304370465-1-9-2020-06-CC-PMAA-BLF7NC-20200202204832

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 304370465
Report Date: 01/09/2020
Date Signed: 01/09/2020 02:35:02 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
11/05/2019 and conducted by Evaluator Leonor Barajas

PUBLIC

COMPLAINT CONTROL NUMBER: 06-CC-20191105101015

FACILITY NAME:	DELHI HEAD START		FACILITY NUMBER:	304370465
ADMINISTRATOR:	SALLADE, TRACI		FACILITY TYPE:	850
ADDRESS:	505 E. CENTRAL AVENUE		TELEPHONE:	(714) 361-8866
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92707
CAPACITY:	60	CENSUS: 47	DATE:	01/09/2020
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Educational Manager Tracy Sallade		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility failed to have Director present in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Barajas, conducted an unannounced complaint inspection as a continuation of complaint allegation and deliver findings. This is a continuation of the investigation initiated on 11/13/19. LPA met with New Director Mayra Brier, who guided LPA on tour of the facility. Educational Manager Tracy Sallade arrived at facility at 9:30a.m. There were 47 preschool children present with 8 staff, in classrooms 1, 2 and 3.

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 Barajas interviewed 8 staff, no children. LPA Barajas also review staff and children records, sign in sign out sheets, requested a children’s roster LIC 9040, Personnel Report LIC 500, and took pictures of daycare facility.

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Leonor Barajas	TELEPHONE: (714) 292-8628
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2020

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 11

Control Number 06-CC-20191105101015

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: DELHI HEAD START	FACILITY NUMBER: 304370465
	VISIT DATE: 01/09/2020

NARRATIVE

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Complainant Party (C/P), reported to licensing Department that facility failed to have a Director present in care. C/P stated facility has not had a center Director since June 7, 2019, old facility director quit. C/P stated since beginning of new school year August 19, 2019 , facility has had no Director. C/P stated facility has an Education Manager, who comes to facility 2-3 times a week or as needed, not on site every day.

During Interviews conducted on 11/13/19, Educational Manager disclosed facility has no Director since June 2019. Educational Manager stated oversees 8 centers and is at Delhi facility 2-3 times a week. Educational Manager stated if she is not at facility Staff#8, Early Head Start Supervisor, provides support. Educational Manager stated facility is in process of hiring a Director.

Based on records reviewed and facility inspection on 11/13/19, LPA was not provided Director information, Designation of Administrative Responsibility (LIC 308) and did not physically observe a Director at Delhi Head Start.

During interviews conducted on 11/13/19 with 6 Staff, all Staff stated facility has no Facility Director. All Staff stated facility has not had a Director since beginning of School year August 19, 2019. All Staff stated Educational Manager and Early Head Start Supervisor Jacqui Godinez, provide support and are at facility at least once or twice a week or as needed.

On 01/09/2020, LPA interviewed a Staff who stated is new Director. New Director stated began physically working at Delhi Head Start as of 01/06/2020.

Based on LPA observation, 8 Staff interviews conducted, records reviewed, and New Director Stating began physically working at Delhi Facility as of 01/06/2020, Facility failed to have full-time permanent Director present. This requirement was not met as evidenced by Educational Manager admitting facility not having a Full Time Director on site since June 2019 and beginning of new school year August 19, 2019 and ending when New Director physicall began working on 01/06/2020. Therefore, the preponderance of evidence standard has been met, the Child Care Center Directors Qualifications and Duties allegation is found to be SUBSTANTIATED. California Code of Regulations , (Title 22, Division & Chapter) is being cited on the attached LIC 9099D, Section 101215.1(b).
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SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Leonor Barajas	TELEPHONE: (714) 292-8628
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2020

LIC9099 (FAS) - (06/04)

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Control Number 06-CC-20191105101015

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: DELHI HEAD START	FACILITY NUMBER: 304370465
	VISIT DATE: 01/09/2020

NARRATIVE

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101215.1(b)- Child Care Center Directors Qualifications and Duties: (b)All child care centers shall have a director.

Exit interview was conducted. Notice of Site Visit was posted during the visit. Educational Manager 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.

