Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 503909382
Report Date: 09/14/2016
Date Signed 09/14/2016 12:24:40 PM


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 E.SHAW AV,STE 300-MS 29-01
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/09/2016 and conducted by Evaluator Claudia Henley
PUBLIC
COMPLAINT CONTROL NUMBER: 04-CC-20160609152305
FACILITY NAME:HINTON, VERA FAMILY CHILD CAREFACILITY NUMBER:
503909382
ADMINISTRATOR:HINTON, VERAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 284-7440
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:14CENSUS: 2DATE:
09/14/2016
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Vera HintonTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Licensee failed to report an incident that occurred on or about May 23, 2016.
INVESTIGATION FINDINGS:
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LPA Claudia Henley conducted a complaint visit today. I was met by licensee Ms. Hinton. There were two children present. LPA Henley interviewed with Ms. Hinton regarding incident reporting to the department and supplied her with the required licensing form (LIC 624B) - "Unusual Incident Reporting-FCCH" during today's visit. Ms. Hinton stated she did not know this was reportable and failed to fill out & send an incident report or call our department regarding the incident which occurred on or about May 23, 2016.

Based upon LPA's interview with licensee, the preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED.
California Code of Regulations, The following deficiencies are in violation of Title 22, Division 12 CCR, are being cited on the attached LIC 9099D. Appeal Rights left with Ms. Hinton.

Site visit notice was posted. Exit interview was conducted.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Valarie ReedTELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Claudia HenleyTELEPHONE: (559) 341-5776
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2016
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 04-CC-20160609152305

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 E.SHAW AV,STE 300-MS 29-01
FRESNO, CA 93710
FACILITY NAME: HINTON, VERA FAMILY CHILD CARE
FACILITY NUMBER: 503909382
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/21/2016
Section Cited
102416.2(b)
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102416.2(b) Reporting Requirements. The licensee shall report to the Department
any of the events as specified in Health and Safety Code Section 1597.467(b)(1)(A)
through (b)(1)(C) that occur during the operation of the family child care home. Licensee failed to submit an incident report (LIC 924B) to the department regarding an incident which
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Licensee was given the LIC 924B to fill out and submit to the department. Licensee to send the form to the department by 9/21/16.
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occured at the facility on or around May 23, 2016
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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.
SUPERVISOR'S NAME: Valarie ReedTELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Claudia HenleyTELEPHONE: (559) 341-5776
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2016
LIC9099 (FAS) - (06/04)
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