198018562-8-30-2019-33-CC-CGUA-BJKSM4-20191205125912

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198018562
Report Date: 08/30/2019
Date Signed: 08/30/2019 05:52:22 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
08/26/2019 and conducted by Evaluator Cynthia Reyes

PUBLIC

COMPLAINT CONTROL NUMBER: 33-CC-20190826163440

FACILITY NAME:	COVINA DEVELOPMENT CENTER		FACILITY NUMBER:	198018562
ADMINISTRATOR:	JEPPSON, PAULA		FACILITY TYPE:	830
ADDRESS:	437 W. SAN BERNARDINO RD. #111		TELEPHONE:	(626) 967-7153
CITY:	COVINA	STATE: CA	ZIP CODE:	91723
CAPACITY:	33	CENSUS: 16	DATE:	08/30/2019
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Sheena Yrma Minaya		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Child in care was bitten by another child

INVESTIGATION FINDINGS:

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

Licensing Program Analysts (LPA) Cynthia Reyes, arrived unannounced at the facility for the purpose of conducting a complaint Investigation regarding the allegation listed above. LPA met with Sheena Yrma Minaya, program manager, who took LPA on a tour of the facility.

Based on LPA Interviews conducted and records reviewed and received, the preponderance of evidence standard has been met, therefore the above allegation of Personal Rights, Child in care was bitten by another child is found to be Substantiated. California Code of Regulations, Title 22 Health and Safety Code Section 1596.8595, is being cited on the attached LIC 9099-D. Per Interviews it was stated that a child was bitten on several occasions by another child and it was the same child who was also known to be a bitter. The facility was unable to provide LPA with any ouch reports to show specific dates. Interviews determined that staff witness one bitting incident and did not witness all or was unable to prevent the biting before it happened.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Cynthia Reyes	TELEPHONE: (323) 981-3369
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2019

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 33-CC-20190826163440

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: COVINA DEVELOPMENT CENTER	FACILITY NUMBER: 198018562
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/30/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/06/2019 Section Cited CCR 101429(a)(1)	1 2 3 4 5 6 7	RESPONSIBILITY FOR PROVIDING CARE AND SUPERVISION FOR INFANTS In addition to Section 101229, the following shall apply: Each infant shall be constantly supervised and under direct visual observation and supervision by a staff person at all times. Under no circumstances shall ANY infant be left unattended	1 2 3 4 5 6 7	Program manager stated she will implement a policy on shadowing a child bitter and send the department a detailed declaration on how she will do that and what steps she will take to ensure the health and safety of children care in care. CCL is recommending that the video regarding biting on the CCL web site be viewed and a staff sign in/out sheet and
	8 9 10 11 12 13 14	-This requirement is not met as evidenced by: A child was bitten on several occasions by another child and it was the same child who was also known to be a bitter. Facility was unable to provide LPA with any ouch reports. This poses an immediate risk to the health and safety of children in care.	8 9 10 11 12 13 14	documentation of what was learned be sent to the department as soon as possible.
	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: Cynthia Reyes	TELEPHONE: (323) 981-3369
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2019

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 33-CC-20190826163440

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: COVINA DEVELOPMENT CENTER	FACILITY NUMBER: 198018562
	VISIT DATE: 08/30/2019

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

Upon receipt, Sheena Yrma Minaya, program manager posted the Notice of Site Visit and the 9099 D page (documentation of deficiencies.) This report and the Notice of Site Visit shall be posted for thirty (30) consecutive days. Failure to maintain posting as required will result in a $100 civil penalty.

A copy of this report shall be provided to the parents/guardians of the children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parents/guardians of any children newly enrolled at the facility for the next 12 months.

The LIC 9224 Acknowledgement of Receipt of Licensing Reports must be maintained in each child's file immediately upon receipt from the parent.

LPA provided Sheena Yrma Minaya with a blank copy of the LIC 9224 Acknowledgement of Receipt of Licensing Report.

Exit interview conducted with Sheena Yrma Minaya, program manager during which appeal rights were given and explained.

A copy of the Appeal Rights (LIC 9058 01/16) was provided. The program managers signature on this report acknowledges receipt of rights. Consultation was also conducted on this date.

Web site address to order forms: http://www.dss.cahwnet.gov/cdssweb/On-lineFor_293.htm#l

INTERNET ADDRESS: http://www.ccld.ca.gov – To access licensing forms, updates and Title 22.

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Cynthia Reyes	TELEPHONE: (323) 981-3369
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2019

LIC9099 (FAS) - (06/04)

Page: 2 of 4