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.
On March 24, 2026, three clients (C1-C3) ran away from the facility, climbed into dumpsters, and ingested unknown items. Staff called 9-1-1 and took [Child 1] to an emergency room after s/he repeatedly vomited.
From the state's report. Violation cited by DHS. 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 that a staff member put arms around the neck, lifted, and slammed the client to the ground. The client left the facility, and the guardian later reported the client had injuries and police involvement. Our summary of the state's report. The state's own wording follows.
"[Staff #9] went behind and put his arms around my neck picked me up and slammed me to the ground." [...] [Former client 7] eloped from the facility. [...] We (facility staff) called the police after the 2nd time [Former client 7] left. After the police left, he and staff #9 finished the shift. [...] Approximately one hour later around 4pm, [Former client 7]'s legal guardian/mother called and said Emergency Medical Services (EMS) and law enforcement made contact with [Former client 7] and he had an injury to his forehead and shoulders. [...] She had not called law enforcement because [Former client 7] “had already made contact with them (law enforcement)." [...] She received a call from the Assistant Program Director who informed her [Former client 7] had eloped and a handgun was involved " proceeded to the house (facility)." [...] She was told when [Former client 7] saw staff #9's handgun he left the facility and threw the metal somewhere on the side of the road.
From the state's report. Deficiency cited, complaint and follow-up survey, Type A1 violation. Cited: V 512} 27D .0304 Client Rights - Harm, Abuse, Neglect. "[...]" 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 inspection, investigative interviews with several clients disclosed a staff member making inappropriate sexual and homophobic remarks.
During the inspection, investigative interviews revealed that a client had eloped from the facility. Upon return, the provider failed to conduct a search of the client who had concealed a box opener on their person and ultimately self harmed with it, cutting their arm and neck.
During the inspection, investigative interviews revealed that a client had swallowed a battery. The provider did not seek immediate medical attention or send the client to the Emergency Room.
From the state's report. Out of compliance, complaint, investigation inspection. Cited: R380-80-6(1)(a)-(i) Client rights; R380-80-5(4) Provider shall protect clients from abuse, prevent abuse.
In plain words: { summary: A child in the program reported that two staff members punched, choked, and spit on her. The program did not suspend the staff members while looking into the claim, and reports to the state registry were delayed. } Our summary of the state's report. The state's own wording follows.
4/23/26 revealed: 3/31/26, Former client (FC) #6 self-injurious behaviors (SIB)/suicidal ideation (SI!) 4/1/26, [Former client 6], SI and elopement 4/2/26, the facility was notified by CPS of client #1's allegation that she was punched and spit on by staff #9 and staff #2 during an incident on 4/15/26, client #4, attempted elopement and jumped out of a moving van 4/16/26, client #1 altercation with peer (client #4) over use of colored pencils; physical altercation between client #1 and client #3; client #1 physical aggression with staff; restrictive intervention due to hitting, spitting on and biting staff (staff #1), and included allegation that staff #1 was abusive and hit client #1 multiple times. [...] One Suicide Attempt, suspect (Former client #6) on scene on 3/31/26. [...] One Physical Assault, suspect on scene on 6/16/26 (client #1). [...] 4/18/26, submitted on 4/21/26, clients #2 and #3 elopement.
"Internal Investigation Summary: On April 2,2026, a social worker (Department of Social Services Investigator) contacted Executive Director [ED/Licensee] and reported that [client #1] alleged she had been physically assaulted by staff (#2 and #9), specifically stating that [staff #2] choked her and [staff #9] punched her in the face An internal investigation was initiated following this report. [...] No documentation of HCPR notification for client #1's allegation that staff #2 and staff #9 "choked and punched client #1 in the face" and spit in client #1's face. [...] "It wasn't until she (client #1) bit me (staff #2) that [staff #9] pinched her (client #1) nose...(client #1) had my arm...[client #1] bit me twice, she had my arm in her mouth until [staff #9] was pinching her (client #1] nose." She and staff #9 were together during the incident, "[Staff #9] never hit her (client #1)."
