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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002428
Report Date: 07/13/2022
Date Signed: 07/13/2022 02:30:14 PM


Document Has Been Signed on 07/13/2022 02:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:ROOSVALL, NEGINFACILITY NUMBER:
384002428
ADMINISTRATOR:ROOSVALL, NEGINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 265-6350
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94133
CAPACITY:12CENSUS: 4DATE:
07/13/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:17 PM
MET WITH:Negin RoosvallTIME COMPLETED:
02:45 PM
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On 7/13/2022 at 1:17PM, Licensing Program Analyst (LPA) Luis J. Gomez met with Licensee, Negin Roosvall. Purpose of inspection was explained and was for an unannounced; plan of correction inspection. Present was the licensee and helper/ occupant caring for four children. All children present are infant age. All adults have their criminal record clearances on files. LPA inspected facility with licensee for health and safety hazards.

At 1:20PM., LPA performed record review, observations and interviews. LPA confirmed licensee is operating within capacity limits stated on the license with four infants in care. Licensee stated all children in her care are receiving services full time.

LPA observed 'LIC 9224, Acknowledge Receipt of Licensing Report' have been signed by authorized representatives and stored in children’s files.

Updated children's schedule/ declaration was submitted by licensee during inspection.

Deficiency issued has been cleared and ‘Letter of Deficiency Cleared’ provided to licensee.

Based on today's inspection, no deficiencies were observed in the areas evaluated according the Title 22 Division 12 Ca. Code of Regulations. Exit interview was discussed with licensee, Negin Roosvall, and signature of this form acknowledges receipt of these documents.

This report must be available in the facility for public review. Notice was provided and must remain posted for 30 days. Licensee was advised for additional questions to call CCL Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.ccld.ca.gov
SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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