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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434406583
Report Date: 04/18/2022
Date Signed: 04/18/2022 12:06:57 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/22/2021 and conducted by Evaluator Susy Cervantes
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20211122165049
FACILITY NAME:CARRENO, ROSAFACILITY NUMBER:
434406583
ADMINISTRATOR:CARRENO, ROSAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 259-5536
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:14CENSUS: 0DATE:
04/18/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Rosa CarrenoTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Sexual Abuse
INVESTIGATION FINDINGS:
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On 04/18/2022 at 11:00 AM, Licensing Program Analyst (LPA) Susy Cervantes met with licensee, Rosa Carreno to deliver complain findings and explained the reason for the visit to them. Present were licensee, their spouse, two son and daughter.

Based on observations, record review(s), and interviews which were conducted by this agency, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Type A deficiency is being cited today. LPA Cervantes informed licensee, Rosa Carreno, that this report dated 04/18/2022 documents one 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 the children in care. Also, LPA Cervantes informed the licensee, Rosa Carreno, to provide a copy of this licensing report dated 04/18/2022 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.

Exit interview conducted and report was reviewed with licensee, Rosa Carreno. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022
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 2
Citations on this Visit Report are Under Appeal!

Control Number 07-CC-20211122165049
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: CARRENO, ROSA
FACILITY NUMBER: 434406583
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
04/19/2022
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 by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including, but not limited to: interference with eating, sleeping or toileting; or withholding shelter, clothing, medication or aids to physical functioning.
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Licensee shall provide adequate supervision to all children in care and ensure that their personal rights are not violated. Licensee shall submit a statement on how she will ensure adequate supervision moving forward.
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This requirement was not met as evidence by:
Based on record review, interviews, and observations conducted, this agency has found an adult at the facility has engaged in inappropriate behavior which poses an immediate risk to the health, safety, and personal rights of the children 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: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2