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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 073409367
Report Date: 11/15/2023
Date Signed: 11/15/2023 11:58:59 AM

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
11/09/2023 and conducted by Evaluator Nyeesha Blount
COMPLAINT CONTROL NUMBER: 02-CC-20231109150452
FACILITY NAME:AMADO,ANA,ANDRADES MENESES,BERNARDA,CONNOR,JESSICAFACILITY NUMBER:
073409367
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 1DATE:
11/15/2023
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:AMADO, ANA TIME COMPLETED:
12:10 PM
ALLEGATION(S):
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License ~ Licensee did not reveal the facility license number in all advertisements.
INVESTIGATION FINDINGS:
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On November 15, 2023 at 11:10 AM Licensing Program Analyst (LPA) Nyeesha Blount, conducted an Unannounced Complaint site inspection to open and deliver complaint findings. LPA met with Licensee Amado, Ana, who are background cleared. LPA advised licensee of the nature of the inspection. Current Census today is (1) children which consists of (1) infant child. LPA obtained a copy of the children's current roster, observations and staff interviews were conducted at the time of the inspection.

Based on LPA's observations, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations,102359 (a)(1)(c) is being cited on the attached LIC 9099D

The attached type B deficiency is cited today and must be corrected by the due date. An exit interview was conducted. Appeal rights were given and discussed. This report must be available for public review for 3 years. Notice of site visit was given.
Substantiated
Estimated Days of Completion: 60
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Nyeesha Blount
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023
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 2
Control Number 02-CC-20231109150452
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: AMADO,ANA,ANDRADES MENESES,BERNARDA,CONNOR,JESSICA
FACILITY NUMBER: 073409367
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2023
Section Cited
CCR
102359(a)(1)(c)
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102359 Advertisements and License Number

(a) Licensees shall reveal each facility license number in all advertisements, publications, or announcements made with the intent to attract clients.
(1) Advertisements, publications, or announcements subject to the requirements of Section 102359(a) include, but are not limited to, those contained in the following:C) Announcement of intent to commence business.
This requirement is not met as evidenced by:
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Licensee will ensure on website and business cards and any other form of advertisement that license number is provided. Licensee will provide copies or photos to LPA via email or phone by POC date of December 15, 2023.
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Based on LPA observations Licensee does not have her license number on her advertised website or business cards she provides for the intent to attract clients.
This poses a potential risk to health and safety of children 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: Mayla Mendoza
LICENSING EVALUATOR NAME: Nyeesha Blount
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2