197416987-2-10-2023-54-CC-KCHS-CP5RQW-20230217121414

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197416987
Report Date: 02/10/2023
Date Signed: 02/10/2023 10:40:22 AM

Unsubstantiated

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 CENTER DR 200B
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/14/2022 and conducted by Evaluator Denise Gibbs

COMPLAINT CONTROL NUMBER: 54-CC-20221114085547

FACILITY NAME:	CHILDREN'S COLLECTIVE, INC. CASA DOMINGUEZ, THE		FACILITY NUMBER:	197416987
ADMINISTRATOR:	BACH, ROCIO		FACILITY TYPE:	850
ADDRESS:	15711 SOUTH ATLANTIC AVE.		TELEPHONE:	(310) 637-1593
CITY:	E. RANCHO DOMINGUEZ	STATE: CA	ZIP CODE:	90221
CAPACITY:	42	CENSUS: 19	DATE:	02/10/2023
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Natasha Stallworth, Site Supervisor		TIME COMPLETED:	10:55 AM

ALLEGATION(S):

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Personal Rights- Staff grabbed child's lip causing injury

INVESTIGATION FINDINGS:

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On February 10, 2023, at 8:45 a.m., Licensing Program Analyst (LPA) Denise Gibbs conducted an unannounced follow-up complaint inspection and met Site Supervisor, Natasha Stallworth. LPA disclosed the purpose of the inspection and was granted entry into the facility by office staff.

There were 19 children and four staff present when the visit began.

During the course of this investigation, LPA observed the facility, conducted interviews and obtained pertinent documentation. Interviews with staff provided no disclosures regarding the allegation. Per staff, a health check was conducted the morning of the incident on 10/10/22 and there were no visible injuries on Child One(C1). Per staff C1 did not go home with any visible injuries. Staff stated that they did not grab C1 lip and did not witness anyone else grab C1 lip. Children interviewed made no disclosures regarding the incident. LPA interviewed C1 parent who informed that the injury in question was a blister under C1 top lip. Parent informed that the injury/blister was observed by her in the morning, before school, on 10/10/22 before the incident occurred.------------Page 1

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Trevino Cochran	TELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise Gibbs	TELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

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 54-CC-20221114085547

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: CHILDREN'S COLLECTIVE, INC. CASA DOMINGUEZ, THE	FACILITY NUMBER: 197416987
	VISIT DATE: 02/10/2023

NARRATIVE

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Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove
the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies will be cited today 2/10/23.

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

Exit interview was conducted with Principal. A copy of this report and appeal rights were discussed and left with Site Supervisor Natasha Stallworth, whose signature on this form confirm receipt of these documents.

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SUPERVISOR'S NAME: Trevino Cochran	TELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise Gibbs	TELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

LIC9099 (FAS) - (06/04)

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