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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 073405692
Report Date: 12/21/2023
Date Signed: 02/01/2024 02:09:32 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/19/2023 and conducted by Evaluator Ashley Akinleye
PUBLIC
COMPLAINT CONTROL NUMBER: 02-CC-20231219095415
FACILITY NAME:SRVSACCA-CREEKSIDEFACILITY NUMBER:
073405692
ADMINISTRATOR:SAMS, DANIFACILITY TYPE:
840
ADDRESS:6055 MASSARA STTELEPHONE:
(925) 743-3170
CITY:DANVILLESTATE: CAZIP CODE:
94506
CAPACITY:188CENSUS: 0DATE:
12/21/2023
UNANNOUNCEDTIME BEGAN:
12:39 PM
MET WITH:Ian GarciaTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Personal rights
INVESTIGATION FINDINGS:
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On 2/1/24 at 10:50 pm Licensing Program Analyst (LPA) Ashley Akinleye arrived at Creekside Elementary: SRVSACCA-CREEKSIDE to further conduct a complaint investigation and provide an amended report for last visit. LPA met with Site DIrector Ian Garcia. During the visit LPA observed children in their classrooms, conducted multiple inteviews with staff and children.

Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, 101223), are being cited on the attached LIC 9099D.”) Exit interview conducted with Ian Garcia.Report provided to Ian Garcia. Appeal rights provided to Ian Garcia.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Ashley Akinleye
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
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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Control Number 02-CC-20231219095415
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: SRVSACCA-CREEKSIDE
FACILITY NUMBER: 073405692
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/15/2024
Section Cited
CCR
101223(a)(3)
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 (3) 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 functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
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Facility will require that all staff participate in personal rights training. Staff will watch personal rights video on CDSS webpage and answer subsequent questions about what they learned. Site Director will submit proof of completion to LPA by POC due date.
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Based upon interviews atleast one teacher is observed to be out of compliance of this regulation.
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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: Loretta Dyson
LICENSING EVALUATOR NAME: Ashley Akinleye
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
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