343616796-8-12-2021-03-CC-MMAA-C63M4V-20210820091723

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 343616796
Report Date: 08/12/2021
Date Signed: 08/12/2021 11:25:43 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
05/24/2021 and conducted by Evaluator Gagandeep Singh

PUBLIC

COMPLAINT CONTROL NUMBER: 03-CC-20210524095123

FACILITY NAME:	OUR LADY OF THE ASSUMPTION		FACILITY NUMBER:	343616796
ADMINISTRATOR:	DUESBURY, ANN MARIE		FACILITY TYPE:	850
ADDRESS:	5055 COTTAGE WAY		TELEPHONE:	(916) 485-1504
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	30	CENSUS: 0	DATE:	08/12/2021
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Ann Marie Duesbury		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Child wandered from the facility.
Facility staff do not enure that children are signed in/out.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gagandeep Singh met with the director, Ann Maire Duesbury, to deliver the findings of the complaint alleging the above allegations. Purpose of the inspection was explained.

During the investigation, LPA interviewed the director and the teacher, who were present on the day of the incident. Through the interviews, it was found that a child was able to leave the classroom unattended and reached the parking lot of the facility without any supervision. Through interviews, it was also found that the facility had procedure of staff checking in and out the children from the facility, rather than child’s authorized representative. Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations are being cited on the attached LIC 9099D and civil penalties are assessed. Copy of this report is reviewed and provide to the director. Notice of site visit is posted and shall remain posted for next 30 days.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maria Mayorga	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Gagandeep Singh	TELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021

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-20210524095123

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: OUR LADY OF THE ASSUMPTION	FACILITY NUMBER: 343616796
	VISIT DATE: 08/12/2021

NARRATIVE

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A Type “A” violation (see continuation) was issued today. The center is informed to provide a copy of the Evaluation Report and the Type “A” Deficiency cited to the parents and guardians of children currently enrolled in care and to parents of newly enrolled children during the next 12 months. A signed and dated LIC 9224 shall be maintained in all Children's files. This report and appeal rights were provided and reviewed with the licensee. Notice of Site Visit shall remain posted for 30 days.

SUPERVISOR'S NAME: Maria Mayorga	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Gagandeep Singh	TELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021

LIC9099 (FAS) - (06/04)

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Control Number 03-CC-20210524095123

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: OUR LADY OF THE ASSUMPTION	FACILITY NUMBER: 343616796
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/12/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/13/2021 Section Cited CCR 101229(a)(1)	1 2 3 4 5 6 7	No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation. This requirement is not met as evidenced by interviews and documents collected;	1 2 3 4 5 6 7	The facility has changed the classrooms to the other side of the building. Outside the new classrooms, there is a hallway, office and lobby area before any child can reach to parking lot. Supervision requirements were explained to the director. Civil penalties were assessed.
	8 9 10 11 12 13 14	it was found that a child went to the parking lot of the facility unsupervised. The child was brought back to the facility by the Principal of the school. This poses an immediate health and safety risk to 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: Maria Mayorga	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Gagandeep Singh	TELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 03-CC-20210524095123

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: OUR LADY OF THE ASSUMPTION	FACILITY NUMBER: 343616796
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/12/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/27/2021 Section Cited CCR 101229.1(b)	1 2 3 4 5 6 7	The person who brings the child to, and removes the child from, the center shall sign the child in/out. This requirement is not met as evidenced by interviews, it was found that children were signed in and out by facility staff, not the person bringing or removing the children. This poses a potential Health and Safety risk to children in care.	1 2 3 4 5 6 7	LPA observed the director has sign in/out form in place. Director agreed to have the each child's representative sign the form during the time of pick up and drop off.
	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
	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: Maria Mayorga	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Gagandeep Singh	TELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021

LIC9099 (FAS) - (06/04)

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