010216514-7-28-2021-52-CC-CCHS-C73RXB-20210921132429

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 010216514
Report Date: 07/28/2021
Date Signed: 07/28/2021 04:48:17 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 STE 1102
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/19/2021 and conducted by Evaluator Lorraine Dacanay-Breaux

COMPLAINT CONTROL NUMBER: 52-CC-20210419154231

FACILITY NAME:	LA PETITE ACADEMY - PLEASANTON		FACILITY NUMBER:	010216514
ADMINISTRATOR:	THERESA GROSS		FACILITY TYPE:	850
ADDRESS:	5725 VALLEY AVENUE		TELEPHONE:	(925) 462-7844
CITY:	PLEASANTON	STATE: CA	ZIP CODE:	94566
CAPACITY:	89	CENSUS: 30	DATE:	07/28/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Theresa Gross		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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9

Personal Rights- A daycare child sustained bruises to his arms at the facility.

INVESTIGATION FINDINGS:

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LPA Dacanay Breaux and LPA E. Woods met with Director, Theresa Gross to delivery the findings of a complaint investigation. There were 27 preschool age children and 3 infants and 11 additional staff. During the course of the investigations interviews were conducted, facilty documents were obtained and various documents from other State agencies were reviewed. Based on interviews conducted it was alleged that a child sustained bruises to his arms at the facility. Based on observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC. 9099D.”

The attached type B deficiency is cited today and must be corrected by the due date. An exit interview was conducted and the report was discussed. Licensee was provided a copy of their appeal rights and the signature on this form acknowledges recipt of the rights.

A SITE VISIT NOTICE WAS POSTED BY STAFF.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Lorraine Dacanay-Breaux	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

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 52-CC-20210419154231

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: LA PETITE ACADEMY - PLEASANTON	FACILITY NUMBER: 010216514
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/10/2021 Section Cited CCR 101223(a)(3)	1 2 3 4 5 6 7	To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.	1 2 3 4 5 6 7	By 08/10/21 Director will train staff by watching a video on personal rights. She will submit all who attended, reviewed and was trained on this video. WIll submit proof to LPA by fax, email, or mail.
	8 9 10 11 12 13 14	This requirement was not met as evidence by IB investagators, the bruises on a child's upper arm appeared consistent with a child being held tighly shows evident of inappropriate handling by staff. This violation poses a potential health and safety risk to 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: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Lorraine Dacanay-Breaux	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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
04/19/2021 and conducted by Evaluator Lorraine Dacanay-Breaux

COMPLAINT CONTROL NUMBER: 52-CC-20210419154231

FACILITY NAME:	LA PETITE ACADEMY - PLEASANTON		FACILITY NUMBER:	010216514
ADMINISTRATOR:	THERESA GROSS		FACILITY TYPE:	850
ADDRESS:	5725 VALLEY AVENUE		TELEPHONE:	(925) 462-7844
CITY:	PLEASANTON	STATE: CA	ZIP CODE:	94566
CAPACITY:	89	CENSUS: 30	DATE:	07/28/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Theresa Gross		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Personal Rights- A daycare child had bruising on arm.

INVESTIGATION FINDINGS:

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

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Lorraine Dacanay-Breaux	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

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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