300603968-10-18-2019-06-CC-PMAA-BHU4QN-20191111181835

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 300603968
Report Date: 10/18/2019
Date Signed: 10/18/2019 12:28:04 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/15/2019 and conducted by Evaluator Ketki Desai

PUBLIC

COMPLAINT CONTROL NUMBER: 06-CC-20191015093749

FACILITY NAME:	MATT KLINE HEADSTART		FACILITY NUMBER:	300603968
ADMINISTRATOR:	HERNANDEZ, WENDOLIN		FACILITY TYPE:	850
ADDRESS:	2043 MEYER PLACE		TELEPHONE:	(949) 548-4480
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92627
CAPACITY:	60	CENSUS: 52	DATE:	10/18/2019
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Education Manager Rose Alvarez & Director Wendy H		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Personal Rights

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ketki Desai conducted an unannounced visit to investigate the above allegation.
LPA met with Director on site Ms. Wendolin Herandez who guided LPA on tour of the facility (Room # 2, 3, & 4) and shortly joined was the Education Manager Ms. Rose Alvarez and the above allegation was discussed.
During today’s inspection the facility was operating within its licensed capacity. A review of adult records on this date indicated that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.
During the investigation LPA interviewed the Education Manager. The complaint was cross reported.

It was reported in 2006-2007, the alleged victim attended the facility and the victim was spanked by the staff, however per the report received no specific staff has been identified. (continued- Page 2)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Ketki Desai	TELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2019

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 06-CC-20191015093749

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: MATT KLINE HEADSTART	FACILITY NUMBER: 300603968
	VISIT DATE: 10/18/2019

NARRATIVE

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LPA interviewed the Education Manager who has been associated to the facility since early 1996 and has performed various roles in different capacity including being a Director. The incident occurred somewhere in-between 2006-2007. Per the Educational Manager the name of the alleged victim has no such association to the program.

LPA checked the staff associations for the past 10 year to narrow down the staff name reflected on the report but since there is no specific name addressed, association was not possible. Educational manager too has no recollection of the staff name provided. Being a historic complaint, no child or staff roster are available for review as the Department only requires the records to be maintained for three years.

Based on the information gathered from the interviews conducted there is insufficient evidence to corroborate the allegation. 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 for violating personal rights of the child is being unsubstantiated.

Exit interview was conducted. Notice of Site Visit was posted during the visit. Facility representative was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Ketki Desai	TELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2019

LIC9099 (FAS) - (06/04)

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