Ascend

Deficiency cited at inspection

On September 24, 2026 at 9:30am, Licensing Program Analyst (LPA) Emelyn Sanchez P. made an announced visit to Ascend Healthcare 3 for the purpose of conducting a Case Management- Annual Continuation Inspection visit. LPA Sanchez P. met with Brenda Reyes, Administrator/Regional Operations Manager. LPA Sanchez P. was granted access to the facility. The facility keeps client files and documents in digital system called KIPU. LPA reviewed the following records during the inspection: Client Records: The program currently has a total of five (5) clients. LPA Sanchez P. reviewed five (5) client records and found each record to meet licensing requirements. LPA Sanchez P. conducted interviews with three (3) clients and a total of two (2) staff. Per California Code Regulations, TITLE 22, DIVISION 6, CHAPTERS 5 no deficiencies were cited. An exit interview was conducted, and a copy of this report was left with Brenda Reyes, Administrator/Regional Operations Manager

Deficiency cited at inspection

On September 23, 2026, 9:45am, Licensing Program Analyst (LPA) Emelyn Sanchez P. arrived at Ascend Healthcare 3, for the purpose of conducting an Annual/Required inspection visit. LPA Sanchez P. met with Brenda Reyes, Administrator/Regional Operations Manager and was granted access into the facility. LPA Sanchez P. toured the interior and exterior of the facility. The facility is a private pay treatment program licensed to provide care and supervision services to six (6) children, ages 12-17 years old, ambulatory only. There is a swimming pool on the premises which meets licensing requirements. The census at the time of the inspection was five (5). The facility is a one story, 4-bedroom, 2 and a half-bathroom house with a living room, dining room, kitchen, laundry area, staff/therapy office, equine therapy farm, a pool, detached garage, and a backyard. The facility is set up as follows: Living room: is furnished with a sectional sofa and an operable wood burning fireplace equipped with an iron screen. Dining room: is furnished with a wooden table, four (4) chairs, a bench and an operable wood burning fireplace equipped with a screen. Kitchen: is equipped with a gas operated 4-burner stove that includes a 2 burner-grill with a flat top stove, a microwave, refrigerator/freezer, a dishwasher, and a pantry. Sharp knives are kept in a locked box in a locked kitchen cabinet. Report Cont. on LIC 809-C Pg. 1 of Bedrooms: 3 bedrooms are used for clients and all rooms are furnished ...

Deficiency cited at inspection

On September 16, 2026, Licensing Program Analyst (LPA) Angelica Borja conducted a Case Management (FN-3556) inspection at Ascend Behavioral Health, located in Clovis, California, and met with Program Manager Luis De Leon. The purpose of the inspection was to discuss a medication error involving Client #1 (C1-see LIC Confidential Names List) that occurred on August 29, 2026. At approximately 8:29 a.m., C1 was administered 3 mg of Risperdal instead of the prescribed 2 mg dose. Staff immediately notified the Licensed Vocational Nurse (LVN), who contacted the Physician Assistant (PA). The PA instructed staff to administer C1's 2 mg dose during the evening medication pass instead of the scheduled 3 mg dose so that C1's total daily dosage would remain unchanged. LPA reviewed the facility's medication administration procedures. Due to the facility's history of multiple medication errors, LPA also discussed scheduling a meeting with agency representatives at the Community Care Licensing Division, Children's Residential Program office in Fresno to address ongoing concerns regarding medication administration. The Department determined that the facility failed to administer C1's medication as prescribed. Therefore, the Group Home is being cited on the attached LIC 809-D under California Code of Regulations, Title 22, Section 80075(b), Health-Related Services. A civil penalty was assessed for a repeat violation. A copy of this report, the LIC 809-D, appeal rights, and civil penalty ...

