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.
Corroborating statements found the facility has had issues with youth using drugs and alcohol while in care, including marijuana, vaping and on July 7, 2024, facility reported a medical emergency as youth was reported to have overdosed on fentanyl. [...] On an isolated incident, the youth was allegedly sexually assaulted by another resident while in care.
From the state's report. Substantiated. "[...]" marks text left out between sentences.
Regarding the allegation that staff hit and kicked youth, staff yelled at youth and staff threw objects at youth, statements made during interviews by 2 of 6 staff and video footage of client pointing to alleged staff, corroborated that staff did hit and kick youth, staff yelled at youth and staff threw objects at youth.
From the state's report. Substantiated.
[Staff 1] then dragged [Child 1] while they were face down to their bedroom".
From the state's report. Substantiated. Cited: 87072(C)(16). 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.
Law enforcement arrived to assist facility with ensuring safety of clients. Furthermore, interviews also confirmed that [Child 1] was pushed by [Staff 2] into the wall when [Child 1] was running towards [Staff 2] during the crisis.
From the state's report. Substantiated (one of several allegations). Cited: 87072(C)(16). 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 staff who spanked the minor was suspended from work the same day and terminated from employment on 11/06/24.
From the state's report. Substantiated (one of several allegations).
On 09/11/2024, Community Care Licensing received allegation that staff choked a minor while in care. [...] In regard to the allegation that staff ([Staff 1]) choked a minor ([Child 1]) while in care; it was specifically reported that on 09/09/2024, they witnessed [Child 1] get "choked" by a facility staff member (name not provided at the time of the disclosure). During investigation, confidential interviews disclosed that it was [Staff 1] that choked [Child 1] as well as physically pushing [Child 1]. [...] Confidential interviews also reported that San Bernardino County's Open Case Investigations (OCI) substantiated this incident for physical abuse against [Staff 1]. Based on the confidential interviews, a review of pertinent documentation and a review of video footage, the preponderance of evidence standard has been met, and the allegation that staff choked [Child 1] while in care is substantiated.
From the state's report. Substantiated. Cited: 87072(c)(1). "[...]" 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 Thursday, November 21st, 2024 at 9: AM, Licensing Program Analyst (LPA) Brittany Crass, made an unannounced, subsequent visit for the purpose of closing out a Case Management, regarding an incident that was reported to the Department on November 12th, 2024, involving the death of a client.
From the state's report. Deficiency cited at inspection.
LPA observed [Child 1] walked out of their bedroom and [Staff 2] and [Staff 3] pushed [Child 1] back into their bedroom while [Staff 8] held the door open.
From the state's report. Substantiated (one of several allegations). Cited: 84072(d)(18). 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 video captures staff [Staff 1] push a resident against a wall and punch the resident's chest area.
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 video shows staff [Staff 1] hit a resident in the face and the resident to immediately turn their face away.
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.
In plain words: A report alleged that a staff member sexually abused a client at the facility by kissing him and touching his genitals over his clothing. The state issued a civil penalty to the program based on this finding of sexual abuse. Our summary of the state's report. The state's own wording follows.
On April 16, 2024, the Department received a complaint alleging a Blissful Living Group Home, Inc. (BLGHI) staff ([Staff 1]) (Reference Confidential Names form LIC811 dated 11/4/24) sexually abused a client in care. [...] A client alleged that while at her home, [Staff 1] sexually abused him by kissing him on the lips and fondling his genitals over his clothing. [...] Under Health and Safety Code (HSC) section 1548(f)(1)(F)(2), a violation the Department determines results in sexual abuse as defined in Section 11165.1 of the Penal Code to a child receiving care through a Short Term Residential Therapeutic Program (STRTP) there shall be a civil penalty of $2,500. [...] A copy of this report, Confidential Names form LIC811 dated 11/4/24, Appeal Rights and form LIC 421D(CRP) for a Civil Penalty Assessment - Death / Serious Bodily Injury / Physical Abuse were given to the facility representative.
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.
In video footage, Staff 2 is observed handling Child 1 in a rough manner and confiscating [Child 1] laptop/chrome book.
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.
During the investigation of the allegations, Staff member physically abused minor in care. [...] Confidential interviews indicated that staff hit the minor while in care during a visit to the hospital.
From the state's report. Substantiated. Cited: 80072(a)(3). "[...]" marks text left out between sentences.
Based on information obtained a preponderance of the evidence was found that staff handled minors in rough manner during restraints.
From the state's report. Substantiated.
