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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 10:49:12 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
PUBLIC
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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Facility did not notify CCL of incident
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 investigation LPA reviewed documentation and conducted interviews. Documentation and interviews revealed that the facility had not reported the incident to CCL that involved a child leaving the facility grounds in April. Based on the preponderance of evidence, the allegation is therefore SUBSTANTIATED. Citation can be found on the attached 9099-D.

Exit interview conducted, appeal rights provided, and a copy of this report was left with Karen Llamas.
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)
Page: 1 of 2
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 B
09/02/2021
Section Cited
CCR
101212(d)(1)(C)(f)
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Reporting Requirements. (1) Events reported shall include the following: (C) Any unusual incident or child absence that threatens the physical or emotional health or safety of any child. (f) The items specified in (d)(1)(A) through (H) above shall also be reported to the child's authorized representative.
This requirement was not met as evidenced by:
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Facility agrees to send the Unusual Incident form detailing the incident in April to LPA Newton by 09/02/2021.
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Based on interviews and documentation reviewed, the facility did not notify CCL of an incident regarding a child wandering off facility grounds which poses a potential Health, Safety, or 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)
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