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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700049
Report Date: 04/01/2022
Date Signed: 04/01/2022 02:34:10 PM

Document Has Been Signed on 04/01/2022 02:34 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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:NALEM, KOMURAVVAFACILITY NUMBER:
015700049
ADMINISTRATOR:NALEM, KOMURAVVAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 458-6580
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
04/01/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Komuravva NalemTIME COMPLETED:
02:40 PM
NARRATIVE
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On 4/1/2022 approximately at 1:20PM, an unannounced case management inspection for a temporary suspension order was made by Licensing Program Analyst (LPA) Kelly Phan, Licensing Program Manager (LPM) Jason Jang, and Regional Manager (RM ) Diane Perez.

During the course of the most recent complaint the licensee provided a false statement as the cause for multiple injuries sustained to a child.

The following type A deficiency is cited; Conduct Inimical.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Kelly Phan
LICENSING EVALUATOR SIGNATURE: DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 04/01/2022 02:34 PM - It Cannot Be Edited


Created By: Kelly Phan On 04/01/2022 at 09:12 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: NALEM, KOMURAVVA
FACILITY NUMBER: 015700049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/01/2022
Section Cited
HSC
1796.38(c)

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Conduct that is inimical to the health, morals, welfare, or safety of either an individual receiving home care services or the people of the State of California.
Licensee provided a false statement in regards to injuries sustained by child in care.
This poses a risk to the health and safety of children in care
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The Department is seeking a temporary suspension of the license effective 4/1/2022

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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:Jason Jang
LICENSING EVALUATOR NAME:Kelly Phan
LICENSING EVALUATOR SIGNATURE:
DATE: 04/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2022


LIC809 (FAS) - (06/04)
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