493009773-12-2-2021-01-CC-AHON-C9G29K-20211206161205

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 493009773
Report Date: 12/02/2021
Date Signed: 12/02/2021 10:54:28 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/26/2021 and conducted by Evaluator Amy Strother

PUBLIC

COMPLAINT CONTROL NUMBER: 01-CC-20211026161418

FACILITY NAME:	PEREZ, EMILIO FCCH		FACILITY NUMBER:	493009773
ADMINISTRATOR:	EMILIO PEREZ		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(707) 230-1631
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95407
CAPACITY:	14	CENSUS: 7	DATE:	12/02/2021
		UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Emilio Perez		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Infant was injured while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Amy Strother made a subsequent complaint investigation inspection, for the purpose of delivering complaint findings, and met with the Licensee. It has been alleged that an infant was injured while in care, specifically that Child 1 (C1) fell onto Child 2(C2), which lead to C2 grabbing onto C1’s face, resulting in two visible scratches to C1’s face and a red mark on the back of C1’s head.
During the investigation, records were reviewed, and interviews were conducted. An unusual incident report regarding the incident was called in by the Licensee to the Department on 10/27/21, followed by a written report received on 10/29/21. An interview was conducted with the Licensee on 11/03/21 at 10:15am. An interview with staff was conducted on 11/04/21 at 5:24pm. No interviews with children were conducted. LPA was unable to qualify any children as witnesses during the investigation. A police report from the Santa Rosa Police Department was obtained and reviewed on 10/29/21 and photos of C1’s injuries obtained and reviewed on 11/12/21.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy Strother	TELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021

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-20211026161418

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: PEREZ, EMILIO FCCH	FACILITY NUMBER: 493009773
	VISIT DATE: 12/02/2021

NARRATIVE

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Interviews and a review of police records corroborate that C1 did sustain minor injuries to the face and head while in care, and that although a staff person was standing close by when the incident occurred, they could not feasibly have prevented C1's injuries. Interviews additionally corroborate that the infants, C1 and C2 were located in a play area that is specific to care for infants of similar age when the incident occurred. It was corroborated that C1’s mother was notified of C1’s injuries at pick up time.
Although interviews and record review corroborate that C1 was injured while in care, based on information gathered during interviews, there is not a preponderance of evidence to support the injury occurred due to a of lack of supervision or because of a violation of C1’s personal rights. Based on interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that an alleged violation occurred, therefore the allegation is UNSUBSTANTIATED.
There were no Title 22 deficiencies cited during today's inspection. This report was reviewed and discussed with the Licensee. Appeal Rights were provided.
Notice of Site Visit shall be posted for 30 days from today's visit.

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy Strother	TELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021

LIC9099 (FAS) - (06/04)

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