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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 543908775
Report Date: 11/10/2022
Date Signed: 11/14/2022 10:38:46 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2022 and conducted by Evaluator Theresa Marquez
PUBLIC
COMPLAINT CONTROL NUMBER: 57-CC-20220819124122
FACILITY NAME:JOHNSON, KYMBERLY FAMILY CHILD CAREFACILITY NUMBER:
543908775
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:0CENSUS: 0DATE:
11/10/2022
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Karen CostaTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Day care child sustained an unexplained mark while in care.

Provider did not meet the day care child's needs.

Provider did not ensure day care child is fed.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/10/2022, Licensing Program Analyst (LPA) Theresa Marquez provided complaint findings to Karen Costa, a relative of licensee Kymberly Johnson. The Kymberly Johnson Family Child Care home closed effective 5/18/2022.
Multiple attempts to reach Johnson regarding this complaint failed, therefore, LPA Marquez met with Costa at Costa's residence . Costa contacted Johnson via telephone and LPA Marquez spoke with Johnson and advised her of the unsubstantiated complaint findings for the 3 listed allegations.
During the course of the investigation, LPA conducted interviews and record review. There is insufficient evidence to determine if day-care child sustained an unexplained mark while in care, if day care child's needs were not met or if day care child was not fed. Although the allegations may have happened or are valid, there is not a preponderance of the evidence that violations occurred; therefore, the allegations are unsubstantiated.
Per California Code of Regulations, Title 22, Division 12, Chapter 3, no deficiencies were cited on this report. This report was reviewed with the licensee Kymberly Johnson via FaceTime. Johnson authorized Karen Costa to sign this document. A copy of this report and Licensee's Appeal Rights were emailed to Karen Costa and emailed to licensee Kymberly Johnson. A copy of this report was also US mailed to Karen Costa.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Luisa Gavoutian
LICENSING EVALUATOR NAME: Theresa Marquez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
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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