198014629-9-5-2019-54-CC-KCHS-BGTMTM-20191010095343

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198014629
Report Date: 09/05/2019
Date Signed: 09/05/2019 12:34:44 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
05/10/2019 and conducted by Evaluator Raul Navarro

PUBLIC

COMPLAINT CONTROL NUMBER: 54-CC-20190510115014

FACILITY NAME:	KING FAMILY CHILD CARE		FACILITY NUMBER:	198014629
ADMINISTRATOR:	KING, SHANNON		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(562) 437-1451
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90813
CAPACITY:	14	CENSUS: 11	DATE:	09/05/2019
		UNANNOUNCED	TIME BEGAN:	11:02 AM
MET WITH:	Shannon King		TIME COMPLETED:	12:49 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Reporting Requirements

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Raul Navarro conducted an unannounced complaint inspection. LPA met with Licensee Shannon King who guided this LPA on a tour of the facility. Also present was Licensee's assistant. There were 11 children present during today’s inspection.

During the course of the investigation LPA Navarro conducted interviews with the Complainant, Licensee, and staff present. Complainant stated that they were not given any notice about an incident that occurred at the facility regarding Child #1. LPA interviewed staff. Staff #1 stated that they observed the incident happened. Incident was not reported to the parent of Child #1. Based on the available information, 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 Number 1) is being cited on the attached LIC. 9099D.

*Report continues on the next page*

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Chambers	TELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Raul Navarro	TELEPHONE: 323-981-3388
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2019

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 54-CC-20190510115014

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: KING FAMILY CHILD CARE	FACILITY NUMBER: 198014629
	VISIT DATE: 09/05/2019

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Exit interview was conducted with Licensee. The Licensee was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these forms.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site inspection by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

Report ends- Page 3 of 3

SUPERVISOR'S NAME: Karen Chambers	TELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Raul Navarro	TELEPHONE: 323-981-3388
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2019

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 54-CC-20190510115014

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: KING FAMILY CHILD CARE	FACILITY NUMBER: 198014629
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/05/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/12/2019 Section Cited CCR 102416.2(f)(1)	1 2 3 4 5 6 7	Reporting Requirements- As soon as possible but no later then the same business day, the licensee shall notify a child's parent or authorized representative regardless of the injuries or acts that affect that child. This requirement was not met as evidenced by interviews conducted with all parties involved. Complainant	1 2 3 4 5 6 7	Per Licensee, they will notify the parent or any incident and provide them with an ouch report. Licensee will have the parents sign the notification and will keep a copy on file.
	8 9 10 11 12 13 14	stated that they were not given any notice about an incident that occurred at the facility regarding Child #1. LPA interviewed staff. Staff #1 stated that they observed the incident happened. Incident was not reported to the parent of Child #1. This is a potential risk to the health and safety of the 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: Karen Chambers	TELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Raul Navarro	TELEPHONE: 323-981-3388
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2019

LIC9099 (FAS) - (06/04)

Page: 3 of 4