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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 033620069
Report Date: 01/20/2023
Date Signed: 01/20/2023 11:13:07 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/19/2022 and conducted by Evaluator Salene Mayberry
COMPLAINT CONTROL NUMBER: 53-CC-20221019160017
FACILITY NAME:GOLD STAR PRESCHOOLFACILITY NUMBER:
033620069
ADMINISTRATOR:LOFFSWOLD, MICHELLEFACILITY TYPE:
850
ADDRESS:335 SOUTH AVENUETELEPHONE:
(209) 256-8059
CITY:JACKSONSTATE: CAZIP CODE:
95642
CAPACITY:25CENSUS: 13DATE:
01/20/2023
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:MIchelle LoffswoldTIME COMPLETED:
11:25 AM
ALLEGATION(S):
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1. Staff did not immediately notify child's responsible party regarding injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Salene Mayberry met with Director, Michelle Loffswold to deliver findings for the above complaint allegation.

During the investigation, LPA toured the facility, observed staff interactions with children in care, conducted interviews and obtained pertinent documents.

It was alleged that “staff did not immediately notify child's responsible party regarding injury.” Interviews revealed that a child in care fell off a play structure from a height of 4 feet 6 inches and subsequently displayed symptoms of a concussion. Later that evening, a trip to the Emergency Room confirmed that the child had suffered a concussion. Staff were aware of the fall and of the child’s subsequent symptoms; yet they failed to promptly notify the child’s guardians.

Report continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Salene Mayberry
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
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 5
Control Number 53-CC-20221019160017
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: GOLD STAR PRESCHOOL
FACILITY NUMBER: 033620069
VISIT DATE: 01/20/2023
NARRATIVE
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Accordingly, based on a preponderance of evidence obtained the complaint regarding the above allegation was SUBSTANTIATED.

A Type B Deficiency was cited on the subsequent page (LIC9099-D) of this report.

An Exit interview was conducted in which the report was reviewed and discussed with the Director. LPA provided a copy of the report and Appeal Rights to Director. A Notice of Site visit was posted by LPA and Director understands it must remain posted for 30 days.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Salene Mayberry
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 53-CC-20221019160017
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: GOLD STAR PRESCHOOL
FACILITY NUMBER: 033620069
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/07/2023
Section Cited
CCR
101212(f)
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101212 Reporting Requirements (f) The items specified in (d)(1)(A) through (H) (B: Any injury to any child that requires medical treatment) above shall also be reported to the child's authorized representative. This requirement was not met as evidenced by:
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Director will hold a staff meeting on 2/1 and review protocols for reporting injuries as well as concussion symptoms with staff. Director will provide LPA with a copy of the staff meeting agenda and staff attendance signatures.
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Interviews revealed a child fell 4’6” off a play structure, was displaying symptoms of a concussion and was later diagnosed with a concussion. Staff were aware of the fall and child’s subsequent symptoms; yet failed to promptly notify the child’s guardians.
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Deficiencies continued:

This is a potential risk to the health and safety of children in care.
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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.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Salene Mayberry
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/19/2022 and conducted by Evaluator Salene Mayberry
COMPLAINT CONTROL NUMBER: 53-CC-20221019160017

FACILITY NAME:GOLD STAR PRESCHOOLFACILITY NUMBER:
033620069
ADMINISTRATOR:LOFFSWOLD, MICHELLEFACILITY TYPE:
850
ADDRESS:335 SOUTH AVENUETELEPHONE:
(209) 256-8059
CITY:JACKSONSTATE: CAZIP CODE:
95642
CAPACITY:25CENSUS: 13DATE:
01/20/2023
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:MIchelle LoffswoldTIME COMPLETED:
11:25 AM
ALLEGATION(S):
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9
1. Staff did not obtain emergency medical care for daycare child
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Salene Mayberry met with Director, Michelle Loffswold to deliver findings for the above complaint allegation.

During the investigation LPA observed staff interactions with children in care, interviewed staff and obtained pertinent documents. It was alleged that “staff did not obtain emergency medical care for daycare child”. Interviews conducted by LPA did not reveal that the severity of the injury required immediate medical intervention by Emergency Medical Services.

Based on conflicting statements and a lack of clear corroborating evidence, the above allegation could not be substantiated or dismissed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the finding is UNSUBSTANTIATED.
Report continued on LIC9099A-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Salene Mayberry
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 53-CC-20221019160017
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: GOLD STAR PRESCHOOL
FACILITY NUMBER: 033620069
VISIT DATE: 01/20/2023
NARRATIVE
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An Exit interview was conducted in which the report was reviewed and discussed with the Director. LPA provided a copy of the report and Appeal Rights to Director. A Notice of Site visit was posted by LPA and Director understands it must remain posted for 30 days.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Salene Mayberry
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5