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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 304370749
Report Date: 07/24/2024
Date Signed: 07/24/2024 10:30:50 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 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
06/20/2024 and conducted by Evaluator Anna Francesca Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 06-CC-20240620135405
FACILITY NAME:SERRANO HEIGHTS ACADEMYFACILITY NUMBER:
304370749
ADMINISTRATOR:GURSAHANI, VIKRAMFACILITY TYPE:
830
ADDRESS:6513 EAST SERRANO AVENUETELEPHONE:
(714) 637-4963
CITY:ANAHEIM HILLSSTATE: CAZIP CODE:
92807
CAPACITY:38CENSUS: 9DATE:
07/24/2024
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Director Vikram GursahaniTIME COMPLETED:
10:50 AM
ALLEGATION(S):
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Licensee does not ensure that the facility is kept clean.
INVESTIGATION FINDINGS:
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On 7/24/2024, at 8:50am Licensing Program Analyst (LPA), Anna Chan conducted an unannounced Complaint investigation inspection. The purpose of the investigation is to deliver findings from a complaint initiated on 6/26/2024. Upon arrival, LPA met Director Vikram Gursahani and was led on a walkthrough of the facility. Director was informed of the purpose of the visit. Census was taken. LPA observed 3 staff and 9 infant children.

A review of the Facility Personnel Report Summary shows all facility staff or individuals who require caregiver background checks have received a criminal record clearance and a child abuse index clearance or an exemption clearance.

Page 1 of 2
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
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 6
Control Number 06-CC-20240620135405
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SERRANO HEIGHTS ACADEMY
FACILITY NUMBER: 304370749
VISIT DATE: 07/24/2024
NARRATIVE
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The Department received a Complaint on 6/20/2024 alleging licensee does not ensure that the facility is kept clean.
Reporting Party (RP) stated the wires of the microwave in the Toddler Room#2 is hazardous to children.

Interview with staff: On 6/26/2024, the LPA interviewed 7 staff at the facility. Staff #1 (S1) stated the carpets are being deep cleaned by a third-party cleaner. 6 staff stated that the carpet in the toddler room#2 is dirty and needs deep cleaning and maintenance.

LPA Observation: Based on LPA’s observation on 06/26/24, two carpets in the toddler room where older infants were, has stains all over it. LPA observed carpets were dirty. Photos were taken during the inspection.

On 6/27/24, LPA received an email from the Director a copy of 4 videos showing a cleaner is sweeping the carpets using a long broom. California Code of Regulation 101438.1(c)(2) states, Carpeted floors and large throw rugs that cannot be washed shall be vacuumed at least daily and cleaned at least every six months, or more often if necessary.

On 06/27/24, LPA received cleaning invoice from the facility, carpets were deep cleaned on April 27, 2024. Although the carpets remain dirty and stained.

Interview with children: Children are non-verbal, therefore none were interviewed during the visit.

Interview with Parents: On 3/11/2024, the LPA called 10 parents. The LPA reached two (2) parents and did not disclose any information that could support the allegation.

Based on observation and conducted interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A substantiated finding means that the complaint is substantiated, and the allegation is valid . See LIC9099D for 1 Type B deficiency cited. Director was given a copy if the regulation violated.

An exit interview was conducted with Vikram Gursahani. The Notice of Site Visit was posted during the visit. The director 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. The director 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.

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SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 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
06/20/2024 and conducted by Evaluator Anna Francesca Chan
COMPLAINT CONTROL NUMBER: 06-CC-20240620135405

FACILITY NAME:SERRANO HEIGHTS ACADEMYFACILITY NUMBER:
304370749
ADMINISTRATOR:GURSAHANI, VIKRAMFACILITY TYPE:
830
ADDRESS:6513 EAST SERRANO AVENUETELEPHONE:
(714) 637-4963
CITY:ANAHEIM HILLSSTATE: CAZIP CODE:
92807
CAPACITY:38CENSUS: 9DATE:
07/24/2024
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Director Vikram GursahaniTIME COMPLETED:
10:50 AM
ALLEGATION(S):
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Staff do not adequately supervise children in care.
Licensee does not ensure that children do not have access to hazardous item(s) while in care.
Staff yell at children in care.
Facility operates out of ratio
Unqualified staff
INVESTIGATION FINDINGS:
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On 7/24/2024, at 8:50am Licensing Program Analyst (LPA), Anna Chan conducted an unannounced Complaint investigation inspection. The purpose of the investigation is to deliver findings from a complaint initiated on 6/26/2024. Upon arrival, LPA met Director Vikram Gursahani and was led on a walkthrough of the facility. Director was informed of the purpose of the visit. Census was taken. LPA observed 3 staff and 9 infant children.

