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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 376300358
Report Date: 06/01/2023
Date Signed: 06/01/2023 12:22:56 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/25/2023 and conducted by Evaluator Jessica M Rubio
PUBLIC
COMPLAINT CONTROL NUMBER: 10-CC-20230525150159
FACILITY NAME:COLES COTTAGE ACADEMYFACILITY NUMBER:
376300358
ADMINISTRATOR:COSTA,WEERATUNGAFACILITY TYPE:
850
ADDRESS:505 CIVIC CENTER DRTELEPHONE:
(949) 836-4465
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:35CENSUS: 27DATE:
06/01/2023
UNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:Weeratunga CostaTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility staff are not following food service guidelines.
INVESTIGATION FINDINGS:
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On June 1, 2023 at 10:07 am, Licensing Program Analyst (LPA) Jessica Rubio arrived unannounced to Coles Cottage Academy (CCC) to initiate the complaint investigation regarding the allegation listed above. LPA met with Director Weeratunga Costa who provided a tour of the facility. LPA conducted interviews with three staff and reviewed the parent handbook as well as current and past menus.

On May 25, 2023, a complaint was received alleging facility staff are not following food service guidelines; specifically, that fruit is not being served with breakfast and that lunch does not always meet the fruit and vegetable guidelines. Interviews and menu review revealed that the facility does not serve the required fruit and/or vegetable with breakfast, however, the facility does provide a fruit and vegetable with lunch.

(Continued on LIC 9099-C)

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Jessica M Rubio
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
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 10-CC-20230525150159
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: COLES COTTAGE ACADEMY
FACILITY NUMBER: 376300358
VISIT DATE: 06/01/2023
NARRATIVE
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Based on interviews and record review, the preponderance of evidence standard has been met and the allegation facility staff are not following food service guidelines pertaining to breakfast are substantiated. The facility is being cited for Title 22 Regulations Section 101227 Food Services. See LIC 9099-D for cited deficiencies.

An exit interview was conducted, appeal rights discussed and a copy of this report was provided to Director Weeratunga Costa. A notice of site visit was also provided and must remain posted for 30 days.
SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Jessica M Rubio
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 10-CC-20230525150159
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: COLES COTTAGE ACADEMY
FACILITY NUMBER: 376300358
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/08/2023
Section Cited
CCR
101227
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(a) In child care centers providing meals to children, the following shall apply: (1) The minimum amount of food components to be served as breakfast as set forth in paragraph (a)(1) of [7 CFR, Part 226.20, Revised January 1, 1990] are as follows: Vegetable(s) and/or fruit(s) 1/2 cup age 3-5 or 1/4 cup age 2
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Director stated she will serve and update the menu to include the required fruit and/or vegetable component in breakfast and provide updated menu to LPA.
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This requirement was not met as evidenced by: Interviews and menu review revealing fruit and or vegetable is not served with breakfast, which poses a potential health, safety or personal rights risk to 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: Pauline Beschorner
LICENSING EVALUATOR NAME: Jessica M Rubio
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3