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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015700598
Report Date: 03/01/2024
Date Signed: 03/01/2024 02:43:14 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/02/2024 and conducted by Evaluator Lorraine Dacanay-Breaux
COMPLAINT CONTROL NUMBER: 52-CC-20240202160325
FACILITY NAME:PLAY PALS SPACE, LLCFACILITY NUMBER:
015700598
ADMINISTRATOR:TORRES, JENNELLEFACILITY TYPE:
850
ADDRESS:14207 E. 14TH STREETTELEPHONE:
(510) 612-5862
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:30CENSUS: 8DATE:
03/01/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Jacquuline Dia De LeonTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Personal RIghts - Child sustained injuries while in care
Personal Rights - Staff does not ensure children are handled in an appropriate manner.
INVESTIGATION FINDINGS:
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On March 1, 2024, Licensing Program Analysts (LPA's) Lorraine Dacanay Breaux, Christina Uribe and Licensing Program Manager (LPM) Chandra Charles arrived to the facility unannounced to conclude an investigation into the above allegations. Upon arrival the LPA's and the LPM was allowed into the facility by owner, Claire Ibrahim. Also present was facility representative, Jacqueline Diaz DeLeon. Present during the visit were eight (8) pre-school children and four (4) additional staff members. LPA informed the facility representative of the reason for visit and toured the facility.

During the course of the investigation LPA observed staff interactions with the daycare children, reviewed all facility staff records, conducted staff interviews which revealed a child was injured at the daycare facility. Based on LPAs interviews and supporting documentation received, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. See LIC 9099D.

Exit interview conducted with the facility representatives, Jackqueline Diaz De Leon, appeal rights and Notice of Site Visit was provided and must remain posted for a period of 30 days.SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Lorraine Dacanay-Breaux
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/02/2024 and conducted by Evaluator Lorraine Dacanay-Breaux
COMPLAINT CONTROL NUMBER: 52-CC-20240202160325

FACILITY NAME:PLAY PALS SPACE, LLCFACILITY NUMBER:
015700598
ADMINISTRATOR:TORRES, JENNELLEFACILITY TYPE:
850
ADDRESS:14207 E. 14TH STREETTELEPHONE:
(510) 612-5862
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:30CENSUS: 8DATE:
03/01/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Jackqueline Dia De LeonTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
Neglect/Lack of supervision - Staff do not ensure adequate care and supervision is provided to children in care.
INVESTIGATION FINDINGS:
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On March 1, 2024, Licensing Program Analysts (LPA's) Lorraine Dacanay Breaux and Christina Uribe ad Licensing Program Manager (LPM) Chandra Charles arrived to the facility unannounced to conclude an investigation into the above allegation. Upon arrival LPA was allowed in by the facility representative, owner, Claire Ibrahim. Also present was facility representative, Jacqueline Diaz DeLeon. Present during the visit were eight (8) pre-school children and four (4) additional staff members. LPA informed the facility representative of the reason for visit and toured the facility.

Based on LPA observation and staff interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. See LIC 9099D.

Exit interview conducted with the facility representative, Jackqueline Diaz De Leon, appeal rights and Notice of Site Visit was provided and must remain posted for a period of 30 days.SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Lorraine Dacanay-Breaux
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
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 6
Control Number 52-CC-20240202160325
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: PLAY PALS SPACE, LLC
FACILITY NUMBER: 015700598
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2024
Section Cited
CCR
101229(a)
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101229(a) The licensee shall provide care and supervision as necessary to meet the children's need.
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Facility Administrator will hold a staff meeting and review safety protocols for supervision and care for children. Facility Administrator will create a written statement which states the safety protocols and wellness guidelines for supervising children in care. Each staff member will sign and date this written statement.
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This requirement was not met as evidenced by: The facility did not ensure proper care on completing a through wellness check on a child resulting in a child's needs being looked over, which poses a potential health, safety, or personal rights risk to children in care.
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Once all staff has completed, facility Administrator will email this written statement to LPA at Lorraine.Dacanay-Breaux@dss.ca.gov no later than the due date of 03/15/2024.
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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.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Lorraine Dacanay-Breaux
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/02/2024 and conducted by Evaluator Lorraine Dacanay-Breaux
COMPLAINT CONTROL NUMBER: 52-CC-20240202160325

FACILITY NAME:PLAY PALS SPACE, LLCFACILITY NUMBER:
015700598
ADMINISTRATOR:TORRES, JENNELLEFACILITY TYPE:
850
ADDRESS:14207 E. 14TH STREETTELEPHONE:
(510) 612-5862
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:30CENSUS: 8DATE:
03/01/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Jacquuline Dia De LeonTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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2
3
4
5
6
7
8
9
Reporting Requirements - Staff do not ensure reporting requirements are followed
INVESTIGATION FINDINGS:
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On March 1, 2024, Licensing Program Analysts (LPA's) Lorraine Dacanay Breaux and Christina Uribe ad Licensing Program Manager (LPM) Chandra Charles arrived to the facility unannounced to conclude an investigation into the above allegation. Upon arrival LPA was allowed in by the facility representative, Jacqueline Diaz DeLeon and owner, Claire Ibahim. Present during the visit were eight (8) pre-school children and four (4) additional staff members. LPA informed the facility representative of the reason for visit and toured the facility.

During the course of the investigation LPA reviewed facility injury reports and conducted interviews with staff. Facility staff did not report the incident to authorized representative in regards to the incident. Based on LPA review of records an staff interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. SEE LIC. 9099D.

Exit interview conducted with the facility representative, Jackqueline Diaz De Leon, appeal rights and Notice of Site Visit was provided and must remain posted for a period of 30 days.SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Lorraine Dacanay-Breaux
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
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 6
Control Number 52-CC-20240202160325
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: PLAY PALS SPACE, LLC
FACILITY NUMBER: 015700598
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2024
Section Cited
CCR
101212(f)
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(f) The items specified in (d)(1)(A) through (H) above shall also be reported to the child's authorized representative.
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Facility Representative will also watch the "Reporting Requirement" video on the CCLD website. Facility Representative will submit a statement stating the correct reporting requirement for Child Care Centers. Statment will be sent to LPA by 03/15/2024.
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(B) Any injury to any child that requires medical treatment. This requirement was not met as evidenced by: A child sustained a injury while in care and the incident was not reported to the authorized representative. This poses an potential risk to the health and safety of children in care.
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Review Title 22 regulation 101212 Reporting Requirements and 101226.3 Observation of the Child. Facility Representatice will email a statement to LPA by 03/15/2024 explaining the steps that will be taken if a child(ren) is injuried.
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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.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Lorraine Dacanay-Breaux
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 52-CC-20240202160325
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: PLAY PALS SPACE, LLC
FACILITY NUMBER: 015700598
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2024
Section Cited
CCR
101223(a)(2)
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101223(a)(2)The licensee shall ensure that each child is accorded the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations...equipment to meet his/her needs.

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Licensees will watch the "Children's Personal Rights in Child Care" training Facility Representative video on the CCLD website. Facility Representative will submit to LPA Breaux a summary of what was learned and how they will ensure children's personal rights are upheld at all times. Summary will be sent to LPA on or before POC date, 03/15/24.
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This requirement was not met as evidenced by: through admission during interview it was found that staff handled child in an inappropriate manner. This presents a potential risk to the health and safety to the children in care.
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Facility Representative will create and write code of conduct on appropriate physical interaction with children. Director will send to LPA on or before POC date, 03/15/2024.
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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.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Lorraine Dacanay-Breaux
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6