073404606-11-20-2020-02-CC-MMEA-BVP7QY-20201124205243

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 073404606
Report Date: 11/20/2020
Date Signed: 11/20/2020 04:49:10 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
05/07/2020 and conducted by Evaluator Tasha Hackett-Alexander

COMPLAINT CONTROL NUMBER: 02-CC-20200507162610

FACILITY NAME:	MAC, JASMINE		FACILITY NUMBER:	073404606
ADMINISTRATOR:	MAC, JASMINE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(925) 689-3766
CITY:	CONCORD	STATE: CA	ZIP CODE:	94521
CAPACITY:	14	CENSUS: 6	DATE:	11/20/2020
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	JASMINE MAC		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

PERSONAL RIGHTS- Child sustained injuries while in care resulting in hospitalization

INVESTIGATION FINDINGS:

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

LPA ALEXANDER MET WITH LICENSEE JASMINE MAC VIA TELE-VISIT TO DELIVER THE INVESTIGATIVE FINDINGS TO THE ABOVE ALLEGATIONS, CONDUCTED BY INVESTIGATOR EDDIE PHUNG WHO IS WITH COMMUNITY CARE LICENSING'S INVESTIGATIVE BRANCH. TODAY LICENSEE, HER HUSBAND AND 6 CHILDREN CONSISTING OF 2 INFANTS AND 4 PRESCHOOLERS ARE PRESENT FOR THE VISIT.

BASED ON THE INVESTIGATIVE FINGDINGS: 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 UNSUBSTANTIATED.

An exit interview was conducted and a copy of this report was provided via email. Licensee was provided a copy of the appeal rights.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Mayla Mendoza	TELEPHONE: (510) 873-6408
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander	TELEPHONE: (510) 622-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2020

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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