079200876-11-14-2025-15-AS-YFLS-DNQRFG-20251124115908

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200876
Report Date: 11/14/2025
Date Signed: 11/14/2025 02:25:12 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
11/07/2025 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20251107120118

FACILITY NAME:	ADULT PACIFIC CARE INC		FACILITY NUMBER:	079200876
ADMINISTRATOR:	MEZA, CLAUDIA		FACILITY TYPE:	735
ADDRESS:	2024 ALVARADO DR		TELEPHONE:	(925) 978-4425
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	6	CENSUS: 4	DATE:	11/14/2025
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Loida Gavilan, Administrator,		TIME COMPLETED:	02:48 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not provide adequate supervision to the clients

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 11/14/25, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegations above. LPA met with Loida Gavilan, Administrator, and explained the purpose of the visit.

During the course of the investigation, LPA interviewed W1 and facility staff, and reviewed facility records.

LPA interviewed W1, who stated that he did not know the name of the individual he saw in the street but believed the individual lived at the facility located in the neighborhood. It was determined through interviews with facility staff that the individual in question, who allegedly was unsupervised outside the facility on the street, is R1.

***report continues on LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025

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 2

Control Number 15-AS-20251107120118

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: ADULT PACIFIC CARE INC	FACILITY NUMBER: 079200876
	VISIT DATE: 11/14/2025

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

***report continues from LIC9099***

R1 was admitted to the facility on June 1, 2025. LPA reviewed R1's records and found that he has a history of wandering away from staff, yelling obscenities, and other maladaptive behaviors. R1 currently has a 1:1 staff person assigned to him 24 hours a day, seven days a week, due to these behaviors and funded by the placement agency. As a safety precaution, R1 is also equipped with an Air Tag to enable staff to locate him quickly.

LPA reviewed R1’s behavior plan dated 7/1/25 which outlines the techniques staff, including the 1:1 staff, should use when dealing with R1’s maladaptive behaviors.

LPAs reviewed training records from the facility, which indicated that all staff were trained on R1’s behavior plan most recently on September 10, 2025. Staff also stated that a monthly staff meeting is held where each resident’s behavior plan is discussed, with particular focus on R1 because of his high-profile status and 1:1 supervision. The most recent staff meeting took place on October 23, 2025.

LPAs reviewed the facility’s staff schedules for November 2025, which confirmed that R1 has a 1:1 staff scheduled to supervise him 24/7. It was observed that approximately four to five staff members rotate shifts to ensure consistent supervision and implementation of R1’s behavior plan.

LPAs interviewed S1 and S2, who stated that staff are instructed not to be on their cell phones while supervising residents. However, they acknowledged that staff sometimes use their phones and are reprimanded when caught. Both S1 and S2 were unaware of the incident that occurred on November 7, 2025.

LPAs also interviewed S3 and S4, both of whom stated they are aware of R1’s behaviors and emphasized the importance of close supervision. They denied ever witnessing staff using cell phones while providing 1:1 supervision of R1.

This agency has investigated the above complaint. We have found that the complaint is unsubstantiated. Although the allegation may have occurred or be valid, there is not a preponderance of evidence to prove whether the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED.

An exit interview was conducted, and a copy of this report was provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 2