334812819-1-28-2022-10-CC-PBER-CBBW5Q-20220204155930

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 334812819
Report Date: 01/28/2022
Date Signed: 01/28/2022 03:41:51 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 STREET, STE 700
RIVERSIDE, CA 92501

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/16/2021 and conducted by Evaluator Susan Brewer

PUBLIC

COMPLAINT CONTROL NUMBER: 10-CC-20211116145832

FACILITY NAME:	FSA-HEMLOCK CDC		FACILITY NUMBER:	334812819
ADMINISTRATOR:	DANIELA PEREZ		FACILITY TYPE:	850
ADDRESS:	23270 HEMLOCK AVE.		TELEPHONE:	(951) 243-3192
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92557
CAPACITY:	110	CENSUS: 35	DATE:	01/28/2022
		UNANNOUNCED	TIME BEGAN:	03:06 PM
MET WITH:	Director Anna Aguirre		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff did not provide adequate supervision.
The incident report does not give all of the relavant information.

INVESTIGATION FINDINGS:

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On the above date and time, Licensing Program Analysts (LPA) Susn Brewer arrived at the facility to conduct an unannounced complaint investigation to deliver the findings for the above referenced allegations. LPA conducted COVID-19 Screening questions prior to entry. LPA met with Ana Aguirre. LPA toured the facility and took census of 35 children 9 staff.

An initial visit was conducted on 11/23/2021. On 11/16/2021 Community Care Licensing received the allegations. The investigation consisted of interviews and record review.

1st Allegation: Staff did provide adequate supervision to children in care. A child sustained injuries of bruising around both eyes and mouth, a lesion inside the lower lip and swelling to the face, inflicted by another day care child punching them and as a result of inadequate supervision.

(Continued on 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Pauline Beschorner	TELEPHONE: (951) 782-6641
LICENSING EVALUATOR NAME: Susan Brewer	TELEPHONE: (951) 970-0343
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022

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 10-CC-20211116145832

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 STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: FSA-HEMLOCK CDC	FACILITY NUMBER: 334812819
	VISIT DATE: 01/28/2022

NARRATIVE

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An Interview with Staff 1/S1 revealed (see LIC811 for S1, C1 and C2) was cleaning activity tables while supervising alone in classroom 6, at the time of the incident. S1 was with the 9 children, which is within acceptable ratios. S1 could view all activity areas in room 6. S1 saw C2 physically swinging his arms in a punching motion towards C1. S1 ran to the activity area to separate C1 and C2. Although S1 was not in the exact area at the time of the incident, S1 responded to the incident when it was noticed. Records and interviews with pertinent parties revealed that since C1’s injury, the concern has been addressed to prevent any further incidents.

2nd Incident: The incident report does not give all of the relevant information. The LPA conducted interviews with pertinent parties, which revealed that the facility lost an in-house incident report which should have been placed in C1s file. It was verified that the facility provided the parent a written report within the following day and failed to make a copy for C1s file. The facility reproduced the written report and provided C1's parent with a 2nd copy for their record. Although the LPA was unable to verify the information documented on the 1st written report intended for record keeping in C1s file, it was verified through interviews that a verbal report was provided to the parent and followed up with a written report the following day. It was also verified by the LPA that the facility was compliant with Title 22 reporting requirements by submitting a written report to the department regarding the incident.

Although the above-mentioned allegations may have happened or is valid there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED at this time. The facility is reminded to continue to provide on-going training on active supervision to all staff who are responsible for supervising children.

An exit interview was conducted, and a copy of this report was reviewed with and appeal rights were provided to Director Ana Aguirre.

SUPERVISOR'S NAME: Pauline Beschorner	TELEPHONE: (951) 782-6641
LICENSING EVALUATOR NAME: Susan Brewer	TELEPHONE: (951) 970-0343
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022

LIC9099 (FAS) - (06/04)

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