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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 376600647
Report Date: 11/18/2024
Date Signed: 11/18/2024 11:42:53 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MISSION VALLEY, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/19/2024 and conducted by Evaluator Vicky Williamson
PUBLIC
COMPLAINT CONTROL NUMBER: 20-CC-20240919163720
FACILITY NAME:CAMPO KUMEYAAY HEAD STARTFACILITY NUMBER:
376600647
ADMINISTRATOR:CRYSTAL KREMENSKYFACILITY TYPE:
850
ADDRESS:39639 OLD HIGHWAY 80TELEPHONE:
(619) 473-9022
CITY:BOULEVARDSTATE: CAZIP CODE:
91905
CAPACITY:40CENSUS: 29DATE:
11/18/2024
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Lari Haney TIME COMPLETED:
11:05 AM
ALLEGATION(S):
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Staff did not notify the authorized representative of an incident timely
INVESTIGATION FINDINGS:
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On 11/18/2024, at 10:05am, Licensing Program Analysts (LPAs) Vicky Williamson and Angela Nguyen conducted an unannounced complaint inspection for the purpose of delivering findings regarding the above allegation. LPAs met with Site Supervisor, Lari Haney. During the inspection there were 29 children present with six (6) staff members.

During the course of the investigation, interviews were conducted with the Early Education Director/Licensee Representatvie, five (5) staff members, and five (5) daycare children. Facility roster, facility sign in/sign out sheet, medical records, incident reports, Class Dojo App documentation, email correspondence and facility photos were reviewed and obtained. Staff and children files were reviewed.

It was alleged that staff did not notify the authorized representative of an incident timely. Licensee Representative and Staff #1 (S1) acknowledged that Child #1 (C1) sustained an injury to her left pinky finger that caused bruising underneath the fingernail. See LIC 9099C Continuation...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
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 20-CC-20240919163720
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MISSION VALLEY, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: CAMPO KUMEYAAY HEAD START
FACILITY NUMBER: 376600647
VISIT DATE: 11/18/2024
NARRATIVE
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S1 admitted that the authorized representative for C1 was not notified of the incident immediately after the incident occurred. Licensee Representative and S1 acknowledged that the incident occurred at 11:35am and C1’s authorized representative was not notified of the incident until 12:32pm. It is noted that the facility submitted an unusual incident report to the Department.

A review of related documentation provided evidence that C1 sustained a dislocation and fracture to the left pinky finger. LPA’s review of email correspondence and Class Dojo App documentation provided evidence that the authorized representative for C1 was notified 57 minutes after the incident occurred.

Based on Licensee Representative and staff member’s own admission, interviews with staff, and related documentation, the preponderance of evidence standard has been met and the allegation that staff did not notify the authorized representative of an incident timely is therefore SUBSTANTIATED.

Per California Code of Regulations, Title 22, Division 12, Chapter 1, a Type B deficiency is being cited on the attached LIC 9099D.

Exit interview was conducted with Site Supervisor, Lari Haney, and a copy of this report and Appeal Rights were provided. A notice of site visit was given and must be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. LPA observed notice of site visit posted on the bulletin board in the lobby.
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 20-CC-20240919163720
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MISSION VALLEY, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: CAMPO KUMEYAAY HEAD START
FACILITY NUMBER: 376600647
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/02/2024
Section Cited
CCR
101226(a)
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(a) The licensee shall immediately notify the child's authorized representative if the child... sustains an injury more serious than a minor cut... The licensee shall obtain specific instructions from the authorized...
The requirement was not met as evidenced by:
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Site Supervisor stated that Facility Representative has implemented and notified staff of the new procedures regarding Title 22 Regulation Health Related Services 101226. Site Supervisor stated that she will ensure that Facility Representative submits a written
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Based on interview and record review, the licensee did not comply with the section cited above in that C1 sustained a serious injury to her left pinky finger and the facility did not immediately notify her authorized representive, which poses a potential safety, or personal rights risk to persons in care.
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plan detailing the new procedures, provide the notification method to staff and staff signatures for proof of notification to Department, no later than 12/2/2024.
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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: Tulam Vu
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3