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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 343622008
Report Date: 11/07/2023
Date Signed: 11/07/2023 03:02:11 PM

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
10/31/2023 and conducted by Evaluator Jennifer Velasco
COMPLAINT CONTROL NUMBER: 03-CC-20231031101453
FACILITY NAME:ICONIC KIDS CHILDCARE & LEARNING CENTERFACILITY NUMBER:
343622008
ADMINISTRATOR:THOMPSON, IONAFACILITY TYPE:
850
ADDRESS:6035 MAIN AVENUETELEPHONE:
(916) 542-7196
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:47CENSUS: 14DATE:
11/07/2023
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Iona ThompsonTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Child was injured, due to lack of supervision
Facility failed to report incidents as required
INVESTIGATION FINDINGS:
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On 11/07/2023, Licensing Program Analyst (LPA) Jennifer Velasco met with Facility Representative, Director Iona Thompson (Director), for the purpose of investigating and delivering findings to a complaint investigation alleging that a child was injured due to lack of supervision, and the facility failed to report incidents as required. During the investigation, LPA observed care, obtained and reviewed relevant facility documentation, and conducted interviews. Based on witness statement, and/or record review, a child (Child1) sustained a dislocated elbow while being handled by staff and, in a separate incident, suffered injuries due to a fall off of a toy. When Child1 fell off the toy, staff was nearby but failed to ensure Child1 got off the toy safely. Neither incident was reported to the Department by the facility, and in each incident, Child1 required emergency medical assessment and care. The preponderance of evidence standard has been met, therefore the above allegations are SUBSTANTIATED. Director was informed that this report dated 11/07/2023 documents two deficiency citations on the LIC 9099-D. Exit interview was conducted and a copy of this report was given to Director Iona Thompson. Notice of site was given and must remain posted for parental review for 30 days. Appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Jennifer Velasco
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 03-CC-20231031101453
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: ICONIC KIDS CHILDCARE & LEARNING CENTER
FACILITY NUMBER: 343622008
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/30/2023
Section Cited
CCR
101229(a)(1)
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The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time ... Supervision shall include visual observation. This requirement was not met,
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Director stated they will provide all staff with training on supervision, with a focus on preventing injuries to children in care. Director stated they will email to LPA on or before POC due date the training materials and the staff sign-in sheet.
LPA email: jennifer.velasco@dss.ca.gov
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as evidenced by: Based on witness statements and photographic evidence, the facility did not comply with the section cited above by failing to prevent a child sustaining an injury that required medical treatment. This is a potential risk to health, safety and or personal rights of children in care.
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Type B
11/30/2023
Section Cited
CCR
101212(d)
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Upon the occurrence... of ... events... a report shall be made to the Department... within the... next working day... In addition, a written report ... shall be submitted to the Department within seven days... This requirement was not met as evidenced by
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Director stated they will provide all staff with training on the need to report to the Department as required any incidents that include injuries that require medical assessment and/or treatment. Director stated they will create a detailed written plan to ensure the facility will meet this requirement
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Based on record review and interview, the facility did not comply with the section cited above by failing to report the incident to licensing department as required. This is considered a potential health, safety, or personal rights risk to persons in care.
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and provide to LPA on or before the POC due date the detailed written plan.
LPA email: jennifer.velasco@dss.ca.gov
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: Natalie Dunaway
LICENSING EVALUATOR NAME: Jennifer Velasco
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
LIC9099 (FAS) - (06/04)
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