Had not been suspended nor received any disciplinary action regarding client #1's allegation that staff #2 and #9 choked, punched and spit on client #1. [...] She worked on 3/19/26 and was in the back of the facility with the other clients (#1, #2, #4, #5, and [Former client 6]) during the incident when client #1 alleged that staff #2 and #9 choked, punched and spit on client #1. [...] The ED/Licensee completed the HCPR report for client #1's allegation that staff #2 and #9 choked, punched and spit on client #1.
From the state's report. Deficiency cited, complaint and follow-up survey. Cited: V 367] 27G .0604 Incident Reporting Requirements; V 132; V 132. "[...]" 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.
"They (staff) put you on 1:1 when you self-harm." [...] Clients were placed on 1:1 "only when you do self-injurious behaviors." [...] "On my 3rd day (1/27/26), there was an incident where [Former client 6] got into the kitchen and grabbed a knife and threatened me. had to remove another client (#5) and took her to [sister facility A] and [Former client 6] cut herself." [...] During an incident on 1/27/26, [Former client 6], who needed 1:1 supervision, was able to obtain a knife and use it to cut herself. [...] Staff #7 left the clients on the van with the Staff #2, who was shadowing, and then later, while [Former client 6] was agitated, left the facility without a backup staff to relieve her.
From the state's report. Deficiency cited, annual and complaint survey, Type A1 violation. Cited: V 315) 27G .1902 Psych. Res. Tx. Facility - Staff. "[...]" 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 the report, Resident #1 indicated that the staff members at the facility would not allow him/her to call Law Enforcement or Emergency Medical Services (EMS) for medical attention. It was further revealed that Resident #1 ran away from the facility for a short period of time. Lastly, it was reported that Resident #1 returned and waited on the facility front porch for law enforcement and EMS that brought him/her to hospital. [...] According to the report, Resident #2, Resident #3, and Resident #4 went to a truck stop where they were picked up by an adult male who brought them to a motel where six (6) men allegedly sexually assaulted them. It was further revealed that local law enforcement was called to the motel and two of the men were subsequently arrested.
From the state's report. Deficiency cited, severity D, licensure complaint survey. "[...]" marks text left out between sentences.
Review on 11/26/25 and 1/16/26 of law enforcement call log from 9/1/25 through 1/13/26 revealed: [...] 9/20/25, 18:21 (6:21pm), MP-RUNWY (missing person-runaway) REPORT; [...] 12/11/25 13:27 (1:27pm), DV-ASLT (domestic violence-physical assault), SUSP-SCN; [...] 9/18/25, client #3 eloped, submitted on 9/22/25. 9/22/25 client #3 eloped, submitted on 10/2/25. [...] Purpose of Investigation: The purpose of this investigation is to review and assess allegations made by consumer, while in hospital for behaviors. [Client #2] alleged inappropriate staff conduct, including inappropriate touching, staff being under the influence of drugs, and staff fighting while on duty.
From the state's report. Deficiency cited, annual complaint and follow-up survey. Cited: V 367. "[...]" marks text left out between sentences.
In plain words: { summary: State reviews showed past facility incidents. These included youth engaging in sexual acts on social media, self-harm, running away, physical fights, hospitalizations for suicide concerns and pregnancy, and crisis center calls. } Our summary of the state's report. The state's own wording follows.
Review on January 14, 2026 at 1:30 p.m. of a list of significant incidents reported by the facility in the previous 36 months to another state entity revealed the following reportable incidents: 1) On 3/30/23, a youth was caught performing sexual acts with men on social media. [...] 3) On 6/20/23, a youth was taken to the hospital for cutting his/her arms and legs. [...] 8) On 9/26/23, a youth ran away from work. [...] 10) On 10/11/23, a youth was taken to the hospital for treatment due to a physical altercation with another youth. [...] 13) On 12/4/23, a youth was taken to the hospital for suicidal thoughts and statements. [...] One youth was taken to the hospital to be checked out due to being pregnant. [...] 22) On 3/24/24, a local crisis center was called due to youth cutting his/herself and swallowing glass. [...] 28) On 6/25/24, a youth was 1013’d for suicide attempt. [...] 42) On 10/21/25, a youth was 1013’d for attempting suicide.
