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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 343622691
Report Date: 06/01/2023
Date Signed: 06/01/2023 10:56:59 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/08/2023 and conducted by Evaluator Erwin Tjhia
COMPLAINT CONTROL NUMBER: 53-CC-20230508125104
FACILITY NAME:ESMAIL, EZDIHARFACILITY NUMBER:
343622691
ADMINISTRATOR:ESMAIL, EZDIHARFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 624-0366
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:14CENSUS: 10DATE:
06/01/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ezdihar EsmailTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Licensee stored a hazardous item near the entrance of the facility
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Erwin Tjhia and Jennie Tedlos met with the licensee, Ezdihar Esmail to deliver findings of the complaint investigation regarding the above allegation. There were 10 children and 1 staff during the visit.

During the investigation, LPAs conducted interviews, and obtained pertinent information. It was alleged that Licensee stored a boat near the facility entrance, and that it was low enough for children to reach the sharp propeller blades. On 05/15/2023 LPAs toured the facility and observed the boat parked on the driveway 3ft 7 inch close to the main entrance of the facility. LPAs observed the boat’s propeller blades, which are 4 inc off the ground, were not covered. LPAs also observed the cleaning chemical under the boat, and accessible to arriving children. Licensee agreed with LPA that blades was not safe for the children or parents that came in and out of the facility. Licensee also stated that she was not aware there was cleaning chemical under the boat.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Erwin TjhiaTELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 53-CC-20230508125104
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: ESMAIL, EZDIHAR
FACILITY NUMBER: 343622691
VISIT DATE: 06/01/2023
NARRATIVE
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Based on LPA observations and interview, the preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. Title 22 regulations are being cited on the attached 9099-D page.

LPAs informed licensee, that this report dated 06/01/2023 documents one Type A citations which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

LPAs also informed the licensee to provide a copy of this licensing report dated 06/01/2023 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Erwin TjhiaTELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 53-CC-20230508125104
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: ESMAIL, EZDIHAR
FACILITY NUMBER: 343622691
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/02/2023
Section Cited
CCR
102417(g)
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102417(g):
The home shall be free from defects or conditions which might endanger a child.
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On 05/15/2023 licensee covered the boat’s propeller blade and moved the cleaning chemicals while LPAs were present
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Based on observation and intervew, the licensee did not comply with the section cited above as LPA observed the boat’s propeller blades by the main entrance were not covered along with the cleaning chemical under it which poses an immediate health, safety or personal rights risk to persons in care.
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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: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Erwin TjhiaTELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3