304312847-6-7-2024-06-CC-MMAE-D64QVY-20240610123107

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 304312847
Report Date: 06/07/2024
Date Signed: 06/07/2024 10:28:22 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 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
04/04/2024 and conducted by Evaluator Giselle Lucero

PUBLIC

COMPLAINT CONTROL NUMBER: 06-CC-20240404112156

FACILITY NAME:	SAMAYOA, NATALIA		FACILITY NUMBER:	304312847
ADMINISTRATOR:	SAMAYOA, NATALIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(949) 209-7137
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92704
CAPACITY:	14	CENSUS: 5	DATE:	06/07/2024
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Licensee Natalia Samayoa		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Care providers did not provide adequate supervision, resulting in a child having access to and burning their mouth with hot coffee

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Lucero conducted an unannounced complaint investigation to deliver the findings for the above allegation. Upon arrival LPA met with Licensee Natalia Samayoa who guided LPA on a walkthrough of the facility. At 8:50 AM LPA observed a total of 5 children which included 1 infant, 2 preschool and 2 school age children.

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 04/04/2024 stating care providers did not provide adequate supervision, resulting in a child having access to and burning their mouth with hot coffee. Reporting Party (RP) reported on 03/28/2024, Child #1 (C1) burned their lip by drinking hot coffee.
(continue to page 2)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Giselle Lucero
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

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 06-CC-20240404112156

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SAMAYOA, NATALIA	FACILITY NUMBER: 304312847
	VISIT DATE: 06/07/2024

NARRATIVE

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(Page 2)
During the investigation LPA Lucero interviewed the licensee, 1 adult, 2 children, obtained medical documents, and reviewed the children’s roster.

On 4/11/2024, LPA interviewed the Licensee. Licensee stated the day of the incident, she had 3 children in care. At around 8:15 AM, the licensee will eat her breakfast after the children are done eating at the dinner table. Licensee stated she had reheated her coffee in the microwave. Child #2(C2) had to use the restroom and licensee accompanied C2 to the restroom and left her coffee on the kitchen counter top. Child #3 (C3) shortly accompanied them in the restroom because C3 also had to use the restroom. Minutes later C1 walked into the restroom was licking their lips making “mmmm” noises. Licensee observed C1’s corner of their lip was red. Licensee started to look inside and around C1’s mouth and licensee was able to see some of the coffee creamer/whip cream. Licensee then figured out that C1 drank her coffee. Licensee stated C1’s mouth was red, nothing else was observed. Licensee observed a chair against the counter and suspects C1 pushed the chair against the counter to have access to the coffee. Licensee stated no one witnessed C1 drink the coffee because they were in the restroom. C1’s authorized representatives were notified right away of the incident and C1 was picked up and taken to urgent care. Licensee stated since the incident occurred, the Licensee shadows C1. Licensee states she leaves her coffee cup on the stove or at the back of the counter top so that C1 cannot have access.

On 04/11/2024, LPA Lucero interviewed 2 children. LPA was unable to interview C1 due to their age.

C2 stated the licensee took C3 to the restroom and C1 drank the Licensee’s coffee and hurt their lip. C2 stated the license usually holds her coffee. C2 disclosed the coffee was on the counter top and thinks C1 reached for it. C2 did not observe C1 drink the coffee. C2 stated C1 was not crying and the licensee applied ointment on C1’s lips.

C3 stated they asked the licensee to take them to the restroom and then C1 drank the Licensee’s coffee. C3 stated the license usually has the coffee on the dining table. C3 stated they think that C1 reached for the coffee. C3 also stated the licensee applied ointment on C1’s lips. C3 did not observe C1 drink the coffee.

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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Giselle Lucero
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 06-CC-20240404112156

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SAMAYOA, NATALIA	FACILITY NUMBER: 304312847
	VISIT DATE: 06/07/2024

NARRATIVE

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(Page 3)
LPA interviewed Adult #1 (A1). A1 stated they were notified by the Licensee about the incident. A1 stated they were informed that C1 got on the table to drink the licensee’s coffee and burned themself. A1 stated the incident may have happened around 9 AM. A1 stated when C1 was picked up, C1 was observed having a little bit of redness around the lips but no blistering. A1 disclosed C1 must have seen the Licensee put the coffee on the counter and climbed for it. A1 also disclosed C1 was taken to urgent care and doctors only observed redness there were no blisters.

LPA obtained and reviewed medical records for C1. Records show C1 was treated for a burn upper lip and cheeks on 03/28/2024. Records state there was mild redness, no blisters.

Based on LPA’s interviews conducted and medical records obtained it has been determined care providers did not provide adequate supervision, resulting in a child having access to and burning their mouth with hot coffee. Therefore, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, Title 22, 102417(a) Operation of a Family Child Care Home is being cited on the attached LIC 9099D.

LPA Lucero informed Licensee Natalia Samayoa that this report dated 06/07/2024 document(s) one (1) Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.
Also, LPA Lucero informed the licensee to provide a copy of this licensing report dated 06/07/2024 that documents any Type A citation(s) 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 was conducted. Notice of Site Visit was posted during the visit. Licensee Natalia Samayoa was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. Licensee was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. First level appeals should be sent to the regional manager to the address listed above.
End of Report.

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Giselle Lucero
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 06-CC-20240404112156

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SAMAYOA, NATALIA	FACILITY NUMBER: 304312847
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/07/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/07/2024 Section Cited CCR 102417(a)	1 2 3 4 5 6 7	102417 Operation of a Family Child Care Home (a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times..... This requirement is not met as evidenced by: Based on interviews and medical records obtained it has been determined....	1 2 3 4 5 6 7	Licensee stated she will submit a statement of understanding and ensuring how children will not have access to her coffee to LPA.
	8 9 10 11 12 13 14	child had access to and burned their mouth with hot coffee due to lack of supervision. This poses an immediate risk to the health of the children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Giselle Lucero
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

LIC9099 (FAS) - (06/04)

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