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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 485407546
Report Date: 03/22/2023
Date Signed: 03/22/2023 11:46:25 AM

Document Has Been Signed on 03/22/2023 11:46 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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: 14TOTAL ENROLLED CHILDREN: 3CENSUS: 2DATE:
03/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Surya Naebkhel - LicenseeTIME COMPLETED:
11:50 AM
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During the course of a complaint investigation visit, Licensing Program Analyst (LPA), Melchisedeck Augustin and Investigation Bureau (IB), Investigator, Jorge Martinez conducted an unannounced Case Management visit due to several deficiencies that were observed. Upon LPA’s arrival, LPA observed two children that were under the age of five years old present, and the staircase near the family room was not barricaded, as well as; the facility roster of the children in care appeared to be incomplete. During the visit, LS barricaded the staircase prior to LPA’s departure, and LS agreed to submit a completed facility roster of the children by the close of the Department’s business day on 03/23/23. LPA discussed with LS the requirements of barricading the staircase whenever children under the age of five years old are present, and LPA consulted on California Code of Regulations (CCR), 102417(g)(3). LS stated appeared to have acknowledge the CCR and LS she understood the requirements of barricading the staircase, and if LS does not comply with CCR 102417(g)(3), the facility would be subject to a deficiency and possible civil penalty.

There were no violation(s) of California Code of Regulations, Title 22 cited during today’s inspection. Appeal Rights were provided.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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