ROP ATCS Sierra Ridge Treatment Center

Deficiency cited at inspection

Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 8/18/22 at 11: AM and met with Paige Woodard, Deputy Program Director to discuss an incident that occurred on 4/11/22. The incident is related to a S1 (see LIC811 dated 8/18/22) supervising youth in the facility dorm and while supervising, did leave his post in the dormitory leaving all youth in his direct care and supervision unsupervised for an undisclosed amount of time, while reportedly short in duration. In the time that the youth were unsupervised, C2 was able to enter C1's room and assault C1. This incident was also reviewed by the Ms. Woodard, LPA Hill and other staff from the agency via camera review. In review of the final incident report submitted to Licensing, S1 stated that the incident was observed by S1 but investigation and camera review shows that this was not possible as S1 left the youth unsupervised in the hallway for a short time. In light of this information, LPA did request that the agency update the reports and provide them to Licensing as this information documented is not accurate. LPA advised the agency that all incident reports need to be complete and accurate before submitting them to Licensing and placing agencies. LPA Hill also discussed ratios of staff to clients during this case management inspection as well. With the varied incident investigations and complaint investigations happening in recent months, it has come to the attention of Licensing that ...

Substantiated

On 7/6/2022, Licensing Program Analyst (LPA) Jessica Caplinger, conducted an unannounced inspection to deliver findings for a complaint with allegations of "Children are not provided a safe environment." LPA met with Paige Woodard, Deputy Director, and discussed the above allegation. During the investigation, LPA Ignacia Villapudua-Soto toured the facility with Deputy Director, Paige Woodard on 2/17/22. On this inspection, LPA Villapudua-Soto informed Deputy Director, Paige Woodard that LPA Jean Stidman would be investigating this complaint and would request documentation via email. On 2/28/22 and 3/1/ LPA Stidman obtained documentation for the complaint investigation of client's daily schedule, clients monthly activity schedule, staff work schedules for January and February 2022, staff time sheets dated 1/13/22-2/9/22, staffing procedure documentation, and ROP Regional Director letter. LPA conducted seven interviews regarding the complaint. Confidential interviews and record review revealed the facility was out of compliance with direct care staff/child ratios. -Continued on 9099-C- On 2/6/22 and 2/7/22 the facility had 19 clients present in the facility which would require five staff between the hours of 7am-10pm. On 2/6/22 between 9am-10pm the facility had between two to four staff clocked in and on 2/7/22 the facility had between two to four staff clocked in between 8:26am-10pm. Based on LPAs observations and confidential interviews which were conducted and record ...

Substantiated

On 7/6/2022, Licensing Program Analyst (LPA) Jessica Caplinger, conducted an unannounced inspection to deliver findings for a complaint with allegations of "Children are not provided a safe environment." LPA met with Paige Woodard, Deputy Director, and discussed the above allegation. During the investigation, LPA Ignacia Villapudua-Soto toured the facility with Deputy Director, Paige Woodard on 2/17/22. On this inspection, LPA Villapudua-Soto informed Deputy Director, Paige Woodard that LPA Jean Stidman would be investigating this complaint and would request documentation via email. On 2/28/22 and 3/1/ LPA Stidman obtained documentation for the complaint investigation of client's daily schedule, clients monthly activity schedule, staff work schedules for January and February 2022, staff time sheets dated 1/13/22-2/9/22, staffing procedure documentation, and ROP Regional Director letter. LPA conducted seven interviews regarding the complaint. Confidential interviews and record review revealed the facility was out of compliance with direct care staff/child ratios. -Continued on 9099-C- On 2/6/22 and 2/7/22 the facility had 19 clients present in the facility which would require five staff between the hours of 7am-10pm. On 2/6/22 between 9am-10pm the facility had between two to four staff clocked in and on 2/7/22 the facility had between two to four staff clocked in between 8:26am-10pm. Based on LPAs observations and confidential interviews which were conducted and record ...

