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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 485407834
Report Date: 06/08/2022
Date Signed: 06/10/2022 01:25:35 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
03/03/2022 and conducted by Evaluator Melchisedeck Augustin
PUBLIC
COMPLAINT CONTROL NUMBER: 13-CC-20220303162245
FACILITY NAME:LEARNING EXPERIENCE-INFANT, THEFACILITY NUMBER:
485407834
ADMINISTRATOR:OLDANI, SABRINAFACILITY TYPE:
830
ADDRESS:1959 PEABODY ROADTELEPHONE:
(707) 305-4336
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:32CENSUS: 18DATE:
06/08/2022
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Jennifer Hansen - Center DirectorTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Child's injuries not reported to authorized representative.
INVESTIGATION FINDINGS:
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**This report is amended**

Licensing Program Analysts (LPAs), Melchisedeck Augustin and Sebastian Phouthavong conducted an unannounced subsequent complaint-Investigation visit and met with Center Director, Jennifer Hansen (CD) to deliver the finding regarding the above allegation. LPA previously met with LS on 03/09/22 to initiate the investigation by discussing the purpose of the visit and obtained a facility roster of the children currently in care. It was alleged a child’s injuries were not reported to the child’s authorized representative. The report further described how a child (C1) sustained injuries on two different occasions.

LPA Augustin interviewed LS, CD, five staff (S1-S5), two adults (A1 & A2), and one parent (P2) from 03/09/22 through 05/17/22. The children were not verbal, too young to interview, or did not qualify to be interviewed. LS’ statement provided evidence to support claims about C1’s injuries not being reported to the child’s authorized representative. (Continue to LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
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 5
Control Number 13-CC-20220303162245
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: LEARNING EXPERIENCE-INFANT, THE
FACILITY NUMBER: 485407834
VISIT DATE: 06/08/2022
NARRATIVE
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LS claimed she did not recall any incident(s) involving any child(ren) sustaining any injury or a black eye, however; LS did recall a different incident which involved a child falling from a chair, resulting in that child biting his/her lip. LS claimed facility management was responsible for notifying parents of injuries to their child while staff were responsible for producing the incident report(s), as well as providing a copy of the incident report which parent(s) would sign and retain a copy for their record. LS felt confident that staff completed a report most of the time, but also expressed if a staff did not notice a child's injury; then that staff did not write an incident report. Furthermore, CD expressed that in the past, staff transitioning between shifts resulted in miscommunication among staff and parent(s) which sometimes led to staff forgetting to notify a parent(s) of incident involving their child.

Statements provided by S1, S2, S4, A1, A2 & P2 did not report they witnessed any incident(s) involving C1 sustaining laceration on the cheek or a black eye or scratch on the nose or ear, however; S3 reported seeing scrapes on C1’s nose but did not know how C1 sustained the injury or could not provide an explanation about the injury. Several staff confirmed if a child sustained an injury at the facility, they were required to produce an incident report, and another staff or management had to sign off on the report. Management was responsible for notifying parent(s) of incidents while staff provided a copy of the report to the parent(s). S2 felt there was a lack of communication at the facility which resulted in staff not always providing parent(s) with an Incident/Accident Report, while S3 confirmed management was responsible for notifying parents of incident but notification to parent(s) depended on the severity of the injury. On 05/18/22, the facility submitted 11 incident reports which documented C1’s involvement in incidents between 10/14/2021 through 03/02/22. Of the 11 reports, there was one report which described an unrelated incident that did not contain the authorized representative’s signature, and another report which indicated the authorized representative was notified of the incident and provided confirmation that another child scratched C1’s face while on a play structure on 03/02/22.

Based on this investigation, the preponderance of the evidence standard has been met as there is enough evidence to support claims about the facility not reporting injuries to the children’s authorized representative. Therefore, the allegation is substantiated. Exit interview conducted and report was reviewed with the Center Director, Jennifer Hansen. 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. The following California Code of Regulations, Title 22, Division 12, Chapter 1, Article 06 violations cited during today’s visit. Appeal Rights were provided. *This report is amended*
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 13-CC-20220303162245
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: LEARNING EXPERIENCE-INFANT, THE
FACILITY NUMBER: 485407834
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/22/2022
Section Cited
CCR
101212(f)
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The items specified in (d)(1)(A) through (H) above shall also be reported to the child's authorized representative.

