093623233-1-26-2021-03-CC-MMAA-BXNQDP-20210127110501

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 093623233
Report Date: 01/06/2021
Date Signed: 01/26/2021 05:00:49 PM

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
08/07/2020 and conducted by Evaluator Michelle Pascual

PUBLIC

COMPLAINT CONTROL NUMBER: 03-CC-20200807160318

FACILITY NAME:	PINE TOP INFANT & TODDLER CTR (INF)		FACILITY NUMBER:	093623233
ADMINISTRATOR:	BROWN, KAREN		FACILITY TYPE:	830
ADDRESS:	5723 PONY EXPRESS COURT		TELEPHONE:	(530) 391-2604
CITY:	POLLOCK PINES	STATE: CA	ZIP CODE:	95726
CAPACITY:	16	CENSUS: 0	DATE:	01/06/2021
		UNANNOUNCED	TIME BEGAN:	03:53 PM
MET WITH:	Stefany Roony		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Personal Rights-
Day care child sustained unexplained injury while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michelle Pascual met with Site Director Stefany Roony, regarding the above stated allegation "Day Care child sustained unexplained injury while in care."

On this day, there were no children present within the facility. LPA met with the site director via facetime to deliver findings, due to COVID-19.
Through the course of the investigation, LPA interviewed several parents and staff to gain further information regarding the allegation. LPA also obtained medical records and a police report to further investigate the nature of the complaint. LPA found that while the incident did occur and the child was taken to the hosptial for treatment via paramedics, after gathering all pertinent information, there was not enough corroborating evidence to state that the rubber band constriction happened at the child care facility. The staff at the facility found the rubber band during a diaper check after the child was crying and in discomfort. It was at this point that the staff called the paradmedics and the sheriff was dispatched. Information obtained from both the medical records and the Sheriff's report also support this information. Due to the lack of corroborating evidence, this allegation is deemed UNSUBSTANTIATED.

This document was amended on 1/26/2021. LPA advised the Site Supervisor of the amendment via tele-inspection (due to COVID).

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maria Mayorga	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Michelle Pascual	TELEPHONE: (916) 704-7665
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2021

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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