019200675-2-27-2025-15-AS-BFOG-DEG6D7-20250304194241

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200675
Report Date: 02/27/2025
Date Signed: 02/27/2025 03:12:00 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/07/2024 and conducted by Evaluator Kelly Nguyen

COMPLAINT CONTROL NUMBER: 15-AS-20240607151935

FACILITY NAME:	SVS PLEASANTON ADULT DAY PROGRAM		FACILITY NUMBER:	019200675
ADMINISTRATOR:	PIER, RON		FACILITY TYPE:	775
ADDRESS:	6602 OWEN DRIVE SUITE 100		TELEPHONE:	(925) 621-3902
CITY:	PLEASANTON	STATE: CA	ZIP CODE:	94588
CAPACITY:	60	CENSUS: 60	DATE:	02/27/2025
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Adrienne Phillips, Program Director		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Client has sustained multiple unexplained injuries while in care.

INVESTIGATION FINDINGS:

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On 2/27/2025 at 12:30p.m. Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced visit to deliver the findings for the above complaint allegations. LPA met with Adrienne Phillips, Program Director explained the purpose of the visit.

Allegation: Client has sustained multiple unexplained injuries while in care: Unsubstantiated

On 6/10/2024, the department conduced staff interview and attempted to interview C1, reviewed record of admission agreement, physician's report, care plan, IPP, any RCEB assessments, emergency information, and any LIC624/SIR's that occurred during August 2023 to present for C1.

Report continued on LIC9099c...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025

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 15-AS-20240607151935

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SVS PLEASANTON ADULT DAY PROGRAM	FACILITY NUMBER: 019200675
	VISIT DATE: 02/27/2025

NARRATIVE

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The complaint indicated that C1 was observed to have unidentified bruises, and that a meeting was held among the care team. The staff at C1s home reported that C1 had returned to the Adult Residential Facility exhibiting bruises. The staff at this subject facility (the Day Program) stated that C1 was observed with bruising when picked up from the residence by their staff.

On 6/21/24, the Department interviewed W1 and W2 who reiterated observing C1 return to the Adult Residential Facility with bruising and a bloody finger. The Department interviewed S1 who stated observing C1 arrive at the Day Program with bruising. S1 further stated having contacted the residence to make inquiry and that the residence staff had no information has to how the bruising happened. The Department also interviewed S2 and S3 who also stated observing C1 arrive at the Day Program with bruising, with no knowledge as to how it was sustained.

On 6/21/24 the Department attempted to interview C1 and found C1 to be non-verbal and no relevant information could be obtained.

On 6/10/24 the Department interviewed S2, S3 and S4 who stated observing bruising when C1 was picked up from the residence and was informed by residence staff that C1 arrived home with bruising and a bloody finger at 3 occasions. S2 and S4 had no direct knowledge as to where the injuries were sustained nor how they happened. S2 also stated that C1 has a history of skin picking behavior.

Report continued on LIC 9099c...

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240607151935

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SVS PLEASANTON ADULT DAY PROGRAM	FACILITY NUMBER: 019200675
	VISIT DATE: 02/27/2025

NARRATIVE

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S1 stated then C1 arrived to the program S1 noticed that C1 appear to have a bruise. Since C1 is

nonverbal S1 was instructed by C1 homes to do all communicating with them. Prior to C1 new home S1 is in close contact with C1 mom. Nothing like that happened during the time that C1 was in the program. S1 asked the home of C1 regarding the bruise on C1, C1 home reply that they do not know where the bruise comes from. S1 documented the conversation that they had regrading C1. The department interview the staff from C1 home regarding the bruise on C1. The home staff stated that they don’t know how C1 had the bruise.

The Department has investigated this complaint and based on interviews and record reviews conducted, it was not established where any observed injuries had taken place, now how they were sustained. Therefore, the above allegation is are unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview was conducted and a copy of this report was provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025

LIC9099 (FAS) - (06/04)

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