Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 490109272
Report Date: 05/25/2016
Date Signed: 05/25/2016 06:03:23 PM


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/25/2016 and conducted by Evaluator Leticia Rosales
PUBLIC
COMPLAINT CONTROL NUMBER: 01-CC-20160525153537

FACILITY NAME:4C'S PETALUMA CHILD DEVELOPMENT CENTERFACILITY NUMBER:
490109272
ADMINISTRATOR:DUSEK, LINDAFACILITY TYPE:
850
ADDRESS:401 S MC DOWELLTELEPHONE:
(707) 763-4990
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY:54CENSUS: 15DATE:
05/25/2016
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Maria VencezTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Failure to report
INVESTIGATION FINDINGS:
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LPA Leticia Rosales-Meza & Kim Miller, Investigator conducted an unannounced visit to investigate the above allegation. Interviews were conducted. Investigation findings reveal that the licensee failed to submit Unusual Incident Report that occurred at the center. Two unusaul incident occurred one during the months of February to March 2016, and then again in April 2016 when the Petaluma Police Department responded to the facility regarding the first incident. This allegation is substantiated.
See LIC 9099D for citation issued during this visit.

Notice of site visit posted. Failure to keep this notice posted for 30 days may result in a civil penalty of $100. Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Leticia RosalesTELEPHONE: (707) 588-5061
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2016
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 01-CC-20160525153537

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: 4C'S PETALUMA CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 490109272
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
05/25/2016
Section Cited
101212(d)(1)(C)
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Reporting Requirements. Any unusual incident or child absence that threatens the physical or emotional health or safety of a child shall be reported to the Department within 24 hours of the occurrence. Investigation findings reveal that the center did report this incident.

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Tracy Williams informed Miller that she will submit Unusual Incident reports in the future. Tracy stated was not aware she should have done a report.
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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: Alexis HollonTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Leticia RosalesTELEPHONE: (707) 588-5061
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2016
LIC9099 (FAS) - (06/04)
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