334842140-12-15-2020-09-CC-GSEA-BWDL5K-20201217072712

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 334842140
Report Date: 12/15/2020
Date Signed: 12/15/2020 10:35:59 AM

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
11/24/2020 and conducted by Evaluator Timeka Reed

PUBLIC

COMPLAINT CONTROL NUMBER: 09-CC-20201124101017

FACILITY NAME:	FSA-CABAZON CDC		FACILITY NUMBER:	334842140
ADMINISTRATOR:	MARY HAMPTON		FACILITY TYPE:	830
ADDRESS:	50390 CARMEN AVENUE		TELEPHONE:	(951) 846-8900
CITY:	CABAZON	STATE: CA	ZIP CODE:	92230
CAPACITY:	23	CENSUS: 3	DATE:	12/15/2020
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Lizeth Ouellette		TIME COMPLETED:	10:25 AM

ALLEGATION(S):

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Staff not providing adequate supervision.

INVESTIGATION FINDINGS:

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Due to Covid-19 pandemic, on December 15, 2020, Licensing Program Analyst (LPA) Timeka Reed delivered findings for the complaint allegation initiated on December 4, 2020, to facility administrator, Lizeteth Ouellette, via Zoom video conference application, due to the executive order issued by Governor Newsom on March 16, 2020 regarding COVID-19.

The complaint alleges staff is not providing adequate supervision to children in care. LPA Timeka Reed interviewed all pertinent parties regarding the allegation.
Interviews conducted resulted in inconsistent information as to whether tasks performed such as diapering and feeding when there is one staff present resulted in inadequate supervision of children; however, interviews are consistent staff are providing adequate supervision of child during staff lunches, staff breaks, and staff work schedules.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Gilbert Sena	TELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Timeka Reed	TELEPHONE: (951) 970-1161
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2020

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 09-CC-20201124101017

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: FSA-CABAZON CDC	FACILITY NUMBER: 334842140
	VISIT DATE: 12/15/2020

NARRATIVE

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This agency investigated the complaint that staff is not providing adequate supervision. The allegation is determined to be unsubstantiated at this time; meaning, although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove the allegations occurred.

A copy of this report along with a notice of site visit was explained and provided to Lizeth Ouellette.

SUPERVISOR'S NAME: Gilbert Sena	TELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Timeka Reed	TELEPHONE: (951) 970-1161
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2020

LIC9099 (FAS) - (06/04)

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