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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 073409068
Report Date: 05/10/2023
Date Signed: 05/10/2023 04:31:57 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
12/08/2022 and conducted by Evaluator Michelle Sutton
PUBLIC
COMPLAINT CONTROL NUMBER: 02-CC-20221208114830
FACILITY NAME:MADRIGALDEFRIAS, MARISAFACILITY NUMBER:
073409068
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 6DATE:
05/10/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Marisa MadrigaldefriasTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Child in care sustained fracture due to licensee's negligence
INVESTIGATION FINDINGS:
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On 5/10/23 at 3:00 PM Licensing Program Analyst (LPA) Michelle Sutton met with licensee Marisa Madrigal De Frias to deliver the findings of the above listed allegation. The complaint investigation was conducted by Special Investigator, Brianna Abeyta of the Bureau of Investigations. Based on the interviews which were conducted and record reviews, it was determined that an infant fell off a small children’s table which caused a fractured clavicle. Licensee admitted to turning her back to infant and the fall was an accident. 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: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
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 3
Control Number 02-CC-20221208114830
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: MADRIGALDEFRIAS, MARISA
FACILITY NUMBER: 073409068
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/11/2023
Section Cited
CCR
102417(a)
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Operation of a Family Child Care Home (a)The licensee shall be present in the home and shall ensure that children in care are supervised at all times.[........]
This requirement is not met as evidenced by
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By 5/11/23 licensee will submit a written plan on how to supervise children at all time and understanding the regulation of Operation of Family Child Care Home.
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Based on observation IB investigation, licensee lack of supervision an infant in care fell off children's table, which caused a fractured clavicle. This is a
immediate 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: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 02-CC-20221208114830
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: MADRIGALDEFRIAS, MARISA
FACILITY NUMBER: 073409068
VISIT DATE: 05/10/2023
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.

The following deficiency were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Marisa Madrigal De Frias.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Michelle Sutton
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3