334842140-5-11-2022-09-CC-AROS-CGPVKN-20220726163038

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 334842140
Report Date: 05/11/2022
Date Signed: 05/11/2022 03:48:21 PM

Substantiated

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
05/04/2022 and conducted by Evaluator Blanca Ruiz-Silva

PUBLIC

COMPLAINT CONTROL NUMBER: 09-CC-20220504114354

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: 4	DATE:	05/11/2022
		UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Site Director, Lizeth Ouellette		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Daycare child was left unattended while in care.
Facility is in disrepair.

INVESTIGATION FINDINGS:

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On May 11, 2022 @ 11:05 a.m. Licensing Program Analyst (LPA) Blanca Ruiz arrived at the facility to conduct an investigation into the above allegations. LPA Ruiz met with Director, Lizeth Ouellette. Facility was toured and census was taken.
It was alleged that on or about the first week of April or May 2022, a child was left unattended while in care and that facility was in disrepair. Upon arrival to the facility LPA toured infant/toddler classrooms an observed a broken gate in classroom A304. it was later disclosed by witnesses and pertinent parties related to the investigation that a toddler was able to leave the classroom due to the gate being broken an in disrepair. Child was able to walked few feet away from the classroom. The day of the incident there was one fully qualify teacher to four toddlers. It was later disclosed that incident occurred when staff was changing another’s child’s diaper. The toddler was able to overpass the broken gate and push the main door that leads to a long hallway ( main common area of the building). Facility director was able to see the toddler walking away from the classroom to the common area through the surveillance cameras and she took the child back to the classroom.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Blanca Ruiz-Silva	TELEPHONE: (951) 233-5594
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022

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 09-CC-20220504114354

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: 05/11/2022

NARRATIVE

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Facility has a work order to install a new gate in the classroom. During this inspection three qualified teacher were in classroom A304 providing care and supervision to four toddlers.

Based on licensee’s own addition and the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, divisions & chapter number are being cited on the attached LIC 9099D.)

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 for the next 12 months.
The Notice of Site Visit and Type A Deficiencies from today’s visit must be posted for 30 days. Failure to keep these posted for the entire 30 days will result in an immediate $100 civil penalty for each.

An exit interview was conducted, Notice of Site Visit posted, appeal rights discussed and given to the Site Director, Lizeth Ouellette, along with a copy of this report and a LIC 9224 form.

A copy of this report was provided to the licensee on this date. THIS REPORT MUST BE AVAILABLE TO THE PUBLIC FOR THREE YEARS.

SUPERVISOR'S NAME: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Blanca Ruiz-Silva	TELEPHONE: (951) 233-5594
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022

LIC9099 (FAS) - (06/04)

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Control Number 09-CC-20220504114354

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/11/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/12/2022 Section Cited CCR 101429(a)(1)	1 2 3 4 5 6 7	(a) In addition to Section 101229, the following shall apply: (1) Each infant shall be constantly supervised and under direct visual observation and supervision by a staff person at all times. This requirement was not met as: Per information obtained during the investigation and staff and licensee's own admission.	1 2 3 4 5 6 7	Licensee agrees to conduct in service training to obtain for staff regarding SUPERVISION and to provide CCL with sign in sheet/ agenda of topic and date and time of training by 05/12/22. Licensee agrees to submit a statement upon completion of training on how the center will prevent this from occurring in the future. Please contact CCL by 05/30/22 to provide training date.
	8 9 10 11 12 13 14	A toddler was able to leave the classroom due to the gate being broken an in disrepair while staff was changing another child's diaper. Facility director was able to see the toddler walking away from the classroom to the common area through the surveillance cameras. Child was taken back to the classroom This is an immediate risk to Health, Safety & Personal Rights to the children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Blanca Ruiz-Silva	TELEPHONE: (951) 233-5594
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022

LIC9099 (FAS) - (06/04)

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