013421458-3-4-2021-52-CC-WNOA-BYTRLM-20210305120720

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 013421458
Report Date: 03/04/2021
Date Signed: 03/04/2021 10:17:24 AM

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
10/10/2019 and conducted by Evaluator Briana Plumboy

PUBLIC

COMPLAINT CONTROL NUMBER: 52-CC-20191010141631

FACILITY NAME:	SALAYEVA, ARIFA		FACILITY NUMBER:	013421458
ADMINISTRATOR:	SALAYEVA, ARIFA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 477-0939
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	14	CENSUS: 4	DATE:	03/04/2021
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Arifa Salayeva- Licensee		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Lack Of Supervision- Daycare Child sustained an unexplained femur fracture while in care at the facility

INVESTIGATION FINDINGS:

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On 3/4/21 at 9:50am, LPA Briana Plumboy met with licensee Arifa Salayeva to deliver the findings of a complaint investigation. The investigation was conducted by Paul Houser Special Investigator of the Bureau of Investigations. Present for the inspection today was licensee and 4 preschool age children. During the course of the investigation, interviews were conducted and records requested and reviewed. During the course of the investigation, there was not enough information to determine if the injury occurred at the facility or was due to a lack of supervision by licensee. From the time the child in care was dropped off, licensee A.Salayeva held him because he didn’t want to be put down. After the child expressed discomfort in his leg during a diaper change, licensee contacted his mother and requested he be picked up and taken to the hospital. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is UNSUBSTANTIATED. A notice of site visit was given and must remain posted for 30 days.Exit interview conducted. Appeal rights were discussed and provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana Plumboy	TELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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