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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 013418996
Report Date: 09/01/2021
Date Signed: 09/01/2021 10:48:20 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/16/2021 and conducted by Evaluator Brittany Newton
COMPLAINT CONTROL NUMBER: 02-CC-20210816160952
FACILITY NAME:CONGREGATION NETIVOT SHALOMFACILITY NUMBER:
013418996
ADMINISTRATOR:LEVITCH, RUTHFACILITY TYPE:
850
ADDRESS:1316 UNIVERSITY AVE.TELEPHONE:
(510) 549-9447
CITY:BERKELEYSTATE: CAZIP CODE:
94702
CAPACITY:30CENSUS: 15DATE:
09/01/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Karen LlamasTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Lack of supervision resulting in day care child wandering away from facility
INVESTIGATION FINDINGS:
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On 09/01/2021, Licensing Program Analyst (LPA) Brittany Newton conducted an unannounced visit for the purpose of closing a complaint investigation. LPA was met by director Karen Llamas. Present for the inspection was 15 preschoolers.
Throughout the course of the investigation LPA conducted interviews and reviewed documentation. Interviews and documentation revealed that in April, a child wandered off of the facility grounds unattended and unsupervised. The child was found by a police officer and a nearby citizen. Based on the preponderance of evidence, the allegation is therefore SUBSTANTIATED. Citation can be found on the attached 9099-D. A civil penalty of $500.00 was also assessed for ZERO TOLERANCE of absence of supervision.
Upon receipt of this report, facility shall provide copies of this licensing report to parents/guardians of all children in care at the facility by the end of business day and to parents/guardians of children newly enrolled at the facility during the next 12 months. All parents/guardians must sign an acknowledgement form of proof of receiving this report (LIC 9224). The LIC 9224 must be placed in the child's file to be reviewed by licensing.
Exit interview conducted, appeal rights provided, and a copy of this report was left with Karen Llamas.
Notice of site visit provided, facility reminded it must remain posted for 30 days.
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Brittany Newton
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
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 02-CC-20210816160952
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CONGREGATION NETIVOT SHALOM
FACILITY NUMBER: 013418996
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/02/2021
Section Cited
CCR
101229(a)(1)
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Responsibility for providing care and supervision. (a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time.
This requirement was not met as evidenced by:
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Facility will submit a plan to LPA Newton detailing how they will ensure and enforce of active supervision and account for children consistently throughout the day by 09/02/2021.
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Based on interviews conducted and documentation reviewed, in April a child wandered off facility grounds which poses an immediate Health, Safety, and Personal rights risk to 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.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Brittany Newton
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2