The most serious findings in the state inspection reports we hold: deaths, sexual and physical abuse, restraints that injured a child, suicide attempts, medical neglect and hospitalisations. Every quote below is the licensing agency's own wording, and each one was read against its report by a person before it was listed here.
The preponderance of evidence standard has been met, therefore the above allegations, staff engaged in sexual interactions with client in care and staff made several inappropriate comments to client in care are found to be SUBSTANTIATED.
From the state's report. Substantiated.
On 08/31/2022, Community Care Licensing (CCL) received an allegation that [Child 1] was injured by staff due to excessive restraint. It was reported that [Staff 1] restrained [Child 1], when [Child 1] attempted to leave the facility and pushed and tussled with [Child 1], resulting in bruises on [Child 1]'s legs. [...] Based on confidential interviews and a review of the gym video footage, the allegation that [Child 1] was injured by staff due to excessive restraint is substantiated.
From the state's report. Substantiated. Cited: 84072(d)(11). "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
The operation failed to report sexual abuse against a child in care by another resident.
From the state's report. Risk level: Medium High. Cited: 748.303(a)(5)(A) - Serious Incident-Report to Licensing soon as aware of an incident of sexual abuse of a child against another child.
On December 8, 2021, Community Care Licensing (CCL) received a complaint alleging neglect/lack of supervision as Youth #1 was reportedly sexually assaulted by another youth resident while in care (see LIC811, dated October 11, 2022). [...] On October 28, 2020, LAPD responded to Adolescent Growth, Inc. concerning an alleged sexual assault between [Youth 1] and Youth #2 reportedly occurring on October 27, 2020, for which [Youth 2] was subsequently arrested.
From the state's report. Substantiated. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
A 32-year-old volunteer for the operation engaged in inappropriate sexualized contact with two 10-year-old males in care.
During the course of the investigation, it was determined that an operational volunteer did not use proper judgement and did not demonstrate self-control in the presence of the children by engaging in inappropriate sexualized contact and behavior with two children in care.
From the state's report. Risk level: High; Risk level: Medium High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation; 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks.
Based on confidential interviews and record review, the preponderance of evidence standard has been met, and the allegations that staff ([Staff 2]) hit minor ([Child 1]) while in care and staff ([Staff 2]) is engaging in inappropriate behavior are substantiated.
From the state's report. Substantiated (one of several allegations). The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
Although the youth in the complaint is unable to corroborate the allegation, five interviews do corroborate that a minor was hit by staff while in care at the facility.
From the state's report. Substantiated.
Employee #1 continued to utilize excessive force, causing injury to Resident #1 before a three-person proper restraint was implemented.
Resident #1 was improperly restrained and remained in the care of Employee #1 in lieu of following their plan examples of "What helps me calm down or stay calm" and "What can staff do to help me" as outlined in their behavior support plan.
Employee #2 and Employee #3 arrived in the common area and witnessed Resident #1 being held down in an unapproved restraint.
Employee #1 was seen through video camera footage delivering several excessive and improper restraints towards Individual #1. Employee #1 is seen at one time pushing Individual #1's head into the door during a hold. [...] Use of excessive force when placing a person in physical or mechanical restraint; This regulation was NOT MET as evidenced by: Per the review of video camera footage by the Office of Human Rights Advocate and Office of Licensing Specialist #2 and Employee #3 watched Employee #1 place Individual #1 in an incorrect restraint without intervening.
A review of video footage on 7-25-22 for an incident occurring on 7-21-22 showed that Employee #1 used excessive force during an inappropriate physical altercation with Resident #1. Video footage reviewed on 7-25-22 confirmed that Employee #1 physically assaulted Resident #1 on 7-21-22. Video footage showed that Employee #2 and Employee #3 did not intervene appropriately when they witnessed Employee #1 holding Resident #1 in an inappropriate restraint. Employee #2 and Employee #3 walked around Employee #1 holding Resident #1 in an inappropriate restraint.
