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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 426216160
Report Date: 08/10/2022
Date Signed: 08/10/2022 04:11:21 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/03/2022 and conducted by Evaluator Francisca Velazquez
PUBLIC
COMPLAINT CONTROL NUMBER: 17-CC-20220603093521
FACILITY NAME:PEREZ FAMILY CHILD CAREFACILITY NUMBER:
426216160
ADMINISTRATOR:MARYPAZ PEREZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 863-3416
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:14CENSUS: 12DATE:
08/10/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Marypaz PerezTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Child had an unexplained injury while in care.
INVESTIGATION FINDINGS:
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On 8/10/22, at 10:45 AM, Licensing Program Analyst (LPA) Francisca Velazquez made an unannounced inspection to the abovementioned Family Child Care Home (FCCH) to deliver a finding with regard to an investigation related to a violation of Personal Rights. Specifically, Child had an unexplained injury while in care. LPA met with Marypaz Perez, the Licensee of the FCCH, and explained the purpose of the inspection. LPA notes twelve (12) children are on site being supervised by Licensee and two (2) assistants Karina Pena and Silvia Escobar.

The investigation included record reviews as well as interviews of the Licensee and assistants, parents of children in care, and the Complainant as well as medical records. Based on telephone communication between Licensee and complainant, it was determined that C1 had a medical emergency at the facility that required C1 to get picked up from facility to receive medical attention. Communication shows Licensee was aware C1 received medical attention and did not report this incident to Community Care Licensing. Cont LIC9099-C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
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 17-CC-20220603093521
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 426216160
VISIT DATE: 08/10/2022
NARRATIVE
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Based on LPAs observation, interviews and medical records the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulation, (Title 22 Division 12 and 102423 (a) (2), is being cited on the attached LIC 9099 D).

Upon receipt, Licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

A closing interview was conducted with the Licensee. Licensee was provided and advised of their right to appeal. LPA informed Licensee of the need to provide a plan of correction to CCLD as well as the time which the plan of correction needs to be submitted to CCLD.

The Notice of Site Visit was provided to the Licensee as required by H&S Code Section 1596.817. The Notice of Site Visit must remain posted for 30 days or a civil penalty of $100.00 may apply.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 17-CC-20220603093521
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 426216160
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/11/2022
Section Cited
CCR
102423(a)(2)
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Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged ...These rights include, but are not limited to, the following...(2)To receive safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement was not met as evidenced by the following:
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Licensee agrees to conduct wellness checks upon arrival. Licensee agrees to document any unusual incident to have accurate details about what occurred. Licensee agrees to send a short summary of how this will be done and submit via email to francisca.velazquez@dss.ca.gov by 8/11/22.
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Based on medical records and interviews with complainant, licensee and assistants it was determined that C1 had an injury at the facility that required C1 to get picked up to be able to get medical attention. This is an immediate risk to the health and safety of 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: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3