Deficiency cited at inspection

On September 10, 2026, at 10:50 a.m., Licensing Program Analyst (LPA) Brent Lockhart conducted an unannounced Case Management inspection at Ascend Behavioral Health Group Home (GH). The purpose of the inspection was to follow up on an incident report (IR) received by the Department. LPA met with Amanda Lilly, Program Manager. On August 17, 2026, the Department received an IR stating medication for C1 (See LIC Confidential Names List, dated 9/10/26) was missed due to newly prescribed medication (M1) requested by the provider on 6/30/26 wasn't filled by the pharmacy. The new M1 increased from five to seven milligrams (MG) didn't become available until 7/22/26. While waiting for the new dose, LPA reviewed M1 logs provided by the facility lead nurse (LN) documenting C1 taking the initial medication that was 5MG. When the new prescribed dose came in on 7/22/26, the facility documented C1's usage. During this inspection, LPA reviewed medication logs, medical provider notes, and guardian notes for C1 as of 9/10/26. No deficiencies were cited during this inspection. A signed copy of this report and LIC811 were provided to Amanda Lilly, Program Manager. No further follow-up is required.

Deficiency cited at inspection

On August 25, 2026, Licensing Program Analyst (LPA) Angelica Borja conducted a Case Management inspection at Ascend Behavioral Health located in Clovis Ca and met with Program Manager Luis De Leon. The purpose of the inspection was to follow up on an incident report submitted to the Department regarding a client ( who sustained a self-inflicted laceration to her forearm. The client disclosed the injury to facility staff on August 15, 2026, and was transported to the hospital for medical treatment. Hospital staff cleaned and bandaged the wound but were unable to suture it because the wound was determined to be too old. During the inspection, LPA conducted interviews with the Program Manager and Psychological Associate. LPA also informed of the client's records, including information related to a previous self-harm incident, the client's clinical reassessment, treatment and safety interventions, supervision requirements, and 15-minute observation logs. Information reviewed indicated that the client was clinically reassessed following a previous self-harm incident and denied current self-harming behavior or suicidal ideation. On August 13, 2026, the facility developed additional clinical measures and coping interventions to assist the client with managing self-harm urges. Facility staff continued to provide supervision in accordance with the client's established supervision requirements. Continued on Page Continued from Page The facility determined that another client received ...

Deficiency cited at inspection

On July 14, 2026, Licensing Program Analyst (LPA) Angelica Borja conducted a Case Management inspection at Ascend Behavioral Health and met with Program Manager Luis De Leon. The purpose of this inspection was to discuss an incident report submitted to the Department on July 6, 2026, regarding a medication administration error that occurred on June 29, 2026. LPA conducted an interview with the Program Manager and reviewed the circumstances surrounding the incident. The incident involved a delay in administering a client's prescribed evening medications outside of the facility's approved medication administration window due to staff oversight. LPA discussed the facility's medication administration procedures, staff responsibilities, and the importance of ensuring medications are administered within the approved timeframes to protect the health and safety of clients. The Program Manager described the corrective actions implemented to prevent similar incidents from occurring in the future. No deficiencies were cited during today's inspection. A copy of this report was left at the facility.

Deficiency cited at inspection

On June 23, 2026, Licensing Program Analyst (LPA) Angelica Borja conducted a Case Management inspection at Ascend Behavioral Health and met with Aaron Vargas. The purpose of this inspection was to discuss concerns with an incident report that was sent into the Department on 06/06/26, the incident in question happened on 06/08/26. LPA conducted an interview and discussed medication administration procedures. The Department determined this to be an immediate risk to health and safety at this time, therefore the Group Home is being cited on the attached LIC809-D under CCR, Health Related Services 80075(b). A civil penalty was also issued for a repeat violation. A copy of this report, appeal rights and civil assessment was left at the facility.

Deficiency cited at inspection

On April 9, 2026, Licensing Program Analyst (LPA) Angelica Borja conducted a Case Management inspection at Ascend Behavioral Health and met with Ciara Armstead-Program Manager. The purpose of this inspection was to discuss concerns with an incident report that was sent into the Department on 4/6/26, the incident in question happened on 3/30/26. LPA conducted an interview and discussed medication administration procedures. The Department determined this to be an immediate risk to health and safety at this time, therefore the Group Home is being cited on the attached LIC809-D under CCR, Health Related Services 80075(b). A civil penalty was also issued for a repeat violation. A copy of this report, appeal rights and civil assessment was left at the facility.

