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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 293626820
Report Date: 09/19/2025
Date Signed: 09/19/2025 10:25:45 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/21/2025 and conducted by Evaluator Matthew Gallo
COMPLAINT CONTROL NUMBER: 03-CC-20250721100523
FACILITY NAME:CLARK, SHELBYFACILITY NUMBER:
293626820
ADMINISTRATOR:CLARK, SHELBYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 913-7683
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY:14CENSUS: 6DATE:
09/19/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Shelby ClarkTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Licensee yelled at a daycare child
INVESTIGATION FINDINGS:
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At 9:45am on 9/19/2025, Licensing Program Analyst (LPA) Matthew Gallo met with licensee Shelby Clark to deliver findings of a complaint investigation into the above allegation. During the visit, LPA observed a census of 6 children consisting of 4 preschool children and 2 infants.

Throughout the course of the investigation, LPA conducted observations and interviews related to the allegation that the licensee yelled at a daycare child. During two visits to the facility on 7/25/2025 and 9/19/2025, LPA observed the licensee to speak with a measured voice to the children when correcting behavior, and observed children to be comfortable when interacting with the licensee. LPA interviewed staff, parents, children, and licensee. Staff, parent, and licensee interviews did not provide additional information to support the allegation. Of the 3 children interviewed, one referenced the licensee speaking loudly and angrily to a child who was in trouble, while another described the licensee as using a soft voice when addressing such situations. Report continues on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Mai Lor
LICENSING EVALUATOR NAME: Matthew Gallo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025
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 03-CC-20250721100523
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: CLARK, SHELBY
FACILITY NUMBER: 293626820
VISIT DATE: 09/19/2025
NARRATIVE
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The preponderance of evidence standard is not met; therefore, the allegation is UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it.

No deficiencies were cited during today's visit.

Exit interview conducted and report was reviewed with the facility representative, Shelby Clark. A notice of site visit was given and must remain posted for 30 days. LPA provided appeal rights.
SUPERVISORS NAME: Mai Lor
LICENSING EVALUATOR NAME: Matthew Gallo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2