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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 483010217
Report Date: 09/25/2024
Date Signed: 10/29/2024 12:47:19 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
09/19/2024 and conducted by Evaluator Glenn Ouye
COMPLAINT CONTROL NUMBER: 01-CC-20240919094947
FACILITY NAME:SMITH, LATISSA FCCHFACILITY NUMBER:
483010217
ADMINISTRATOR:SMITH, LATISSAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 712-4839
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:14CENSUS: 11DATE:
09/25/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Latissa SmithTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Licensee did not follow reporting requirements
INVESTIGATION FINDINGS:
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**This is an amended report from original report dated 9/25/2024.**

Licensing Program Analyst (LPA) Glenn Ouye arrived to open a complaint investigation regarding the allegation shown above.

LPA conducted interviews with S1 (licensee) and C1 during the investigation. S1 confirmed her knowledge of C1 left arm fracture which occurred at 2:09pm on June 17, 2024. S1 also showed LPA a video of the incident.

During the interview S1 admitted that the department (CCLD) was not notified by telephone or fax by the close of busniess of the next working day and the department was not notifed with a written report within seven days following the incident where C1 sustained an fractiured left arm. The inteview with S1 it was confirmed that the reporting requirments regulations were not met.

S1 said that she text messaged the parent the next morning on June 18, 2024 at 8:25am and was told by the parent that C1 injured his arm on June 17, 2024 while at her daycare.


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Glenn Ouye
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
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-20240919094947
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: SMITH, LATISSA FCCH
FACILITY NUMBER: 483010217
VISIT DATE: 09/25/2024
NARRATIVE
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S1 provided copies of text messages between S1 and parent of C1. S1 said that she did verbally notify the parent that C1 fell and but C1 appeared to be fine when C1 left for the day. Video footage shows an unknown person helping C1 up and walking C1 out of the view of the video. S1 said that the first communication with parent about the child's injury was on the following day, June 18, 2024 at 8:25am. Notification to the parent or responsible party is required to occur as soon as possible but no later than the same business day.

Based on the interview with S1 there is a preponderance of evidence to indicate that the allegation: "licensee did not follow reporting requirements" by not reporting the incident to the department. The allegation is substantiated. California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D. Appeal rights were provided.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with the licensee,
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Glenn Ouye
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 01-CC-20240919094947
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: SMITH, LATISSA FCCH
FACILITY NUMBER: 483010217
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2024
Section Cited
CCR
102416.(d)(2)
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Reporting Requirements-The licensee shall report to the Department as provided by Health and Safety Code Sections 1597.467(b)(1) and (2)-a written report shall be submitted to the department within seven days following the occurrence of any events. This requirement was not met as evidenced by
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Licesnee agreed to read and review reporting requirement regulations with LPA Ouye during the visit to clear the deficiency. Deficiency cleared at time of visit.
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S1 statement that she did not submit the unusual incident report to the department within 7 days of the event which poses a potential health and safety risk to the 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: Leslie Lepori
LICENSING EVALUATOR NAME: Glenn Ouye
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3