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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200563
Report Date: 11/29/2023
Date Signed: 11/29/2023 02:13:46 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
11/21/2023 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20231121160002
FACILITY NAME:MISSION-HOPE DAY PROGRAM-ANTIOCHFACILITY NUMBER:
079200563
ADMINISTRATOR:GAMEZ, JUANITA NIMFA YFACILITY TYPE:
775
ADDRESS:10 SOUTH LAKE DRIVETELEPHONE:
(925) 706-7517
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:49CENSUS: 33DATE:
11/29/2023
UNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Mitizi Wardini, Program DirectorTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Client sustained unexplained injuries while in care
INVESTIGATION FINDINGS:
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On 11/29/2023 at 1:25pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct the 10-day initial visit and deliver complaint findings for the allegation above. LPA met with Mitzi Wardini, Program Director, and explained the reason for the visit.

During the investigation LPA interviewed staff and collected the following documents: facility roster, staff roster, incident report dated 11/22/2023 for C1.

During record review the incident report dated 11/22/2023 indicated that C1 had behaviors inside the van on 11/17/2023 and received bruising. S1 stated during interview that C1 did not return to the day program until 11/22/2023 and had on some type of knee protectors. During the visit S1 called the home where C1 resides and

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

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
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-20231121160002
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: MISSION-HOPE DAY PROGRAM-ANTIOCH
FACILITY NUMBER: 079200563
VISIT DATE: 11/29/2023
NARRATIVE
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Continued from LIC9099.

discovered the home was an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/DD). The Administrator at the home informed the day program that C1 was taken to urgent care for treatment.

Based upon the information obtained and the interviews during the investigation. The above allegation is 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 report was given.

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

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2