153908554-5-26-2022-04-CC-DMAA-CFV3DX-20220629181017

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 153908554
Report Date: 05/26/2022
Date Signed: 05/26/2022 10:21:12 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, 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
05/20/2022 and conducted by Evaluator Jose Penate

PUBLIC

COMPLAINT CONTROL NUMBER: 04-CC-20220520085712

FACILITY NAME:	SAMAYOA, SANDRA FAMILY CHILD CARE		FACILITY NUMBER:	153908554
ADMINISTRATOR:	SAMAYOA, SANDRA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(661) 379-5921
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93307
CAPACITY:	14	CENSUS:	DATE:	05/26/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Licensee, Sandra Samayoa		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Day care child was injured while in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 05/26/2022, LPA Jose Penate arrived at facility to conduct an unannounced complaint inspection to investigate the above allegation. LPA Penate spoke with Licensee, Sandra Samayoa and discussed the purpose of the inspection. A tour of the facility was conducted both inside and outside and census was taken.

Based on interviews and records review, the allegation of Day care child was injured while in care has been investigated. Licensee contacted CCL on 5/20/22 to report incident and stated that Child #1 was bit on finger and first aid was provided to the puncture wound from the dog bite. LPA interviewed licensee and confirmed that an injury did occur at the facility to a child in care.

Continued on next page, see LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Duane Matsubara	TELEPHONE: (559)650-7855
LICENSING EVALUATOR NAME: Jose Penate	TELEPHONE: (559) 341-5860
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022

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 04-CC-20220520085712

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: SAMAYOA, SANDRA FAMILY CHILD CARE	FACILITY NUMBER: 153908554
	VISIT DATE: 05/26/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on statements from staff and records review during this investigation; allegation of Day care child was injured while in care the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Per California Code of Regulations, Title 22, Division 12, the following deficiency is being cited on the attached LIC9099D, see next page.

Exit interview was conducted with Licensee, Sandra Samoyoa.

A Notice of Site Visit Form was posted and must remain posted for 30 days.
The licensee was provided a copy of their appeal rights and their signature on this form acknowledges receipt of this form.

SUPERVISOR'S NAME: Duane Matsubara	TELEPHONE: (559)650-7855
LICENSING EVALUATOR NAME: Jose Penate	TELEPHONE: (559) 341-5860
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 04-CC-20220520085712

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: SAMAYOA, SANDRA FAMILY CHILD CARE	FACILITY NUMBER: 153908554
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/26/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/26/2022 Section Cited CCR 102417(g)	1 2 3 4 5 6 7	Operation of a Family Child Care Home. The home shall be free from defects or conditions which might endanger a child. On 5/19/22 at approximately 4:00PM a child was attempting to take dogs bone. Dog looked back and bit the child’s finger	1 2 3 4 5 6 7	Licensee stated that she will no longer allow dog to be accessible to children in care. Pet will be in inaccessable rooms or in the backyard while the children are inside the facility.
	8 9 10 11 12 13 14	Child did receive medical treatment from primary physician where it was determined that child was bit by a dog. This poses a potential risk to the Health, Safety, or Personal Rights 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: Duane Matsubara	TELEPHONE: (559)650-7855
LICENSING EVALUATOR NAME: Jose Penate	TELEPHONE: (559) 341-5860
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3