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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700049
Report Date: 04/20/2022
Date Signed: 04/20/2022 01:50:37 PM

Document Has Been Signed on 04/20/2022 01:50 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: 0DATE:
04/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Komuravvya NalemTIME COMPLETED:
02:00 PM
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On 4/20/2022 at 1:30PM, Licensing Program Analysts (LPAs) Kelly Phan and Jonathan Williams arrived at the facility for an unannounced case management visit. The purpose of today's visit is to confirm compliance with Temporary Suspension Order (TSO) served to Licensee on 4/1/2022. LPAs were met by licensee, Komuravva Nalem, and her husband.

LPAs did not observe any children in care at the facility during today's visit. Licensee stated to LPAs that she is not currently caring for children. LPAs confirmed with licensee that only their own two children are present at the facility. The licensee is complying with Temporary Suspension Order (TSO) with the notice posted for public review at their facility door.

Exit interview conducted.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Kelly Phan
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2022
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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