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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 444415860
Report Date: 10/22/2021
Date Signed: 10/24/2021 04:59:55 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/28/2021 and conducted by Evaluator Elizabeth Larios
COMPLAINT CONTROL NUMBER: 07-CC-20210728120402
FACILITY NAME:MAZLOOM, SEDIQUEFACILITY NUMBER:
444415860
ADMINISTRATOR:MAZLOOM, SEDIQUEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 656-1590
CITY:SCOTTS VALLEYSTATE: CAZIP CODE:
95066
CAPACITY:14CENSUS: 9DATE:
10/22/2021
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Sedique MazloomTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Unfingerprinted staff working at the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Elizabeth Larios, conducted an unannounced complaint investigation to deliver investigation finding. LPA met with Licensee, Sedique Mazloom and explained the purpose of the inspection.

Based on observation, record reviews and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations is found to be SUBSTANTIATED. Staff Crystal Rozinsky began employment on 7/12/2021 and was not associated to the facility and staff Robin Smith was observed in LIC 500 (Personnel Report) and does not have a criminal record clearance.

Type A deficiency cited & Civil Penalties assessed. Exit interview was conducted, where this report was reviewed and discussed with Sedique Mazloom.

A NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED ON OR ADJACENT TO THE INTERIOR SIDE OF THE MAIN DOOR INTO THE FACILITY FOR 30 CONSECUTIVE DAYS.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Elizabeth LariosTELEPHONE: (408) 497-9236
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
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 2
Control Number 07-CC-20210728120402
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MAZLOOM, SEDIQUE
FACILITY NUMBER: 444415860
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/23/2021
Section Cited
CCR
102370(d)(1)&(2)
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Criminal Record Clearance - All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department: (2) Request a transfer of a criminal record clearance as specified in Section 102370(j)
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Licensee has submitted supporting documentation to CCL to transfer staff Crystal Rozinsky to the facility. Staff Crystal Rozinsky is now associated to the facility. Licensee will submit a written plan by 10/23/21 detailing how to prevent this violation from occurring in the future.Civil Penalties assessed at today's visit in the amount of $1000.00
($1000.00 x 10 days)
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This requirement was not met as evidenced by:Crystal Rozinsky began employment on 7/12/2021 and was not associated, and Robin Smith was observed in LIC 500 and does not have a criminal record clearance which poses an immediate risk to the Health, Safety or Personal Rights to the children in care
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AB633 Parent Notification is required. This page shall be provided to all parents of children currently enrolled and any future children being enrolled for the next 12 months per AB633 requirements.
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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: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Elizabeth LariosTELEPHONE: (408) 497-9236
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2