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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013413922
Report Date: 10/02/2023
Date Signed: 10/02/2023 02:14:54 PM

Document Has Been Signed on 10/02/2023 02:14 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
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: 31DATE:
10/02/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Ruby Masih- DirectorTIME COMPLETED:
02:30 PM
NARRATIVE
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On 10/2/23, LPAs Briana Plumboy & Randall Dunevant met with Director Ruby Masih on another matter which resulted in a case management inspection and discovered staff (S5) does not have the tuberculosis test on file. Present for the inspection was 6 staff and 31 preschool age children in care.

An exit interview was conducted with Ms. Masih.

See 809-D for deficiencies cited during today's inspection. 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: 10/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2023
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 10/02/2023 02:14 PM - It Cannot Be Edited


Created By: Briana Plumboy On 10/02/2023 at 12:02 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
, 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: 10/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/02/2023
Section Cited
CCR
101216(g)(1)

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(g) All personnel...shall be in good health...(1)... good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.
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On or before 11/2/23, Director will submit S5's TB test to LPA Plumboy
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This requirement was not met as evidenced by: S5 did not have TB on file. This poses a potential risk to the health and safety of the children in care.
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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: 10/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2023


LIC809 (FAS) - (06/04)
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