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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 376300359
Report Date: 12/21/2022
Date Signed: 12/27/2022 10:27:22 AM

Unsubstantiated


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
09/14/2022 and conducted by Evaluator Cindy Hamilton
PUBLIC
COMPLAINT CONTROL NUMBER: 10-CC-20220914111714
FACILITY NAME:COLES COTTAGE ACADEMYFACILITY NUMBER:
376300359
ADMINISTRATOR:COSTA,WEERATUNGAFACILITY TYPE:
830
ADDRESS:505 CIVIC CENTER DRTELEPHONE:
(949) 836-4465
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:20CENSUS: 12DATE:
12/21/2022
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Gabriella Adame, Lead TeacherTIME COMPLETED:
11:25 AM
ALLEGATION(S):
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Child sustained an unexplained injury while in care.
INVESTIGATION FINDINGS:
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On December 27, 2022 at 9:45 AM, LPA Cindy Hamilton arrived at the facility to deliver an amended report of the report originally dated 12/21/2022. LPA met with Lead Teacher Gabriela Adame.

On December 21, 2022, at 9:57 a.m., Licensing Program Analyst (LPA) Cindy Hamilton, met with Coles Cottage Academy (CCC) Lead Teacher Gabriella Adame to deliver the findings for the above stated allegation.  During the investigation, LPA Hamilton conducted interviews with four staff.  LPA Hamilton conducted a health and safety inspection of the CCC on September 22, 2022 and no safety concerns were noted.  LPA obtained and reviewed the facility’s class rosters, Unusual Incident Reports (UIRs), and other pertinent documentation.

On September 14, 2022, Community Care Licensing (CCL) received information stating that Child #1 (C1) sustained an unexplained bruising while in care. It was alleged that on September 13th, C1 was taken to urgent care after a bruise was observed on C1’s right ear that allegedly occurred at the CCC.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Cindy Hamilton
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022
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 2
Control Number 10-CC-20220914111714
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: 376300359
VISIT DATE: 12/21/2022
NARRATIVE
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Due to conflicting information being provided during confidential interviews, LPA was unable to corroborate that the injury/bruise occurred at the CCC since the incident was not witnessed or observed at the facility and therefore was not reported. In addition, Pertinent interviews conducted revealed that that there have been no concerns or witnessed incidents of abuse of any of the children attending the CCC. Per records review, LPA observed multiple Ouch reports for C1 that occurred at the CCC but was unable to locate the specific report that disclosed a bruise on C1’s right ear due to the CCC’s being unaware of the injury.

Based on confidential interviews and records review, the allegations that child sustained an unexplained injury while in care, may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated. A copy of this report, appeal rights and Notice of Site Visit were provided to facility

The Notice of Site Visit was posted prior to LPA leaving the facility and was reminded this notice must be posted for 30 days..
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Cindy Hamilton
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2