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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409362
Report Date: 01/29/2025
Date Signed: 01/29/2025 11:47:48 AM

Document Has Been Signed on 01/29/2025 11:47 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 CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:SAFANIEV, NATALIEFACILITY NUMBER:
073409362
ADMINISTRATOR/
DIRECTOR:		SAFANIEV, NATALIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 652-2804
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
01/29/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Natalie SafanievTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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LPA D. Campos conducted a Case Management inspection as a result of a complaint investigation. An incident occurred when a child in care received an injury to his mouth for which he received medical attention. Reporting requirements were discussed with licensee. Licensee disclosed she did not report the incident to the licensing office as she was not aware of the reporting requirement regulation.
Please see LIC809D for deficiency cited today.

Exit interview conducted and report reviewed with the licensee Natalie Safaniev.

A Notice of Site Visit was provided and must remain posted for 30 days.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Diana Campos
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/29/2025 11:47 AM - It Cannot Be Edited


Created By: Diana Campos On 01/29/2025 at 11:23 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: SAFANIEV, NATALIE
FACILITY NUMBER: 073409362

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/12/2025
Section Cited
CCR
102416.2(a)(b)(1)

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102416.2Reporting Requirements The licensee shall report the following information the Department by telephone or fax within the Department's next business day and during normal working hours (8am to 5pm)
(b) The licensee shall report to the Department any of the events as specified in Health and Safety Code Sections 1597.467(b)(1)(A) through (b)(1)(C) that occur during the operation of the family child care home.
(1) Medical treatment means treatment by a medical professional, as defined in Section 101152(m).
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Licensee shall submit to the licensing department by the POC date a summary of her understanding of the reporting requirement regulation. As well as submit an unusual incident report regarding the incident that occurred on 10/28/24 for which medical attention was received.
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This requirement was not met as evidenced by: Licensee stated she did not report the incident involving a child who received an injury while in care for which he received medical attention due to being unaware of the reporting requirement regulation. Which is a potential risk to the health and safety of 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:Sherelle Johnson
LICENSING EVALUATOR NAME:Diana Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025


LIC809 (FAS) - (06/04)
Page: 2 of 2