343623875-8-25-2021-03-CC-SDLA-C6AN8C-20210827101408

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 343623875
Report Date: 08/25/2021
Date Signed: 08/25/2021 02:07:58 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
06/18/2021 and conducted by Evaluator Jan Hoshida

PUBLIC

COMPLAINT CONTROL NUMBER: 03-CC-20210618100848

FACILITY NAME:	4TH R - PASO VERDE		FACILITY NUMBER:	343623875
ADMINISTRATOR:	DJALILI, MARIA		FACILITY TYPE:	840
ADDRESS:	3883 DEL PASO ROAD		TELEPHONE:	(916) 566-4496
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95834
CAPACITY:	150	CENSUS: 0	DATE:	08/25/2021
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Maria Djalilito		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Other: Staff are not abiding by facility’s peanut free policy
Medication: Staff did not administer day care child's correct medication

INVESTIGATION FINDINGS:

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On 08/25/21 at 1:20pm, Licensing Program Analyst (LPA) Jan Hoshida met with Program Coordinator Maria Djalilito to deliver findings and conclude the complaint investigation of the above allegations. LPA conducted a health and safety inspection. Upon arrival, there were no day care children present during the inspection.

It was alleged that staff are not abiding by facility’s nut free policy and staff did not administer day care child’s correct medication.

During the investigation, LPA conducted a health and safety inspection the facility, conducted observations of staff and children both indoors and out, and conducted interviews with pertinent parties. LPA reviewed facility files and obtained records relevant to the complaint investigation.

REPORT CONTINUED ON NEXT PAGE

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maria Mayorga	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Jan Hoshida	TELEPHONE: (916) 917-6572
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 03-CC-20210618100848

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: 4TH R - PASO VERDE	FACILITY NUMBER: 343623875
	VISIT DATE: 08/25/2021

NARRATIVE

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Based on document review, the facility does not have a written peanut or nut free policy within their handbook. LPA observed and learned through interviews that after the incident on 06/17/21, the facility has signs posted that indicate that the facility is nut-free, and has informed all children, staff, and families of their nut-free policy.

Staff interviewed stated that they administered the medication based on the physician’s prescription that was provided, medication release forms obtained, and through approval of day care child’s authorized representative.

Due to conflicting information obtained through interviews and documentation, LPA was unable to determine if a violation occurred.

Based on the investigation conducted, although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. As a result, the allegations are UNSUBSTANTIATED.

Report reviewed with Program Coordinator and copies were provided. Notice of Site Visit was issued and Program Coordinator understands that it must remain posted for 30 days. Appeal Rights were also provided and discussed.

SUPERVISOR'S NAME: Maria Mayorga	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Jan Hoshida	TELEPHONE: (916) 917-6572
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

LIC9099 (FAS) - (06/04)

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