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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 013418921
Report Date: 05/05/2021
Date Signed: 05/06/2021 04:46:28 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
04/26/2021 and conducted by Evaluator Lakeisha Chew
COMPLAINT CONTROL NUMBER: 02-CC-20210426143349
FACILITY NAME:KANBERGS, CHRISTINEFACILITY NUMBER:
013418921
ADMINISTRATOR:KANBERGS, CHRISTINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 521-7132
CITY:ALAMEDASTATE: CAZIP CODE:
94501
CAPACITY:14CENSUS: 10DATE:
05/05/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:KANBERGS, CHRISTINETIME COMPLETED:
05:43 PM
ALLEGATION(S):
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Personal Rights - Staff handled child in a rough manner
INVESTIGATION FINDINGS:
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On May 5, 2021, Licensing Program Analyst (LPA) L. Chew made an unannounced inspection for the purpose of conducting a complaint investigation. LPA introduced and displayed identification to staff members and parents/guardians present. LPA identified purpose for today’s visit. Licensee was not present during inspection
LPA met with fingerprint cleared/associated staff member Karen Cabalbag-Fullen. Census were taken. Present at the facility 2 additional fingerprint cleared/associated staff members and 10 children in care (2 infants, 2 school-age and 6 preschool-age). LPA observed a separate single cottage area located outside in the backyard. It was alleged that staff handled child in a rough manner. During the investigation, observations made, interviews conducted, and records reviewed.
Based on LPA's observations and interviews which were conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, 102423(a)(4) (Title 22, Division 12 are being cited on the attached LIC9099 D. (continued).
This report will remain on file for 3 years. (continue)


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Lakeisha Chew
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021
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 3
Control Number 02-CC-20210426143349
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: KANBERGS, CHRISTINE
FACILITY NUMBER: 013418921
VISIT DATE: 05/05/2021
NARRATIVE
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An exit interview was conducted. LPA discussed, reviewed the reports and appeal rights with staff member. A copy of the reports and appeal rights was provided. Notice of Site Visit provided. Staff member was reminded to have forms posted for 30 days.

Staff member acknowledges that for Type A Deficiencies only upon receipt, the Owner/Director shall post the LIC 9099D with Type A deficiencies for 30 days 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.

The LIC 9224 must be signed by every child in care parents/guardians. A copy of report must be kept with the children's forms as a receipt whenever any Type A documents are provided by the licensee. A copy of the LIC 9224 was provided to staff member

Staff member was advised, failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Lakeisha Chew
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 02-CC-20210426143349
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: KANBERGS, CHRISTINE
FACILITY NUMBER: 013418921
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2021
Section Cited
CCR
102423(a)(4)
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102423(a)(4) - Personal Rights
(4) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature.
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By 5/6/2021 Licensee will submit a written summary of her understanding of and an agreement to abide by CCL Regulations..
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This requirement was not met as evidenced by interviews conducted. It was determined that staff handled child in a rough manner as a form of disciplince, leaving a bruise on child arm. This poses an immediate risk for the health and safety of children in care.
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By 5/20/21 All staff members ill watch the Personal Rights Video at https://ccld.childcarevideos.org/ on the www.ccld.ca.gov website.
Staff members will submit individual written summaries of understanding and agreement to abide by CCL Regulations
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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: Loretta Dyson
LICENSING EVALUATOR NAME: Lakeisha Chew
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3