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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 444409060
Report Date: 06/29/2021
Date Signed: 06/30/2021 11:38:13 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/06/2021 and conducted by Evaluator Elizabeth Larios
COMPLAINT CONTROL NUMBER: 07-CC-20210506141545
FACILITY NAME:MENA, MONICAFACILITY NUMBER:
444409060
ADMINISTRATOR:MONICA MENAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 840-1294
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY:14CENSUS: 10DATE:
06/29/2021
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Monica Mena TIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Lack of supervision resulting in child sustaining injuries.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Larios conducted an unannouced inspection to deliver the complaint allegation listed above. LPA met with Licensee Monica Mena and explained the purpose of the inspection.

Complainant alleges lack of supervision resulting in child sustaining injuries. Interviews were conducted with staff. LPA also spoke to parents, who provided information about their experience and observation. Records were also obtained and reviewed.

Based on the information obtained, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. Therefore, the allegation is found to be UNSUBSTANTIATED.

CONTINUE IN LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Elizabeth Larios
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
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 07-CC-20210506141545
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MENA, MONICA
FACILITY NUMBER: 444409060
VISIT DATE: 06/29/2021
NARRATIVE
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Exit interview was conducted, where this report was reviewed and discussed with Licensee.

A NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED ON OR ADJACENT TO THE INTERIOR SIDE OF THE MAIN DOOR INTO THE FACILITY FOR 30 CONSECUTIVE DAYS.
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Elizabeth Larios
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2