304206024-10-21-2021-06-CC-JHAN-C87MGL-20211027093605

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 304206024
Report Date: 10/21/2021
Date Signed: 10/21/2021 09:33:06 AM

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
09/16/2021 and conducted by Evaluator Carmen Odom

COMPLAINT CONTROL NUMBER: 06-CC-20210916135556

FACILITY NAME:	FUENTES, JUANA DEL CARMEN		FACILITY NUMBER:	304206024
ADMINISTRATOR:	FUENTES, CARMEN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(714) 543-0561
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92701
CAPACITY:	14	CENSUS: 4	DATE:	10/21/2021
		UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Juana Del Carmen Fuentes - licensee		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Daycare child sustained an injury while in care

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Carmen Odom conducted an unannounced complaint inspection to deliver the findings for the above allegations. This is a continuation of the investigation initiated on 09/17/21. Upon arrival LPA Odom met with Licensee, Juana Del Carmen Fuentes. At 8:40am the licensee guided LPA on tour of the facility. A census was taken. At the time of the census the licensee was caring for 4 children; which included 1 infant, 2 preschool, and 1 school age children.

A review of staff 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.

Continue to page 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen Odom	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

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 06-CC-20210916135556

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: FUENTES, JUANA DEL CARMEN	FACILITY NUMBER: 304206024
	VISIT DATE: 10/21/2021

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

Page 2
The Department received a complaint on 09/16/21 alleging child sustained an injury while in care. The complainant party (CP) alleged that on 9/15/21 during pick up CP observed Child #1 (C1) had a black left eye. CP asked licensee what happened, licensee stated, C1 was playing and bumped heads with another child. CP took C1 for medical attention due to C1’s eye being swollen and unable to see. CP stated, Licensee did not contact CP to inform about C1’s injury.

During the investigation LPA Villa interviewed complaining party, Licensee, 1 staff, 1 child, 3 adults, and 4 parents. LPA Villa reviewed the Children’s Roster and medical report.

During an interview on 09/17/21, Licensee (S1) stated, on 9/15/21 at 10:00am 4 children were playing in the backyard. S1 observed, C1 and Child #3 (C3) were running and they bumped into each other C1 hit his left eye on C3’s head. S1 stated immediately an ice pack was placed on C1’s eye and Vaseline. S1 stated parents were not notified until 3:00pm during pick up time. LPA Villa asked S1 why parents were not notified immediately. S1 stated, they were never told about reporting requirements.

During an interview on 09/17/21, Staff #2 (S2) stated, on 9/15/21 they did not observe the accident between C1 and C3. S2 was outside in the backyard assisting two other children when the accident occurred. S1 was outside in the backyard caring for C1 and C3. S2 realized C1 was hurt when C1 started crying and S1 immediately attended to C1’s injury. S2 stated, parents were not notified about the injury until 3:00pm during pick up.

LPA Villa attempted to interview four children on 9/17/21, 1 out 4 children qualified to interview. Child #2 (C2) disclosed they did not observe the accident, because they were inside the facility working on schoolwork. C2 stated, they heard C1 cry and S1 brought C1 inside the home to place ice and Vaseline on C1’s eye. C2 stated, they did observe C3 rubbing their head as if they got hurt. C2 stated they love it here compared to another daycare in the past.

Continue to page 3.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen Odom	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 06-CC-20210916135556

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: FUENTES, JUANA DEL CARMEN	FACILITY NUMBER: 304206024
	VISIT DATE: 10/21/2021

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

Page 3

LPA Villa interviewed 3 adults on 9/20/21 and 9/24/21. All three adults confirmed the same story S1 told CP, C1 bumped into C3 and while playing the backyard. All three adults stated, they were upset due to S1 and S2 giving conflicting times and not being notified immediately of C1’s injury. Adult #3 (A3) stated, they decided to give the provider another chance, because C1 has been attending the childcare over 2 years and this was the first time C1 had an injury at the childcare facility. C1 returned to the childcare facility on 9/17/21.
LPA Villa interviewed 4 parents on 9/23/21. None of the parents disclosed any information regarding the incident. All the parents expressed how happy they are with the care and supervision S1 provides to the childcare children.

In the course of the investigation it was discovered that S1 did not report incident to licensing office within 24 hours. LPA asked S1 the reason why the incident was not reported, S1 stated, I was never told about report requirements.

Based on LPA’s facility inspection, observations, interviews conducted with complainant party, licensee, staff, parents, children and records reviewed it was determined there was insufficient evidence that someone in the childcare facility intentionally hurt C1, or that the injury was not an accident. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

In the areas that were evaluated, the facility was not in compliance of the California Code of Regulations, Title 22, Division 12. The following citation under Reporting requirements 102416(b) was issued today on the attached LIC 809D.

Exit interview was conducted with Licensee, Juana Del Carmen Fuentes in Spanish. Notice of Site Visit was posted during the visit. Licensee 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. Licensee was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. First level appeals should be sent to the regional manager to the address listed above.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen Odom	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 06-CC-20210916135556

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: FUENTES, JUANA DEL CARMEN	FACILITY NUMBER: 304206024
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/21/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/21/2021 Section Cited CCR 102416.2(b)	1 2 3 4 5 6 7	102416.2(b) Reporting Requirements. The licensee shall report to the Department any of the events as specified in Health and Safety Code Section 1597.467(b)(1)(A) through (b)(1)(C) that occur during the operation of the family child care home. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will complete and submit LIC624B Unusual incident report by the following day 10/22/21 to licensing office. LPA provided LIC624 form.
	8 9 10 11 12 13 14	Based on observation and interview, Licensee failed to report incident involving C1’s injury while in care. This poses a potential risk to the health and safety of 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: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen Odom	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4