434407067-11-5-2019-07-CC-ASTR-BJGVN2-20191202153421

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 434407067
Report Date: 11/05/2019
Date Signed: 11/05/2019 04:26:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/27/2019 and conducted by Evaluator Samantha Yip

PUBLIC

COMPLAINT CONTROL NUMBER: 07-CC-20190927122356

FACILITY NAME:	DOMINGUEZ, ANA		FACILITY NUMBER:	434407067
ADMINISTRATOR:	DOMINGUEZ, ANA & LOPEZ, VA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 776-0050
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	14	CENSUS: 5	DATE:	11/05/2019
		UNANNOUNCED	TIME BEGAN:	02:58 PM
MET WITH:	Ana "Mellie" Dominguez		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

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Staff yell at daycare child.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Samantha Yip and Marilou Monico conducted an unannounced subsequently complaint investigation. LPA met with Licensee Ana "Mellie" Dominguez and explained the reason for the inspection. Present during the inspection were Licensee, her mother, and 5 children.

During the course of the investigation, LPAs interviewed Licensee and children. Licensee stated her forms about discipline is to redirect the children or talk to the children. LPAs also conducted observation on 10/01/2019. On 10/01/2019, LPA Rodriguez observed S-1 yelling at children. Based observation, the above allegation is found to be substaintated.

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2019

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 07-CC-20190927122356

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: DOMINGUEZ, ANA	FACILITY NUMBER: 434407067
	VISIT DATE: 11/05/2019

NARRATIVE

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LPA discussed with Licensee about forms of discipline and about the way Licensee and her mother talk to children.

As a result of this investigation, a Type B deficiency has been cited. An exit interview was conducted, where this report, the citation, plan of correction, and appeal rights were discussed and provided to Licensee. A notice of site visit has been issued and must be posted for 30 consecutive days.

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2019

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 07-CC-20190927122356

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: DOMINGUEZ, ANA	FACILITY NUMBER: 434407067
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/05/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/12/2019 Section Cited CCR 102423(a)(4)	1 2 3 4 5 6 7	Personal Rights. To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including... This requirement is not met as evident by:	1 2 3 4 5 6 7	By POC 11/12/2019, Licensee stated that she will submit a written plan on how she will ensure children's personal rights are not violated, such as children are not yelled at.
	8 9 10 11 12 13 14	Based on observation, LPA observed that S-1 yelled at children in care. This poses a potential risk to the health and safety to the 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: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2019

LIC9099 (FAS) - (06/04)

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