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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200833
Report Date: 09/29/2023
Date Signed: 09/29/2023 02:17:31 PM

Document Has Been Signed on 09/29/2023 02:17 PM - 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: 32DATE:
09/29/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Nikia Smith, Program DirectorTIME COMPLETED:
02:15 PM
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On 9/29/2023, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a case management visit regarding two (2) separate incident reports received for C1. LPA was greeted by Nikia Smith, Program Director, and explained reason for visit.

During visit LPA collected the physician's report and the Individual program plan (IPP) for C1. Incidents reports for C1 both were sent on 09/22/2023. LPA spoke with S1 and was advised that the behaviorist for C1 has been contacted for an assessment. S1 also stated the program will schedule a interdisciplinary meeting (IDT). S1 stated the program will not let C1 have any pens or pencils unless supervised.

No citations are being issued on this date.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2023
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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