343623875-6-24-2021-03-CC-SDLA-C6AN8D-20210827101408

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 343623875
Report Date: 06/24/2021
Date Signed: 06/24/2021 01:04:18 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: 17	DATE:	06/24/2021
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Maria Djalili		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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Personal Rights: Staff allowed child to consume peanuts which child is allergic to.

INVESTIGATION FINDINGS:

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On 6/24/21 at 8:30 am, Licensing Program Analyst (LPA) Jan Hoshida met with Program Coordinator Maria Djalilito conduct an initial 10-day complaint investigation regarding the above allegation. LPA conducted a health and safety inspection. Upon arrival, there were 17 children supervised by three staff.

During today's inspection, LPA conducted interviews, reviewed files, and obtained pertinent documents to assist with the investigation.

It was alleged that staff allowed child to consume peanuts which child is allergic to.

Staff stated that candy which contained nuts was brought on site by a staff member and was used in an activity with the children. Staff stated that the child with a nut allergy consumed the candy with nuts.

REPORT CONTINUED ON NEXT PAGE

Substantiated

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: 06/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

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: 06/24/2021

NARRATIVE

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Based on the information provided during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations Title 22 are being cited on the attached LIC 9099-D. This report must be posted for 30 days and must be provided to the parents of the children currently in care, as well as the parents of children enrolled over the next 12 months.

An exit interview was conducted in which the report was reviewed and discussed with Program Coordinator.
Appeal rights were discussed and a printed version was given to Program Coordinator. A Notice of Site Visit was provided to be posted for 30 days.

SUPERVISOR'S NAME: Maria Mayorga	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Jan Hoshida	TELEPHONE: (916) 917-6572
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/24/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/25/2021 Section Cited CCR 101227(a)(7)(b)	1 2 3 4 5 6 7	FOOD SERVICES: A child shall not be served any food to which the child's record indicates he/she has an allergy. This requirement was not meet as evidenced by:	1 2 3 4 5 6 7	Program Coordinator has conducted individual staff trainings regarding not bringing anything containing nuts on site. Program Coordinator has posted lists of children with food allergies within each classroom. Program Coordinator has implemented new policies where all food
	8 9 10 11 12 13 14	Staff stated that candy which contained nuts was brought on site by a staff member and was used in an activity with the children. Staff stated that the child with a nut allergy consumed the candy with nuts.	8 9 10 11 12 13 14	items for program activities will be brought only by management. Program Coordinator will provide additional individual staff training regarding which specific allergies that children have. Program Coordinator will provide LPA with meeting agenda with staff signatures by 6/25/21 via email.
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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: Maria Mayorga	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Jan Hoshida	TELEPHONE: (916) 917-6572
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

LIC9099 (FAS) - (06/04)

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