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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073402613
Report Date: 01/26/2023
Date Signed: 01/26/2023 03:33:13 PM

Document Has Been Signed on 01/26/2023 03:33 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
BAY AREA-CC OAKLAND, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:CONTRA COSTA CO. HEAD START - BALBOA CDCFACILITY NUMBER:
073402613
ADMINISTRATOR:DOSS, MARILYNFACILITY TYPE:
830
ADDRESS:1001 - SOUTH 57TH STTELEPHONE:
(510) 374-7025
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY: 38TOTAL ENROLLED CHILDREN: 38CENSUS: 10DATE:
01/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Marilyn DossTIME COMPLETED:
03:47 PM
NARRATIVE
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On Thursday, January 26, 2023 at 1:16 PM, Licensing Program Analyst (LPA) Caroline Colson met with Marilyn Doss, Center Director, for an unannounced Case Management Inspection. Tana Reed, Site Supervisor 1, arrived during the inspection. There are 10 Infant/Toddlers and 7 staff members including the director are present. An incident occurred when a teacher went into a storage room and left the children without any adult supervision.

Appeal Rights were given. A Notice of Site Inspection was given to post. Exit interview was conduct with Tana Reed, Site Supervisor 1.

Please See LIC 809 D for Deficiency
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Caroline Colson
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2023
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 01/26/2023 03:33 PM - It Cannot Be Edited


Created By: Caroline Colson On 01/26/2023 at 02:00 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: CONTRA COSTA CO. HEAD START - BALBOA CDC
FACILITY NUMBER: 073402613

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/26/2023
Section Cited
CCR
101429(a)(1)

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Responsibility for Providing Care and Supervision for Infants
Each infant shall be constantly supervised and under direct visual observation and supervision by a staff person at all times.
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BY POC DUE DATE: The staff member has been removed from the classroom. The deficiency was cleared during today's inspection.
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During a viewing of video footage, staff observed the teacher leave the classroom with four children alone which she went into a storage room. The teacher closed the door behind her. Furthermore, the teacher also left the children alone with an Aide. This is an immediate health and safety risk to children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are 1000.00 per violation and $100 per day until corrected.

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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:Caroline Colson
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023


LIC809 (FAS) - (06/04)
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