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Leonor Barajas	TELEPHONE: (714) 292-8628
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2020

LIC9099 (FAS) - (06/04)

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Control Number 06-CC-20191105101015

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: DELHI HEAD START	FACILITY NUMBER: 304370465
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/09/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/17/2020 Section Cited CCR 101215.1(b)	1 2 3 4 5 6 7	101215.1(b)- Child Care Center Directors Qualifications and Duties: (b)All child care centers shall have a director. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Delhi Headstart hired a Director. As of 01/06/2020, Delhi Head Start has a Physical Fulltime Director: Mayra Bires.
	8 9 10 11 12 13 14	Based on records reviewed and interviews conducted with 8 Staff, and Educational Manager admitting facility has no Director Since June 2019 and All 6 staff disclosed facility does not have a permanent Director since beginning of School year August 19, 2019 through 01/03/2020. This is a potential health and safety risk to the 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: Patricia Magana	TELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Leonor Barajas	TELEPHONE: (714) 292-8628
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2020

LIC9099 (FAS) - (06/04)

Page: 4 of 11

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
11/05/2019 and conducted by Evaluator Leonor Barajas

PUBLIC

COMPLAINT CONTROL NUMBER: 06-CC-20191105101015

FACILITY NAME:	DELHI HEAD START		FACILITY NUMBER:	304370465
ADMINISTRATOR:	SALLADE, TRACI		FACILITY TYPE:	850
ADDRESS:	505 E. CENTRAL AVENUE		TELEPHONE:	(714) 361-8866
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92707
CAPACITY:	60	CENSUS: 47	DATE:	01/09/2020
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Educational Manager Tracy Sallade		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility is out of teacher child ratio in Room 2 and 3
Children's bathroom is wet and has a urine odor
Facility Failed to meet child's needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Barajas conducted an unannounced complaint inspection as a continuation of complaint allegations listed above and to deliver findings. This is a continuation of the investigation initiated on 11/13/19. Upon arrival LPA met with Educational Manager, Tracy Sallade, who guided LPA on tour of the facility. LPA observed 11 preschool children napping with 1 staff in room 3, 6 toddlers napping with 1 staff in room 2, there was another staff present in room 1, had no children, and was leaving facility to pick up children from school. During today’s inspection the facility was operating within its licensed capacity and within compliance of staffing ratios.

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.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Leonor Barajas	TELEPHONE: (714) 292-8628
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2020

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

LIC9099 (FAS) - (06/04)

Page: 5 of 11

Control Number 06-CC-20191105101015

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: DELHI HEAD START	FACILITY NUMBER: 304370465
	VISIT DATE: 01/09/2020

NARRATIVE

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During the investigation, LPA interviewed Educational Manager, 6 staff members on 11/13/19, and conducted a second inspection on 01/09/2020 and interviewed a Staff and New Director, no children were interviewed, reviewed staff time cards, reviewed children’s sign in/out sheets, reviewed personal files, obtained copy of the Children’s Roster (LIC 9040), Personnel Report (LIC 500), and reviewed facility reports on file.

Complaint allegation: Children’s bathroom is wet and has urine odor.

The Educational Manager (EM) denied the allegations. Educational Manager stated facility has a Janitor who cleans restrooms every night. EM disclosed staff usually clean after children use restrooms. EM stated staff and teachers are responsible to clean after there classroom use to maintain restrooms clean.

During investigation six staff members interviewed on 11/13/19, stated facility has a janitor who cleans restrooms and facility every night. All Staff stated facility is not wet or smell like urine. A staff stated its normal for restroom to sometimes smell like urine as children sometimes miss urinals or have accidents. Same staff stated, teachers and staff are responsible to clean after there classroom uses restroom to keep restrooms clean.

LPA Barajas conducted a facility inspection on 11/13/19 and 01/09/2020. During the walk-through children’s restroom were not observed wet or smelling like urine. LPA conducted a walk through in the morning and again in the afternoon on same day and restrooms were clean, dry and odorless.

Based on the interviews conducted with Educational Manager, 6 staff, and LPA own observation, there is insufficient evidence to prove if the violation did or did not occur. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation of Children’s bathroom is wet and has a urine odor did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Complainant reported a second allegation: Facility failed to meet child’s needs. Complainant Party stated the educational needs are not being met for Child#1. Complainant Party stated child has an IEP and there is a specialist who visits facility once a week and works with child and conducts observations.