From the state's report. Deficiency cited, severity E, licensure complaint survey. "[...]" marks text left out between sentences.
In plain words: { summary: A child in the program used a razor to self-harm after staff talked with her. A former child in the program left the group home, returned, and used a rusty nail to self-harm. } Our summary of the state's report. The state's own wording follows.
10/10/25- Client #3's self-harm incident. 10/17/25- Client #3's AWOL, police involvement and hospitalization. [...] 10/31/25- [Former client 4]'s AWOL, police involvement and hospitalization incident. [...] The staff called the non-emergency police line." [...] The staff continued to process with [Client #3]. [Client #3] ate breakfast and went back to her room. [Client #3] kept her personal razor and broke the razor out of it, using it to self-harm. [Client #3] walked back up to the staff, showing them her arms. [...] After talking with them, [Former client 4] went AWOL at 6:47 pm and was brought back to the group home by [Local County] EMS (Emergency Medical Services) around 7:30 pm. [...] Once back at the group home, the staff monitored and followed [Former client 4] throughout the house. [Former client 4] found a rusty nail while she was AWOL the first time and used that to self-harm. [...] Staff reported that [Former client 4] hit the tree and the ground hard.
From the state's report. Deficiency cited, annual and complaint survey. Cited: V 367| 27G .0604 Incident Reporting Requirements. "[...]" 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 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 childs 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.
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.
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.
Based on the information that LPA was able to obtain, [Staff 1] did have an inappropriate relationship with [Child 1] by mainitaining contact with him while he was on unauthorized absence from the facility and posing as his mother to try to enroll him in school.
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.
Additionally, assessments completed by SP2 showed that [the alleged victim] experienced and/or was “high risk” to sexual trafficking and/or commercial sexual exploitation to which the facility maintained certification in compliance with FFPSA that specialized its programming in serving youth with this history and/or vulnerability of being victim to. [...] Additionally, there were no attempts made by staff persons to contact the G prior to or after [the alleged victim] left the facility, with the G being unaware that there were any concerns with [the alleged victim]’s behavior, health, and/or safety until [the alleged victim] arrived at the G’s home in “the middle of the night.” It was later determined that after [the alleged victim] left the facility, [the alleged victim] was sexually assaulted by the C who was then criminally charged, convicted, and sentenced for sexually assaulting a minor ([the alleged victim]) during the evening of May 25, 2024.
From the state's report. Maltreatment determined as to neglect 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.
On 9/22/24 Client #1 tried to elope and was laken to the hospital for evaluation. [...] Client #1 told hospital staff that Staff #1 pushed her and denied her water. [...] Staff #1 came and pushed her back into her bedroom.
From the state's report. Deficiency cited, annual, complaint, and follow-up survey. Cited: V 132) G.S. 131E-256(G) HCPR-Notification,. "[...]" marks text left out between sentences.
The operation failed to obtain timely medical care for a child after they ingested over the counter medication during an unauthorized departure.
From the state's report. Risk level: High. Cited: 748.1531(a)(2) - Medical care-A child in care must receive medical care as needed for injury, illness, and pain.
Staff (Staff #1) then tried to open the door and realized that there was something pushed a against the door. [...] "Arrestee Information: [Staff #1]. Type of arrest: Taken into custody. [...] Charge #1: Rape- 2nd degree. [...] Charge #3: Statutory rape of a child <15 or =15. [...] He (Former Client #6) then asked [Staff #1] if he wanted him to do oral sex on him. [Former Client #6] then performed oral sex on [Staff #1]. [Staff #1] ejaculated in client's mouth. [Staff #1] then cleaned himself with [Former Client #6]'s shirt. [Former Client #6] afterwards told [Staff #2] at the facility." [...] " then ran away from the home (facility) and Cc went to the police." Facility staff called the police when he ran away. He told police there was evidence. [...] Later that day, Former Client #6 informed Staff #2 about the sexual abuse. [...] Staff #1 was charged with Rape- 2nd degree, Indecent Liberties and Statutory rape of a child <15 or =15.
