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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 073409342
Report Date: 10/03/2023
Date Signed: 10/03/2023 10:26:41 AM

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, SUITE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/03/2023 and conducted by Evaluator Tasha Hackett-Alexander
COMPLAINT CONTROL NUMBER: 02-CC-20230703163529
FACILITY NAME:DA COSTA, ADRIANAFACILITY NUMBER:
073409342
ADMINISTRATOR:DA COSTA, ADRIANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(628) 888-4530
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:14CENSUS: 3DATE:
10/03/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:ADRIANA DA COSTATIME COMPLETED:
10:45 AM
ALLEGATION(S):
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9
Day care child sustained unexplained bruising while in care.
INVESTIGATION FINDINGS:
1
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10
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13
Licensing Program Analyst Tasha Alexander met with Licensee Adriana Da Costa to deliver the findings to the above complaint allegation.

Upon arrival there are 2 infants and 1 preschooler presesnt along with licensee. During this analyst's last visit, an interview was conducted with licensee and relevant documents were received. Further investigation was conducted.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

an exit interview was conducted

A notice of site visit was given to Ms. Da Costa and must be posted for 30 days.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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