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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 573621481
Report Date: 04/21/2022
Date Signed: 04/21/2022 04:40:06 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/12/2022 and conducted by Evaluator Chayntel Hunter
PUBLIC
COMPLAINT CONTROL NUMBER: 53-CC-20220412163538
FACILITY NAME:HODGE, TIFFANYFACILITY NUMBER:
573621481
ADMINISTRATOR:HODGE, TIFFANYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(618) 663-0574
CITY:WOODLANDSTATE: CAZIP CODE:
95776
CAPACITY:14CENSUS: 13DATE:
04/21/2022
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Licensee, Tiffany HodgeTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Licensee does not follow safe sleep practice
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Chayntel Hunter met with Licensee, Tiffany Hodge to open and close the complaint investigation regarding the above allegation.

During the course of the investigation, LPA Hunter conducted interviews, and obtained information pertaining to allegation. It was alleged that Licensee did not follow safe sleep practices. Upon arrival LPA Hunter observed an infant asleep in an infant rocker. Licensee explained child does have a crib for when the child is asleep, and understands rockers are not to be used as sleeping devices and children are to be immediately removed. Based on LPA observations the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Title 22 regulations are being cited on the attached 9099-D page.

Report continues on 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Justin L Denton
LICENSING EVALUATOR NAME: Chayntel Hunter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
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 53-CC-20220412163538
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: HODGE, TIFFANY
FACILITY NUMBER: 573621481
VISIT DATE: 04/21/2022
NARRATIVE
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An exit interview was conducted with the Licensee. A notice of site visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

LPA Hunter informed licensee that this report dated 04/21/22 document(s) Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Hunter informed the licensee to provide a copy of this licensing report dated 04/21/22 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.
SUPERVISORS NAME: Justin L Denton
LICENSING EVALUATOR NAME: Chayntel Hunter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 53-CC-20220412163538
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: HODGE, TIFFANY
FACILITY NUMBER: 573621481
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/21/2022
Section Cited
CCR
102425(i)
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Infant Safe Sleep (i) If an infant falls asleep before being placed in a crib or play yard, the provider shall move the infant to a crib or play yard as soon as possible. This requirement was not met as evidenced by:
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 Licensee explained child does have a crib for when the child is asleep, and understands rockers are not to be used as sleeping devices and children to be immediately removed.
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LPA Hunter observed an infant asleep in an infant rocker. This is an immediate health and safety risk to 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.
SUPERVISORS NAME: Justin L Denton
LICENSING EVALUATOR NAME: Chayntel Hunter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4