393619809-1-28-2021-53-CC-BENN-BXQ2G7-20210128162238

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 393619809
Report Date: 01/27/2021
Date Signed: 01/28/2021 11:08:40 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
09/08/2020 and conducted by Evaluator Marissa Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 53-CC-20200908153536

FACILITY NAME:	HERNANDEZ, ELVIA, ANTONIO, & DAISY		FACILITY NUMBER:	393619809
ADMINISTRATOR:	HERNANDEZ, E/A & D		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(209) 426-6244
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	14	CENSUS: 3	DATE:	01/27/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Elvia Hernandez		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Uncleared adult in the home

INVESTIGATION FINDINGS:

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Elvia Hernandez is Spanish speaking and Licensing Program Analyst (LPA) Marissa Soto spoke with Elvia Hernandez in Spanish and have translated the conversation to English below.
Due to the COVID-19 pandemic Licensing Program Analyst (LPA) Marissa Soto conducted a Tele-Visit via FaceTime with Licensee, Elvia Hernandez on 01/27/2021 at 3:00pm in lieu of conducting a site inspection regarding the above complaint allegation. Facility is still open during the COVID-19 pandemic, and todays census consisted of 3 children supervised by Licensee Eliva and Licensee Antonio. Licensee took LPA on virtual tour to each room that children have access to, including the backyard. The purpose of the tele-visit was to inform the Licensee of the findings for the above complaint allegations.
It was alleged that an uncleared adult in the home. During the investigation, LPA conducted an in-person tour of the facility, made observations, and conducted interviews the licensee, 6 adults, and one child. Five out of the six adults did not provide any corroboration or evidence to support the allegation. LPA Soto interviewed 1 child and the child did not provide any corroboration or evidence that could support the allegations. LPA was obtained proof of a separate dwelling with a different address.
----Report Continues on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Marissa Soto	TELEPHONE: (916) 926-9488
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2021

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 53-CC-20200908153536

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: HERNANDEZ, ELVIA, ANTONIO, & DAISY	FACILITY NUMBER: 393619809
	VISIT DATE: 01/27/2021

NARRATIVE

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Based on the information gathered throughout the course of the investigation there was not a preponderance of evidence to prove or dismiss the allegation. This complaint has been determined to be UNSUBSTANTIATED: meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

Exit interview conducted and appeal rights were discussed. A copy of this report, Notice of Site Visit, and appeal rights were emailed to the Licensee. Hard copy of the report with signature will be on file.

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Marissa Soto	TELEPHONE: (916) 926-9488
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2021

LIC9099 (FAS) - (06/04)

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