From the state's report. Deficiency cited, complaint survey, Type A1 violation; Deficiency cited, complaint survey. Cited: V 512) 27D .0304 Client Rights - Harm, Abuse, Neglect; V 132) G.S. 131E-256(G) HCPR-Notification,. "[...]" marks text left out between sentences.
For example: 1/2/24 Two youths eloped, stole a vehicle, hit a pole and rolled the vehicle multiple times. 1/28/24 A child eloped and stole clothing and jewelry from Wal-Mart. 1/4/24 A child eloped, stole alcohol, was observed by law enforcement to be intoxicated and trying to break into a house. 1/5/24 A child eloped. 1/6/24 Another child eloped, stole monster drinks and Tylenol from Wal Mart returned to the facility and stated she overdosed on the Tylenol. [...] 3/11/24 A child eloped. 3/11/24 A child eloped and upon return reported she was stabbed, tased and sexually assaulted by a man. 3/12/24 A child eloped. 3/19/24 Three children eloped. 3/20/24 Two children eloped. 3/22/24 Two children eloped together. 3/24/24 Three children eloped together. 3/9/24 A child eloped. 3/31/24 three children eloped, stole alcohol and tested intoxicated. 4/1/24 Four children eloped and stole alcohol. [...] 4/16/24 A child eloped.
From the state's report. Deficiency cited. Cited: 16.04.18.207 QUALITY OF SERVICES. An organization must carry out its licensed programs in an environment that is safe, accessible, and appropriate for the .... "[...]" marks text left out between sentences.
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.
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.
In plain words: The state found that the administrator failed to keep the required log of unauthorized absences for at least 12 months. The complaint stated that a resident ran away after a fight and later passed away, and that other residents also ran away after fights. Our summary of the state's report. The state's own wording follows.
Based on documentation review, record review, and interview, the administrator failed to maintain a log of unauthorized absences for at least 12 months after the date of a resident's absence to include the name of a resident absent without authorization, name of the individual to whom the report required in subsection (K)(7) was submitted, and the date of the report. [...] The complaint alleged a resident (later identified as [Resident 2]) had an unauthorized absence and later passed away. [...] The email stated "[Resident 2] and two other [residents] ganged up fought another [resident] and afterwards they ran away." 7. [...] The text message stated "[Resident 3] fought another [resident] then ran away." 8. [...] The text message stated "[Resident 4] ran away at 8:00 am [sic] after fighting another resident." 9. The Compliance Officer requested to review the facility's written log of unauthorized absences.
From the state's report. Deficiency cited, complaint and compliance (annual). Cited: K. An administrator shall: 8. Maintain a written log of unauthorized absences for at least 12 months after the date of a resident's absence that includes the .... "[...]" 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 said two staff members sexually assaulted her while they were trying to get her phone back. The report says there is no documentation of an investigation or of protective measures being put in place. Our summary of the state's report. The state's own wording follows.
No documentation of an investigation into the allegations made by Former Client (FC) #7 that Staff #3 and Staff #4 sexually assaulted her on No documentation to support systems were put MHL0601558 Be WING 01/03/2024 in place to protect clients during an investigation after sexual assault allegations were made against Staff #3 and Staff #4 on 10/20/2023. [...] Description: Client ([Former client 7]) stated that staff (Staff #3 and Staff #4) were sexually assaulting her when staff were trying to get the phone back from the client. [...] Type of incident: Client/Staff Sexual Assault Allegation. Synopsis of incident: On Friday 10/20/2023 Client ([Former client 7]) stole staff phone and ran into her bathroom... and was making statements that staff (Staff #3 and Staff #4) were sexually assaulting her while she was in the bathroom. [...] The allegation of sexual assault incident with [Former client 7] occurred on 10/20/2023.
From the state's report. Deficiency cited, annual and complaint survey. Cited: V 132 G.S. 131E-256(G) HCPR-Notification,. "[...]" 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 report noted several serious incidents in the program, including a medical emergency from suspected drug use, aggressive physical restraints by staff that caused injuries, sexual misconduct, criminal activity, and a child leaving without permission. Our summary of the state's report. The state's own wording follows.
