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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 393616379
Report Date: 07/22/2019
Date Signed: 07/22/2019 10:56:51 AM



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
07/05/2019 and conducted by Evaluator Mary Ponce
PUBLIC
COMPLAINT CONTROL NUMBER: 53-CC-20190705125717
FACILITY NAME:GRAHAM, CYNTHIA MFACILITY NUMBER:
393616379
ADMINISTRATOR:GRAHAM, CYNTHIA MFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 836-0282
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:14CENSUS: 13DATE:
07/22/2019
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Cynthia Graham TIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
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9
Minor sustained an unexplained injury while in care.
INVESTIGATION FINDINGS:
1
2
3
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5
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9
10
11
12
13
Licensing Program Analysts (LPAs) Mary Ponce and Chayntel Hunter met with licensee to deliver findings regarding the above allegation. It was alleged that a child sustained an unexplained injury while in care. During today's inspection LPAs toured all areas accessible by children in care. During the investigation, LPA Ponce conducted interviews, made observations, and obtained pertinent documention. Based on conflicting information during interviews, there is not a preponderence of evidence to show that a child sustained an injury while in care; therefore, this allegation is UNSUBSTANTIATED. No deficiencies have been cited during today's inspection.

Appeal Rights and Notice of Site Visit were provided. Notice of Site Visit must remain posted for 30 days.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Mary PonceTELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2019
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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