Incident investigation·December 16, 2021

Page 1 of 2 On 12/16/21 Licensing Program Analyst (LPA) Mahnaz (Nancy) Malek conducted a case management of the facility for an incident which was self reported by the facility representative to our office on 12/14/21. The Covid-19 Emergency Response questionnaire was answered by Justin Pukasamsombut who was supervising 4 school age children in room # 1. The 5th school age child arrived during the inspection. A review of staff records on this date indicated that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions. According to the facility self report, it states it was observed by a witness that 4 children were left unattended in room # 1 while staff #1 was in the other room on 12/13/21. Today LPA discussed the incident with the program Director (Mariana Bosch) over the phone, interviewed one staff, and 5 present children. Staff # 1 mentioned in the incident was not present. Based on the information obtained through the witness of the incident, 3 staff, and 4 children out of 5 present children today, there are enough evidence that staff # 1 was left 4 children unattended in room # 1 while being in room # 2. However the length of the time of absence of supervision is unknown. According to interviews the duration of absence might have happened couple of minutes. Room # 1 and Room # 2 are connected. There is an slight open entrance between them. Therefore there was no visual observation of children from room to room except for the slight entrance. It was confirmed by interviews that staff # 1 was not able to see the children when the incident happened. Based on the information obtained, it was found out the absence of supervision has occurred for 4 school age children on 12/13/21 while staff # 1 was in room # 2. Continued on page 2 Page 2 of 2 Section 101229 (a)(1 Responsibility for Providing Care and Supervision was cited on LIC 809D. Upon receipt of Type A violations, the licensee shall post and provide copies of the report to parents/guardians of the children in care at the facility, and to the parents/guardians of children newly enrolled at the facility during the next 12 months. The licensee is to keep Acknowledgement Receipt (LIC 9224) signed by parents in each child\342\200\231s file. The Notice of Site Visit was posted. Facility representative was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. Exit interview was conducted. End of report