These incidents included a client medical emergency as a result of reportedly smoking methamphetamine, an unnecessary and aggressive physical restraint that resulted in serious client injury, a physical restraint in which a staff punched a client in the face multiple times that resulted in client injury, 5 incidents of client sexual misconduct, criminal activity, and an AWOL incident.
From the state's report. Out of compliance, complaint, focus inspection. Cited: R501-1-11(2)(a)-(f) Licensed Program Complaints and Critical Incidents.
[Staff 1] was unable to be interviewed due to whereabouts unknown at this time. On July 22, 2022, the Department received a complaint that alleged staff placed minor in (Continued) (Continued) a choke hold.
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 staff member pushed a child onto a bed and punched the child in the face, leaving a mark and causing pain. Police came to the home after the child texted a friend about another staff member. Our summary of the state's report. The state's own wording follows.
Client #2 eloped from the facility. [...] He had eloped from the facility about 3 times. [...] Staff #1 had pushed him to the bed and punched him in the face a couple months ago. Law Enforcement (LE) responded to the home after he texted a friend about staff #6. [...] Staff #1 stated "you want to kick the wall." Client #1 said "why are you hurting me?" Staff #1 said “you ain't got no money you ain't going to do no Property damage, You ain't kicking no doors and walls. [...] Staff #1 pushed him to the bed and “punched” him in the face once [...] He had a mark on the right side of his face from being punched by staff #1. He was in pain for about 2 days after he was punched by staff #1. [...] Staff #1 "pushed" client #1 onto the bed. [...] There was an allegation a staff hit a client in the jaw. [...] The CPS worker said the allegation was a 40 year old male, who she identified as staff #1, had body slammed client #1.
From the state's report. Deficiency cited, complaint survey, Type A1 violation. Cited: V 366] 27G .0603 Incident Response Requirments V 366 | |. "[...]" marks text left out between sentences.
Three clients reported a staff member solicited nude photos from one client who was Absent Without Leave (AWOL) from the facility. [...] In addition to soliciting nude photos, the clients reported the staff member allowed the clients to use the staff member's cell phone to access social media, which went against facility policy. The staff member also visited a client while the client was AWOL, brought the client food, and took the client to the staff member's home.
From the state's report. Substantiated. "[...]" marks text left out between sentences.
Staff allowed client to reside with staff and engaged in continued sexual abuse of client, when client went AWOL.
From the state's report. Substantiated (one of several allegations). Cited: 87072(d)(11).
In plain words: A staff member placed a client in physical, chemical and seclusion restraints after the client became verbally and physically aggressive, kicked doors, tried to leave the building and self‑harmed. The client was injured, receiving bruises, and the incident was recorded in multiple reports. Our summary of the state's report. The state's own wording follows.
restraint/seclusion, not in terms of Based on interview and record review, the facility practicing techniques, but with regard to failed to ensure no injury occurred during a which techniques are approved, when to physical restraint for 3 (Clients #5, #7, and #9) of use restraint/seclusion or not use it 12 (Clients #1-#12) sampled clients who had and the emphasis on avoiding injuries to documented use of restraints and or seclusion. clients and staff and avoiding restraint The findings are: whenever possible. [...] Staff was able to keep client and peer from making it out of the building but client became very physically aggressive with staff, punching them, pushing them, being verbally aggressive. [...] At 1:19:23, the client kicked door and walked down the hallway with four staff following him, pacing with his head down, kicking doors.
Staff pushed, then grabbed the client and drug to the door, then placed Client #7 in a hold at the door. [...] Client and peer used laundry basket to break light covers and used pieces to self-harm with ...1. [...] Client then started kicking doors open in an attempt to elope ...1.
Client then was trying to elope by kicking doors around the unit. [...] Client threw staff phone on the floor and while staff attempted a restraint client hit and grabbed at staff until being place in a restraint." 2.) An Incident Report Packet dated 4/11/21 by BI #4 documented, "...client became verbally aggressive with staff. [...] Once client entered room she began to self-harm.
