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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 334803735
Report Date: 06/12/2020
Date Signed: 06/12/2020 06:39:47 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: 2DATE:
06/12/2020
UNANNOUNCEDTIME BEGAN:
05:15 PM
MET WITH:Licensee Vireena Kuppanda via telephoneTIME COMPLETED:
06:45 PM
ALLEGATION(S):
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Child sustained head injury while in care of licensee.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Diana Brasel on the above noted date and time attempted to conduct a tele-inspection visit, via Face time with the licensee. The purpose of the tele-inspection is to deliver the concluded findings for this complaint investigation, which was initiated on November 15, 2019. Due to the executive order issued by Governor Newsom on March 16, 2020 regarding COVID-19 and DPH guidelines of social distancing the visit will be conducted via licensee's landline. LPA made contact with the licensee, arrangements were made to call the licensee back approximately 30 minutes later to review and discuss the findings. The licensee doesn't have Facetime, the visit will be done by phone only. The concluded findings are based upon the investigation report from Investigations Branch (IB) Investigator, Gina Tallagua.

During the investigation, Investigator Gina Tallagua conducted interviews, obtained pertinent documents, which included a police report from the Corona Police Department (CPD) and medical records from Kaiser Permanente Hospital (KPH).
---Continued on LIC 9099C---
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: 05/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2020
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 3
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
VISIT DATE: 06/12/2020
NARRATIVE
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During the mid-morning of 11/12/2019, the licensee tripped and fell while holding the infant child in her
arms.

The licensee did not report falling to the parents nor did she seek medical care for the infant child. Approximately an hour and half after the parents picked the child up, due to the parents noticing swelling to the infant’s right side of their head, the parents called the licensee, and asked if the child fell or hit their head while at the day care. The licensee stated, no.

The following day, a CPD Detective confronted the licensee about the injury to the child. The licensee admitted to the Detective she tripped and fell while holding the infant child. The licensee’s statement about the incident was corroborated by witnesses of the incident. The medical report from KPH stated, the infant was diagnosed with a displaced skull fracture and hematoma.

Based on the information obtained during the investigation process, the preponderance of evidence standard has been met. The above allegation is therefore substantiated.
See LIC 9099D for deficiency cited per California Code of Regulations Title 22, Division 12.

(Type A violations) Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

An exit interview was conducted via telephone with the licensee and her spouse, in which the report was reviewed with the licensee. The Licensee was advised the report would be emailed.

LPA Diana Brasel provided the licensee with a copy of the report via email with an electronic “read receipt”. The electronic read receipt of the emailed report acknowledges receipt of this report and will be used in lieu of a signature. Along with the report, a Notice of Site (LIC 9213), a copy of Acknowledgment of Receipt form (LIC 9224), and a copy of the Appeal Rights (LIC 9058) were emailed to the licensee.
SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Diana BraselTELEPHONE: 951-782-4952
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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: 06/12/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/15/2020
Section Cited
CCR
102423(a)(2)
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Personal Rights: (a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following:
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By the POC due date, the licensee shall provide a written statement to CCL, stating she understands the seriousness of the incident, & how she plans to prevent a future situation from happening Licensee agrees to review Community Care Licensing training videos (https://ccld.childcarevideos.org)
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(2) To receive safe, healthful, & comfor- table accommodations, furnishings, & equipment. This requirement was not met as evidenced by the licensee falling while holding the infant & not reporting to the infant’s parents or seeking pro-fessional medical care. As a result of the fall, the infant was diagnosed with displaced skull fracture and hematoma. This is an immediate health and safety risk to the children in care.

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regarding Supervising Children in FCCH & Children's Personal Rights in Child Care. By 06/15/2020, the licensee shall pro- vide a written statement, self-acknow-ledging she has reviewed the videos & what she has learned. In addition, a Non-
Compliance Conference will be scheduled with the licensee as soon as possible.

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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: 05/22/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2020
LIC9099 (FAS) - (06/04)
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