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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 073409126
Report Date: 11/22/2021
Date Signed: 11/22/2021 12:30:37 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
11/16/2021 and conducted by Evaluator Diana Campos
PUBLIC
COMPLAINT CONTROL NUMBER: 02-CC-20211116140659
FACILITY NAME:ALLEN, MELISSAFACILITY NUMBER:
073409126
ADMINISTRATOR:ALLEN, MELISSAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 509-4014
CITY:MARTINEZSTATE: CAZIP CODE:
94553
CAPACITY:14CENSUS: 7DATE:
11/22/2021
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Melissa AllenTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Personal Rights- Day care child wandered away from facility.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA's) Melissa Guirit and Diana Campos met with licensee Melissa Allen for a complaint investigation regarding the above allegation. Present for the investigation were licensee, one assistant and 7 preschool children in care. During the course of the investigation, home was toured with licensee, interviews were conducted and records reviewed. Per licensee an incident occurred when a child wandered away from the home without her knowledge.
Based on the LPA's observations, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, 102423(a)(2), are being cited on the attached LIC 9099D for absence of supervision resulting in a child wandering away from the home.
An exit interview was conducted with licensee, and a notice of site visit was posted.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana CamposTELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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 2
Control Number 02-CC-20211116140659
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: ALLEN, MELISSA
FACILITY NUMBER: 073409126
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/23/2021
Section Cited
CCR
102423(a)(2)
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Each child receiving services from a family child care home shall have certain rights...To receive safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement was not met as evidenced by:
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Although fence has been repaired, licensee will submit a written statement of her review and understanding of the personal rights regulations.
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Licensee stated a child wandered away from the home due to a disrepair in the backyard fence. This poses an immediate risk to the health and safety of children in care.
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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.
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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 JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana CamposTELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC9099 (FAS) - (06/04)
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