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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 343614395
Report Date: 06/22/2023
Date Signed: 06/22/2023 04:39:32 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/11/2023 and conducted by Evaluator Josiah Gathing
PUBLIC
COMPLAINT CONTROL NUMBER: 03-CC-20230511092846
FACILITY NAME:MISSION AVENUE PRESCHOOLFACILITY NUMBER:
343614395
ADMINISTRATOR:CHRISTINA DIAZ BUSHMANFACILITY TYPE:
830
ADDRESS:2433 MISSION AVENUETELEPHONE:
(916) 487-4647
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:22CENSUS: 9DATE:
06/22/2023
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Christina Diaz BushmanTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Staff speaks inappropriately in the presence of infants
INVESTIGATION FINDINGS:
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On June 22, 2023, at approximately 12:15 PM. Licensing Program Analyst (LPA) Josiah Gathing and Licensing Program Manager (LPM) Seychelle De Luca met with Director Christina Diaz Bushman for the purpose of a complaint investigation and to deliver findings. It was alleged that staff speaks inappropriately in the presence of infants.
Throughout the course of the investigation, LPA conducted interviews, reviewed documents, and made observations. Staff stated in interview that a staff member used inappropriate language in the presence of infants. Staff also stated in interview that a staff member yelled at an infant in the presence of a parent. This incident led to the termination of the staff member's employment.
Therefore, based on interview, the preponderance of evidence standard has been met, and the allegation is substantiated. An exit interview was conducted and a notice of site visit provided. Notice of site visit shall remain posted for 30 days.
CONT. ON LIC 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Josiah GathingTELEPHONE: (916) 799-9668
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/11/2023 and conducted by Evaluator Josiah Gathing
PUBLIC
COMPLAINT CONTROL NUMBER: 03-CC-20230511092846

FACILITY NAME:MISSION AVENUE PRESCHOOLFACILITY NUMBER:
343614395
ADMINISTRATOR:CHRISTINA DIAZ BUSHMANFACILITY TYPE:
830
ADDRESS:2433 MISSION AVENUETELEPHONE:
(916) 487-4647
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:22CENSUS: 9DATE:
06/22/2023
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Christina Diaz BushmanTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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9
Daycare infant sustained multiple injuries while in care
INVESTIGATION FINDINGS:
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On Thursday, June 22, 2023, at approximately 12:15 PM Licensing Program Analyst (LPA) Josiah Gathing met with Director, Christina Diaz Bushman, for the purpose of a complaint investigation and to deliver findings. It was alleged that a daycare child sustained multiple injuries while in care. Throughout the course of the investigation, LPA conducted interviews, reviewed documents, and made observations. LPA observed incident reports in infant files reporting injuries and accidents. Staff stated in interview that they were not aware of any injuries that were not reported. LPA was not able to determine that the injuries reported in the allegation occurred while the child was in care at the facility.
Although the alleged violations may have happened or are valid, the preponderance of evidence standard has not been met to fully prove or disprove that they did or did not occur, therefore, they are unsubstantiated. An exit interview was conducted and a notice of site visit provided. Notice of site visit shall remain posted for 30 days.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Josiah GathingTELEPHONE: (916) 799-9668
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 03-CC-20230511092846
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MISSION AVENUE PRESCHOOL
FACILITY NUMBER: 343614395
VISIT DATE: 06/22/2023
NARRATIVE
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Title 22 deficiencies are cited on the subsequent pages of this report. Director acknowledges, that FOR TYPE A DEFICIENCIES ONLY upon receipt, licensee shall post LIC 9099D with Type A deficiencies for 30 days 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 during the next 12 months. LIC 9224 must be signed by parents/guardians and kept with the children's forms as a receipt whenever any Type A documents are provided by the licensee. LIC 9224 and Appeal Rights were provided. Director's signature on this report acknowledges receipt of these rights. This report was reviewed with the Director. An exit interview was conducted. A Notice of Site Visit was provided and shall remain posted for a period of 30 days.
Upon receipt, facility representative 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 enrolled at the facility during the next 12 months. Parents/guardians must acknowledge receipt of this report and citation by signing a LIC9224, “ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS”. A copy of this form should be placed in each child file upon receipt from parent.
LPA discussed this report with Director and conducted an exit interview. LPA also provided appeal rights. Notice of site visit posted.
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Josiah GathingTELEPHONE: (916) 799-9668
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 03-CC-20230511092846
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MISSION AVENUE PRESCHOOL
FACILITY NUMBER: 343614395
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/23/2023
Section Cited
CCR
101223(a)(1)
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101223 Personal Rights (a)The licensee shall ensure that each child is accorded the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations... This requirement was not met as evidenced by:
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The teacher in question was terminated from employment.
Director will provide personal rights training with staff.
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Based on interviews the facility did not comply with the above regulation as a teacher yelled at a child in care which poses Health, Safety, or Personal Rights risk to persons 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: Josiah GathingTELEPHONE: (916) 799-9668
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4