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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 485407546
Report Date: 12/05/2022
Date Signed: 12/05/2022 04:23:12 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/02/2022 and conducted by Evaluator Melchisedeck Augustin
COMPLAINT CONTROL NUMBER: 01-CC-20220902140539
FACILITY NAME:NAEBKHEL, SURYA FAMILY CHILD CARE HOMEFACILITY NUMBER:
485407546
ADMINISTRATOR:NAEBKHEL, SURYAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 600-8145
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:14CENSUS: 5DATE:
12/05/2022
UNANNOUNCEDTIME BEGAN:
02:36 PM
MET WITH:Surya Naebkhel - LicenseeTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Provider does not keep cribs free of loose items
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Melchisedeck Augustin made a subsequent complaint-investigation visit and met with Licensee, Surya Naebkhel (LS) for the purpose of delivering finding for the above allegation. LPA previously met with LS on 09/08/22 to discuss the purpose of the visit, made observations, and to initiate the investigation. It was alleged the provider does not keep cribs free of loose items. The report noted an infant (C1) under 12 months old was covered with a blanket while sleeping.

LPA, Augustin interviewed Licensee (LS), one adult (A1), two staff (S2 & S3), and three parents (P1-P3) from 09/06/22 through 11/17/22; and obtained a facility roster of the children currently in care. The children were not verbal, too young to interview, or did not qualify to be interviewed.

LS denied the allegation, stating she currently did not have any infants under 12 months old enrolled into care, and she never put any infant(s) under 12 months old in a play pen or other sleeping equipment with loose items. (Continue to LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
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 3
Control Number 01-CC-20220902140539
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: NAEBKHEL, SURYA FAMILY CHILD CARE HOME
FACILITY NUMBER: 485407546
VISIT DATE: 12/05/2022
NARRATIVE
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LS conveyed she was aware of Infant Safe Sleep requirements which included but was not limited to placing children under 12 months old in a play pen for a nap on their back without any toys, blankets, or loose items.

Statements provided by S2 & S3 indicated infant(s) napped in a front bedroom or living room area. According to S2, LS put babies in a basket and if a baby needed a blanket, LS covered the child with a blanket. On 09/02/22, the Department received evidence in the form of text messages which depicted an infant under the age of 12 months (C1) sleeping in a basinet that was intended for sleeping instead of a crib. On March 03, 2022, C1 was completely covered with a blanket from the neck down. LPA reviewed the Department records which validated the sender of the text’s contact information matched the contact information on the facility’s public profile which belonged to the Licensee.

Based on LPA’s investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 12 & Chapter 1, is being cited on the attached LIC 9099D. Exit interview conducted, and report was reviewed with the Licensee, Surya Naebkhel. Appeal rights were provided. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 01-CC-20220902140539
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: NAEBKHEL, SURYA FAMILY CHILD CARE HOME
FACILITY NUMBER: 485407546
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2022
Section Cited
CCR
102425(B)
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Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by: Based on text messages the Department received on 09/02/22 which corroborated LS completely covered a child under 12 months
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The Licensee stated she no longer had infant(s) under 12 months old enrolled into care and she would no longer cover infants with a blanket while they napped. Licensee submitted a written plan detailing how she intends to comply with California Code of Regulation(s) 102425(B).
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old with a blanket from the neck down, while the infant was napping in a basinet. This poses/posed a potential health, safety and/or personal rights risk to the 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: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3