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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 414002550
Report Date: 01/09/2020
Date Signed: 01/09/2020 11:19:33 AM



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
11/05/2019 and conducted by Evaluator April Cowan
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20191105110603
FACILITY NAME:NAVARRO, ANAFACILITY NUMBER:
414002550
ADMINISTRATOR:NAVARRO, ANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 394-4150
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY:14CENSUS: 12DATE:
01/09/2020
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ana NavarroTIME COMPLETED:
11:35 AM
ALLEGATION(S):
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9
Personal Rights (Licensee inappropriately handles day care children).
INVESTIGATION FINDINGS:
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On 01/09/20, at 9:00 AM, Licensing Program Analyst (LPA) met with licensee, Ana Navarro, for an unannounced subsequent complaint inspection. The purpose of inspection was explained to licensee. Present in the facility is licensee, two helpers, caring for 12 children (2 infants and 10 Preschoolers). Licensee's son and son's friend are in an off-limit area.
In today’s inspection, LPA along with licensee inspected for health and safety hazards. LPA observed no deficiencies during inspection. In today's inspection, licensee admitted that she allowed and uncleared adult to work in the facility without completing their paperwork first.
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 allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion: 45
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April CowanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2020
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
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
11/05/2019 and conducted by Evaluator April Cowan
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20191105110603

FACILITY NAME:NAVARRO, ANAFACILITY NUMBER:
414002550
ADMINISTRATOR:NAVARRO, ANAFACILITY TYPE:
810
ADDRESS:1032 INVERNESS DRIVETELEPHONE:
(650) 394-4150
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY:14CENSUS: 12DATE:
01/09/2020
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ana NavarroTIME COMPLETED:
11:35 AM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Uncleared adult associated to the facility
INVESTIGATION FINDINGS:
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5
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7
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9
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11
12
13
On 01/09/20, at 9:00 AM, Licensing Program Analyst (LPA) met with licensee, Ana Navarro, for an unannounced subsequent complaint inspection. The purpose of inspection was explained to licensee. Present in the facility is licensee, two helpers, caring for 12 children (2 infants and 10 Preschoolers). Licensee's son and son's friend are in an off-limit area.
In today’s inspection, LPA along with licensee inspected for health and safety hazards. LPA observed no deficiencies during inspection. In today's inspection, licensee admitted that she allowed and uncleared adult to work in the facility without completing their paperwork first.
Based on LPA’s observation and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is founded to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.
Substantiated
Estimated Days of Completion: 45
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April CowanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2020
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 3
Control Number 05-CC-20191105110603
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: NAVARRO, ANA
FACILITY NUMBER: 414002550
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/09/2020
Section Cited
CCR
102370(d)(1)
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102370(d)(1) Criminal Record Clearance
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility:(1) Obtain a California clearance or a criminal record exemption as required by the Department.
This requirement was not met as evidenced by:
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Licensee agreed that she would complete paperwork on adults that are to be hired before bringing them in to work.
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Based on interviews, licensee did not meet this requirement. Both licensee and staff have admitted that an uncleared individual worked in the facility for at least 2 days.
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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: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April CowanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3