073406563-10-30-2020-02-CC-MMEA-BUZ6ZN-20201102201522

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 073406563
Report Date: 10/30/2020
Date Signed: 10/30/2020 03:22:33 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
06/15/2020 and conducted by Evaluator Paul Peterson

PUBLIC

COMPLAINT CONTROL NUMBER: 02-CC-20200615092339

FACILITY NAME:	JACKSON, GLORIOUS & DEREK		FACILITY NUMBER:	073406563
ADMINISTRATOR:	JACKSON, GLORIOUS & DEREK		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 237-2611
CITY:	RICHMOND	STATE: CA	ZIP CODE:	94804
CAPACITY:	14	CENSUS: 5	DATE:	10/30/2020
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Glorious Jackson		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Provider hit daycare child resulting in injury.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Paul Petersen conducted a complaint investigation site inspection for this facility via tele-visit. LPA met with licensee, Glorious Jackson, and reviewed the investigation findings. Also present at the time of this tele-visit were 5 children in care. Investigator, Dinah Watkins, of the Community Care Licensing Investigations Branch conducted an investigation of the above allegation. Based on the investigative findings, although the allegation may have happened or be valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time.

An exit interview was conducted and a copy of the complaint investigation report 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: Paul Peterson	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020

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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