From the state's report. Non-compliance, DBHDS investigation; Non-compliance, systemic, DBHDS investigation; Non-compliance, systemic, DBHDS inve. Cited: 12VAC35-46-625. A. (7) The provider shall have and implement written policies and procedures for the on- site provision of a structured program of care or ...; 12VAC35-46-900. A. (3) Within 30 days of admission, the provider shall develop and implement a written behavior support plan that allows the resident to ...; 12VAC35-46-800. A. (2) There shall be evidence of a structured program of care designed to: 2. Provide protection, guidance, and supervision;; 12VAC35-115-50. B. (2) In receiving all. "[...]" marks text left out between sentences.
During investigation, confidential interviews, police reports, and physical evidence were obtained, it was determined that a staff sexually abused client in care. Therefore, the preponderance of evidence standard has been met, therefore the above allegation, Staff sexually abused client in care is found to be SUBSTANTIATED.
From the state's report. Substantiated. Cited: 84072(d)(11).
A report obtained by law enforcement reflects that BOD and the minor sustained bodily injuries due to an unauthorized restraint initiated by BOD.
From the state's report. Substantiated.
While the interviews had inconsistencies, video camera footage indicated the staff member did grab the arm of a client with unnecessary force.
From the state's report. Substantiated. Cited: 84072(d)(11).
A child was inappropriately restrained.
From the state's report. Risk level: High. Cited: 748.2461(b)(6) - Short Personal Restraint-Caregiver may not use restraint that twists or places the child's limb(s) behind the child's back.
In plain words: A child in the program received a head injury during a physical restraint. The facility failed to make sure the restraint did not cause the injury, and the child was sent to the emergency room for a scan. Our summary of the state's report. The state's own wording follows.
Based on record review, the facility failed to ensure a physical restraint did not result in injury for 1 (Client #1) of 1 sampled client who received a head injury during a physical restraint. [...] 6. List any revisions for the resident's plan of care, treatment, or services: Sent to ER [Emergency Room] [Hospital]...Description of injuries: R had silver dollar size hematoma on R [right] lower occipital lobe @ [at] base; Description of Treatment: APRN [Advanced Practice Registered Nurse] notified resident sent to [Hospital] for CT [computed tomography] scan of head..." b.
From the state's report. Deficiency cited, complaint survey with poc. Cited: N 128 PROTECTION OF RESIDENTS N 128. "[...]" marks text left out between sentences.
It was also confirmed that staff slapped client in the face. Based on LPA's interview with Administrator and record review(s), the preponderance of evidence standard has been met, therefore the above allegations, Staff inappropriately restrained a minor while in care and Staff slapped a minor while in care is found to be SUBSTANTIATED.
From the state's report. Substantiated. Cited: 80072(a)(3), 87095(a)(1)(5).
During the course of the investigation, it was determined a child in care was physically abused by a caregiver when he was choked.
From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.
In plain words: A staff member sexually abused a child in the facility on May 12, 2022. The state investigation concluded the allegation was substantiated and cited the facility for violating the child's personal rights. Our summary of the state's report. The state's own wording follows.
The allegation that staff sexually abused a minor while in care is related to an incident that took place at the facility on 5/12/2022 involving [Staff 1] and [Child 1] (see LIC811 dated 8/26/22). [...] Based on information obtained and interviews conducted by the Investigations Branch, the allegation that a staff sexually abused a minor while in care is SUBSTANTIATED meaning the "preponderance of the evidence" standard has been met. The facility is being cited for Personal Rights section 87072(c)(11) as the licensee shall ensure that each child is accorded the personal rights specified in Welfare and Institutions Code Section 16001.9, including the right to be free of physical, sexual, emotional, or other abuse as it pertains to [Staff 1] engaging in a sexual relationship with a client while in the facility.
From the state's report. Substantiated. Cited: 87072(c)(11). "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
The facility is found in violation of this rule as both staff and youth witnesses saw Staff 1 push Youth A.
From the state's report. Violation established, special investigation. Cited: R 400.4158 Intervention standards and prohibitions.
Staff engaged in physical discipline by slamming child on a table due to child refusing to follow instructions.
Staff member slammed child on a table during the incident.
From the state's report. Risk level: High. Cited: 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.; 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.
A youth in care was injured in the face during an attempt of a restraint by a staff member.
