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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 343623873
Report Date: 01/05/2022
Date Signed: 01/05/2022 12:21:40 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
10/18/2021 and conducted by Evaluator Fabiola Diaz
COMPLAINT CONTROL NUMBER: 03-CC-20211018103641
FACILITY NAME:JIMENEZ, MELINAFACILITY NUMBER:
343623873
ADMINISTRATOR:JIMENEZ, MELINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 247-2530
CITY:RIO LINDASTATE: CAZIP CODE:
95673
CAPACITY:14CENSUS: 4DATE:
01/05/2022
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Melina JimenezTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Hazards accessible to children
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Fabiola Diaz and Arianna Manabat arrived at the facility at approximately 9:10 am and met with licensee to close a complaint investigation, regarding the above allegation. LPAs began a tour of the facility at approximately 9:15 am. Upon arrival, LPA observed 3 day care children, and a 4th child arrived at a later time. During the investigation LPA Diaz made observations, conducted interviews and gathered documents pertaining to the investigation.
It was alleged that hazards are accessible to children at the facility. Today's observations corroborated the allegation. LPAs observed detergents, cleaning supplies, hair products, and other hazards inside the facility within the on-limits areas. LPAs observed wooden pieces with exposed nails on the ground within the outside play space. Licensee explained day care children have recently not been using the outside play space since there was recent flooding.
Based on LPA’s 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.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Fabiola DiazTELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
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-20211018103641
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: JIMENEZ, MELINA
FACILITY NUMBER: 343623873
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/06/2022
Section Cited
CCR
102417(g)(4)
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(g) The home shall be free from defects...Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines...items which could pose a danger...to children shall be stored where they are inaccessible to children.
This requirement is not met as evidenced by:
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Licensee remove all cleaning compounds and hazardous items inside the facility and made them inaccessible to day care children.
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Based on observation and interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPAs observed cleaning compounds and hazardous items accessible to children inside and outside the facility.
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Licensee stated she will provide photos of the outside play space by 1/06/2022 to demonstrate all hazards have been removed.
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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: Fabiola DiazTELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
10/18/2021 and conducted by Evaluator Fabiola Diaz
COMPLAINT CONTROL NUMBER: 03-CC-20211018103641

FACILITY NAME:JIMENEZ, MELINAFACILITY NUMBER:
343623873
ADMINISTRATOR:JIMENEZ, MELINAFACILITY TYPE:
810
ADDRESS:5720 W. 6TH STREETTELEPHONE:
(916) 247-2530
CITY:RIO LINDASTATE: CAZIP CODE:
95673
CAPACITY:8CENSUS: 4DATE:
01/05/2022
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Melina JimenezTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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9
Licensee is rarely present at the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Fabiola Diaz and Arianna Manabat arrived at the facility at approximately 9:10 am and met with licensee to close a complaint investigation, regarding the above allegation. LPAs began a tour of the facility at approximately 9:15 am. Upon arrival, LPA observed 3 day care children, and a 4th child arrived at a later time. During the investigation LPA Diaz made observations, conducted interviews and gathered documents pertaining to the investigation. It was alleged that the licensee is rarely present at the facility. Parent and staff interviews consisted of conflicting information. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Fabiola DiazTELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 03-CC-20211018103641
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: JIMENEZ, MELINA
FACILITY NUMBER: 343623873
VISIT DATE: 01/05/2022
NARRATIVE
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Appeal Rights were provided, and an exit interview was conducted. A Notice of Site Visit was posted and must remain posted for 30 days. Report continues on LIC9099-C. LPAs informed licensee that this report dated 1/5/2022 documents one Type A citation. Type A citation shall be posted for 30 consecutive days as there are immediate risks to the health, safety, or personal rights of children in care.

Also, LPAs informed the licensee to provide a copy of this licensing report dated 1/5/22 that documents any Type A citations to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Fabiola DiazTELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4