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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 414002120
Report Date: 03/29/2024
Date Signed: 03/29/2024 01:27:33 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 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
03/22/2024 and conducted by Evaluator Maria Olguin-Leon
COMPLAINT CONTROL NUMBER: 05-CC-20240322141225
FACILITY NAME:CHAM, DELBAR KHOSRAVIFACILITY NUMBER:
414002120
ADMINISTRATOR:CHAM, DELBAR K.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 556-1428
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:14CENSUS: 2DATE:
03/29/2024
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Delbar ChamTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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An antenna is falling off side of home into patio where children play.
INVESTIGATION FINDINGS:
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On March 29, 2024 @ approx. 12:55pm., Licensing Program Analysts (LPAs) Maria Olguin- Leon and Melissa Zaragoza met with Licensee, Delbar Cham. Purpose of the inspection was explained and was for an unannounced, complaint investigation. Present today was Licensee and 2 preschoolers. LPAs inspected facility for health and safety hazards.

LPAs observed and determined the allegation an antenna is falling off side of home into patio where children play to be substantiated.

Based on LPA’s observations, the preponderance of evidence standards has been met, therefore, the above allegation is found to be SUBSTANTIATED. A Type “B” violation was issued today in accordance to the California Code of Regulations, Title 22, Division 12, Chapter 1, citation was being cited on the attached LIC9099D.

This report and exit interview were conducted and appeal rights were given to Licensee, Delbar Cham. Notice of Site Visit shall remain posted for 30 days.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
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 05-CC-20240322141225
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: CHAM, DELBAR KHOSRAVI
FACILITY NUMBER: 414002120
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/05/2024
Section Cited
CCR
102417(g)
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102417 Operation of a Family Child Care Home

(g)The home shall be free from defects or conditions which might endanger a child.

This requirement has not been met as evidenced by:

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Licensee will have her gardener remove antenna from roof and submit a photo to LPA showing removal of antenna by POC date of 04/05/2024.
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Based on observations, LPAs confirmed an outdoor antenna located in rear of home was loose and hanging over into patio area. This possesses a potential 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.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2