010206158-2-15-2022-02-CC-SJON-CCBQT6-20220308112634

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 010206158
Report Date: 02/15/2022
Date Signed: 02/15/2022 04:35:58 PM

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
11/19/2021 and conducted by Evaluator Diana Campos

PUBLIC

COMPLAINT CONTROL NUMBER: 02-CC-20211119162159

FACILITY NAME:	BOOTH MEMORIAL DAY CARE		FACILITY NUMBER:	010206158
ADMINISTRATOR:	CRAWFORD, BRIDGETT		FACILITY TYPE:	850
ADDRESS:	2794 GARDEN STREET		TELEPHONE:	(510) 535-5088
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94601
CAPACITY:	60	CENSUS: 25	DATE:	02/15/2022
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Bridgett Crawford		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Lack of supervision which resulted in injury to a child.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 02/15/2022, Licensing Program Analyst (LPA) Diana Campos made an unannounced subsequent visit for the purpose of closing the above complaint allegation. Present during the inspection were 9 staff and 25 children in care. The above allegation was investigated by the Investigations Bureau Melissa Burgoon. An incident occurred when a child sustained an arm fracture during an outdoor activity. During the course of IB’s investigation it was determined that the allegation is unsubstantiated meaning that the allegation may have happened or is valid but there is not a preponderance of evidence to prove the alleged violation did or did not occur.

Exit interview conducted with Center Director Bridgette Crawford.
Notice of Site Visit provided and must remain posted for 30 days.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana Campos	TELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022

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 7

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
11/19/2021 and conducted by Evaluator Diana Campos

PUBLIC

COMPLAINT CONTROL NUMBER: 02-CC-20211119162159

FACILITY NAME:	BOOTH MEMORIAL DAY CARE		FACILITY NUMBER:	010206158
ADMINISTRATOR:	CRAWFORD, BRIDGETT		FACILITY TYPE:	850
ADDRESS:	2794 GARDEN STREET		TELEPHONE:	(510) 535-5088
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94601
CAPACITY:	60	CENSUS: 25	DATE:	02/15/2022
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Bridgett Crawford		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff falsified documents

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 02/15/2022, Licensing Program Analyst (LPA) Diana Campos made an unannounced subsequent visit for the purpose of closing the above complaint allegation. Present during the inspection were 9 staff and 25 children in care. An incident occurred when facility staff presented parent with two incident reports regarding a child’s fall on the playground. A review of IB’s investigation revealed that staff initially reported child jumped off playground slide. However, after a review of video footage of the incident staff corrected report to indicate child fell off the slide. Based on the Investigation Bureau's interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED.
See 9099D for deficiency cited today

Exit interview conducted with Center Director Bridgette Crawford.
Notice of Site Visit was provided and must remain posted for 30 days.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana Campos	TELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 02-CC-20211119162159

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: BOOTH MEMORIAL DAY CARE	FACILITY NUMBER: 010206158
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/15/2022 Section Cited HSC 1596.885(c)	1 2 3 4 5 6 7	Health and Safety Code Section 1596.885(c): Conduct which is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of this state.	1 2 3 4 5 6 7	Director will submit a written plan of action on how to prevent this from repeating in the future.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Staff issued an incident report to parent with wrong information. This poses a potential risk to the health and safety of children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana Campos	TELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 7

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
11/19/2021 and conducted by Evaluator Diana Campos

COMPLAINT CONTROL NUMBER: 02-CC-20211119162159

FACILITY NAME:	BOOTH MEMORIAL DAY CARE		FACILITY NUMBER:	010206158
ADMINISTRATOR:	CRAWFORD, BRIDGETT		FACILITY TYPE:	850
ADDRESS:	2794 GARDEN STREET		TELEPHONE:	(510) 535-5088
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94601
CAPACITY:	60	CENSUS: 25	DATE:	02/15/2022
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Bridgett Crawford		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff failed to report incident to all appropriate parties

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 02/15/2022, Licensing Program Analyst (LPA) Diana Campos made an unannounced subsequent visit for the purpose of closing the above complaint allegation. Present during the inspection were 9 staff and 25 children in care. An incident occurred when facility staff failed to report an incident to facility administration, child’s parent and the licensing office within the required time. A review of IB’s investigation revealed that staff did not report the incident due to miscommunication between staff. Based on the Investigation Bureau's interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. See the attached LIC 9099D for deficiency cited.

Exit interview conducted with Center Director Bridgett Crawford.
Notice of Site Visit was provided and must remain posted for 30 days.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana Campos	TELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 02-CC-20211119162159

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: BOOTH MEMORIAL DAY CARE	FACILITY NUMBER: 010206158
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/16/2022 Section Cited CCR 101212(a)(d)(B)	1 2 3 4 5 6 7	Health related Services - The licensee shall immediately notify the child's authorized representative if the child becomes ill or sustains an injury more serious than a minor cut or scratch. The licensee shall obtain specific instructions from the authorized representative regarding action to be taken. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Director will submit a written plan of action on how to avoid repeating this in the future.
	8 9 10 11 12 13 14	staff delayed in informing child's authorized parent/guardian representative of child's injury. This poses an immediate risk to the health and safety of children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana Campos	TELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 7

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
11/19/2021 and conducted by Evaluator Diana Campos

PUBLIC

COMPLAINT CONTROL NUMBER: 02-CC-20211119162159

FACILITY NAME:	BOOTH MEMORIAL DAY CARE		FACILITY NUMBER:	010206158
ADMINISTRATOR:	CRAWFORD, BRIDGETT		FACILITY TYPE:	850
ADDRESS:	2794 GARDEN STREET		TELEPHONE:	(510) 535-5088
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94601
CAPACITY:	60	CENSUS: 25	DATE:	02/15/2022
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Bridgett Crawford		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not follow physicians orders

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 02/15/2022, Licensing Program Analyst (LPA) Diana Campos made an unannounced subsequent visit for the purpose of closing the above complaint allegation. Present during the inspection were 9 staff and 25 children in care. The above allegation was investigated by the Investigations Bureau Melissa Burgoon. A review of IB’s investigation revealed that staff did not follow physician’s orders as stated in child’s file regarding injury related incidents. Based on the Investigation Bureaus interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. See the attached LIC 9099D for deficiency cited.

Exit interview conducted with Center Director Bridgett Crawford.
Notice of Site Visit was provided and must remain posted for 30 days.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana Campos	TELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 02-CC-20211119162159

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: BOOTH MEMORIAL DAY CARE	FACILITY NUMBER: 010206158
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/16/2022 Section Cited CCR 101226(a)(b)	1 2 3 4 5 6 7	Health Realted Services:The licensee shall immediately notify the child's authorized representative if the child becomes ill or sustains an injury more serious than a minor cut or scratch. The licensee shall obtain specific instructions from the authorized representative regarding action to be taken.	1 2 3 4 5 6 7	Director will submit a written plan of action on how to prevent this from repeating in the future.
	8 9 10 11 12 13 14	The licensee shall make prompt arrangements for obtaining medical treatment for any child if necessary. This requirement was not met as evidenced by: Staff did not follow indications as per physician's note in child's file. This poses an immediate risk to the health and safety of children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana Campos	TELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022

LIC9099 (FAS) - (06/04)

Page: 7 of 7