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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 214200039
Report Date: 11/22/2021
Date Signed: 11/22/2021 04:44:13 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/15/2021 and conducted by Evaluator Farhan Bashir-Tariq
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20210915155236
FACILITY NAME:CHAN-ROSADO, BEATRIZFACILITY NUMBER:
214200039
ADMINISTRATOR:CHAN-ROSADO, BEATRIZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 459-5845
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY:14CENSUS: 12DATE:
11/22/2021
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Beatriz Chan-RosadoTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Licensee failed to report an incident.
INVESTIGATION FINDINGS:
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On 11/22/21 at 4:00 pm., Licensing Program Analyst (LPA), Farhan Bashir-Tariq arrived at the facility above unannounced to deliver the findings of this complaint investigation. Purpose of inspection was explained. There were 12 children present today with Licensee and Husband, Antonio Chimal. All adults living or working have fingerprints clearance on file. Facility was working in compliance to staff and children ratio on this day. LPA made an initial visit to the facility on 09/21/21, a subsequent visit on 11/16/21 and a final visit today to deliver the findings of this complaint. During the course of investigation, LPA conducted interviews with Licensee, children, parents. As part of this investigation, copies of the following documents were received from Licensee : facility roster. Licensee failed to report incidents involving C1 as per Child Care Licensing regulations.

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.”)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Farhan Bashir-Tariq
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 05-CC-20210915155236
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CHAN-ROSADO, BEATRIZ
FACILITY NUMBER: 214200039
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2021
Section Cited
CCR
102416.2(3)(b)(1)(c)
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102416.2...Reporting Requirements
(3) Health and Safety Code Section 1597.467(b)(1) provides in part:
"A report shall be made to the Department…following the occurrence during the operation of a family day care home of any of the following events:
C) Any unusual incident or child absence that threatens the physical or emotional health or safety of any child."
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Licensee need to submit the report of incident to Department By 11/29/21. LPA spoke to Licensee about the reporting requirements.

LPA provided the phone number for Desk Duty-Child Care and advised license to call if they have any questions. Further information about reporting requirements can also be obtained from website: www.ccld.ca.gov
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This requirement is not met as evidenced by record reviews.
Based on interview and record reviews, Licensee failed to follow the protocol to submit licensing reports to file unusual incidents.
This poses a potential 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: Garfield Leung
LICENSING EVALUATOR NAME: Farhan Bashir-Tariq
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC9099 (FAS) - (06/04)
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