490170204-1-20-2021-01-CC-AHON-BXLSL2-20210125125735

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 490170204
Report Date: 01/20/2021
Date Signed: 01/20/2021 01:21:19 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/28/2020 and conducted by Evaluator Jennifer Velasco

COMPLAINT CONTROL NUMBER: 01-CC-20201028140925

FACILITY NAME:	CLARK, CHARLOTTE FAMILY CHILD CARE HOME		FACILITY NUMBER:	490170204
ADMINISTRATOR:	CLARK, CHARLOTTE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(707) 763-3683
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	14	CENSUS: 7	DATE:	01/20/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Cindy Clark		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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Provider yells at the daycare children.
The provider's behavior may be danger to the health and safety of children in care.

INVESTIGATION FINDINGS:

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Due to the COVID-19 public health emergency, an announced tele-visit was conducted by Licensing Program Analyst J. Velasco (LPA), who met with staff Cindy Clarke (S1) to deliver investigation findings. It was alleged that the provider yelled at children in care; specifically, that provider has been overheard yelling at children in care frequently. It was also alleged that the provider's behavior may be hazardous to children in care; specifically, that the provider's behavior may pose a potential or actual risk to the health and/or safety of children in care. On 11/02/2020, LPA conducted initial complaint investigation inspection via tele-visit due to Covid 19 public health emergency. During both the initial investigation inspection and subsequent investigation inspection, S1 denied both allegations and stated she does not yell at the children, and neither does licensee (L1). S1 also stated neither S1 nor L1 engages in behavior that is dangerous to children in care. Subsequent to the initial investigation inspection, LPA obtained and reviewed facility documents and interviewed multiple witnesses re: the complaint allegations. LPA interviewed one adult (A5) on 11/09/2020, one adult (A3) on 01/05/2021, three children (C1, C3, C4) on 01/07/2021, and one adult (A4) on 01/19/2021.
Continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer Velasco	TELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2021

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 01-CC-20201028140925

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: CLARK, CHARLOTTE FAMILY CHILD CARE HOME	FACILITY NUMBER: 490170204
	VISIT DATE: 01/20/2021

NARRATIVE

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Continued from LIC 9099.
Document review and witness statements failed to corroborate the allegation that a facility provider yelled at children in care and failed to corroborate the allegation that a facility provider engaged in behavior that posed a potential or actual risk to the health and/or safety of children in care. Based on interviews conducted and records reviewed, although the allegations may have happened or be valid, there is not a preponderance of the evidence to prove that the alleged violations occurred; therefore, the allegations are unsubstantiated. Appeal rights were provided. This report was read and reviewed with S1, whose original signatures were not recorded on this report. S1 was provided with a copy of the LIC9099 Complaint Investigation Report (CIR) and Appeal Rights in an email dated 01/20/2021 and confirmation of read receipt of the CIR is on file. All licensing reports are public information and must be made available upon request for at least three years. There were no Title 22 deficiencies cited during today's inspection.

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer Velasco	TELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2021

LIC9099 (FAS) - (06/04)

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