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     Department of Children and Family Services

     Policy and Procedure Guide

Division No: 3 Child Welfare

    Chapter No: 9 Licensing

    Item No: 1 Licensing Complaint Process


     Effective Date: 2/27/2004

POLICY: The Fresno County licensing unit within the Department of Children

    and Family Services will investigate all complaints received regarding

    licensed Fresno County foster family homes.

PURPOSE: To establish processes that assure that all complaints received

    about County foster family homes are investigated and resolved

    in an appropriate and timely manner.

REFERENCE: Community Care Licensing Division (CCLD) Evaluators Manual

DEFINITIONS: Forms referenced in this PPG are:

    LIC 802 Complaint Report

    LIC 809 Facility Evaluation Report

    LIC 812 Detail Supportive Information

    LIC 856 Complaint Response

    LIC 957 Complaint Control Log

    LIC 9099 Complaint Investigation Report


I. Accepting Complaints

    A. Complaints may be received by telephone, letter or in person.

    B. The complaint recipient must assure the complainant that the reporting

    party (RP) identity will remain confidential unless the RP chooses to

    waive this right. This protection also applies to organizations. The

    complaint recipient must advise the RP that he/she can receive the

    results of an investigation by providing a name and phone number, and

    may request a copy of the LIC9099, as long as it is not "unfounded”. If

    it is marked "unfounded”, the document becomes confidential.

     Page 1of 6

Division No: 3 Child Welfare

    Chapter No: 9 Licensing

    Item No: 1 Licensing Complaint Process


     Effective Date: 2/27/2004

    C. The Complaint Response (LIC856) must be completed and page one

    mailed to the RP for complaints, which are received, by mail. When

    the complaint is received by telephone or in person, the complaint

    recipient must advise the RP that he/she will be notified of the findings.

    If it is not possible to make phone contact, page 2 of the LIC856 can

    be mailed. LIC856 is a confidential document. II. Recording the Complaint

    The responding evaluator must:

    A. Use a Complaint Form (LIC802). The LIC802 is a confidential

    document. It must state who, what, when, where, why, and how. If

    the complaint is received by mail, attach it to the LIC 802.

    B. Provide the basic allegations of the complaint in the summary.

    C. Not write a complaint unless a licensing violation is alleged.

    D. Obtain as much information as possible: dates, times, names,

    locations, etc.

    D. Use the front of the LIC802 for a brief description of the specific

    allegation. Document on the back additional pertinent information in

    the top section called “Details of Allegations”. If more space is needed,

    use form LIC812.

III. Establishing Controls

    Visits involving any death of a child must be made within two business days.

    All other investigation visits must be made within 10 calendar days of receipt

    of the complaint. The visit may be delayed beyond 10 days only with the

    approval of an authorized supervisor.

IV. Planning the Investigation

    A. Upon receipt of the complaint, the evaluator identifies the extent of the

    problem and the relevant laws and regulations.

    B. As part of the initial planning the evaluator reviews the file for past

    complaints, deficiencies previously cited, compliance conferences

    already conducted and/or any conditions of probation.

    C. Before the visit, the evaluator collects as much information regarding

    the allegation as possible. This information may be from documents or

    contacts with others with knowledge of the issues. The evaluator is not,

    however, to delay the 10-day or expedited visit (if one is needed), while

    waiting for additional information if it can be collected later.

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Division No: 3 Child Welfare

    Chapter No: 9 Licensing

    Item No: 1 Licensing Complaint Process


     Effective Date: 2/27/2004

    D. The evaluator determines if other agencies may have jurisdiction as

    well and contacts them to discuss the allegations if appropriate.

    E. If the police are also investigating, the evaluator contacts them before

    making the visit. Law enforcement has the authority to delay a 10-day

    visit if it appears that licensing contact will interfere with legal


    E. If moreinformation is needed from the RP, the evaluator documents

    that need in the Pre-Investigation Contact section on the back of the

    LIC802. If more room is needed, the evaluator uses form LIC812.

    F. Complaints are not investigated if the motivation is harassment. Even

    if the motive is harassment, the evaluator should complete a LIC802

    and route it to the supervisor who determines whether a visit needs to

    be made.

V. Entrance Interview

    A. Complaint visits are always unannounced.

    B. Before entering, evaluators must identify themselves.

    C. Once inside, evaluators should explain the purpose of the visit. With

    the exception of allegations of abuse, all other specific allegations are

    to be shared with the caregiver before departing from the initial visit.

    Details however are not required at this stage and can be discussed at

    the conclusion of the investigation.

    D. Evaluators should explain that the law requires that all complaints be

    investigated, and briefly outline what will be done while in the home

    and that before leaving, findings, if available will be discussed and if

    deficiencies are found, they will be described on the Licensing Report.

VI. Documenting the Investigation

    A. The official form for documenting a complaint is the Complaint

    Investigation Report (LIC9099).

    B. With exception of “unfounded” complaints, the LIC9099 is a public

    record and shall not contain names of children.

    C. The evaluator completes the LIC 9099 after the home inspection, the

    home, records review, and interviews, and prior to departing. In

    special circumstances, it may be necessary to leave, write the LIC9099

    and return to present it and obtain a Plan of Correction (POC).