This will be effective as that caused the injuries and developed and of 9-12-21. implemented a plan to prevent further potential injuries for 1 (Client and #9) 3 (Clients #5, #7 and #9) sampled clients who received an injury during a personal restraint. [...] At 1:19:23, the client kicked a door and walked down the hallway with four staff following him, pacing with his head down, kicking doors. [...] On 8/13/21, at 9:05 a.m., Registered Nurse (RN) #2 was asked, "How did [Client #9] get injured during a restraint on 7/27?" She stated, "He's a very aggressive, big child. He was attacking staff, and staff had to put him in a restraint, and he was taken to the floor and he got bruising.
A Seclusion and Restraint Form dated 4/12/21, documented, "Date and Time Initiated; 4/12/2021 7:21 AM; Date and Time Ended: 4/12/21 8:20 AM...Behavior demonstrated to justify use of procedure: Physically and verbally aggressive with staff, kicking doors, attempting to elope, property damage...Beginning Time: 7:23 AM; Procedure: Seclusion...Client Behavior: Combative, Cursing...Beginning Time : 7:32 AM; Procedure: Chemical Restraint; Location: Seclusion Room;...Client Behavior: Cursing..." A Report To Quality Assurance dated 4/12/21 documented, "...he began kicking doors and being non-compliant, client was asked by staff to stop but he continued until he kicked and broke one of the doors, the nurse was notified and from there client was placed in seclusion and given a chemical..." A Behavioral Intervention Observation Log dated 4/12/21 documented, "...Time 7:23 am; Procedure: 3 (Seclusion); ...Client Behavior: 2 (Calm)...Time: 7:32 am; Procedure: 4 (Chemical);...Client Behavior: 2...Time: 7:33 am; Procedure: 4...Client Behavior: 2...Time: 7:48; Procedure: 3 (Seclusion)...Client Behavior: 2...Time 8:03 am; Procedure: 3...Client Behavior: 2...8:03 am; Procedure: 3...Client Behavior: 2...8:18 am; Procedure: 3...Client Behavior: 2...8:20 am; Procedure: 3...Client Behavior: 2...release from procedure ...." Documentation indicated the client was calm at the time he was placed in seclusion, was calm at the time of the administration of the chemical restraint in the seclusion room and remained calm for 57 minutes before he was released. b.
A Seclusion and Restraint Form dated 6/21/21 documented, "...Aggressive with staff and kicking open unit doors attempting to elope... [...] Self-Inflicted... [...] The Seclusion and Restraint form dated 5/12/21 at 10:02 a.m. documented, "...kicking unit doors, self-harming, physically aggressive with staff..." RN #2 was documented as participating in the ESI for Client #3 but was not listed as participating in the Client Debriefing.
From the state's report. Deficiency cited, complaint survey with poc. Cited: N 128 PROTECTION OF RESIDENTS N 128; N 140 ORDERS FOR USE OF RESTRAINT OR N 140 Upon review of these identified issues, it is; N 149 ORDERS FOR USE OF RESTRAINT OR N 149; N 202 MEDICAL TREATMENT FOR INJURIES N 202 This deficiency has the potential to impact 9-15-21; N 130 PROTECTION OF RESIDENTS N 130 This deficiency has the potential to impact; N 188 POST INTERVENTION DEBRIEFINGS N 188 This deficiency has the potential to impact 9-15-21. "[...]" marks text left out between sentences.
In plain words: State inspectors found the facility failed to provide proper treatment, keep continuous watch during sleep hours, and follow its licensed capacity limit. The facility also failed to create plans to address behaviors such as running away, sexualized actions, and self-harm. Our summary of the state's report. The state's own wording follows.
Based on observation, interview and record review the facility staff failed to provide intensive, active therapeutic treatment and interventions to ensure safety and to minimize the occurrence of behaviors, failed to assure staff were providing continuous supervision during sleep hours and failed to operate within the scope it was licensed for by admitting a 5th client while it was operating at its licensed capacity of 4 clients affecting 2 of 2 current audited clients (#1 #2), 2 of 2 current unaudited clients (#3 #6) and 2 of 2 former clients ([Former client 4] [Former client 5]). [...] Based on interview and record review, the facility failed to develop and implement strategies and interventions within a treatment plan to address behaviors of elopement, sexualized behaviors and self injury affecting 1 of 2 former clients ([Former client 4]).
