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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 493004282
Report Date: 11/17/2021
Date Signed: 11/17/2021 11:12:27 AM



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
09/03/2021 and conducted by Evaluator Jennifer Velasco
COMPLAINT CONTROL NUMBER: 01-CC-20210903150930
FACILITY NAME:FOURSHA, GWENDOLEN FAMILY CHILD CARE HOMEFACILITY NUMBER:
493004282
ADMINISTRATOR:FOURSHA, GWENDOLENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 529-4953
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:14CENSUS: 6DATE:
11/17/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Gwendolen FourshaTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Licensee is not adhering to Covid-19 masking safety protocols.
INVESTIGATION FINDINGS:
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A follow up complaint investigation inspection was conducted by Licensing Program Analyst Jennifer Velasco (LPA), who met with Licensee Gwendolen Foursha (L1). It was alleged that L1 was not following Covid-19 public health emergency guidance re: masks; specifically, that L1 was not ensuring children wore masks in the facility. L1 did not deny the allegation and stated the parents could decide if their children wore masks in care. On 09/13/2021, LPA conducted an initial complaint investigation inspection, during which the facility was toured, documents were obtained, and interviews were conducted. During the investigation, LPA reviewed facility documents and conducted interviews on 09.08.21, 09.13.21, 11.05.21, and 11.16.21. LPA interviewed one child (C4), four adults (A1, A3-A5), and L1. Witness statements and document review provided corroboration of the allegation that children were not wearing masks indoors. Based on interviews and facility documents, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. The following violation of the California Code of Regulations, Title 22; Division 6, was observed: see LIC 9099-D. This report was reviewed and discussed with L1. Appeal Rights were provided, and exit interview was conducted. All licensing reports are public information and must be made available upon request for at least three years. Notice of Site Visit shall be posted for 30 days from today’s visit.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer VelascoTELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
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 2
Control Number 01-CC-20210903150930
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: FOURSHA, GWENDOLEN FAMILY CHILD CARE HOME
FACILITY NUMBER: 493004282
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2021
Section Cited
CCR
102423(a)(2)
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On multiple dates in 2021, Licensee (L1) did not ensure the personal rights of children in care to safe and healthful accommodations and engaged in conduct inimical to the health, welfare, and safety of persons in
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L1 stated she would develop and email to LPA before close of business (COB) on POC deadline a detailed written plan for ensuring children two years and older wear masks in care when indoors and not eating or sleeping.
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care, in that facility staff did not ensure children two years of age and over wore face coverings while in the facility, as required by the CA Dept. of Public Health Guidance on the Use of Face Coverings issued June 18, 2020 and updated November 16, 2020, and an individual mask exception did not apply.
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L1 also stated she would document children wearing masks in care and email to LPA by COB on POC deadline 11.18.2021.
LPA email: jennifer.velasco@dss.ca.gov
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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 HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer VelascoTELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
LIC9099 (FAS) - (06/04)
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