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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197493885
Report Date: 04/22/2020
Date Signed: 04/23/2020 09:09:12 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
04/13/2020 and conducted by Evaluator Adrian Risher
PUBLIC
COMPLAINT CONTROL NUMBER: 30-CC-20200413164134
FACILITY NAME:HAYES FAMILY CHILD CAREFACILITY NUMBER:
197493885
ADMINISTRATOR:HAYES, TONIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 335-9622
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY:14CENSUS: 8DATE:
04/22/2020
UNANNOUNCEDTIME BEGAN:
12:39 PM
MET WITH:Toni Hayes-LicenseeTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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personal rights-child received a burn while in care
INVESTIGATION FINDINGS:
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On 04/22/2020 at 12:39pm, Licensing Program Analyst (LPA) Adrian Risher, conducted a complaint televisit via FACETIME regarding the above-mentioned allegation. LPA met with Toni Hayes, Licensee. LPA explained the purpose of the inspection. LPA toured the facility with Toni Hayes at 12:55 PM and observed 8 children in care along with 1 assistant.
LPA Risher conducted interviews with Licensee, Staff 1 and child 1. Licensee provided LPA with a copy of children's roster.
Based on the investigation which included interviews with relevant parties and observations by the LPA, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, Title 22, Division 12, Chapter 1, Article 06, Section 102423 is being cited on the attached LIC 9099D page.
Exit interview was conducted and a copy of the report was provided via email. Appeal rights were reviewed and provided. A plan of correction was discussed and provided to the Licensee.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Victor BautistaTELEPHONE: (424) 301-3008
LICENSING EVALUATOR NAME: Adrian RisherTELEPHONE: (424) 301-3050
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2020
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 30-CC-20200413164134
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: HAYES FAMILY CHILD CARE
FACILITY NUMBER: 197493885
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/22/2020
Section Cited
CCR
102423(a)(2)
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102423(a)(2) Personal Rights
To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.
This requirement was not met as evidenced by:

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Licensee will submit a declaration that states that Licensee and staff will no longer use the glue gun during operating hours to prevent this from happening again. The declaration will be submitted to the department by 04/29/2020.
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Based on observation and interviews, the child sustained a burn by the glue gun while in care. The facility did not implement all available safety measures to prevent child from having access to the desginated area for the craft activity. This poses a potential health & safety risk to the 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: Victor BautistaTELEPHONE: (424) 301-3008
LICENSING EVALUATOR NAME: Adrian RisherTELEPHONE: (424) 301-3050
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2020
LIC9099 (FAS) - (06/04)
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