414004546-8-4-2021-05-CC-GLEG-C5S2WX-20210810174612

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 414004546
Report Date: 08/04/2021
Date Signed: 08/04/2021 03:24:25 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
07/01/2021 and conducted by Evaluator April Cowan

PUBLIC

COMPLAINT CONTROL NUMBER: 05-CC-20210701154938

FACILITY NAME:	TERRA NOVA CHRISTIAN PRESCHOOL		FACILITY NUMBER:	414004546
ADMINISTRATOR:	TATIANA HILLMAN		FACILITY TYPE:	830
ADDRESS:	1125 TERRA NOVA BLVD.		TELEPHONE:	(650) 355-2962
CITY:	PACIFICA	STATE: CA	ZIP CODE:	94044
CAPACITY:	20	CENSUS: 26	DATE:	08/04/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Tatiana Hillman		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Child sustained unexplained injury while in care

INVESTIGATION FINDINGS:

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On August 4, 2021 at 1:30 AM, Licensing Program Analyst (LPA) Cowan met with director for an unannounced subsequent complaint inspection. The purpose of inspection was explained to director. Present in the facility is director and 6 staff caring for 24 children.

Based on the information obtained from interviews conducted with director, parents, and viewing video footage, LPA found that children in care had sustained unexplained injuries. Upon discussing the nature of the allegation with director, she is aware that a staff member has tried to harm children in care. Director has self reported the incident.

Based on LPA’s observation and interviews which were conducted, 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.
Allegation is determined to be Substantiated

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April Cowan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021

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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Control Number 05-CC-20210701154938

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: TERRA NOVA CHRISTIAN PRESCHOOL	FACILITY NUMBER: 414004546
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/04/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/04/2021 Section Cited CCR 101223(a)(1)(2)	1 2 3 4 5 6 7	101223(a)(1)(2) Personal Rights (a) The licensee shall ensure that each child is accorded the following personal rights: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Director agrees to fired staff member effective immediately as of 8/4/21
	8 9 10 11 12 13 14	Based on interviews with parents and observations of video footage, children in care have experienced unexplained injuries. This poses a potential risk to children in care.	8 9 10 11 12 13 14
	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: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April Cowan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021

LIC9099 (FAS) - (06/04)

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