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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 483010214
Report Date: 11/29/2023
Date Signed: 11/29/2023 09:15:33 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
10/02/2023 and conducted by Evaluator Robert Maciel
PUBLIC
COMPLAINT CONTROL NUMBER: 01-CC-20231002142940
FACILITY NAME:SMITH-WINSTON, ANGELEKA FCCHFACILITY NUMBER:
483010214
ADMINISTRATOR:SMITH-WINSTON, ANGELEKAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 504-5177
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:14CENSUS: DATE:
11/29/2023
UNANNOUNCEDTIME BEGAN:
07:00 AM
MET WITH:Angeleka Smith-WinstonTIME COMPLETED:
09:25 AM
ALLEGATION(S):
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Adult residing in the home without a criminal record clearance
INVESTIGATION FINDINGS:
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A complaint investigation visit was conducted today by Licensing Program Analyst (LPA), Robert Maciel and Glenn Ouye who met with Licensee, Angeleka Smith-Winston for the purpose of delivering complaint investigation findings for the above allegation. Today, LPA conducted an interview, made observations. It was alleged that an uncleared adult is residing in the home.

During the course of the investigation, LPAs conducted interviews with the Licensee, adults, parents, and children from 10/02/2023 through 11/29/2023. Licensee confirmed that Adult 3 (A3) has present in the home when Child 10 (C10) was dropped off at 7:03 AM on 11/29/23. The facility is in violation of criminal record clearance requirements due to an uncleared adult residing in the facility and/or in the presence of children in care and thus, an immediate Civil Penalty is being assessed.

(Continues on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
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-20231002142940
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SMITH-WINSTON, ANGELEKA FCCH
FACILITY NUMBER: 483010214
VISIT DATE: 11/29/2023
NARRATIVE
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Based on the information gathered during this investigation, the preponderance of the evidence standard has been met. Therefore, the allegation is determined to be substantiated. California Code of Regulations, Title 22, is being cited on the attached LIC 9099-D. Appeal rights were provided. An exit interview was conducted, and this report was read and discussed with the facility’s Licensee, Angeleka Smith-Winston. The Notice of Site Visit shall be posted for 30 days.

Type A citation shall be posted for 30 consecutive days as there is immediate risk(s) to the health, safety, or personal rights of children in care. LPA Maciel informed the licensee to provide a copy of this licensing report dated 11/29/2023 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 01-CC-20231002142940
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SMITH-WINSTON, ANGELEKA FCCH
FACILITY NUMBER: 483010214
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/30/2023
Section Cited
CCR
102370(d)
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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility. . .this requirement was not met as evidenced by
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Licensee stated she would change her hours of operation to 7AM - 2PM Monday - Friday and 7AM - 1:30 PM on Wednesday and restrict any uncleared adults from the facility during hours of operation.
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based on interviews conducted with licensee, an uncleared adult was present in the home in the presence of children in care which poses an immediate health, safty and/or personal rights risk to 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: Alexis Hollon
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC9099 (FAS) - (06/04)
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