A review of the Facility Personnel Report Summary shows all facility staff or individuals who require caregiver background checks have received a criminal record clearance and a child abuse index clearance or an exemption clearance.

Page 1 of 2

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 06-CC-20240620135405
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SERRANO HEIGHTS ACADEMY
FACILITY NUMBER: 304370749
VISIT DATE: 07/24/2024
NARRATIVE
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The Department received a Complaint on 6/20/2024 alleging (1) Staff do not adequately supervise children in care. (2) Licensee does not ensure that children do not have access to hazardous item(s) while in care. (3) Staff yell at children in care. (4) Facility operates out of ratio (5) Unqualified staff

On 6/26/24, LPA interviewed 7 staff. (1) Based on staff interview on 06/26/24, 5 staff stated they do not use personal phones while supervising children. 6 staff stated they have not seen other staff use a cellphone for personal use while caring for children. Staff 1 stated, there is an ipad in the class to be used during class hours and to communicate with parents. (2) Based on staff interviews on 06/26/24, 6 staff stated they re-direct children when children walk up close to the microwave. 6 staff also stated there is a chair that blocks the way where the plugs were. (3) Based on staff interviews on 06/26/24, 6 staff stated they have not witnessed another staff yelling at children. 3 staff stated they hear firm voices but not yelling. (4) 6 staff stated facility is in ratio and enrollment is low. All 7 Staff stated they are always in ratio. (5) Based on staff interviews, 7 staff stated, aides are always supervised by a fully qualified teacher and never left alone with children unless children are napping.

On 6/26/24, LPA observed no hazardous items accessible to children in care. There is a chair barricading the side where the microwave is plugged. The plug is about 2ft from the ground. LPA also observed the facility met ratio requirements.

Records Reviewed: LPA reviewed employee handbook, there is “cellphone” and “ratio” policy in place. Based on the employee handbook, cellphones are not permitted in the classrooms while supervising children. LPA reviewed children’s attendance and staff attendance between June 3-25, 2024. The attendance sheet showed facility is in ratio. On 06/26/24 LPA reviewed 6 staff files. Based on records reviewed, 4 staff are fully qualified and 2 staff are qualified aides.

Interview with children: Children are non-verbal; therefore, none were interviewed during the visit.

Page 2 of 3

SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 06-CC-20240620135405
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SERRANO HEIGHTS ACADEMY
FACILITY NUMBER: 304370749
VISIT DATE: 07/24/2024
NARRATIVE
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Interview with Parents: On 7/5/2024, LPA called 13 parents. The LPA reached two (2) parents and did not disclose any information that could support the allegation.

Based on observation, interviews conducted and records reviewed, although the allegations may or may not have happened, the preponderance of evidence standard has not been met, therefore the above allegations were found to be UNSUBSTANTIATED.

Exit interview was conducted with Director Vikram Gursahani. Notice of Site Visit was posted during the visit. Director 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. The Director was provided with 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.

Page 3 of 3

SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 06-CC-20240620135405
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SERRANO HEIGHTS ACADEMY
FACILITY NUMBER: 304370749
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2024
Section Cited
CCR
101438.1(c)(2)
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101438.1(c)(2) Infant Care General Sanitation(c) Washing, cleaning and sanitizing requirements for areas used by staff with infants...(2) Carpeted floors and large throw rugs that cannot be washed shall be vacuumed at least daily and cleaned at least every six months, or
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Director stated, the facility deep cleaned the carpets after the initial investigation on June 29, 2024. DIrector stated that they will instruct the cleaners to vacuum the carpets as necessary. Proof of cleaning receipt will be sent to LPA by due date of 8/23/24.
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more often if necessary. This requirement is not met as evidenced by: Based on observation the carpets were dirty. Based on staff interview, 6 staff stated the carpets are dirty and needs deep cleaning. This poses as a potential risk to health and safety of 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: Martha Malane
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6