197750052-5-24-2021-12-CC-SHEG-C8CSNY-20211101140216

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197750052
Report Date: 05/24/2021
Date Signed: 05/24/2021 02:30:46 PM

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
05/19/2021 and conducted by Evaluator Brigitte Tsutaoka

PUBLIC

COMPLAINT CONTROL NUMBER: 12-CC-20210519142330

FACILITY NAME:	IT'S A SMALL WORLD		FACILITY NUMBER:	197750052
ADMINISTRATOR:	CANCHOLA, ANTONIO&YESENIA		FACILITY TYPE:	830
ADDRESS:	44221 10TH ST WEST		TELEPHONE:	(661) 492-0550
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY:	39	CENSUS: 15	DATE:	05/24/2021
		UNANNOUNCED	TIME BEGAN:	10:16 AM
MET WITH:	Licensee Yesenia Canchola		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Allegation 2: Licensee failed to report an incident.

INVESTIGATION FINDINGS:

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On May 24, 2021 at 10:16AM, Licensing Program Analyst (LPA) Tsutaoka conducted an initial inspection on the above allegation. LPA disclosed the purpose of the inspection to Licensee Yesenia Canchola, who guided LPA on a tour of the facility. Upon entry, LPA counted 15 children in care and 4 staff.

At 10:45 AM, LPA conducted interview with Licensee who disclosed she had not notified Licensing of the incident. LPA also reviewed the FAS database and determined a report was not made by Licensee regarding the incident.

Based on LPAs observations, interviews conducted, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found SUBSTANTIATED. California Code of Regulations, Title 22, Division 12 Chapter 1, 101212 (d) Reporting Requirements Type B violation is being cited on attached LIC9099D.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carissa Bell	TELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Brigitte Tsutaoka	TELEPHONE: (661) 202-3786
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021

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-20210519142330

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: IT'S A SMALL WORLD	FACILITY NUMBER: 197750052
	VISIT DATE: 05/24/2021

NARRATIVE

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Licensee was advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. A copy of this licensing report (LIC9099) must also be posted for 30 days. If these requirements are not met, civil penalties in the amount of $100 per violation will be assessed.

An exit Interview was conducted, a copy of this Report, Appeal Rights, and a Notice of Site visit was provided to the Licensee.

SUPERVISOR'S NAME: Carissa Bell	TELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Brigitte Tsutaoka	TELEPHONE: (661) 202-3786
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021

LIC9099 (FAS) - (06/04)

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Control Number 12-CC-20210519142330

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: IT'S A SMALL WORLD	FACILITY NUMBER: 197750052
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/24/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/28/2021 Section Cited CCR 101212(d)	1 2 3 4 5 6 7	101212 Reporting Requirements (d)... A report shall be made to the Department by telephone or fax within the Department's next working day...a written report ... shall be submitted to the Department within seven days. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Licensee agreed to submit the completed Unusual Incident Report (LIC624) detailing the incident by 05/28/21.
	8 9 10 11 12 13 14	Based on observation, interview, and record review, Licensee did not notify the Department of the incident within the time frame required, which poses a potential Health and Safety 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: Carissa Bell	TELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Brigitte Tsutaoka	TELEPHONE: (661) 202-3786
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021

LIC9099 (FAS) - (06/04)

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