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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 414001409
Report Date: 05/09/2022
Date Signed: 05/09/2022 04:30:00 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/05/2022 and conducted by Evaluator Luis Gomez
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20220505100718
FACILITY NAME:DIAZ, MARIA BETTINA C.FACILITY NUMBER:
414001409
ADMINISTRATOR:DIAZ, MARIA BETTINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 579-2678
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY:14CENSUS: 5DATE:
05/09/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Maria Bettina DiazTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Licensee is not following proper infant safe sleep practices.
INVESTIGATION FINDINGS:
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On 5/9/2022 at 1:45P.M., Licensing Program Analyst (LPA) Luis J. Gomez met with licensee, Maria Bettina Diaz. Purpose of inspection was explained and was for an unannounced complaint investigation. Present was licensee caring for 5 children. (2 Infant age, 3 Preschool age) LPA inspected facility with licensee for health and safety hazards.

During today’s inspection, LPA performed site observations, reviewed facility records and interviewed licensee. Deficiencies were obseved during inspection and cited on attached Case Managment Report, LIC809.

During the course of the investigation, site observations were conducted on 5/9/2022. A review of the facility records was completed, which included the children's files. LPA conducted interviews with the licensee all involved parties. Based on interviews, observations, record review, LPA confirmed bumpers/ wrap attached to sides of infant crib. (REFER TO LIC9099C FOR CONT.)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
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 3
Control Number 05-CC-20220505100718
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: DIAZ, MARIA BETTINA C.
FACILITY NUMBER: 414001409
VISIT DATE: 05/09/2022
NARRATIVE
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(Page 2)
Based on information obtained, the preponderance of evidence standard has been met, therefore the allegation(s) are found to be SUBSTANTIATED. California code of Regulations (Title 22, Section 12 Chapter 1) are being cited on attached 9099D. Appeal Rights were provided to the facility.

This report will be kept in the Facility File and will be made available for Public Review upon request. Website for Forms and Regulations: www.ccld.ca.gov. This report and rights to comment and appeal have

Signed copy of this report was provided to the licensee.

SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 05-CC-20220505100718
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: DIAZ, MARIA BETTINA C.
FACILITY NUMBER: 414001409
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/11/2022
Section Cited
CCR
102425(b)(3)
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102425(b)(3) Infant Safe Sleep: There shall be no objects hanging above or attached to the side of the crib. This requirement was not met as evidenced by:
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Licensee will removed bumpers/ wraps from side of infant cribs by the due date: 5/11/2022. Proof of correction will be submitted to the department via email.
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Based on interviews, observations and record review, LPA confirmed bumpers/ wrap attached to sides of infant crib. This poses a potential health and safety risk to children in care.
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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: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3