Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198018831
Report Date: 05/11/2017
Date Signed 05/11/2017 12:34:43 PM


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/16/2017 and conducted by Evaluator Seung Lee
COMPLAINT CONTROL NUMBER: 33-CC-20170316111511
FACILITY NAME:PINE TREE PRESCHOOLFACILITY NUMBER:
198018831
ADMINISTRATOR:ANGIE GOMEZFACILITY TYPE:
850
ADDRESS:311 S. NORMANDIE AVE.TELEPHONE:
(213) 365-0909
CITY:LOS ANGELESSTATE: CAZIP CODE:
90020
CAPACITY:63CENSUS: 36DATE:
05/11/2017
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Angie Gomez TIME COMPLETED:
12:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff interacted with children in a physically inappropriate manner
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Seung Lee conducted an unannounced complaint inspection. Upon arrival LPA Lee met with Director Angie Gomez who guided the analyst on a tour of the facility.

During the course of the investigation, LPA Lee interviewed the Director and staff members of the facility. LPA Lee also interviewed several children and parents receiving services from the facility. It was disclosed that a staff member was terminated on October of 2016. The termination was triggered by a child's grand parent requesting a camera recording of the teacher in the toddler classroom. After the footage was reviewed it was determined by the facility that the teacher's behavior was not consistent with the school's policies and standards in regards to providing safe and appropriate care for the children.

The Director disclosed that the termination of the teacher and the incident that triggered these events were not reported because the Director called the department complaint hotline and was advised that the the incident should be documented for internal records. The Director stated that she believed she was following
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra CooperTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Seung LeeTELEPHONE: (323) 981-3381
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2017
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 33-CC-20170316111511
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: PINE TREE PRESCHOOL
FACILITY NUMBER: 198018831
VISIT DATE: 05/11/2017
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
appropriate protocol since she did contact the department and followed the advise given. LPA Lee informed the Director that in the future incidents should be reported to the regional office directly rather than the complaint hotline. The Director stated that she was not aware that a direct call is supposed to be made to the office, and believed at the time she was satisfying reporting requirements since she did call the complaint hotline.

LPA Lee was not able to review the video footage upon request, because the incident happened too long ago and recording from the camera's are only stored for a few months befre being deleted.

Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of the evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 12 & Chapter 3 (FCC) (1 DCC) number) are being cited on the attached LIC9099D.

A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement form must be maintained in each child’s file immediately upon receipt from parent. Licensee was provided with a copy of the parent Acknowledgement of Receipt of Licensing Reports Form during this visit. A copy of the Parent Notification Requirements was also provided to the licensee.



The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00. Exit interview was conducted with Angie Gomez, Director, including, but not limited to Provider Rights, Appeal Procedures


SUPERVISOR'S NAME: Cassandra CooperTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Seung LeeTELEPHONE: (323) 981-3381
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2017
LIC9099 (FAS) - (06/04)
Page: 2 of 3


Control Number 33-CC-20170316111511

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: PINE TREE PRESCHOOL
FACILITY NUMBER: 198018831
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/11/2017
Section Cited
101223(a)(3)
1
2
3
4
5
6
7
Personal Rights.

Each child shall be free from corporal or unusual punishment, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature.It was determined that a staff member in the toddler
1
2
3
4
5
6
7
Director stated that the staff was already given additionial training on child abuse, mandated reporting, and dealing with children with challenging behaviors. Director stated that there was a staff meeting on appropriate documentation of incidents and when and where to make these reports.
8
9
10
11
12
13
14
classroom was behaving inappropriately with the children. The staff member was terminated for her conduct on October of 2016. This is an immediate risk to children in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Cassandra CooperTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Seung LeeTELEPHONE: (323) 981-3381
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2017
LIC9099 (FAS) - (06/04)
Page: 3 of 3