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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 073408262
Report Date: 05/25/2022
Date Signed: 05/25/2022 03:20:00 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
03/25/2022 and conducted by Evaluator Michelle Sutton
PUBLIC
COMPLAINT CONTROL NUMBER: 02-CC-20220325101158
FACILITY NAME:LEARNING EXPERIENCE, THEFACILITY NUMBER:
073408262
ADMINISTRATOR:ROBYN KINGFACILITY TYPE:
830
ADDRESS:4831 LONE TREE WAYTELEPHONE:
(925) 281-7640
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:32CENSUS: 8DATE:
05/25/2022
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Fauzia KamalTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Daycare child sustained unexplained injuries while in care
INVESTIGATION FINDINGS:
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On 5/25/22 at 1:50 PM Licensing Program Analyst (LPA) Michelle Sutton conducted a Complaint Investigation at Learning Experience and met with Director Fauzia Kamal and owner Rajya Ponnaluri. Complaint allegation is that the Daycare child sustained unexplained injuries while in care. During the course of the investigation, LPA inspected the facility, reviewed records, and conducted interviews. While in care Child 1 sustained unexplained injuries, no staff could confirm what happned to Child 1. Based on the observations and interviews which were obtained throughout the investigation, the preponderance of evidence standard has been met, Therefore, the allegation is SUBSTANTIATED. California Code of Regulations, Title 22, Division 12 is being cited on 9099-D page.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Michelle Sutton
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022
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 7
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
03/25/2022 and conducted by Evaluator Michelle Sutton
PUBLIC
COMPLAINT CONTROL NUMBER: 02-CC-20220325101158

FACILITY NAME:LEARNING EXPERIENCE, THEFACILITY NUMBER:
073408262
ADMINISTRATOR:ROBYN KINGFACILITY TYPE:
830
ADDRESS:4831 LONE TREE WAYTELEPHONE:
(925) 281-7640
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:32CENSUS: 8DATE:
05/25/2022
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Fauzia KamalTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff did not properly report an incident involving a daycare child
INVESTIGATION FINDINGS:
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On 5/25/22 at 1:50 PM Licensing Program Analyst (LPA) Michelle Sutton conducted a Complaint Investigation at Learning Experience and met with Director Fauzia Kamal and owner Rajya Ponnaluri. Complaint allegation is that staff did not properly report an incident involving a daycare child. During the course of the investigation, LPA inspected the facility, reviewed records, and conducted interviews. Facility did not report Child 1 injuries to parent. Based on the observations and interviews which were obtained throughout the investigation, the preponderance of evidence standard has been met, Therefore, the allegation is SUBSTANTIATED. California Code of Regulations, Title 22, Division 12 is being cited on 9099-D page.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Director Fauzia Kamal.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Michelle Sutton
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 02-CC-20220325101158
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: LEARNING EXPERIENCE, THE
FACILITY NUMBER: 073408262
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/01/2022
Section Cited
CCR
101212(f)
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101212 Reporting Requirements
(f) The items specified in (d)(1)(A) through (H) above shall also be reported to the child's authorized representative. This requirement is not met as evidence by;

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By 6/1/22 Director will submit a written statement understanding Licensing Reporting Requirements.
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Based on observation, interviews and record review so it was confirmed that Child 1 did sustain unexplained injuries while in care and it was not reported to parent.This is a potienal risk to Health and Safety or Personal Rights risk to persons 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.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Michelle Sutton
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7
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
03/25/2022 and conducted by Evaluator Michelle Sutton
PUBLIC
COMPLAINT CONTROL NUMBER: 02-CC-20220325101158

FACILITY NAME:LEARNING EXPERIENCE, THEFACILITY NUMBER:
073408262
ADMINISTRATOR:ROBYN KINGFACILITY TYPE:
830
ADDRESS:4831 LONE TREE WAYTELEPHONE:
(925) 281-7640
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:32CENSUS: 8DATE:
05/25/2022
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Fauzia KamalTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Daycare child choked on a piece of food while in care
INVESTIGATION FINDINGS:
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On 5/25/22 at 1:50 PM Licensing Program Analyst (LPA) Michelle Sutton conducted an Unannounced Complaint Investigation at Learning Experience and met with Director Fauzia Kamal and owner Rajya Ponnaluri. The LPA inspected the facility, reviewed records, and conducted interviews. Complaint allegation is that Daycare child choked on a piece of food while in care. Based on LPA observations, interviews and information obtained throughout the investigation, the allegation is UNSUBSTANTIATED. 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 allegation is UNSUBSTANTIATED. No Deficiencies have been cited for the allegation.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Director Fauzia Kamal.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Michelle Sutton
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022
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 7
Control Number 02-CC-20220325101158
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: LEARNING EXPERIENCE, THE
FACILITY NUMBER: 073408262
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/26/2022
Section Cited
CCR
101223(a)(3)
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101223 Personal Rights(a) The licensee shall ensure[..] (3)To be free from corporal or unusual punishment, infliction of pain,[..] This requirement is not met as evidence by;
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Due 5/26/22 Director will submit to CCLD a written statement understanding the regulation of Personal Rights.
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Based on observation, interviews and record review it was confirmed that Child 1 did sustain unexplained injuries while in care.This is an immediate risk to Health and Safety or Personal Rights risk to persons in care.
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By next week, Facility with conduct staff training/meeting on Personal Rights and Responsibilty for providing care and supervision. Facility will submit an agenda and a sign-in sheet of all staff present.
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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: Sherelle Johnson
LICENSING EVALUATOR NAME: Michelle Sutton
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 02-CC-20220325101158
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: LEARNING EXPERIENCE, THE
FACILITY NUMBER: 073408262
VISIT DATE: 05/25/2022
NARRATIVE
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Due to the issuance of a Type A Citation during today's inspection, a copy of this Licensing Report must be POSTED in the facility and PROVIDED to each existing parent by the end of today or next day child is in care. Report also must be PROVIDED to the parent of children who are enrolled over the next 12 months. In addition, a copy of the LIC 9224 Acknowledgement of Receipt of Licensing Reports must be signed by each
parent and kept in each child's file.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Director Fauzia Kamal.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Michelle Sutton
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 7