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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 573622056
Report Date: 09/24/2019
Date Signed: 09/24/2019 02:19:49 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
06/28/2019 and conducted by Evaluator Chayntel Hunter
PUBLIC
COMPLAINT CONTROL NUMBER: 53-CC-20190628160651
FACILITY NAME:ESCAMILLA, DONITAFACILITY NUMBER:
573622056
ADMINISTRATOR:ESCAMILLA, DONITAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 921-6498
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:14CENSUS: 5DATE:
09/24/2019
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Licensee Donita EscamillaTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Licensee restrained child in high chair
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Chayntel Hunter and Christopher Jackson met with Licensee Donita Escamilla on 09/24/19 at 1:45 PM to deliver complaint findings for the above allegation. During the course of the investigation, LPA Morillas conducted interviews, and obtained information pertaining to allegation. It was alleged that licensee restrained C1 in a high chair for disciplinary purposes. During the course of the investigation, Licensee stated that she uses the chair for time out. Based off the information obtained there is a preponderance of evidence to prove the alleged violation occurred, therefore the allegation is SUBSTANTIATED.

The following Title 22 Deficiency is being cited on the subsequent 809-D page. Upon receipt of Type A citations, licensee shall post and provide copies of the LIC 809-D for parents/guardians of children in care and for parents/guardians of newly enrolled children for the next 12 months. Licensee must also keep the signed LIC 9224, acknowledging receipt of LIC 809-D in each child's file. Appeal Rights and Notice of Site Visit were provided. Notice of Site Visit must remain posted for 30 days for parental review.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2019
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-20190628160651
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: ESCAMILLA, DONITA
FACILITY NUMBER: 573622056
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/25/2019
Section Cited
CCR
102423(a)(4)
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To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including, but not limited to: interference with eating, sleeping or toileting; or withholding shelter, clothing,
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Licensee stated that the high chair will no longer be used for disciplinary purposes.
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medication or aids to physical functioning. This requirement was not met as evidenced by: Licensee admitted to using a high chair to restrain 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: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2019
LIC9099 (FAS) - (06/04)
Page: 2 of 2