From the state's report. Risk level: High. Cited: 748.2551(c)(2) - EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force.
In plain words: A former client reported to a school counselor that the chief executive officer was too rough during a physical hold. The report stated this caused bruises on the arms and legs and pain in the head and buttocks. Our summary of the state's report. The state's own wording follows.
An investigation had been completed this month (July 2022) regarding a client (former client (FC) #2) who made an allegation that the Chief Executive Officer/Qualified Professional (CEO/QP) physically abused him; [Former client 2] had reported to his school counselor (5/27/22) that the CEO/QP was too rough when he restrained him which resulted in bruises on his arms and legs and pain in his head and buttocks.
From the state's report. Deficiency cited, annual and complaint survey, Type A1 violation. Cited: V 132. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
(Continued on page LIC9099-C) The investigation revealed on February 7, 2022, several non-resident female juveniles were able to enter the facility and physically assault [Child 1]. [...] The Department has determined a lack of supervision contributed to the physical assault by juvenile non-residents on [Child 1].
From the state's report. Substantiated. Cited: 87078(a)(b). "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
A staff unnecessarily grabbed, pulled, and pushed a child as a means to get the child to comply.
From the state's report. Risk level: High. Cited: 748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment.
Specifically, it was reported [Staff 1] made inappropriate sexual comments to [Child 1] on at least two occasions.
From the state's report. Substantiated. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
It was reported to Community Care Licensing (CCL) that staff #1 threw an object at [Child 1] and [Staff 1] mishandled [Child 1] with an inappropriate restraint. [...] Confidential staff interviews reported that [Staff 1] then threw a plastic bottle of soda at [Child 1]. [...] The preponderance of evidence standard has been met, therefore the allegations that [Staff 1] threw an object at [Child 1] and [Staff 1] mishandled [Child 1] with an inappropriate restraint is found to be Substantiated.
From the state's report. Substantiated. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
LPA Diaz asked for medical documentation and further information regarding to [Child 1]'s death. At this time LPA Diaz was informed that the incident continues to be under investigation with the Sheriff Department. [...] At the time of this report, the cause of death had not yet been determined.
From the state's report. Deficiency cited at inspection. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
The facility is found in noncompliance for the use of corporal punishment as evidence supports Staff 1 engaged in corporal punishment when he placed his feet under Youth A causing him to fall in what appears to be an attempt to cause a negative consequence to stop his attempted kicking.
From the state's report. Violation established, special investigation. Cited: R 400.158 Discipline.
Documentary evidence revealed that Staff #1 caused an injury to Client #1 in the form of a red handprint on [Child 1]'s back which is consistent with statements that [Staff 1] "slapped" [Child 1] on the back.
From the state's report. Substantiated. Cited: 87072(c)(11). The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
On , child A was mistreated by staff member A. Staff member A made an attempt to strike a resident by throwing a punch towards the resident during an altercation.
From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.b Specific Rights.
A staff member hit a child in the chest after the child had a verbal altercation with the staff member.
From the state's report. Risk level: High. Cited: 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work..
A caregiver knowingly failed to report sexual abuse to the Child Abuse Hotline which allowed sexualized contact to continue be exhibited toward children by two caregiver(s) at the operation.
During the course of the investigation, it was determined that two operational caregiver(s) did not use proper judgement and did not demonstrate self-control in the presence of the children by engaging in inappropriate sexualized contact and behavior with six children in care.
From the state's report. Risk level: Medium High. Cited: 748.303(a)(3)(A) - Serious Incident-Report to Licensing as soon as aware of allegations or indications of abuse, neglect, or exploitation of a child; 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks.
During the course of this investigation, it was determined that a staff member conducted an unnecessary EBI and used unnecessary strength forcing a child in care to the ground causing a bruise on their face.
From the state's report. Risk level: High. Cited: 748.2551(c)(1) - EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child.
