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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 274415959
Report Date: 09/20/2023
Date Signed: 09/20/2023 10:17:35 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/20/2023 and conducted by Evaluator Susy Cervantes
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20230920072105
FACILITY NAME:GONZALEZ ANAYA, ARACELIFACILITY NUMBER:
274415959
ADMINISTRATOR:ARACEI GONZALEZ ANAYAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 789-5946
CITY:SOLEDADSTATE: CAZIP CODE:
93960
CAPACITY:14CENSUS: 6DATE:
09/20/2023
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Araceli Gonzales AnayaTIME COMPLETED:
10:25 AM
ALLEGATION(S):
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Reporting requirements- licensee failed to report head injury for child in care to parents and the department
INVESTIGATION FINDINGS:
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On 09/20/2023 at 9:50 AM, Licensing Program Analyst (LPA) Susy Cervantes met with licensee Araceli Gonzales Anaya for a complaint investigation. Present was licensee and their mom with 6 children in care: one infant and five preschool.

Based on LPAs record review and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Type B deficiency was cited. Exit interview conducted and report was reviewed with the licensee Araceli Gonzales Anaya. A notice of site visit was given and must remain posted for 30 days.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
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 2
Control Number 07-CC-20230920072105
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GONZALEZ ANAYA, ARACELI
FACILITY NUMBER: 274415959
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2023
Section Cited
CCR
102416.2(b)
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The licensee shall report the following information the Department by telephone or fax within the Department's next business day and during normal working hours (8am to 5pm). (b) The licensee shall report to the Department any of the events as specified in Health and Safety Code Sections 1597.467(b)(1)(A) through (b)(1)(C) that occur during the operation of the family child care home.
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Licensee will review regulation 102416.2 and will submit a letter stating their understanding of the regulation and what they plan to do to prevent this from happening again by close of business on October 04, 2023.
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This requirement ws not met as evidenced by: Based on record review and interviews, the licensee failed to inform parents and the department of a head injury that a child sustained while in care. This poses a potential risk to the health, safety, and personal rights of the 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: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2