<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 343621006
Report Date: 06/24/2022
Date Signed: 07/26/2022 09:06:17 AM

Unsubstantiated


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
06/20/2022 and conducted by Evaluator Alize Tillery
PUBLIC
COMPLAINT CONTROL NUMBER: 03-CC-20220620083507
FACILITY NAME:STEPHENS, THEONIAFACILITY NUMBER:
343621006
ADMINISTRATOR:STEPHENS, THEONIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 822-1048
CITY:SACRAMENTOSTATE: CAZIP CODE:
95838
CAPACITY:14CENSUS: 4DATE:
06/24/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Theonia StephensTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Uncleared adult
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On Friday, June 24, 2022, at approximately 1:30 PM, Licensing Program Analysts (LPAs) Alize Tillery and Kelly Ferrara met with Licensee, Theonia Stephens, to conduct an unannounced inspection to initiate the complaint investigation regarding the above allegation. Upon arrival, LPAs observed 4 children supervised by licensee. During today’s visit, Licensee was the only adult present in the home.
During the inspection, LPAs conducted an interview with Licensee. Interview with Licensee revealed that another adult has visited the home during operation hours, temporarily around lunch time, on no more than 6 occassions. Licensee stated this individual is going through the fingerprint process as well. Licensee stated she understands adults working or residing in the home must be fingerprint cleared and may not interact with the children until the fingerprint process is completed.
During the inspection, LPA conducted interviews with parents; interviews revealed that parents have not observed another adult in the home besides Licensee and Licensee's assistant.
LPAs were unable to determine a violation occurred. There is not a preponderance of evidence to prove or disprove the allegation did or did not occur, therefore the above allegation is found to be UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Alize TilleryTELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
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 3
Control Number 03-CC-20220620083507
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: STEPHENS, THEONIA
FACILITY NUMBER: 343621006
VISIT DATE: 06/24/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Alize TilleryTELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 03-CC-20220620083507
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: STEPHENS, THEONIA
FACILITY NUMBER: 343621006
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
CCR
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
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: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Alize TilleryTELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3