Severe reports

Enhanced Civil Penalty package for a violation that is determined to have resulted in the death of a client was approved on 05/18/2026. Pursuant to the Enhanced Civil Penalty law, Health & Safety Code section 1548 (e)(3)(A) for the death of a client receiving care at a transitional housing placement provider the Department issues an immediate civil penalty of $7,500.00. [...] A copy of this report and a Civil Penalty Assessment - Death/Serious Bodily Injury/Physical Abuse (Form 421-D) was provided to the Administrator.

From the state's report. Deficiency cited at inspection. "[...]" marks text left out between sentences.

The following was discussed: In November 6, 2024, the Facility had a serious incident that occurred, which subsequently resulted in the death of a youth in care. [...] It was not until approximately four hours after the incident that staff were aware of the youth's condition which ultimately resulted in death.

From the state's report. Deficiency cited at inspection. "[...]" marks text left out between sentences.

This report is regarding the death of a 14-year-old male client ([Child 1]), which reportedly occurred on October 28, 2025 at the facility. [...] Upon arrival, the Paramedics took over care of [Child 1] and transported [Child 1] via ambulance to the hospital, while FM proceeded to the hospital as well. [...] Hospital medical staff, along with a hospital social worker, informed facility staff and the [Child 1]'s mother that resuscitation efforts were unsuccessful, and [Child 1] was pronounced deceased. [...] The facility administrator acknowledged that the client's death was not reported to Community Care Licensing as required. [...] During the Case Management incident inspection, the Department obtained information regarding the death of a client while in care at the facility.

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 purpose of this inspection was to deliver findings for a serious incident which had resulted in a client's death in November 2024. [...] It was not until approximately four hours after the incident that staff were aware of the youth's condition which ultimately had resulted in a client's death.

From the state's report. Deficiency cited at inspection. "[...]" marks text left out between sentences.

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.

On 07/16/2025 at 01: PM, Licensing Program Analyst (LPA) Connie Goldie, made an unannounced, subsequent visit for the purpose of closing out a Case Management, regarding an incident that was reported to the Department on 06/20/2025, involving the death of a client. [...] Additionally, LPA Goldie received a copy of [Child 2]'s statements made to law enforcement and the client's, [Child 1]'s complete file.

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.

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.

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.

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.

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.

[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.

On 12/20/2022, the Administrator reported an attempted suicide at the facility by [Child 1]. [...] FM Dewalt called 911 as the Administrator Losh and Staff Scholes started CPR. [Child 1] was transported to Saint Joseph's hospital in Stockton then Life-flighted to Oakland Children's Hospital. [...] [Child 1] was pronounced deceased on 12/22/22 at 10:30 pm. [...] The cause of death was listed as suicide by hanging.

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.

Under Health and Safety Code section 1548(f)(1)(C)(ii), a violation that the Department determines results in physical abuse as defined in section 1548(f)(2) to a child receiving care through a STRTP, there shall be a civil penalty of $2500.00. Under H&S 1548, "physical abuse" includes neglect as defined in 11165.2 of the Penal Code, when the person responsible for the child's welfare is a licensee, administrator, or employee of any facility licensed to care for children. A copy of this report, the Confidential Names Form, Appeal Rights, and the signed LIC 421-D (CRP) Civil Penalty Assessment - Death / Serious Bodily Injury / Physical Abuse were provided to the facility representative.

From the state's report. Deficiency cited at inspection.

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.

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.

In plain words: A staff member sexually abused a client multiple times during one‑on‑one walks on facility grounds, and the state gave the facility a report and civil‑penalty forms. Our summary of the state's report. The state's own wording follows.

LPA Yamamoto met with the facility representative named above and discussed the following: On 3/4/21, the Department received a complaint that staff sexually abused client in care and engaged in conduct inimical to clients in care. Confidential statements obtained during the investigation revealed that the sexual abuse occurred multiple times on facility grounds when client and staff went for one on one walks. [...] Per Health and Safety Code section 1548(2), "physical abuse" includes sexual abuse as defined by Penal Code section 11165.1 which includes Section 288a oral copulation. [...] A copy of this signed report, Confidential Names Form (LIC 811), Appeal Rights and Form LIC 421-D (CRP) Civil Penalty Assessment - Death / Serious Bodily Injury / Physical Abuse were provided to the facility representative.

From the state's report. Deficiency cited at inspection. "[...]" marks text left out between sentences.

LPA Yamamoto met with the facility representative named above and discussed the following: On 1/25/21, the Department received an incident report that on 1/23/21, a client in placement was found unresponsive at the facility after staff exited a bathroom. Staff called 911 and first responders arrived. Client was taken by paramedics to the hospital where client later died. On the same day, the Department received a complaint alleging neglect/lack of supervision resulting in a client's death. [...] A copy of this signed report, Confidential Names Form (LIC 811), Form LIC 421-D (CRP) Civil Penalty Assessment - Death / Serious Bodily Injury / Physical Abuse and Appeal Rights were provided to the facility representative.

From the state's report. Deficiency cited at inspection. "[...]" marks text left out between sentences.

The Department received a complaint alleging that a client, who was left unsupervised, choked on food resulting in client's death. [...] Staff called 911 and was instructed to perform chest compressions by the 911 operator. [...] Client passed away at the hospital.

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

In plain words: The state investigated a complaint that a staff member failed to properly supervise a fifteen-year-old resident before the child died. The state determined the violation resulted in the resident's death and issued an immediate seven thousand dollar fine to the program. Our summary of the state's report. The state's own wording follows.

On July 23, 2021, the Department concluded a complaint investigation alleging that staff #1 (See the Confidential Names List, LIC 811, dated September 3, 2021) neglected to provide the supervision necessary to meet the needs of fifteen-year-old client #1, prior to [Child 1]'s death. [...] Pursuant to the Enhanced Civil Penalty law, the Health and Safety (H&S) code section 1548 (e)(3)(A) 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 be issuing an immediate civil penalty of $7,000.00." An exit interview was completed and appeal rights discussed. Copies of this report, the Confidential Names List, Appeal Rights and a Civil Penalty Assessment - Serious Bodily Injury/Physical Abuse (Form 421-D) were provided to the executive director.

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.

On February 16, 2021, CCL received an allegation that staff (Staff #1) neglected a minor (Child #1) resulting in a death. [...] Based on record review, observation of video footage, and confidential interviews the allegation that staff (Staff #1) neglected a minor (Child #1) resulting in a death is substantiated.

From the state's report. Substantiated. Cited: 87078(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.

The purpose of inspection is to deliver the case management investigation findings of the reported death of non minor dependent participant on 02/26/21. [...] Confidential Interviews and documentation reveal that program staff were aware of ongoing issues that were happening at the apartment complex which resulted in the death of a non-minor dependent participant in care.

From the state's report. Deficiency cited at inspection. "[...]" marks text left out between sentences.