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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 493004938
Report Date: 05/09/2023
Date Signed: 05/09/2023 11:06:11 AM

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
12/19/2022 and conducted by Evaluator Amy Strother
PUBLIC
COMPLAINT CONTROL NUMBER: 01-CC-20221219113822
FACILITY NAME:MENDEZ, ANA FAMILY CHILD CARE HOMEFACILITY NUMBER:
493004938
ADMINISTRATOR:MENDEZ, ANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 795-1202
CITY:COTATISTATE: CAZIP CODE:
94931
CAPACITY:14CENSUS: 8DATE:
05/09/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Quetzali HernandezTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Licensee did not notify a child's parent or authorized representative regarding illness that affect the child
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Amy Strother conducted an unannounced complaint investigation inspection, for the purpose of delivering complaint findings, and met with the Licensee's assistant, Quetzali Hernandez, Staff 1 (S1). It has been alleged that Licensee did not notify a child's parent or authorized representative regarding illness that affect the child, specifically when Child 1 (C1) had labored shallow breathing while in care on 12/15/22.
During the initial complaint investigation to the facility on 12/23/22 LPA Rosales conducted an interview with the Licensee at 12:15pm. The Licensee denied the allegation. Licensee stated she kept a close eye on C1 and met C1’s needs but didn't feel she needed to contact parent because child was fine.

Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
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-20221219113822
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: MENDEZ, ANA FAMILY CHILD CARE HOME
FACILITY NUMBER: 493004938
VISIT DATE: 05/09/2023
NARRATIVE
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Licensee stated there is a lot of winter flu going around so everyone and especially children are sick with cold symptoms, in which C1 showed to have a stuffy nose, and of course children cry and get fussier, "but overall C1 was breathing fine here." Interviews were conducted with Staff 1 (S1) on 12/23/22 at 12:05pm and with Adult 1 (A1) on 12/23/22 and 4/05/23. On 05/09/23 LPA Strother requested to review C1’s fifteen-minute check sleep log from 12/15/22. S1 stated that they do not have sleep logs to provide and were not aware of the safe sleep regulations at the time, see Case Management report dated 05/09/23.

On 12/15/22 A1 dropped C1 off at the Family Child Care Home at 6:30am, Adult 2 (A2) picked up C1 at approximately 4:50pm and took C1 to Santa Rosa Memorial Hospital’s Emergency Room due to labored shallow breathing. C1’s 12/15/22 medical records were reviewed showing arrival at Santa Rosa Memorial Hospital’s Emergency Room at 5:09pm, where C1 was placed on high flow oxygen due to significant respiratory distress, hospitalized and discharged on 12/18/22 at 10:15am.

Based on interviews conducted and records reviewed, there is a preponderance of evidence to prove that the alleged violation occurred, therefore the allegation is Substantiated.

Title 22 deficiency was cited based on the above finding. Appeal Rights were provided. Exit interview conducted and report was reviewed and discussed with facility representative, Quetzali Hernandez.

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.

LPA Strother informed facility representative, Quetzali Hernandez that this report dated 05/09/23 documents one Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Strother informed licensee to provide a copy of this licensing report dated 05/09/23 that documents a Type A citation 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: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 01-CC-20221219113822
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: MENDEZ, ANA FAMILY CHILD CARE HOME
FACILITY NUMBER: 493004938
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2023
Section Cited
CCR
102425(j)(3)(A)
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102425(j)The provider shall supervise infants while they are sleeping and adhere to the following requirements: (3)If the provider observes any of the indicators referenced in Subsection j(2)(A) or (B) above, the provider shall do the following: (A)Immediately notify the infant’s authorized representative.
This requirement was not met as evidenced by:
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Licensee, will write out a procedure for following safe sleep regulations to include what conditions shall be immediately reported to an infant’s authorized representative when observed and what to do if the parent is not responsive.
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Based on interviews conducted and records reviewed the Licensee did not notify C1's authorized representative of C1's labored breathing on 12/15/22, which poses an immediate Health and Safety risk to children in care.
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Written procedure will be sent to LPA Leticia Rosales's email: leticia.rosales@dss.ca.gov
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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: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
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