<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 304370698
Report Date: 03/10/2023
Date Signed: 03/10/2023 05:40:44 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/07/2023 and conducted by Evaluator Nguyen K Tran
PUBLIC
COMPLAINT CONTROL NUMBER: 06-CC-20230307085737
FACILITY NAME:COUNTRY VILLAGE PRESCHOOL FOOTHILL RANCHFACILITY NUMBER:
304370698
ADMINISTRATOR:FERGUSON, JENNIFERFACILITY TYPE:
830
ADDRESS:27005 BURBANK ROADTELEPHONE:
(949) 380-4300
CITY:FOOTHILL RANCHSTATE: CAZIP CODE:
92610
CAPACITY:12CENSUS: 4DATE:
03/10/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jennifer Ferguson, DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not document sleep checks for infants in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 03/10/2023, Licensing Program Analyst (LPA) Tran and LPA Nunez conducted a 10-day initial investigation regarding the allegations about staff do not document sleep checks for infants in care. LPAs met with Director Jennifer Ferguson. Observed at the time of the investigation was a total of 4 infants and 1 staff. LPA informed the Director of the allegation.

A review of the Facility Personnel Report Summary on 03/10/2023 indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

During today's investigation, LPA reviewed children's files and interviewed 2 staff.

(Continue next page)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Nguyen K Tran
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
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 5
Control Number 06-CC-20230307085737
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: COUNTRY VILLAGE PRESCHOOL FOOTHILL RANCH
FACILITY NUMBER: 304370698
VISIT DATE: 03/10/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Page 2 of Report)

During the interviews, both interviewed staff admitted that they did not complete the Sleep Log to document visual checks every 15 minutes while the infants are asleep.

During record review, LPAs reviewed 4 infant's files and did not observed Sleep log in their files.

Based on the information gathered from LPAs' interviews conducted with 2 staff on 03/10/2023, and review of 4 infant files on 03/10/2023, the preponderance of evidence standard has been met, therefore the above allegation that staff do not document sleep checks for infants in care is found to be SUBSTANTIATED. California Code of Regulations, Title 22 Section 101419(a)(2)(C) Responsibility for Providing Care and Supervision for Infants is being cited on the attached LIC9099D.

Exit interview was conducted. The Notice of Site Visit was posted. Appeal Rights was explained. A copy of appeal rights (LIC 9058) was provided. First level appeal is to Regional Manager, address is above on the report.

(End of Report)

SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Nguyen K Tran
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 06-CC-20230307085737
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: COUNTRY VILLAGE PRESCHOOL FOOTHILL RANCH
FACILITY NUMBER: 304370698
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2023
Section Cited
CCR
101419(a)(2)(C)
1
2
3
4
5
6
7
101419(a)(2)(C) Documentation shall be maintained in the infant’s file... include the following: 1.Date. 2.Infant’s name.
3.Time of each 15-minute check.
4.Initials of staff person who
conducted each check.
This requiremnet is not met evidenced by:
1
2
3
4
5
6
7
Director stated she will submit proof of Sleep logs for the infants in care to LPA by by due date.
8
9
10
11
12
13
14
Based on interview and record review, Staff Staff 1 and Staff 2 admitted that facility did not complete Sleep log ofr 4 infants in care, which poses a potential risk health, safety and personal rights for the children in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Rina Lopez
LICENSING EVALUATOR NAME: Nguyen K Tran
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5