From the state's report. Deficiency cited, annual, complaint, and follow-up survey, Type A1 violation. Cited: V 293} 27G .1701 Residential Tx. Child/Adol - Scope. "[...]" 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.
Additionally, as had one hospitalization for self-harm and suicidal ideation prior to placement in a therapeutic foster home as placed in a therapeutic foster home after she was discharged from American Children’s Home abruptly, June 2018. [...] Additionally, HB hes had one hospitalization for self-harm and suicidal ideation prior to placement in a therapeutic foster home. was placed in a therapeutic foster home after she was discharged from American Children's Home abruptly, June Initially, ME cclimated well to her foster family. [...] For recipients identified as high risk for dangerous é or self injurious behaviors the discharge/transition fan includes admission to the appropriate level of care. [...] New behaviors have arisen this month. i had sneaked a railroad spike to the home and started self-harming. [...] 2/19/2019- Recently participated in self-harming behaviors which has led to her be hospitalized.
From the state's report. Deficiency cited, complaint and follow-up survey, Type A1 violation. Cited: V 296 anything management staff will be asked to put. "[...]" marks text left out between sentences.
Client #1 made an allegation against Staff #5 regarding Staff #5 using a choke hold while on the van. [...] Client #1 made an allegation against Staff #5 regarding Staff #5 using a choke hold while on the van. [...] Was brought into the library by Staff #4 when he attempted to elope and Staff #4 who grabbed his shirt and pushed him against the wall; [...] Client #1 made an allegation against Staff #5 regarding Staff #5 using a choke hold while on the van, Review on 10/2/19 of the North Carolina Incident Response Improvement System revealed:
From the state's report. Deficiency cited, complaint and follow-up survey. Cited: V132. "[...]" marks text left out between sentences.
In plain words: A client said a former staff member forced him to perform oral sex and sexually abused him on two dates after earlier inappropriate touching. The client told a staff member, who reported the abuse to a qualified professional and the program’s licensee. Our summary of the state's report. The state's own wording follows.
"[Client #2] further stated that he was forced to perform oral sex on [Former staff 11] on May 19, 2019 around 9 pm while at the facility. [Client #2] stated that [Former staff 11] stood up and told [client #2] to come over to where he was standing and grabbed his head and pulled his head down to his penis area." [...] He was sexually abused by [Former staff 11] on 5/17/19 and 5/19/19. Three to four weeks prior to 5/17/19 and 5/19/19 sexual assaults, [Former staff 11] had touched his butt "like four times before." [...] Denied that he ever told [Former staff 11] about his past or that he was sexually abused. [...] Client #2 made her aware that [Former staff 11] sexually abused him and she contacted the QP, the Licensee #1 and an unknown staff. [...] On 5/20/19 at approximately 12:27 a.m. he received a call from the QP that [Former staff 11] has allegedly sexually abused client #2. [...] And he said the guy eventually molested him.
From the state's report. Deficiency cited, 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.
The MP had built a program for boys "that a [North Carolina (NC) law enforcement association] could model statewide;" [...] 2/12/17 Juvenile Petition: physically abused and injured or sexually abused by parents Interview on 6/25/18 with Client #1 revealed: [...] Staff #14 "had put him (Client #6) on the floor on his stomach because he started punching stuff and being violent;" [...] Staff #14 and Staff #13 told him he had no rights and then had slammed him on the floor trying to restrain him; [...] Staff #14 had left Client #2 at the "temple" or "mud dog"( public baseball field with concrete/rock stairs) to work out running up the stairs and around the ball field because Client #2 had said he was going to run away; [...] Staff #14 had worked for the local Sheriff's Department for 2 % years; [...] Staff #14 walked back to the client's room and Client #5 was kicking the bed and thumping the wall;
From the state's report. Deficiency cited, annual and complaint survey, Type A1 violation. Cited: V 514. "[...]" marks text left out between sentences.
