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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 073406974
Report Date: 11/19/2021
Date Signed: 11/19/2021 04:04:23 PM



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
11/16/2021 and conducted by Evaluator Morgan Pringle
COMPLAINT CONTROL NUMBER: 52-CC-20211116093624
FACILITY NAME:GAUR, DIVYAFACILITY NUMBER:
073406974
ADMINISTRATOR:GAUR, DIVYAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 560-0956
CITY:SAN RAMONSTATE: CAZIP CODE:
94582
CAPACITY:14CENSUS: 2DATE:
11/19/2021
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Divya GaurTIME COMPLETED:
03:57 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Personal Rights - Child sustained unexplained injury while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/19/2021 Licensing Program Analyst (LPA) Morgan Pringle met with Licensee Divya Gaur to investigate a complaint filed against the facility alleging a child sustained an unexplained injury while in care.

There were two (2) preschool children prestent during the visit and the Licensee's fingerprint cleared husband.

Based on interviews LPA determined 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.

Notice of Site Visit and Appeal Rights were given. Exit interview conducted.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
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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