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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 233010356
Report Date: 05/06/2025
Date Signed: 05/06/2025 03:33:32 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC 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
03/12/2025 and conducted by Evaluator Robert Maciel
PUBLIC
COMPLAINT CONTROL NUMBER: 01-CC-20250312120400
FACILITY NAME:SOUTH COAST DAY CAREFACILITY NUMBER:
233010356
ADMINISTRATOR:KRISTIN YAGERFACILITY TYPE:
850
ADDRESS:40 SCHOOL STREETTELEPHONE:
(818) 219-7478
CITY:POINT ARENASTATE: CAZIP CODE:
95468
CAPACITY:16CENSUS: 9DATE:
05/06/2025
UNANNOUNCEDTIME BEGAN:
11:39 AM
MET WITH:Kevin PolkTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Staff did not report child's injuries to authorized representative.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Robert Maciel made an unannounced Complaint Investigation visit and met with Executive Director, Kevin Polk. LPA interviewed staff. It was alleged that staff did not report child's injuries to authorized representative, specifically an incident in which staff administered first aid to a child that was not reported to that child's authorized representative.

Interviews conducted and with adults and staff from 03/13/2025 to 05/06/2025 and review of facility records revealed that on 6/10/24, there was an incident in which first aid was provided to a child (C1) that was not reported to that child's authorized representative, corroborating the allegation.

Based on the evidence obtained, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D. Appeal rights were provided and exit interview conducted with Executive Director, Kevin Polk. The Notice of Site Visit must be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melchisedeck Augustin
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
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
SANTA ROSA CC 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
03/12/2025 and conducted by Evaluator Robert Maciel
PUBLIC
COMPLAINT CONTROL NUMBER: 01-CC-20250312120400

FACILITY NAME:SOUTH COAST DAY CAREFACILITY NUMBER:
233010356
ADMINISTRATOR:KRISTIN YAGERFACILITY TYPE:
850
ADDRESS:40 SCHOOL STREETTELEPHONE:
(818) 219-7478
CITY:POINT ARENASTATE: CAZIP CODE:
95468
CAPACITY:16CENSUS: 9DATE:
05/06/2025
UNANNOUNCEDTIME BEGAN:
11:39 AM
MET WITH:Kevin PolkTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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9
Staff caused injury to day care child.

Staff did not provide comfortable accomodations to child.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Robert Maciel made an unannounced Complaint Investigation visit and met with Executive Director, Kevin Polk. LPA interviewed staff and reviewed facility records. It is alleged that staff caused injury to day care child and staff did not provide comfortable accomodations to a child.

Interviews conducted with adults and staff from 03/13/2025 to 05/06/2025 and review of facility records do not corroborate the allegations.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, and the findings are unsubstantiated. An exit interview was conducted with Executive Director, Kevin Polk. The Notice of Site Visit must be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melchisedeck Augustin
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
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 01-CC-20250312120400
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SOUTH COAST DAY CARE
FACILITY NUMBER: 233010356
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2025
Section Cited
CCR
101226.3(b)
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(b): Any unusual behavior, any injury or signs of illness requiring assessment and/or administration of first aid by staff shall be reported to the child's authorized representative and recorded in the child's record.

This requirement was not met as evidenced by:
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Executive Director stated that the facility would begin implementation of a system for recording incidents that occur and would send LPA Maciel updated staff policy that describes the system by email at robert.maciel@dss.ca.gov by 5/20/25.
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Based on interview and record review, there was an incident on 6/10/24 in which first aid was provided to a child (C1) that was not reported to that 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: Melchisedeck Augustin
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3