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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 173010031
Report Date: 06/21/2023
Date Signed: 06/21/2023 11:36:16 AM

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
04/14/2023 and conducted by Evaluator Sebastian Phouthavong
COMPLAINT CONTROL NUMBER: 01-CC-20230414142743
FACILITY NAME:MILA'S PRESCHOOL AND CHILDCARE CENTER-PRESCHOOLFACILITY NUMBER:
173010031
ADMINISTRATOR:KRYSTAL GOMEZFACILITY TYPE:
850
ADDRESS:21036 WASHINGTON STREETTELEPHONE:
(707) 809-7117
CITY:MIDDLETOWNSTATE: CAZIP CODE:
95461
CAPACITY:30CENSUS: 11DATE:
06/21/2023
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Director, Krystal GomezTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff did not report daycare child's injury to appropriate parties
INVESTIGATION FINDINGS:
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A subsequent complaint investigation visit was conducted today by Licensing Program Analyst (LPA), Sebastian Phouthavong who met with Director, Krystal Gomez for the purpose of delivering complaint investigation findings for the above allegation. LPA, previously met with Director on 04/24/2023 to initiate the investigation by discussing the allegation, conducting interviews, making observations, and requesting documents.
It is alleged that Staff did not timely report daycare child's injury to appropriate parties. The facility was toured inside and out. There were 11 children being supervised by 2 staff at the facility during this time.
During the course of the investigation, LPA conducted interviews with the Director (L1), Licensee (L2), three staff members (S1-S3), three parents (P1-P3), and three children (C2-C4) from 04/24/2023 – 06/21/2023. On 04/12/2023, an incident occurred at the facility involving a child who tripped, fell, and sustained an injury. Staff (S2, S3, L1) did confirm the notification process when an incident occurred which included providing first aid, notifying the parents, and issuing a written report.
(Continue on LIC 809-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
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 5
Control Number 01-CC-20230414142743
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: MILA'S PRESCHOOL AND CHILDCARE CENTER-PRESCHOOL
FACILITY NUMBER: 173010031
VISIT DATE: 06/21/2023
NARRATIVE
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(Continue from LIC 809)
According to S2 and L1, this incident occurred towards the end of the day, within ten minutes before parent’s arrival, so the parents were not called to alert them of this incident. Furthermore, L1 admitted that she did not notify Community Care Licensing (CCL) within the next working day of the incident and did not submit a written report within 7 days as required by regulation. L2 stated a written report was mailed to CCL on 04/14/2023 but CCL did not receive any report of this incident. L1-S1 stated a written report was given to the parents the following day. Interviews from P1-P2 stated they have received notification of incidents when they occurred, but P2 stated there was one occasion when P2’s child received an injury at the facility and was not immediately notified.

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. 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 facility’s Director, Krystal Gomez. The Notice of Site Visit shall be posted for 30 days.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
04/14/2023 and conducted by Evaluator Sebastian Phouthavong
COMPLAINT CONTROL NUMBER: 01-CC-20230414142743

FACILITY NAME:MILA'S PRESCHOOL AND CHILDCARE CENTER-PRESCHOOLFACILITY NUMBER:
173010031
ADMINISTRATOR:KRYSTAL GOMEZFACILITY TYPE:
850
ADDRESS:21036 WASHINGTON STREETTELEPHONE:
(707) 809-7117
CITY:MIDDLETOWNSTATE: CAZIP CODE:
95461
CAPACITY:30CENSUS: 11DATE:
06/21/2023
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Director, Krystal GomezTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff did not prevent daycare child from being injured while in care
INVESTIGATION FINDINGS:
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A subsequent complaint investigation visit was conducted today by Licensing Program Analyst (LPA), Sebastian Phouthavong who met with Director, Krystal Gomez for the purpose of delivering complaint investigation findings for the above allegation. LPA, previously met with Licensees on 04/24/2023 to initiate the investigation by discussing the allegation, conducting interview(s), making observations, and requesting documents.

It is alleged that Staff did not prevent daycare child from being injured while in care, specifically a child (C1) tripped, fell, and sustained an injury to the face. The facility was toured inside and out. There were 11 children being supervised by 2 staff at the facility during this time.
During the course of the investigation, LPA conducted interviews with the Director (L1), Licensee (L2), three staff members (S1-S3), three parents (P1-P3) & 3 children (C2-C4) from 04/24/2023 – 06/21/2023. Statements from L1-S2 stated staff attempted to prevent an incident from occurring, by sending a child, who was running inside, to time out, while S2 was cleaning a water spill.
(Continue on LIC809-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 01-CC-20230414142743
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: MILA'S PRESCHOOL AND CHILDCARE CENTER-PRESCHOOL
FACILITY NUMBER: 173010031
VISIT DATE: 06/21/2023
NARRATIVE
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(Continue from LIC 809)
Staff further stated that while on time out, the child got up, started running again, and slipped on the water spill. It could not be confirmed when exactly the spill occurred, how the fall actually happened, or if staff were adequately supervising C1 during the time out before the injury occurred. Interviews from Parents (P1-P3) indicated there are no concerns with the facility at this time. P1 did state there was a past issue with her child misbehaving and the center was able to address this issue and find a solution. P2 stated an injury did occur with her child but there was no discussion of how the incident could’ve been prevented. Statements from C2-C4 indicated that they feel safe at the center, not having any concerns at this time. C4 stated the center has a no running inside policy and would apply a time out for misbehaving, collaborating with L1 & S2 statements.

Based on the information gathered during this investigation, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations occurred and therefore are determined to be unsubstantiated. There were no Title 22 deficiencies cited. This report was reviewed and discussed with the facility’s Director, Krystal Gomez. Appeal rights were provided. Notice of Site Visit shall be posted for 30 days from today's visit.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 01-CC-20230414142743
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: MILA'S PRESCHOOL AND CHILDCARE CENTER-PRESCHOOL
FACILITY NUMBER: 173010031
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/28/2023
Section Cited
CCR
101212(d)
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101212(d).... during the operation of the child care center of any of the events ....a report shall be made to the Department by telephone or fax within the...next working day and during its normal business hours. In addition, a written report… submitted.. within seven days....
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Director reviewed the Reporting Requirments and will submit a Unusual Incident Report of the incident to LPA, Sebastian Phouthavong my email: sebastian.phouthavong@dss.ca.gov by 06/28/2023
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Based on facility record review, the center did not notify and submit an Unsual Incident Report to CCL. This poses a potential Health and Safety risk to 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: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5