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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197700426
Report Date: 03/02/2022
Date Signed: 03/02/2022 12:54:34 PM

Unsubstantiated


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
12/10/2021 and conducted by Evaluator Justin Dorsey
COMPLAINT CONTROL NUMBER: 12-CC-20211210114120
FACILITY NAME:PEREZ FAMILY CHILD CAREFACILITY NUMBER:
197700426
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
03/02/2022
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Diana PerezTIME COMPLETED:
01:08 PM
ALLEGATION(S):
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The licensee and children do not wear Face Cover
INVESTIGATION FINDINGS:
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On 03/02/22 Licensing Program Analysts (LPA's) Justin Dorsey and Justeene Tamayo conducted an complaint investigation at the facility to deliver complaint investigation findings. Upon arrival LPA's met with Licensee Diana Perez. LPA's observed 0 children in care.
During the course of the investigation LPA Dorsey interviewed, licensee, complainant, a child, and a parent of the program. As part of the investigation LPA Dorsey obtained the facilities children roster and documents relevant to the investigation. After observations and interviews with parties related to the allegations it was found that the allegations could not be collaborated. Therefore, the allegations have been found unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the facility is not providing a safe and healthful environment, Therefore the above allegations are Unsubstantiated.
An exit interview was conducted, and a copy of this report was provided to Licensee Perez along with Notice of Site Visit and Appeal Rights.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Justin Dorsey
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
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
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
12/10/2021 and conducted by Evaluator Justin Dorsey
COMPLAINT CONTROL NUMBER: 12-CC-20211210114120

FACILITY NAME:PEREZ FAMILY CHILD CAREFACILITY NUMBER:
197700426
ADMINISTRATOR:DIANA PEREZFACILITY TYPE:
810
ADDRESS:5419 ESSEX DRTELEPHONE:
(818) 916-4583
CITY:PALMDALESTATE: ZIP CODE:
93552
CAPACITY:8CENSUS: 0DATE:
03/02/2022
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Diana PerezTIME COMPLETED:
01:08 PM
ALLEGATION(S):
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2
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9
The licensee did not report positive Covid-19 to the RO
INVESTIGATION FINDINGS:
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13
On 03/02/22 Licensing Program Analysts (LPA's) Justin Dorsey and Justeene Tamayo conducted an complaint investigation at the facility to deliver complaint investigation findings. Upon arrival LPA's met with Licensee Diana Perez. LPA's observed 0 children in care.
During this investigation, LPA received pertinent documents related to this investigation, which included the facility children’s roster and documents related to the allegation. LPA also interviewed the licensee, complainant, a child and parent of the program. Upon interview with the licensee it was found that she did not report a COVID-19 positive in the home to licensing. Based on information obtained, interviews with relevant complaint parties, licensee, parents and children the allegations are deemed SUBSTANTIATED and a citation will be issued. A finding of substantiated means that allegations were valid because the preponderance of the evidence standard has been met.
An exit interview was conducted, a copy of this report read out, notice of site visit and appeal rights was given to licensee Perez.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Justin Dorsey
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 12-CC-20211210114120
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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 197700426
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/09/2022
Section Cited
CCR
102416.2(b)
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102416.2 Reporting Requirements (b) The licensee shall report to the Department
any of the events as specified in Health and Safety Code Section 1597.467(b)(1)(A)
through (b)(1)(C) that occur during the operation of the family child care home. This requirement is not met as evidenced by:
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Per licensee she will submit a LIC 624 to LPA Dorsey by POC due date 03/09/22
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Based on interview and observation licensee did not report a COVID-19 positive in the home to licensing, which poses a potential Health, Safety or Personal Rights 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: Claretta Yates
LICENSING EVALUATOR NAME: Justin Dorsey
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3