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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 343624830
Report Date: 11/13/2024
Date Signed: 11/13/2024 03:12:33 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
09/30/2024 and conducted by Evaluator Erwina Pascual-Golamco
PUBLIC
COMPLAINT CONTROL NUMBER: 03-CC-20240930144009
FACILITY NAME:BUILDING KIDZ RANCHO CORDOVAFACILITY NUMBER:
343624830
ADMINISTRATOR:LAW, DANIELLEFACILITY TYPE:
830
ADDRESS:1945 ZINFANDEL DRIVETELEPHONE:
(916) 706-2653
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY:15CENSUS: 0DATE:
11/13/2024
ANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mercy IshidaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Type A licensing report not provided to parents/authorized representatives for citation date 03/20/24.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Erwina Pascual-Golamco (LPA) and Licensing Program Manager Natalie Dunaway (LPM) met with Licensee Mercy Ishida to deliver findings of the above allegation.

Throughout the course of the investigation, LPA toured the facility, observed staff provide care to children, reviewed files, and conducted interview. It was alleged that Type A licensing report not provided to parents/authorized representatives for citation date 03/20/24. LPA reviewed sample of children's files on 10/09/24 visit. 6 out of 6 sample files, did not have signed LIC9224 for citation date 03/20/24 for verification. LPA's record review corroborated the allegation Type A licensing report not provided to parents/authorized representatives for citation date 03/20/24 . The preponderance of evidence standard has been met, and the allegation is SUBSTANTIATED. Continued on LIC9099-C...

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
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 3
Control Number 03-CC-20240930144009
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: BUILDING KIDZ RANCHO CORDOVA
FACILITY NUMBER: 343624830
VISIT DATE: 11/13/2024
NARRATIVE
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A Tittle 22 deficiency was cited today. This report was reviewed with Licensee, and an exit interview was conducted. Appeal Rights was provided to Licensee, who will post it for a period of 30 days for parental review.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 03-CC-20240930144009
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: BUILDING KIDZ RANCHO CORDOVA
FACILITY NUMBER: 343624830
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/27/2024
Section Cited
HSC
1596.8595(4)
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ยง1596.8595 Posting licensing report by child care facility or home; duration of posting; civil penalty for failure to comply; reports to be provided to parents or guardian of each child receiving services (4) The licensee shall keep verification of receipt in each child's file.
This requirement is not met as evidenced by:
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Licensee stated she will provide the LIC9224 reports to parents/authorized representatives by 4PM POC due date, and will email LPA attestation statement that it is complete.
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based on record review, Licensee (L) did not comply with the section cited above, LPA reviewed sample of children's files on 10/09/24 visit. 6 out of 6 sample files, did not have signed LIC9224 for citation date 03/20/24 for verification, which poses a potential health, safety, or personal rights risk to persons in care.
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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: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3