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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434416723
Report Date: 11/30/2023
Date Signed: 11/30/2023 05:54:19 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, 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
11/21/2023 and conducted by Evaluator Samantha Yip
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20231121153937
FACILITY NAME:SINGH, POOJAFACILITY NUMBER:
434416723
ADMINISTRATOR:POOJA, SINGHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 442-8503
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:14CENSUS: 9DATE:
11/30/2023
UNANNOUNCEDTIME BEGAN:
01:56 PM
MET WITH:Pooja SinghTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Conduct Inimical
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Samantha Yip and Doni Fici conducted an unannounced complaint investigation for the above allegation. LPA met with Licensee Pooja Singh and explained the reason for the inspection.

During this investigation, LPA conducted interview with third party and reviewed additional documents. Based on the information obtained, the above allegation is found to be SUBSTANTIATED, meaning the preponderance of evidence was met.

-------------------continues on 9099 dated 11/30/2023 page 2----------------------
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
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 4
Control Number 07-CC-20231121153937
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: SINGH, POOJA
FACILITY NUMBER: 434416723
VISIT DATE: 11/30/2023
NARRATIVE
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-----------------continuation of 9099 dated 11/30/2023 page 1-----------------------

Based on interview with third party, Licensee is enrolled in the food program. Licensee failed to change the child's name on her claim report. The food program indicated that it was an issue with her paperwork. Licensee understands that since the food program is a federal program that she needs to ensure that paperwork if filled out correctly. Licensee submitted an plan of correction to the food program on 11/21/2023.

As a result of this inspection, a Type B citation was issued. Exit interview conducted and report was reviewed with Licensee Pooja Singh. A notice of site visit has been issued and must remain posted for 30 days.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 07-CC-20231121153937
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: SINGH, POOJA
FACILITY NUMBER: 434416723
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/07/2023
Section Cited
CCR
102402(a)(3)
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Revocation or Suspension of a License or Registration. Conduct in the operation or maintenance of a family day care home which is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California.
This requirement is not met as evidenced by:
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By POC 12/07/2023, Licensee will submit a written statement that she understands that paperwork filed with any federal program
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Based on interview and record review, Licensee did not change the name of the child that she was claiming through the food program, which poses a potential health and safety risk to children in care.
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needs to be filled out correctly.
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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: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4