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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 173000694
Report Date: 10/23/2024
Date Signed: 10/23/2024 03:12:45 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/16/2024 and conducted by Evaluator Sebastian Phouthavong
COMPLAINT CONTROL NUMBER: 01-CC-20241016084623
FACILITY NAME:KELSEYVILLE MIGRANT HEAD STARTFACILITY NUMBER:
173000694
ADMINISTRATOR:ADRIANA MENDOZAFACILITY TYPE:
850
ADDRESS:5081 A KONOCTI ROADTELEPHONE:
(707) 279-1022
CITY:KELSEYVILLESTATE: CAZIP CODE:
95451
CAPACITY:20CENSUS: 7DATE:
10/23/2024
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Adriana MendozaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff handled daycare child in a rough manner
INVESTIGATION FINDINGS:
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An initial complaint investigation inspection was made to the facility by Licensing Program Analysts (LPA), Sebastian Phouthavong, who met with Site Supervisor, Adriana Mendoza to discuss the allegation filed against the facility. It is alleged staff handled daycare child in a rough manner specifically a child was carried from a play structure.

During the course of the investigation, LPA reviewed records and conducted interviews with the Site Supervisor (D1), Regional Manager (RM) and three staff (S1-S3) D1 and RM admitted that the alleged incident occurred, and a child was carried by two staff members by the child’s armpit areas and lower legs for the purpose of a diaper change. Furthermore, D1 and RM stated the facility has addressed the incident. Interviews conducted by staff (S1 – S3) corroborated with D1 and RM’s statements.

Based on the information gathered during this investigation, the preponderance of the evidence standard has been met. Therefore, the allegation is determined to be substantiated.
(Continued on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
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 01-CC-20241016084623
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: KELSEYVILLE MIGRANT HEAD START
FACILITY NUMBER: 173000694
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2024
Section Cited
CCR
101223(a)(1)
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101223 Personal Rights: (a) The licensee shall ensure that each child is accorded the following personal rights: 1) To be accorded dignity in his/her personal relationships with staff and other persons.
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Site Supervisor stated the incident has been addressed by means of a staff meeting and a plan was created to ensure the incident does not occur again. In addition, LPA provided the regulations 101223 Personal Rights and Site Supervisor will review it all staff members and will submit a statement of
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Based on interviews from D1, RM & Staff (S1-S3), a child was carried by two staff members for the purpose of a diaper change, which poses a potential health, safety or personal rights risk to persons in care.
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completion with staff’s signatures and date to the department by 10/31/2024.
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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: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 01-CC-20241016084623
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: KELSEYVILLE MIGRANT HEAD START
FACILITY NUMBER: 173000694
VISIT DATE: 10/23/2024
NARRATIVE
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(Continued from LIC9099)

California Code of Regulations, Title 22, is being cited on the attached LIC 9099-D. Appeal rights were provided. An exit interview was conducted, and this report was read and discussed with the Site Supervisor, Adriana Mendoza. The Notice of Site Visit shall be posted for 30 days.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3