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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 334803735
Report Date: 11/15/2019
Date Signed: 11/15/2019 03:03:22 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/13/2019 and conducted by Evaluator Diana Brasel
PUBLIC
COMPLAINT CONTROL NUMBER: 09-CC-20191113153649
FACILITY NAME:KUPPANDA FAMILY CHILD CAREFACILITY NUMBER:
334803735
ADMINISTRATOR:KUPPANDA, VIREENAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 371-8650
CITY:CORONASTATE: CAZIP CODE:
92882
CAPACITY:14CENSUS: 8DATE:
11/15/2019
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Vireena & Suresh KuppandaTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Provider failed to report to child's authorized representative an injury sustained by day care child while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst's Diana Brasel and Nelson Zuniga arrived at the facility on the above noted date and time, to conduct an investigation into the above complaint allegation. Upon arrival LPA's met with the licensee's, disclosed the purpose of the visit. LPA's gathered needed documents for this investigation, at time of visit. The licensing department received information that child #1 sustained an injury while in care at the facility. The nformation disclosed from the licensee is that the incident was not reported to the child's parent or to the Licensing Agency.

Based upon the information gathered, the preponderance of evidence standard has been met these allegations are therefore substantiated.
See LIC 9099D for deficiencies cited per California Code Regulations Title 22, Division 12.
An exit interview was conducted. Notice of site visit was issued and must be posted for 30 days. Also provided, copy of appeal rights (LIC9058 12/2015 and the signature of this report acknowledges receipt of the appeal rights.
A copy of this report must be available to the public for three years.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Diana BraselTELEPHONE: 951-782-4952
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 09-CC-20191113153649
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: KUPPANDA FAMILY CHILD CARE
FACILITY NUMBER: 334803735
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/25/2019
Section Cited
CCR
102416.2(a)(b)(1)
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Reporting Requirements: The licensee shall report the following information to the Department by telephone or fax within the Department's next business day and during normal working hours (8am to 5pm). The licensee shall report to the Department any of the events as specified in Health and Safety Code Sections 15973467 (b)(1)(A)
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The licensee agreed to submit the required LIC 624B report to Licensing no later Monday.
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through(b)(1)(C) that occur during the operation of the family child care home. (1) Medical treatment means treatment by a medical professional, as defined in Section 101152(m). This requirement has not been met, as the licensee failed to submit the required LIC 624B to licensee reporting the incident that occurred.
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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: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Diana BraselTELEPHONE: 951-782-4952
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2019
LIC9099 (FAS) - (06/04)
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