On 5/13/2024, Community Care Licensing Division (CCLD) received an allegation that on 4/24/2024, Client ([Child 1]) was transported to the hospital following an attempted suicide by hanging with a belt (refer to LIC811, dated 10/15/2024). [...] Staff on duty brought [Child 1] down and performed cardiopulmonary resuscitation (CPR) until paramedics arrived. [Child 1] was resuscitated, transported to the hospital, intubated, and diagnosed with Hypoxia. [...] Based on confidential interviews, record review, and analysis of circumstances, the Department has determined that the preponderance of evidence standard has been met; therefore, the allegation that staff did not provide necessary care and supervision to [Child 1] resulting in [Child 1]'s attempted suicide by hanging with a belt while in care is substantiated.
From the state's report. Substantiated. Cited: 84078(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.
Incident report received on January 5, 2024 referenced a, "need for proper follow up supervision and protocols to be implemented following the incident by requesting additional supervision...." Emails received show two on-duty staff, written up for "failure to provide appropriate supervision during your shift, which resulted in one student being subjected to three separate incidents of physical assault with three other students over the course of a two hour period.
From the state's report. Substantiated.
Page The Department received a complaint alleging staff ([Staff 1]) hosted minors at her home, fondled a client's ([Child 1]) genitals and kissed [Child 1] mouth to mouth in her bedroom.
From the state's report. Substantiated. Cited: 87072(c)(1). 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 August 16, 2023, CCL received allegations that staff physically abused residents, staff emotionally and verbally abused residents, Staff handled residents in an aggressive manner, staff employed inappropriate forms of discipline with residents, staff inappropriately restrained residents, and staff did not accord dignity to residents in care. [...] Based on the confidential interviews and documentary evidence, the Department has determined that there is a preponderance of evidence that staff [Staff 1] and [Staff 2] physically abused clients [Child 1], [Child 2], [Child 3] and [Child 4] while in care.
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.
The investigation revealed, reported allegations of Youth #1 being inappropriately touched by former staff member ([Staff 1]) was previously investigated by the San Luis Obispo Police Department in February 2020 and the matter was closed. In September of 2020, the same allegation of being inappropriately touched by [Staff 1] was investigated by CCL Investigator Mariana Lomeli and substantiated regarding [Staff 1] sexually abusing minors in care.
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.
Based on the information that this LPA was able to gather the allegations that client was confined to his room, that staff handled client in a rough manner and that [Child 1] was inappropriately supervised are substantated.
From the state's report. Substantiated. Cited: 84078(b), 84072(d)(23). 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, LPA interviewed staff and clients which revealed that staff handled minor in a rough manner.
From the state's report. Substantiated.
The Department received a complaint on September 21, 2023, alleging staff pushed child. [...] Confidential interviews revealed that [Staff 1] admitted [Child 1] came towards [Staff 1] and in self-defense [Staff 1] pushed [Child 1] away and [Child 1] fell and hit [Child 1]'s back. Based on interviews and record review, the preponderance of evidence standard has been met and the Department has determined that [Staff 1] pushed [Child 1].
From the state's report. Substantiated. Cited: 84072(c)(15). "[...]" 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.
Based on confidential interviews, observations, and record review, including review of police investigation report and interviews with alleged victim and suspect, it was alleged that a staff member hit a resident with an open hand on the face.
From the state's report. Substantiated.
In plain words: A state report found that a staff member dragged, kicked, and pulled the hair of a child in the program. The state substantiated these allegations of rough handling based on interviews and file reviews. Our summary of the state's report. The state's own wording follows.
On March 15, 2024, the Department received the allegation that staff dragged and kicked minor in care. [...] A confidential interview stated that [Staff 2] attempted to grab on to [Child 1]'s arm for a hold, however, [Staff 1] grabbed and dragged [Child 1] into the garage. A confidential interview maintained that staff kicked and stepped on [Child 1]'s foot during the dragging. Based on confidential interviews, the preponderance of evidence standard has been met, therefore, the allegation that [Staff 1] dragged and kicked [Child 1] in care is substantiated.
It was further reported that [Child 1] stood up and charged back at [Staff 1] and [Staff 1] grabbed [Child 1] by the hair and yanked [Child 1]'s head back. [...] Based on confidential interviews and file reviews, the preponderance of evidence standard has been met, therefore, the allegation that [Staff 1] handled [Child 1] in care in a rough manner is substantiated.
From the state's report. Substantiated; Substantiated (one of several allegations). Cited: 80072(a)(1); 80072(a)(3). "[...]" 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.
(continued on LIC 9099c) Specifically, it was stated that [Staff 1] grabbed [Child 3] by the shirt and pulled [Child 3] towards to [Staff 1] and [Staff 1] made an inappropriate statement to [Child 3].
