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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015700049
Report Date: 04/01/2022
Date Signed: 04/01/2022 02:32:22 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/20/2021 and conducted by Evaluator Kelly Phan
PUBLIC
COMPLAINT CONTROL NUMBER: 52-CC-20211220084803
FACILITY NAME:NALEM, KOMURAVVAFACILITY NUMBER:
015700049
ADMINISTRATOR:NALEM, KOMURAVVAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 458-6580
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:14CENSUS: 12DATE:
04/01/2022
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Komuravva NalemTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Personal Rights - Child has sustained injuries while in care
Facility failed to report incident to Licensing
INVESTIGATION FINDINGS:
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On 4/01/2022 approximately at 1:20PM Licensing Program Analyst (LPA) Kelly Phan and Licensing Program Manager (LPM) Jason Jang, and Regional Manager (RM) Diane Perez arrived at the facility unnanounced for the purposes of delivery of Revocation and Expedited Temporary Suspension Order (TSO) for the above allegations.

The allegations that Licensee Nalem failed to report incident to licensing and a day care child has sustained injuries while in care are SUBSTANTIATED. Based on the investigation conducted by Investigator Jorge Martinez of Investigation Bureau (IB), there is preponderance of evidence to prove the allegations did occur, meaning the allegations are valid. See LIC 9099D in violation of Title 22, Division 12, Chapter 3 102416.2(3)(c) & 102423(a)(2).
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 52-CC-20211220084803
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
CCR
102423(a)(2)
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Personal Rights 102423(a): Each child receiving services from a family child care home shall have certain rights... These rights include, but are not limited to, the following:(2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.
This requirement is not met as evidenced by:
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Temporary Suspension Order (TSO)
Revocation
Enhanced civil penalty
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Based on observations, interviews and record review from investigation branch (IB), licensee did not comply with section stated above as a daycare child has sustained injuries while in her care, which poses an immediate health, safety, or personal rights risk to children in care.
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CCR
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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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 52-CC-20211220084803
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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 B
04/01/2022
Section Cited
CCR
102416.2(3)(c)
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Reporting Requirements 102416.2(3)(c): Health and Safety Code Section 1597.467(b)(1) provides in part:"A report shall be made to the Department…following... any of the following events...Any unusual incident or child absence that threatens the physical or emotional health or safety of any child."
This requirement is not met as evidenced by:
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Temporary Suspension Order (TSO)
Revocation
Enhanced civil penalty
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Based on interviews and record review from investigation branch (IB) and facility file, licensee did not comply with section stated above as licensee has failed to report this incident to licensing and appropriate agencies. Reports and statements from IB collected indicated that licensee was present and acknowledged to not reporting the incident, which pose potential an immediate health, safety, or personal rights risk to children 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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3