485407546-4-19-2023-01-CC-LLEI-CR4NXN-20230421105125

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 485407546
Report Date: 04/19/2023
Date Signed: 04/19/2023 09:11:57 AM

Unsubstantiated

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
03/13/2023 and conducted by Evaluator Melchisedeck Augustin

PUBLIC

COMPLAINT CONTROL NUMBER: 01-CC-20230313144422

FACILITY NAME:	NAEBKHEL, SURYA FAMILY CHILD CARE HOME		FACILITY NUMBER:	485407546
ADMINISTRATOR:	NAEBKHEL, SURYA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(916) 600-8145
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	14	CENSUS: 2	DATE:	04/19/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Surya Naekhel - Licensee		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Child sustained injuries while in care.
Licensee not providing adequate supervision to child in care.

INVESTIGATION FINDINGS:

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A subsequent complaint investigation visit was made today by Licensing Program Analyst (LPA), Melchisedeck Augustin to deliver the findings of this complaint investigations and LPA met with Licensee, Surya Naebkhel (LS). It was alleged that a child sustained injuries while in care and Licensee was not providing adequate supervision to a child in care. The report noted the child (C1) sustained multiple injuries which consisted of bruising to the forehead, thigh, lip, and chipped tooth.

This complaint was referred to the Department’s Investigations Branch, which was accepted as an assignment, resulting in IB Investigator, Jorge Martinez, interviewing Licensee (LS) and one adult (A1) on 03/22/23. The children were not verbal, too young to interview, or did not qualify to be interviewed. LS acknowledged the injury to C1’s lip and conveyed C1 had an existing bruise on the forehead but LS denied knowledge of the other injuries or not providing adequate supervision to C1. LS stated C1 cried a lot, had emotional outbursts, was not harmed by another child, never fell, or climbed on anything to cause C1 to sustain an injury. LS also claimed staff never hit or spanked C1. (Continue to LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 01-CC-20230313144422

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: 04/19/2023

NARRATIVE

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LS described an instance when she gave C1 food while sitting at the kids table, C1 threw it off the table and immediately dropped their head down, hitting the mouth and lip. LS reported C1’s behavior to A1 who allegedly expressed that C1 had the same behavior at home. According to LS, care was provided primarily in a room at the front of the home or the living room, and staff never left the children unattended.

A1 reported LS notified her that C1 was hurt in the mouth, and when asked how C1 sustained the injuries, LS allegedly stated she did not notice any bruise(s) and did not explain how C1 sustained the injuries. A1 also acknowledged that C1 is very physical and falls or bangs oneself into objects. At the time of IB’s interview, C1 was observed three times hitting their head on the table or a chair.

Based on the investigation, it could not be determined how and where C1 sustained the injuries, and there were no witnesses or conclusive evidence to confirm C1 sustained the injuries because of inadequate supervision. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated. 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. There were no violation(s) of California Code of Regulations, Title 22, Division 12 cited at this time. Appeal Rights were provided.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

LIC9099 (FAS) - (06/04)

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