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SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Leonor Barajas	TELEPHONE: (714) 292-8628
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2020

LIC9099 (FAS) - (06/04)

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Control Number 06-CC-20191105101015

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: DELHI HEAD START	FACILITY NUMBER: 304370465
	VISIT DATE: 01/09/2020

NARRATIVE

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During Interviews conducted the Educational Manager stated, facility has inclusion Staff#9, who meets with parents upon enrollment to discuss children special needs, IEP’s, all Staff go over assessment’s, conducts classroom observation, provide Staff with strategies depending on child's needs. Educational Manager stated is responsible of conducting classroom observation and provides redirection and strategies. Educational Manager stated facility needs for children are all different and each case is evaluated differently.

During interviews conducted on 11/13/19, 6 staff were interviewed. A staff stated there is no children in her classroom with IEP. Three Staff disclosed there are children in classroom with IEP. Five Staff disclosed there is an inclusion teacher who visits facility once a week. A Staff disclosed if there are children in classroom with speech delay, they practice repeating words, if behavioral children then facility has goals, solutions cards, for communication and refer parents to office for help. A Staff disclosed if Staff notice a child needs help, they notify Staff#5 and contacts Inclusion Teacher. A staff Stated facility is pretty good at following IEP’s and helping children with needs. A Staff was interviewed on 01/09/2020 and stated she must facilitate 10% approximately 8 children, and which ever children are identified throughout the year. Staff stated works directly with teachers and also the behavioral children, observes, looks at teachers ASQ tool to access children where they are developmentally at age level. Staff also stated assists parents to go to district to access therapy, resources, programs, services, and all children needs. Staff stated advocates parents, works with parents and explains children's rights. She can suggest/encourage but can’t make them do anything. Staff stated Child#1 needs are being met as needed as child has no IEP.

Based on the statements provided on 11/13/19 and 01/09/2020 by Educational Manager, 7 staff and the information gathered from the record reviews there is insufficient evidence to prove facility failed to meet children’s needs. 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 is UNSUBSTANTIATED.

Complaint Party(C/P), reported an allegation: Facility is out of teacher child ratio in Room 2 and 3. Complainant Party stated classrooms were pretty good with ratio. C/P disclosed the staff varied, usually have staff from another classroom to cover. C/P stated usually classrooms are out of ratio when staff took lunch or breaks.

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SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Leonor Barajas	TELEPHONE: (714) 292-8628
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2020

LIC9099 (FAS) - (06/04)

Page: 7 of 11

Control Number 06-CC-20191105101015

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: DELHI HEAD START	FACILITY NUMBER: 304370465
	VISIT DATE: 01/09/2020

NARRATIVE

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During interview conducted with Educational Manager from what she is aware of Facility has not been out of ratio. Educational Manager stated full day classrooms have 2 teachers and assistant. Delhi Center has an additional substitute assistant/teacher to help with breaks and lunch. The additional substitute is from Company Piazza, Substitutes float around and don't have a permanent center.

During interviews conducted on 11/13/19, 7 staff interviewed disclosed facility has not been out of ratio or over capacity. All staff disclosed facility has assistants and extra substitute assistants/teachers who help at center from different facilities or if needed from company Piazza. Two Staff disclosed facility is pretty good with ratio, if a child needs to use restroom, then assistant or teacher takes few kids with them depending on number of staff to be in compliance with ratio and capacity.

During facility Inspection LPA requested copies of Sign in Sign out sheet and beginning 10/01/2019 through 11/12/2019 and Staff Sign in and Sign Out sheets beginning 09/30/19 through 11/15/2019 and based on number of children and Staff, classrooms 2 and 3 were within capacity and ratios.

Based on the statements provided by Educational Manager and 7 staff and the information gathered from the record reviews there is insufficient evidence to prove facility is out of teacher child ratio in Room 2 and 3. 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 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.

End of Report

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Leonor Barajas	TELEPHONE: (714) 292-8628
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2020

LIC9099 (FAS) - (06/04)

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