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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 073408263
Report Date: 01/27/2023
Date Signed: 01/27/2023 01:04:10 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/23/2023 and conducted by Evaluator Cherie Acosta
COMPLAINT CONTROL NUMBER: 02-CC-20230123154349
FACILITY NAME:LEARNING EXPERIENCE, THEFACILITY NUMBER:
073408263
ADMINISTRATOR:ROBYN KINGFACILITY TYPE:
850
ADDRESS:4831 LONE TREE WAYTELEPHONE:
(925) 281-7640
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:130CENSUS: 55DATE:
01/27/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Raiya PonnaluriTIME COMPLETED:
01:05 PM
ALLEGATION(S):
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Staff revealed confidential information.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Cherie Acosta and Michelle Sutton conducted an unannounced visit to investigate the above allegation. LPAs met with Raiya Ponnaluri.

During the visit LPAs conducted interview. Based on interviews conducted it is determined that staff revealed confidential information which put children's health and safety at risk.

Based on interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is to be substantiated.

See 9099-D for deficiency cited today.
Report reviewed with Raiya Ponnaluri
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Cherie Acosta
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
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 2
Control Number 02-CC-20230123154349
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: LEARNING EXPERIENCE, THE
FACILITY NUMBER: 073408263
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2023
Section Cited
CCR
101223(a)(2)
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Personal Rights. The licensee shall ensure that each child is accorded the following personal rights:To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

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Owner agrees to develop a written plan of action to ensure there are no future incident. A copy of the plan shall be sent to CCL by 2/10/23
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This requirement was not met as evidenced by staff revealed confidential information which poses a potential risk to the health and safety of children in care.
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• Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.

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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: Sherelle Johnson
LICENSING EVALUATOR NAME: Cherie Acosta
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC9099 (FAS) - (06/04)
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