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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 073405692
Report Date: 04/02/2025
Date Signed: 04/02/2025 02:30:00 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
02/25/2025 and conducted by Evaluator Arminder Singh
PUBLIC
COMPLAINT CONTROL NUMBER: 02-CC-20250225125956
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: 38DATE:
04/02/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Nicole Ward and Bridgett ElliotTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility falied to inform parent that child did not attend the facility
INVESTIGATION FINDINGS:
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On 04/02/2025, Licensing Program Analyst (LPA) Arminder Singh conducted an unannounced visit to deliver the finding of the above allegation and met with Director Nicole Ward and Assistant Director, Bridgett Elliott. LPA explained the purpose of today's visit.

It was alleged that facility failed to inform parent that child did not attend the facility. During the course of the investigation, interviews were conducted, and documents were reviewed. Based on the evidence and interviews conducted it was determined that facility failed to inform parent that child did not attend the facility, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division & Chapter Number
101229(a)(1) are being cited on the attached LIC 9099D.

LIC9224 was provided to the Director and Assistant Director. The facility shall post and/or provide copies of this licensing report to parents/guardians of children in care and to parents/guardians newly enrolled at the facility during the next 12 months. Exit interview was conducted, Appeal Rights were provided, Notice of Site Visit was provided and must be posted for 30 days.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Arminder Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
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 02-CC-20250225125956
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: 04/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/02/2025
Section Cited
HSC
101229(a)(1)
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Responsibility for Providing Care and Supervision 101229(a)(1) (zero tolerance) No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time
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Facility will provide proof that staff has been provided adequate training on what the protocol is for when a child is not at facility. Facility agrees to send proof of training no later than 04/03/2025.
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except as specified in sections 101216.2(e)(1) and 101230(c)(1).
On 02/19/2025 Facility falied to inform parent that child did not attend the facility.
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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: Mayla Mendoza
LICENSING EVALUATOR NAME: Arminder Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2