191598968-4-12-2022-33-CC-CGAN-CDNW4H-20220420165735

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191598968
Report Date: 04/12/2022
Date Signed: 04/12/2022 04:15:07 PM

Substantiated

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
02/28/2022 and conducted by Evaluator Lissete Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 33-CC-20220228125002

FACILITY NAME:	EL MONTE CITY SCHOOL DISTRICT - LE GORE		FACILITY NUMBER:	191598968
ADMINISTRATOR:	AUDELIA MACIAS		FACILITY TYPE:	850
ADDRESS:	11121 E. BRYANT RD.		TELEPHONE:	(818) 575-2393
CITY:	EL MONTE	STATE: CA	ZIP CODE:	91731
CAPACITY:	84	CENSUS: 47	DATE:	04/12/2022
		UNANNOUNCED	TIME BEGAN:	12:59 PM
MET WITH:	Anzhela Hirsch, Site Supervisor		TIME COMPLETED:	01:44 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff released child to unauthorized adult

INVESTIGATION FINDINGS:

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

On 4/12/2022, Licensing Program Analyst (LPA) Lissete Gonzalez conducted an unannounced facility inspection to conclude the investigation for the above complaint allegation. LPA met with Site Supervisor, Anzhela Hirsch.

During the course of this investigation LPA L. Gonzalez conducted interviews with staff, the reporting party (RP) and other witnesses. LPA obtained a copy of the facility roster, sign in/sign out sheets, facility policies, and staff training. Disclosures made during interviews corroborate the allegation that staff released child #1 to an unauthorized adult. Interview disclosures state the unauthorized adult did not exit the facility premises with child #1. Review of the sign-in/sign-out sheet dated 2/25/2022 depicts a crossed out signature of the unauthorized adult for child #1’s release. The signature for child #1's release on 2/25/2022 was obtained from the child's authorized representative at the time of the incident.

REPORT CONTINUES ON NEXT PAGE: 1 OF 2

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christina Gabelman	TELEPHONE: (323) 981-3383
LICENSING EVALUATOR NAME: Lissete Gonzalez	TELEPHONE: (323) 981-3383
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

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 33-CC-20220228125002

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: EL MONTE CITY SCHOOL DISTRICT - LE GORE	FACILITY NUMBER: 191598968
	VISIT DATE: 04/12/2022

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

On 2/28/2022 an Unusual Incident was self-reported by the facility via email to Community Care Licensing. It was reported to the Department that the incident occurred at the facility on 2/25/2022. The facility reported the incident to the Department in a timely manner. The Unusual Incident reported that child #1 was accidentally released to an unauthorized adult that was at the facility to pick up a child with a similar first name. The report indicates child #1’s authorized representative was present when the incident occurred.

Based upon the evidence as presented above, the allegation has been determined to be Substantiated. A finding of Substantiated means that the preponderance of evidence standard has been met. California Code of Regulations (Title 22, Division 12, Chapter 1) is being cited on the attached LIC 9099D.

Please refer to 9099D for documentation of deficiencies.

A notice of site visit was given and must remain posted for 30 days.
Exit interview conducted and report was reviewed with the facility representative, Anzhela Hirsch.

END OF REPORT

SUPERVISOR'S NAME: Christina Gabelman	TELEPHONE: (323) 981-3383
LICENSING EVALUATOR NAME: Lissete Gonzalez	TELEPHONE: (323) 981-3383
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 33-CC-20220228125002

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: EL MONTE CITY SCHOOL DISTRICT - LE GORE	FACILITY NUMBER: 191598968
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/12/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/06/2022 Section Cited CCR 101229.1(b)	1 2 3 4 5 6 7	101229.1 Sign In and Sign Out (b) The person who brings the child to, and removes the child from, the center shall sign the child in/out. This requirement is not met as evidenced by: On 2/25/2022, staff #1 released child #1 to an unauthorized adult. Witness interviews corroborated the allegation of child #1's release to the unauthorized adult. Interview	1 2 3 4 5 6 7	Per Site Supervisor, training on Care & Supervision that includes sign in and sign out procedures was provided to staff. The participation list will be provided to LPA as proof of correction.
	8 9 10 11 12 13 14	disclosures also indicate child #1 did not exit the facility premises with the unauthorized adult and child #1's authorized representative was present when the incident occurred. Review of the sign-in/sign-out sheet dated 2/25/2022 depicts a signature of the unauthorized adult for child #1’s release. This poses a potential health, safety and personal rights risk to 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: Christina Gabelman	TELEPHONE: (323) 981-3383
LICENSING EVALUATOR NAME: Lissete Gonzalez	TELEPHONE: (323) 981-3383
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3