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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 566215193
Report Date: 06/28/2023
Date Signed: 06/28/2023 06:48:22 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/26/2023 and conducted by Evaluator Elvin Baddley
COMPLAINT CONTROL NUMBER: 17-CC-20230626083052
FACILITY NAME:SHEA FAMILY CHILD CAREFACILITY NUMBER:
566215193
ADMINISTRATOR:ANA VICTORIA SHEAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 300-7432
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:14CENSUS: 3DATE:
06/28/2023
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Patricia Estacio JimenezTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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1. Uncleared adult providing care to day care children
INVESTIGATION FINDINGS:
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On 6/28/23, at 4:30 PM, Licensing Program Analysts (LPA) Elvin Baddley and Giovani Gonzalez made an unannounced inspection to the aforementioned Family Child Care Home (FCCH) in order to initiate and complete the investigation of the above allegation. LPAs met with Patricia Estacio Jimenez, Assistant of the FCCH and explained the nature of the inspection. LPAs notes 3 children are on site at the time of the inspection along with another Assistant (cleared and associated).

The investigation included record reviews, interviews of the Assistant, A1 and A2. The allegation of the complaint referenced the FCCH having and an uncleared adult providing care to day care children.

The allegation was corroborated, as A1, a tenant of the residence, reported A2 was providing care for two children (biological children of A1) at the residence. Additionally, A2 informed LPAs A2 has cared for two children at the residence since June 7, 2023, which corresponds to the end of the school year.
(CONT. 9099-C, Page 2)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Elvin Baddley
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023
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 17-CC-20230626083052
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: SHEA FAMILY CHILD CARE
FACILITY NUMBER: 566215193
VISIT DATE: 06/28/2023
NARRATIVE
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 A review of the LIS revealed A2 is not associated with the FCCH or criminally cleared. It should be noted LPA Gonzalez provided translation to and for A2 who is primarily Spanish speaking.

Today, a Type A deficiency is cited under Title 22 Division 12 and Appeal rights are given. Upon receipt of this report, licensee shall post and provide copies of this licensing report to parents/guardian of children in care at the facility and to parent/guardians of children newly enrolled at the facility during the next 12 months. Licensee to provide Acknowledgment of Receipt of Licensing Report (LIC 9224) for each child in care and have each parent sign the form that they have received a copy of the report (LIC 9099, LIC 9099-C and and LIC 9099-D)..

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Facility representative Patricia Estacio Jimenez.

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Elvin Baddley
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 17-CC-20230626083052
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: SHEA FAMILY CHILD CARE
FACILITY NUMBER: 566215193
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/29/2023
Section Cited
CCR
102370(d)(1)
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Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption....
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A2 must obatin get a criminal record clearance and submit all documents to the Community Care Licensing (CCL) by 6/29/2023.

A $500 civil penalty was assessed
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This requirement is not met as evidence by: Based on LPAs' interviews and observations A2, an uncleared adult, has been providing care for two children at FCCH's residence since 6/7/23. This pose 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: Maria Mueller
LICENSING EVALUATOR NAME: Elvin Baddley
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3