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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 010205830
Report Date: 02/09/2024
Date Signed: 02/09/2024 03:17:46 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/06/2023 and conducted by Evaluator Diana Campos
COMPLAINT CONTROL NUMBER: 02-CC-20231206162947

FACILITY NAME:AGNES MEMORIALFACILITY NUMBER:
010205830
ADMINISTRATOR:SANDRA PHELPSFACILITY TYPE:
850
ADDRESS:2372 INTERNATIONAL BLVDTELEPHONE:
(510) 533-1101
CITY:OAKLANDSTATE: CAZIP CODE:
94601
CAPACITY:24CENSUS: 10DATE:
02/09/2024
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Sandra PhelpsTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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facility failed to report an injury/incident report to Licensing.
INVESTIGATION FINDINGS:
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On 02/09/2024 LPA D. Campos met with Director, Sandra Phelps for a subsequent visit regarding the above allegation. During the course of the investigation, interviews were conducted and records reviewed. It was alleged that the school did not report an injury regarding a child who sustained a fracture while in care. Interviews revealed the facility staff drove the child to the hospital and notified the child's parent.
Interviews and record reviews revealed that the facility did not report the incident to CCL by phone or in writing as required by Title 22 regulations. Based on the investigative findings the above allegation is found to be substantiated. See LIC809D for deficiency cited.
Notice of Site Visit provided and must remain posted for 30 days.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Diana Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 02-CC-20231206162947
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: AGNES MEMORIAL
FACILITY NUMBER: 010205830
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/08/2024
Section Cited
CCR
101212(a)(d)(1)(B)
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Each licensee... shall furnish to the Department reports as required by the Department including...: Upon the occurrence, during the operation of the child care center of any of the events specified in... below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in... below shall be submitted to the Department within seven days following the occurrence of such event.
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Facility shall submit a written unusual incident report regarding the injury. Additionally facility shall submit to LPA by the POC date a summary of her understanding of the reporting requirements regulation.
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 Events reported shall include the following: Any injury to any child that requires medical treatment
This requirement was not met as evidenced by: Facility failed to report to licensing an injury regarding day care child sustaining a fracture. This poses a potential risk to the health and safety of persons 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: Sherelle Johnson
LICENSING EVALUATOR NAME: Diana Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
LIC9099 (FAS) - (06/04)
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