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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 304371252
Report Date: 12/09/2022
Date Signed: 12/09/2022 10:43:15 AM

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
10/03/2022 and conducted by Evaluator Stella Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 06-CC-20221003095254
FACILITY NAME:APPLE TREE PRESCHOOL & KINDERGARTENFACILITY NUMBER:
304371252
ADMINISTRATOR:PERANCULLO, MARBENFACILITY TYPE:
850
ADDRESS:2211 WEST WOODLEY AVENUETELEPHONE:
(714) 772-1005
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:60CENSUS: 22DATE:
12/09/2022
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Margarita Calero, assistant directorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Care and supervision - Day care child sustained injuries while in care.
INVESTIGATION FINDINGS:
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On 12/09/2022 Licensing Program Analyst, Stella Gutierrez made an unannounced visit to the facility for the purpose to deliver findings of complaint that was received at the Orange County Regional Child Care Program Office. LPA was met by , Margarita Calero who explained the reason for today’s visit. During today’s inspection.
A review of the Facility Personnel Report Summary conducted on 12/09/2022 indicates all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

A complaint was received on 10/03/2022 alleging that Daycare child sustain injuries while in care. On 10/05/2022 Complainant was interviewed by LPA. Complainant stated that when C1 as picked up on 09/27/2022 it was observed that the child had redness and bruising around the both eye areas. The director stated that another child had fallen on C1 while C1 was sleeping. On 09/28/2022 C1’s eyes were swollen, and the left eye was black. Page 1 of 3
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Stella Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
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 4
Control Number 06-CC-20221003095254
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: APPLE TREE PRESCHOOL & KINDERGARTEN
FACILITY NUMBER: 304371252
VISIT DATE: 12/09/2022
NARRATIVE
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The director was asked again what happen to C1 on 09/29/2022. The complainant stated that the director recanted the statement that another child fell on C1 and assumed that is what happen. The director then stated to the complainant that a teacher in the classroom went to retrieve their purse from a closet and a bed frame fell on top of C1.

On 10/07/2022 LPA, Gutierrez made an unannounced inspection to the facility to investigate the alleged allegation. LPA interviewed director, 2 staff and 05 children during the visit, reviewed facility records for attendance for staff and children on 09/27/2022. LPA also observed the classroom where the incident took place on 09/27/2022.

During the staff interviews on 10/07/2022, it was revealed by director that the parent was not called immediately and that the parent was told a different statement when C1 was picked up on 09/27/2022 than what happened due to a language barrier with the staff that was present on 09/27/2022. On 09/28/2022 LPA asked the director if the parent was provided an incident report. The director stated that a report was given on 09/27/2022 but did not provide an updated incident report on 09/28/2022. The director also stated that the facility did not report the incident to their local licensing regional office. Staff #1 was interviewed who stated that when the incident happened, he/she was at lunch right outside the classroom and was called in by Staff #2 to help. S1 stated that when they entered the classroom C1 was crying and then fell back to sleep. S1 stated that S2 said that two other children were playing with the cots, one of the cots fell on C1 while C1 was sleeping. S2 stated that during nap time 12:00 – 2:30 PM, S2 observed C2 go under the cot elevating it and the cot landed on C1. S2 stated that they immediately checked on C1, who didn’t appear to have injuries at the time, C1 fell back asleep.

On 10/07/2022 LPA, Gutierrez interviewed 05 children and due to the children’s age development LPA could not qualify C1 and C2. There were no disclosures regarding the incident by the other 3 children interviewed.

LPA contacted 7 parents. On 11/16/2022 and 11/23/2022 LPA left messages for 3 of the parents and 4 parent interviews were conducted 11/08/2022-11/16/2022. Parent #1, Parent #2 and Parent #4 stated that their children come home with bruises, scratches and at one time there was an injury that resulted in medical attention. All three parents stated that there was no aid applied and Parent #1 and #2 stated that the incidents that occurred were never communicated to them until they addressed concerns with the facility director. Page 2 of 3

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Stella Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 06-CC-20221003095254
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: APPLE TREE PRESCHOOL & KINDERGARTEN
FACILITY NUMBER: 304371252
VISIT DATE: 12/09/2022
NARRATIVE
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LPA reviewed Records on 10/07/2022 for the date of 09/27/2022, records show that the incident occurred between 12:01 PM -1:03 PM while Staff #2 was providing supervision and care. It was further revealed upon records review and statement provided by the director that the incident was not reported in a timely manner to the parent as well as not reporting other incidents to parents and the facilities local licensing regional office.

Based on records, interview statements and observation, the allegation referenced on this report is substantiated. A substantiated finding means that the complaint is substantiated, and the allegation is valid because the preponderance of the evidence standard has been met. The following violations were revealed and is being cited Type B deficiencies in accordance with California Code of Regulations, Title 22, Division 12, Chapter 1, Section 101229 (a) Responsibility for Care and Supervision and Section 101212 (d) (1) (B) (C) (f) Reporting Requirements please refer to attached 9099 (D).



Exit interview conducted and report was reviewed with the Assistant Director, Margarita Calero. Appeal Rights and deficiencies were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058) 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.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.



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SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Stella Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 06-CC-20221003095254
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: APPLE TREE PRESCHOOL & KINDERGARTEN
FACILITY NUMBER: 304371252
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/23/2022
Section Cited
CCR
101229(a)
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101229 (a) Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the children's needs.
This requirement was not met based on statements that the incident could have been prevented by Staff #2.
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The assistant director agrees to provide a training on this regulation to all staff at the facility. LPA will be email a copy of the agenda and a role sheet -signed by staff who attended. stella.gutierrez@dss.ca.gov
Type B
12/16/2022
Section Cited
CCR
101212(d)
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101212 Reporting Requirements: (d) (1) (B) (C) (f) Report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours.(f) The items specified in (d)(1)(A) through (H) above shall also be reported to the child's authorized representative.

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Assistant director was provide a copy of this regulation and stated to the LPA that the director will report any incidents that have not been reported to their local licensing office and future incidents as well. Also, that the authorized representatives will receive a communication from the facility
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This regulation was not met by evidence of no reports received in the department facility file of the incidents discussed and the incident reported. The facility did not report the incidents to the department or the authorize representatives of the children.
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when incidents occur in a timely manner via phone call if needed and a written ouch report.
The director was provided a written declaration statement for reporting requirements to submit to LPA via email to stella.gutierrez@dss.ca.gov by 12/16/2022
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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: Patricia Magana
LICENSING EVALUATOR NAME: Stella Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4