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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197403941
Report Date: 12/09/2021
Date Signed: 12/15/2021 09:59:53 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/08/2021 and conducted by Evaluator Adrian Risher
PUBLIC
COMPLAINT CONTROL NUMBER: 30-CC-20211008134517
FACILITY NAME:POLAND FAMILY DAY CAREFACILITY NUMBER:
197403941
ADMINISTRATOR:POLAND, VICTORIA D.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 841-8467
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY:14CENSUS: 2DATE:
12/09/2021
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Victoria PolandTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
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9
Neglect/Lack of Supervision:Day care child sustained an injury while in care.
INVESTIGATION FINDINGS:
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13
On 12/09/2021 at 2:50pm, Licensing Program Analyst (LPA) Adrian Risher, conducted a subsequent complaint visit regarding the above-mentioned allegation to deliver the findings. LPA met with Victoria Poland, Licensee. LPA explained the purpose of the inspection. LPA observed 2 children in care with 1 assistant.

On 10/08/2021, ESCCRO received a complaint regarding a child sustaining an injury at the daycare. Reporting Party stated child 1 was scratched by another child while in care. An incident report was written but it was not provided to CCL.

On 10/14/2021, LPA Risher conducted the initial complaint visit. During the visit, LPA conducted an interview with the Licensee and child #3. Licensee provided a copy of the facility roster and incident report. Licensee stated child #1 was scratched by another child. She cleaned the injury and put Vaseline on it. The incident report was not given to the parents but they were notified verbally.
Unsubstantiated
Estimated Days of Completion: 70
SUPERVISOR'S NAME: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Adrian RisherTELEPHONE: (424) 301-3050
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
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 2
Control Number 30-CC-20211008134517
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: POLAND FAMILY DAY CARE
FACILITY NUMBER: 197403941
VISIT DATE: 12/09/2021
NARRATIVE
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Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the above alleged violations did or did not occur, therefore the allegations are found to be unsubstantiated. There is lack of evidence to support that the allegation of Neglect/Lack of Supervision was valid. Child #1 was injured by another child. Licensee rendered aid and documented the injury.

Exit interview was conducted and a copy of the report was provided. Appeal rights were reviewed and provided. A plan of correction was discussed and provided to the Licensee.
SUPERVISOR'S NAME: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Adrian RisherTELEPHONE: (424) 301-3050
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2