198013169-10-21-2021-54-CC-VCOK-C85UR9-20211025154817

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198013169
Report Date: 09/14/2021
Date Signed: 10/21/2021 03:18:52 PM

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
08/27/2021 and conducted by Evaluator Jeanette Estrada

COMPLAINT CONTROL NUMBER: 54-CC-20210827152618

FACILITY NAME:	DOUGLAS FAMILY CHILD CARE		FACILITY NUMBER:	198013169
ADMINISTRATOR:	DOUGLAS, SHAKENA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(562) 375-3636
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90805
CAPACITY:	14	CENSUS: 8	DATE:	09/14/2021
		UNANNOUNCED	TIME BEGAN:	03:40 PM
MET WITH:	Licensee Shakena Douglas		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Child sustained injury while in care.

INVESTIGATION FINDINGS:

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THIS IS AN AMENDED REPORT. A NEW 9099 and 9099D DATED 10/21/21 HAVE BEEN ADDED TO THIS COMPLAINT.
Licensing program analyst (LPA) Jeanette Estrada conducted an unannounced complaint visit for the purpose of delivering findings for the above allegation. LPA met with Licensee. There were 8 Children with 2 staff present.
During the investigation LPA conducted interviews with the Licensee, witnesses and Child 1’s parent. LPA also reviewed surveillance video of the incident on 9/1/21 which was provided by the Licensee. The information and evidence obtained confirmed that although Child 1 did sustain an injury while in care, Child 1 was immediately assisted by the Staff at the facility.
On 8/25/21 Child 1 was running in the outdoor area. Child 1 ran into a cement block holding up a tetherball pole and sustained an injury on their head. Child 1 was being supervised by Staff 1 and Staff 2. Staff 1 assisted Child 1 as soon as they fell, Child 1 was taken inside the home.

***Continued on PAGE 2***

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3828
LICENSING EVALUATOR NAME: Jeanette Estrada	TELEPHONE: (323) 229-6521
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021

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 54-CC-20210827152618

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: DOUGLAS FAMILY CHILD CARE	FACILITY NUMBER: 198013169
	VISIT DATE: 09/14/2021

NARRATIVE

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Per interviews with the Licensee and Staff, the Licensee immediately took Child 1 to the nearest hospital and called the Parent on the way there. The Licensee informed the Parent of the incident over the phone and waited with Child 1 until the Parent arrived. Parent also confirmed that Licensee assisted Child 1 appropriately and in a timely manner.
On 9/1/21 LPA observed the surveillance video of the incident. LPA observed that Child 1 was running, fell and Staff 1 was already walking towards Child 1 as they fell. The Licensee gave the Parent a handwritten Incident Report for the injury. However, even though the Child did sustain an injury while in care and the Licensee tended to the child and informed the parent as soon as the incident occurred, the Licensee did not report the incident to the Department within the required 24-hour timeframe.

The Department finds the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. The facility is being cited for failure to report the incident (See LIC 9099D).

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. Appeal rights were provided. Exit interview was conducted with Licensee.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3828
LICENSING EVALUATOR NAME: Jeanette Estrada	TELEPHONE: (323) 229-6521
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021

LIC9099 (FAS) - (06/04)

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Control Number 54-CC-20210827152618

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: DOUGLAS FAMILY CHILD CARE	FACILITY NUMBER: 198013169
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/14/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/14/2021 Section Cited HSC 1597.467(b)(1)(B)	1 2 3 4 5 6 7	1597.467(b)(1)(B)Injury or acts of violence reporting requirements. Report shall be made to the department by telephone or fax during the department's normal business hours before the close of the next working day following the occurrence during the operation of a family day care home of any of the following events:(B) Any injury to any child that requires medical treatment.	1 2 3 4 5 6 7	Licensee stated she will adhere to reporting requirements and will train staff on reporting requirements. Licensee submitted written report LIC 624B of incident to LPA on date of visit (9/14/21)
	8 9 10 11 12 13 14	This requirement is not met as evidenced by based on interviews and record review. On 8/25/21 Child 1 sustained a head injury and received medical attention. Licensee did not report the injury to the Department by COB 8/26/21 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: Valarie Cook	TELEPHONE: (323) 513-3828
LICENSING EVALUATOR NAME: Jeanette Estrada	TELEPHONE: (323) 229-6521
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021

LIC9099 (FAS) - (06/04)

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