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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197492945
Report Date: 10/22/2021
Date Signed: 10/22/2021 02:08:20 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/19/2021 and conducted by Evaluator Brigitte Tsutaoka
PUBLIC
COMPLAINT CONTROL NUMBER: 12-CC-20211019121109
FACILITY NAME:KIDS TOWN CHILDCARE CENTER, LLCFACILITY NUMBER:
197492945
ADMINISTRATOR:ANA GARCIAFACILITY TYPE:
840
ADDRESS:1825 WEST AVENUE J, SUITE 125TELEPHONE:
(661) 951-2070
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:45CENSUS: 1DATE:
10/22/2021
UNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:Ana Garcia TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Allegation 1: Reporting Requirements
INVESTIGATION FINDINGS:
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On October 22, 2021 at 8:43AM, Licensing Program Analyst (LPA) Brigitte Tsutaoka conducted an unannounced complaint inspection on the above allegation. LPA disclosed the purpose of inspection and was granted entry by Director Ana Garcia. Upon entry, LPA counted 0 children in care. At approximately 12:00PM, 1 child arrived.
At 8:50AM, LPA conducted interviews with Director and Staff 3 who confirmed the incident did occur and disclosed the incident had not been reported to Licensing. LPA also reviewed the FAS database and determined a report was not made by facility regarding the incident. LPA provided consultation and a copy of the Reporting Requirements regulations.
Based on LPA observations, interviews conducted, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found Substantiated. California Code of Regulations, Title 22, Division 12 Chapter 1, 101212 (d) Reporting Requirements Type B violation is being cited on attached LIC9099D.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Brigitte Tsutaoka
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
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 4
Control Number 12-CC-20211019121109
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: KIDS TOWN CHILDCARE CENTER, LLC
FACILITY NUMBER: 197492945
VISIT DATE: 10/22/2021
NARRATIVE
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Director was advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If this requirement is not met, civil penalties in the amount of $100 per violation will be assessed.

An exit Interview was conducted, a copy of this Report, Appeal Rights, and a Notice of Site visit was provided to the Director.
SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Brigitte Tsutaoka
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 12-CC-20211019121109
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: KIDS TOWN CHILDCARE CENTER, LLC
FACILITY NUMBER: 197492945
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2021
Section Cited
CCR
101212(d)
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101212 Reporting Requirements (d)... A report shall be made to the Department by telephone or fax within the Department's next working day...a written report ... shall be submitted to the Department within seven days.
This requirement was not met as evidence by:
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Director agreed to submit the completed Unusual Incident Report (LIC624) detailing the incident to the Department no later than 10/27/2021.
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Based on observation, interview, and record review, Director did not notify the Department of the incident within the time frame required, which 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: Carissa Bell
LICENSING EVALUATOR NAME: Brigitte Tsutaoka
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4