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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200833
Report Date: 08/09/2023
Date Signed: 08/09/2023 01:48:39 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
06/01/2023 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20230601103019
FACILITY NAME:SVS ANTIOCH ADULT DAY PROGRAMFACILITY NUMBER:
079200833
ADMINISTRATOR:WRIGHT, SHAVILAFACILITY TYPE:
775
ADDRESS:2310 COUNTRY HILLS DRTELEPHONE:
(925) 331-3116
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:75CENSUS: 35DATE:
08/09/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Nikia Smith, Program DirectorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff slaps client while in care.
INVESTIGATION FINDINGS:
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On 8/9/2023 at 1:30pm, Licensing Program Analysts (LPAs) L. Hall and L. Holmes arrived unannounced to deliver complaint findings for the allegation above. LPA met with Nikia Smith, Program Director, and explained the purpose of the visit.

During the course of the investigation LPA interviewed staff, reporting party (RP), client, and obtained records. Staff stated during interviews that on the day in question, May 25, 2023, there wasn’t any complaint or allegation of any staff hitting a client or mistreating any clients. C1 stated during the interview that she was never hit while being a client and never seen any other clients being hit or mistreated. Based on the investigation the allegation is unsubstantiated.

Continued on LIC9099C.






Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023
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-20230601103019
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: SVS ANTIOCH ADULT DAY PROGRAM
FACILITY NUMBER: 079200833
VISIT DATE: 08/09/2023
NARRATIVE
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Continued from LIC9099.

Based upon the interviews during 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 this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2