198013169-10-21-2021-54-CC-VCOK-C85UR8-20211025154817

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198013169
Report Date: 10/21/2021
Date Signed: 10/21/2021 03:17:57 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: 7	DATE:	10/21/2021
		UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Licensee-Shakena Douglas		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Child sustained injury while in care.

INVESTIGATION FINDINGS:

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On 10/21/21 Licensing Program Analysts (LPAs) Jeanette Estrada and Susann Sanchez conducted an unannounced complaint visit for the purpose of amending the 9099 dated 9/14/21 and issuing a citation. The complaint finding remains as substantiated.

In addition to the original citation from 9/14/21 the facility is being cited a Type A citation for Personal Rights. Even though the facility staff acted appropriately and timely, the child did sustain an injury requiring medical attention while in care due to running into unsafe equipment (cement block that was holding up a tether ball pole) in the outdoor play yard.

One Type A, California Code of Regulations (Title 22, Division 12 & Chapter Number 1), is being cited on the attached LIC 9099D

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: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/21/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/28/2021 Section Cited CCR 102423(a)(2)	1 2 3 4 5 6 7	Personal Rights(a)(2) Each child receiving services from a family child care home shall have certain rights that shall not be waived…by the licensee regardless of consent or authorization from the child's authorized representative.These rights include, but are not limited to, the following: To receive safe…equipment.	1 2 3 4 5 6 7	Licensee removed tetherball from yard on 8/25/21. Licensee will review the child care licensing video regarding personal rights and the regulation. Licensee will send an acknowledgement of understanding by 10/28/21.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by based on interviews and review of surveillance video,on 8/25/21 Child 1 sustained a head injury and received medical attention.Licensee did not ensure that Child 1 was provided with safe equipment which posed an immediate health and safety risk to children in care.	8 9 10 11 12 13 14	Licensee will also check the home regulary to ensure children are using safe equipment. On this day Licensee has submitted to LPA a declaration that equipment checks will be done weekly.
	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: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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: 10/21/2021

NARRATIVE

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Type A (POSTING OF NOTICE OF SITE VISIT)
The notice of site visit was posted where the parent/guardian of children enter and exit the facility. A copy of this report shall also be posted where the parent/guardian of children enter and exit the facility. Both the notice of site visit and licensing report shall remain posted for 30 consecutive days. Failure to maintain posting as required will result in a $100.00 civil penalty. A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon their return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled child for the next 12 months. A signed Acknowledgement of Receipt (LIC9224) shall be in each child’s file, acknowledging receipt.

Exit interview conducted with Licensee Shakena Douglas , during which appeal rights were explained. A copy of the appeal rights (LIC9058 01/16) were provided. The licensees signature on this report acknowledges receipt of her rights.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3828
LICENSING EVALUATOR NAME: Jeanette Estrada	TELEPHONE: (323) 229-6521
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC9099 (FAS) - (06/04)

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