This requirement was not met as evidenced by: Based on statements provided by LS and staff which provided enough evidence to support claims about the facility not reporting C1’s
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The Center Director submitted documentation which indicated she individually met with staff to discuss the contents of CCR 101212. The Center Director stated she planned to continue to individually meet with staff to discuss the regulations and facility management now completed the Incident/Accident report(s), were responsible for notify parents of incidents, as well as
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injuries to the child’s authorized representative. This poses/posed a potential health, safety and/or personal rights risk(s) to children in care.
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provided parents with a copy of the reports. Center Director stated she would submit a written plan to the Department by 06/22/22 via mail, email or fax.

Email: melchisedeck.augustin@dss.ca.gov
Fax: 70-588-5099
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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: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
03/03/2022 and conducted by Evaluator Melchisedeck Augustin
PUBLIC
COMPLAINT CONTROL NUMBER: 13-CC-20220303162245

FACILITY NAME:LEARNING EXPERIENCE-INFANT, THEFACILITY NUMBER:
485407834
ADMINISTRATOR:OLDANI, SABRINAFACILITY TYPE:
830
ADDRESS:1959 PEABODY ROADTELEPHONE:
(707) 305-4336
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:32CENSUS: 18DATE:
06/08/2022
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Jennifer Hansen - Center DirectorTIME COMPLETED:
10:00 AM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Child was injured while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Melchisedeck Augustin and Sebastian Phouthavong conducted an unannounced subsequent complaint-Investigation visit and met with Center Director, Jennifer Hansen (CD) to deliver the finding regarding the above allegation. LPA previously met with LS on 03/09/22 to initiate the investigation by discussing the purpose of the visit and obtained a facility roster of the children currently in care. It was alleged a child was injured while in care. The report described the child’s (C1) injuries as a laceration on the left cheek, a black eye, and a scratch on the nose and ear that was sustained on two different occasions.

LPA Augustin interviewed LS, CD, five staff (S1-S5), two adults (A1 & A2), and one parent (P2) from 03/09/22 through 05/17/22. The children were not verbal, too young to interview, or did not qualify to be interviewed. LS’ statement did not provide evidence to support claims about C1 sustaining an injury at the facility and LS claimed she did not recall any incident(s) involving any child(ren) sustaining any injury or a black eye, however; LS did recall different incident which involved a child falling from a chair, resulting in that child biting his/her lip. (Continue to LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 13-CC-20220303162245
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: LEARNING EXPERIENCE-INFANT, THE
FACILITY NUMBER: 485407834
VISIT DATE: 06/08/2022
NARRATIVE
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Statements provided by S1, S2, S4, A1, A2 & P2 did not report they witnessed any incident(s) involving C1 sustaining laceration on the cheek or a black eye or scratch on the nose or ear, however; S3 reported seeing scrapes on C1’s nose but did not know how C1 sustained the injury or could not provide an explanation about the injury. Several staff confirmed if a child sustained an injury at the facility, they were required to produce an incident report and another staff or management had to sign off on the report; and Management was responsible for notifying parent(s) of incidents while staff provided a copy of the report to the parent(s). On 05/18/22, the facility submitted 11 incident reports which documented C1’s involvement in incidents between 10/14/2021 through 03/02/22. Of the 11 reports, there was one report confirming an interaction between C1 and another child which resulted in C1 being scratched on the face by the other child while on a play structure on 03/02/22, however; this incident did not occur as a result of lack or absence of supervision. Aside from the one report confirming the scratch on C1’s face, there were no other witness(es) or evidence to corroborate claims about C1 sustaining other injuries while in care.

Based on this investigation, there is not enough evidence to support claims about C1 sustaining a scratch on the nose and a black eye while in care; and therefore, the allegation is unsubstantiated. Exit interview conducted and report was reviewed with the Center Director, Jennifer Hansen. 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. The were no California Code of Regulations, Title 22, Division 12, Chapter 1, Article 06 violations cited during today’s visit. Appeal Rights were provided.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5