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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197417453
Report Date: 10/08/2021
Date Signed: 10/08/2021 10:41:12 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
08/19/2021 and conducted by Evaluator Silva Garibyan
PUBLIC
COMPLAINT CONTROL NUMBER: 30-CC-20210819164558
FACILITY NAME:CORONA ACADEMY CAMPUS/CA. CHILDRENS ACADEMYFACILITY NUMBER:
197417453
ADMINISTRATOR:CHAVEZ,JENNYFACILITY TYPE:
850
ADDRESS:13036 SHERMAN WAYTELEPHONE:
(818) 764-4054
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:48CENSUS: 12DATE:
10/08/2021
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Jenny Chavez/Site SupervisorTIME COMPLETED:
10:42 AM
ALLEGATION(S):
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Health-Related Services: Child sustained scratches, the licensee did not document the injury in the child's record and did not notify the child's authorized representative of the nature of the injury when the child was picked up from the center.
INVESTIGATION FINDINGS:
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On October 8, 2021 at 8:00 am, Licensing Program Analyst (LPA) Silva Garibyan, conducted an unannounced site visit to the licensed facility for the purpose of delivering the finding. LPA met with Jenny Chavez/Site Supervisor and explained the purpose of the visit.
During the Complaint investigation, interviews were conducted, and observations were made regarding the allegation. Child's injury has not been documented in the child's record and the authorized representative has not been notified of the nature of the injury when the child was picked up from the center based on available information which revealed the facility did not adhere to Title 22 Regulations.

Based on LPA's observation, interviews conducted, and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED according to the California Code of Regulations, Title 22, Division 12, Chapter 1, Section 101226(a)(2).. A copy of this report, Appeal Rights, and Notice of Site Visit were explained and provided to the Site Supervisor Jenny Chavez.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
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-20210819164558
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: CORONA ACADEMY CAMPUS/CA. CHILDRENS ACADEMY
FACILITY NUMBER: 197417453
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/22/2021
Section Cited
CCR
101226(a)(2)
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Health-Related Services: In the case of less serious injuries including, but not limited to, minor cuts, scratches and bites from other children requiring assessment and/or administration of first aid by staff, the licensee shall document the injury in the child's record and notify the child's authorized representative of the nature of
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The site supervisor agrees to provide training regarding Health-Related Services and to provide the training staff sign-in and agenda. Lastly, The site supervisor also agrees to provide a written statement on how the facility will comply with this requirement by 10/22/2021.
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 the injury when the child is picked up from the center. This requirement is not met as evidenced by:Based on interviews and record reviews the licensee did not document the injury did not notify the child's authorized representative which poses a potential health, safety or personal rights risk to persons 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: Mary Ruiz
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
08/19/2021 and conducted by Evaluator Silva Garibyan
PUBLIC
COMPLAINT CONTROL NUMBER: 30-CC-20210819164558

FACILITY NAME:CORONA ACADEMY CAMPUS/CA. CHILDRENS ACADEMYFACILITY NUMBER:
197417453
ADMINISTRATOR:CHAVEZ,JENNYFACILITY TYPE:
850
ADDRESS:13036 SHERMAN WAYTELEPHONE:
(818) 764-4054
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:48CENSUS: DATE:
10/08/2021
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Jenny Chavez/Site SupervisorTIME COMPLETED:
10:42 AM
ALLEGATION(S):
1
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7
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9
Personal Rights: Child sustained burn in the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Silva Garibyan conducted a visit to the facility for the purpose of delivering the findings on the above allegation.

Based upon the evidence obtained through the course of investigation which include observations at the facility, interview with relevant parties there is insufficient evidence to support or disprove that Child #1 sustained burn in the facility. The day of the incident the teacher observed Child #1 fall on the painted concrete floor and sustained scratches. The teacher helped the child up and washed the arm. Therefore, these allegations have been determined unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.
An exit interview was conducted and a copy of this report was provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
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 3