191200190-2-22-2022-33-CC-CGAN-CC73DR-20220303170955

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191200190
Report Date: 02/22/2022
Date Signed: 02/22/2022 02:25:07 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/10/2021 and conducted by Evaluator Crystal Green

PUBLIC

COMPLAINT CONTROL NUMBER: 33-CC-20211210135739

FACILITY NAME:	CHILDREN'S COUNTRY HOUSE		FACILITY NUMBER:	191200190
ADMINISTRATOR:	NIELSON, DEBERA		FACILITY TYPE:	850
ADDRESS:	2821 SANTA ROSA		TELEPHONE:	(626) 798-8083
CITY:	ALTADENA	STATE: CA	ZIP CODE:	91001
CAPACITY:	34	CENSUS: 19	DATE:	02/22/2022
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Janet Shambrey		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Personal Rights

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Crystal Green conducted an unannounced follow-up complaint inspection to deliver finding for the allegation above. Upon arrival Licensing staff met with Teacher, Janet Shambrey, who guided analyst on a tour of the facility. Census was taken.

Allegation states child personal rights were violated by facility staff while in care. Reporting Party (RP) alleges on 12/07/2021, it was observed by a parent that staff #1 slapped child #1 hand. The parent that observed the incident immediately withdrew their child from the program. The incident was immediately address by the Director on site which resulted in the immediate termination of staff #1 however no report was made to the department regarding the incident that occurred on 12/07/2021. Per Director, Staff #1 was immediately relieved of their duties at the facility. During this investigation, LPA conducted interviews and obtained documents relating to the allegation.

*Report continues on the next page*

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christina Gabelman	TELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Crystal Green	TELEPHONE: (323) 980-4930
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2022

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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Control Number 33-CC-20211210135739

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CHILDREN'S COUNTRY HOUSE	FACILITY NUMBER: 191200190
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/22/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/22/2022 Section Cited CCR 101223(a)(3)	1 2 3 4 5 6 7	101223(a)(3)- To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting;...	1 2 3 4 5 6 7	Per Director, staff was immediately terminated from facility however due to the nature of the incident, the director will also provide copies to the parents of the children in care for up to one year. A copy of the LIC 9224 - Acknowledgement of Receipt of Licensing Reports was provided to the Director.
	8 9 10 11 12 13 14		8 9 10 11 12 13 14
Type B 02/22/2022 Section Cited CCR 101212(d)	1 2 3 4 5 6 7	101212(d)-Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours.	1 2 3 4 5 6 7	Director will report all unusual inicdent report to the department as required by Title 22 within 24 hours of incident and submit a written report with 7 days following the occurence of unusual incident.
	8 9 10 11 12 13 14	In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event.	8 9 10 11 12 13 14

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: Christina Gabelman	TELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Crystal Green	TELEPHONE: (323) 980-4930
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2022

LIC9099 (FAS) - (06/04)

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Control Number 33-CC-20211210135739

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CHILDREN'S COUNTRY HOUSE	FACILITY NUMBER: 191200190
	VISIT DATE: 02/22/2022

NARRATIVE

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Based on information obtained during this inspection, at this time the above is found to be substantiated, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, (Title 22, Division & Chapter) relating to this allegation have been cited on LIC 9099-D.

Exit interview was conducted with the Teacher and was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these forms.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site inspection by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

Upon receipt of this report, the licensee shall post ANY licensing report documenting a type “A” citation. This must remain posted for 30 days during hours of operation. In addition to posting this report, the director will also provide copies to the parents of the children in care for up to one year. A copy of the LIC 9224 - Acknowledgement of Receipt of Licensing Reports was explained and provided to the Director.

SUPERVISOR'S NAME: Christina Gabelman	TELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Crystal Green	TELEPHONE: (323) 980-4930
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2022

LIC9099 (FAS) - (06/04)

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