Deficiency cited at inspection

On March 12, 2026, Licensing Program Analyst (LPA) Angelica Borja conducted a Case Management inspection at Ascend Behavioral Health and met with Ciara Armstead-Program Manager. The purpose of this inspection was to discuss concerns with an incident report that was sent into the Department on 2/10/26, the incident in question happened on 2/09/26. LPA conducted an interview and discussed medication administration procedures. The Department determined this to be an immediate risk to health and safety at this time, therefore the Group Home is being cited on the attached LIC809-D under CCR, Health Related Services 80075(b). A copy of this report and appeal rights was left at the facility.

Deficiency cited at inspection

On March 12, 2026, Licensing Program Analyst (LPA) Angelica Borja conducted a Case Management inspection at Ascend Behavioral Health and met with Ciara Armstead-Program Manager. The purpose of this inspection was to discuss concerns with an incident report that was sent into the Department on 2/10/26, the incident in question happened on 2/09/26. LPA conducted an interview and discussed medication administration procedures. The Department determined this to be an immediate risk to health and safety at this time, therefore the Group Home is being cited on the attached LIC809-D under CCR, Health Related Services 80075(b). A copy of this report and appeal rights was left at the facility.

Deficiency cited at inspection

On March 12, 2026, Licensing Program Analyst (LPA) Angelica Borja conducted a Case Management inspection at Ascend Behavioral Health and met with Ciara Armstead-Program Manager. The purpose of this inspection was to discuss concerns with an incident report that was sent into the Department on 2/19/26, the incident in question happened on 2/15/26. LPA conducted an interview and discussed medication administration procedures. The Department determined this to be an immediate risk to health and safety at this time, therefore the Group Home is being cited on the attached LIC809-D under CCR, Health Related Services 80075(b). A civil penalty was also issued for a repeat violation. A copy of this report, appeal rights and civil assessment was left at the facility.

Deficiency cited at inspection

On February 18, 2026, Licensing Program Analyst (LPA) Angelica Borja conducted a post-licensing inspection at Ascend Behavioral Health and met with Program Manager, Aaron Vargas. A inspection of the facility was conducted indoors and outdoors. The group home currently has two clients in care. The group home currently employs one Administrator, one Facility Manager, eight Direct Care staff, Program Director, Clinical VP, Clinical Lead, Clinicians/Therapists, one LVN, and two Case Managers/Counselors. LPA reviewed 5 staff files and two client files. LPA interviewed two staff and one client. LPA observed individual beds with appropriate clean linens and in good repair. Cleaning chemicals inaccessible to clients. The facility is maintained at 70 degrees. All facility smoke and carbon monoxide detectors appear to be in appropriate working order, fire extinguisher is properly charged and was last serviced in April 2025. The Group Home currently has no firearms and one swimming pool. Medications are centrally stored and locked. A review of the Licensing Information System on February 18, 2026, indicates that all facility staff are associated to the Group Home and have DOJ, FBI, and child abuse index check clearances. At this time the Group Home is in the process of accreditation. One Technical Advisory was cited during todays inspection A copy of this report and appeal rights was left at the facility at the conclusion of this inspection.

Deficiency cited at inspection

On February 18, 2026, Licensing Program Analyst (LPA) Angelica Borja conducted a post-licensing inspection at Ascend Behavioral Health and met with Program Manager, Aaron Vargas. A inspection of the facility was conducted indoors and outdoors. The group home currently has two clients in care. The group home currently employs one Administrator, one Facility Manager, eight Direct Care staff, Program Director, Clinical VP, Clinical Lead, Clinicians/Therapists, one LVN, and two Case Managers/Counselors. LPA reviewed 5 staff files and two client files. LPA interviewed two staff and one client. LPA observed individual beds with appropriate clean linens and in good repair. Cleaning chemicals inaccessible to clients. The facility is maintained at 70 degrees. All facility smoke and carbon monoxide detectors appear to be in appropriate working order, fire extinguisher is properly charged and was last serviced in April 2025. The Group Home currently has no firearms and one swimming pool. Medications are centrally stored and locked. A review of the Licensing Information System on February 18, 2026, indicates that all facility staff are associated to the Group Home and have DOJ, FBI, and child abuse index check clearances. At this time the Group Home is in the process of accreditation. One Technical Advisory was cited during todays inspection A copy of this report and appeal rights was left at the facility at the conclusion of this inspection.