In plain words: Due to a failure to provide proper staffing and supervision, young people in the program were sexually abused and exploited by a van driver and another man from the community. Our summary of the state's report. The state's own wording follows.
An admission assessment dated 3/9/18 noting “was admitted from a crisis center, Full Scale 1Q of 92, victim of physical, sexual and emotional abuse, witnessed her father being shot and killed by the police, held client and her mom hostage in a standoff, situational drug related incidents such as seizures, mini strokes, panic attacks and blacking out, self-injurious behaviors (picks skin), prior inpatient and outpatient treatment, verbal altercations, issues with being disrespectful and not following rules, destroys property, got high off of Xanax and overdosed (took 21 pills), sniffing cleaning products, AWOL from previous placements, poly-substance abuse (marijuana, alcohol, methamphetamines, over the counter drugs, crack/cocaine, opiates, hallucinogens, barbiturates and inhalants)."
Because of the failure to provide appropriate staffing and supervision, clients were sexually abused and exploited by the Church van driver (CVD) and another non-staff adult male in the community.
From the state's report. Deficiency cited, complaint and follow-up survey. Cited: V 295 27G .1703 Residential Tx. Child/Adol - Reg. for A; V 293.
In plain words: A child in the program stole a school laptop from the office to contact men and then ran away from the group home. Staff found her, talked to her about the dangers of contacting older men, and she agreed to follow safety rules before running away later that shift. Our summary of the state's report. The state's own wording follows.
One elopement noted in September 2017. [...] Due to hospitalization between 03/06/18 and 03/21/18, client #8 was not able to be interviewed. [...] 02/25/18, client had been caught inappropriately using her alternative school laptop...client had stolen her school laptop from the staff's office and was attempting to utilize in her bedroom to facetime men...staff discovered Cc client using the laptop during a routine check and retained the tablet..staff educated the client on the dangers of seeking older men, giving out her personal information such as the residential placement's address and attempting to link up with men to be sexually active... client was able to contract for safety and agreed not to steal electronics, utilize face book again to contact men and to really focus on her school work...later in the shift, client eloped from the group home. [...] She was hospitalized in that area.
From the state's report. Deficiency cited, complaint survey. Cited: V 296] 27G .1704 Residential Tx. Child/Adol - Min.. "[...]" marks text left out between sentences.
On Saturday April 2, 2016, Staff Member A did not provide adequate supervision to Child #6, Child #8 and Child #9 who absconded from the program and entered the upstairs program, at approximately 11:00 PM, where they participated along with children from the upstairs program in a physical assault on Child #2 and Child #3.
From the state's report. Citation, renewal inspection, licence action taken. Cited: 55 Pa. Code § 3800.55.f.
Child #1 eloped around 8:35pm and was hit by a train shortly after, resulting in the death of Child #1.
From the state's report. Citation. Cited: 55 Pa. Code § 3800.55.a.
Child 4 eloped from the presence of his/her 7:1 staff member as the child exited the facility's vehicte following the transport to the child's school, Child 4 ran into the wooded area next to the school, The child's 1:1 staff member and 3 other staff members pursued the child. [...] Staff Member A was then removed from the restraint and separated from the child, The restraint technique utilized by Staff Member A was an Inappropriate restraint that was not within the scope of the restraint {raining that Staff Member A received on 5/30/2043.
From the state's report. Citation. Cited: 55 Pa. Code § 3800.208.b. "[...]" marks text left out between sentences.
(b) While Consumer #6 alleged abuse (staff kicked him in the mouth) during the restraint which resulted in his assault charge, the abuse allegation was investigated internally. [...] (c) Consumer #1 was inappropriately restrained by Staff #30 on 3/17/01. [...] The consumer suffered a sprained wrist, requiring a trip to the emergency room, during the restraint. [...] Findings include: (a) Staff #5, according to internal investigation, was negligent in her duty to supervise Consumer #7 when he eloped on 1/29/01.
From the state's report. Deficiency cited, survey. Cited: C 102 64-11-5.2.a. Governing Body. "[...]" 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.