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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 103911798
Report Date: 12/14/2022
Date Signed: 12/14/2022 02:31:46 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/14/2022 and conducted by Evaluator Ka Vang
PUBLIC
COMPLAINT CONTROL NUMBER: 04-CC-20221114152352
FACILITY NAME:PEREZ, MARIA FAMILY CHILD CAREFACILITY NUMBER:
103911798
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 3DATE:
12/14/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Maria PerezTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Provider did not provide adequate supervision to day care child resulting in day care child sustaining injuries.
INVESTIGATION FINDINGS:
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On 12/14/2022, Licensing Program Analysts (LPAs) Ka Vang and Priscilla Zamudio conducted an unannounced follow-up inspection to conclude the complaint investigation that initiated on 11/15/2022. Licensee is a Spanish speaking; therefore, LPA Priscilla provided Spanish translation. LPAs met with Licensee Maria Perez to discuss the purpose of the inspection and the investigation finding. A census was taken.

During the course of the investigation, LPAs interviewed licensee, Reporting Party (RP) and other who have knowledge of the allegation. LPA also obtained and reviewed pertinent records relevant to the allegation above and records indicated that Reference #1 (R1) sustained injuries but there was no evidence that licensee failed to provide adequate supervision at the daycare facility that result in R1 sustained injuries.

Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged allegation did or did not occur, therefore, the allegation is UNSUBSTANTIATED.

(Continued on LIC9099-C).
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Michael Duarte
LICENSING EVALUATOR NAME: Ka Vang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
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 2
Control Number 04-CC-20221114152352
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: PEREZ, MARIA FAMILY CHILD CARE
FACILITY NUMBER: 103911798
VISIT DATE: 12/14/2022
NARRATIVE
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Per California Code of Regulations, Title 22, Division 12, Chapter 3, no deficiency was cited during today’s inspection.

An exit interview was conducted with Licensee Maria Perez. A copy of this report and appeal rights were provided. A note of Site Visit (LIC 9213) form was given to licensee to post and it must remain posted for 30 days.
SUPERVISORS NAME: Michael Duarte
LICENSING EVALUATOR NAME: Ka Vang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2