384000867-11-1-2021-05-CC-CINO-C8GTCB-20211105143626

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 384000867
Report Date: 11/01/2021
Date Signed: 11/01/2021 10:40:19 AM

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
04/20/2021 and conducted by Evaluator Luis Gomez

PUBLIC

COMPLAINT CONTROL NUMBER: 05-CC-20210420093231

FACILITY NAME:	MISSION HEAD START-WOMEN'S BUILDING CENTER		FACILITY NUMBER:	384000867
ADMINISTRATOR:	REYES, CINDY		FACILITY TYPE:	850
ADDRESS:	3543 18TH STREET		TELEPHONE:	(415) 701-1995
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94110
CAPACITY:	23	CENSUS: 16	DATE:	11/01/2021
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Cyndee Nieves, Richard Ybarra		TIME COMPLETED:	11:50 AM

ALLEGATION(S):

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Facility staff member poses a risk to day care children.

INVESTIGATION FINDINGS:

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On 11/1/2021 at 9:50A.M.,Licensing Program Analyst (LPA), Luis Gomez conducted an unannounced subsequent complaint inspection to discuss the above allegation and met with Senior Director, Cindy Nieves and CEO, Richard Ybarra. Present at site was the Director and 3 staff supervising 16 children. Allegation was investigated by the Department’s Investigations Branch (IB).

During the course of the investigation, IB conducted interviews with Staff, Children, Guardians, and obtained by Police and Federal Bureau of Investigations (FBI) reports. It was determined that Staff, Robyn “Jace” Wong, exhibited conduct inimical behavior with children. Facility self-reported to CCLD that staff member was arrested by FBI on 04/13/21. Staff and Facility were served with an immediate exclusion of the Staff on 04/16/21.

(REFER TO 809-C FOR CONT.)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021

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 05-CC-20210420093231

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: MISSION HEAD START-WOMEN'S BUILDING CENTER	FACILITY NUMBER: 384000867
	VISIT DATE: 11/01/2021

NARRATIVE

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(Page 2)
Based on information obtained by IB, facility staff member posed a risk to day care children. The preponderance of evidence standard has been met; therefore the allegations are found to be SUBSTANTIATED.

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

Type “A” violations were issued today. Facility 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 Director. Notice of Site Visit was observed being posted.

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 05-CC-20210420093231

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: MISSION HEAD START-WOMEN'S BUILDING CENTER	FACILITY NUMBER: 384000867
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/01/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/01/2021 Section Cited HSC 1596.885(c)	1 2 3 4 5 6 7	§1596.885(c): Conduct which is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of this state. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Facility self-reported to CCLD that Staff was arrested by FBI on 04/13/21. Facility and Staff were served with an immediate exclusion from the department on 04/16/21. Staff continues to be incarcerated. Deficiency cleared as of today, 11/1/2021.
	8 9 10 11 12 13 14	Based on information obtained by the Department’s Investigations Branch (IB), Staff, Robyn “Jace” Wong posed a risk to day care children. This poses an Immediate Health and Safety risk to children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021

LIC9099 (FAS) - (06/04)

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