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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 414004158
Report Date: 11/30/2020
Date Signed: 11/30/2020 12:15:40 PM



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
09/03/2020 and conducted by Evaluator Marie Rodriguez
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20200903140144
FACILITY NAME:ESPINOZA, VICTORIAFACILITY NUMBER:
414004158
ADMINISTRATOR:ESPINOZA, VICTORIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 520-9802
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:14CENSUS: 10DATE:
11/30/2020
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Victoria EspinozaTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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- Licensee failed to adhere to child's special dietary restrictions and ensure safety of child while in day care.
INVESTIGATION FINDINGS:
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Due to the current COVID-19 pandemic and field visits being suspended at this time, Licensing Program Analyst (LPA) Marie Rodriguez conducted a tele-visit with Licensee Victoria Espinoza by phone to deliver finding and close the complaint investigation on the above allegation. Facility was open with 10 children present at time of the tele-visit.

During the course of the investigation, interviews were conducted and pertinent documents received were reviewed. Based on information obtained, it was determined that on September 1, 2020 the Licensee accidentally fed a child (C1) food that contained an ingredient the child was allergic to. Licensee had purchased pasta that was different than the one she normally used and did not realize it contained an ingredient the child was allergic to. The ingredients were reviewed upon the child's parents arrival to pick up child when the parents were informed that the child had vomited prior to their arrival. Parents were not contacted about the child's condition when it occurred since the incident happened right before the parents arrival and the Licensee gave the child a bath to clean off any remnants of the vomit.

(Continued on LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Marie RodriguezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2020
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
Control Number 05-CC-20200903140144
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: ESPINOZA, VICTORIA
FACILITY NUMBER: 414004158
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/18/2020
Section Cited
CCR
102423(a)(2)
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Personal Rights - (a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include: (2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.
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Licensee will provide a written Plan of Correction (POC) on how to ensure the health and safety of children with allergies while in Licensee's care and how to prevent future reoccurrences of this deficiency. POC will be submitted via email by the POC DUE DATE.
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This requirement has not been met as evidenced by:

Based on interviews conducted, Licensee accidentally fed a child (C1) food that contained an ingredient the child was allergic to. Licensee failed to provide the child with safe and healthful accomodations for a food allergy which 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: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Marie RodriguezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 05-CC-20200903140144
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: ESPINOZA, VICTORIA
FACILITY NUMBER: 414004158
VISIT DATE: 11/30/2020
NARRATIVE
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(Continued from LIC 9099)

Based on information gathered, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Deficiency cited today under California Code of Regulations, Title 22, Division 12, follows on LIC 9099D.

Report reviewed and discussed with Licensee Victoria Espinoza. Appeals Rights explained. A copy of report and Appeals Rights were emailed to Licensee.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Marie RodriguezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3