393621390-11-29-2021-53-CC-BENN-C99MQ9-20211130084820

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 393621390
Report Date: 11/29/2021
Date Signed: 11/29/2021 12:37:22 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
09/02/2021 and conducted by Evaluator Christopher Jackson

COMPLAINT CONTROL NUMBER: 53-CC-20210902113938

FACILITY NAME:	STEPHEN, DAISY		FACILITY NUMBER:	393621390
ADMINISTRATOR:	STEPHEN, DAISY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 802-7171
CITY:	MOUNTAIN HOUSE	STATE: CA	ZIP CODE:	95391
CAPACITY:	14	CENSUS: 7	DATE:	11/29/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Daisy Stephen		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Personal Rights: Licensee does not ensure that child's diapering needs are met

INVESTIGATION FINDINGS:

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On 11/29/21 Licensing Program Analyst (LPA) Christopher Jackson met with licensee Daisy Stephen to deliver the findings for the complaint investigation regarding the allegation “Licensee does not ensure that child's diapering needs are met”.
During the investigation, LPA Jackson conducted interviews, and obtained information pertinent to allegation. It was alleged that a child (C1) had sustained diaper rash while in care. Statements revealed that the licensee checks diapers at 3:30 PM, however, children are not picked up till 4:00 PM from the program. Although the licensee explained children are checked thorough out the day. LPA could not dismiss the statement from the licensee regarding the gap in time in which children are not changed. The licensee stated they will develop a plan to ensure children’s diapering needs are met.
Based on the information obtained during the investigation the evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. The following Title 22 Deficiency are being cited on the subsequent 9099-D page. Appeal Rights and Notice of Site Visit were provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Justin L Denton	TELEPHONE: (916) 926-0269
LICENSING EVALUATOR NAME: Christopher Jackson	TELEPHONE: (916) 216-8837
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 53-CC-20210902113938

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: STEPHEN, DAISY	FACILITY NUMBER: 393621390
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/29/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/29/2021 Section Cited CCR 102423(a)(2)	1 2 3 4 5 6 7	To receive safe, healthful, and comfortable accommodations, furnishings, and equipment. This regulation was not meet as evidenced by licensee did not ensure the diapering needs of a child in care. This poses a potential health and safety risk to children in care.	1 2 3 4 5 6 7	The licensee stated they would ensure diaper checks for children at the end of the day before leaving the facility. To ensure children leaving the facility are sent home in a clean diaper.
	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
	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: Justin L Denton	TELEPHONE: (916) 926-0269
LICENSING EVALUATOR NAME: Christopher Jackson	TELEPHONE: (916) 216-8837
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4

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
09/02/2021 and conducted by Evaluator Christopher Jackson

PUBLIC

COMPLAINT CONTROL NUMBER: 53-CC-20210902113938

FACILITY NAME:	STEPHEN, DAISY		FACILITY NUMBER:	393621390
ADMINISTRATOR:	STEPHEN, DAISY		FACILITY TYPE:	810
ADDRESS:	1035 S. ATWOOD COURT		TELEPHONE:	(408) 802-7171
CITY:	MOUNTAIN HOUSE	STATE: CA	ZIP CODE:	95391
CAPACITY:	14	CENSUS: 7	DATE:	11/29/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Daisy Stephen		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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9

Personal Rights: Licensee does not ensure that child is adequately fed
Criminal Record Clearance: Uncleared adult is supervising children

INVESTIGATION FINDINGS:

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On 11/29/21 Licensing Program Analyst (LPA) Christopher Jackson met with licensee Daisy Stephen to deliver the findings for the complaint investigation regarding the allegations of “Licensee does not ensure that child is adequately fed” and “Uncleared adult is supervising children.”
During the investigation, LPA Jackson conducted interviews, and obtained information pertinent to allegations. For the first allegation, interviews conducted revealed that the licensee offers an AM and PM snack time, as well as a lunch time. LPA obtained a copy of the menu utilized by the home day care. Although LPA observed the menu used by the program, LPA could not dismiss the duration of time children have to finish their lunch. Regarding the second allegation, interviews revealed the licensee has a family member, that recently relocated to the area, and was staying at the home temporarly. However, LPA did not receive any statements verifying the length of time the family members had stayed at the home. The licensee stated the family only stayed for a duration of a week and they did not assist the licensee with the home day care.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Justin L Denton	TELEPHONE: (916) 926-0269
LICENSING EVALUATOR NAME: Christopher Jackson	TELEPHONE: (916) 216-8837
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 53-CC-20210902113938

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: STEPHEN, DAISY	FACILITY NUMBER: 393621390
	VISIT DATE: 11/29/2021

NARRATIVE

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Based on the information obtained throughout the course of this investigation the above allegations could not be substantiated or dismissed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the finding is UNSUBSTANTIATED. Title 22 regulations regarding criminal record clearance and personal rights were reviewed and discussed with the licensee today.

SUPERVISOR'S NAME: Justin L Denton	TELEPHONE: (916) 926-0269
LICENSING EVALUATOR NAME: Christopher Jackson	TELEPHONE: (916) 216-8837
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4