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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075600400
Report Date: 10/08/2025
Date Signed: 10/08/2025 12:33:16 PM

Substantiated


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
06/27/2025 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250627165103
FACILITY NAME:DELL'S RESIDENTIAL HOMEFACILITY NUMBER:
075600400
ADMINISTRATOR:WILLIAMS, SARENAFACILITY TYPE:
735
ADDRESS:4444 BELLE DRIVETELEPHONE:
(925) 978-0345
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:4CENSUS: 4DATE:
10/08/2025
UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Ricky Hazan, DireTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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Licensee is operating beyond the scope of license

Staff are not providing adequate supervision to residents in care.
INVESTIGATION FINDINGS:
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On 10/08/2025, at 11:25am,, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver a complaint finding for the allegations above. LPA met with Ricky Hazan, Direct Support Staff, and explained the reason for the visit.

During the course of the investigation the Department conducted interviews with staff, witnesses, obtained and reviewed records.

Allegation: Licensee is operating beyond the scope of license.

During the investigation W1 stated the facility was operating beyond the

Continued on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20250627165103
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: DELL'S RESIDENTIAL HOME
FACILITY NUMBER: 075600400
VISIT DATE: 10/08/2025
NARRATIVE
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Continued from LIC9099.

scope of license by having an additional client present at the facility. The facility is licensed for four (4) ambulatory clients only. W1 stated that S2 stated the client was visiting from the other facility and participating in the day program at this facility. Based on interview with W2 the facility is receiving funding for two (2) clients, which lives at the facility, for participating in the day program.
Allegation: Staff are not providing adequate supervision to residents in care.

W1 stated during the interview that S3 was asleep in the garage, not providing adequate supervision to the two (2) clients that were present. The other two (2) clients were upstairs with S4, and there was one (1) client resting in one of the bedrooms. W1 stated when leaving S3 was observed to be sleeping again. S1 stated a conversation was had with S3, and S3 admitted being asleep and it would not happen again.

Based on interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. A copy of the appeal rights and this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250627165103
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: DELL'S RESIDENTIAL HOME
FACILITY NUMBER: 075600400
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/09/2025
Section Cited
CCR
80010(a)
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(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation.
This requirement was not met as evidence by:
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Administrator agreed to submit a self-certification to not operate beyond the conditions and limitations specified on the license going forward.
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Based on observation and record review the Licensee did not comply with the section above by having more clients present that what facility is licensed for, which poses a potential safety risk for persons in care.
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Type B
10/15/2025
Section Cited
CCR
80078(a)
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(a) The licensee shall provide care and supervision as necessary to meet the client's needs.
This requirement was not met as evidence by:
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Administrator agreed to submit a written plan on how in the future the facility will prevent staff form sleeping while providing supervision to the clients and submit plan along with an activity calendar for the facility and the day program to CCLD by POC date.
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Based on observation the Licensee did not comply with the section cited above in providing care for clients which poses a potential health and safety risk to persons in care.
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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: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3