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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803735
Report Date: 12/19/2023
Date Signed: 12/19/2023 12:59:46 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/14/2023 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20231214150120
FACILITY NAME:EQUIVENTURE DAY PROGRAMFACILITY NUMBER:
486803735
ADMINISTRATOR:DINGLASAN, CYNTHIAFACILITY TYPE:
775
ADDRESS:258 SUNSET AVE. STE. MTELEPHONE:
(707) 759-3888
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:45CENSUS: 45DATE:
12/19/2023
UNANNOUNCEDTIME BEGAN:
10:06 AM
MET WITH:Nell Bunyi, Program ManagerTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Personal Rights
INVESTIGATION FINDINGS:
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On 12/19/2023, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of initiating complaint investigation and was greeted by Program Manager Nell Bunyi. LPA interviewed staff, reviewed video surveillance footage and made observations.

Compliant alleges a facility staff (S6) had violated the personal rights of client (C1). Upon interviews with staff (S1,S2,S3,S4,S5) review of facility video surveillance footage and observations, LPA confirmed that staff S6 had inappropriately responded to client C1's behaviors resulting in S6 hitting C1 on the shoulder for a total of two times. Copy of surveillance footage was acquired. No indications of injury were observed or noted.

Allegation, client personal rights violated is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6.
Continued onto LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
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 3
Control Number 21-AS-20231214150120
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: EQUIVENTURE DAY PROGRAM
FACILITY NUMBER: 486803735
VISIT DATE: 12/19/2023
NARRATIVE
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Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

The licensee was informed that a civil penalty may be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20231214150120
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: EQUIVENTURE DAY PROGRAM
FACILITY NUMBER: 486803735
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/20/2023
Section Cited
CCR
82072(a)(1)
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Personal Rights: (a)(1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met as evidence by:**
Based on interviews with multiple staff, review of facility video surveillance footage and LPA observations it was confirmed that
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Licensee failed to ensure client personal rights were protected. Licensee agrees to review regulations 82072 Personal Rights and 82061 Reporting Requirements in their entirety. LIC9099 Proof of Corrections self-certifying review to be submitted to CCLD by 12/20/2023.
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on 12/8/2023, staff S6 had inappropriately responded to client C1 behavior resulting in S6 hitting C1 on the shoulder. This is an immediate personal rights risk to client C1 and clients in care.
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In addition, training is to be scheduled and completed for staff S6 on personal rights and crisis prevention interventions. Completed training to be submitted to CCLD by 1/3/2023.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3