Investigator Barajas conducted the investigation in conjunction with El Dorado County Sheriff Department. Investigation with the Department showed that [Staff 1] (see LIC811 dated 7/15/22) and [Child 1] engaged in a sexual relationship, including oral sex and sexual intercourse, while [Child 1] was residing in the facility and continued after [Child 1] left the program. The sexual relationship began while [Child 1] was under the age of 18. Investigator Barajas and El Dorado County Sheriff also conducted additional interviews with two additional clients of the facility ([Child 2] and [Child 3]) who disclosed that they exchanged nude photos with [Staff 1] and that [Staff 1] made sexually explicit statements to them, including wanting to meet up with the youth and have sexual relations with the youth.
From the state's report. Substantiated. Cited: 87072(c)(11). The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
Staff pushed child and was observed on camera doing so.
From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.
Therefore, there was a preponderance of the evidence that physical abuse of [the alleged victim] occurred.
From the state's report. Maltreatment determined as to physical abuse of an alleged victim by a staff person.. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
Community Care Licensing received information on November 01, 2021 alleging that Facility Staff handled child in a rough manner, more specifically that Staff # 1 ([Staff 1]) had kicked Child # 1 ([Child 1]). [...] According to confidential information, [Staff 1] was observed to have pulled and kicked [Child 1] during an incident which occurred inside [Child 1]'s cottage on surveillance video. LPA Mena was shown surveillance video where [Staff 1] is observed kicking [Child 1] near the exit door while [Child 1] was laying on the ground. [...] Based on interviews and information gathered during the investigation, the preponderance of evidence standard has been met and the Department has determined the allegation that Facility Staff handled child in a rough manner, more specifically that Staff # 1 ([Staff 1]) had kicked Child # 1 ([Child 1]) is substantiated.
From the state's report. Substantiated. Cited: 87072(d)(11). "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
Confidential interviews reported that the incident involved [Staff 1] not letting [Child 1] keep a slime and [Staff 1] ended up dragging [Child 1] and putting [Child 1] in restraint that was not appropriate.
From the state's report. Substantiated. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
The residents returned to the facility and shared pills amongst each other and several residents were rushed to the hospital due to ingestion.
From the state's report. Risk level: High. Cited: 748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being.
Caregiver struck a 14 year old child with a shoe.
From the state's report. Risk level: High. Cited: 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work..
Both staff were aware of concerns of Youth A being physically hit by Staff 2 and there was no report made to Child Protective Services.
From the state's report. Repeat violation established, special investigation. Cited: R 400.4131 Compliance with child protection law; development of plan.
The records and the interviews indicated that a staff member did choke the minor through the improper use of a manual restraint.
From the state's report. Substantiated.
In plain words: A child in the program reported that a staff member pinched and kicked them following a restraint. The state reviewed video and interviews and found evidence that the staff member appeared to kick or try to trip the child. Our summary of the state's report. The state's own wording follows.
Supervisor reports that she was emailed Sunday evening (did not read until on duty Monday) regarding an unauthorized restraint and staff pinching the client. [...] The email stated, "Hi was rounding today by phone [unidentified person] and [Client #3] (A) made an allegation that a staff [Staff #2] pinched him and put him a restraint yesterday. have not given a restrain order this weekend and wanted to pass this along for administration to check on it ... [...] Incident (s): The [Client #3] met with his [therapist] on 3/21/22 and reported that a staff member [Staff #8] kicked him following a restraint on 3/18/2022. [...] Conclusions: Based on interviews with staff, consumer, and review of the video there is evidence to show that staff member [Staff #8] placed her foot out appearing to kick or try to trip the consumer. [...] "[Staff #8] kicked me." Interview on 05/04/2022 with Staff #6 revealed:
From the state's report. Deficiency cited, annual and complaint survey. Cited: V 512} 27D .0304 Client Rights - Harm, Abuse, Neglect. "[...]" marks text left out between sentences.
Two staff implemented an improper hold by forcibly pushing and restraining a child against the wall.
From the state's report. Risk level: High. Cited: 748.2551(c)(2) - EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force.
In plain words: A child in the program got a cut requiring stitches after a staff member took them to the floor. Witnesses and a discipline document stated that the staff member used excessive force and an unapproved technique. Our summary of the state's report. The state's own wording follows.
