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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 093616215
Report Date: 07/18/2022
Date Signed: 08/04/2022 08:21:48 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/11/2022 and conducted by Evaluator Arianna Manabat
COMPLAINT CONTROL NUMBER: 03-CC-20220511130748
FACILITY NAME:COUNTRY KIDS DAYCARE & PRESCHOOLFACILITY NUMBER:
093616215
ADMINISTRATOR:SPRINGER, ASHLEEFACILITY TYPE:
850
ADDRESS:610 PLEASANT VALLEY ROADTELEPHONE:
(530) 642-1630
CITY:DIAMOND SPRINGSSTATE: CAZIP CODE:
95619
CAPACITY:28CENSUS: DATE:
07/18/2022
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Ashlee SpringerTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Daycare child sustained unexplained injury while in care
Parents were not notified properly of injury
INVESTIGATION FINDINGS:
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On July 19th, 2022 Licensing Program Analyst (LPA) Arianna Manabat and Licensing Program Manager (LPM) Natalie Dunaway met with Director Ashlee Springer at approximately 1:50Pm to close a complaint. Upon arrival, LPA and LPM observed 12 preschool students in care with two staff.

It was alleged that a daycare child sustained an unexplained injury while in care and the parent of child was not notified of the severity of the injury. During the investigation, LPA inspected the facility, interviewed the Director, staff, parents, and Reporting Party (RP). Based on interviews and record review, the above allegations were found to be SUBSTANTIATED as documentation of a child’s injury was not consistent with the information communicated with the authorized representative. In addition, it was found that there have been other injuries which were not communicated to the authorized representative within a timely manner.
Continued on 9099-C..........
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Natalie DunawayTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Arianna ManabatTELEPHONE: (279) 200-2886
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
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 3
Control Number 03-CC-20220511130748
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: COUNTRY KIDS DAYCARE & PRESCHOOL
FACILITY NUMBER: 093616215
VISIT DATE: 07/18/2022
NARRATIVE
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Through interviews and record review, LPA Manabat found that there have been children who have sustained injuries in care that could not be properly explained by staff members. This includes Incident reports, issued by the facility, which state that Child 1 (C1) sustained injuries to the forehead, which is inconsistent with photos of C1’s injury that shows injury to the back of the head. It was also found that another child (C2) sustained an injury in care which required medical attention by authorized representatives but, through record review was found that, the authorized representative was not properly notified within a timely manner. This poses an immediate health and safety risk to children in care. California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D.

Type A acknowledgement forms are to be signed by current parent of the facility and new parents for the next twelve months. Appeal rights were provided and exit interview conducted. The Notice of Site Visit must be posted for 30 days.
SUPERVISOR'S NAME: Natalie DunawayTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Arianna ManabatTELEPHONE: (279) 200-2886
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 03-CC-20220511130748
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: COUNTRY KIDS DAYCARE & PRESCHOOL
FACILITY NUMBER: 093616215
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/20/2022
Section Cited
CCR
101226(a)
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101226 (a) The licensee shall immediately notify the child's authorized representative if the child becomes ill or sustains an injury more serious than a minor cut or scratch. The licensee shall obtain specific instructions from the authorized representative regarding action to be taken.

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Nothing to correct because we do write the reports. Kind of hard communicate with the authorized representatives. Licensee did not come up with a plan of correction.
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Based on observation the facility did not comply with the above regulation as evidenced by the licensee not properly communicating the severity of the child’s injury to the authorized representative, which poses a health, safety, or personal rights risk to persons in care.
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Type A
07/20/2022
Section Cited
CCR
101226.3(a)
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101226.3 Observation of the Child
(a) The behavior and health of the children shall be continually observed throughout the period of attendance.

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Licensee did not provide a plan of correction.
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Based off interview and record review, the facility did not comply with the above regulation as evidenced by staff not properly observing or addressing two children’s head injuries that were sustained in care which poses a health, safety, or personal rights risk to persons in care.
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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: Natalie DunawayTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Arianna ManabatTELEPHONE: (279) 200-2886
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3