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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 393622079
Report Date: 07/22/2019
Date Signed: 07/22/2019 11:56:52 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
06/14/2019 and conducted by Evaluator Mary Ponce
PUBLIC
COMPLAINT CONTROL NUMBER: 53-CC-20190614093734
FACILITY NAME:FISHER, KRISTIFACILITY NUMBER:
393622079
ADMINISTRATOR:PERDUE, KRISTIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 740-0165
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:14CENSUS: DATE:
07/22/2019
UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:TIME COMPLETED:
12:25 PM
ALLEGATION(S):
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lack of supervision resulted in child soaked in urine
staff grabbed child in a rough manner
INVESTIGATION FINDINGS:
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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 in care was able to access a potty training toilet causing urine to wet their clothes due to a lack of supervision. It was also alleged that after the incident, staff grabbed the child in a rough manner. During the investigation, LPA Ponce conducted interviews, made observations, and collected pertinent documentation. Based on inconsistent information gathered during interviews there is not a preponderance of evidence showing that the allegation took place; therefore, this allegation is UNSUBSTANTIATED.

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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