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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 013418935
Report Date: 06/01/2021
Date Signed: 06/01/2021 06:41:50 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
05/26/2021 and conducted by Evaluator Sidney Cortez
PUBLIC
COMPLAINT CONTROL NUMBER: 52-CC-20210526122052
FACILITY NAME:AMADO, MIRZAFACILITY NUMBER:
013418935
ADMINISTRATOR:AMADO, MIRZAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 782-6235
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY:14CENSUS: DATE:
06/01/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Mirza AmadoTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Lack of Supervision




*** Please note that LPA Cortez experienced multiple consistency check and technical difficulties during the investigation.
INVESTIGATION FINDINGS:
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On 06/1/2021 at 10:30am, Licensing Program Analyst (LPA) Sidney Cortez met with licensee Mirza Amado to deliver the findings of the complaint investigation regarding the above allegation. Also present was her 17 year old son. LPA toured the facility and observed there were 4 children in care.

Based on the licensee's admittance of not visually supervising the chidlren while playing on the backyard, observations, interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, 101229a is being cited on the attached LIC 9099D. Failure to submit Proof of Corrections (POC) by Plan of Correction date may result in additional civil penalties.

An exit interview was conducted with Licensee.
Appeal rights provided and discussed.
A notice of site visit was posted and must remain posted for a period of 30 days.

Substantiated
Estimated Days of Completion: 10
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Sidney CortezTELEPHONE: (510) 295-5031
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021
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 3
Control Number 52-CC-20210526122052
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: AMADO, MIRZA
FACILITY NUMBER: 013418935
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/01/2021
Section Cited
CCR
101229a
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The licensee shall provide care and supervision as necessary to meet the children's needs...Supervision shall include visual observation.

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Licensee will create a plan and schedule to ensure all children are being visually supervised

Licensee will communicate with parents and talk to them about talking to there children about appropriate and inappropriate touching

Licensee will create ground rules with the children on daycare about personal space and touching. Plan of correction is due in 14 business days
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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 NoronaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Sidney CortezTELEPHONE: (510) 295-5031
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 52-CC-20210526122052
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: AMADO, MIRZA
FACILITY NUMBER: 013418935
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/01/2021
Section Cited
CCR
101229a
1
2
3
4
5
6
7
The licensee shall provide care and supervision as necessary to meet the children's needs...Supervision shall include visual observation.

1
2
3
4
5
6
7
Licensee will create a plan and schedule to ensure all children are being visually supervised

Licensee will communicate with parents and talk to them about talking to there children about appropriate and inappropriate touching

Licensee will create ground rules with the children on daycare about personal space and touching. Plan of correction is due in 14 business days
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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 NoronaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Sidney CortezTELEPHONE: (510) 295-5031
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3