073403811-8-27-2019-02-CC-ARON-BG628M-20190918171034

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 073403811
Report Date: 08/27/2019
Date Signed: 08/27/2019 01:29:17 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
08/12/2019 and conducted by Evaluator Geneen Redmond

PUBLIC

COMPLAINT CONTROL NUMBER: 02-CC-20190812152939

FACILITY NAME:	LEE-OLORTEGUI, SILVIA		FACILITY NUMBER:	073403811
ADMINISTRATOR:	LEE-OLORTEGUI, SILVIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(925) 288-1956
CITY:	CONCORD	STATE: CA	ZIP CODE:	94519
CAPACITY:	14	CENSUS: 6	DATE:	08/27/2019
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:			TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Personal Rights: Child sustained unexplained bruises while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Redmond, conduted an unannounced, Complaint Investigation follow up visit from visits conducted on 08/13/19 and 08/20/19 regarding the above listed allegation.

During previous visits, LPA made observations, reviewed facility documentation and conducted interviews. Interviews of staff determined that a child sustained unexplained bruises while under the care and supervision of the Licensee. Based on the information LPA obtained, the preponderance of evidence standard has been met. Therefore, the above allegation is - SUBSTANTIATED.

NOTICE: A violation of Title 22 Health and Safety Regulations has occurred. A deficiency has been cited with a Plan of Correction (POC) issued to the Licensee, in order to correct the deficiency (see LIC 9099D form).

Instructions for clearing the POC: - CONTINUED

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Antranette Robinson	TELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Geneen Redmond	TELEPHONE: (510) 873-6410
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2019

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-20190812152939

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: LEE-OLORTEGUI, SILVIA	FACILITY NUMBER: 073403811
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/27/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/28/2019 Section Cited CCR 102423(a)(4)	1 2 3 4 5 6 7	Personal Rights To be free from corporal or unusual punishment, infliction of pain... (See section cited for complete description). THIS REQUIREMENT WAS NOT MET: A child (C1), under the care and supervision of the Licensee obtained	1 2 3 4 5 6 7	1. Licensee and all staff shall complete training on Personal Rights. 2. Videos on Personal Rights can be obtained at the CCLD website: https://childcarevideos.org 2. Licensee and staff shall write a summary of what was learned by watching the videos.3. Licensee shall obtain signatures and dates
	8 9 10 11 12 13 14	unexplained bruises.This is an immediate threat to the health and safety of children in care if not corrected.	8 9 10 11 12 13 14	of all staff and provide a written list of signatures to LPA by 08/28/19. NOTICE: Failure to complete POC's by POC due date, may result in civil penalty assessment of up to $100 per day, per violation.
	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: Antranette Robinson	TELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Geneen Redmond	TELEPHONE: (510) 873-6410
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2019

LIC9099 (FAS) - (06/04)

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Control Number 02-CC-20190812152939

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: LEE-OLORTEGUI, SILVIA	FACILITY NUMBER: 073403811
	VISIT DATE: 08/27/2019

NARRATIVE

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INSTRUCTIONS FOR CLEARING POC CONTINUED

A serious deficiency, which is a Type A violation, has being cited on the POC form.

The POC shall be corrected within 24 hours.

The Licensee shall post and provide copies of the Complaint Investigation Report and POC to all parents/guardians of children currently enrolled and in care at the facility.

All parents/guardians shall sign an Acknowledgement of Receipt of Licensing Report (LIC9224) and a copy shall be placed in each child's file.

A list compiled of the parent's signatures including the date the LIC 9224 was signed shall be compiled.

The completed POC and the list of parent signatures shall be by faxed to LPA by POC due date at:

ATTENTION: LPA REDMOND (510) 622-2641

Exit Interview: An exit interview has been conducted with the Licensee. This Complaint Investigation Report, Plan of Correction (POC), Appeal Rights and Notice of Site Visit was issued to and discussed with the Licensee.

Notice of Site Visit: Shall be posted at the time of the inspection and shall remain posted for 30 days.

Record Retention: This Complaint Investigation Report and POC shall be made available to the public upon request for 3 years from the date of this report. A copy of the report shall also be provided to newly enrolled children at the facility during the next 12 months and a copy of the LIC 9224 shall be placed in the children’s files.

SUPERVISOR'S NAME: Antranette Robinson	TELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Geneen Redmond	TELEPHONE: (510) 873-6410
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2019

LIC9099 (FAS) - (06/04)

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