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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 100403874
Report Date: 05/06/2025
Date Signed: 05/06/2025 12:54:21 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/12/2025 and conducted by Evaluator Stephanie Vega-Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 04-CC-20250312100248
FACILITY NAME:FRESNO EOC MENDOTA HEAD STARTFACILITY NUMBER:
100403874
ADMINISTRATOR:WESTBROOK, LISAFACILITY TYPE:
850
ADDRESS:295 WEST TUFTTELEPHONE:
(559) 263-1205
CITY:MENDOTASTATE: CAZIP CODE:
93640
CAPACITY:40CENSUS: 28DATE:
05/06/2025
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:LISA WESTBROOKTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff did not meet child’s diapering needs.
INVESTIGATION FINDINGS:
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On 5/06/2025, Licensing Program Analyst (LPA) Stephanie Vega-Gonzalez conducted an unannounced complaint inspection at facility to deliver the finding for the above-mentioned allegation. LPA met with Director, Lisa Westbrook who accompanied LPA during tour of facility both inside and outside. LPA explained the allegation and took a census. During the investigation, LPA interviewed day care director, day care staff, day care children, day care parents and reviewed facility records.

Through evidence obtained through facility documents: in-house diapering logs and sign-in and out sheets it was determined children that solely used diapers were changed once during the day. LPA observed during record review that staff were not following their daily schedule and procedures when changing diapers and the documentation. Based upon observations, and information gathered through interviews and facility records, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
(Continue on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cynthia Brannon
LICENSING EVALUATOR NAME: Stephanie Vega-Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
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 7
Control Number 04-CC-20250312100248
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: FRESNO EOC MENDOTA HEAD START
FACILITY NUMBER: 100403874
VISIT DATE: 05/06/2025
NARRATIVE
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Per California Code of Regulations, Title 22, Division 12, Chapter 1, this deficiency is being cited on the attached LIC 9099D).

An exit interview conducted with Director, Lisa Westbrook.
A copy of this report and Appeal Rights were provided and discussed with Director, Lisa Westbrook..
A Notice of Site Visit was provided and must remain posted for 30 days.
Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Cynthia Brannon
LICENSING EVALUATOR NAME: Stephanie Vega-Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 04-CC-20250312100248
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: FRESNO EOC MENDOTA HEAD START
FACILITY NUMBER: 100403874
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2025
Section Cited
CCR
101223(a)(2)
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101223(a)(2) Personal Rights (a)The licensee shall ensure that each child is accorded the following personal rights
(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
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Director, Lisa Westbrook stated that staff had a training on diapering on April 30, 2025 in regard on how to follow proper diapering procedures and policies. Director stated that a training will be given to staff, to ensure that diapering logs correlates with the daily
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attendance. Director will provide the Department with training material and a list of staff signatures for both training's by POC due date.
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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.
SUPERVISORS NAME: Cynthia Brannon
LICENSING EVALUATOR NAME: Stephanie Vega-Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/12/2025 and conducted by Evaluator Stephanie Vega-Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 04-CC-20250312100248

FACILITY NAME:FRESNO EOC MENDOTA HEAD STARTFACILITY NUMBER:
100403874
ADMINISTRATOR:WESTBROOK, LISAFACILITY TYPE:
850
ADDRESS:295 WEST TUFTTELEPHONE:
(559) 263-1205
CITY:MENDOTASTATE: CAZIP CODE:
93640
CAPACITY:40CENSUS: 28DATE:
05/06/2025
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:LISA WESTBROOKTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff inappropriately handled child in care.
Staff did not report injury to child’s authorized representative.
INVESTIGATION FINDINGS:
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On 05/06/2025, Licensing Program Analyst (LPA) Stephanie Vega-Gonzalez conducted an unannounced complaint inspection at facility to deliver findings for the above-mentioned allegations. LPA met with Director, Lisa Westbrook who accompanied LPA during tour of facility both inside and outside. LPA explained the allegations and a census was taken. During the investigation, LPA interviewed day care director, day care staff, day care children, day care parents and reviewed facility records.

During the investigation, LPA interviewed various individuals and reviewed facility records; Fresno EOC Head Start ouchy reports, documented unusual incident reports, and staff records. Based on the evidence presented in the facility reports the allegations of, Staff inappropriately handled child in care and Staff did not report injury to child’s authorized representative, this agency determined that the complaint allegations are Unsubstantiated.

(Continue on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cynthia Brannon
LICENSING EVALUATOR NAME: Stephanie Vega-Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 04-CC-20250312100248
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: FRESNO EOC MENDOTA HEAD START
FACILITY NUMBER: 100403874
VISIT DATE: 05/06/2025
NARRATIVE
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During the investigation, LPA was not able to obtain the preponderance of evidence from the reporting party. In addition, LPA interviewed day care parents who had no concerns regarding the care of their children or communication regarding incidents from the day care center. LPA interviewed day care staff who stated that they had not observed any inappropriately handling and that they were following the procedures to communicate with authorized representative regarding reporting injury. During facility record review, LPA observed there was documentation of staff development trainings for staff rectifications as per the center’s policy and procedures. Lastly, LPA observed that the center had followed Title 22 regulations by following reporting requirements. Yet, LPA observed that the center had not documented two incidents as per their in-house procedures but had followed proper Title 22 measures by reporting it to the Department. Meaning although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

Per California Code of Regulations, Title 22, Division 12, Chapter 1, no deficiency are cited during today's visit.

An exit interview conducted with Director, Lisa Westbrook.
A copy of this report and Appeal Rights were provided and discussed with Director, Lisa Westbrook.
A Notice of Site Visit was provided and must remain posted for 30 days.
Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Cynthia Brannon
LICENSING EVALUATOR NAME: Stephanie Vega-Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7