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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 304313899
Report Date: 06/06/2022
Date Signed: 06/06/2022 02:39:19 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, 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
04/04/2022 and conducted by Evaluator Nguyen K Tran
PUBLIC
COMPLAINT CONTROL NUMBER: 06-CC-20220404113518
FACILITY NAME:KAKI, SUNDA BENITO & CHAUMONT, NICHOLASFACILITY NUMBER:
304313899
ADMINISTRATOR:KAKI, SUNDA BENITO &FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 623-1396
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:14CENSUS: 6DATE:
06/06/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Sunda Kaki, LicenseeTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Licensee hit a daycare child while in care.
INVESTIGATION FINDINGS:
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On 06/06/2022, Licensing Program Analyst (LPA) Tran conducted an in-person inspection to deliver the finding regarding the above complaint allegation. LPA Tran met with Licensee Sunda Benito Kaki. The Covid-19 Emergency Response questionnaires were asked. A tour around the facility was conducted, and a census was taken. Observed at the time of the visit was a total of 3 infants and 3 preschool children and Licensee. A review of staff criminal clearance 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.

On 04/04/2022, the Regional Office received allegation regarding Licensee hit a daycare child while in care. A Referral was generated by the Child Abuse Hotline. According to Reporting Party, child said that her teacher, Benito Chaumont hit child on the hand on 03/30/2022. It was also reported that child has said the teacher hit child on a previous occasion.
(Continue next page)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 795-0859
LICENSING EVALUATOR NAME: Nguyen K TranTELEPHONE: (714) 658-6048
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
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-20220404113518
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: KAKI, SUNDA BENITO & CHAUMONT, NICHOLAS
FACILITY NUMBER: 304313899
VISIT DATE: 06/06/2022
NARRATIVE
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(Page 2 of Report)

During investigation, LPA Tran interviewed RP, 3 staff and 4 children and 3 parents.

During staff interviews, 3 out of 3 interviewed staff denied that they have or have witnessed any staff at the day care, hit a child. Staff also described their disciplinary as talking to child, give warnings and re-directions, use time-out, keep explaining to child and get parents involved if needed. During children interviews, 4 out of 4 children were not qualified for the interviews, other children are infants and not verbal to be interviewed. During parents interviews, 3 out of 3 interviewed parents, has no concerns related to the allegation. They are happy with service being provided at the day care. During interview with RP, when asked about the scratches on child's hand, RP was not sure that was from being hit by the day care staff.

During record review of the Child Abuse Hot Line report, no investigation was deemed necessary. Referral was taken as informational report.

Based on the interviews conducted with RP, 3 staffs, 4 children and 3 parents, there is insufficient evidence to corroborate the allegation that Licensee hit a day care child while in care . Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that Licensee hit a day care child while in care did or did not occur, therefore, the allegation that Licensee hit a day care child while in care is UNSUBSTANTIATED.

Appeal Rights were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058)
and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with Licensee Sunda Benito Kaki.

(End of Report)
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 795-0859
LICENSING EVALUATOR NAME: Nguyen K TranTELEPHONE: (714) 658-6048
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 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
04/04/2022 and conducted by Evaluator Nguyen K Tran
PUBLIC
COMPLAINT CONTROL NUMBER: 06-CC-20220404113518

FACILITY NAME:KAKI, SUNDA BENITO & CHAUMONT, NICHOLASFACILITY NUMBER:
304313899
ADMINISTRATOR:KAKI, SUNDA BENITO &FACILITY TYPE:
810
ADDRESS:26521 VIA GORRIONTELEPHONE:
(650) 623-1396
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:14CENSUS: 6DATE:
06/06/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Sunda Kaki, LicenseeTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Licensee violated child's personal right by sharing child's picture and personal information to other parents without permission.
INVESTIGATION FINDINGS:
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On 06/06/2022, Licensing Program Analyst (LPA) Tran conducted an in-person inspection to deliver the finding regarding the above complaint allegation. LPA Tran met with Licensee Sunda Benito Kaki. The Covid-19 Emergency Response questionnaires were asked. A tour around the facility was conducted, and a census was taken. Observed at the time of the visit was a total of 3 infants and 3 preschool children and Licensee. A review of staff criminal clearance 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.

On 04/07/2022, during interview with Reporting Party( RP) regarding the allegation made on 04/04/2022, RP reported additional allegation regarding Licensee violated child's personal right by sharing child's picture and personal information to other parents without permission. According to RP, Licensee posted a picture of day care child in the group chat with other parents and shared information about child's being ill.

(Continue next page)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 795-0859
LICENSING EVALUATOR NAME: Nguyen K TranTELEPHONE: (714) 658-6048
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 06-CC-20220404113518
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: KAKI, SUNDA BENITO & CHAUMONT, NICHOLAS
FACILITY NUMBER: 304313899
VISIT DATE: 06/06/2022
NARRATIVE
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(Page 2 of Report)

During investigation, LPA Tran reviewed children's files, the facility's Caregiver Policy Handbook and postings record on the group chat from RP and from Licensee, LPA Tran found that facility did not obtain consent of child's parent to share picture and child's information to other parents, however, on 03/17/2022, Licensee posted a picture child on the group chat with all parents and shared that child has a pink eye.

Based on the record review of the children's files, the facility's Caregiver Policy Handbook and postings record on the group chat from RP and from Licensee, the preponderance of evidence standard has been met, therefore the above allegation that Licensee violated child's personal right by sharing child's picture to other parents without permission is found to be SUBSTANTIATED. California Code of Regulations, Title 22 Division 12 Chapter 1, Section 102423 (a) Personal Rights is being cited on the attached LIC 9099D.

Appeal Rights and deficiency were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with Licensee Sunda Benito Kaki.

(End of Report)
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 795-0859
LICENSING EVALUATOR NAME: Nguyen K TranTELEPHONE: (714) 658-6048
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 06-CC-20220404113518
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: KAKI, SUNDA BENITO & CHAUMONT, NICHOLAS
FACILITY NUMBER: 304313899
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/20/2022
Section Cited
CCR
1102423(a)
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102423 Personal Rights (a) Each child receiving services from a family child care home shall have certain rights....include, but are not limited to, the following: (1) To be treated with dignity.

This requirement is not met as evidenced by:
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Licensee stated they will submit a statemnent of understanding about the regulation, will update and submit the updated the facility Caregiver Policy Handbook regarding the obtaining parent's permission to share picture to only authorized representatives, to LPA Tran by 06/20/2020.
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Based on record review, licensee failed to obtain parent's permission to share information and picture of child to other parents.

This posed a potential Health and Safety Risk or personal Rights to children in care.
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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 LopezTELEPHONE: (714) 795-0859
LICENSING EVALUATOR NAME: Nguyen K TranTELEPHONE: (714) 658-6048
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5