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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 393620781
Report Date: 11/22/2019
Date Signed: 02/07/2020 03:14:47 PM



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
11/15/2019 and conducted by Evaluator Stacey Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 53-CC-20191115175508
FACILITY NAME:CREATIVE CHILD CARE @ DON AVENUE CDCFACILITY NUMBER:
393620781
ADMINISTRATOR:EISON, DEBRAFACILITY TYPE:
850
ADDRESS:8121 DON AVENUETELEPHONE:
(209) 956-2686
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:109CENSUS: 57DATE:
11/22/2019
UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Mayra Madigral TIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Personal Rights
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
* This is an amended report*

Licensing Program Analyst (LPA) Stacey Williams arrived at the facility for the purpose of conducting a complaint investigation inspection regarding the allegation listed above. LPA met with Site Supervisor Mayra Madigral. LPA observed (57) fifty seven children supervised by seven staff.

It was alleged that child #2 was injured by child#1 (refer to confidential names list, LIC811) while in the facility. Community Care Licensing received an incident report from the facility detailing the incident. A case management inspection was conducted which included a facility tour, observations, and interviews with the parent of child#2 and facility staff. After investigation of information received and evidence provided, it was determined that adequate supervision was met when the incident occurred, however child #2's personal rights were violated. The facility was cited on November 15, 2019 based on the incident. The facility has since cleared the plan of correction(POC).
This complaint is substantiated, however a plan of correction is cleared based on receipt of POC documentation from the November 15, 2019 inspection.
Exit interview conducted and appeal rights were provided to the Site Supervisor. Notice of Site Visit was posted.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Stacey WilliamsTELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2020
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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