079200563-4-30-2025-15-AS-KHOS-DH3JRL-20250527071654

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200563
Report Date: 04/30/2025
Date Signed: 04/30/2025 12:45:31 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
04/11/2025 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20250411103849

FACILITY NAME:	MISSION-HOPE DAY PROGRAM-ANTIOCH		FACILITY NUMBER:	079200563
ADMINISTRATOR:	GAMEZ, JUANITA NIMFA Y		FACILITY TYPE:	775
ADDRESS:	10 SOUTH LAKE DRIVE		TELEPHONE:	(925) 706-7517
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	49	CENSUS: 32	DATE:	04/30/2025
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Mitzi Wardini, Program Director		TIME COMPLETED:	12:44 PM

ALLEGATION(S):

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Staff hit client

Due to lack of supervision, client was physically assaulted by another client

INVESTIGATION FINDINGS:

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On 4/30/2025 at 12:20pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Mitzi Wardini, Program Director, and explained the reason for the visit.

During the investigation LPA interviewed staff, witness, reviewed and obtained records.

Allegation: Staff hit client

During interview with W1 it was stated that C1 had a large bruise on her arm (picture submitted). When W1 asked what happened C1 stated S2 hit her. S1 was interviewed on April 24, 2025. S1 stated the program investigated by interviewing staff; however,

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025

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-20250411103849

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: 04/30/2025

NARRATIVE

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Continued from LIC9099.

no one observed C1 being hit. S1 stated that C1 was not crying or complaining at all on the day the alleged incident occurred. S1 stated when C1 was interviewed with her responsible party C1 changed the name of the person that hit her. S2 stated during interview that she did not work with C1 that day. LPA reviewed staff schedule dated April 2, 3, and 4, which indicated S2 worked with C1 on April 2, 2025. S2 also stated she taught C1 how to say her name. S2 only remembered seeing C1 walking around inside the facility. S5 stated during interview that she was assigned to C1 on the date of the alleged incident. S5 observed C1 walking around facility and recalled only once C1 cried because she wanted more snacks. S5 stated a bruise was not observed because C1 had on a jacket with long sleeves. S1, S3, and S4 also were interviewed and all stated no one staff or client hit C1.

Allegation: Due to lack of supervision, client was physically assaulted by another client

During initial interview W1 stated C1 physically assaulted by another client due to lack of supervision. W1 further stated C1 was hit in the head with a backpack and received a cut on her forehead. W1 stated it happened because C1 was allowed to go into a space with a known violent client. S4 was interviewed on April 24, 2025. S4 stated that she was in the van with C1 and C1 was saying “stop” and crying. C2 came to get in the van and threw a backpack at C1. The backpack hit C1 in the forehead. S4 observed blood coming from C1’s forehead and called for help. S6 came and escorted C2 back into facility. S1 stated C1 was not left unsupervised at any time. S1 stated she called C1’s responsible party to advise of the incident and inquire if they should take C1 to the hospital. S1 also stated at the time of the incident it was one staff member, 1 client, and another client getting into the van, therefore, the ratio of staff to client was met.

Continued on LIC9099C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20250411103849

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: 04/30/2025

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Continued from LIC9099C. Based upon the 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 report was given.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025

LIC9099 (FAS) - (06/04)

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