From the state's report. Substantiated. Cited: 87072(c)(1). 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 alleged Staff hit youth. [...] On 03/08/2024, the Department received a complaint alleging that a staff hit youth. [...] [Staff 1] stated that she did not slapped or punch the youth. [...] [Child 1] stated that he spat on [Staff 1] again and [Staff 1] slapped him again. [Child 1] stated that he spat on [Staff 1] for a third time and [Staff 1] punched him on the face and kicked the PS5. [Child 1] stated that there was another staff that got there just before [Staff 1] punched him and the other kids were in the van. A second staff worker who was present and witness the incident stated that [Staff 1] punched [Child 1] on the face.
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 was unable to interview client 2 due to aging out of foster care and whereabouts unknown. On March 13, 2023, the Department received a complaint that alleged a facility staff has engaged in inappropriate relationships with residents and facility staff has spoken inappropriately to residents. [...] Regarding the allegation that [Staff 2] has engaged in an inappropriate relationship with [Child 1], confidential interviews confirmed [Staff 2] brought [Child 1] to their residence for a home cooked meal but documented a mall trip in the client file. [...] Based on confidential interviews, the preponderance of evidence standard has been met, and the allegation that [Staff 2] has engaged in an inappropriate relationship with [Child 1] and [Staff 2] has spoken inappropriately to [Child 1] is supported and proven by evidence, therefore the allegations are substantiated at this time.
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.
Specifically, it was reported on September 7, 2023, [Child 1], Child #2 and Child #3 were left alone upstairs in the facility at which time [Child 1] was sexually abused.
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.
Review and analysis of the facility surveillance video footage capturing the incident on September 17, 2023, determined that [Staff 1] used excessive force when pushing/forcing the quiet room door open with both hands while [Child 1] was visibly positioned on the opposite side of the door. [...] Based on confidential statements and documentary evidence, the Department has determined substantiated findings for inimical conduct displayed by [Staff 1] using excessive force causing a wrist fracture to [Child 1].
From the state's report. Substantiated (one of several allegations). "[...]" 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.
One staff absconded from the facility with a minor in care, across state lines. [...] Other behaviors were reported that corroborate an inappropriate relationship between the staff and client at the facility. continued on 9099-C page Based on IB findings, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations, staff had inappropriate interactions with client in care and staff absconded with client across state lines are SUBSTANTIATED, Facility is cited per Health and Safety code 1558 (a)(2) Conduct Inimical.
From the state's report. Substantiated. "[...]" marks text left out between sentences.
Specifically, it was reported that two staff members threatened to spank [Child 2] and [Child 3].
From the state's report. Substantiated. Cited: 84072(d)(10). 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.
Interviews conducted with children had similar statements and stated that a staff grabbed and pulled a child's hair and staff punching a child in the back after children threw water and condiments at staff. [...] Staff stated there was an incident that occurred where a child threw soap and water at a staff.
From the state's report. Substantiated. "[...]" marks text left out between sentences.
As a result, [Child 1] was found unconscious from an overdose and later passed away. [...] As a result, [Child 1] suffered an overdose and loss of life while under the direct care of STRTP [Staff 4]. Pursuant to the Enhanced Civil Penalty law, the Health and Safety Code 1548 (e)(3) states a violation the Department determines "resulted in the death of a person receiving care through a short term residential therapeutic program" the Department will issue an immediate civil penalty of $7,500.00. [...] A copy of this report, the Confidential Names List, and a Civil Penalty Assessment - Serious Bodily Injury/Physical Abuse (Form 421-D) were provided to the administrator.
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.
Based on confidential interviews and record reviews, the allegation of sexual abuse had maintained consistent through multiple interviews. [...] The allegations were also investigated by the Alameda County Sheriff's Office. [...] Based on the confidential interviews and record review, the allegation that staff sexually abused a youth in care has met the preponderance of doubt and is therefore substantiated.
From the state's report. Substantiated. "[...]" marks text left out between sentences.
Based on LPA's observations, record review, and interviews, a resident in care sustained bruising on their arm following an improper restraint performed by staff.
From the state's report. Substantiated.
During the investigation of staff had inappropriate relationship with youth, LPA toured the facility with LaKeisha Carter, Director on 8/29/23 and with Kim Robinson Assistant Director on 9/13/23. [...] LPA's Jean Stidman and Stephannie Verna conducted interviews with the reporting party, two staff, one resource parent and three clients on 8/29/23, 9/13/23, 9/14/23 and 11/9/23.Two out of two youth interviewed reported the staff had an inappropriate relationship with youth.
From the state's report. Substantiated. Cited: 84072(d)(10). "[...]" marks text left out between sentences.
The referral reported staff ([Staff 1]) allegedly raped a former client, who is now an adult (A1).
From the state's report. Substantiated. Cited: 87072(c)(15). 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.
Based on the information obtained, there is a preponderance of the evidence to prove that staff handled minor in care in a rough manner.
From the state's report. Substantiated.
