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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 280108344
Report Date: 07/25/2024
Date Signed: 07/25/2024 03:44:56 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/02/2024 and conducted by Evaluator Cindy Castro
PUBLIC
COMPLAINT CONTROL NUMBER: 01-CC-20240502090421
FACILITY NAME:CANV KIDS DEVELOPMENT & FAMILY PROGRAM AKA LOS NINFACILITY NUMBER:
280108344
ADMINISTRATOR:KATHY PEEBLESFACILITY TYPE:
850
ADDRESS:1510 MYRTLE AVENUETELEPHONE:
(707) 253-4482
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:60CENSUS: 30DATE:
07/25/2024
UNANNOUNCEDTIME BEGAN:
01:37 PM
MET WITH:Evelyn Fuentes TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff did not ensure an individual removing a day care child from the facility followed sign in/out procedures.
INVESTIGATION FINDINGS:
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On 07/25/24, Licensing Program Analyst (LPA) Cindy Castro, made a subsequent complaint investigation inspection, for the purpose of delivering complaint findings, and met with Site Supervisor (S1), Evelyn Fuentes. It has been alleged that facility staff did not ensure an individual removing a day care child from the facility followed sign in/out procedures.

LPA, previously conducted an inspection on 05/08/2024 to initiate the investigation and met with the Site Supervisor to discuss the allegations, conduct interviews, make observations, and request documents.

During the investigation, LPA conducted interviews with Center Director (CD), three staff members (S1-S3) and one parent (P1) from 05/08/2024 to 06/14/2024. CD admitted that the staff who released C1 did not follow the sign out procedures and that it was early in the morning and staff do not take the sign out sheet outside with them. Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Cindy Castro
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
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 5
Control Number 01-CC-20240502090421
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CANV KIDS DEVELOPMENT & FAMILY PROGRAM AKA LOS NIN
FACILITY NUMBER: 280108344
VISIT DATE: 07/25/2024
NARRATIVE
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Staff S1-S3 acknowledged that that sign in/out procedures were not followed by staff who released C1. S1 stated everyone needs to make sure anyone who signs out child does it at a correct time and signs in with their name. S1 further added that during pick up, the sign in/ out sheet is located outside with the children in the yard. If the parents or anyone else comes unexpected, the sign in/out sheet is inside the facility. S2 stated that it was on Friday 04/26/24 when the incident occurred. S2 added that the sign in/out stays inside in the morning and in the afternoon, it is taken outside. Furthermore, S2 stated that when she does not recognize the person picking up the child she will then ask for ID even if the teachers from other classrooms recognize the person. S2 added that she has no idea why A1 would sign in as someone else. S3 stated that if she does not recognize the person as being authorized to pick up, she will ask for their ID to ensure the child’s protection. That the sign in/out book is between the classrooms in the morning and in the afternoon, it is outside with children. S3 stated, “I do not check on the signatures because that is the associate teacher’s job, and I am substitute teacher”.

According to LPA’s records reviewed on 05/08/2024, C1’s Identification and Emergency Contact Form (LIC700) had Adult (A1) who was reported by staff (S1-S3) to have removed C1 from facility, as a listed authorized person that could take child from the facility but the signature on the sign in/out did not match A1’s name. In addition, Parent (P1) stated that he thought the signatures on the sign out were forged because the signature is different.

Based on interview with Center Director (CD) and Staff (S1-S3), the preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D. Appeal rights were provided.



Exit interview conducted, and report was reviewed with Site Supervisor, Evelyn Fuentes.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Cindy Castro
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 01-CC-20240502090421
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CANV KIDS DEVELOPMENT & FAMILY PROGRAM AKA LOS NIN
FACILITY NUMBER: 280108344
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2024
Section Cited
CCR
101229.1(a)(1)
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101229.1 Sign In and Sign Out
(a)In addition to the sign-in procedure requirement of Section 101226.1(b), the licensee shall develop, maintain, and implement a written procedure to sign the child in/out of the child care center that shall, at a minimum, include the following:(1)The person who signs the child in/out shall use his/her full legal signature and shall record the time of day.

This requirement was not met as evidenced by:
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Site Supervisor stated that facility has implemented that Lead Teachers take the sign in/out forms with them everytime they are on the playground to assure that regulations are being followed. Site Supervisor will create a Sign in/out procedure statement that will be reviewed and signed by all staff and provide proof to the Department by 08/16/24.
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Based on interviews and sign in/out records reviewed. CD, S1-S3 admitted to not following the sign in/out procedures, which posed a potential health, safety or personal rights risk to persons in care.

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Via mail, email or fax. Email:cindy.castro@dss.ca.gov Fax: (707)588-5099
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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: Alexis Hollon
LICENSING EVALUATOR NAME: Cindy Castro
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5