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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 384002428
Report Date: 06/27/2022
Date Signed: 06/27/2022 03:58:15 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/22/2022 and conducted by Evaluator Luis Gomez
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20220622092542
FACILITY NAME:ROOSVALL, NEGINFACILITY NUMBER:
384002428
ADMINISTRATOR:ROOSVALL, NEGINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 265-6350
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94133
CAPACITY:12CENSUS: 6DATE:
06/27/2022
UNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Negin Roosvall TIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Licensee is operating beyond the terms and conditions of the license.
INVESTIGATION FINDINGS:
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On 6/27/2022 at 1:05PM., Licensing Program Analyst (LPA) Luis J. Gomez met with Licensee, Negin Roosvall. Purpose of the inspection was explained and was for unannounced; complaint investigation. Present was the licensee and helper caring for six children. All adults present have their criminal record clearance on file. LPA inspected facility for health and safety hazards.

During inspection, LPA performed site observations, interviews and reviewed the facility records. At 1:10PM., Based on observations, LPA confirmed bouncing chair located in facility playroom. Advisory Note: Technical Assistance (LIC9102TA) was issued during inspection.

During the course of the investigation, site observations were conducted on 6/27/2022. A review of the facility records was also complete, which included the children’s files, staff files and children’s roster. LPA conducted interviews with the licensee, staff and all involved parties. Based on interviews, observations, record review; LPA confirmed licensee is operating over capacity with six infants in care. (REFER TO LIC9099C FOR CONT.)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022
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 05-CC-20220622092542
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ROOSVALL, NEGIN
FACILITY NUMBER: 384002428
VISIT DATE: 06/27/2022
NARRATIVE
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(Page 2)

Based on information obtained, the preponderance of evidence standard has been met, therefore the allegation(s) are found to be SUBSTANTIATED. California code of Regulations (Title 22, Section 12 Chapter 1) are being cited on attached 9099D. Appeal Rights were provided to the facility.

Type “A” violations were issued today. Facility is advised to provide a copy of the Evaluation Report and the Type “A” Deficiencies cited, to the parents and guardians of children currently enrolled in care and to parents of newly enrolled children during the next 12 months. A signed and dated LIC 9224 (Deficiency and Acknowledgment of Receipt of Licensing Reports) shall be maintained in all Children's files.



This report will be kept in the Facility File and will be made available for Public Review upon request. Website for Forms and Regulations: www.ccld.ca.gov. This report and rights to comment and appeal have

Signed copy of this report was provided to the licensee.

SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 05-CC-20220622092542
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ROOSVALL, NEGIN
FACILITY NUMBER: 384002428
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/01/2022
Section Cited
CCR
102416.5(a)
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102416.5(a) Staffing Ratio and Capacity: The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time. This requirement is not met as evidenced by:
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Licensee will reduce infant enrollment to the required four infants by the due date: 7/1/2022.

Updated schedule will be submitted to the Department via email.
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Based on interviews, observations, record review; LPA confirmed licensee is operating overcapacity with six infants in care. This poses an immediate health and safety risk to children 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: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3