Substantiated : 87072(c)

Licensing Program Analyst (LPA) Tamara Hill was at the facility on 5/20/2022 at 4: PM when the complaint for this incident came in. LPA met with Paige Woodard, Deputy Program Director to discuss the allegation and findings for this allegation as this incident was already investigated during the case management inspecton on 5/20/2022. LPA Hill obtained documentation related to this incident and youth involved while at the facility on 5/20/2022. LPA conducted an interview with C1 (see LIC811 dated 5/20/2022) on 5/19/2022 and interviewed staff on 5/20/2022 while at the facility. LPA Hill and Ms. Woodard discussed the incident that happened at the facility on 5/18/2022 which included C1 (see LIC811 dated 5/20/2022) being beat up while in their room. LPA Hill, Jodean Hall, Licensing Program Manager, Ms. Woodard, Galey Betzler, ROP Compliance, and representatives from San Bernardino County Probation all met on 5/19/2022 to discuss the incident via video technology. During this video conference, Ms. Woodard was able to share the video of the incident where it was observed that S1 left the dorm to make a phone call, leaving that wing of the dorm unsupervised for a period of approximately four minutes. In that time, it was observed that youth entered C1's room twice and subsequently reported that they had been assaulted by youth both times they entered C1's bedroom. This incident was investigated during a case management inspection conducted by LPA Hill on 5/20/2022. The allegation ...

Substantiated : 87072(c)(10)

Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 5/20/22 at 10: AM and met with Paige Woodard, Deputy Program Director, to discuss the findings of the complaint allegations as stated. LPA Hill informed Ms. Woodard that the complaint investigation included initial complaint inspection on 1/18/2022 by LPA Jean Stidman. During this inspection, three youth and one staff were interview and additional documentation was obtained related to the allegations. Additional staff were interviewed from 1/26/2022 to 5/12/2022. During the investigation that staff handled minor in a rough manner, minor sustained an inury while in care, staff spoke inappropriately towards a minor and staff did not seek medical attention for minor in care, LPA Stidman interviewed Paige Woodard Deputy Program Director (PD), staff PD, S2, S3, S5 and client C1 (see LIC811 dated 5/20/22). LPA Stidman reviewed two client files and one staff file and obtained documentation of the incident on 1/8/22, C1's Student statement form & Youth Grievance Form, C1's medical report dated 1/12/22, C1's & C2's Student intake forms, STRTP admission agreement, Student authorized contact list, Daily notes dated 12/1/21 to 1/11/22, California STRTP admissions review, CWS Case plan update, Needs and services plan. LPA Stidman reviewed five disciplinary actions for S3 from 5/4/21 to 12/31/21. Confidential interviews were consistent that S3 used an an inappropriate restraint on C1 resulting in C1 ...

Deficiency cited at inspection

Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection to the facility on 5/20/22 to discuss a serious incident that took place in the facility 5/18/2022. LPA met with Paige Woodard, Deputy Program Director to discuss the incident. LPA Hill and Ms. Woodard discussed the incident that happened at the facility on 5/18/2022 that included C1 (see LIC811 dated 5/20/2022) being beat up by a group of youth while C1 was in their room. LPA Hill, Jodean Hall, Licensing Program Manager, Ms. Woodard, Galey Betzler, ROP Compliance Director, and representatives from San Bernardino County Probation all met on 5/19/2022 to discuss the incident via video technology. During this video conference, Ms. Woodard was able to share the video of the incident where it was observed that S1 left the dorm to make a phone call, leaving that wing of the dorm unsupervised for a period of approximately four minutes. In that time, two youth were observed to enter C1's bedroom and be in C1's bedroom for a few seconds, then the youth and C1 came out of the room. It appears that while the youth are in the hallway, words were exchanged amongst all the youth. C1 eventually returned to their bedroom and a few seconds later, three youth went into C1's room while one youth stayed in the doorway watching the door that staff had exited out of. LPA Hill conducted an interview with C1 via video technology on 5/19/2022. LPA Hill interviewed S1 on 5/20/2022 while at the facility. LPA ...

