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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408284
Report Date: 03/19/2024
Date Signed: 03/19/2024 11:43:43 AM

Document Has Been Signed on 03/19/2024 11:43 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 CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:NOMURA PRESCHOOLFACILITY NUMBER:
073408284
ADMINISTRATOR:HERNANDEZ, KEIKOFACILITY TYPE:
850
ADDRESS:5511 BURLINGAME AVE.TELEPHONE:
(510) 526-7847
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY: 90TOTAL ENROLLED CHILDREN: 30CENSUS: 28DATE:
03/19/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Matthew ClarkTIME COMPLETED:
12:00 PM
NARRATIVE
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On 03/19/2024 at 11:15 AM Licensing Program Analysts (LPA) Brittany Crass and Ashley Curry conducted an unannounced case management inspection to follow up on a lead exceedance at the facility. LPA met with Administrator Matthew Clark to explain the purpose of today's inspection. The licensee failed to maintain a lead value at or below the Action Level for water lead testing resulting with values of 5.5ppb or greater for outlet G and H. Water testing results identified with Action Level Exceedance as defined in WD section 101700.3 are not deemed safe to drink (See 809D). Admin states this is an outside fountain that had not been in use since before 2020. The Administrator indicated it had an exceedance because it was tested after not being in use for many years, which caused the exceedance. Original testing was completed on 11/10/2022, and then G and H faucets were flushed and retested on 12/15/2022 which no longer shows an exceedance. The administrator stated both outlets are still not being used by children in care.

Exit interview conducted, appeal rights were given, and report was reviewed with the administrator Matthew Clark.

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Brittany Crass
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024
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 03/19/2024 11:43 AM - It Cannot Be Edited


Created By: Brittany Crass On 03/19/2024 at 11:21 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: NOMURA PRESCHOOL
FACILITY NUMBER: 073408284

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/19/2024
Section Cited
CCR
101700(b)(2)

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Licensee shall maintain a LEAD value at or below the Action Level of 5.5 ppb in all outlets subject to the testing requirements of these Written Directives, for the health and safety of children in care.

This requirement is not met as evidence by:
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The deficiency was cleared during todays visit. The facility retested both outlets and there is no longer an exceedance.
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Based on interview and record review, the licensee did not comply with the section cited above as outlet G and H exceeded the acceptable amount of lead allowed in a child care center, 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:Mayla Mendoza
LICENSING EVALUATOR NAME:Brittany Crass
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024


LIC809 (FAS) - (06/04)
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