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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 010206066
Report Date: 02/01/2022
Date Signed: 02/01/2022 04:16:38 PM

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 STE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/01/2022 and conducted by Evaluator Jaylena Miller
PUBLIC
COMPLAINT CONTROL NUMBER: 52-CC-20220201114328
FACILITY NAME:RESURRECTION LUTHERAN INFANT CARE CENTERFACILITY NUMBER:
010206066
ADMINISTRATOR:WAZHMA MASARWEHFACILITY TYPE:
830
ADDRESS:7557 AMADOR VALLEY BOULEVARDTELEPHONE:
(925) 828-2122
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY:36CENSUS: 5DATE:
02/01/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Washma MasarwehTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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child being bitten by another daycare child.
INVESTIGATION FINDINGS:
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On 2/1/2022 at 9:00am Licensing Program Analyst (LPA) Jaylena Miller conducted an unannounced complaint investigation regarding the above allegation and met with Facility Director Wazhma Masarweh and explained the purpose of the visit.
During the investigation LPA Miller conducted and interview with facility director. On 1/3/2022 the facility director did self-report an incident regarding C1 (16 months old) and C2 (23 months old) and that C1 bit C2 on the forearm. Both C1 and C2s parents were notified regarding the incident. C1s parents are currently working with a pediatrician regarding the biting as C1 is currently teething.
Based on LPA Miller’s interviews which were conducted, records reviewed and observations, the preponderance of evidence has been met, therefore the above allegation is to be SUBSTANTIANTED. As a result, and per California Code of Regulations, Title 22 Division 12, Chapter 1, Section 101223(a)(3) is being cited on LIC 9099-D. This report must remain on file for three years. The director was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. Notice of site visit was provided and must be posted for 30 days. Exit interview conducted with facility director, Wazhma Masarweh.
Please see LIC 9099-D for deficiency cited
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jaylena Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2022
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 52-CC-20220201114328
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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: RESURRECTION LUTHERAN INFANT CARE CENTER
FACILITY NUMBER: 010206066
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/01/2022
Section Cited
CCR
101223(a)(3)
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Personal Rights 101223(a)(3)
(a) The licensee shall ensure that each child is accorded the following personal rights: (3) To be free from... infliction of pain...
This requirement was not met as evidence by:
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Facility will separate C1 and C2 as well as the facility will have a staff meeting/training for more redirection techniques. Facility director will provide LPA with a list of different redirection techniques that they came up with during their meeting by 3/1/2022.
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Based on interviews and records review the facility was unable to prevent the infliction of pain on C2 when C1 bit C2 on the forearem which poses a potential risk to the health and safety of children in care.
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Failure to correct with result in $100 per day civil penalty until corrected. Repeat violations are $250 civil penalty 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: Jaylena Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2022
LIC9099 (FAS) - (06/04)
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