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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 343620812
Report Date: 11/04/2020
Date Signed: 11/04/2020 02:51:41 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
08/12/2020 and conducted by Evaluator Kelly Ferrara
PUBLIC
COMPLAINT CONTROL NUMBER: 03-CC-20200812102912
FACILITY NAME:BURNS, BREANNAFACILITY NUMBER:
343620812
ADMINISTRATOR:BURNS, BREANNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 293-2458
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:14CENSUS: 13DATE:
11/04/2020
ANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Breanna BurnsTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Facility did not file an Unusual Incident report
Lack of Supervision leading to day care child injured
Unsafe conditions in the home
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Ferrara conducted a tele-inspection (due to Covid-19) with Licensee Breanna Burns to deliver complaint findings for the above allegations. LPA verified that there are currently 13 children present at the facility with Licensee and an assistant. During the investigation, LPA conducted interviews with Licensee and the assistants and reviewed relevant documentation.
It was alleged that the Licensee did not submit an Unusual Incident Report after Child #1 obtained a serious injury in the home that required medical care. The injury occurred in November 2019. LPA did not receive an email from Licensee until August 2020 with pictures, hospital documentation, and an Unusual Incident Report. The injury that was obtained should have been reported to the Department within 24 hours and a written report sent within seven days.
It was alleged that the children were playing outside on a swing set and were not properly supervised, leading to the injury that occurred to Child #1. LPA reviewed the medical report for the child which detailed the injuries obtained. Based on interviews with the Licensee and assistants, there is typically an adult with a group of children, supervising and playing with them.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Kelly FerraraTELEPHONE: (916) 425-5932
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020
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-20200812102912
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: BURNS, BREANNA
FACILITY NUMBER: 343620812
VISIT DATE: 11/04/2020
NARRATIVE
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However on the day of the incident, school age children were pushing Child #1 and another child on a swing while the Licensee and assistant were both inside. According to a statement written by a child who observed the incident, they were pushing the children on the swing for 10-15 minutes and the children were changing positions while the swing was moving. It went too high causing Child #1 to let go of the swing and fall on to her face obtaining the injuries. LPA determined that if an adult had been outside supervising, they could have monitored the swing to be used appropriately or stopped it from going too high.

It was alleged that the outdoor play area was unsafe for children to play. This was based on playground equipment that had been taken apart and was going to be removed from the home. However, the Licensee did not restrict access to the play equipment and continued to let children play on it in a way that was not intended for use. LPA observed through videos, pictures, and during the tele-inspection that the slide structure had been separated into multiple pieces, with the ladder propped up on to a wooden bridge and the slide not attached to anything stable. LPA learned that the Licensee recently had the play equipment removed from the home and will be buying a new play structure.

Based on the information obtained during the investigation, LPA determined the allegations are substantiated, meaning that the preponderance of evidence standard has been met. Citations have been issued on the following page. Appeal rights were provided and exit interview was conducted. Notice of site was posted.

Licensee acknowledges that for TYPE A DEFICIENCIES ONLY upon receipt, Licensee shall post LIC 9099-D with Type A deficiency 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 within 24 hours and kept with the children's forms as a receipt.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Kelly FerraraTELEPHONE: (916) 425-5932
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 03-CC-20200812102912
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: BURNS, BREANNA
FACILITY NUMBER: 343620812
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2020
Section Cited
CCR
102417(a)
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The licensee shall be present in the home and shall ensure that children in care are supervised at all times. This requirement was not met as evidenced by: A lack of supervision by Licensee or an assistant led to Child #1 falling from a swing and obtaining an injury. This is an immediate health and safety risk to children in care.
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Licensee shall submit a written plan of how she will provide proper supervision to the children in care and train the assistants on the plan. Licensee and staff will sign and date the document. Licensee shall submit the plan to LPA by POC due date.
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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: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Kelly FerraraTELEPHONE: (916) 425-5932
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 03-CC-20200812102912
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: BURNS, BREANNA
FACILITY NUMBER: 343620812
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/11/2020
Section Cited
HSC
1597.467(b)(1)
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A report shall be made to the department…. during the department's normal business hours before the close of the next working day following the occurrence… of any of the following events: (B) Any injury to any child that requires medical treatment. (1), a written report shall be submitted to the department within seven days…
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Licensee shall review the regulations regarding reporting requirements and submit a signed, written statement that she has read and understands what must be reported to the Department. Licensee shall submit this document to LPA by POC due date.
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The following requirement was not met as evidenced by: Licensee submitted an Unusual Incident Report on 8/11/20, which was approximately nine months after the incident occurred on 11/7/20. This poses a potential health and safety risk to children in care.
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Type B
11/11/2020
Section Cited
CCR
102417(d)
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The home shall provide safe toys, play equipment and materials. This requirement was not met as evidenced by: The play equipment outside was taken apart and not being used as intended, leading to unsafe conditions in the home. This poses a potential health and safety risk to children in care.
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LPA observed that the play equipment has already been removed from the home. Licensee understands that the new play equipment must be used as intended and anchored securely according to the manufacture instructions. Licensee shall submit pictures of the new equipment to LPA.
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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: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Kelly FerraraTELEPHONE: (916) 425-5932
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 4