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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201349
Report Date: 05/20/2025
Date Signed: 05/20/2025 02:06:27 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
03/04/2025 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250304131045
FACILITY NAME:CATALYST CARES ADULT DAY PROGRAMFACILITY NUMBER:
079201349
ADMINISTRATOR:FREEMAN, MAVISFACILITY TYPE:
775
ADDRESS:3905 SAN PABLO DAM ROADTELEPHONE:
(510) 390-5538
CITY:EL SOBRANTESTATE: CAZIP CODE:
94803
CAPACITY:60CENSUS: 30DATE:
05/20/2025
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Mavis Freeman, CEO/Administrator TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff restrained client without the authority to do so.
Staff applied essential oils to client’s skin without a physician’s order.
Staff did not notify responsible party.
Staff did not notify the Department of manual restraint in a timely manner.
INVESTIGATION FINDINGS:
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On 05/20/2025 around 01:10 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver the finding for the complaint investigation. LPA met with Mavis Freeman, CEO/Administrator and explained the purpose of the visit.

During the course of the investigation and visits, LPA conducted interviews and obtained statements from Staff (S1, S2, S3, S4), Witnesses (W1, W2) and Client #2 (C2). LPA and S1 toured the facility, LPA requested a staff and resident roster including but not limited to Client #1 (C1) attendance records, face sheet, self-injurious reports, training records, behavior plans, behavior response policy, admission agreement, LIC 624s, progress and assessment reports.

Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
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-20250304131045
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: CATALYST CARES ADULT DAY PROGRAM
FACILITY NUMBER: 079201349
VISIT DATE: 05/20/2025
NARRATIVE
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...continued from LIC9099.

Allegations: UNSUBSTANTIATED

Staff restrained client without the authority to do so.

The alleged allegation occurred on 02/20/2025 at R1’s Day Program. W2 reported what was relayed to him/her from W1 to the Contra Costa County Sheriff's Department, and law enforcement was dispatched on 02/27/2025. ADM provided LPA with proof of communications regarding R1 that included text messages, emails, attendance records, and LIC 624 which were all related to R1's behavioral history from 2024 to 2025. Interviews and statements from S1, S2, S3, S4, W1, and W2, and the history report for the police incident did not reveal that any staff hit R1, or any other Clients. S1 had not received any written or oral communications from W1 or W2 regarding the allegation to investigate any wrong doings prior to 02/27/2025. Staff are trained for crisis intervention, exercises environmental restraints, verbal and non-verbal redirecting.

Staff applied essential oils to client’s skin without a physician’s order.

W2 stated that S1 applied an essential oils lotion to R1’s skin. S1 and LPA toured the facility and S1 presented scented air diffusion that is centrally located at the entrance of the facility and the contents remains locked in the facility. S2 has locked lotions that are available to staff and residents upon request. W1 and W2 could not provide any date, times or witnessing of an application of essential oils to C1. S1 stated that he/she has used the same products since the facility has opened 05/2024, has given lotion and hand sanitizers as gift bags, and not at any time was S1 made aware of any grievances surrounding the products.

Continued on LIC 9099C...

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250304131045
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: CATALYST CARES ADULT DAY PROGRAM
FACILITY NUMBER: 079201349
VISIT DATE: 05/20/2025
NARRATIVE
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...continued from LIC9099C.

Staff did not notify responsible party.

On 02/20/25 repairs to the facility’s front window was taking place at the facility for a broken window. W2 stated that C1 had dialed 911, but the local police department was not dispatched and C1 would not tell W2 what happened. S1 stated that the repairs were to replace the window, was not related to any of the clients, no injuries had occurred at the facility, and S1 was unaware of any calls made by C1. W2 stated that an unknown staff member said the window repair was none of W2’s business. W2 was unable to identify who the staff member was or why R1 would have called 911. No police reports were on record for a 911 calls made by C1 on any dates from the facility.

Staff did not notify the Department of manual restraint in a timely manner.

On 02/20/2025, the alleged allegation occurred at R1’s Day Program. W2 reported what was relayed to him/her from W1 to the Contra Costa County Sheriff's Department, and law enforcement contacted S1 by phone on 02/27/2025. ADM provided LPA with proof of communications regarding R1 that included text messages, emails, attendance records, and LIC 624 which were all related to R1's behavioral history from 2024 to 2025. Interviews and statements from S1, S2, S3, S4, W1, and W2, and the history report for the police incident did not reveal that any staff manually restrained R1, or any other Clients. S1 had not received any written or oral communications from W1 or W2 regarding the allegation/s in order to investigate any wrong doings prior to 02/27/2025. S1, S2, S3, and S4 are all crisis trained; environmental restraints and redirecting were initiated before and during the pick-up of R1 from the facility by W1.

Based on information obtained, the allegations are UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that the allegations are not valid because the preponderance of the evidence standard has not been met.

No deficiencies cited, exit interview conducted, a copy of this report provided Mavis Freeman, CEO/Administrator.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3