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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 070203461
Report Date: 10/04/2023
Date Signed: 10/04/2023 01:45:13 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
09/28/2023 and conducted by Evaluator Tasha Hackett-Alexander
COMPLAINT CONTROL NUMBER: 02-CC-20230928154214

FACILITY NAME:SMITH, HENRIETTAFACILITY NUMBER:
070203461
ADMINISTRATOR:SMITH, HENRIETTAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 235-3631
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY:12CENSUS: 1DATE:
10/04/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:HENRIETTA SMITHTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Personal Rights- Provider failed to prevent child from sustaining an injury while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Tasha Alexander met today with Licensee Henrietta Smith in regards to the above complaint allegations.

Upon arrival, licensee is present along with one infant over 12 months old. Today an interview was conducted with licensee, a tour of the home was conducted and documents were received.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 12 & Chapter 1, are being cited on the attached LIC. 9099D.

An exit interview was conducted

A notice of site visit was posted.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
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 02-CC-20230928154214
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: SMITH, HENRIETTA
FACILITY NUMBER: 070203461
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2023
Section Cited
CCR
102423(a)(2)
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102423 Personal Rights
(a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following:
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LICENESEE WILL SUBMIT A WRITTEN PLAN OF ACTION ON HOW SHE WILL ENSURE THE SAFETY OF CHILDREN IN CARE ON PREVENTING AN INCIDENT OF THIS NATURE IN THE FUTURE AND SUBMIT TO COMMUNITY CARE LICENSING BY 10//18/23.
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(2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.: THIS REQUIREMENT WAS NOT MET AS EVIDENCED BY INTERVIEWS AND A REVIEW OF DOCUMENTS WHICH REVEALED THAT WHILE SITTING ON A COUCH WITH A CHILD, THE PROVIDER BRIEFLY TURNED AWAY AND THE CHILD FELL OFF OF THE COUCH ONTO A TOY, INJURING HIM/HERSELF ON THE WOODEN BOTTOM OF THE TOY.
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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: Loretta Dyson
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
LIC9099 (FAS) - (06/04)
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