304312394-11-13-2019-06-CC-RLOZ-BJAM2S-20191126081401

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 304312394
Report Date: 11/13/2019
Date Signed: 11/13/2019 12:25:16 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
10/18/2019 and conducted by Evaluator Wendy Port

PUBLIC

COMPLAINT CONTROL NUMBER: 06-CC-20191018085204

FACILITY NAME:	HERNANDEZ-AREVALO ASCENCION E & AREVALO ROBERTO		FACILITY NUMBER:	304312394
ADMINISTRATOR:	AREVALO ESPERANZA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(714) 415-9125
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92805
CAPACITY:	14	CENSUS: 3	DATE:	11/13/2019
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Ascencion Esperanza Hernandez-Arevalo, Licensee		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility failed to report injury

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Port and LPA Odom conducted a visit to the facility in response to a complaint received regarding the above allegation. This is a continuation of the investigation initiated on 10/23/2019. There was 1 preschool age child present with the licensee upon arrival. Assistant, Ariadna Jimenez arrived with a school age child during today's inspection. An additional preschool age child was dropped off by a parent during inspection.

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. During the investigation LPA conducted an interview with the licensee, 2 assistants, 1 parent, reviewed photographs of the injury and attempted to interview day care children.

Continued on Page 2 (LIC 9099 C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Wendy Port	TELEPHONE: (714) 293-9315
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2019

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 5

Control Number 06-CC-20191018085204

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: HERNANDEZ-AREVALO ASCENCION E & AREVALO ROBERTO	FACILITY NUMBER: 304312394
	VISIT DATE: 11/13/2019

NARRATIVE

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Page 2 (Continued from LIC 9099)

The complainant stated a child sustained an injury that required medical attention. The licensee stated there was a child who fell from a chair and hit their lip on the table causing a laceration on the lip. The licensee stated she was not aware she must report the incident to the licensing office. The parent stated she took the child to the doctor where the child was applied stitches on their lip. The two assistants interviewed stated they were not present when the incident occurred. The subject child was non verbal. LPA attempted to interview other children, however children did not speak to LPA. The photographs reviewed depict a laceration to the lip.

Based on interviews which were conducted, The licensee failed to report the incident which required medical attention . This requirement was not met as evidenced by licensee's disclosure of not reporting the incident and the parents interview where it was confirmed the child received medical attention. Therefore, the preponderance of evidence standard has been met, the allegation: Facility failed to report injury is found to be substantiated. California Code of Regulations, Title 22 Division 12, Article 6, Section 102416.2(b) is being cited on the attached LIC 9099D.

Exit interview was conducted. 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: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Wendy Port	TELEPHONE: (714) 293-9315
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2019

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 06-CC-20191018085204

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: HERNANDEZ-AREVALO ASCENCION E & AREVALO ROBERTO	FACILITY NUMBER: 304312394
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/13/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/15/2019 Section Cited CCR 102416.2	1 2 3 4 5 6 7	Reporting Requirements. 102416.2 The licensee shall report to the Department any of the events as specified in Health and Safety Code Sections 1597.467(b)(1)(A) through (b)(1)(C) that occur during the operation of the family child care home. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	LPA provided licensee with regulations 102416.2 Reporting Requirements and LIC 624B in Spanish. Licensee will sent written LIC 624B regarding the incident to the licensing office by the due date of 11/15/2019.
	8 9 10 11 12 13 14	Based on interviews which were conducted, The licensee failed to report the incident which required medical attention . This requirement was not met as evidenced by licensee's disclosure of not reporting the incident and the parents interview where it was confirmed the child received medical attention. This poses a potential safety risk to 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: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Wendy Port	TELEPHONE: (714) 293-9315
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2019

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
10/18/2019 and conducted by Evaluator Wendy Port

PUBLIC

COMPLAINT CONTROL NUMBER: 06-CC-20191018085204

FACILITY NAME:	HERNANDEZ-AREVALO ASCENCION E & AREVALO ROBERTO		FACILITY NUMBER:	304312394
ADMINISTRATOR:	AREVALO ESPERANZA		FACILITY TYPE:	810
ADDRESS:	909 EAST NORTH STREET		TELEPHONE:	(714) 415-9125
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92805
CAPACITY:	14	CENSUS: 3	DATE:	11/13/2019
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Ascencion Esperanza Hernandez-Arevalo, Licensee		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Lack of supervision resulting in injury to child in care

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Wendy Port	TELEPHONE: (714) 293-9315
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2019

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 06-CC-20191018085204

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: HERNANDEZ-AREVALO ASCENCION E & AREVALO ROBERTO	FACILITY NUMBER: 304312394
	VISIT DATE: 11/13/2019

NARRATIVE

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Page 2 (Continued LIC 9099)

The complainant stated a child sustained an injury that required medical attention. The complainant questioned the supervision being provided since the child sustained the injury. The licensee stated there was a child who fell from a chair and hit their lip on the table causing a laceration on the lip. The licensee stated she was present when the injury occurred, the child climbed on the chair and as she told them to please get down the child slipped off the chair and hit their lip on the table. The parent stated she was called by the licensee and informed of the incident, the parent took the child to the doctor where the child was applied stitches on their lip. The two assistants interviewed stated they were not present when the incident occurred. The subject child was non verbal. LPA attempted to interview other children, however children did not speak to LPA. The photographs reviewed depict a laceration to the lip.

Based on the information gathered from the interviews conducted and photographs reviewed there was insufficient evidence to corroborate that the injury occurred due to lack of supervision. There were no other adults presents and children were not interviewed due to being non verbal. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged supervision violation did or did not occur, therefore the allegation: Lack of supervision resulting in injury to child in care is 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: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Wendy Port	TELEPHONE: (714) 293-9315
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2019

LIC9099 (FAS) - (06/04)

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