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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200012
Report Date: 03/14/2025
Date Signed: 03/14/2025 01:21:42 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
05/24/2024 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20240524091025
FACILITY NAME:COMMUNITY INTEGRATED SUPPORT SERVICESFACILITY NUMBER:
079200012
ADMINISTRATOR:ANGELA HAGUEFACILITY TYPE:
775
ADDRESS:1600 A STREETTELEPHONE:
(925) 777-0696
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:30CENSUS: 22DATE:
03/14/2025
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Mary Jane Mejia, Program ManagerTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Client sustained unexplained injuries due to lack of staff supervision.
INVESTIGATION FINDINGS:
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On 3/14/2025 at 12:45pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegation above. LPA met with Mary Jane Mejia, Program Manager and explained the reason for the visit.

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

Allegation: Client sustained unexplained injuries due to lack of staff supervision.

During initial interview W1 stated C1 sustained an unexplained injury while attending the day program and was given different reasons for why it happened. W4 stated

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

DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025
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 2
Control Number 15-AS-20240524091025
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: COMMUNITY INTEGRATED SUPPORT SERVICES
FACILITY NUMBER: 079200012
VISIT DATE: 03/14/2025
NARRATIVE
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Continued from LIC9099C.

during interview C1’s eye was swollen very little when C1 arrived form the day program, but the eye was swollen more the next day. W4 also stated the facility staff was told there was a little accident at the day program. Based on interview with S4 C1’s gait is a little off and while getting lunch at Panda Express C1 bumped into S5 but was caught before falling. S4 stated C1 stayed in the van with S4 during the outing at the park. S4 also stated C1 was fine when he arrived at the home. S5 stated at Panda Express while getting lunch C1 tripped, S5 caught C1, slowly lowered C1 to the floor, S4 and S5 then picked C1 up, checked C1 for injuries, and asked C1 was he in any pain. S5 stated C1 was fine. S5 then stated they all got into the van and went to the park to have lunch. S2 stated the day of the incident C1 was having bad allergies and pictures were taken due to C1’s eyes being swollen. S1 stated that C1 did not return to the day program until May 29, 2024. S1 stated the home sent pictures of C1’s eye to the day program on May 21/2024.

Based upon the interviews conducted and information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of this report provided.

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

DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2