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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200833
Report Date: 09/06/2023
Date Signed: 09/06/2023 11:36:21 AM

Document Has Been Signed on 09/06/2023 11:36 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 PROGRAMFACILITY NUMBER:
079200833
ADMINISTRATOR:WRIGHT, SHAVILAFACILITY TYPE:
775
ADDRESS:2310 COUNTRY HILLS DRTELEPHONE:
(925) 331-3116
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 75CENSUS: 43DATE:
09/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Nikia Smith, DirectorTIME COMPLETED:
11:45 AM
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On 9/6/23 at 11:00 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct a staff interview. LPA met with Nikia Smith and explained the purpose of the visit.

During the visit LPA interviewed S1 regarding an incident that occurred on 8/7/23 while S1 was dropping off C1 at his care facility.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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