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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 300600959
Report Date: 12/08/2022
Date Signed: 12/08/2022 05:20:57 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/28/2022 and conducted by Evaluator Carmen Odom
PUBLIC
COMPLAINT CONTROL NUMBER: 06-CC-20221028144324
FACILITY NAME:TEMPLE BETH SHOLOM CHILDREN'S LEARNING CENTERFACILITY NUMBER:
300600959
ADMINISTRATOR:LEVIN, TAMARAFACILITY TYPE:
850
ADDRESS:2625 NORTH TUSTIN AVENUETELEPHONE:
(714) 628-4640
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:92CENSUS: 25DATE:
12/08/2022
UNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Tamara Levin - DirectorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Child was injured by another child because staff did not provide adequate supervision.
Staff did not report child's injury in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Odom and Lucero conducted an unannounced complaint investigation. This is a continuation of the investigation initiated on 11/01/2022. Upon arrival LPA met with Director, Tamara Levin to deliver complaint findings. Director guided LPA on a tour of the facility. LPA took census, at 3:40pm LPA observed a total of 25 preschool age children with 6 staff members.

A review of staff records on this date indicated that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

The Department received a complaint on 10/28/22 alleging Child #1 (C1) was injured by another child because Staff #1 (S1) did not provide adequate supervision and staff did not report child’s injury in a timely manner.
Continue to page 2
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Carmen Odom
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
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 5
Control Number 06-CC-20221028144324
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: TEMPLE BETH SHOLOM CHILDREN'S LEARNING CENTER
FACILITY NUMBER: 300600959
VISIT DATE: 12/08/2022
NARRATIVE
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Complaining party (CP) stated S1 was inside the classroom bathroom changing a child’s diaper when the incident occurred, Child #2 (S2) bit C1 on both cheeks. S1 did not notify CP of the incident after 2 hours when the incident occurred. CP disclosed S1 left a message stating the that injury was minor and S1 did not inform CP that the injury was on the face and C1 was bit twice.

During the investigation LPA Odom interviewed complaining party, director, 2 staff members, attempted interviewing 3 children, conducted a facility inspection, took pictures and reviewed the children’s roster, personnel report, ouch report, sign in and out sheet, pictures of Child #1 (C1), doctors’ notes and e-mail threads.

During the investigation, Director (S3) was interviewed on 11/01/22. S3 stated the first hour S1 is alone in the classroom with about 5 children in care. If a child needs diaper change staff will grab a mat and place it right in front of the doorway of the bathroom where staff can continue to maintain supervision while they change the diaper. S3 disclosed C2 had never bitten any child before so the incident was unexpected. S3 stated on 10/26/22 the day of the incident S1 called CP to notify CP about C1’s incident. C1’s injury did not break the skin, S1 placed an ice pack on the injury and S1 wrote an ouch report for both parents. S1 gave the ouch report to both parents during pick up and S3 also had a meeting with both parents regarding the incident on the same day of the incident. At 3:22pm, S1 sent pictures of C1’s injuries.

During the investigation, 2 staff members were interviewed on 11/01/22. S1 stated the incident occurred on 10/26/22 at 8:45am, S1 had to change a child’s diaper they went inside the classroom bathroom without a door, while S1 was changing the child’s diaper S1 heard C1 cry. S1 finished changing the diaper and went over to C1 to find out why C1 was crying. S1 observed that C1 had bite mark on their cheek, S1 asked C2 what happened and C2 told S1 they bit C1. S1 immediately placed an ice pack on C1’s face, notified S3, and wrote the ouch report. On the ouch report S1 documented, they heard child cry and after checking on the children that’s when S1 realized that C2 had bit C1. At around 10:00am S1 called CP to inform CP of C1’s injury. S1 told CP that the bite did not break the skin, and C1 was doing fine. At 3:22pm S1 sent pictures to CP of C1’s right and left cheeks with red bite mark on left cheek.

On 11/01/22 LPA Odom attempted to interview 3 children, none of the children qualified for interviews.
Continue to page 3.
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Carmen Odom
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 06-CC-20221028144324
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: TEMPLE BETH SHOLOM CHILDREN'S LEARNING CENTER
FACILITY NUMBER: 300600959
VISIT DATE: 12/08/2022
NARRATIVE
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In the course of the investigation it was reported that C1 had another injury on their lip during outdoor playtime and S1 failed to report the incident to CP and did not provide an incident report to CP before the end of the day.

Based on LPA’s facility inspection, observations, interviews conducted with complainant party, director, 2 staff, pictures provided, records reviewed it has been determined that the S1 did not provide adequate supervision and failed to report child’s injury. Therefore, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. California Code of Regulations, Title 22, 101229(a)(1) Responsibility for Providing Care and Supervision and 101226(a)(2) Health-Related Services is being cited on the attached LIC 9099D.

LPA Odom informed Director that this report dated 12/08/22 documents 1 Type A citation Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk to the health, safety, or personal rights of children in care.
Also, LPA Odom informed the Director to provide a copy of this licensing report dated 12/08/22 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Exit interview conducted and report was reviewed with the Director Tamara Levin. A notice of site visit was given and must remain posted for 30 days.

Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above.
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Carmen Odom
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 06-CC-20221028144324
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: TEMPLE BETH SHOLOM CHILDREN'S LEARNING CENTER
FACILITY NUMBER: 300600959
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
12/08/2022
Section Cited
CCR
101229(a)(1)
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101229 Responsibility for Providing Care and Supervision (a) The licensee shall provide... supervision as necessary to meet the children's needs. No child(ren) shall be left without the supervision of a teacher at any time,... Supervision shall include visual observation. This requirement was not met as evidenced by:
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Director stated anytime S1 needs to change a diaper they will call Director or another staff to assist with supervision while S1 is changing a diaper. Director is providing training to S1 on supervision. Director stated they will train all staff on supervision. LPA provided director the e-learning list for supervision and reporting requirements. Director will submit plan of
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Based on observation and interviews conducted it was determined S1 did not provide adequate supervision while changing child’s diaper, in which, C2 bit C1 twice on the face. This poses an immediate safety risk to children care.
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correction by 12/9/22.
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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: Judy Hanson
LICENSING EVALUATOR NAME: Carmen Odom
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 06-CC-20221028144324
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: TEMPLE BETH SHOLOM CHILDREN'S LEARNING CENTER
FACILITY NUMBER: 300600959
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/08/2022
Section Cited
CCR
101226(a)(2)
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101226 Health-Related Services (a) The licensee shall... notify (2) In the case of less serious injuries... licensee shall document the injury in the child's record and notify the child's authorized representative of the nature of the injury when the child is picked up from the center. This requirement was not met as evidenced by:
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Director stated S1 gave CP the ouch report to follwing day during dop off. Director told S1 they have to inform all parents of any incident by the end of the day.
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Based on interviews conducted it was determined that S1 failed to inform CP of C1's lip injury before the end of the day when child was picked up from the childcare center. This poses a potential safety risk to the 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: Judy Hanson
LICENSING EVALUATOR NAME: Carmen Odom
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5