493004282-11-17-2021-01-CC-AHON-C92PH3-20211123101917

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 493004282
Report Date: 11/17/2021
Date Signed: 11/17/2021 11:10:40 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 HOME		FACILITY NUMBER:	493004282
ADMINISTRATOR:	FOURSHA, GWENDOLEN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(707) 529-4953
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	14	CENSUS: 6	DATE:	11/17/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Gwendolen Foursha		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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9

Facility is operating over capacity.
Facility is operating out of ratio.

INVESTIGATION FINDINGS:

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13

A subsequent, unannounced complaint investigation inspection was conducted by Licensing Program Analyst Jennifer Velasco (LPA), who met with Licensee Gwendolen Foursha (L1). It was alleged the facility operated both over capacity and out of ratio; specifically, on multiple occasions an assistant (S1) was the sole care provider to as many as 16 children, and on multiple occasions L1 was the sole care provider to as many as 12 children. L1 denied the allegations and stated the facility operates within ratio and capacity regulations. 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 interviews and document reviews failed to corroborate the allegations that the facility operated over capacity and/or out of ratio. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. An exit interview was conducted. The Notice of Site Visit must be posted for 30 days.

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: 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)

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