Severe reports

On May 2, 2025, Community Care Licensing (CCL) received the allegations that staff ([Staff 1]) handled a minor ([Child 1]) in a rough manner and that staff ([Staff 1]) bit a minor ([Child 1]) while in care. [...] It was further reported that [Child 1] was admitted to a psychiatric hospital following the incident due to being considered a danger to others. ...CONTINUED A review of video and photo evidence revealed that [Staff 1] bit [Child 1] during a physical altercation at night outside, while [Child 1] was holding [Staff 1] down. [...] Based on confidential interviews and records reviewed, the allegations that staff handled a minor in a rough manner and staff bit minor in care are substantiated because the preponderance of evidence has been met.

From the state's report. Substantiated. Cited: 87072(c)(1), 87072(c)(16). "[...]" 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 physically assaulted client in care, Program does not allow clients to attend school of origin, Staff do not ensure that medication is readily available to clients, Facility is not addressing safety concerns of clients, Facility does not provide appropriate personal hygiene items. [...] Facility is being cited for violation of Interim Licensing Standards, Section, 87072(c)(1), 87072(d)(27), 87072(c)(16), and California Code of Regulations, Title 22, Division Six, Section 80075(b) Health related services, as described on the following LIC 9099-D. Civil pentalties are being assessed for Staff physically assaulting client in care and also for Staff not ensuring that medication is readily available to clients.

From the state's report. Substantiated. Cited: 87072(c)(1), 87072(d)(27), 87072(c)(16), 80075(b). "[...]" marks text left out between sentences.

The complainant reported that on November 19, 2025, Child A disclosed that they had bruises all over from staff restraining them and that staff threw them into a wall.

From the state's report. Non-compliant, complaint visit. Cited: He-C 4001.22(e) Program staff shall use seclusion and restraint in accordance with RSA 126-U and He-C 901..

The facility is found in noncompliance as per interviews and review of documentation Staff 1 was observed to have pushed Youth A and grab the back of Youth A’s shirt.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

Specifically, it was reported that on 05/06/ [Child 1] was in kitchen with [Staff 1] and they engaged in a verbal altercation led into [Child 1] hitting [Staff 1] on the head and [Staff 1] responded by pushing [Child 1]. [...] Interviews further revealed that [Staff 1] responded to being hit by jumping up from their chair and pushing [Child 1] into the fridge hard enough to make the fridge shake.

From the state's report. Substantiated. Cited: 87072(C)(16). "[...]" 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 staff member reportedly asked the child whether her boyfriend believed she was engaging in sexual activity.

From the state's report. Risk level: Medium High. Cited: 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks.

During the unnecessary physical restraint, a staff member pulled the client downward, causing the client’s head to strike the staff member’s knee and subsequently hit the floor; the client incurred a concussion.

From the state's report. Out of compliance, investigation inspection. Cited: R380-80-5(4) Provider shall protect clients from abuse, prevent abuse.

A staff member picked up a youth while on runaway status and transported them to their home. Staff did not notify the operation or law enforcement of the child’s whereabouts while engaging in an inappropriate relationship with the child.

From the state's report. Risk level: Medium High. Cited: 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks.

A caregiver shoved a toddler causing them to fall to the floor instead of using a less forceful technique such as blocking the toddler.

From the state's report. Risk level: High. Cited: 748.2461(a)(2) - Short Personal Restraint-Caregiver must use minimal amount of reasonable and necessary physical force.

Based on the video observed, staff was seen pushing child towards the wall and grabbing him by the neck.

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 that an incident occurred on facility ground on or about 2/2/2025, resulting in [Child 1] being taken to the hospital. [...] ***Continue LIC-812C*** Record review further revealed the facility had requested and been approved to have a one-to-one staff assigned to [Child 2], due to previous assaultive behaviors.

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.

Staff B and Staff C each stated that during the restraint, there was a miscommunication leading to each staff member attempting a different restraint type, resulting in the resident hitting their head on a windowsill.

From the state's report. Non-compliant, complaint visit. Cited: He-C 4001.22(e) Program staff shall use seclusion and restraint in accordance with RSA 126-U and He-C 901..

A caregiver became irate and shoved and physically aggressed a child.

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..