A. Maltreatment: On January 5, 2022, [the alleged victim] sustained a cut on his/her chin and received stitches after being taken down to the floor by [the staff person]. [...] However, P1 was in the timeout room at the time of the incident and stated that the way [the staff person] took [the alleged victim] to the floor was “excessive” and that s/he noticed blood on [the alleged victim]’s face after the incident; P2 watched the video and said that [the staff person]’s actions were not consistent with his/her training; and [the staff person]’s Staff Discipline Document stated that [the staff person] used “excessive force” when taking [the alleged victim] to the floor, using a technique that was not approved by the facility.
From the state's report. Maltreatment determined as to neglect and physical abuse of an alleged victim by a staff person.. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
During the investigation of staff physically abused minor, staff verbally abused minor, staff threatened minor and staff broke minor's toy.
From the state's report. Substantiated. Cited: 84072(d)(11).
A child in care was so distraught after the staff member pushed the child into their room and closed the door that the child began banging loudly on the door to her room.
A staff member pushed a child two times causing the child to fall.
From the state's report. Risk level: High. Cited: 748.2301(b)(2) - Disciplinary Measures-must not be physically or emotionally damaging to the child; 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work..
A caregiver was informed by 16-year-old and 14-year-old child in care that they were sexually assaulted and the caregiver observed blood on the children(s) clothing. The caregiver then failed to immediately seek medical attention or contact law enforcement as related to the incident.
She had the children shower after a sexual assault before returning them to the operation.
From the state's report. Risk level: High; Risk level: Medium High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation; 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks.
Several children indicated staff threatened to physical harm children in care.
From the state's report. Risk level: High. Cited: 748.1101(b)(4)(A)(ii) - Children's rights-The right to be free from being subjected to or threatened with corporal punishment, including spanking or hitting.
The Department received a complaint on December 17, 2021, that staff #1 physically abused [Child 1] while in care. [...] Additional confidential interviews revealed that [Staff 1] had kicked [Child 3]. [...] Confidential interviews indicate that [Staff 1] did not push [Child 2].***CONTINUED on LIC C***** Additional confidential interviews revealed that [Staff 1] did not kick [Child 3]. Based on confidential interviews that staff #1 physically abused [Child 1] while in care is Substantiated as the preponderance of evidence standard has been met for the allegation.
From the state's report. Substantiated. Cited: 87072(11). "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
On 02/24/2022, the Department received an allegation that a minor was sexually abused while in care. It was reported that staff #1 walked client #1 to the shower and raped [Child 1]. [...] Confidential interviews stated [Staff 1] had sexual intercourse with [Child 1] and charges will be filed against [Staff 1]. Based on confidential interviews, the allegation that [Child 1] was sexually abused while in care is substantiated.
From the state's report. Substantiated. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.
In plain words: An investigation found the facility failed to properly supervise young people, leading to emergency hospital care for two clients. The state issued a civil penalty for physical abuse resulting in serious injury. Our summary of the state's report. The state's own wording follows.
The complaint, which was conducted by CCL Investigations Branch, alleged that the facility failed to properly supervise clients resulting in emergency attention and hospitalization for two clients. [...] The Department determined issuance of Civil Penalty per Health and Safety Code 1548 (f)(C)(i) For a violation that the department determines constitutes physical abuse, as defined in paragraph (2), or resulted in serious bodily injury, as defined in Section 243 of the Penal Code, to a person receiving care at, but not limited to, short-term residential therapeutic program. [...] A copy of this report, Confidential Names Form, Appeal Rights, and form UC 421-D(CRP) for a Civil Penalty Assessment- Death/ Serious Bodily Injury/ Physical Abuse were provided to Facility Representative.
From the state's report. Deficiency cited at inspection. "[...]" marks text left out between sentences.
A program reads every inspection report we collect and picks out findings that describe serious harm, using the state's own severity rating or complaint outcome where there is one. A person then reads the report and approves or rejects each one. Only findings the state substantiated are listed: a citation, or a complaint the investigator upheld. A child running away is listed only when it ended in a death or a serious injury. This page is not complete: it covers the states and reports reviewed so far, and a facility's absence here says nothing about its record. Every report we hold, flagged or not, is on the state trackers.