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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 393623017
Report Date: 11/30/2022
Date Signed: 11/30/2022 11:37:38 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/07/2022 and conducted by Evaluator Stacey Williams
COMPLAINT CONTROL NUMBER: 53-CC-20221007155008
FACILITY NAME:GORDON,MARYFACILITY NUMBER:
393623017
ADMINISTRATOR:GORDON,MARYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 627-9276
CITY:TRACYSTATE: CAZIP CODE:
95391
CAPACITY:14CENSUS: 6DATE:
11/30/2022
UNANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:Mary Gordon TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Personal Rights
INVESTIGATION FINDINGS:
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On November 30, 2022, Licensing Program Analyst (LPA) Stacey Williams arrived at the facility for the purpose of delivering complaint findings. LPA met with Licensee. LPA observed six children supervised by Licensee and two Assistants.

An investigation was conducted regarding the allegation of personal rights of a child (C1) in Licensee’s childcare program. It was alleged that C1 sought medical attention after being exposed to nuts at the childcare. Licensee stated that she did not offer the nuts to C1 as part of their meal. Licensee acknowledged that she served nuts to children in care. It was unknown how C1 ingested the nuts. Licensee confirmed C1 had a documented nut allergy on file. Based on the information received, the allegation is determined to be substantiated.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
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 3
Control Number 53-CC-20221007155008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: GORDON,MARY
FACILITY NUMBER: 393623017
VISIT DATE: 11/30/2022
NARRATIVE
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Title 22 Deficiency has been cited on the attached page, LIC 9099D. Upon receipt of Type A citations, facility shall post and provide copies of the LIC 9099D for parents/guardians of children currently in care and for parents/guardians of newly enrolled children for the next 12 months. Facility must also keep the signed LIC 9224, acknowledging receipt of Licensing Reports LIC 9099D in each child's files.

Exit interview conducted at which time the report was reviewed with Licensee, Mary Gordon. A Notice of Site Visit was posted by LPA Williams and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.00.

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 53-CC-20221007155008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: GORDON,MARY
FACILITY NUMBER: 393623017
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/01/2022
Section Cited
CCR
102423(a)(4)
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To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including, but not limited to: interference with eating, sleeping or toileting; or withholding shelter, clothing, medication or aids to physical functioning.
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Licensee stated that she no longer serves nuts in the facility. Licensee will incorporate a nut free policy for her childcare program. Licensee will inform all enrolled parents of the amendment to the policy. Licensee will review Title 22 Regulations concerning personal rights with staff.
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This requirement was not met as evidenced by:
Child in care (C1) had a documented nut allergy. C1 was exposed to nuts while at the facility which resulted in medical care. This is an immediate risk to the health and safety of children in care.


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Licensee will submit proof review/ notification to parents to CCL by POC date: 12/1/22.
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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: Stacey Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3