480104414-12-29-2022-01-CC-AHON-CMQQM5-20230103111655

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 480104414
Report Date: 12/29/2022
Date Signed: 12/29/2022 02:42:59 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/28/2022 and conducted by Evaluator Yang Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 01-CC-20221028155239

FACILITY NAME:	VACAVILLE CHRISTIAN EARLY EDUCATION PRESCHOOL		FACILITY NUMBER:	480104414
ADMINISTRATOR:	STEPHANIE YAMATO		FACILITY TYPE:	850
ADDRESS:	1117 DAVIS STREET		TELEPHONE:	(707) 446-1776
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	170	CENSUS: 30	DATE:	12/29/2022
		UNANNOUNCED	TIME BEGAN:	10:53 AM
MET WITH:	Stephanie Yamato, Center Director		TIME COMPLETED:	12:39 PM

ALLEGATION(S):

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Facility did not notify child's authorized representative of an incident in a timely manner

INVESTIGATION FINDINGS:

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An unannounced follow-up complaint investigation visit to the facility was made today by Licensing Program Analyst (LPA), Y. Yang to deliver complaint investigation findings. It has been alleged that the facility did not notify a child’s authorized representative of an incident in a timely manner. Specifically, it was alleged that on 10/19/2022, child C1’s authorized representatives were not notified in a timely manner about C1’s suspected head injury.
The LPA met with the facility’s center director, Stephanie Yamato today to discuss the investigation findings. The facility was toured inside and out. During the initial investigation visit made by the LPA on 11/01/22, the LPA interviewed Center Director Yamato (staff S1) regarding the allegation. Yamato stated that staff are required to immediately notify a child’s authorized representatives of incidents involving head injuries and bites. Yamato stated that for less serious injuries such as bumps and scrapes, a note with information is provided to authorized representatives at pick up time. Yamato stated that she was not present at the facility at the time of C1’s suspected injury but did hear about it afterwards. (Continued on LIC 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang Yang	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022

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 01-CC-20221028155239

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VACAVILLE CHRISTIAN EARLY EDUCATION PRESCHOOL	FACILITY NUMBER: 480104414
	VISIT DATE: 12/29/2022

NARRATIVE

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During the investigation, interviews were conducted with the facility’s staff members S2-S5 on 11/01/22. Staff members corroborated Center Director Yamato’s statements regarding illness/injury reporting procedures. Interviews revealed that S4 was the staff member responsible for supervising C1 at the time of the incident. Per the “Vacaville Christian School- Injury/Illness Report” obtained during the investigation, on 10/19/22 staff S4 wrote that child C1 sustained an injury while in care that appeared to be a concussion. S4 wrote that C1 and other children were on a tire swing when C1 let go and fell inside the tire while it was still in motion. S4 indicated that the “action taken” was providing ice. The “phone call” box was not checked. S4 stated that C1 informed her that C1 hit their head after falling through the tire swing. S4 stated that C1 did not have any visible injuries and no concussion symptoms. S4 stated that she completed the illness/injury report and placed a copy on a teacher’s roll call clipboard and the parent’s copy into a filing box in the classroom. S4 stated that her shift ended before C1 was picked up. S4 stated that she did not communicate with C1’s parents regarding her observations and/or concerns. S4 stated that C1’s parents were not made aware of the incident until the following morning.

Although it was later corroborated that C1 did not in fact sustain a concussion or other injury, staff S4 believed at the time that C1 did sustain a concussion (as demonstrated by the Vacaville Christian School- Injury/Illness Report for C1 dated 10/19/22). The facility should have immediately notified C1’s authorized representatives so that a medical professional could be consulted to determine the appropriate care. S4 later acknowledged that her understanding of a concussion was incorrect and stated that she completed the Injury/Illness report incorrectly.

Based on available information and the information obtained from staff members, the preponderance of evidence standard has been met; therefore, the allegation is found to be substantiated. California Code of Regulations, Title 22, is being cited on the attached LIC 9099-D. An exit interview was conducted, and this report was read and discussed with the facility’s center director, Stephanie Yamato. Appeal rights were provided. The Notice of Site Visit shall be posted for 30 days.

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang Yang	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022

LIC9099 (FAS) - (06/04)

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Control Number 01-CC-20221028155239

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VACAVILLE CHRISTIAN EARLY EDUCATION PRESCHOOL	FACILITY NUMBER: 480104414
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/29/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/16/2023 Section Cited CCR 101226(a)	1 2 3 4 5 6 7	Health-Related Services. The licensee shall immediately notify the child's authorized representative if the child becomes ill or sustains an injury more serious than a minor cut or scratch. The licensee shall obtain specific instructions from the authorized representative regarding action to be taken. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Center Director Stephanie Yamato stated that she will provide training to all preschool staff members regarding injury reporting procedures, follow-up actions, and incident/injury report writing. Center Director Yamato stated that she will submit proof of training including attendance sheet and topics covered to CCLD by 01/16/2023.
	8 9 10 11 12 13 14	Based on the interviews conducted by the LPA and staff S4's own admission on 11/01/22, it was corroborated that the facility did not notify child C1's authorized representatives of their concerns regading a suspected head injury in a timely manner. Please note: although it was later corroborated that C1 did not in fact sustain a concussion or other injury, staff S4 believed at the time that C1 did sustain a concussion. The facility should have immediately notified C1’s authorized representatives so that a medical professional could be consulted to determine the appropriate care. This posed a potential risk to the health and safety of child(ren) in care.	8 9 10 11 12 13 14
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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: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang Yang	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022

LIC9099 (FAS) - (06/04)

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