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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 566202007
Report Date: 01/07/2021
Date Signed: 01/07/2021 11:56:31 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/26/2020 and conducted by Evaluator Francisco Pedroza
PUBLIC
COMPLAINT CONTROL NUMBER: 17-CC-20201026163808
FACILITY NAME:NELSON FAMILY CHILD CAREFACILITY NUMBER:
566202007
ADMINISTRATOR:NELSON, KERIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 404-6342
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:14CENSUS: 9DATE:
01/07/2021
UNANNOUNCEDTIME BEGAN:
10:43 AM
MET WITH:Keri NelsonTIME COMPLETED:
11:55 AM
ALLEGATION(S):
1
2
3
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5
6
7
8
9
Personal Rights- Infant sustained injury while in care
INVESTIGATION FINDINGS:
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5
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9
10
11
12
13
On January 7, 2021 at 10:45 AM, Licensing Program Analyst (LPA) Francisco Pedroza conducted an unannounced tele-inspection to conclude a complaint investigation. LPA met with Licensee Keri Nelson and explained the nature and the purpose of the inspection. Due to COVID-19 and the Department of Public Health guidelines, a tele-inspection was completed via Facetime. Licensee provided LPA a tour of the home inside and out. There were nine children in care at the time of the inspection.

Allegation stated an Infant sustained injury while in care. LPA made two unannounced tele-inspections and toured the facility on each inspection. LPA interviewed the RP and licensee regarding the allegations. RP stated the child had sustained a dislocated shoulder. Licensee confirmed that an infant did sustain an injury when he/she went down a 2-feet high infant slide at the backyard. The child was taken to the doctor to be evaluated.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco PedrozaTELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2021
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 4
Control Number 17-CC-20201026163808
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: NELSON FAMILY CHILD CARE
FACILITY NUMBER: 566202007
VISIT DATE: 01/07/2021
NARRATIVE
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Per the medical documents reviewed, the child sustained Nursemaid’s which is consistent with a child using his/her hands to brace themselves during a fall. Licensee was present when the incident occurred but was unable to stop the fall. Licensee self-reported the incident to Community Care Licensing. Based on LPAs observations, interviews conducted, and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. No deficiencies cited.

A closing interview was conducted with Licensee Nelson. A copy of this report was reviewed and provided to Licensee via email. The delivered receipt confirmation from email will be in lieu of her signature once she received the report. LPA requested a signed copy be provided to Community Care Licensing.
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco PedrozaTELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/26/2020 and conducted by Evaluator Francisco Pedroza
PUBLIC
COMPLAINT CONTROL NUMBER: 17-CC-20201026163808

FACILITY NAME:NELSON FAMILY CHILD CAREFACILITY NUMBER:
566202007
ADMINISTRATOR:NELSON, KERIFACILITY TYPE:
810
ADDRESS:3948 RUSS COURTTELEPHONE:
(805) 404-6342
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:14CENSUS: 9DATE:
01/07/2021
UNANNOUNCEDTIME BEGAN:
10:43 AM
MET WITH:Keri NelsonTIME COMPLETED:
11:55 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Neglect/Lack of Supervision - Licensee did not ensure that infant in care was supervised appropriately
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On January 7, 2021 at 10:45 AM, Licensing Program Analyst (LPA) Francisco Pedroza conducted an unannounced tele-inspection to conclude a complaint investigation. LPA met with Licensee Keri Nelson and explained the nature and the purpose of the inspection. Due to COVID-19 and the Department of Public Health guidelines, a tele-inspection was completed via Facetime. Licensee provided LPA a tour of the home inside and out. There were (Ratio) children in care at the time of the inspection.

Allegation stated licensee did not ensure that an infant in care was supervised appropriately. LPA made two unannounced tele-inspections and toured the facility on each inspection. LPA interviewed the licensee regarding the incident that resulted in a child getting injured. Licensee advised that she was in the backyard at the time the incident occurred with two other children. Licensee self-reported the incident to Community Care Licensing. LPA observed the slide that the child was injured on.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco PedrozaTELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 17-CC-20201026163808
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: NELSON FAMILY CHILD CARE
FACILITY NUMBER: 566202007
VISIT DATE: 01/07/2021
NARRATIVE
1
2
3
4
5
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The slide manufacturer and model guidelines were researched. The slide was age-appropriate for the child according to manufacturer’s guidelines. Interviews did not collaborate the allegation that licensee does not supervise children appropriately. Parents interviewed were satisfied with the care and supervision rendered by the licensee. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

A closing interview was conducted with Licensee Nelson. A copy of this report was reviewed and provided to Licensee via email. The delivered receipt confirmation from email will be in lieu of her signature once she received the report. LPA requested a signed copy be provided to Community Care Licensing.
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco PedrozaTELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4