570308535-2-4-2022-53-CC-JSMH-CBVRRJ-20220222121514

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 570308535
Report Date: 02/04/2022
Date Signed: 02/04/2022 01:19:27 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/12/2021 and conducted by Evaluator Jeevun Birk

PUBLIC

COMPLAINT CONTROL NUMBER: 53-CC-20211112104118

FACILITY NAME:	RUSSELL PARK CHILD DEVELOPMENT CENTER		FACILITY NUMBER:	570308535
ADMINISTRATOR:	SHELBY FARIA		FACILITY TYPE:	850
ADDRESS:	400 RUSSELL PARK		TELEPHONE:	(530) 753-2487
CITY:	DAVIS	STATE: CA	ZIP CODE:	95616
CAPACITY:	80	CENSUS: 36	DATE:	02/04/2022
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Sarah Tibbet		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Day care child sustained unexplained injuries while in care.

INVESTIGATION FINDINGS:

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On 2/4/2022 at 9:10 AM Licensing Program Analysts (LPAs) Jeevun Birk-Miller and Salene Mayberry conducted an unannounced complaint inspection and met with Director, Sarah Tibbet. The purpose of the inspection was to deliver the findings for the above allegation. During the course of the investigation LPA Birk-Miller conducted interviews with staff and parents of children in care. LPA also collected documents and photos. It was alleged that a day care child sustained unexplained injuries while in care. It was alleged that Child #1 (C1) had an injury to the mouth area. Director stated when injuries or accidents happen at the facility they are witten on reports and then the parent is notified. Director stated there had been verbal discussions with C1's parent regarding the incident to determine what caused the chipped tooth. Four of four staff interviewed stated that when incidents or injuries occur whether witnessed or unwitnessed accident reports are written and parents are notified via message or a phone call. One of four staff interviewed stated they were present when the incident ocurred, staff wrote a report right when it happened and parents were notified. LPA reviewed accident reports for C1. There were three ocassions when injuries to mouth occured, but the chipped tooth had not been observed during those incidents by staff. Continue to 9099-C page.

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Jeanne Smith	TELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Jeevun Birk	TELEPHONE: (916) 917-6078
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022

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 53-CC-20211112104118

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: RUSSELL PARK CHILD DEVELOPMENT CENTER	FACILITY NUMBER: 570308535
	VISIT DATE: 02/04/2022

NARRATIVE

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LPA observed a few injury reports for the child as well. Five of five parents interviewed did not disclose any concerns about being notified of incidents/injuries or any unexplained injuries. Based on the information obtained throughout the course of this investigation the above allegations could not be substantiated or dismissed. Although the allegation may have happened or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the finding is UNSUBSTANTIATED. An exit interview was conducted with the Director. Notice of Site Visit was posted by LPA Birk-Miller and shall remain posted for 30 days.

SUPERVISOR'S NAME: Jeanne Smith	TELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Jeevun Birk	TELEPHONE: (916) 917-6078
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022

LIC9099 (FAS) - (06/04)

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