013421935-5-12-2023-52-CC-CCHS-CS4VDL-20230523162051

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 013421935
Report Date: 05/12/2023
Date Signed: 05/12/2023 01:10:23 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 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
03/16/2023 and conducted by Evaluator Russell Haderer

COMPLAINT CONTROL NUMBER: 52-CC-20230316132347

FACILITY NAME:	WILSON, DANA		FACILITY NUMBER:	013421935
ADMINISTRATOR:	WILSON, DANA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(925) 321-1232
CITY:	FREMONT	STATE: CA	ZIP CODE:	94536
CAPACITY:	14	CENSUS: 9	DATE:	05/12/2023
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Dana Wilson		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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8 - Record Keeping - Provider does not have day care children's records updated.

INVESTIGATION FINDINGS:

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On 5/12/2023 at approximately 12:00pm, Licensing Program Analyst (LPA) Russ Haderer arrived unannounced to complete the complaint investigation for an allegation of violation of Personal Rights. Present in the home today was the licensee, and 9 children in care (3 infants; 6 two-years old) and a parent volunteer (parent of a child in care). The facility is in ratio today.

The complainant alleged that licensee does not keep children’s records updated.

LPA was present on 3/20/2023 to open the investigation and reviewed all children’s files. During the review, LPA found that records were complete for most children, however, records for one child was missing the signed/dated receipt of Parent’s Rights (form LIC995A) and for the same child there were not immunization records present in the file.

Continued.....

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

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-20230316132347

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: WILSON, DANA	FACILITY NUMBER: 013421935
	VISIT DATE: 05/12/2023

NARRATIVE

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During this current visit on 5/12/2023 the LPA completed another full review of children’s files again and found discrepancies and missing or unsigned forms.

Based on the file review completed by the LPA during the 3/20/2023 visit and the annual inspection done 5/12/2023 the licensee did not have complete records as required by Title 22 regulations which poses/posed a potential health and safety risk to persons in care.

Based on the file reviews, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

California Code of Regulations, 102418(g) and 102419(i), are being cited on the attached LIC. 9099D.

An exit interview was conducted where the citation and plan of correction were discussed. Appeal rights were given and explained to the licensee. Notice of Site Visit was issued and must be posted for 30 days.

See LIC 9099D for corrective action to be taken.

SUPERVISOR'S NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 52-CC-20230316132347

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: WILSON, DANA	FACILITY NUMBER: 013421935
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/12/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/17/2023 Section Cited CCR 102418(g)	1 2 3 4 5 6 7	102418(g) immunization (g) The licensee shall document each child's immunizations as required by the California Code of Regulations,	1 2 3 4 5 6 7	Licensee will review CCLD online video Record Keeping in Family Child Care. After viewing the video, licensee will complete sign a statement acknowledging she viewed and understands the record keeping requirements for a family child care home and will submit an original ink-signed and dated copy to the LPA.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above for maintaining immunization records for a child in care which poses/posed a potential health and safety risk.	8 9 10 11 12 13 14
Type B 05/17/2023 Section Cited CCR 102419(i)	1 2 3 4 5 6 7	102419(i) Parent’s Rights (i) The licensee shall obtain a signed and dated receipt from one parent or authorized representative that acknowledges that he/she was given a copy.....	1 2 3 4 5 6 7	Licensee will review CCLD online video Record Keeping in Family Child Care. After viewing the video, licensee will complete sign a statement acknowledging she viewed and understands the record keeping requirements for a family child care home and will submit an original ink-signed and dated copy to the LPA.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above for maintaining the signed and dated receipt for Parent’s Rights form which poses/posed a potential health and safety risk to persons in care.	8 9 10 11 12 13 14

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
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC9099 (FAS) - (06/04)

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