The nurse determined that Urgent Care or ER services were not needed and recommended that a PCP appointment be scheduled for further evaluation. [...] Shorty after, around 1450 the Member got up from [Resident 1's] seat and rushed towards [Resident 1's] peer and physically assaulted peer by throwing a barrage of punches to peer's torso and head.

From the state's report. Deficiency cited, complaint. Cited: R9-10-703.C.2.a. Administration C. An administrator shall ensure that: 2. Policies and procedures for behavioral health services and physical health services .... "[...]" 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.

Additional Non-Compliance Found During Investigation: Behavior Management: Staff member choked a resident.

From the state's report. Found during a substantiated complaint investigation. Cited: 340:110-3-154.2(b)(1) behaviors that could cause physical pain, such as shaking, striking, spanking, grabbing, yanking, pulling, pushing ....

[Staff 1] later reported BHTs provide medication administration as BHTs punch out the medications from the pharmacy-provided multi-dose packaging, place them into a cup, and give to residents. [...] The MAR stated “… Count off by 2 … 5/22/25 7:58 Chlorpromazine 25 given two to equal 50mg gave, nd [sic] two 25 mg at bedtime … 5/23/25 8:00am Chlorpromazine 25 given 50mg wrong dosage given.” 16. [...] In an interview, [Staff 1] stated the medication errors were “staff errors.” 23.

From the state's report. Deficiency cited, complaint. Cited: R9-10-718.B.3.a-b. Medication Services B. If a behavioral health residential facility provides medication administration, an administrator shall ensure that .... "[...]" 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: A former client reported having an inappropriate sexual relationship with a staff member that started at the facility and continued after the client left. The facility rules strictly forbid staff from having personal or sexual relationships with clients. Our summary of the state's report. The state's own wording follows.

"Staff members who engage in romantic or sexual relationships with clients are abusing their power and can be seen as taking advantage of their clients." [...] "Employees are prohibited from engaging in a personal relationship, including any type of sexual contact, with clients." [...] Mid Year Employee Evaluation completed by the DON and dated 8/12/25 included, "...does have 4 medication errors at the present time...completed medication review refresher in 3/2025...has been challenged to stay focused and focus on his responsibilities." [...] He informed Staff #1 to not contact him anymore on 9/12/25 because he felt like Staff #1 hadn't loved him and only wanted a sexual relationship; [...] Based on what [Former client 5] had informed him in September 2025 (exact date unknown) Staff #1 and [Former client 5] had an inappropriate relationship that began while the client was at the facility and continued after the client was discharged;

From the state's report. Deficiency cited, annual and complaint survey, Type A1 violation. Cited: V 512. "[...]" 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 || child A, B, C, and D were verbally and physically assaulted by staff member A. Following the assault, Staff Member A left the premises to go to MM car and retrieve a loaded handgun and returned to the premises and attempted to engage the residents in fighting outside the building.

From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.c Specific Rights.

On August 15, 2025, the Department received a complaint alleging that staff handled youth(s) in a rough manner.

From the state's report. Substantiated. Cited: 87072(c)(16).

Additional Non-Compliance Found During Investigation: Child Endangerment: Staff member living in the same home with residents was charged with molestation of his adopted children.

From the state's report. Found during a substantiated complaint investigation. Cited: 340:110-3-153.1(k)(4) Child endangerment. An individual whose health or behavior would endanger residents' health, safety, or well-being is ....

A child in care was physically assaulted by staff member at the operation.

A staff member at the operation performed an inappropriate restraint on a child in care, restricting the child's ability to breathe and causing pain.

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.; 748.2461(a)(1) - Short Personal Restraint-Caregiver must minimize risk of physical discomfort, harm, or pain to child.

A child in care received a serious physical injury during a restraint.

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.

The agency is found in noncompliance when Staff 1 engaged in a physical altercation that involved hitting and pushing Youth A and Youth B. 7 TECHNICAL ASSISTANCE Staff 1 failed to use his radio to call for assistance in this incident.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions..

The facility is found in violation as Staff 1 bit Youth A when Youth A was on top of Staff 1, with her legs wrapped around Staff 1’s neck.

From the state's report. Violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

Death of a resident; c.

