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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 343620703
Report Date: 06/11/2019
Date Signed: 06/11/2019 01:10:55 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
04/16/2019 and conducted by Evaluator Christopher Bello
PUBLIC
COMPLAINT CONTROL NUMBER: 03-CC-20190416135542
FACILITY NAME:PADILLA, ANNFACILITY NUMBER:
343620703
ADMINISTRATOR:PADILLA, ANNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 856-2766
CITY:SACRAMENTOSTATE: CAZIP CODE:
95826
CAPACITY:14CENSUS: 6DATE:
06/11/2019
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Ann PadillaTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Lack of supervision resulting in inappropriate interaction between day-care children
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Christopher Bello and Marea Behvand met with licensee, Ann Padilla, to close a complaint investigation regarding the above allegation. Upon arrival, LPAs observed six Children. Also present was licensee’s daughters and minor resident. During the investigation LPAs conducted interviews with the licensee and residents of the home who witnessed the incident. The licensee on 4/15/19 self-reported the incident to the department. The interviews and self-report corroborated the allegation. Based on LPAs' investigation the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED.
Title 22 deficiencies are cited on the subsequent page of this report. Director/Licensee acknowledges, that for TYPE A DEFICIENCIES ONLY upon receipt, Director/Licensee shall post LIC 9099-D 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 Director. LIC 9224 and Appeal Rights were provided. An exit interview was conducted and a Notice of Site Visit posted which must remain posted for 30 days.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Christopher BelloTELEPHONE: (916) 862-0844
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2019
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 2
Control Number 03-CC-20190416135542
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: PADILLA, ANN
FACILITY NUMBER: 343620703
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/17/2019
Section Cited
CCR
102417(a)
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Operation of a Family Child Care Home. The licensee shall be present in the home and shall ensure that children in care are supervised at all times. This is not met by evidence: Licensee self reported an incident regarding lack of supervision. This is considered a immediate risk to the
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Licensee stated that she will write a statement on what the facility learned and waht they will change to prevent future incidents by POC date: 6/17/19
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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: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Christopher BelloTELEPHONE: (916) 862-0844
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2019
LIC9099 (FAS) - (06/04)
Page: 2 of 2