073407708-5-20-2019-02-CC-AEVS-BCUTSR-20190605145934

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 073407708
Report Date: 05/20/2019
Date Signed: 05/20/2019 04:50:53 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
05/02/2019 and conducted by Evaluator Belinda DeVall

PUBLIC

COMPLAINT CONTROL NUMBER: 02-CC-20190502155227

FACILITY NAME:	LOPEZ, GUADALUPE		FACILITY NUMBER:	073407708
ADMINISTRATOR:	LOPEZ, GUADALUPE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(925) 516-7645
CITY:	OAKLEY	STATE: CA	ZIP CODE:	94561
CAPACITY:	14	CENSUS: 9	DATE:	05/20/2019
		UNANNOUNCED	TIME BEGAN:	04:05 PM
MET WITH:	Guadalupe Lopez		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Neglect/Lack of Supervision - Lack of supervision resulting in child causing injury to another child in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Belinda Devall arrived at 4:05 P.M. and met with licensee Guadalupe Lopez for the purpose of an UNANNOUNCED COMPLAINT INVESTIGATION regarding the above allegation against the facility. Interview with a child was conducted.

During the course of investigation, interview with licensee and children were conducted. Interviews revealed that a child hit a child with a plastic baseball bat in the backyard. The licensee was inside the home. Based on LPAs interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 12 & Chapter number 1, are being cited on the attached LIC. 9099D. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and appeal rights were provided and discussed.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anika Evans	TELEPHONE: (510) 286-4350
LICENSING EVALUATOR NAME: Belinda DeVall	TELEPHONE: (510) 725-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2019

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-20190502155227

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: LOPEZ, GUADALUPE	FACILITY NUMBER: 073407708
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/20/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/28/2019 Section Cited CCR 102417(a)	1 2 3 4 5 6 7	Operation of a Family Child Care Home. The licensee shall be present in the home and shall ensure that children in care are supervised at all times. This requirement was not met as evidence by interviews confirming	1 2 3 4 5 6 7	By 05/28/2019, licensee will submit a written plan of action on ways she will ensure visual supervision of children in care at all times.
	8 9 10 11 12 13 14	that a day care child was hit by another day care child with a plastic baseball bat and there was no adult present outside. This is a potential risk to the health and safety of children in care	8 9 10 11 12 13 14
	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: Anika Evans	TELEPHONE: (510) 286-4350
LICENSING EVALUATOR NAME: Belinda DeVall	TELEPHONE: (510) 725-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2019

LIC9099 (FAS) - (06/04)

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