Substantiated : 87072(c)

Licensing Program Analyst (LPA) Tamara Hill was at the facility on 5/20/2022 at 4: PM when the complaint for this incident came in. LPA met with Paige Woodard, Deputy Program Director to discuss the allegation and findings for this allegation as this incident was already investigated during the case management inspecton on 5/20/2022. LPA Hill obtained documentation related to this incident and youth involved while at the facility on 5/20/2022. LPA conducted an interview with C1 (see LIC811 dated 5/20/2022) on 5/19/2022 and interviewed staff on 5/20/2022 while at the facility. LPA Hill and Ms. Woodard discussed the incident that happened at the facility on 5/18/2022 which included C1 (see LIC811 dated 5/20/2022) being beat up while in their room. LPA Hill, Jodean Hall, Licensing Program Manager, Ms. Woodard, Galey Betzler, ROP Compliance, and representatives from San Bernardino County Probation all met on 5/19/2022 to discuss the incident via video technology. During this video conference, Ms. Woodard was able to share the video of the incident where it was observed that S1 left the dorm to make a phone call, leaving that wing of the dorm unsupervised for a period of approximately four minutes. In that time, it was observed that youth entered C1's room twice and subsequently reported that they had been assaulted by youth both times they entered C1's bedroom. This incident was investigated during a case management inspection conducted by LPA Hill on 5/20/2022. The allegation ...

Substantiated : 87072(c)(10)

Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 5/20/22 at 10: AM and met with Paige Woodard, Deputy Program Director, to discuss the findings of the complaint allegations as stated. LPA Hill informed Ms. Woodard that the complaint investigation included initial complaint inspection on 1/18/2022 by LPA Jean Stidman. During this inspection, three youth and one staff were interview and additional documentation was obtained related to the allegations. Additional staff were interviewed from 1/26/2022 to 5/12/2022. During the investigation that staff handled minor in a rough manner, minor sustained an inury while in care, staff spoke inappropriately towards a minor and staff did not seek medical attention for minor in care, LPA Stidman interviewed Paige Woodard Deputy Program Director (PD), staff PD, S2, S3, S5 and client C1 (see LIC811 dated 5/20/22). LPA Stidman reviewed two client files and one staff file and obtained documentation of the incident on 1/8/22, C1's Student statement form & Youth Grievance Form, C1's medical report dated 1/12/22, C1's & C2's Student intake forms, STRTP admission agreement, Student authorized contact list, Daily notes dated 12/1/21 to 1/11/22, California STRTP admissions review, CWS Case plan update, Needs and services plan. LPA Stidman reviewed five disciplinary actions for S3 from 5/4/21 to 12/31/21. Confidential interviews were consistent that S3 used an an inappropriate restraint on C1 resulting in C1 ...

Deficiency cited at inspection

On 2/17/ Licensing Program Analyst (LPA) Maignacia Villapudua-Soto conducted a Case Management Inspection for LPA Jean Stidman with Paige Woodward, Deputy Program Director. Facility failed to submit written reports of incidents by the next working day, the 24-hour reports and the full reports within seven days following the occurrence. The facility was informed of the issue via email from LPA Jean Stidman on 1/25/22. The facility failed to report incidents dated 1/23/22, 1/27/22, 1/30/22, 1/31/22, 2/5/22 and 2/26/22 until 1/25/22, 2/3/22, 2/4/22, 2/3/22, and 2/9/22 respectively. The facility is cited on the attached LIC 809D under the California Code of Regulations Title 22, Division 6, Chapter 1, 80061(b) Reporting Requirements. Facility failed to maintain coverage by direct care staff on 2/8/22 at 8:05am of at least one awake and on duty direct care staff present at the facility for every four children, or fraction thereof, present at the facility. An Incident Report regarding this incident was submitted on 2/14/22 by Paige Woodard, Deputy Program Director (DPD), who observed the incident. On 2/14/ LPA Stidman spoke with DPD by telephone. DPD stated eight clients were unsupervised upstairs as the only staff was downstairs supervising another client. The facility is cited on the attached LIC 809D under the Short-Term Residential Therapeutic Program, Interim Licensing Standards version 4, 87065.5(b)(1)(C) Direct Care Staff/Child Ratios. Refer to 809D for Title 22 ...