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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 573621481
Report Date: 01/31/2024
Date Signed: 01/31/2024 03:48:37 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/08/2023 and conducted by Evaluator Lauren Scott
PUBLIC
COMPLAINT CONTROL NUMBER: 53-CC-20231208110711
FACILITY NAME:HODGE, TIFFANYFACILITY NUMBER:
573621481
ADMINISTRATOR:HODGE, TIFFANYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(618) 663-0574
CITY:WOODLANDSTATE: CAZIP CODE:
95776
CAPACITY:14CENSUS: 14DATE:
01/31/2024
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Licensee, Tiffany HodgeTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Child was handled roughly while in care, resulting in injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Lauren Scott and Licensing Program Manager (LPM) Chayntel Hunter met with licensee, Tiffany Hodge to deliver the findings of the complaint investigation regarding the above allegation.

During the course of the investigation, LPA Scott conducted interviews, and obtained information pertaining to allegation. It was alleged that a child was handled roughly by licensee's husband, which resulted in an injury to the child. Through interviews, video evidence and medical documentation it was revealed the licensee's husband grabbed a child and caused bruising to the child's ear lobe.

Report continues on 9099-C.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Lauren Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
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 4
Control Number 53-CC-20231208110711
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: HODGE, TIFFANY
FACILITY NUMBER: 573621481
VISIT DATE: 01/31/2024
NARRATIVE
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Based on the interviews and documentation obtained, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Title 22 regulations are being cited on the attached 9099-D page.

An exit interview was conducted with the licensee. A notice of site visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

LPA Scott informed licensee, Tiffany Hodge, that this report dated DATE documents one Type A citation. Type A citations which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Scott also informed the licensee to provide a copy of this licensing report dated DATE that documents any Type A citations 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.
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Lauren Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 53-CC-20231208110711
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: HODGE, TIFFANY
FACILITY NUMBER: 573621481
VISIT DATE: 01/31/2024
NARRATIVE
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Based on the interviews and documentation obtained, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Title 22 regulations are being cited on the attached 9099-D page.

An exit interview was conducted with the licensee. A notice of site visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

LPA Scott informed licensee, Tiffany Hodge, that this report dated 1/31/24 documents one Type A citation. Type A citations which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Scott also informed the licensee to provide a copy of this licensing report dated 1/31/24 that documents any Type A citations 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.
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Lauren Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 53-CC-20231208110711
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HODGE, TIFFANY
FACILITY NUMBER: 573621481
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/31/2024
Section Cited
CCR
101223(a)(3)
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(a)The licensee shall ensure that each child is accorded the following personal rights:
(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation... or other actions of a punitive nature... This requirement was not met as evidenced by:
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Temporary Suspension Order (TSO) was served to Licensee on 01/31/2024

Enhanced civil penalties of $2,000 are being assessed and provided.
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Based on interviews and review of video footage and medical documentation, it was revealed that licensee's husband caused an injury to a child in care.

This poses an immediate 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: Chayntel Hunter
LICENSING EVALUATOR NAME: Lauren Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4