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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 343621637
Report Date: 11/21/2019
Date Signed: 11/21/2019 05:46:23 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
09/19/2019 and conducted by Evaluator Joleen Kenney
PUBLIC
COMPLAINT CONTROL NUMBER: 03-CC-20190919151346
FACILITY NAME:PIERCE, TIFFANYFACILITY NUMBER:
343621637
ADMINISTRATOR:PIERCE, TIFFANYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 743-0397
CITY:SACRAMENTOSTATE: CAZIP CODE:
95833
CAPACITY:14CENSUS: 12DATE:
11/21/2019
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Tiffany PierceTIME COMPLETED:
05:55 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
A child was not provided safe accommodations and sustained an injury.
Licensee failed to report an incident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
 Licensing Program Analyst (LPA) Joleen Kenney conducted an unannounced complaint inspection and met with the Licensee, Tiffany Pierce. It was alleged that a child was not provided safe accommodations and sustained an injury. It was reported that a child fell from the facility van when exiting and sustained an injury. The Licensee stated that she was in the van assisting another child and was unable to stop the child from falling. During the investigation, records and videos were reviewed and interviews were conducted with the Licensee and parent. The information obtained during the investigation revealed inconsistencies. Based on the investigation, this allegation was determined to be unsubstantiated.
It was also alleged that the Licensee failed to report an incident. It was stated that there was an incident that occurred involving child #1 (C1) and that the Licensee failed to report the incident to the parent and to the Licensing agency. The Licensee denied the allegation and stated that she did not have any knowledge of an incident involving child #1 until the parent text the Licensee with limited information regarding an incident and did not state any information that medical care was required. Based on the investigation and lack of information, this allegation was determined to be unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Joleen KenneyTELEPHONE: (916) 799-9668
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2019
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-20190919151346
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: PIERCE, TIFFANY
FACILITY NUMBER: 343621637
VISIT DATE: 11/21/2019
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
An unsubstantiated finding means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation did or did not occur, therefore this complaint is unsubstantiated. An exit interview was conducted. Appeal rights were given. A Notice of Site Visit was provided and posted during this inspection.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Joleen KenneyTELEPHONE: (916) 799-9668
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2019
LIC9099 (FAS) - (06/04)
Page: 2 of 2