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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700236
Report Date: 12/05/2023
Date Signed: 12/05/2023 11:49:32 AM

Document Has Been Signed on 12/05/2023 11:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:MEHRA, SUMEDHA & TARUNFACILITY NUMBER:
015700236
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
12/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Licensee, Sumedha MehraTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jyoti Saini arrived at the facility unannounced for a ten-day visit and observed an uncleared fingerprint person supervising four infants and one preschooler. During the course of the investigation, LPA observed that the individual was left alone with the children several times. The licensee acknowledges that the individual is here to help the facility. LPA notified the provider about Health and Safety Code Section 1596.871, stating that the individual shall have fingerprint clearance before working, residing, or volunteering in a licensed facility. The provider acknowledges that she understands.

See 809-D for the TYPE A deficiency cited on today's visit.

California Code of Regulations, {Title 22, Division 12, Chapter 1, Section 102370(d) is being cited on the attached LIC809-D. THE LICENSEE MUST POST ANY TYPE A DEFICIENCIES DURING TODAY'S VISIT WITH THE NOTICE, AND THE LICENSEE UNDERSTANDS THE NOTICE AND TYPE A DEFICIENCIES MUST REMAIN POSTED FOR THIRTY DAYS. REQUIREMENTS FOR THE AB 633 FACT SHEET AND A COPY OF THE ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS (LIC 9224) WERE DISCUSSED WITH PROVIDER. PROVIDER UNDERSTANDS THIS REQUIREMENT.

An exit interview was conducted with Licensee, Sumedha Mehra.

A notice of site visit was given and must remain posted for a period of 30 days.

The Facility's appeal rights were reviewed and given to the licensee, Sumedha Mehra.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jyoti Saini
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2023
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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Document Has Been Signed on 12/05/2023 11:49 AM - It Cannot Be Edited


Created By: Jyoti Saini On 12/05/2023 at 11:04 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: MEHRA, SUMEDHA & TARUN
FACILITY NUMBER: 015700236

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2023
Section Cited
CCR
102370(d)

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102370(d) 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:
This requirement is not met as evidenced by:
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The Licensee shall immediately exclude the assistant provider lacking fingerprint clearance.Staff member was immediately removed from the facility to perform fingerprint LiveScan.
A civil penalty of $100 is being assessed.
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Based on observation,interview,record review the licensee did not comply with the section cited above. S1 did not have an eligible criminal background clearance 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:Wynn Norona
LICENSING EVALUATOR NAME:Jyoti Saini
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023


LIC809 (FAS) - (06/04)
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