073401855-5-10-2021-02-CC-SJON-C3D4ZK-20210525193251

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 073401855
Report Date: 05/10/2021
Date Signed: 05/10/2021 01:09:00 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, SUITE 1102
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/01/2021 and conducted by Evaluator Cherie Acosta

COMPLAINT CONTROL NUMBER: 02-CC-20210301155233

FACILITY NAME:	ALAMO COUNTRY SCHOOL		FACILITY NUMBER:	073401855
ADMINISTRATOR:	LISA PAGE		FACILITY TYPE:	850
ADDRESS:	1261 LAVEROCK LANE		TELEPHONE:	(925) 406-4332
CITY:	ALAMO	STATE: CA	ZIP CODE:	94507
CAPACITY:	64	CENSUS: 38	DATE:	05/10/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Lisa Page		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Lack of supervision resulting in child being injured.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analysts (LPAs) Cherie Acosta and Michelle Sutton conducted an unannounced inspection to investigate the above allegation. Present during today's inspection were 6 staff and 38 children.
It was reported that a child in care was injured due to a lack of supervision. Based on interviews conducted the facility was in ratio at the time the injury occurred. Although a child did receive a minor injury LPA is unable to prove that the injury occurred due to a lack of supervision.
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 allegation is deemed unsubstantiated.
Report was reviewed with Lisa Page. Appeal rights were provided.
Notice of site visit was provided at time of inspection and must be posted for 30 days.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Cherie Acosta	TELEPHONE: (510) 622-1623
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021

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 9

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
03/01/2021 and conducted by Evaluator Cherie Acosta

COMPLAINT CONTROL NUMBER: 02-CC-20210301155233

FACILITY NAME:	ALAMO COUNTRY SCHOOL		FACILITY NUMBER:	073401855
ADMINISTRATOR:	LISA PAGE		FACILITY TYPE:	850
ADDRESS:	1261 LAVEROCK LANE		TELEPHONE:	(925) 406-4332
CITY:	ALAMO	STATE: CA	ZIP CODE:	94507
CAPACITY:	64	CENSUS: 38	DATE:	05/10/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Lisa Page		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Day care child sustained an unexplained injury while in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analysts (LPAs) Cherie Acosta and Michelle Sutton conducted an unannounced inspection to investigate the above allegation. Present during today's inspection were 6 staff and 38 children.
It was reported that a child sustained an unexplained injury while in care. During the investigation LPA conducted multiple interviews. It is determined that a child received a scratch on the face while in care. The facility staff did not witness the incident and it is unknown as to how the child received the injury.
Based on interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is to be substantiated.

Report was reviewed with Lisa Page. Appeal rights were provided.
Notice of site visit was provided at time of inspection and must be posted for 30 days.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Cherie Acosta	TELEPHONE: (510) 622-1623
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 9

Control Number 02-CC-20210301155233

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: ALAMO COUNTRY SCHOOL	FACILITY NUMBER: 073401855
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/20/2021 Section Cited CCR 101223(a)2	1 2 3 4 5 6 7	Personal Right The licensee shall ensure that each child is accorded the following personal rights: to be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.	1 2 3 4 5 6 7	Director shall submit a written plan of action explaining how staff will conduct visual assessments of children through out the day.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: A child in care received an unexplained injury while in care which poses a potential 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.
	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: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Cherie Acosta	TELEPHONE: (510) 622-1623
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 9

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
03/01/2021 and conducted by Evaluator Cherie Acosta

COMPLAINT CONTROL NUMBER: 02-CC-20210301155233

FACILITY NAME:	ALAMO COUNTRY SCHOOL		FACILITY NUMBER:	073401855
ADMINISTRATOR:	LISA PAGE		FACILITY TYPE:	850
ADDRESS:	1261 LAVEROCK LANE		TELEPHONE:	(925) 406-4332
CITY:	ALAMO	STATE: CA	ZIP CODE:	94507
CAPACITY:	64	CENSUS: 38	DATE:	05/10/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Lisa Page		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not provide incident report to day care child's authorized representative.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analysts (LPAs) Cherie Acosta and Michelle Sutton conducted an unannounced inspection to investigate the above allegation. Present during today's inspection were 6 staff and 38 children.
It was reported that staff did not provide incident report to day care child's authorized representative. It was confirmed by the director that a child received a scratch while in care and an "ouch" report was not provided to the child's authorized representative.

Based on interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is to be substantiated.
Report was reviewed with Lisa Page. Appeal rights were provided.
Notice of site visit was provided at time of inspection and must be posted for 30 days.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Cherie Acosta	TELEPHONE: (510) 622-1623
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 8 of 9

Control Number 02-CC-20210301155233

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: ALAMO COUNTRY SCHOOL	FACILITY NUMBER: 073401855
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/20/2021 Section Cited CCR 101226(a)2	1 2 3 4 5 6 7	Health-Related Services In the case of less serious injuries including, but not limited to, minor cuts, scratches and bites from other children requiring assessment and/or administration of first aid by staff, the licensee shall document the injury in the	1 2 3 4 5 6 7	Director shall submit a written plan of action to CCL by 5/20/21
	8 9 10 11 12 13 14	child's record and notify the child's authorized representative of the nature of the injury when the child is picked up from the center. This requirement was not met as evidenced by: A child in care received a scratch and the facility failed to provide an "ouch" report which poses a potential 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.
	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: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Cherie Acosta	TELEPHONE: (510) 622-1623
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021

LIC9099 (FAS) - (06/04)

Page: 9 of 9

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
03/01/2021 and conducted by Evaluator Cherie Acosta

COMPLAINT CONTROL NUMBER: 02-CC-20210301155233

FACILITY NAME:	ALAMO COUNTRY SCHOOL		FACILITY NUMBER:	073401855
ADMINISTRATOR:	LISA PAGE		FACILITY TYPE:	850
ADDRESS:	1261 LAVEROCK LANE		TELEPHONE:	(925) 406-4332
CITY:	ALAMO	STATE: CA	ZIP CODE:	94507
CAPACITY:	64	CENSUS: 38	DATE:	05/10/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Lisa Page		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff failed to follow admissions agreement contract.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analysts (LPAs) Cherie Acosta and Michelle Sutton conducted an unannounced inspection to investigate the above allegation. Present during today's inspection were 6 staff and 38 children.
It was reported that staff failed to follow admissions agreement contract. During the investigation LPA conducted interviews and reviewed the admissions agreement. The admission agreement indicates that if a child receives a minor injury an "ouch" report will be placed on the child's sign in/out sheet. Based on interviews conducted it is determined that a child received a minor injury while in care and an "ouch" report was not provided to the authorized representative,
Based on interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is to be substantiated.
Report reviewed with Lisa Page. Appeal rights were provided.
Notice of site visit was provided at time of inspection at must be posted for 30 days.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Cherie Acosta	TELEPHONE: (510) 622-1623
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021

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 9

Control Number 02-CC-20210301155233

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: ALAMO COUNTRY SCHOOL	FACILITY NUMBER: 073401855
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/20/2021 Section Cited CCR 101219(f)	1 2 3 4 5 6 7	Admission Agreements The licensee shall comply with all terms and conditions set forth in the admission agreement. This requirement was not met as evidenced by : A child in care received a scratch while in care	1 2 3 4 5 6 7	Director shall subit a written plan of action and submit to CCL 5/20/21
	8 9 10 11 12 13 14	and facility failed to provide the authorized representative an "ouch" report which poses a potential 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.
	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: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Cherie Acosta	TELEPHONE: (510) 622-1623
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 9