493008417-7-12-2021-01-CC-AHON-C5YV5F-20210817160750

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 493008417
Report Date: 07/12/2021
Date Signed: 07/12/2021 02:46:55 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
05/28/2021 and conducted by Evaluator Jennifer Velasco

COMPLAINT CONTROL NUMBER: 01-CC-20210528160740

FACILITY NAME:	ROSS, SHAELA FCCH		FACILITY NUMBER:	493008417
ADMINISTRATOR:	ROSS, SHAELA & ROBYN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(707) 483-9741
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95405
CAPACITY:	14	CENSUS: 6	DATE:	07/12/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Shaela Ross		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Day care child sustained an injury while in care

INVESTIGATION FINDINGS:

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An unannounced subsequent complaint investigation inspection was conducted by Licensing Program Analyst Jennifer Velasco (LPA), who met with Licensee Shaela Ross (L1). It was alleged that a child (C1) sustained injury while in care; specifically, that C1 did not have scratching or bruising on their torso prior to being dropped off at the facility and had scratching and bruising on their torso subsequent to being picked up from the facility. During the investigation, LPA reviewed facility documents, toured the facility, and conducted interviews on 06/01/2021 with four adults, A1-A3 and L1; on 06/21/2021 with one adult, A4; on 06/23/2021 with one adult, A7; on 06/24/2021 with two adults, A4 and A7. Documentation and witness statements corroborate the allegation that a child sustained injury in care, when a second child (C2) repeatedly pinched C1 on the torso. Based on interviews and facility documents, the preponderance of evidence standard has been met; therefore, the above allegations are 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 Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer Velasco	TELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021

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-20210528160740

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: ROSS, SHAELA FCCH	FACILITY NUMBER: 493008417
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/12/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/06/2021 Section Cited CCR 102417(a)	1 2 3 4 5 6 7	Operation of a Family Child Care Home. The licensee shall ... ensure that children in care are supervised at all times. This standard has not been met as evidenced by witness statements and photographic and film documentation of a child (C1) sustaining multiple minor injuries	1 2 3 4 5 6 7	Licensee (L1) stated she will develop a detailed written plan for ensuring constant supervision of all children in care and will as part of that plan provide staff training on supervision. L1 stated she will provide the detailed written plan and documentation of
	8 9 10 11 12 13 14	at the hands of another child (C2) while in care. This poses a risk to the health and safety of children in care.	8 9 10 11 12 13 14	staff training to LPA by POC date via email, fax, or mail. LPA's email: jennifer.velasco@dss.ca.gov Fax: 707-588-5099
	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: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer Velasco	TELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021

LIC9099 (FAS) - (06/04)

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