343614395-10-25-2021-03-CC-SDLA-C8FKVJ-20211104081425

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 343614395
Report Date: 10/25/2021
Date Signed: 10/25/2021 11:26:31 AM

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
08/13/2021 and conducted by Evaluator Karyn Guerra

PUBLIC

COMPLAINT CONTROL NUMBER: 03-CC-20210813144312

FACILITY NAME:	MISSION AVENUE PRESCHOOL		FACILITY NUMBER:	343614395
ADMINISTRATOR:	DUSTI KIRN		FACILITY TYPE:	830
ADDRESS:	2433 MISSION AVENUE		TELEPHONE:	(916) 487-4647
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	22	CENSUS: 14	DATE:	10/25/2021
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Christina Bushman		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Lack of supervision resulting in day care child ingesting an unknown substance while in care

INVESTIGATION FINDINGS:

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At 10:15 a.m. on Monday, October 25th, 2021, Licensing Program Analyst (LPA) Karyn Guerra, met with Christina Bushman, for the purpose of a complaint inspection to deliver findings. DIrector, Dusti Kirn, was stated to be supporting the sister facility, San Juan Preschool, in Citrus Heights, and was not present during today's inspection. It was alleged that there was a lack of supervision resulting in day care child ingesting an unknown substance while in care. There was a concern that a child came home with their own sippy cup that had a greyish soapy substance in it. Throughout the course of the investigation, LPA conducted interviews and made observations. It was stated in interviews with facility staff that some items brought from home may stay in children's backpacks because the facility utilizes their own utencils, cups, and bottles. Director and Staff reviewed the cleaning process for used bottles. Director and Staff stated

Report continued on 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Seychelle De Luca	TELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Karyn Guerra	TELEPHONE: (916) 216-7790
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021

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 03-CC-20210813144312

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: MISSION AVENUE PRESCHOOL	FACILITY NUMBER: 343614395
	VISIT DATE: 10/25/2021

NARRATIVE

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that children who are old enough use disposable paper cups while at the facility. Theallegation is unsubstantiated. Although the alleged violation may have happened or is valid, there is not a preponderance of evidence to prove or disprove that the alleged violation occurred, therefore, it is unsubstantiated. An exit interview was conducted and a notice of site visit provided. Notice of site visit shall remain posted for a period of 30 days.

SUPERVISOR'S NAME: Seychelle De Luca	TELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Karyn Guerra	TELEPHONE: (916) 216-7790
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021

LIC9099 (FAS) - (06/04)

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