313621518-5-10-2022-03-CC-KPES-CEGLFA-20220516084248

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 313621518
Report Date: 05/10/2022
Date Signed: 05/10/2022 09:26:43 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/07/2022 and conducted by Evaluator Amanda Blesi

PUBLIC

COMPLAINT CONTROL NUMBER: 03-CC-20220207155405

FACILITY NAME:	GRAY, DECEMBER		FACILITY NUMBER:	313621518
ADMINISTRATOR:	GRAY, DECEMBER		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(916) 204-9281
CITY:	LINCOLN	STATE: CA	ZIP CODE:	95648
CAPACITY:	14	CENSUS: 11	DATE:	05/10/2022
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	December Gray		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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PERSONAL RIGHTS: Day care child ingested a foreign object resulting in hospitalization.

INVESTIGATION FINDINGS:

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On May 10, 2022 at 8:30 a.m., Licensing Program Analyst, Amanda Blesi met with Licensee, December Gray, to deliver a complaint finding for the allegation above. During today's inspection there were 11 children in care of licensee Gray and one assistant. Also present was licensee's husband and son. The investigation was conducted by the Department’s Investigation Branch, Investigator, Shannan Borton. It was alleged that a day care child ingested a foreign object resulting in hospitalization. Investigator Borton conducted interviews with children, parent, and staff. During the course of the investigation, Investigator Borton concluded licensee, December Gray, failed to provide a safe environment by having an unsafe toy (Magnet Men) accessible to children in care. One of the day care children (C1) chewed on the Magnet Men toy and ingested magnets out of the toy. C1 had surgery on 2/4/22, where three small magnets were removed from the child’s abdominal cavity. Based on the evidence obtained, there is a preponderance of evidence to support the allegation, therefore the finding is SUBSTANTIATED.

Deficiencies are cited on the subsequent page of this report. See LIC9099-D

Continued on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Keven Peters	TELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda Blesi	TELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022

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 3

Control Number 03-CC-20220207155405

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: GRAY, DECEMBER	FACILITY NUMBER: 313621518
	VISIT DATE: 05/10/2022

NARRATIVE

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Licensee is being cited an enhanced civil penalty for violation of personal rights in the amount of $2,000.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted, and report was reviewed with the licensee December Gray.

LPA Amanda Blesi informed licensee December Gray that this report dated May 10, 2022 document(s) One Type A citation which shall be posted for 30 consecutive days as there is immediate risk(s) to the health, safety, or personal rights of children in care. Also, LPA Amanda Blesi informed the licensee to provide a copy of this licensing report dated May 10, 2022 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

SUPERVISOR'S NAME: Keven Peters	TELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda Blesi	TELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 03-CC-20220207155405

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: GRAY, DECEMBER	FACILITY NUMBER: 313621518
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/11/2022 Section Cited CCR 102423(a)(2)	1 2 3 4 5 6 7	Personal Rights: To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.	1 2 3 4 5 6 7	Licensee states she has removed the Magnet Men from the facility and went through all the toys in the day care and removed all that she felt could pose a danger to children. In addition, she removed a bookcase and rearranged the play room to allow for better visibility in that area.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: licensee failed to provide a safe environment for children when a five-year old child ingested magnets from a toy in the day care resulting in the child needing surgery and hospitalization. This is an immediate risk to the health and safety of children in care. Enhanced civil penalty in the amount of $2,000 is assessed.	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: Keven Peters	TELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda Blesi	TELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022

LIC9099 (FAS) - (06/04)

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