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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 343610520
Report Date: 09/02/2021
Date Signed: 09/02/2021 01:38:54 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/17/2021 and conducted by Evaluator Alize Tillery
PUBLIC
COMPLAINT CONTROL NUMBER: 03-CC-20210817101420
FACILITY NAME:POPPY PATCH-PHASE IIIFACILITY NUMBER:
343610520
ADMINISTRATOR:TATE, SHANELFACILITY TYPE:
830
ADDRESS:9638 BUTTERFIELD WAYTELEPHONE:
(916) 845-4949
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY:60CENSUS: 19DATE:
09/02/2021
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Shanel TateTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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- Child substantiated injuiries while in care
- Child consumed large amounts of play foam
- Facility did not notify parent of incident
INVESTIGATION FINDINGS:
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On 9/2/21 at 10:15 AM, Licensing Program Analysts (LPAs) Alize Tillery and Chris Bello, met with Director Shanel Tate to conclude the investigation and deliver findings for the above allegations. Upon arrival, today’s census was 19 children and 6 staff.

During the course of this investigation, LPA Tillery and Bello conducted interviews with the complainant, director, 2 staff, and parents. It was alleged that a child received an injury in care; information obtained during interviews confirmed that a child did receive an injury resulting in bruising. It was also alleged that a child consumed a large amount of modeling foam beads; information obtained during interviews confirmed that the children were not playing with age appropriate modeling foam beads, which led to a child consuming an unknown amount. Both of the incidents are considered as immediate risks to the children in care. Neither incidents were reported to the parent; this is considered a potential risk to the children in care. Director stated that she has communicated with staff regarding these allegations.



Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Alize TilleryTELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 03-CC-20210817101420
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: POPPY PATCH-PHASE III
FACILITY NUMBER: 343610520
VISIT DATE: 09/02/2021
NARRATIVE
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LPAs discussed the importance of personal rights and supervision. Based on information obtained during interviews, the preponderance of evidence standard has been met, therefore all allegations are found to be SUBSTANTIATED. See 9099D for deficiencies cited.

Upon receipt, licensee shall post and provide copies of this licensing report to parents/ guardians of children who are currently enrolled as well as parents/guardians of children newly enroll at the facility during the next 12 months. Parents/guardians must acknowledge receipt of this report and citation by signing a LIC 9224, “ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS”. A copy of this form should be placed in each child file upon receipt from parent.

LPAs reviewed the report with Director and provided copies. Appeal Rights were also issued and discussed. A Notice of Site Visit was issued, and Director acknowledges it must remain posted for 30 days.
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Alize TilleryTELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 03-CC-20210817101420
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: POPPY PATCH-PHASE III
FACILITY NUMBER: 343610520
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/10/2021
Section Cited
CCR
101226(a)
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(a) The licensee shall immediately notify the child's authorized representative if the child becomes ill or sustains an injury more serious than a minor cut or scratch. The licensee shall obtain specific instructions from the authorized representative regarding action to be taken.
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Director will train staff on reporting requirements. Director will complete this training by plan of correction date 9/10/2021 and provide proof of completion to LPA Tillery.
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This requirement was not met, evidenced by:
Director confirmed that staff did not report a severe bite that a child received while in care. This is considered a potential risk to the children in care.
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CCR
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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: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Alize TilleryTELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 03-CC-20210817101420
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: POPPY PATCH-PHASE III
FACILITY NUMBER: 343610520
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/03/2021
Section Cited
CCR
101429(a)(1)
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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, evidenced by: Director confirmed that a child received unexplainable injury while in care. This is considered as an immediate risk to the children in care
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Director will conduct a training with staff on Supervision and provide proof of completition to LPA Tillery by plan of correction date 9/3/2021.
Type A
09/02/2021
Section Cited
CCR
101223(a)(2)
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To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

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Director confirmed that an internal investigation was conducted and the molding foam beads have since been removed from the infant room and given to their older facility.
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This requirement was not met, evidenced by:
Director confirmed that staff were unaware on how much molding foam beads the child consumed. This is considered as an immediate risk to the children in care
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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: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Alize TilleryTELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4