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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 566215054
Report Date: 11/07/2023
Date Signed: 11/07/2023 12:35:14 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA BARBARA CC RO, 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
08/24/2023 and conducted by Evaluator Susana Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 17-CC-20230824120443
FACILITY NAME:TEMPLE ETZ CHAIM PRESCHOOLFACILITY NUMBER:
566215054
ADMINISTRATOR:DEBBIE BLUMENTHALFACILITY TYPE:
830
ADDRESS:1080 E. JANSS ROADTELEPHONE:
(805) 497-6852
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:50CENSUS: 33DATE:
11/07/2023
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Debbie BlumenthalTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff did not adequately supervise infant in care resulting in infant sustaining a fall.
Staff did not report an incident involving infant in care.
Staff did not adhere to food safety protocols.
INVESTIGATION FINDINGS:
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On November 7, 2023 Licensing Program Analysts (LPA's) Susana Martinez and Veronica Diaz conducted an unannouced inspection to deliver the findings of the above mentioned allegations. LPA's met with Site Director Debbie Blumenthal and advised her for the purpose of the inspection. Together with the director, LPA's toured the facility inside and outside. At the time of inspection there were 33 infants in the care of 12 adults.

The Department received a complaint indicating staff do not adequately supervise infant in care resulting in infant sustaining a fall, staff did not report an incident involving infant in care, and staff did not adhere to food safety protocols. LPA conducted staff interviews and record reviews. LPA interviewed Director and asked if she had any idea what the complaint was regarding, Director stated it maybe due to a teacher who quit recently. LPA asked Director if any child in care has ever been injured and required medical attention, Director stated no. LPA asked Director if she is aware of any incident involving a mix up of baby formula, breast milk, Director stated no.
Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Susana MartinezTELEPHONE: 805-689-4212
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
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-20230824120443
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: TEMPLE ETZ CHAIM PRESCHOOL
FACILITY NUMBER: 566215054
VISIT DATE: 11/07/2023
NARRATIVE
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LPA also interviewed staff members who have worked in the infant center. Three out of five staff members interviewed admitted to having knowledge of an incident where a staff member gave an infant the wrong breast milk. Staff members alerted the Director right away and monitored the child. Per review of the incident log, this was not reported to the Department. Staff members also admitted to having knowledge of an incident that occurred in an infant room involving a child falling off of a changing table. Staff members described how the incident occurred, indicating a staff member placed a child on the changing table to put the child's shoes on and while turning attention to something else, child fell from changing table. Staff stated that Director was made aware of the incident. It was unknown to staff if child who fell went to seek medical attention. Per review of incident reports, the center did not report the unusual incident.

Based on LPA's observations, interviews which were conducted, documents gathered and/or record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found SUBSTANTIATED. California Code of Regulations, Title 22, Division 12, are being cited on the attached LIC 9099D.

2 type A deficiencies and 1 type B deficiency was issued during today's inspection.

LPA Martinez informed Director Debbie Blumenthal that this report dated 11/7/2023 documents Two Type A citations which shall be posted for 30 consecutive days as there is/are immediate risks to the health, safety, or personal rights of children in care.

Also, LPA Martinez informed the Director Debbie Blumenthal to provide a copy of this licensing report dated 11/07/2023 that documents any Type A citations to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

An exit interview was conducted and Plans of Corrections were reviewed and developed with the Director. A copy of this report and appeal rights were discussed and left with Director, Debbie Blumenthal, whose signature on this form confirm receipt of these documents.

Notice of site visit was given.

SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Susana MartinezTELEPHONE: 805-689-4212
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 17-CC-20230824120443
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: TEMPLE ETZ CHAIM PRESCHOOL
FACILITY NUMBER: 566215054
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2023
Section Cited
CCR
101229(a)(1)
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101229Responsibility for Providing Care and Supervision(a)The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time ... Supervision shall include visual observation. This requirement is not met as evidenced by:
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The center is to submit a written plan on how they plan to prevent this incident from occuring again. The plan shall be submitted by 11/21/23. The center will also be invited into the office for an informal meeting at a later time.
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Based on observation and interviews conducted, Center did not comply with the deficiency cited above as a child fell off a changing table which poses an immediate risk to the health, safety and or personal rights of children in care.
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Type A
11/07/2023
Section Cited
CCR
101427(a)
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101427 Infant Care Food Service (c) The infant shall be fed in accordance with the individual plan. This requirement is not met as evidenced by:
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The center is to submit a written plan on how they plan to prevent this incident from occuring again. The plan shall be submitted by 11/21/23. The center will also be invited into the office for an informal meeting at a later time.
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Based on observation and interviews conducted, Center did not comply with the deficiency cited above as a child was given the wrong breast milk which poses an immediate risk to the health, safety and or personal rights of children in care.
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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: Ana TolentinoTELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Susana MartinezTELEPHONE: 805-689-4212
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 17-CC-20230824120443
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: TEMPLE ETZ CHAIM PRESCHOOL
FACILITY NUMBER: 566215054
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2023
Section Cited
CCR
101212(d)(1)(C)
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101212(d)(1)(C) Upon the occurrence, during the operation of the child care center of any of the events...below, a report shall be made to the Department by telephone or fax within the Department's next working day... (1) Events reported shall include the following:(C) Any unusual incident... that threatens the physical or emotional health or safety of any child. This requirement was not met as evidence by:
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The center is to submit a written plan on how they plan to prevent this incident from occuring again. The plan shall be submitted by 11/21/23. The center will also be invited into the office for an informal meeting at a later time.
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Based on observation, interviews conducted, and record review, Licensee did not comply with the deficiency cited above as unusual incidents were not reported to the Department which poses a potential risk to the health, safety and or personal rights of children in care.
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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: Ana TolentinoTELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Susana MartinezTELEPHONE: 805-689-4212
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4