198017907-1-27-2021-33-CC-CGAN-BYHUX6-20210223145749

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198017907
Report Date: 01/27/2021
Date Signed: 01/27/2021 02:12:41 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 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
10/27/2020 and conducted by Evaluator Lissete Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 33-CC-20201027163836

FACILITY NAME:	INFANT CENTER OF LA VERNE UNITED METHODIST CHURCH		FACILITY NUMBER:	198017907
ADMINISTRATOR:	NIEVES, VALERIE		FACILITY TYPE:	830
ADDRESS:	3205 D STREET		TELEPHONE:	(909) 596-5369
CITY:	LA VERNE	STATE: CA	ZIP CODE:	91750
CAPACITY:	12	CENSUS: 5	DATE:	01/27/2021
		UNANNOUNCED	TIME BEGAN:	01:44 PM
MET WITH:	Valerie Nieves		TIME COMPLETED:	02:08 PM

ALLEGATION(S):

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Child sustained injury while in care.

INVESTIGATION FINDINGS:

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At 1:44p.m. on January 27, 2021, Licensing Program Analyst (LPA) Lissete Gonzalez conducted a Complaint Inspection to conclude the investigation regarding the above complaint allegation. LPA contacted Director, Valerie Nieves, via telephone due to COVID-19 precautionary measures. At 1:45p.m the call was transferred to FaceTime to complete the tele-inspection. Director, Valerie Nieves, guided LPA on a virtual tour of the facility. There were five (5) children present.

The allegation states (1) Child sustained injury while in care. During the investigation, interviews were conducted with the reporting party, day-care staff, and witnesses. LPA obtained a copy of the children’s roster, parent handbook, Child #1's ouch report, and additional documentation. Based on the evidence obtained during the investigation through interviews, observation, and review of records the above allegation is Unsubstantiated. Although the allegation may have happened or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. REPORT CONTINUES ON NEXT PAGE: 1 OF 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christina Gabelman	TELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Lissete Gonzalez	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2021

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 33-CC-20201027163836

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: INFANT CENTER OF LA VERNE UNITED METHODIST CHURCH	FACILITY NUMBER: 198017907
	VISIT DATE: 01/27/2021

NARRATIVE

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No deficiencies are being cited at this time.

Exit interview conducted with Director, Valerie Nieves. Appeal Rights explained and provided. A copy the report (LIC 9099) and Appeal Rights (LIC 9058) were sent via Email to the Director. An electronic read receipt confirms receipt of the reports. The Director was provided with the mailing address to the Monterey Park Regional Office (1000 Corporate Center Drive, Suite 200B, Monterey Park, CA 91754) and agrees to send a copy of the signed LIC 9099 reports by email to LPA and mail original forms to the regional office.

REPORT CONTINUES ON NEXT PAGE: 2 OF 2

SUPERVISOR'S NAME: Christina Gabelman	TELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Lissete Gonzalez	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2021

LIC9099 (FAS) - (06/04)

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