073407766-8-19-2019-02-CC-DPEZ-BFFTN4-20190827145208

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 073407766
Report Date: 08/19/2019
Date Signed: 08/19/2019 01:52:47 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, SUITE 1102
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/05/2019 and conducted by Evaluator Dayna Collier

PUBLIC

COMPLAINT CONTROL NUMBER: 02-CC-20190805095547

FACILITY NAME:	SHAMLOU, MARIBELLE		FACILITY NUMBER:	073407766
ADMINISTRATOR:	SHAMLOU, MARIBELLE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(925) 339-7900
CITY:	OAKLEY	STATE: CA	ZIP CODE:	94561
CAPACITY:	14	CENSUS: 5	DATE:	08/19/2019
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Maribelle Shamlou		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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PERSONAL RIGHTS: Child sustained bruises while in care

INVESTIGATION FINDINGS:

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LPA Dayna Collier met with licensee Maribelle Shamlou for a complaint investigation regarding the above allegation. Present for the investigation were licensee, licensee's assistant Fatima and 4 children in care consisting of 2 infants, 2 preschoolers and 1 school age child. During the course of the investigation, interviews were conducted. It was alleged that an infant sustained bruises while in care. Both licensee and her assistant observed an area of redness on the child and believed that it may have been caused by the infant leaning in the high chair. The description of the red area observed on the child at the facility is an area examined by medical professionals and was determined to be caused by lifting the child. Due to the infant's minimal mobility, licensee and her assistant were required to lift the infant, pick up the infant and were assisting the infant in standing and attempting to walk. Per licensee, the infant was not checked for any additional bruising after the initial observation of redness. Based on the LPA's observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. Appeal rights were provided. A SITE VISIT NOTICE WAS POSTED.
Calif. Code of Regulations, (Title 22, Div. & Chap.102423 , are being cited on the attached LIC 9099D.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Diane Perez	TELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Dayna Collier	TELEPHONE: (510) 725-7021
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2019

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-20190805095547

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: SHAMLOU, MARIBELLE	FACILITY NUMBER: 073407766
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/19/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/26/2019 Section Cited CCR 102423(a)(2)	1 2 3 4 5 6 7	102423 Personal Rights (a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following:	1 2 3 4 5 6 7	POC: By 8/26/19, licensee will create a written plan of action and will submit a copy to Licensing detailing the steps that will be taken to ensure a safe and comfortable environment.
	8 9 10 11 12 13 14	(2) To receive safe, healthful, and comfortable accommoThdations, furnishings, and equipment. This requirement was not met as evidenced by interviews conducted. This poses a potential risk for children in care. A CHILD SUSTAINED AT LEAST 1 AREA OF BRUISING WHILE IN CARE.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Diane Perez	TELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Dayna Collier	TELEPHONE: (510) 725-7021
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2019

LIC9099 (FAS) - (06/04)

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