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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197700095
Report Date: 06/25/2021
Date Signed: 06/30/2021 12:39:51 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/19/2021 and conducted by Evaluator Monique Jessica Ayala
PUBLIC
COMPLAINT CONTROL NUMBER: 12-CC-20210519092859
FACILITY NAME:RIVERA FAMILY CHILD CAREFACILITY NUMBER:
197700095
ADMINISTRATOR:CHERELLE & LEON RIVERAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 462-9073
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:14CENSUS: 10DATE:
06/25/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Cherelle Rivera, LicenseeTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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9
Personal Rights: Child sustained an injury while in care
INVESTIGATION FINDINGS:
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13
After superviser review this report is being Amended by Licensing Program Analyst (LPA) Monique Ayala on 06/30/2021 to indicate that the Type B decificeny will now be a Type A.

On 06/25/2021, Licensing Program Analyst (LPA) Monique Ayala met with the licensee, for the purposes of concluding the complaint investigation for the above allegation. LPA toured the facility and gathered the census of children present. There were 10 children in care with the supervision of the licensee and her assistant.

Based on LPA's observation, interviews conducted with licensee, staff, day-care children and other relevant parties and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found SUBSTANTIATED. Day care child sustained injury which required medical attention, child received stitches on upper lip.

An exit interview was conducted and a copy of this report was provided to the licensee along with appeal rights and Notice of Site Visit via email on 06/30/2021.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
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 12-CC-20210519092859
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: RIVERA FAMILY CHILD CARE
FACILITY NUMBER: 197700095
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
07/09/2021
Section Cited
CCR
102423(a)(2)
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Personal Right: Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee .....These rights include, but are not limited to, the following: To receive safe, healthful, and comfortable equipment. This requirement was not met as evidenced by..
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Licensee will place signs throughout the facility informing children not to swing or play on equipment. Licensee will have an all staff meeting reminding staff on supervision. Licensee will sbumit a roster with staff that attending the meeting and images of the signs posted throughout the facility.
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Based on observation, interviews and record review, Child #1 sustained an injury on upper lip while in care at the facility that required medical attention. This poses 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: Mariela Ramon
LICENSING EVALUATOR NAME: Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/19/2021 and conducted by Evaluator Monique Jessica Ayala
COMPLAINT CONTROL NUMBER: 12-CC-20210519092859

FACILITY NAME:RIVERA FAMILY CHILD CAREFACILITY NUMBER:
197700095
ADMINISTRATOR:CHERELLE & LEON RIVERAFACILITY TYPE:
810
ADDRESS:3120 CROWNE DRIVETELEPHONE:
(310) 462-9073
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:14CENSUS: 10DATE:
06/25/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Cherelle Rivera, LicenseeTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Personal Rights: Licensee did not seek medical attention in a timely manner
INVESTIGATION FINDINGS:
1
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3
4
5
6
7
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9
10
11
12
13
On 06/25/2021 Licensing Program Analyst (LPA) Monique Ayala conducted an unannounced complaint investigation for the above allegation, LPA was greeted by licensee. LPA toured the facility and gathered the census of children present. There were 10 children in care with the supervision of the licensee and her assistant.

The investigation consisted of interviews conducted with Licensee, Licensee’s assistants, day-care children, and other relevant complaint parties. The interviews revealed that there were no witnesses that could corroborate that the provider did not seek medical attention in a timely manner. Based on the evidence obtained the above allegation is deemed UNSUBSTANTIATED.

An exit interview was conducted and a copy of this report was provided to the licensee along with Notice of Site Visit and Appeal Rights.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3