280108344-5-13-2022-01-CC-AHON-CEHLJL-20220517084808

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 280108344
Report Date: 05/13/2022
Date Signed: 05/13/2022 04:30:15 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/14/2022 and conducted by Evaluator Leticia Rosales

PUBLIC

COMPLAINT CONTROL NUMBER: 01-CC-20220214121717

FACILITY NAME:	CANV KIDS DEVELOPMENT & FAMILY PROGRAM AKA LOS NIN		FACILITY NUMBER:	280108344
ADMINISTRATOR:	KATHY PEEBLES		FACILITY TYPE:	850
ADDRESS:	1510 MYRTLE AVENUE		TELEPHONE:	(707) 253-6173
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	60	CENSUS: 36	DATE:	05/13/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Evelyn Fuentes, Site Supervisor		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Child sustained injuries while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Leticia Rosales-Meza conducted an unannounced subsequent complaint investigation inspection for the purpose of delivering the finding, and met with Evelyn Fuentes, Site Supervisor. It has been alleged child sustained injuries while in care, specifically that Child 1 (C1) had bruises on C1’s back and upper right shoulder the size of a nickel.

During the initial complaint investigation to the facility on 02/22/22 at 3:30 PM, LPA met with Evelyn Fuentes, Site Supervisor and Evelyn was notified of the allegation; and LPA obtained a facility roster of the children currently in care.

An interview was conducted with Parent 1 (P1) on 3/03/21 at 4:49 PM. Interviews were conducted with Staff (S1-S3) on 5/13/2022 starting at 1:46 PM. Interviews of S1-S3 did not provide corroborating evidence to support the allegation that C1 sustained injuries while in care.

Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Leticia Rosales	TELEPHONE: (707) 588-5061
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022

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 01-CC-20220214121717

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CANV KIDS DEVELOPMENT & FAMILY PROGRAM AKA LOS NIN	FACILITY NUMBER: 280108344
	VISIT DATE: 05/13/2022

NARRATIVE

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During the inspection tours of the facility, LPA observed the Staff appropriately communicating with the children, conducting indoor playtime activities with the children; and staff supervising and promptly tending to the needs of the children in care.

Based on interviews conducted and records obtained, there is not a preponderance of evidence to prove the allegation. The finding is determined to be Unsubstantiated.

This report was reviewed and discussed with the Site Supervisor. Appeal rights were provided. There were no Title 22 deficiencies cited during today’s inspection.

NOTICE OF SITE VISIT POSTED TO REMAIN POSTED FOR 30 DAYS

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Leticia Rosales	TELEPHONE: (707) 588-5061
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022

LIC9099 (FAS) - (06/04)

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