From the state's report. Violation established, special investigation. Cited: CCI Rule 400.4150 Incident reporting.

The facility is found in noncompliance as per video review, Supervisor pushed Youth A.

From the state's report. Violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

Category A providers shalt send a copy of alt evel III incidents involving a client death to the Division of Health Service Regulation within 72 hours of becoming aware of the incident.

From the state's report. Deficiency cited, complaint survey. Cited: V 296' 27G .1704 Residential Tx. Child/Adol - Min..

In plain words: The state found multiple safety and health problems at the program. Issues included privacy violations, medication errors, improper seclusion room use, and many building hazards like mold, broken windows, and unlocked cleaning supplies. Our summary of the state's report. The state's own wording follows.

Compliance issues included HIPPA violation, timeliness of physicals, using a room for seclusion and not following the seclusion use requirements, not meeting the seclusion room physical requirements, seclusion room documentation, and medication errors resulting in a child receiving the wrong dosage.Maintenance concerns with some, needing to be addressed with expeditious correction to mitigate the risk for harm or injury, included: a broken window, mold in a bathroom ceiling and rafters, cluttered laundry room, missing door jams with nails protruding, sharp metal pieces in a window sill, cleaning supplies and other hazardous items in an unlocked closet due to locks not working, missing smoke detectors, laundry stacked against a gas water heater, bathroom door with only one hinge causing the door to not open/close/swing properly, missing floor vents, missing cabinet faces in the kitchen, an oven door that does not close completely, a loose doorknob in the bathroom, significant peeling paint in the bathroom, excessive holes in the walls throughout the house, wires protruding from a removed thermostat, sticker type weeds in the yard, a partially removed window well grate cover.

From the state's report. Deficiency cited, provisional license. Cited: 16.04.18.102.04 DISPOSITION OF APPLICATIONS. 04. Provisional License. A provisional license may be issued to an organization when a licensing standard is not ....

Per interviews, Staff 1, Youth A, Youth B, and Youth D reported Staff 2 choked Youth A while Youth A was lying on her back on the ground and Staff 2 was straddling her. Per interviews, Youth A, Youth D, and Youth F reported Staff 2 hit or attempted to hit Youth A during the altercation.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

In plain words: A complainant said a resident had scratches and bruises and was told by a staff member that the resident was in PCM restraints. A licensing coordinator reviewed video of the resident and a staff member in the calming space and found the techniques used did not follow the program’s PCM curriculum. Our summary of the state's report. The state's own wording follows.

The complainant stated that they observed scratches and bruises on Resident A, and that upon inquiring with program staff, the complainant was informed that Resident A is placed in "P[C]M restraints." The licensing coordinator reviewed video footage of the resident and staff in the Calming Space, which showed behavior management techniques being used that were not compliant with the Professional Crisis Management (PCM) curriculum utilized by the program.

From the state's report. Non-compliant, complaint visit. Cited: He-C 4001.22(g) Restraint techniques used shall be consistent with the curriculum required in (f) above and be reviewed at least annually with program staff to ....

A caregiver locked a child in care out of the operation, which resulted in the child kicking the door and breaking it.

From the state's report. Risk level: High. Cited: 748.685(c)(2) - Caregiver responsibility - provide a safe environment.

In plain words: A staff member and a child fought after the child struck the staff member. The staff member repeatedly slapped, kicked, and punched the child, leaving scratches and a welt on the child's face. Our summary of the state's report. The state's own wording follows.

The report stated, -"The nature and extent of the adult's vulnerability [in the alleged or suspected abuse, neglect or exploitation]: Suspected child abuse, consisting of staff slapped, kicked and punched client." -"The nature and extent of the adult's child injuries or physical neglect or of the exploitation of the adult's child property [include changes to the resident's physical, cognitive, functional, or emotional condition]: Client has scratches on arms and a welt mark across [Resident 1]'s face. [...] Staff then challenged the client, at which point the client lunged towards staff and struck [Staff 5] in the head. Staff raised [their], slapped the client and began punching [Resident 1] with a closed fist. [...] Staff eventually stopped; however, the client continued using profanity, kicked the staff, and pulled [Staff 5's] hair. Staff then became more aggressive by grabbing and hitting the client again.

