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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013413922
Report Date: 10/02/2023
Date Signed: 10/02/2023 02:14:54 PM


Document Has Been Signed on 10/02/2023 02:14 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:NURTUREKIDS MONTESSORI, PRESCHOOL & EXTENDED CAREFACILITY NUMBER:
013413922
ADMINISTRATOR:RELAN, SHASHIFACILITY TYPE:
850
ADDRESS:38000 CAMDEN STREETTELEPHONE:
(510) 797-2222
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:53CENSUS: 31DATE:
10/02/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Ruby Masih- DirectorTIME COMPLETED:
02:30 PM
NARRATIVE
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On 10/2/23, LPAs Briana Plumboy & Randall Dunevant met with Director Ruby Masih on another matter which resulted in a case management inspection and discovered staff (S5) does not have the tuberculosis test on file. Present for the inspection was 6 staff and 31 preschool age children in care.

An exit interview was conducted with Ms. Masih.

See 809-D for deficiencies cited during today's inspection. This report must be kept available for public review for three years. Exit interview conducted and appeal rights provided.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2023
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 10/02/2023 02:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: NURTUREKIDS MONTESSORI, PRESCHOOL & EXTENDED CARE
FACILITY NUMBER: 013413922

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/02/2023
Section Cited
CCR
101216(g)(1)

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(g) All personnel...shall be in good health...(1)... good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.
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On or before 11/2/23, Director will submit S5's TB test to LPA Plumboy
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This requirement was not met as evidenced by: S5 did not have TB on file. This poses a potential risk to the health and safety of the children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 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: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2023
LIC809 (FAS) - (06/04)
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