATE: CAZIP CODE:
94579
CAPACITY: 48TOTAL ENROLLED CHILDREN: 48CENSUS: 36DATE:
12/19/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH:Mia Lopez, Director of OperationsTIME COMPLETED:
11:16 AM
NARRATIVE
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Licensing Program Analyst (LPA) Sidney Cortez met with Director Mary Gaston and Mia Lopez to conduct a Case Management inspection for the Lead Testing results at this facility. In addition to the director, 36 children and nine staff members are present today. The facility operates Monday - Friday from 7:00 am to 5:30 pm.

LPA Inspected the facility for health and safety. It was concluded that one outlet outside area exceeded the Action Level established by the state for exposure.LPA obtained photos of the faucet that have exceeded 5.5 ppb. LPA discussed a Plan of Correction, and received documentation for the post-testing requirements during the inspection. Find the attached deficiency (LIC 809-D)

A notice of site visit was given and must remain posted for 30 days.

Appeal Rights were given.

An exit interview was conducted, and the report was reviewed with the Director, Mary Gaston and Mia Lopez.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Sidney Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2023
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 12/19/2023 11:37 AM - It Cannot Be Edited


Created By: Sidney Cortez On 12/19/2023 at 09:10 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: PRIMARY SCHOOL-BAY AREA, THE
FACILITY NUMBER: 015700744

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

101700.3(b)(1)

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101700.3(b)(1)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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The facility has already had the city turned off the faucet and placed a cap. Therfore that faucet can no longer be used at all.
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 Based on record review, the facility has one outlet outside that have an ALE of 5.5ppb 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:Wynn Norona
LICENSING EVALUATOR NAME:Sidney Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023


LIC809 (FAS) - (06/04)
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