Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197409882
Report Date: 02/20/2018
Date Signed: 02/20/2018 11:47:33 AM


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6167 BRISTOL PARKWAY #400
CULVER CITY, CA 90230
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/07/2017 and conducted by Evaluator Mariela Ramon
PUBLIC
COMPLAINT CONTROL NUMBER: 30-CC-20170307103452
FACILITY NAME:GUZMAN FAMILY CHILD CAREFACILITY NUMBER:
197409882
ADMINISTRATOR:GUZMAN, ISABELFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 763-7849
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91601
CAPACITY:14CENSUS: 11DATE:
02/20/2018
UNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Isabel Guzman, LicenseeTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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Unexplained death - Licensee's husband noticed infant was unresponsive while in care at the facility.
INVESTIGATION FINDINGS:
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Mariela Ramon, Licensing Program Analyst-.Complaint Specialist (CS) conducted a subsequent visit to the facility for the purpose of concluding the investigation regarding the above allegation. Upon arrival, CS observed licensee and her husband providing care to 3 infants and 8 preschool age children in care.

The investigation of the above allegation was conducted by Investigator Eugene Martinez. The investigation consisted of interviews with all pertinent complaint parties including, but not limited to Police Detectives, Medical Professionals, and Subjects of the Investigation.

Please Complaint Investigation Report LIC 9099C for additional information.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla CaldwellTELEPHONE: (951) 337-4351
LICENSING EVALUATOR NAME: Mariela RamonTELEPHONE: (310) 337-4809
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2018
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 4
Control Number 30-CC-20170307103452
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6167 BRISTOL PARKWAY #400
CULVER CITY, CA 90230
FACILITY NAME: GUZMAN FAMILY CHILD CARE
FACILITY NUMBER: 197409882
VISIT DATE: 02/20/2018
NARRATIVE
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The investigation revealed that on 03/06/17 at approximately 11:30 a.m., infant was fed milk, burped, and then placed on the infant’s back in a crib. Licensee’s husband checked on the infant every 20 to 30 minutes and at approximately 2:00 p.m, licensee’s husband noticed the infant was unresponsive. Licensee contacted 911 and administered First Aid and CPR. Paramedics arrived shortly after and provided aid and transported the infant to Saint Joseph Medical Center where the infant expired the same day.

Based on the evidence obtained during the investigation and the results of the autopsy report it was determined that the cause of the infant’s death was Sudden Unexplained Infant Death (SUID). There is no preponderance of evidence to prove or disprove that the allegation is found to be true, therefore the finding is Unsubstantiated.

An exit interview was conducted with licensee, a copy of this report was provided along with the appeal rights.
SUPERVISOR'S NAME: Carla CaldwellTELEPHONE: (951) 337-4351
LICENSING EVALUATOR NAME: Mariela RamonTELEPHONE: (310) 337-4809
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2018
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6167 BRISTOL PARKWAY #400
CULVER CITY, CA 90230
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/07/2017 and conducted by Evaluator Mariela Ramon
PUBLIC
COMPLAINT CONTROL NUMBER: 30-CC-20170307103452

FACILITY NAME:GUZMAN FAMILY CHILD CAREFACILITY NUMBER:
197409882
ADMINISTRATOR:GUZMAN, ISABELFACILITY TYPE:
810
ADDRESS:11108 TIARA STREETTELEPHONE:
(818) 763-7849
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91601
CAPACITY:14CENSUS: 11DATE:
02/20/2018
UNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Isabel Guzman, LicenseeTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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Reporting Requirements - Licensee failed to contact the Deparment to report the infant's incident that occurred on 03/06/17.
INVESTIGATION FINDINGS:
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Mariela Ramon, Licensing Program Analyst-.Complaint Specialist (CS) conducted a subsequent visit to the facility for the purpose of concluding the investigation regarding the above allegation. Upon arrival, CS observed licensee and her husband providing care to 3 infants and 8 preschool age children in care.

The investigation of the above allegation revealed that the licensee failed to contac the Department to file an incdent erport within 24 hours of the incident; therefore, there is sufficient evidence to prove and Substantiate the allegation of Reporting Requirements. Facility was cited a Type B deficiency. Please see Complaint Investigation Report LIC 9099D for deficiency cited.'

The Department did receive a written incident report within the required time frame.

An exit inteerview was conducted with licensee and a copy of this report was provided along with the appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla CaldwellTELEPHONE: (951) 337-4351
LICENSING EVALUATOR NAME: Mariela RamonTELEPHONE: (310) 337-4809
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2018
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 30-CC-20170307103452
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6167 BRISTOL PARKWAY #400
CULVER CITY, CA 90230

FACILITY NAME: GUZMAN FAMILY CHILD CARE
FACILITY NUMBER: 197409882
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/20/2018
Section Cited
CCR
102416.2(d)
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Reporting Requirements. The licensee shall report to the Department as provided by the Health and Safety. A report shall be made to the department by telephone or fax during the department's normal business hours before the close of the next working day
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Licensee provided CS with a written statement indicating that she will ensure to report to the Department unusual incidents that occurred at the facility. POC cleared.
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following the occurrence during the operation of family day care home of…the…events." Licensee failed to contact the Department to report an incident that occurred 03/06/17. This is a type B deficiency that if not corrected, it could become a risk to the Health, Safety or the personal rights of 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.
SUPERVISOR'S NAME: Carla CaldwellTELEPHONE: (951) 337-4351
LICENSING EVALUATOR NAME: Mariela RamonTELEPHONE: (310) 337-4809
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2018
LIC9099 (FAS) - (06/04)
Page: 4 of 4