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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 343614029
Report Date: 11/08/2022
Date Signed: 11/08/2022 02:02:25 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
09/26/2022 and conducted by Evaluator Karyn Guerra
PUBLIC
COMPLAINT CONTROL NUMBER: 03-CC-20220926104550
FACILITY NAME:SMALLVILLE PRESCHOOLFACILITY NUMBER:
343614029
ADMINISTRATOR:NULL SHANNONFACILITY TYPE:
850
ADDRESS:4706 ARDEN WAYTELEPHONE:
(916) 480-0632
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:48CENSUS: 23DATE:
11/08/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Shannon NullTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Licensee is providing an unsafe play area for children.

Staff do not provide information regarding incidents to the child's authorized person
INVESTIGATION FINDINGS:
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At 10:45 a.m. on Tuesday, November 8th, 2022, Licensing Program Analysts (LPAs) Karyn Guerra and Soleil Marx met with Licensee, Shannon Null, for the purpose of an unannounced complaint inspection and to deliver findings. It was alleged that Licensee is providing unsafe play area for children and that staff do not provide information regarding incidents to the child's authorized person. There was a concern that a child sustained an unreported injury under the slide area. Throughout the course of the investigation, LPA conducted interviews and made observations. Staff interviews stated that teachers are assigned stations during outdoor play to ensure supervision of children. The door under the slide play structure is left open to allow for better visual supervision. LPA did not observe any supervision concerns during observations. Parent interviews did not reveal any supervision or communication concerns. Licensee stated that a staff meeting was conducted to address outdoor supervision. LPA came to learn that typical injury reporting

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

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
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-20220926104550
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: 11/08/2022
NARRATIVE
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process is to notify parents via phone call or written injury report. The allegations are unsubstantiated. Although the alleged violations may have happened or are valid, the preponderance of evidence standard was not met to fully prove or disprove they did or did not occur, therefore they are unsubstantiated. An exit interview was conducted and a notice of site visit provided. Notice of site visit shall remain posted for 30 days.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Karyn Guerra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2