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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 426210153
Report Date: 08/15/2023
Date Signed: 08/15/2023 03:12:50 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/01/2023 and conducted by Evaluator Maryrose Breault
PUBLIC
COMPLAINT CONTROL NUMBER: 17-CC-20230601143421
FACILITY NAME:ISLA VISTA CHILDREN'S CENTERFACILITY NUMBER:
426210153
ADMINISTRATOR:SERINEH VARTANIFACILITY TYPE:
830
ADDRESS:6842 PHELPS RD.TELEPHONE:
(805) 968-0488
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY:27CENSUS: 11DATE:
08/15/2023
UNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Serineh VartaniTIME COMPLETED:
03:29 PM
ALLEGATION(S):
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Care and Supervision - Staff did not follow infant's feeding plan.
Care and Supervision - Staff did not meet infant's diapering needs.
Care and Supervision - Staff did not arrange emergency medical care for infant.
INVESTIGATION FINDINGS:
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On August 15th 2023 at 1:18PM Licensing Program Analyst (LPA) Rosie Breault, made an unannounced inspection to conclude the complaint allegations of three (3) counts of care and supervision that were initiated on June 1st, 2023. LPA met with Director Serenih Vartani and explained the nature and purpose of the inspection. At the time of the inspection there were eleven (11) children and four (4) staff.

During the course of investigation, parent, staff and reporting party (RP) interviews were conducted. Regarding count 1: Staff did not follow infant's feeding plan. Child's parent reported to Community Care Licensing (CCL) that C1 was “breast-fed baby and that she did not give staff consent to feed infant C1 these foods.” LPA reviewed child’s (herein referred to as C1) submitted “Child’s Preadmission Health History” report signed by parent on 05/09/2023. In report parent wrote C1 diet pattern consists of breast milk sometimes, baby oats, a veggie puree, baby cereal and “still figuring out state buds”.
CONTINUED ON LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0347
LICENSING EVALUATOR NAME: Maryrose BreaultTELEPHONE: (805) 635-5097
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/01/2023 and conducted by Evaluator Maryrose Breault
PUBLIC
COMPLAINT CONTROL NUMBER: 17-CC-20230601143421

FACILITY NAME:ISLA VISTA CHILDREN'S CENTERFACILITY NUMBER:
426210153
ADMINISTRATOR:SERINEH VARTANIFACILITY TYPE:
830
ADDRESS:6842 PHELPS RD.TELEPHONE:
(805) 968-0488
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY:27CENSUS: 11DATE:
08/15/2023
UNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Serineh VartaniTIME COMPLETED:
03:29 PM
ALLEGATION(S):
1
2
3
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5
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9
Care and Supervision - Staff did not notify responsible party of infant's change in condition.
INVESTIGATION FINDINGS:
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On August 15th 2023 at 1:18PM, Licensing Program Analyst (LPA) Rosie Breault made an unannounced inspection to conclude the complaint allegation of one (1) count of care and supervision that were initiated on June 1st, 2023. LPA met with Director Serenih Vartani and explained the nature and purpose of the inspection. At the time of the inspection there were eleven (11) children and four (4) staff present.
Per interview with director, director admitted to LPA the teachers should have contacted parent as the incident was out of the ordinary, regardless of whether they deem it to be severe or not. Based on director admission the preponderance of evidence standard has been met, therefore the allegation is SUBSTANTIATED, and a Type B deficiency has been cited.
Exit interview conducted, appeal rights and Notice of Site Visit provided to Director.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0347
LICENSING EVALUATOR NAME: Maryrose BreaultTELEPHONE: (805) 635-5097
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
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 4
Control Number 17-CC-20230601143421
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: ISLA VISTA CHILDREN'S CENTER
FACILITY NUMBER: 426210153
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/01/2023
Section Cited
CCR
101218.1(a)
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licensee shall develop, implement and maintain an admission procedure that enables the person in charge of admissions to… Enables the person responsible for admissions to understand the state of the child's health and physical and emotional development…
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Director to submit to LPA written statement as to how to remain compliance with the Title 22 Division 12 regulation that was violated. Statement to be submitted no later than 08/30/2023 to: Maryrose.breault@dss.ca.gov
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This evidence is met by:

Director admission that facility should have contacted parents for change of infant's status.
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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: Ana TolentinoTELEPHONE: (805) 562-0347
LICENSING EVALUATOR NAME: Maryrose BreaultTELEPHONE: (805) 635-5097
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 17-CC-20230601143421
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: ISLA VISTA CHILDREN'S CENTER
FACILITY NUMBER: 426210153
VISIT DATE: 08/15/2023
NARRATIVE
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RP reported to Community Care Licensing (CCL) that on 05/30/2023 RP observed C1 "to have hives and to be white and red." On 05/30/2023, director self-reported an unusual incident with C1 with an allergic reaction to an unknown allergy. LPA reviewed individual meal record and meal pattern for the day of 05/30/2023 which indicated C1 ate formula, cereal, mac and cheese, pumpkin, mango, and raspberry. RP did submit medical records of C1 being seen that same day at the emergency room which state C1 had a severe allergic reaction but note submitted did not indicate what the reaction was to, and may return to school on 06/01/2023. Per interview with director on 06/7/2023, director stated she has not received any information regarding C1 allergies and does not feel comfortable having C1 back in care until allergy is identified. Based on the information provided, interviews and document review, the preponderance of evidence standard has not been met, therefore the allegation is UNSUBSTANTIATED.

Regarding count 2: Staff did not meet infant's diapering needs. RP reported to CCL that C1 sustained diaper rash at center and C1 is kept dirty at the center. LPA reviewed “Parent Consent for Administration of Medications and Medication Chart” signed and dated by parent on 05/30/2023 stating C1 is to be administered Aquaphor for “poopy diaper” as needed from 05/30/2023 until needed. Aquaphor was applied by staff member same day the consent form was given. Parents interviewed indicated their children’s diapering needs are being met. Based on the information provided, interviews and document review, the preponderance of evidence standard has not been met, therefore the allegation is UNSUBSTANTIATED.

Regarding count 3: Staff did not arrange emergency medical care for infant. Per director statement, C1 did notice C1 scratching face but did not appear to be in distress. RP stated C1 was rushed to emergency room upon pick up and that C1 parent’s stated C1 appeared to be in anaphylactic shock at that time. Evidence submitted did not state C1 was in distress rather his face was red, raised and with bumps upon pick up. No medical evidence was entered to support the child was in anaphylactic shock. Evidence entered did not indicate was C1 is/was allergic to. Majority of parents interviewed stated they are satisfied with the level of care and supervision being received and they would refer facility to other parents. Based on the information provided, interviews and document review, the preponderance of evidence standard has not been met, therefore the allegation is UNSUBSTANTIATED.


Exit interview was conducted with licensee. Copy of report and appeal rights provided. Notice of Site Visit (LIC 9213) posted during LPA inspection and must remain posted for 30 consecutive days. Failure to maintain posting as required will result in a civil penalty of $100.00.
SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0347
LICENSING EVALUATOR NAME: Maryrose BreaultTELEPHONE: (805) 635-5097
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4