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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 344500274
Report Date: 09/18/2023
Date Signed: 09/18/2023 05:12:01 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. 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
07/27/2023 and conducted by Evaluator Corina Beckby
COMPLAINT CONTROL NUMBER: 53-CC-20230727103033
FACILITY NAME:LOPEZ, PAULINAFACILITY NUMBER:
344500274
ADMINISTRATOR:PAULINA LOPEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 612-5905
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:14CENSUS: 7DATE:
09/18/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Paulina LopezTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Adult in home spoke inappropriately to a daycare child
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Corina Beckby met with Licensee, Paulina Lopez to deliver the findings of the complaint investigation regarding the above allegations.

During the course of the investigation, LPA Beckby conducted interviews, toured the home, and obtained information pertaining to the allegation. It was alleged that an assistant spoke inapporpriately to a daycare child.

Based on the interviews and documents provided, it was revealed that an assistant used inappropriate language in front of a child. Therefore, the preponderance of evidence standard has been met, and the above allegation is found to be SUBSTANTIATED. Title 22 regulations are being cited on the attached 9099-D page.

Continued on 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Corina Beckby
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023
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 53-CC-20230727103033
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: LOPEZ, PAULINA
FACILITY NUMBER: 344500274
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2023
Section Cited
CCR
101223(a)(1)
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Persoal Rights 101223(a)(1)
(a) The licensee shall ensure that each child is accorded the following personal rights:
(1) To be accorded dignity in his/her personal relationships with staff and other persons.
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Assistant will watch training videos (Supervising Children in Family Child Care and Children's Personal Rights in Child Care) from the department website ccld.childcarevideos.org. Licensee will document assistant watching videos, date and sign. Assistant will also write a statement
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statement acknowledging the inapropriateness and will be more mindful of what is said in front of the children, including in a joking manner. Statement and acknowledgement of watching videos will be sent via email to LPA by due date.
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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: Bettina Engelman
LICENSING EVALUATOR NAME: Corina Beckby
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 53-CC-20230727103033
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LOPEZ, PAULINA
FACILITY NUMBER: 344500274
VISIT DATE: 09/18/2023
NARRATIVE
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page 2...

LPA Beckby informed Licensee, Paulina Lopez, this report dated September 18, 2023 documents a Type B citation which poses a potential risk to the health, safety, or personal rights of children in care. An exit interview was conducted with the licensee. A notice of site visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Corina Beckby
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3