334844715-10-26-2022-09-CC-KWIS-CKXQ4T-20221107105051

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 334844715
Report Date: 10/26/2022
Date Signed: 10/26/2022 05:04:07 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
09/29/2022 and conducted by Evaluator Destinee Hogue

PUBLIC

COMPLAINT CONTROL NUMBER: 09-CC-20220929125627

FACILITY NAME:	CORDOVA FAMILY CHILD CARE		FACILITY NUMBER:	334844715
ADMINISTRATOR:	CORDOVA,GABRIELA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(951) 396-0973
CITY:	CORONA	STATE: CA	ZIP CODE:	92879
CAPACITY:	14	CENSUS: 0	DATE:	10/26/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Licensee, Gabriela Cordova		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Personal Rights-Licensee mixed infants nursing milk
Personal Rights-Licensee refused to serve home prepared food for infant

INVESTIGATION FINDINGS:

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On 10/26/2022, an Informal Conference was held at 1:30pm in the Riverside Regional Office. Present during the Informal Conference were, Licensing Program Manager (LPM) Kimberly Williams, Licensing Program Analysts (LPAs) Destinee Hogue and Claudia Caywood. During today's Informal Conference, LPAs concluded the complaint investigation initiated on 10/06/22 while at the facility and discussed the findings of the above allegations with Licensee.

It was reported, on more than one occassion, Licensee Gabriela Cordova refused to feed a child(ren) food that a child's authorized representative provided to the facility. It was also reported that Licensee mixed a child(ren)'s nursing milk with formula that is only for emergencies.

During initial inspection on 10/06/22 and today (10/26/22), Licensee admitted to refusing a child(ren)'s food from home. Licensee disclosed she is enrolled in the food program and is not allowed to serve food brought from home. On or about September 19, 2022, Licensee admitted to mixing a child(ren)'s breast milk with formula because a child's authorized representative did not bring sufficient breast milk for the child(ren).

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberly Williams	TELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Destinee Hogue	TELEPHONE: (951) 218-5196
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

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-20220929125627

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: CORDOVA FAMILY CHILD CARE	FACILITY NUMBER: 334844715
	VISIT DATE: 10/26/2022

NARRATIVE

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Based on the above information, the Department has determined the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED.

See LIC9099D for cited deficiency.

LPAs informed Licensee Gabriela Cordova that this report dated 10/26/2022 document(s) (x1) Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care. Also, LPAs informed the Licensee Gabriela Cordova to provide a copy of this licensing report dated 10/26/2022 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the Licensee Gabriela Cordova.

SUPERVISOR'S NAME: Kimberly Williams	TELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Destinee Hogue	TELEPHONE: (951) 218-5196
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC9099 (FAS) - (06/04)

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Control Number 09-CC-20220929125627

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: CORDOVA FAMILY CHILD CARE	FACILITY NUMBER: 334844715
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/26/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/27/2022 Section Cited CCR 102423(a)(2)	1 2 3 4 5 6 7	PERSONAL RIGHTS. (a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged...(2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to update facility contract specifically, food policy. Licensee also agrees to submit a written statement detailing her plan to ensure a child(ren) is fed according to their meal plan.
	8 9 10 11 12 13 14	Based on interviews, Licensee admitted to refusing a child(ren)'s food brought from home and Licensee admitted to mixing a child(ren)'s breast milk with formula which poses an immediate health, safety, and personal rights risk to children in care.	8 9 10 11 12 13 14	During this inspection, LPA Hogue provided a copy of Title 22 Regulation, 102423-Personal Rights.
	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: Kimberly Williams	TELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Destinee Hogue	TELEPHONE: (951) 218-5196
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC9099 (FAS) - (06/04)

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