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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 313611358
Report Date: 05/21/2024
Date Signed: 05/21/2024 10:10:19 AM

Substantiated


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
05/13/2024 and conducted by Evaluator Lea Habtom
PUBLIC
COMPLAINT CONTROL NUMBER: 03-CC-20240513140643
FACILITY NAME:PENA DE LICATA, ROSAFACILITY NUMBER:
313611358
ADMINISTRATOR:PEÑA DE LICATA, ROSAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 408-7838
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:14CENSUS: DATE:
05/21/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Rosa Pena De Licata TIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Licensee did not provide licensing reports to authorized representative of day care child as required
INVESTIGATION FINDINGS:
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On May 21, 2024, Licensing Program Analysts (LPAs) Lea Habtom and Loraine Perez met with licensee, Rosa Pena De Licata, to open an close a complaint for the above allegations. Upon arrival, LPAs observed 6 children being supervised by licensee and her assistant. All staff present today have fingerprint clearances and associations.

Licensee did not provide licensing reports to authorized representative of day care child as required.

During the investigation, LPA Lea Habtom toured the facility, conducted observation, and interviewed those pertinent to the investigation. It was alleged that the licensee did not provide licensing reports to the authorized representative for a Type A citation issued on April 16, 2024. LPA L. Habtom reviewed the files of a few children that were present during the inspection on April 16, 2024, and found that a licensing acknowlegment form (LIC 9224) was missing. Licensee interview also revealed that one family did not get the LIC 9224 form, the licensing acknowledgment form due to disenrollment.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Lea Habtom
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
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 4
Control Number 03-CC-20240513140643
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: PENA DE LICATA, ROSA
FACILITY NUMBER: 313611358
VISIT DATE: 05/21/2024
NARRATIVE
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Based on the corroborating information collected LPA Lea Habtom has found that the allegation licensee did not provide licensing reports to authorized representatives to be SUBSTANTIATED: meaning that the allegation is valid because the preponderance of the evidence standard has been met.

Title 22 deficiency was cited on 9099-D. This report was reviewed with licensee, Rosa Pena De Licata. A notice of site visit was provided to be posted for 30 days. Appeal rights provided.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Lea Habtom
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 03-CC-20240513140643
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: PENA DE LICATA, ROSA
FACILITY NUMBER: 313611358
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/21/2024
Section Cited
HSC
1596.8595(c)(1)
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1596.8595 (c)(1) Health & Safety: A licensed child day care facility shall provide to the parents or guardians of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health,
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LPA L. Habtom reviewed LIC 9224 & printed Health & Safety code for licensee regarding providing Type A citations to families. The family missing the LIC 9224 is no longer enrolled.
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safety, or personal…this requirement was not met as evidenced by licensee interview and a child file that did not have the LIC 9224 acknowledgment of licensing report.
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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: Keven Peters
LICENSING EVALUATOR NAME: Lea Habtom
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4