The Penal Code Section 11165.6 defines child abuse or neglect as a physical injury or death inflicted by other than accidental means upon a child by another person. [...] A copy of this report, the Confidential Names List, and a Civil Penalty Assessment - Serious Bodily Injury/Physical Abuse (Form 421-D) were provided to the Facility Director.
From the state's report. Deficiency cited at inspection. "[...]" marks text left out between sentences.
On May 22, 2023, Community Care Licensing (CCL) received two allegations alleging due to a lack of care and supervision minor (Child #1) overdosed while in care and Minor ([Child 1]) did not receive medical treatment in a timely manner. [...] Confidential interviews and medical records note overdose as cause of [Child 1] being found unconscious. [...] Based on confidential interviews and record review the allegations alleging due to a lack of care and supervision minor (Child #1) overdosed while in care and Minor ([Child 1]) did not receive medical treatment in a timely manner are substantiated.
From the state's report. Substantiated. Cited: 87078(a). "[...]" 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.
[Staff 1] offered [Child 1] the bottled water, poured water on [Child 1]'s face causing [Child 1] to escalate, attacking [Staff 1] and bit [Staff 1]'s leg.
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.
According to SIA Birk's report, based on confidential interviews and documentation there were multiple consistent statements of multiple clients being sexually assaulted and/or inappropriately touched while at the facility.
From the state's report. Substantiated. Cited: 84072(d)(10).
On June 16, 2023, Community Care Licensing (CCL) received two allegations alleging Staff ([Staff 1]) sexually abused a minor ([Child 1]) in care and staff ([Staff 1]) bribed minor ([Child 1]). Specifically, it was reported when [Child 1] resided at the facility, [Staff 1] propositioned [Child 1] for sexual activities in exchange for items including drugs, candy, and things unavailable at the facility. Consistent confidential interviews and record review provided a preponderance of evidence of [Child 1] being sexually abused by [Staff 1] by [Staff 1] bribing [Child 1] to participate in sexual activities. Based on record review and confidential interviews the allegations alleging Staff ([Staff 1]) sexually abused a minor ([Child 1]) in care and staff ([Staff 1]) bribed minor are substantiated.
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.
LPA's observation, interviews conducted, and records reviewed were consistent that a facility employee inappropriately handled a client in care when the client was shoved. Evidence, including interviews, incident and Law Enforcement reports, video footage, and the facility's completed internal investigation, revealed that a facility employee ([Staff 2]) shoved a client during an incident on 06/21/2023. Additionally, the video footage obtained and reviewed clearly shows the alleged staff forcefully shoving a client.
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 July 28, 2023, Community Care Licensing (CCL) received the allegation that staff handled minor in a rough manner. [...] Based on confidential interviews, the allegation that [Staff 1] handled [Child 1] in a rough manner is SUBSTANTIATED because the preponderance of evidence standard has been met.
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.
[Child 1] was transported to the hospital by ambulance from the facility with confusion and shortness of breath. [...] [Child 1]'s condition continued to de-escalate over time and on March 1, 2023, [Child 1] succumbed to death due to medical complications. During the week proceeding [Child 1]'s hospitalization, [Child 1] had been observed exhibiting symptoms of not feeling well while at school. Documentary evidence determined that [Child 1] died from illnesses that were contracted while in the care of the facility. [...] The Department has determined substantiated findings that staff did not provide medical attention in a timely manner contributed to [Child 1]'s death. [...] A copy of this report, Appeal Rights, and form UC 421-D(CRP) Civil Penalty Assessment- Death/ Serious Bodily Injury/ Physical Abuse was provided to Facility Representative during this visit.
From the state's report. Substantiated. Cited: 84078(b), 84064(f)(4). "[...]" 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.
Information obtained revealed enough evidence to determine that the allegation took place and staff performed an inappropriate restraint.
From the state's report. Substantiated.
On April 4, 2023, Community Care Licensing (CCL) received the allegation that facility staff handled minor in a rough manner and facility staff inappropriately restrained minor causing injury. [...] Based on confidential interviews and document review, the allegations that facility staff handled [Child 1] in a rough manner and facility staff inappropriately restrained [Child 1] causing injury are SUBSTANTIATED because the preponderance of evidence has been met.
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.
According to SIA Birk's report, based on confidential interviews and documentation there were multiple consistent statements of multiple clients being sexually assaulted and/or inappropriately touched while at the facility.
From the state's report. Substantiated.
Regarding the allegations that staff spoke inappropriately to minor in care, and staff handled minor in a rough manner: both current and past statements from Bar Du clients support the statements from clients in this investigation regarding the way [Staff 1] has spoken to them, and physically handled them.
From the state's report. Substantiated (one of several allegations). Cited: 87072(d)(11), 87072(c)(10). 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 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.