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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 013423590
Report Date: 06/08/2022
Date Signed: 06/08/2022 05:37:27 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/28/2022 and conducted by Evaluator Phyllis Dyer
PUBLIC
COMPLAINT CONTROL NUMBER: 02-CC-20220328105432
FACILITY NAME:HARDY, PEGGY & JACKSON, LAHOMAFACILITY NUMBER:
013423590
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 2DATE:
06/08/2022
UNANNOUNCEDTIME BEGAN:
03:36 PM
MET WITH:Lahoma JacksonTIME COMPLETED:
06:05 PM
ALLEGATION(S):
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7
8
9
Personal Rights - Provider leaves the back door, leading to where children sleep, open.
INVESTIGATION FINDINGS:
1
2
3
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5
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7
8
9
10
11
12
13
LPA Dyer met with Lahoma Jackson regarding the above allegation that Provider leaves the back door open, leading to where the children sleep, open. Present today: the licensee, 1 preschool child, 1 school age child. Community Care Licensing (CCL) Regulations state that children shall receive safe, healthful and comfortable accommodations, furnishings and equipment. Children did not receive safe accommodations as a father of children was able to climb over licensee’s fence, open back door, retrieve his children, and leave. Licensee was sleeping, did not awaken, and was not aware parent had entered the home or left with the children until hours later. Therefore, the above allegation is Substantiated. California Code of Regulations, (Title 22, Div 12), are being cited on the attached LIC 9099D and must be corrected by the due date. Upon receipt, Licensee shall post and provide copies of this Complaint Investigation Report (LIC 9099/D) to parents of children in care at the facility. The LIC 9099/D must also be provided to parents newly enrolled at the facility during the next 12 months. All parents must sign Acknowledgement of receipt form (LIC 9224). The LIC 9224 form must be placed in each child’s file to be reviewed by Licensing. Licensee will be called into the CCL office for a Non- Compliance Conference. Exit interview conducted and appeal rights were given. Notice of site visit posted.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Phyllis Dyer
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/28/2022 and conducted by Evaluator Phyllis Dyer
PUBLIC
COMPLAINT CONTROL NUMBER: 02-CC-20220328105432

FACILITY NAME:HARDY, PEGGY & JACKSON, LAHOMAFACILITY NUMBER:
013423590
ADMINISTRATOR:HARDY, PEGGYFACILITY TYPE:
810
ADDRESS:7317 OUTLOOK AVENUETELEPHONE:
(510) 875-0350
CITY:OAKLANDSTATE: CAZIP CODE:
94605
CAPACITY:8CENSUS: 2DATE:
06/08/2022
UNANNOUNCEDTIME BEGAN:
03:36 PM
MET WITH:Lahoma JacksonTIME COMPLETED:
06:05 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Operation of a Family Child Care Home - There were no caregivers available when authorized representative picked up the children.
INVESTIGATION FINDINGS:
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2
3
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5
6
7
8
9
10
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13
 LPA Dyer met with Lahoma Jackson regarding the above allegation that there were no caregivers available when authorized representative picked up the children. Present today: licensee, 1 preschool child, 1 schoolage child. Community Care Licensing (CCL) regulation state that the licensee shall be present in the home and shall ensure that children in care are supervised at all times. Licensee went upstairs to an off limit area, left 2 children downstairs, and fell asleep on her bed. Children were left unsupervised as the licensee was sleeping on a separate level of the home. There was no digital monitor to assist the licensee in observing or watching the children. Therefore, the above allegation is Substantiated. California Code of Regulations, (Title 22, Div. 12), are being cited on the attached LIC 9099D and must be corrected by the due date. Upon receipt, Licensee shall post and provide copies of this Complaint Investigation Report (LIC 9099/D) to parents of children in care at the facility. The LIC 9099/D must also be provided to parents newly enrolled at the facility during the next 12 months. All parents must sign Acknowledgement of receipt form (LIC 9224). The LIC 9224 form must be placed in each child’s file to be reviewed by Licensing. Licensee will be called into the CCL office for a Non- Compliance Conference. Exit interview conducted. Notice of site visit posted and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Phyllis Dyer
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 02-CC-20220328105432
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: HARDY, PEGGY & JACKSON, LAHOMA
FACILITY NUMBER: 013423590
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/09/2022
Section Cited
CCR
102417
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2
3
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6
7
Operation of a Family Child Care Home. The licensee shall be present in the home and shall ensure that children in care are supervised at all times.
1
2
3
4
5
6
7
Licensee will need to provide a statement as to how she will ensure that children in care are supervised at all times.
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14
Licensee left children downstairs, went upstairs to her bedroom and fell asleep on her bed. Children were left unsupervised as she was sleeping on a separate level without a digital monitor. This poses an immediate Health and Safety risk to clients in care.
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9
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13
14
Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
1
2
3
4
5
6
7
1
2
3
4
5
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7
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3
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5
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7
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2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Phyllis Dyer
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/28/2022 and conducted by Evaluator Phyllis Dyer
PUBLIC
COMPLAINT CONTROL NUMBER: 02-CC-20220328105432

FACILITY NAME:HARDY, PEGGY & JACKSON, LAHOMAFACILITY NUMBER:
013423590
ADMINISTRATOR:HARDY, PEGGYFACILITY TYPE:
810
ADDRESS:7317 OUTLOOK AVENUETELEPHONE:
(510) 875-0350
CITY:OAKLANDSTATE: CAZIP CODE:
94605
CAPACITY:8CENSUS: 2DATE:
06/08/2022
UNANNOUNCEDTIME BEGAN:
03:36 PM
MET WITH:Lahoma JacksonTIME COMPLETED:
06:05 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Personal Rights - Provider was intoxicated while caring for day-care children.
INVESTIGATION FINDINGS:
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2
3
4
5
6
7
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9
10
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12
13
LPA Dyer met with Licensee Lahoma Jackson regarding the above allegation that provider was intoxicated while caring for day-care children. Present today is the licensee, 1 school aged child, and 1 preschool child.
Interviews were conducted. Contradictory statements have been made by both parties. 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 results are Unsubstantiated.
Exit interview conducted. Appeal rights were discussed and given. This report must be kept available for public review for 3 years. Notice of Site visit must be posted for 30 days.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Phyllis Dyer
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 02-CC-20220328105432
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: HARDY, PEGGY & JACKSON, LAHOMA
FACILITY NUMBER: 013423590
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/09/2022
Section Cited
CCR
102423(a)(2)
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2
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5
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7
Personal Rights..Each child receiving services from a family child care home shall have certain rights …To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.

Children did not receive safe accommodations
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3
4
5
6
7
Licensee will need to provide a statement as to how she will ensure that children in care will have safe accommodations at all times and children's personal rights will not be violated.
8
9
10
11
12
13
14
as father was able to climb over licensee's fence, open back door, retreive children, and leave. Licensee was sleeping, did not awaken, and was not aware that parent had entered the home or left with children for an extended period of time. This poses an immediate Health and Safety risk to clients in care.
8
9
10
11
12
13
14
Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Phyllis Dyer
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5