Severe reports

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.

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.

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.

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.

[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.

([Child 1]) was upset with ([Staff 1]) and threatened ([Staff 1]) and started hitting the staff member, which resulted in ([Staff 1]) stabbing ([Child 1]) in the left abdomen. The facility contacted the authorities, and ([Child 1]) was transported to the hospital by ambulance.

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: 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.

On August 31, 2021, Community Care Licensing Division (CCLD) received complaint allegations concerning Staff member #1 who reportedly hit resident Client #1 with a vehicle while dropping minor off at school (see Confidential Names form LIC811, dated March 29, 2022). [...] Information obtained revealed enough evidence to prove the alleged, as [Staff 1] admitted that [Staff 1] was distracted and unintentionally hit [Child 1] with the vehicle as [Staff 1] was backing up while attempting to exit the parking lot at the School after dropping off facility clients on August 25, 2021. [Child 1] was taken to the hospital to be treated for injuries.

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 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 December 27, 2020, CCLD received a complaint referral alleging Neglect / Lack of Supervision as Child #1 reportedly had access to hazardous items and [Child 1] ingested hazardous items while in care (see Confidential Names form LIC811, dated 5/28/2021). Information obtained during the investigation including interviews and review of related medical records for [Child 1] indicates in part, numerous hospitalization's for [Child 1] due to ingesting foreign objects and being placed on involuntary psychiatric holds between August 2020 and February 2021. [Child 1] was hospitalized on 12/14/2020, for "foreign body ingestion" of glass. Records indicate [Child 1] ingested two fistfuls of glass shards. On 08/31/2020, [Child 1] was admitted to the hospital emergency room with complaint of swallowing glass and ingesting a metallic screw seen on x-ray. [...] On 10/04/2020, [Child 1] was admitted to the emergency room for ingesting window screws.

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.