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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013413922
Report Date: 09/28/2023
Date Signed: 09/28/2023 10:42:04 AM

Document Has Been Signed on 09/28/2023 10:42 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:NURTUREKIDS MONTESSORI, PRESCHOOL & EXTENDED CAREFACILITY NUMBER:
013413922
ADMINISTRATOR:RELAN, SHASHIFACILITY TYPE:
850
ADDRESS:38000 CAMDEN STREETTELEPHONE:
(510) 797-2222
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 53TOTAL ENROLLED CHILDREN: 35CENSUS: 26DATE:
09/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Ruby Masih- DirectorTIME COMPLETED:
10:55 AM
NARRATIVE
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On 9/28/23, LPA Briana Plumboy met with Director Ruby Masih on another matter and discovered an unfingerprinted adult woman (S1) at the facility. The Director asked the woman to leave the premises when LPA Plumboy arrived. The adult does not have a clearance.

The attached Type A deficiency regarding criminal record clearance is being cited today on the attached 809-D. A civil penalty in the amount of $200 is being assessed. Upon receipt of the licensing report, licensee shall post for 30 days and provide copies to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. LIC 9224 Acknowledgement of Receipt of Licensing Reports should be signed by guardians and placed in each child’s file.


An exit interview was conducted with Ms. Masih.

This report must be kept available for public review for three years. Exit interview conducted and appeal rights provided.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Briana Plumboy
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2023
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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Document Has Been Signed on 09/28/2023 10:42 AM - It Cannot Be Edited


Created By: Briana Plumboy On 09/28/2023 at 10:21 AM
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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: NURTUREKIDS MONTESSORI, PRESCHOOL & EXTENDED CARE
FACILITY NUMBER: 013413922

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/29/2023
Section Cited
CCR
101170(e)(1)

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Criminal Record Clearance. Prior to working or volunteering in a licensed child care facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption.
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Licensee will submit proof that M.Shani has been fingerprinted for criminal record clearance, to LPA by email, fax or mail by 10/2/23. Licensee will not allow M.Shani to be present until she is fingerprint cleared and associated to this center.
Licensee will ensure that, prior to working or volunteering at this center, all Staff have been fingerprint cleared and associated to this center.
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LPA observed an adult in the yard who was asked to leave due to CCLD being present and found that she is not fingerprint cleared.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.

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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:Wynn Norona
LICENSING EVALUATOR NAME:Briana Plumboy
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023


LIC809 (FAS) - (06/04)
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