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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 483010050
Report Date: 06/18/2024
Date Signed: 06/18/2024 12:59:32 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/19/2024 and conducted by Evaluator Elpidia Hernandez Torres
COMPLAINT CONTROL NUMBER: 01-CC-20240319143354
FACILITY NAME:PAYNE, JESSICA FCCHFACILITY NUMBER:
483010050
ADMINISTRATOR:PAYNE, JESSICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 655-6210
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:14CENSUS: 10DATE:
06/18/2024
UNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Licensee Jessica PayneTIME COMPLETED:
10:47 AM
ALLEGATION(S):
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Provider does not appropriately supervise daycare children
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Elpidia Hernandez Torres, conducted a subsequent complaint investigation inspection on 06/18/2024 at 09:45AM for the purpose of delivering the findings regarding the above allegation. LPA was previously at the facility on 03/25/24 to discuss the purpose of the visit and request facility roster ( LIC 9040), and staff contact information. It was alleged that provider does not appropriately supervise daycare children.

During the course of the investigation, interviews were conducted with licensee, assistants, four children, and five guardians between 03/25/24-06/11/24. On 04/10/24 licensee reported this complaint might be referring to an incident where a child was sitting in the day care room recording herself on her ipad and another child kicked the ipad. Licensee reported she was in the kitchen when this incident happened. Licensee reported her assistants provide supervision by watching the children and being in the same room as the children. Assistant (S1) corroborated licensee statement, reporting when they are present and working at the day care they are providing supervision over the children.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
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 01-CC-20240319143354
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PAYNE, JESSICA FCCH
FACILITY NUMBER: 483010050
VISIT DATE: 06/18/2024
NARRATIVE
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Guardian's (G1) interview revealed there was one occasion when they arrived to pick up their children, and saw them playing alone in the back yard, without adult supervision. Children interviews corroborated the statement, reporting they play in the back yard without adult supervision, while licensee is in the home watching over the younger kids. Child interview (C4) revealed there was one occasion, where children were playing in the back yard alone and another child had gotten stuck in a swing and C4 asked licensee’s older son through the window to go out there and help. Two other children interviews revealed children play in the playroom, while licensee is in the living room with the younger children. One child reported licensee is usually in the living room with younger children, and her assistant (S2) is usually in the garage.

On 03/25/24 LPA arrived to the home at 01:28PM and rang the doorbell, there was no answer. LPA called Licensee left a voice message and there was no answer. Licensee’s assistant S1 answered the door and reported licensee was present in the home but was in a room with the door closed. LPA entered the home and observed S1 in the living room alone supervising 11 children. LPA asked S1 to go see where licensee was, S1 was not able to get a hold of licensee. LPA stepped outside of the home, to the drive way, at 01:47 PM a child under 10 years old came outside and began to play basketball alone without adult supervision. Shortly after, licensee stepped outside of the home and reported to LPA, she had to leave to do pick-ups, and would be taking two children with her, while both her assistants where in the home with the rest of the children.

Through the course of the investigation, LPA received evidence of a child left alone in a bathroom for an extended period of time without an adult going to check on child.

Based on interviews conducted, observations made, and evidence received the preponderance of evidence standard has been met and the above allegation is found to be substantiated. The California Code of Regulations, Title 22, Division 12 & Chapter 1, section 102417(a) is being cited on attached LIC 9099D . This report was reviewed with the Licensee and an exit interview was conducted. A copy was provided and Notice of Site Visit shall be posted for 30 days. Appeal Rights were provided.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 01-CC-20240319143354
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PAYNE, JESSICA FCCH
FACILITY NUMBER: 483010050
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/02/2024
Section Cited
CCR
102417(a)
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102417 Operation of a Family Child Care Home (a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. This was not met as evidence by. . .
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The licensee reported moving forward when the children are separated by age the younger and the older ones there will be an adult supervising in each area the living room and the play room.
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Based on interviews conducted, evidence received, and observations made on 03/25/2024 the licensee did not appropriately supervise day care children. This poses a potential health and safety risk to children in care.
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 If there isn't an additional adult present then the children will not be able to separate by age. All children will be together in one location. Licensee agreed to email, mail or fax LIC 9098 self certification.
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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: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC9099 (FAS) - (06/04)
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