073404524-3-20-2024-02-CC-SJON-D4CP9R-20240415110734

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 073404524
Report Date: 03/20/2024
Date Signed: 03/20/2024 03:52:20 PM

Unsubstantiated

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, SUITE 1102
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/20/2024 and conducted by Evaluator Monica Mathur

PUBLIC

COMPLAINT CONTROL NUMBER: 02-CC-20240220135942

FACILITY NAME:	CUSTODIO-NOMELLINI, CARMEN		FACILITY NUMBER:	073404524
ADMINISTRATOR:	CUSTODIO-NOMELLINI, CARMEN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(925) 934-8396
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94598
CAPACITY:	14	CENSUS: 5	DATE:	03/20/2024
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Carmen Custodio-Nomellini		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Rerporting Requirements: Provider did not communicate incidents to day care child's responsible party in a timely manner.

INVESTIGATION FINDINGS:

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On 3/20/24 Licensing Program Analyst (LPA) Monica Mathur conducted an unannounced Subsequent Complaint Investigation at Carmen Custodio-Nomellini's daycare home. LPA met with Licensee, Carmen and explained the purpose of today’s inspection. Present in the home were Licensee with 5 children (2 infants, 3 preschool age). Complainant alleges that Licensee did not communicate incidents to day care child's responsible party in a timely manner.

During course of investigation LPA conducted facility inspection, observations, record review, interviews and obtained documents. It was determined that in February 2024 an incident occured where a child C1 fell in the playroom and got injured in the mouth area. Licensee states she was present in the room and attended to the child immediately, checked and saw a very small scratch on the gums, a drop of blood and with no significant injury. Licensee stated child's tooth was not wobbling at the time. Investigation could not determine the extent of injury sustained at daycare and whether it warranted child's parents to be informed immediately or not. Licensee stated she informed parents same day at pick up.
continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica Mathur	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

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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Control Number 02-CC-20240220135942

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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CUSTODIO-NOMELLINI, CARMEN	FACILITY NUMBER: 073404524
	VISIT DATE: 03/20/2024

NARRATIVE

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Based on the interviews and information obtained throughout the investigation, the allegation is UNSUBSTANTIATED which means 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. No Deficiency has been cited for this allegation.
Technical Violation for Reporting Requirements was given.

Exit interview conducted with Licensee, Carmen Custodio-Nomellini.
A NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica Mathur	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC9099 (FAS) - (06/04)

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