015700241-4-7-2022-52-CC-WNOA-CE9PUW-20220509113811

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015700241
Report Date: 04/07/2022
Date Signed: 04/07/2022 12:14:45 PM

Substantiated

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
03/30/2022 and conducted by Evaluator Jaylena Miller

PUBLIC

COMPLAINT CONTROL NUMBER: 52-CC-20220330093418

FACILITY NAME:	TSURUTA, YUKIKO		FACILITY NUMBER:	015700241
ADMINISTRATOR:	TSURUTA, YUKIKO		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 598-7058
CITY:	FREMONT	STATE: CA	ZIP CODE:	94539
CAPACITY:	14	CENSUS: 10	DATE:	04/07/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Yukiko Tsuruta		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Licensee does not practice safe sleep protocol

INVESTIGATION FINDINGS:

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On 04/7/2022 Licensing Program Analysts (LPAs) Jaylena Miller and April Wright conducted an unannounced initial 10 day complaint investigation regarding the above allegation and met with Licensee Yukiko Tsuruta and explained the purpose of the visit.

During the investigation LPAs conducted a physical plant inspection and observed 3 infants laying in cribs where bumper pads were present in all three cribs and a hanging mobile attached to one of the cribs. LPAs observed 7 play yards in the nap room where 3 infants were sleeping with blankets. LPAs observed a total of 9 infants and 1 preschooler. LPAs conducted an interview with Licensee and reviewed children’s records. Based on LPAs physical plant inspection, interview conducted, and records reviewed, the preponderance of evidence standard has been met, therefor the above allegation is to be SUBSTANTIATED. As a result, and per California Code of Regulations, Title 22 Division 12, Chapter 1, Section 102425(b)(2)(3) is being cited on LIC 9099-D.

Please see LIC 9099-C for continuance

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jaylena Miller	TELEPHONE: (510) 292-8297
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022

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 52-CC-20220330093418

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: TSURUTA, YUKIKO	FACILITY NUMBER: 015700241
	VISIT DATE: 04/07/2022

NARRATIVE

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LPAs provided licensee with Technical Assistance for safe sleep and went over the following:
-Infants must sleep in equipment and furniture designed for infant sleeping (crib/play yard)
-Infants must be put to sleep on their back
-Infant sleep area must be free from loose articles (bumper pads, blankets, pillows and hanging mobiles)
-All infants enrolled must have a LIC 9227
-Sleep log is required for all infants (when they go to sleep, wake up and 15 minute checks)

LPAs reminded licensee it is her responsibility to keep up with and follow all safe sleep regulations.

The licensee must post this report for thirty days. The licensee must give each parent of the children in care and future parents of newly enrolled children, for the next one year following today’s date, a copy of this report. Parents are to sign an LIC 9224- Acknowledgment of Receipt of Licensing reports and this form shall be placed in each child’s file. Failure to post report and or provide a copy of this report to parent’s/authorized guardians can result in additional monetary assessments to the facility. This report must remain on file for three years. The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. Notice of site visit was provided and must be posted for thirty days. Exit interview conducted with licensee, Yukiko Tsuruta.

Please see LIC 9099-D for deficiency cited

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jaylena Miller	TELEPHONE: (510) 292-8297
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022

LIC9099 (FAS) - (06/04)

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Control Number 52-CC-20220330093418

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: TSURUTA, YUKIKO	FACILITY NUMBER: 015700241
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/07/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/07/2022 Section Cited CCR 102425(b)(2)(3)	1 2 3 4 5 6 7	102425 Infant Safe Sleep b) Cribs or play yards shall be free from all loose articles and objects. (2) Bumper pads shall not be used. (3) There shall be no objects hanging above or attached to the side of the crib. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Licensee shall remove all bumper pads, hanging mobile, blankets and pillows from infant sleeping area by 4/8/2022. Licensee shall review Safe Sleep regulations and submit to LPA a written plan detailing how infants will be placed in cribs to sleep in compliance with Safe Sleep regulations by 4/15/2022 EOB.
	8 9 10 11 12 13 14	Based on physical plant inspection, interviews conducted and records reviewed Licensee did not ensure safe sleep protocols which poses an immediate risk to the health and safety 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 per violation and $100 per day until corrected.
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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 Norona	TELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jaylena Miller	TELEPHONE: (510) 292-8297
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022

LIC9099 (FAS) - (06/04)

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