Beloved Ones

Deficiency cited at inspection

On August 12, 2026 at 12:30PM, Licensing Program Analyst (LPA) Kaitlyn Wong conducted an unannounced inspection of the above facility to follow up on an incident that was reported by the facility on 8/8/26. LPA met with Desiree Terry, Administrator and explained the purpose of the visit. LPA conducted a walk through of the facility. At the time of the inspection, there was one client present and two staff members present. During the inspection, two additional staff members arrived to the facility. Per the incident report dated 8/2/26, one client was found with contraband on the property. The facility reminded the client that contraband was not allowed on the property and plans to conduct a CFT meeting. LPA conducted one staff interview. LPA requested pertinent documentation to be sent to LPA via email by 5PM August 17, 2026. Additional information can be found on the LIC 812's dated 8/12/26. No deficiencies were cited at this time. An exit interview was conducted and a copy of this report was left with Desiree Terry, Administrator, whose signature below confirms receipt.

Deficiency cited at inspection

On August 12, 2026 at 12:30pm, Licensing Program Analyst (LPA) Kaitlyn Wong made an unannounced inspection at the above facility. The purpose of the inspection was to conduct a required annual inspection. LPA met with Desiree Terry, Administrator and informed of the purpose of the visit. The short-term residential therapeutic program is licensed to serve a capacity of 4 ambulatory clients aged 7-17. At the time of the inspection, there were two staff and one client present at the facility. Two additional staff arrived during the time of the inspection. LPA used the CARE Inspection Tool and conducted a tour of the facility site both inside and outside, and conducted confidential interviews with 1 staff member and 0 residents. 1 resident declined to interview. LPA was informed that the facility's licensing fees have been paid. Based on interviews, LPA observed the facility to be knowledgeable of facility policies, mandated reporting, and intervention procedures. LPA observed the facility to be in good condition, clean and well organized. Kitchen and bathrooms are sanitary. The facility has supply of non-perishable foods and the refrigerator is stocked with perishable foods and has a temperature 37 degrees. The freezer temperature read 0 degrees. The facility currently has 2 residents and they each have their own bedroom and bathroom with individual beds and plenty of storage for personal items. The rooms and common spaces are nicely decorated and furnished. Medications ...

Deficiency cited at inspection

On June 18, 2026, at 12: PM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced case management inspection at the facility. During the inspection, LPA Silva met with Kenny Herrera, Administrator. The purpose of this inspection was to follow up on an incident report submitted to the Department on 05/29/26. According to the report, two clients (C1 and C2) slept outside on the trampoline until 4:00 a.m., then went inside the facility and slept together in C1's bedroom. Prior incident reports indicate that similar incidents had occurred over the previous several days. This case management follow-up included telephone interviews with staff: S1 on 06/01/26, 06/02/26, and 06/03/26; S3 on 06/03/26; and the Director (DR) on 06/02/26. The LPA also reviewed documentation, including incident reports, the overnight activity log, and email communication between the Director and County Social Worker Supervisors (CSWS). Review of the incident reports and confidential interviews revealed that on Saturday, 05/30/26, staff removed the doors from clients' bedrooms and installed curtains instead. The decision was prompted by concerns that clients had repeatedly locked themselves inside their rooms while smoking or using substances, barricaded doors to prevent required safety checks, eloped from care through bedroom windows, accessed secured areas, made threats toward staff, vaped inside the facility, damaged facility property, and engaged in other unsafe behaviors compromising ...

Substantiated

*INVESTIGATION WAS RECONDUCTED AND NEW FINDINGS DELIVERED ON JUNE 16, 2026* On May 15, 2026 at 11:40AM, Licensing Program Analyst (LPA) Kaitlyn Wong conducted an unannounced inspection to the facility to deliver findings for the above allegation. LPA Wong met with Monique Garrett, Administrator, and informed the purpose of the visit. During the investigation, LPA Wong conducted confidential interviews and client and facility records. It was found that the needs and services plans developed by the facility do not include pertinent information regarding services consistent with the case plan prepared by the placing agency, including mention of psychiatric services that will be provided for psychotropic medication management. Based on confidential interviews, observations, and record review, the preponderance of evidence standard has been met, and therefore the following allegation is found to be SUBSTANTIATED. LPA is issuing one Type B citation for Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) section 87068.2(c) Needs and Services Plan. An exit interview was conducted, appeal rights discussed, and a copy of this report was left with Monique Garrett, Administrator whose signature on this form confirms receipt.

Deficiency cited at inspection

On April 21, 2026 at 8: AM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced Annual Required Inspection at the above facility and met with Kenny Herrera, Administrator. This STRTP is licensed to serve up to two (2) children ages 7-17 years of age. The facility also provides services to non-minor dependents pursuant to W&I Code 16501.1 (C)(1). There are two (2) minors currently in placement LPA obtained and reviewed the following updated documentation: · LIC Personnel, Client Roster · LIC C Emergency Disaster Plan/Mass Casualty Plan · Current Board Meeting Minutes · Continuous Quality Improvement Report The Compliance and Regulatory Enforcement (CARE) Tool was used by the LPA during today's inspection which consisted of a review of the following domains: Physical Plant, Operations, Disaster Preparedness Plan, Staff Files, Client Files, Core Therapeutic Services and Emergency Intervention Plan. LPA conducted a physical plant inspection. This facility is a one-story 2-bedroom home with two (2) bathrooms. There are no bodies of water on the premises. There are no firearms or ammunition in the facility. Overall, the facility is clean, sanitary and in good condition. LPA reviewed two (2) client records and three (3) staff records. All staff have been subjected to criminal records review and have been fingerprinted and cleared with DOJ, FBI and CACI. Documentation of initial and annual staff training, including training on emergency intervention, is on file. ...

Deficiency cited at inspection

On April 17, 2026 at 12:10pm, Licensing Program Analysts (LPA) Kaitlyn Wong and Jonathan Medina made an unannounced inspection at the facility to conduct a required annual inspection. LPAs met with Monique Garrett, Administrator and informed of the purpose of the visit, but end the inspection with Barbara King, Facility Manager. The Short Term Residential Therapeutic Program (STRTP) is licensed to provide care for 6 ambulatory clients ages 7-17. At the time of the inspection there were 1 staff and 0 clients present at the facility, but during the duration of the inspection another 2 staff and 2 client arrived. Prior to the inspection, LPAs conducted a review of the facility's employee background clearance and Program Statement. LPAs conducted 1 staff and 1 client interviews. Based on interviews, LPA observed staff to be knowledgeable of facility policies, mandated reporting, and intervention procedures. Upon review, LPAs used the CARE tools to review five (5) random staff files and found that 3 out of 5 staff files did not contain health screenings. One Type B deficiency was cited under California Code of Regulations (CCR) Title Section 80066(a)(10). LPAs also observed that 2 out of 5 staff files did not contain TB test results. One Type B deficiency was cited under CCR 80066(a)(11). LPAs observed 3 out of 4 pertinent staff files did not contain the required documentation of job shadowing. One Type B deficiency was cited under CCR 87065.1(d)(1)(D)(4). [Continued on LIC809-C] ...