    D. Except where the complaint is determined as unfounded, the evaluator

    must not mail the LIC9099 to the caregiver in lieu of a return visit.

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    Division No: 3 Child Welfare

    Chapter No: 9 Licensing

    Item No: 1 Licensing Complaint Process


     Effective Date: 2/27/2004

E. The LIC9099 includes identification of who conducted the investigation,

    the purpose of the visit, which was contacted at the home, followed by

    the complaint allegation and a summary of the investigation findings.

    The investigative findings should be specific to the allegations, and as

    concise and brief as possible. The report must conclude with a finding:

    Substantiated, Inconclusive, or Unfounded.

    F. Deficiencies are to be cited on a separate LIC809. G. Substantiated The allegation is valid because the preponderance of

    the evidence (POTE) standard has been met. LIC 9099 with

    substantiated findings and the LIC 809s attached to them are public

    documents. Per the Evaluator’s Manual Section 3-2603, POTE means

    that 51% of the evidence supports a substantiated finding that the

    violation occurred. Put another way, POTE means the body of

    evidence has more convincing force than the evidence opposed to it,

    i.e. a review of all the evidence reveals that it is more likely than not

    that the violation occurred. If a complaint is substantiated the facility

    must be cited. This item is important to remember because it requires

    that the person who records the complaint on the LIC802 to document

    the allegation in such a manner that it relate specifically to a licensing


    H. Inconclusive Although the allegation may have happened or is valid,

    the preponderance does prove that the alleged violation occurred. LIC

    9099’s with an inconclusive finding is considered a public document.

    I. Unfounded The allegation is false, could not have happened and/or

    is without reasonable basis. All documentation in reference to an

    unfounded complaint is confidential information. The LIC9099 is

    designed to accommodate one allegation per form. However, the

    evaluator may document more than one allegation per form provided

    space is available and the findings are the same for each allegation (i.e.

    unfounded, substantiated, inconclusive). Also, and as an example, it is

    not appropriate to combine all buildings and grounds allegations under

    one allegation. If the complaint is for broken glass, dirty floors, and

    dirty restrooms, these allegations must be treated as separate

    allegations and could potentially result in 3 separate LIC9099’s.

    J. If an allegation requires further investigation, the LIC9099 is to be

    retained in the confidential file until a resolution is reached. If the

    finding is substantiated or inconclusive, then both LIC9099’s go in the

    public section. If the finding is unfounded, then both are maintained in

    the confidential section.

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    Division No: 3 Child Welfare Chapter No: 9 Licensing Item No: 1 Licensing Complaint Process (REPLACES: COMPLAINTS FAMILY CARE HOMES PPG 31-8-5 ISSUE DATED 1/99)

     Effective Date: 2/27/2004

    K. The evaluator should notify the caregivers in writing as soon as

    possible if the finding is either substantiated or inconclusive. For

    complaints that are unfounded, licensing staff shall notify the caregiver

    in writing within 30 days of the finding.

    L. If licensing staff feel the facts in a complaint alleging physical or sexual

    abuse require an inconclusive finding, then a California Department of

    Social Services (CDSS) Legal Consult must be completed prior to the

    inconclusive finding being delivered.

    M. In addition to the LIC9099’s and LIC809’s, the evaluator documents

    conversations, actions taken and other activity on LIC812’s. The

    evaluator also collects all available pertinent supporting documents

    such as police reports, CPS reports, medical records, etc.

VII. Exit Interview

    A. The purpose of the exit interview is to make sure that the caregiver

    clearly understands what, if anything, is expected of him/her. If there is

    a need for further investigation, the evaluator should explain that

    further evaluation and possible follow-up visits are necessary before a

    decision can made on findings. In this case, the evaluator should

    check the box on the LIC 9099 that indicates, “Needs Further

    Investigation” and give an estimate of time such as 30, 45, 60, or 90

    days. The investigation should not exceed 90 days.

    B. At minimum, the evaluator should discuss each deficiency with the

    caregiver and the evaluator should obtain a specific POC and due date.

    The POC should be written on the LIC 809 by the caregiver. If the

    caregiver refuses or is not able to write a POC, then the evaluator can

    write it and document the reason why it was completed by the


    C. If the caregiver disagrees with the application of any regulation, the

    deficiency, the POC or any finding of consequence, he/she may write

    this disagreement on the LIC809. The evaluator should then inform

    the caregiver of appeal rights and procedures.

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Division No: 3 Child Welfare

    Chapter No: 9 Licensing

    Item No: 1 Licensing Complaint Process


     Effective Date: 2/27/2004

VIII. Clearing the Complaint

    After completing the investigation, the evaluator must indicate the resolution

    code on the front of the LIC802 for each allegation, complete the remaining

    sections on the back and sign it. The LIC802, LIC9099, LIC809 (if applicable)

    and all supporting documents and evidence are forwarded to the supervisor

    for review and LIC802 sign-off. The Complaint Control Log is updated and

    the documents are filed appropriately in the case file.

Submitted by: Patti Poulsen, Program Manager Date: 2/19/04

    Approved by: Cathi Huerta, Assistant Director Date: 2/19/04

    DCFS Director: Gary D. Zomalt Date: 2/20/04

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