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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 485407185
Report Date: 04/11/2024
Date Signed: 04/11/2024 10:23:51 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/18/2024 and conducted by Evaluator Melchisedeck Augustin
PUBLIC
COMPLAINT CONTROL NUMBER: 01-CC-20240118125711
FACILITY NAME:LITTLE FLOWERS MONTESSORIFACILITY NUMBER:
485407185
ADMINISTRATOR:GUILATCO, ANTOINETTEFACILITY TYPE:
850
ADDRESS:3561 ALAMO DRIVETELEPHONE:
(707) 474-8715
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:120CENSUS: 65DATE:
04/11/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jaclyn Smith - Center DirectorTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Facility did not meet reporting requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Melchisedeck Augustin made an unannounced complaint-investigation visit and met with Center Director (CD), Jaclyn Smith, for the purpose of delivering finding for the above allegation. LPA previously met with CD on 01/22/24 to initiate the investigation by discussing the purpose of the visit, conducting an interview with CD, staff, and children; and requested a facility roster of the children in care. It is alleged that the facility did not meet reporting requirements. The report noted the facility did not notify the Department of incidents involving a child (C1) sustaining a black eye and hitting a tooth, and the child’s ear was split in three places.

LPA interviewed CD, four staff (S1-S4), five children (C1-C3 & C7-C8), six parents (P1-P6), and one adult (A1), starting on 01/22/24 through 03/25/24. Some children were not verbal, too young to interview, or did not qualify to be interviewed. (Continue to LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
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 01-CC-20240118125711
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: LITTLE FLOWERS MONTESSORI
FACILITY NUMBER: 485407185
VISIT DATE: 04/11/2024
NARRATIVE
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CD denied claims about not meeting reporting requirements and stated she notified parent(s) and Department of unusual incidents including injury to C1’s left ear. CD stated she did not have any knowledge of C1 sustaining a black eye and hitting a tooth, and that incident did not occur during her tenure at the facility.

S1-S4 and children either witnessed, were aware of, or acknowledged the injury to C1’s left ear, however; they did not report any concerns related to the facility not meeting reporting requirements. Another staff notified S3 of the injury to C1’s tooth but S3 did not witness the incident and did not provide any further details. Staff stated they were uncertain if the facility notified the Department of the incidents but confirmed the facility notified C1’s guardian(s) of the incident involving injury to C1’s ear. According to staff, if/when an incident occurred, the staff that witnessed the incident was required to produce a written ouch report which was forwarded to CD for review and signature, and CD would then provide the classroom with a copy of the signed report for staff to place in the child’s file for parents to retrieve.

Statements provided by P1-P6 & A1 noted the facility notified them of all incidents involving their child(ren) either verbally or via telephone, and parents confirmed they also received a written ouch report which provided further notification of the incident(s). C1’s guardian described during C1’s first day in care, she was notified of an incident where C1 was playing on the playground, C1 hit his face on a playground structure which resulted in C1 sustaining a black eye which required medical treatment. Although C1’s guardian was notified of the incident, a review of Department records indicated the facility did not notify the Department of the injury to C1’s eye, and the facility violated California Code of Regulations (CCR) 101212(d)(1)(B) which required the facility to notify the Department of any injury to any child that requires medical treatment.

Based on LPA’s investigation, 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, Article 06, is being cited on the attached LIC 9099D. Exit Interview conducted and report was discussed and reviewed with Center Director, Jaclyn Smith. Notice of Site Visit shall be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 01-CC-20240118125711
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: LITTLE FLOWERS MONTESSORI
FACILITY NUMBER: 485407185
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/18/2024
Section Cited
CCR
101212(d)(1)(B)
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Events reported shall include the following: Any injury to any child that requires medical treatment.

This requirement was not met as evidenced by: Based on a review of Department records which confirmed the facility did not notify the Department of C1's injury which required
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Center Director stated she would produce a written statement detailing how she intends to comply with CCR 101212(d)(1)(B), and the Director intends to submit the facility's POC to the Department by 04/18/24 via mail, email or fax.
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medical treatment. This poses a potential health, safety and/or personal rights risk to the children in care.
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Email: melchisedeck.augustin@dss.ca.gov
Fax: 707-588-5026

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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: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC9099 (FAS) - (06/04)
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