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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 343623422
Report Date: 05/15/2023
Date Signed: 05/15/2023 11:56:28 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVER CITY (SACTO)CC, 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
03/22/2023 and conducted by Evaluator Erwina Pascual-Golamco
COMPLAINT CONTROL NUMBER: 03-CC-20230322080459
FACILITY NAME:BUILDING KIDZ OF RANCHO CORDOVAFACILITY NUMBER:
343623422
ADMINISTRATOR:MANCHESTER, ANGELINAFACILITY TYPE:
850
ADDRESS:1941 ZINFANDEL DRIVETELEPHONE:
(916) 706-2653
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY:45CENSUS: 27DATE:
05/15/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Mercy IshidaTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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staff did not provide authorized representative with an incident report
INVESTIGATION FINDINGS:
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Licensing Program Analysts Erwina Pascual-Golamco and Jennifer Velasco (LPA) met with Owner Mercy Ishida to deliver findings. LPAs toured the facility, including all activity and classroom spaces, restrooms, food service and outdoor play areas. Census included 27 preschool children being supervised by 4 classroom staff. Director was reminded never to exceed the conditions, limitations, and capacity specified on the license. Facility hours of operation are Monday through Friday from 7:00 AM to 6:00 PM.

It was alleged that staff did not provide authorized representative with an incident report. Throughout the course of the investigation LPA conducted interviews, and obtained relevant and reviewed documentation. Witness statements, and document reviews corroborated the allegations that staff did not provide authorized representative with an incident/injury report. The preponderance of evidence standard has been met, and the allegation is substantiated.

Title 22 deficiencies were cited during today's inspection and are documented on continuation page LIC809 D. This report was reviewed with Owner and an exit interview was conducted. Appeal Rights were provided. A Notice of Site Visit (NOS) was provided to Owner who will post it for a period of 30 days for parental review.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023
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-20230322080459
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: BUILDING KIDZ OF RANCHO CORDOVA
FACILITY NUMBER: 343623422
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/29/2023
Section Cited
CCR
101226.3(b)
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(b) Any unusual behavior, any injury or signs of illness requiring assessment and/or administration of first aid by staff shall be reported to the child's authorized representative and recorded in the child's record.
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Owner stated she will develop a detailed written plan to prevent this from hapenning again and email LPA by POC due date.
erwina.pascual-golamco@dss.ca.gov
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this requirement was not met as evidence by witness statements and documentation that staff failed to provide authorized representative with an incident/injury report. This is a potential risk to health, safety and or personal rights of children incare.
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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.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2