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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197414574
Report Date: 10/30/2024
Date Signed: 12/18/2024 11:18:15 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/23/2024 and conducted by Evaluator Elicia Calvillo
COMPLAINT CONTROL NUMBER: 58-CC-20241023091720
FACILITY NAME:KIDSVILLE U.S.A.FACILITY NUMBER:
197414574
ADMINISTRATOR:PERERA, MAUREENFACILITY TYPE:
840
ADDRESS:8472 CORBIN AVENUETELEPHONE:
(818) 886-3508
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:57CENSUS: 0DATE:
10/30/2024
UNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Maureen Perera, DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff left daycare child unattended inside a facility vehicle
INVESTIGATION FINDINGS:
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***THIS IS AN AMENDED REPORT WHICH SUPERSEDES THE PREVIOUS REPORT***
On 10/30/2024 at 08:35 AM, Licensing Program Analysts (LPAs) Elicia Calvillo and Dawn Dowling conducted a complaint visit and to deliver findings on the above allegation. LPAs identified self and met with Brittany Wijeskera, Assistant Director, who allowed entry into the facility and provided LPAs a guided tour of the inside and outside of the facility Upon arrival there were 0 children and 0 staff present, Maureen Perera, Director arrived shortly after.

During today’s visit, LPA addressed the allegation that staff left daycare child unattended inside a facility vehicle. Throughout the course of the investigation, LPA obtained the LIC 9040 Child Care Facility Roster, interviewed Licensee, interviewed staff, personnel record review, and obtained other pertinent documentation.


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Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Elicia Calvillo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
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 58-CC-20241023091720
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: KIDSVILLE U.S.A.
FACILITY NUMBER: 197414574
VISIT DATE: 10/30/2024
NARRATIVE
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Information provided by the Reporting Party (RP) indicates that staff left daycare Child #1 unattended inside a facility vehicle.

Director disclosed that Child #1 was left from 02:41PM to 03:38 PM unattended in a facility van . Director stated that they immediately addressed the pick up and drop off protocols with Staff #1, Staff #2, and Staff #3 but also conducted an all staff training to review safety protocols.

When interviewing staff. Staff #1 indicated that they left Child #1 unattended in the facility van from 02:41PM to 03:38PM. Staff #2 indicated that around 03:36PM, Staff # 2 found Child #1 unattended in a facility van. Staff #3 indicated that Child #1 was not accounted for until 03:38PM when child #1 was found in the facility van.



Based on LPA’s observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 12 Chapter 3, Section number 101223(a)(2) Personal Rights, 101229 (a)(1) Responsibility for Providing Care and Supervision, are being cited on the attached deficiencies page.

Due to Child #1 being left in the facility vehicle for 57 minutes, $500 immediate civil penalty is being assessed on today’s visit.

A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement form must be maintained in each child’s file immediately upon receipt from parent. Director was provided with a copy of the parent Acknowledgement of Receipt of Licensing Reports Form during this visit.

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SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Elicia Calvillo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 58-CC-20241023091720
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: KIDSVILLE U.S.A.
FACILITY NUMBER: 197414574
VISIT DATE: 10/30/2024
NARRATIVE
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The Notice of Site Visit (LIC 9213) must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

Exit interview was conducted with Maureen Perera, Director, including, but not limited to Provider Rights, Appeal Procedures and Agencies Consultative Role.

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SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Elicia Calvillo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 58-CC-20241023091720
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: KIDSVILLE U.S.A.
FACILITY NUMBER: 197414574
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2024
Section Cited
HSC
101223(a0(2)
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101223 Personal Rights (a) The licensee shall that each child is accorded the following personal rights:(2)To be accorded safe, healthful, and ....

This requirement is not met as evidenced by
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Licensee stated they will provide staff training on personal rights and will provide LPA copy of the meeting agenda and sign in sheet by the plan of correction due date 10/31/2024.
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Based on observations, interviews, and record reviews that the investigations revealed, Child #1 was left unattended in facility vehicle which poses an immediate health, safety, and personal rights risk to children in care.
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Type A
10/31/2024
Section Cited
HSC
101229(a)(1)
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101229 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision …(1) No child(ren) shall be left without the supervision… Supervision shall include visual observation.This requirement is not met as evidenced by
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Licensee stated they will update the pick up and drop off procedures for staff and provide staff training by the plan of correction due date 10/31/2024. Director provided LPA with staff training and staff attendance sheet for the plan of correction.
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Based on observations, interviews, and record reviews that the investigations revealed, Child #1 was left unattended from 02:41PM to 03:38PM in facility vehicle which poses an immediate health, safety, and personal rights risk to children in care. A civil penalty of $500 is being assessed for the absence of supervision.
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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: Rita Ramos
LICENSING EVALUATOR NAME: Elicia Calvillo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4