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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197403941
Report Date: 06/23/2022
Date Signed: 06/23/2022 10:17:39 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/16/2022 and conducted by Evaluator Lillian J Casillas
PUBLIC
COMPLAINT CONTROL NUMBER: 30-CC-20220616140940
FACILITY NAME:POLAND FAMILY DAY CAREFACILITY NUMBER:
197403941
ADMINISTRATOR:POLAND, VICTORIA D.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 841-8467
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY:14CENSUS: 7DATE:
06/23/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Victoria PolandTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Personal Rights: Daycare child sustained burn while in care
INVESTIGATION FINDINGS:
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On 6/23/2022, Licensing Program Analyst (LPA) Lillian Casillas conducted an unannounced complaint visit for the purpose of initiating the investigation regarding the allegation above. LPA met with Licensee, Victoria Poland. LPA observed 7 children and 1 staff.

During today’s investigation, LPA reviewed the LIC 624B Unusual Incident Report (UIR) submitted to the Department on 6/22/2022 and Child 1 (C1)’s file. LPA interviewed Licensee and Child 1. Per the UIR, on 6/15/2022 at approximately 12:45PM, C1 was carrying a bowl of noodles to the lunch table when C1 fell down 2 steps and the noodles fell on C1’s upper left leg. The area was red and Licensee put a cold-compress on C1's leg. When C1 woke up from naptime around 3:00 PM, Licensee checked C1's leg again and noticed blistering. Licensee put the cold compress on C1's leg again and called Adult 1 (A1) who took C1 to Urgent Care. Licensee spoke with the A1 later that evening who stated it was a heat burn. A1 stated the doctor provided a cream and gauze. C1 returned to daycare on 6/16/2022.
[CONTINUE ON PAGE 2]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Lillian J Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
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 3
Control Number 30-CC-20220616140940
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: POLAND FAMILY DAY CARE
FACILITY NUMBER: 197403941
VISIT DATE: 06/23/2022
NARRATIVE
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PAGE 2

Based on interviews with relevant parties, record review, and observation, there is a preponderance of evidence to prove the alleged violation did occur. Per Licensee’s admission and the LIC 624B UIR, Licensee served noodles hot enough to inflict burns on C1’s leg. Therefore, the allegation is SUBSTANTIATED. A Type A deficiency was cited during today's inspection (see LIC 9099-D for details).

Upon receipt of this report, the Licensee shall post the LIC 9213 Notice of Site Visit and any Licensing report documenting a type “A” deficiency. The report and the Notice of Site Visit shall be posted for 30 consecutive days. Failure to maintain posting as required, will result in an immediate $100 civil penalty. A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement of Receipt (LIC 9224) form must be maintained in each child’s file immediately upon receipt from parent. Licensee was provided with a copy of the LIC 9224 Acknowledgement of Receipt of Licensing Reports.

An exit interview was conducted. A copy of this report was provided to Licensee, Victoria Poland, along with Appeal Rights and LIC 9213 Notice of Site Visit.
SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Lillian J Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 30-CC-20220616140940
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: POLAND FAMILY DAY CARE
FACILITY NUMBER: 197403941
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/23/2022
Section Cited
CCR
102423(a)(2)
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102423 Personal Rights (a) Each child…shall have certain rights…These rights include, but are not limited to, the following: (2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement is not evidenced by:
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Licensee agrees review the “The Dangers of Instant Soup: 1 in 5 Children Rushed to the ER Each Year” https://www.childhoodpreparedness.org/post/dangersofinstantsoup article and flyer “Prevent Childhood Pediatric Burns” by the Institute for Childhood Preparedness. Article and flyer were
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Based on interview, record review, and observation, Licensee failed to provide safe accommodation when C1 was served noodles hot enough to inflict burns on C1’s leg, which poses an immediate health, safety, or personal rights risk to children in care.
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provided to Licensee. Licensee agrees to provide a LIC 855 Declaration summarizing contents of article and flyer to LPA via mail and email by 6/30/2022.
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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: Maureen Neal
LICENSING EVALUATOR NAME: Lillian J Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3