Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 493009183
Report Date: 07/18/2019
Date Signed: 07/18/2019 11:50:43 AM


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/15/2019 and conducted by Evaluator Jennifer Velasco
COMPLAINT CONTROL NUMBER: 01-CC-20190515120039
FACILITY NAME:NORTH BAY CHILDRENS CENTER-VALLEY VISTAFACILITY NUMBER:
493009183
ADMINISTRATOR:MCDONALD, PAMALLAFACILITY TYPE:
850
ADDRESS:730 NORTH WEBSTER STREETTELEPHONE:
(707) 778-4762
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY:24CENSUS: 17DATE:
07/18/2019
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Pamalla McDonaldTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Lack of supervision resulting in a child sustaining unexplained injuries while in care.
INVESTIGATION FINDINGS:
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At 10:00 a.m. on 07/18/2019, Licensing Program Analyst (LPA) J. Velasco conducted an unannounced subsequent complaint investigation inspection for the purpose of delivering complaint findings and met with director Pamalla McDonald. It has been alleged that staff failed to adequately supervise children resulting in a child (C1) sustaining an injury; specifically, that C1 sustained bruising caused by unknown actions taken by a staff (S1) .

LPA met with the facility director (D1) during a prior inspection at 8:30 a.m. on 05/17/2019 and discussed the allegation. During that inspection, LPA toured the facility, observed staff supervision of children, obtained a current roster of children in care and contact information for staff and reviewed facility documents. At 8:43 a.m., LPA interviewed four children (C1-C4) and two staff (S2-S3) and interviewed facility director (D1). Interviews did not corroborate the allegation.

Continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer VelascoTELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2019
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 01-CC-20190515120039
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: NORTH BAY CHILDRENS CENTER-VALLEY VISTA
FACILITY NUMBER: 493009183
VISIT DATE: 07/18/2019
NARRATIVE
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Continued from LIC 9099.

During the subsequent investigation, LPA interviewed one adult (A7) at 1:30 p.m. on 06/25/2019 and interviewed C1 and two adults (A6-A7) at 1:45 p.m. on 06/28/2019. Interviews did not corroborate the allegation. Interviews failed to produce information regarding how or when C1 sustained the bruising; specifically, whether C1 had bruising before his first attendance at the facility during the week specified in the complaint. LPA reviewed a related Unusual Incident Report (UIR) submitted to the Department by the facility on 05/17/2019. LPA investigation of the UIR did not result in citation of facility deficiencies.

During the subsequent investigation inspection on 07/18/2019, LPA observed 17 children supervised by three staff, within ratio and capacity requirements. At 8:00 a.m., LPA interviewed an adult (A3). Interview did not corroborate the allegation. At 9:30 a.m., LPA interviewed a staff (S1). The interview did not corroborate the allegation. At 10:00 a.m., LPA interviewed a child (C5). The interview did not corroborate the allegation. At 10:30 a.m., LPA again discussed the allegation with D1. At 11:00 a.m., LPA reviewed facility documents and again observed staff care and supervision of children. LPA observations and facility documentation review failed to corroborate the allegation.

Although either a lack of supervision or unspecified action taken by S1 may have caused C1's bruising, based on information obtained through interviews, LPA observations, document reviews and photographic evidence, there was insufficient evidence to support the allegation that C1 sustained unexplained injuries while in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegation is UNSUBSTANTIATED.

An exit interview was conducted, and Appeal Rights were provided and discussed with the director, whose signature on this form confirms receipt of these documents. There were no Title 22 deficiencies cited during today's inspection.

Notice of Site Visit shall be posted for 30 days from today’s visit.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer VelascoTELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2019
LIC9099 (FAS) - (06/04)
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