198004154-6-5-2019-33-CC-CGUA-BDWPJS-20190709112159

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198004154
Report Date: 06/05/2019
Date Signed: 06/05/2019 10:05:30 AM

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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/11/2019 and conducted by Evaluator Ariel Almazan

PUBLIC

COMPLAINT CONTROL NUMBER: 33-CC-20190311172002

FACILITY NAME:	WOODBURY VILLAGE, INC.-INFANT CENTER		FACILITY NUMBER:	198004154
ADMINISTRATOR:	DANIELLE SVIHOVEC-MESQUITA		FACILITY TYPE:	830
ADDRESS:	712 W. MT. VIEW ST.		TELEPHONE:	(626) 794-3211
CITY:	ALTADENA	STATE: CA	ZIP CODE:	91001
CAPACITY:	41	CENSUS: 30	DATE:	06/05/2019
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Danielle Svihovec		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Record Keeping: Staff are failing to require child vacinnations.

INVESTIGATION FINDINGS:

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An unannounced complaint inspection was made on this day by Licensing Program Analyst (LPA) Ariel Cazares to the licensed day care. LPA met with Director to discuss the above allegation. At the time of arrival LPA observed 30 children with 14 staff.

LPA conducted an investigation into the above allegation. LPA conducted interviews, reviewed files, and obtained copies of pertinent documents. LPA interviewed complainant, who stated that the facility had an outbreak of pertussis due to children not being vaccinated. Complainant stated that the facility is not maintaining updated immunization records and records are only requested upon enrollment. Per complainant, the other occasion that the record was requested was after the notice of the outbreak.

LPA conducted interview with director of the facility. Per director, there was only one child was confirmed to have been affected by pertussis. Per director the immunization record is requested every time there is a new change and every year or when a child transitions to a new classroom.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Ariel Almazan	TELEPHONE: (323) 981-2949
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2019

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 33-CC-20190311172002

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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: WOODBURY VILLAGE, INC.-INFANT CENTER	FACILITY NUMBER: 198004154
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/05/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/14/2019 Section Cited CCR 101220.1(g)(1)	1 2 3 4 5 6 7	Immunizations (g) The licensee shall document each child's immunizations and shall maintain such documentation in the center for as long as the child is enrolled. (1) This requirement includes updating each child's immunization record when the child is due to receive required immunizations after	1 2 3 4 5 6 7	Per Director a spreadsheet was created to track children's immunizations. Notice was added to the Needs and Service Plan in order to remind parents to provided updated record. A copy of the updated parent handbook addressing immunizations will be submitted to LPA by POC due date of 6/14/19.
	8 9 10 11 12 13 14	enrollment in the child care center. This requirement was not been met as evidenced by LPA's investigation revealing that the facility was not maintaining immunization records after enrollment. This poses a potential risk to the health and safety of 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: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Ariel Almazan	TELEPHONE: (323) 981-2949
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2019

LIC9099 (FAS) - (06/04)

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Control Number 33-CC-20190311172002

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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: WOODBURY VILLAGE, INC.-INFANT CENTER	FACILITY NUMBER: 198004154
	VISIT DATE: 06/05/2019

NARRATIVE

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LPA was provided with copies of all notices of the outbreak and what was provided to parents, including the Public Health Department’s report. LPA obtained copies of 20 children’s immunizations records from their facility file. LPA reviewed each child’s record. LPA observed that records were obtained around the time of enrollment, but only 13 had updated records which were dated after the outbreak occurred (2/11/19). Based on this review, LPA determined that children’s immunization records were not updated as required. LPA observed that several children had immunizations given in between the date noted on their initial physician’s report and the date of the outbreak (2/11/19), but there were no records maintained in their file from in between that time frame as required for any updates. The facility failed to require and maintain immunizations records.

LPA was able to verify that the child confirmed to have been affected by Pertussis did have the vaccinations as required. LPA also verified with Public Health Department’s nurse that assistance was provided to the facility during the surveillance period of 2/11/19-3/19/19.

Based on LPA’s observations and interviews which were conducted and records review, 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 & Section 101220.1, are being cited on the attached LIC 9099-D.

Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. A "Notice of Site Visit" and copy of the report was issued. Notice of Site Visit must remain posted for 30 days. Failure to do so will result in a $100.00 civil penalty. This report must remain on file for three (3) years. This report must be posted for 30 days in clear view, at the entrance of the Woodbury Village, Inc.- Infant Center. The report cannot be covered/concealed.

Exit interview conducted and a copy of this report was left with Owner/Director Danielle Svihovec. A copy of this report and appeal rights were provided and explained.

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Ariel Almazan	TELEPHONE: (323) 981-2949
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2019

LIC9099 (FAS) - (06/04)

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