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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073404524
Report Date: 06/11/2019
Date Signed: 06/11/2019 03:24:21 PM

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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:CUSTODIO-NOMELLINI, CARMENFACILITY NUMBER:
073404524
ADMINISTRATOR:CUSTODIO-NOMELLINI, CARMENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 934-8396
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:14CENSUS: DATE:
06/11/2019
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
02:06 PM
MET WITH:Custodio-Nomellini, CarmenTIME COMPLETED:
03:50 PM
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Licensing Program Manager, Anika Evans, Licensing Program Analyst, Ronda Hollie, met with Licensee, Carmen Custodio-Nomellini, for the purpose of an Informal Office Conference.
The conference was called to discuss, the substantiated complaint that parent's have been denied access to the day care area's, the licensee has operated out of ratio on two occasion's having too many infants, too many children without a helper being present, and not having person's fingerprint cleared or properly associated in the presence of children. The Licensee has addressed the above issues and has established a Plan of Correction.

Additionally, the licensee was asked to come to the Informal Meeting as there has been at least three separate allegations that the licensee has violated children's personal rights by grabbing children and for not meeting the diapering needs of children.
Although the allegation's have been unsubstantiated, the Department is concerned that the allegations keep arising. The licensee states that she does not grab children and she changes diaper's appropriately. The licensee states that she will begin to document and have parent's sign an well check at pick up.

PLEASE SEE NEXT PAGE FOR CONTINUED REPORT
SUPERVISOR'S NAME: Anika EvansTELEPHONE: (510) 286-4350
LICENSING EVALUATOR NAME: Ronda HollieTELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2019
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: CUSTODIO-NOMELLINI, CARMEN
FACILITY NUMBER: 073404524
VISIT DATE: 06/11/2019
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continued from page one.

We are hoping that this visit, will address your concerns as well as the Departments.

During the visit, the licensee was given the following the Regulatory Documents:
102370 - Criminal Record Clearance
102423- Personal Rights;
102416.5 - Staffing Ratio and Capacity along with a visual capacity document;
102419 - Admission Procedures and Parental Authorized Representative Rights.
SUPERVISOR'S NAME: Anika EvansTELEPHONE: (510) 286-4350
LICENSING EVALUATOR NAME: Ronda HollieTELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2019
LIC809 (FAS) - (06/04)
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