384000668-6-18-2019-05-CC-AMAG-BE5NYT-20190716105317

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 384000668
Report Date: 06/18/2019
Date Signed: 06/18/2019 02:17:55 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/12/2019 and conducted by Evaluator Cindy Interiano

PUBLIC

COMPLAINT CONTROL NUMBER: 05-CC-20190212162220

FACILITY NAME:	CAI, XIU HUA & LAU, OLIVIA W.		FACILITY NUMBER:	384000668
ADMINISTRATOR:	CAI, XIU HUA & LAU, OLIVIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 242-0965
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94122
CAPACITY:	14	CENSUS: 10	DATE:	06/18/2019
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Licensee, Olivia W. Lau		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Child sustained severe injuries while in care due to Neglect/Lack of supervision
Failure to report incident to CCLD

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs), Cindy Interiano and Winnie Ly, conducted an unannounced complaint inspection, and met with Licensees, Xiu Hua Cai and Olivia W. Lau to discuss the above allegation. Present in the facility is Licensee, Co-Licensee, and Helper caring for 10 children (4 Infants, 6 PreK).
During the course of the investigation, Investigations Bureau (IB) Investigator, Shanie Churchwell obtained medical and conducted interviews with Licensees, Helpers, Guardians, and Children. It was determined child sustained a severe injury which required medical attention.
Licensees did not self-report incident. Licensees states they now understands the reporting requirements of unusual incidents: calling within 24 hours and submitting an LIC 624 within 7 days.
See page 2. . .

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2019

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 05-CC-20190212162220

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CAI, XIU HUA & LAU, OLIVIA W.	FACILITY NUMBER: 384000668
	VISIT DATE: 06/18/2019

NARRATIVE

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Page 2. . .

Based on information obtained, the preponderance of evidence standard has been met, therefore the allegations of a child sustaining severe injury while in care due to neglect or lack of supervision and the lack of reporting to CCLD are found to be SUBSTANTIATED.

***See attached page for deficiencies cited against the facility under CCR,Title 22, Div. 12, Chapt. 1.***

Type “A” violations were issued today. Licensee is advised to provide a copy of the Evaluation Report and the Type “A” Deficiencies cited, to the parents and guardians of children currently enrolled in care and to parents of newly enrolled children during the next 12 months. A signed and dated LIC 9224 (Deficiency and Acknowledgment of Receipt of Licensing Reports) shall be maintained in all Children's files.

This report will be kept in the Facility File and will be made available for Public Review upon request. Website for Forms and Regulations: www.ccld.ca.gov. This report and rights to comment and appeal have been discussed with Licensee. Notice of Site Visit was observed being posted.

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2019

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 05-CC-20190212162220

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CAI, XIU HUA & LAU, OLIVIA W.	FACILITY NUMBER: 384000668
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 06/18/2019 Section Cited CCR 102417(a)	1 2 3 4 5 6 7	102417 (a) Operation of a Family Child Care Home (a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times.	1 2 3 4 5 6 7	Civil Penalty of $1350.00 has been assessed due to injury caused by lack supervision. License is being referred to CCL’s Legal Department.
	8 9 10 11 12 13 14	This requirement was not met as evidence based on information obtained by IB Investigator Churchwell. Child sustained a severe injury which required medical attention. This poses an Immediate safety risk to children in care.	8 9 10 11 12 13 14
Type B 06/18/2019 Section Cited CCR 102416(b)	1 2 3 4 5 6 7	102416(b) Reporting Requirements. Licensee shall report to CCLD any event(s) as specified in Health and Safety Code Sec.1597.467(b)(1)(A) through (b)(1)(C) that occur during the operation of the family child care home.	1 2 3 4 5 6 7	Licensees reported incident on 02/20/19. License is being referred to CCL’s Legal Department.
	8 9 10 11 12 13 14	This requirement is not met based on Licensees not calling to report 02/11/19 incident until 02/20/19. This poses a potential safety risk to children in care.	8 9 10 11 12 13 14

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: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2019

LIC9099 (FAS) - (06/04)

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