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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197413473
Report Date: 04/29/2022
Date Signed: 04/29/2022 04:37:09 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/17/2022 and conducted by Evaluator Justeene Tamayo
PUBLIC
COMPLAINT CONTROL NUMBER: 12-CC-20220317121709
FACILITY NAME:VAZQUEZ FAMILY CHILD CAREFACILITY NUMBER:
197413473
ADMINISTRATOR:VAZQUEZ, PATRICIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 722-0946
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:14CENSUS: 6DATE:
04/29/2022
UNANNOUNCEDTIME BEGAN:
03:42 PM
MET WITH:Janessa Vazquez TIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Reporting Requirements: Licensee failed to notify the Department of an unusual incident that occurred on or about 03/15/22.
INVESTIGATION FINDINGS:
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On 04/29/22, Licensing Program Analyst (LPA) Justeene Tamayo and Licensing Program Manager (LPM) Mariela Ramon met with staff member Janessa Vazquez. Licensee Vazquez came shortly after to the facility for the purpose of concluding an investigation concerning the above complaint allegation.

On or about March 15, 2022, child sustained a minor scratch that resulted in a minor bloody nose while in care at the facility. It was alleged child’s guardian observed blood stains on the child’s shirt.

The licensee failed to notify the department of the incident timely. Based on the information obtained, the above allegation is deemed Substantiated. A finding of substantiated means that allegation is valid.
An exit interview was conducted, and a copy of this report was read and provided to the Licensee on this date, along with a copy of her appeal rights.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Justeene TamayoTELEPHONE: 661-202-3796
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022
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 12-CC-20220317121709
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: VAZQUEZ FAMILY CHILD CARE
FACILITY NUMBER: 197413473
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2022
Section Cited
CCR
102416.2(a)
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The licensee shall report the following information to the Department by telephone or fax within the Department's next business day and during normal working hours (8am to 5pm).
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Licensee will submit an LIC 624 UIR of the incident that occured
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This requirement was not met as evidence by: Based on observation, interview, and record review, Licensee did not notify the Department of the incident that occurred on 03/15/2022 within the time frame required. This is a type B deficiency...which can pose a potential Health and Safety risk to children in care.

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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.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Justeene TamayoTELEPHONE: 661-202-3796
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022
LIC9099 (FAS) - (06/04)
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