<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 070208893
Report Date: 01/20/2023
Date Signed: 01/20/2023 02:26:27 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, 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
12/23/2022 and conducted by Evaluator Monica Mathur
PUBLIC
COMPLAINT CONTROL NUMBER: 02-CC-20221223104801
FACILITY NAME:SRVSACCA - KIDS COUNTRY-VISTA GRANDEFACILITY NUMBER:
070208893
ADMINISTRATOR:GRAVELYN, JEANETTEFACILITY TYPE:
840
ADDRESS:667 DIABLO ROADTELEPHONE:
(925) 837-0330
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY:120CENSUS: 24DATE:
01/20/2023
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Ann TanciocoTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Responsibility for Providing Care & Supervision - child wandered away from facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 1/20/23 Licensing Program Analyst (LPA) Monica Mathur conducted an unannounced Subsequent Complaint Investigation at SRVSACCA Kids Country Vista Grande. Director, Jeannette Gravelyn was not present today and LPA met with Executive Director, Ann Tancioco. Finding for the above allegation was delivered during the inspection.

Complainant alleges that day care child wandered away from facility. During the course of the investigation, LPA inspected the facility, reviewed records and conducted interviews. It was determined that on two separate incidents that occured on dates 11/11/22 and 12/16/22 Child 1 (C1) wandered away from facility, was missing for several minutes before being found. Facility self-reported both incidents to CCLD and was cited Type As with civil penalties on case management reports of 11/16/22 and 12/21/22. Facility has submitted their plan of corrections.

Based on the interviews and information obtained throughout the investigation, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. However, since facility has been cited on 11/16/22 and 12/21/22 for both incidents involving C1 wandering away, no deficiency is being cited today. Facility is reminded to reinforce active visual supervision at all times. A Non Compliance Conference with CCLD Management will be scheduled to discuss citations. Exit interview was conducted with Executive Director, Ann Tancioco and Assistant Director, Katie Whitehouse. and Appeal rights were provided. NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED FOR 30 DAYS.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
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