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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 364815781
Report Date: 03/04/2021
Date Signed: 03/04/2021 01:16:57 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/14/2020 and conducted by Evaluator Donna Maddox
COMPLAINT CONTROL NUMBER: 12-CC-20201214152815
FACILITY NAME:FUENTES FAMILY CHILD CAREFACILITY NUMBER:
364815781
ADMINISTRATOR:FUENTES, ROSAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 473-9238
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92407
CAPACITY:14CENSUS: DATE:
03/04/2021
UNANNOUNCEDTIME BEGAN:
02:08 PM
MET WITH:TIME COMPLETED:
02:09 PM
ALLEGATION(S):
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Personal rights: Infant sustained injury that required medical attention while in care of licensee
INVESTIGATION FINDINGS:
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LPA conducted interviews with licensee, staff, siblings, and parents prior to concluding this complaint investigation. Although there is evidence child #1 sustained an injury, LPA is unable to ascertain where the injury occurred. Both complainant and licensee deny the injury occurred while in their care.

Based on the information and interviews, LPA has concluded there is insufficient evidence to substantiate the allegation of personal rights, therefore, this complaint is rendered Unsubstantiated.

A finding that the complaint is Unsubstantiated means, although the allegation may have happened or is valid, there is not a preponderance of the evidence to substantiate.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Donna MaddoxTELEPHONE: (661) 568-8971
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021
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 2
Control Number 12-CC-20201214152815
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: FUENTES FAMILY CHILD CARE
FACILITY NUMBER: 364815781
VISIT DATE: 03/04/2021
NARRATIVE
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An exit interview was conducted, a copy of this report was read and forwarded to licensee, Rosa Fuentes via email for confirmation with "Read Receipt". A hard copy was mailed along with the the Notice of Site Visit.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Donna MaddoxTELEPHONE: (661) 568-8971
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2