[Staff 5] slaps [Resident 1] eight times and kicks them once (15:16:39-15:16:45).

[Staff 5] pushes [Resident 1], grabs and holds their arm, slaps them twice (15:14:45 to 15:14:48).

From the state's report. Deficiency cited, complaint and initial monitoring. Cited: R9-10-711.B.1. Resident Rights B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;; R9-10-711.B.2.i. Resident Rights B. An administrator shall ensure that: 2. A resident is not subjected to: i. Restraint;; R9-10-711.B.2.i. Resident Rights B. An administrator shall ensure that: 2. A resident is not subjected to: i. Restraint;. "[...]" 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.

An operational staff member responded to a child in a physically aggressive manner by pushing the child as a means of discipline prior to conducting an inappropriate restraint.

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.

On August 7, 2025, the client's severe self-harm required transport to the emergency room for treatment and necessitated multiple sutures. Three days later, the client was not adequately supervised and self-harmed again by removing multiple sutures from the prior injury. This incident resulted in a second transport to the emergency room for additional treatment.

During the investigation inspection, the evidence substantiated that on September 17, 2025, a client with a history of significant self-injurious behavior engaged in a serious self-harm incident that resulted in a transport to the emergency room which necessitated over 30 sutures. A second client engaged in self-harm with the same contraband which also resulted in transport to the emergency room and sutures.

From the state's report. Out of compliance, investigation inspection. Cited: R380-80-5(10) Services and supervision to meet each clients needs.

This agency has investigated the complaint alleging staff did not provide adequate supervision resulting in minor engaging in sexual behavior with an adult.

From the state's report. Substantiated. Cited: 80078(a).

In plain words: A former client refused to be searched, threatened to run away, and left a message claiming abuse. He then walked out, threatened to kill the director and the director's family, and attacked another child in the program. The report also notes two suicide attempts outside the facility. Our summary of the state's report. The state's own wording follows.

Is attempting suicide outside (facility). [...] 7/21/25 4:00pm "...Once arrive to the house (facility) he ([Former client 5]) refused to get searched staff had to ask him repeatedly to get searched it's required staff directed him to go to his room he refused to and grabbed the house and demanded staff to call his social worker or he's running away staff called the social worker number [Former client 5] then left a message stating that he has been rapped and help him he is being molested and demanded help now...([Former client 5]) walked out the door while staff was talking to the other client and demanded staff to give him [Executive Director (ED)]'s address so he([Former client 5]) can go to his (ED) house and kill and take his (ED)whole family out...He ([Former client 5]) then ran to the other client (#2) room door and kicked it open and attacked the other client (#2). [...] 7/12/25, Attempted to hang himself in the backyard of the facility;

From the state's report. Deficiency cited, annual and complaint survey. Cited: V 367|. "[...]" 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.

Per Youth A’s interview, Youth A reported having sexual interactions with Staff 1 as well as additional concerns of Staff 1 having boundary concerns with Youth A and Youth D as Staff 1 reportedly reached out to Youth D after Youth D left the facility.

From the state's report. Violation established, special investigation. Cited: CCI Rule 400.4112 Criminal history check, subject to requirements; staff qualifications.

The document stated, "...Staff informed...[Resident 1] attempted suicide by choking [Resident 1's] self with a shirt to the point [Resident 1] was unconscious [sic] staff immediately called 911. Staff explained that the incident occurred after [Resident 1's] peer was being moved to CRC...[Resident 1] became upset leading [Resident 1] to thoughts about when [Resident 1] would be going home...[Resident 1] went to [Resident 1's] room and shortly after [Resident 1] was found on the floor unconscious with a shirt tight around [Resident 1's] neck. [Police Department] was already on site because of another incident...[Resident 1] was transported to [hospital]...[Resident 1] moved to a higher level of care for now..." 2. [...] The document stated, "...Member attempted to self-harm using a bed sheet to choke [Resident 1's] self. [...] [Staff 7] reported [Staff 1] immediately called 911, removed the shirt, and checked to see if [Resident 1] was breathing. [Staff 7] reported EMS took [Resident 1] to [hospital] and [Resident 1] was transferred to a higher level of care.

