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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 414004859
Report Date: 12/05/2022
Date Signed: 12/05/2022 10:52:00 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/05/2022 and conducted by Evaluator Leslit Tapia-Mandujano
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20221005085909
FACILITY NAME:JIMENEZ, ANDREAFACILITY NUMBER:
414004859
ADMINISTRATOR:JIMENEZ, ANDREAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 454-7249
CITY:EAST PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY:14CENSUS: 4DATE:
12/05/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee, Andrea JimenezTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Provider handled daycare child in a rough manner.
INVESTIGATION FINDINGS:
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On December 5th, 2022 at approximately 9am, Licensing Program Analyst (LPA) Tapia-Mandujano conducted an unannounced inspection and met with Licensee, Andrea Jimenez. Purpose of the inspection was explained, and it was to report the investigation findings for the above allegation. Complaint was received by the Department on 10/05/22. Present in the facility are Licensee and staff caring for 4 children (3 infants and 1 preschool age). LPA and licensee inspected the facility for health and safety hazards.

During the Investigation, LPA conducted file review, interviews with involved parties, and received pertinent documentation. During the course of the investigation, LPA determined that a child was handled in a rough manner due to the eveidence that was received.

Based on LPA’s observations, interviews, record review which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 12, Chapter 1, are being cited. Please refer to 9099D for more information.


Continued on Page 2...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
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 3
Control Number 05-CC-20221005085909
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: JIMENEZ, ANDREA
FACILITY NUMBER: 414004859
VISIT DATE: 12/05/2022
NARRATIVE
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LPA Tapia-Mandujano informed licensee Andrea Jimenez that this report dated 12/05/22 documents a Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA informed the licensee Andrea Jimenez to provide a copy of this licensing report dated 12/05/22 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Upon receipt of this report, Facility shall post the Notice of Site Visit. The report and the Notice of Site Visit shall be posted for 30 consecutive days. Failure to maintain postings as required, will result in an immediate $100 civil penalty. This report is public and can be reviewed.

After today’s visit, an exit interview was conducted with Licensee, Andrea Jimenez. A copy of this report was reviewed and provided to licensee.
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 05-CC-20221005085909
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: JIMENEZ, ANDREA
FACILITY NUMBER: 414004859
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/05/2022
Section Cited
CCR
102423(a)(4)
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102423(a)(4): Personal Rights: Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged...These rights include, but are not limited to the following:..To be free from corporal or unusual punishment, infliction of pain... or other actions of a punitive nature...

This requirement is not me by:
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LPA reviewed the Personal Rights regulations with licensee.

An informail office meeting will be scheduled to discuss the deficiencies.
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Based on observation, the licensee did not comply with the section cited above as a child was handeled in a rough manner while in care, which poses an immediate 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: Cindy Interiano
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
LIC9099 (FAS) - (06/04)
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