376628971-6-15-2021-20-CC-CGRY-C4A2ER-20210623172018

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 376628971
Report Date: 06/14/2021
Date Signed: 06/15/2021 08:42:56 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/25/2021 and conducted by Evaluator Adrian Castellon

COMPLAINT CONTROL NUMBER: 20-CC-20210325090724

FACILITY NAME:	DORVILUS, ROSE ERTHA FAMILY CHILD CARE		FACILITY NUMBER:	376628971
ADMINISTRATOR:	ROSE ERTHA DORVILUS		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(619) 394-9731
CITY:	SPRING VALLEY	STATE: CA	ZIP CODE:	91977
CAPACITY:	14	CENSUS: 5	DATE:	06/14/2021
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Rose Dorvilus		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Adult living in home does not have criminal record clearance.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Adrian Castellon arrived to conduct an unannounced inspection to deliver complaint findings for the above listed allegation. LPA Castellon met with licensee Dorvilus and discussed the purpose of the inspection. There were five children present at time inspection. It was alleged an uncleared adult was living in the home.

LPA Castellon conducted interviews with licensee Dorvilus, a facility assistant, and daycare parents. Licensee Dorvilus stated uncleared Adult #1 was residing in home for approximately 4 months without proper clearances until the adult moved out of the home on April 2, 2021, the day LPA Castellon began the investigation. Licensee Dorvilus states she was under the impression that Adult #1 was cleared. Licensee understands a civil penalty will be assessed for $500.00. Based on Licensees admission, the preponderance of evidence standard has been met that an uncleared adult living in the home, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 12, Chapter 3, is being cited on the attached LIC 9099D.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cynthia Gray	TELEPHONE: (619) 767-2258
LICENSING EVALUATOR NAME: Adrian Castellon	TELEPHONE: (619) 767-2237
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

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 20-CC-20210325090724

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: DORVILUS, ROSE ERTHA FAMILY CHILD CARE	FACILITY NUMBER: 376628971
	VISIT DATE: 06/14/2021

NARRATIVE

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AB633 requires 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. An Acknowledgment of Receipt of Licensing Reports, Form LIC 9224 must be signed and placed in each child’s file.

Licensee was provided appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. Notice of Site Visit (LIC 9213) was provided to be posted at the facility for 30 days. LPA observed form LIC 9213 posted. An exit interview was conducted.

SUPERVISOR'S NAME: Cynthia Gray	TELEPHONE: (619) 767-2258
LICENSING EVALUATOR NAME: Adrian Castellon	TELEPHONE: (619) 767-2237
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC9099 (FAS) - (06/04)

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Control Number 20-CC-20210325090724

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: DORVILUS, ROSE ERTHA FAMILY CHILD CARE	FACILITY NUMBER: 376628971
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/14/2021 Section Cited CCR 102370(d)(1)	1 2 3 4 5 6 7	Criminal Record Clearance. All individuals subject to a criminal record review as specified in Section 1596.871 prior to working, residing or volunteering in a licensed home, shall obtain a California clearance or a criminal record exemption as required by the Department. Requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee Dorvilus states that she will have all adults fingerprint cleared prior to the adults living or working at the daycare facility. Licensee states that she will ensure that the adult is also associated to the facility. The adult in question has moved out of the facility.
	8 9 10 11 12 13 14	Licensees Dorvilus' admission that uncleared adult #1 was living in the home for approximately 4 months without a criminal record clearance. This poses a Potential Health and Safety risk to the clients in care.	8 9 10 11 12 13 14
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	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Cynthia Gray	TELEPHONE: (619) 767-2258
LICENSING EVALUATOR NAME: Adrian Castellon	TELEPHONE: (619) 767-2237
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC9099 (FAS) - (06/04)

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