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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 485407546
Report Date: 12/05/2022
Date Signed: 12/05/2022 04:22:11 PM

Document Has Been Signed on 12/05/2022 04:22 PM - 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: 4CENSUS: 5DATE:
12/05/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Surya Naebkhel - LicenseeTIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA), Melchisedeck Augustin, conducted an unannounced Case Management visit to deliver citations to Licensee, Surya Naebkhel (LS). During the course of a complaint investigation, LPA Augustin, obtained evidence showing that LS did not comply with infant safe sleep requirements.

On 09/02/22, the Department received evidence in the form of text messages which depicted a child under 12 months old that could not climb out a crib or play yard was sleeping in a basinet that was intended for sleeping instead of a crib or a play yard. Report was reviewed with LS and appeal rights were provided. A notice of site visit was given and must remain posted for 30 days along with the report. 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
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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Document Has Been Signed on 12/05/2022 04:22 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 12/05/2022 at 03:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
12/15/2022
Section Cited
CCR
102425(A)

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There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard.

This requirement was not met as evidenced by: Based on evidence the Department received in the form of text messages on 09/02/22 which depicted a child under 12 months old that was
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Licensee stated she removed the basinet and no longer had a basinet, and would not utilize the basinet for infants under 12 months to nap in. The Licensee also submitted a written statement detailing how she intends to comply with with CCR 102425(A).
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unable to climb out a crib or play yard was sleeping in a basinet that was intended for sleeping instead of a crib or a play yard. 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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