334840336-12-4-2020-10-CC-DPAR-BX92LD-20210113162920

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 334840336
Report Date: 10/15/2020
Date Signed: 12/04/2020 05:07:45 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
03/10/2020 and conducted by Evaluator Sean R Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 10-CC-20200310165243

FACILITY NAME:	PROMISE CHRISTIAN KIDS CLUB		FACILITY NUMBER:	334840336
ADMINISTRATOR:	MADRID, JAMI		FACILITY TYPE:	840
ADDRESS:	25664 MADISON AVENUE		TELEPHONE:	(951) 600-8201
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92562
CAPACITY:	60	CENSUS: 0	DATE:	10/15/2020
		UNANNOUNCED	TIME BEGAN:	12:03 PM
MET WITH:	PATRICIA GREEN- ASSISTANT DIRECTOR		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility did not provide adequate supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sean Williams made an unannounced phone call to PROMISE CHRISTIAN KIDS CLUB for the purpose of concluding a complaint investigation via telephone regarding the above allegation(s). LPA Williams It was alleged that the facility did not provide adequate supervision to a child in care, and the child sustained an injury. This report was completed via Tele-Inspections Report Delivery Instructions.

During the course of the investigation, LPA Williams conducted interviews with all relevant individuals pertinent to this investigation. It was learned during interviews, that the staff member who was supervising the child was not aware that the child was playing in a laundry bin/trash receptacle and scraped their leg, causing a minor injury to themselves.

The staff member who was supervising the child admitted that they did not know the child hid in the laundry bin/trash receptacle and sustained a scrape on their leg. That same staff member also acknowledged that this action was a lack of supervision on the part of facility staff in this case.
(THIS IS AN AMENDED REPORT CONTINUED ON NEXT PAGE)

Substantiated

Estimated Days of Completion: 60

SUPERVISOR'S NAME: Dawn Parker	TELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: Sean R Williams	TELEPHONE: (951) 204-2046
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2020

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-20200310165243

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: PROMISE CHRISTIAN KIDS CLUB	FACILITY NUMBER: 334840336
	VISIT DATE: 10/15/2020

NARRATIVE

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Please note: This is an amended report to reflect the correct allegations on the LIC9099. The child being injured is not considered an allegation.

Due to the fact the child had to report the injury to the staff member, and the staff member did not know that the child scraped their leg, shows a lack of supervision on the part of the facility staff member. Licensee's signature will be obtained via email.

This is a violation of Title 22 regulations and the facility will be cited for lack of supervision. (SEE LIC809D). (101229 (a) (1) Responsibility for Providing Care and Supervision)

Please note: There was conflicting information regarding weather the child hid in a laundry bin or a trash receptacle. Due to the sign on the outside of the container referring to it as trash, it was determined that the said container was being used as a trash receptacle. (A photo was taken)

In this case, the preponderance of evidence standard has been met, and the allegation(s) is deemed, SUBSTANTIATED at this time on this date.

A NOTICE OF SITE VISIT COULD NOT BE LEFT AT THE FACILITY DUE TO THE COVID-19 CRISIS. A TYPE B DEFICIENCY WAS CITED DURING THIS TELE- INSPECTION.

This report was completed via Tele-Inspections Report Delivery Instructions. Licensee's signatures will be obtained via email. Licensee will receive a copy of this report and appeal rights via email. This report must be made available to the public upon request for the next 3 years

SUPERVISOR'S NAME: Dawn Parker	TELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: Sean R Williams	TELEPHONE: (951) 204-2046
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2020

LIC9099 (FAS) - (06/04)

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Control Number 10-CC-20200310165243

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: PROMISE CHRISTIAN KIDS CLUB	FACILITY NUMBER: 334840336
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/15/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/26/2020 Section Cited CCR 101229(a)(1)	1 2 3 4 5 6 7	101229(a)(1) Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)	1 2 3 4 5 6 7	The facility Director agrees to providing training to all staff members on the Responsilbility for Providing Care and Supervision in a licensed facility. The Director also agrees to submit proof of training to LPA S. Williams via a sign in/out sheet with printed names and signatures of staff members who supervise children.
	8 9 10 11 12 13 14	(1) and 101230(c)(1). Supervision shall include visual observation. This requirement was not met as evidenced by the staff member who was supervising the child admitted to not knowing the child was hiding in the laundry bin/trash receptacle and scraped their leg while playing on the yard. >>>>>>>>>>>>>>>>>>>>>>>	8 9 10 11 12 13 14	>>> Also, the child had to report the injury to the staff member. This is Lack of Supervision on the part of facility staff.
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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: Dawn Parker	TELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: Sean R Williams	TELEPHONE: (951) 204-2046
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2020

LIC9099 (FAS) - (06/04)

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