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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 344500083
Report Date: 11/23/2021
Date Signed: 11/23/2021 05:15:02 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
10/05/2021 and conducted by Evaluator Aruna Sridharan
PUBLIC
COMPLAINT CONTROL NUMBER: 53-CC-20211005151237
FACILITY NAME:SCRUGGS, PAULINEFACILITY NUMBER:
344500083
ADMINISTRATOR:SCRUGGS, PAULINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 418-1463
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:14CENSUS: 2DATE:
11/23/2021
UNANNOUNCEDTIME BEGAN:
03:49 PM
MET WITH:Pauline ScruggsTIME COMPLETED:
05:20 PM
ALLEGATION(S):
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Personal Rights-Child was provided food that the child is allergic to.
INVESTIGATION FINDINGS:
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At 4:10pm Licensing Program Analyst (LPA) met with licensee Pauline Scruggs to deliver the findings for the above allegation. Today's census is 2 preschoolers.

The complaint had the allegation that the child was provided foof that the child is allergic to. Licensee had submitted Unusual incident report and had acknowledged in the interview that the child was served food that the child was allergic to. The preponderance of all available information shows that the incident violated the child's personal rights. Therefore, this allegation is SUBSTANTIATED.

Deficiencies are cited on the subsequent pages of this report under the California Code of Regulations, Title 22.
(FOR TYPE A ONLY) Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. The LIC 9224 may be signed by parents/guardians and kept as a receipt whenever any Type A documents are provided by the licensee. LIC 9224 is available on the website. If the LIC 9224 is not used, the licensee shall prepare a statement indicating the documents have been provided. Licensee shall require the parent/guardian to sign and date the statement and shall keep the signed statement as receipt. Verification of receipt shall be kept in each child's file at the facility.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Justin L DentonTELEPHONE: (916) -92-0269
LICENSING EVALUATOR NAME: Aruna SridharanTELEPHONE: (916) 917-9273
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
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 3
Control Number 53-CC-20211005151237
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: SCRUGGS, PAULINE
FACILITY NUMBER: 344500083
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/24/2021
Section Cited
CCR
102423(a)92)
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102423(a)(2)-To receive safe, healthful, and comfortable accommodations, furnishings, and equipment. This regulation was not met as evidenced by:

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The licensee will have an action plan to adhere to diets and allergic medications. The facility will have the allergies list available to assistants.
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The child was served food that the child is allergic to.
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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: Justin L DentonTELEPHONE: (916) -92-0269
LICENSING EVALUATOR NAME: Aruna SridharanTELEPHONE: (916) 917-9273
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3