013422941-9-9-2022-02-CC-LDYN-CJMCZL-20220926022232

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 013422941
Report Date: 09/09/2022
Date Signed: 09/09/2022 04:37:36 PM

Unsubstantiated

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
07/25/2022 and conducted by Evaluator Phyllis Dyer

PUBLIC

COMPLAINT CONTROL NUMBER: 02-CC-20220725134500

FACILITY NAME:	ARRIAGA, ELIZABETH		FACILITY NUMBER:	013422941
ADMINISTRATOR:	ARRIAGA, ELIZABETH		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 302-5849
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94603
CAPACITY:	14	CENSUS: 2	DATE:	09/09/2022
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Elizabeth Arriaga		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Child was injured while in care.

INVESTIGATION FINDINGS:

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LPA Dyer conducted an unannounced complaint inspection to deliver the findings of the above allegation. LPA met with licensee Elizabeth Arriaga. The licensee was present with 2 preschool aged children.
It was alleged that a child was injured while in care.
Licensee stated that an incident occurred at the facility. The licensee was with a child who fell. She immediately applied first aid to the injury. Children have sustained occasional minor injuries as a result of normal routines of children’s play. When the child fell, there was no evidence to prove that it was due to a lack of supervision. Therefore, the allegation is Unsubstantiated. Exit interview conducted. Licensee was provided copy of their appeal rights. This report must be kept available for public review for 3 years.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Loretta Dyson	TELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Phyllis Dyer	TELEPHONE: (510) 725-7006
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

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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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
07/25/2022 and conducted by Evaluator Phyllis Dyer

COMPLAINT CONTROL NUMBER: 02-CC-20220725134500

FACILITY NAME:	ARRIAGA, ELIZABETH		FACILITY NUMBER:	013422941
ADMINISTRATOR:	ARRIAGA, ELIZABETH		FACILITY TYPE:	810
ADDRESS:	10803 PEARMAIN STREET		TELEPHONE:	(510) 302-5849
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94603
CAPACITY:	14	CENSUS: 2	DATE:	09/09/2022
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Elizabeth Arriaga		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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9

Licensee did not report injury to authorized representative.

INVESTIGATION FINDINGS:

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LPA Dyer conducted an unannounced complaint inspection to deliver the findings of the above allegation. LPA met with licensee Elizabeth Arriaga. The licensee was present with 2 preschool aged children.
It was alleged that licensee did not report injury to authorized representative. During the course of the investigation, interviews were conducted. Licensee states the child fell off a chair. Licensee states she saw the fall as it happened, helped the child up, and applied first aid to the injury. However, when the child was picked up, the parent was not notified of the injury. The parent noticed the injury after she left the facility (while sitting in her vehicle) and returned to the facility to discuss it.
Because the licensee did not report the injury to the parent, the above allegation is Substantiated. California Code of Regulations, (Title 22, Division 12), are being cited on the attached LIC 9099D and must be corrected by the due date.
Exit interview conducted. Licensee was provided copy of their appeal rights. This report must be kept available for public review for 3 years.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Loretta Dyson	TELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Phyllis Dyer	TELEPHONE: (510) 725-7006
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

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 02-CC-20220725134500

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: ARRIAGA, ELIZABETH	FACILITY NUMBER: 013422941
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/09/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/26/2022 Section Cited CCR 102416.2	1 2 3 4 5 6 7	Reporting Requirement (f) As soon as possible but no later then the same business day, the licensee shall notify a child's parent or authorized representative regardless of the injuries or acts that affect that child as specified in Health and Safety Code Section 1597.467(a).	1 2 3 4 5 6 7	Licensee states she will provide a written plan of action by 9/19/22 detaining how she will ensure that if a child is injured at the facility, the parent will be notified no later than the same business day.
	8 9 10 11 12 13 14	(1) Any injury suffered by a child in care shall be reported to that child's parent or authorized representative ... This requirement was not met as evidenced by licensee and witness interviews. Licensee failed to notify a child’s parent of an injury that occurred at the facility. This poses a potential health risk to the Personal Rights of children in care.	8 9 10 11 12 13 14	Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250.00 per violation and $100 per day until corrected.
	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: Loretta Dyson	TELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Phyllis Dyer	TELEPHONE: (510) 725-7006
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

LIC9099 (FAS) - (06/04)

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