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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 343614029
Report Date: 12/15/2021
Date Signed: 12/15/2021 12:29:21 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/11/2021 and conducted by Evaluator Karyn Guerra
PUBLIC
COMPLAINT CONTROL NUMBER: 03-CC-20211011093941
FACILITY NAME:SMALLVILLE PRESCHOOLFACILITY NUMBER:
343614029
ADMINISTRATOR:NULL SHANNONFACILITY TYPE:
850
ADDRESS:4706 ARDEN WAYTELEPHONE:
(916) 480-0632
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:30CENSUS: 28DATE:
12/15/2021
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Shannon NullTIME COMPLETED:
12:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Day care child was injured by another day child while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At 11:45 a.m. on Wednesday, December 15th, 2021, Licensing Program Analyst (LPA) Karyn Guerra met with Licensee, Shannon Null, for the purpose of a complaint inspection to deliver findings. It was alleged that a day care child was injured by another child while in care. There was a concern that Child 1(C1) was hit over the pants by Child 2 (C2) while playing outside, resulting in injury. Throughout the course of the investigation, LPA conducted interviews, made observations, and reviewed documentation. Licensee denied the allegation and supplied video surveillance for review. LPA interviewed staff who stated they did not observe the alleged incident. Staff interviewed stated that teachers supervise from various stations while outdoors. Parent and children interviews did not reveal any supervision concerns. There was not evidence to corroborate the allegation, and it could not be determined if the incident occurred while in care at the facility.

report continued on 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Karyn Guerra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
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-20211011093941
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: SMALLVILLE PRESCHOOL
FACILITY NUMBER: 343614029
VISIT DATE: 12/15/2021
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
The allegation is unsubstantiated. Although the alleged violation may have happened or is valid, there is not a preponderance of evidence to fully prove or disprove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and a notice of site visit provided. Notice of site visit shall remain posted for a period of 30 days.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Karyn Guerra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2