From the state's report. Deficiency cited, complaint. Cited: R9-10-716.A.2.b. Behavioral Health Services A. An administrator shall ensure that: 2. If a behavioral health residential facility is licensed to provide .... "[...]" 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: A staff member used an improper restraint on a child by pulling the child from a vehicle, slamming the child to the ground, applying body weight, and placing the child in a choke hold. Our summary of the state's report. The state's own wording follows.

First caregiver on scene conducted an improper restraint on a child in care that involved removing the child from a vehicle and slamming the child's face down to the ground, placing their weight on the child, then placing the child in a choke hold as the child was moved from the ground into the caregiver's vehicle.

From the state's report. Risk level: High. Cited: 748.2605(a)(2) - Personal Restraints Prohibited-Restraints that obstruct child's airway.

The provider was out of compliance with R380-80-4(2) by a staff member, who witnessed child abuse, not immediately notifying Child Protective Services intake or law enforcement. During the investigation, the evidence substantiated that a staff member witnessed another staff member forcefully hit a client in the stomach and did not report it to the provider or to CPS.

The staff member hit a client in the stomach, a use of unapproved and non-trauma-informed behavior management.

From the state's report. Out of compliance, complaint, investigation inspection. Cited: R380-80-4(2) Report abuse or neglect; R501-1-4(5)(a)-(l) Congregate care behavior management policy.

Staff 5 utilized inappropriate restraint techniques with Youth A by restraining Youth A against the wall, positioning Youth A to face her rather than away from her, as well as using her knee against his back 6 and holding Youth A’s arms across his neck.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.5159 Youth restraint; pregnant youth; reduction, prevention; prohibited.

The purpose of the visit was to conduct case management follow-up on reports received by Community Care Licensing (CCL) reporting the death of Client 1 [LIC Confidential Names List was provided to licensee]. On September 8, 2025, it was reported to CCL that on September 2, 2025, [Child 1] left the facility without permission and was subsequently struck by a SPRINTER train. It was further reported that the facility received a call from the San Diego County Medical Examiner's Office on September 3, 2025, at which time facility staff was notified of [Child 1]'s death.The facility notified the client's family and placing agency.

From the state's report. Deficiency cited at inspection. 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 program self-reported that on August 31, 2025, Staff A shoved Resident A. Staff B stated that they witnessed Staff A shove Resident A, which they considered unnecessary rough handling of Resident A. The licensing coordinator reviewed video footage of the incident from two separate angles, confirming that Staff A roughly handle Resident A by shoving them out of the kitchen.

From the state's report. Non-compliant, complaint visit. Cited: He-C 4001.22(b)(11) Program staff shall not use rough handling on residents, including but not limited to, grabbing, pushing, pulling, and dragging..

Evidence does support the allegations that Staff 1 slapped Youth A and Youth B along with pushing Youth B on to a couch while saying derogatory statements to Youth B. TECHNICAL ASSISTANCE: Technical assistance was offered regarding staff’s interactions with the youth in the program and other staff.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

On January 23, 2025, Community Care Licensing (CCL) received allegation staff improperly restrained a minor in care. [...] Based on confidential interviews and records reviewed, the allegation that staff improperly restrained a minor in care is SUBSTANTIATED because the preponderance of the evidence standard has been met.

From the state's report. Substantiated. "[...]" marks text left out between sentences.

Staff 1 pushing Youth A backwards with two hands in a forward motion causing Youth A to stumble backwards. Staff 1 pushing Youth A into a wooden chair in the TV area, which caused Youth A to then fall to the ground.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

Confidential statements and an internal investigation determine that staff did not follow program protocol to prevent inappropriate behaviors between minors and resulting in a minor being sexually assaulted.

From the state's report. Substantiated.

The agency is found in non-compliance based on staff and youth interviews, and video footage, staff pushed Youth A, which is a prohibited form of discipline.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

It was determined that a child in care in care was treated in an unnecessary manner and harsh manner when a caregiver pushed them.

From the state's report. Risk level: High. Cited: 748.1101(b)(4)(A) - Children's rights-The right to be free from any harsh, cruel, unusual, unnecessary, demeaning, or humiliating treatment or punishment..

The facility is found in noncompliance as per interviews and video review Staff 1 grabbed Youth A by the collar area of his shirt and pushed Youth A against the wall.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.