304310918-2-28-2022-06-CC-PMAA-CC6QS2-20220303112446

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 304310918
Report Date: 02/28/2022
Date Signed: 02/28/2022 10:24:35 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/13/2021 and conducted by Evaluator Mila Quinto

COMPLAINT CONTROL NUMBER: 06-CC-20211213161000

FACILITY NAME:	FERNANDO, ANN		FACILITY NUMBER:	304310918
ADMINISTRATOR:	FERNANDO, ANN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(714) 875-5584
CITY:	CYPRESS	STATE: CA	ZIP CODE:	90630
CAPACITY:	14	CENSUS: 3	DATE:	02/28/2022
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Ann Fernando, Licensee		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Child sustained unexplained injuries while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Mila Quinto conducted an investigation visit to the home daycare to deliver the finding of the complaint initiated on 12/7/21 regarding a child sustained an injury while in care. LPA met with licensee, Ann Fernando. The Covid-19 Emergency Response questionnaire was reviewed and answered by the licensee. There was a total of 3 preschool children.

A review of facility Personnel Report Summary on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

The complainant alleged a child sustained an injury while in care. On 12/17/21, LPA conducted an interview with the licensee and licensee’s assistant. Licensee stated on 12/7/21, Child 1(C1) was playing with other children in the playroom when C1 fell on right-side landing on right ear. Licensee stated C1 had a red mark on right ear after falling on right side. C1 cried for only a short period.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Mila Quinto
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2022

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 06-CC-20211213161000

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: FERNANDO, ANN	FACILITY NUMBER: 304310918
	VISIT DATE: 02/28/2022

NARRATIVE

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Licensee did not observe C1 complaining nor crying afterwards. Licensee stated there was no other incident on this day. Licensee left the home prior to C1 pick up time, C1 was left with assistant. Licensee’s assistant stated did not witness C1 falling and no other incident while in care. C1 was with licensee’s assistant from 3:30pm until 5:30pm and during this time, C1 was in the playpen until pick up time. On 2/28/22, LPA interviewed 1 child and there was no disclosure. The 2 children were not interviewed as they were not qualified to be interviewed. On 1/31/22, LPA called 7 parents and left messages. LPA was able to interview 3 of the 7 parents. There were no disclosures made from the 3 parents interviewed. LPA did not receive a return call from the 4 parents.

On 1/31/22 and 2/23/22, LPA called the parents of C1 who stated when C1 came home, parents observed bruises on C1’s ear. The parents inquired with licensee that evening about C1’s bruises via text message and sent pictures of C1’s injuries to licensee. During the interview with the parents, LPA requested the medical report; however, none was provided. The only report LPA was provided was the discharge papers, there was no medical diagnosis nor any finding.

This agency has investigated the complaint alleging child sustained unexplained injuries while in care. Although the allegation may have happened or is valid, there is not enough preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Exit interview was conducted. Notice of Site Visit was posted during the visit. Licensee was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. Licensee was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. First level appeals should be sent to the regional manager to the address listed above.

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Mila Quinto
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2022

LIC9099 (FAS) - (06/04)

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