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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 343622148
Report Date: 11/22/2024
Date Signed: 11/22/2024 03:59:48 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/18/2024 and conducted by Evaluator Josiah Gathing
PUBLIC
COMPLAINT CONTROL NUMBER: 03-CC-20241118143614
FACILITY NAME:DAVIS, KATIEFACILITY NUMBER:
343622148
ADMINISTRATOR:DAVIS, KATIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 425-5118
CITY:SACRAMENTOSTATE: CAZIP CODE:
95820
CAPACITY:14CENSUS: 0DATE:
11/22/2024
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Katie DavisTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Provider is not keeping the facility free of pests
Facility screen doors are in disrepair
Provider does not keep facility yard free of debris
INVESTIGATION FINDINGS:
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On Friday, November 22, 2024, at approximately 2:50PM Licensing Program Analysts (LPAs) Josiah Gathing and Julia Maryanvoa met with Licensee, Katie Davis, for the purpose of a complaint investigation and to deliver findings. It was alleged that 1) Provider is not keeping the facility free of pests
2) Facility screen doors are in disrepair 3) Provider does not keep facility yard free of debris the outdoor play area contained debris. Throughout the course of the investigation, LPAs conducted interview, reviewed documents, and made observations. During the investigation, LPAs observed that the bathroom is not free of pests, screen doors are in disrepair, and the back play area is not free of debris. Licensee provided a plan of action to address the deficiencies.
Therefore, based on observation, the preponderance of evidence standard has been met, and the allegations are substantiated. An exit interview was conducted and a notice of site visit provided. Notice of site visit shall remain posted for 30 days.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Josiah Gathing
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
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 3
Control Number 03-CC-20241118143614
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DAVIS, KATIE
FACILITY NUMBER: 343622148
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2024
Section Cited
CCR
102417(b)
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102417 Operation of a Family Child Care Home (b) The home shall be kept clean and orderly...
This requirement was not met as evidenced by:
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The licensee plans to schedule an indoor pest treatement and provide a receipt for the service. The licensee is also planning to clean mold with water and bleach.
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Based on observation the facility did not comply with the above regulation as there has been evidence of an insect infestation and mold in the bathroom which poses Health, Safety, or Personal Rights risk to persons in care
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Type B
12/20/2024
Section Cited
CCR
102417(d)
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102417 Operation of a Family Child Care Home (d) The home shall provide safe toys, play equipment and materials.
This requirement was not met as evidenced by:
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The licensee plans to go to Home Depot to replace the back screen door and repair the front screen door with zipties.
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Based on observation the facility did not comply with the above regulation as outdoor play area was not free of debris which poses 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: Seychelle De Luca
LICENSING EVALUATOR NAME: Josiah Gathing
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 03-CC-20241118143614
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DAVIS, KATIE
FACILITY NUMBER: 343622148
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2024
Section Cited
CCR
102417(g)
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102417 Operation of a Family Child Care Home (g) The home shall be free from defects or conditions which might endanger a child...
This requirement was not met as evidenced by:
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The Licensee plans to clean the debris from the outdoor play area once it stops raining and maintain the cleanliness by picking up debris on daily basis.
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Based on observation the facility did not comply with the above regulation as the screen doors are in disrepair which poses 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: Seychelle De Luca
LICENSING EVALUATOR NAME: Josiah Gathing
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3