Deficiency cited at inspection

On February 17, 2026 at 9:10am, Licensing Program Analyst (LPA), Emelyn Sanchez P. made an unannounced visit to Ascend Healthcare, for the purpose of conducting a Required- Year inspection visit. LPA Sanchez P. met with Jaqueline Waldron, Director of Operations who granted access to the facility. LPA Sanchez P. toured the interior and exterior of the facility. The facility is licensed to provide care and supervision services for up to six (6) male and female children, ages 12-17 years old, ambulatory only. There is a swimming pool on the premises which meets licensing regulations. The facility also has a camera waiver on file. The census at the time of the inspection was five (5). The facility is a two story, 3-bedroom, 4 and a half bathroom house which includes a Living room, Dining room, Kitchen, Office, Staffing/Medical office, a converted Garage, Classroom and a Backyard. The facility is set up as follows: Living room: is furnished with a sectional sofa, 2 chairs, and has an non-operating fireplace equipped with an iron screen. Dining room: is furnished with a wooden table and eight (8) chairs. Kitchen: is equipped with a 4-burner gas operated stove, a microwave, refrigerator/freezer, a dishwasher, and a toaster. Staffing/Medical office: is located on the first floor near the garage. Report Cont. on LIC 809-C. Pg. 1 of The office is equipped with a computer, chair, and desk. LPA Sanchez P. observed the room to have a locked cabinet which is used to store medication. ...

Deficiency cited at inspection

On December 3, 2025 at 9:20am, Licensing Program Analyst (LPA) Emelyn Sanchez P. made an unannounced visit to Ascend Healthcare #6 for the purpose of conducting a Case Management- Annual Continuation Inspection visit. LPA Sanchez P. met with Jaqueline Waldron, Administrator/Director of Operations. LPA Sanchez P. was granted access to the facility. The facility keeps staff and client files and documents in digital system called KIPU and Isolved. LPA reviewed the following records during the inspection: Client Records: The program currently has a total of five (5) clients. LPA Sanchez P. reviewed three (3) client records and found each record to meet licensing requirements. Staff Records: The program currently has a total of thirty-eight (38) staff. LPA reviewed a total of two (2) staff records and found records to be out of compliance per licensing requirements. LPA Sanchez P. obtained the LIC 500 to verify staff to client ratio. LPA Sanchez P. reviewed the Facility Profile and Personnel Report and confirmed that personnel have required criminal record clearance: DOJ, FBI and Child Abuse; which meet licensing requirements. LPA Sanchez P. conducted interviews with two (2) clients and a total of two (2) staff. The following deficiency is being cited for violating California Code of Regulations Title 22, Division Regulation 80066 (a)(10) Personnel Records. (see page D). An exit interview was conducted, and a copy of this report was left with Jaqueline Waldron ...

Deficiency cited at inspection

On December 3, 2025, Licensing Program Analyst (LPA) Briana Placencia conducted a Case Management inspection at Ascend Behavioral Health and met with Ciara Armstead-Program Manager. The purpose of this inspection was to discuss concerns with an incident report that was sent into the Department on 12/01/2025, the incident in question happened on 11/21/2025. LPA conducted an interview and discussed medication administration procedures. The Department determined this to be an immediate risk to health and safety at this time, therefore the Group Home is being cited on the attached LIC809-D under CCR, Health Related Services 80075(b). A copy of this report and appeal rights was left at the facility.