Severe reports

Spoke with [Former client 3] again and this time she reported staff #1 slammed her head into the wall and staff #2 pulled her by hair and pushed her back on couch [...] [Former client 3] reported that both staff #1 and staff #2 assaulted her Interviews on 7/22/26 and 7/27/26 the Director reported: She was aware that [Former client 3] reported that staff #1 hit her to her DSS legal guardian [...] She did not know that the allegation from [Former client 3] required an IRIS because the police had not been called

From the state's report. Deficiency cited, 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.

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.

In plain words: { summary: Six staff members failed to protect a child who had a history of self-harm. The child was found hanging in a bathroom and died by suicide. } Our summary of the state's report. The state's own wording follows.

Based on observation, record reviews and interviews, 6 of 8 audited paraprofessional staff (#1, #2, #4, #5, #6 and #9) failed to protect client from harm and neglect affecting 1 of 1 deceased client ([Deceased client 9]). [...] "She has an extensive history of self-injurious behaviors, suicidal ideation and at least three reported suicide attempts." Review on 3/19/26 of the North Carolina (NC) Incident Response Improvement System (IRIS) revealed: [...] "On March 15, 2026, (Executive Vice President) received a call from Chief Executive Officer (CEO) informing me that a client [Deceased client 9] had attempted suicide at the Cornerstone Treatment Facility (facility). [...] "Staff reported that [Deceased client 9] was found ina bathroom hanging from the shower curtain rod by a ligature. [...] "Based on all information gathered, [Deceased client 9] died as a result of suicide by ligature. [...] "She [Deceased client 9] had previously cut herself a week or two before this incident."

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.

In plain words: { summary: A former client damaged an office door while a staff member called the emergency services. The staff member and former clients reported that physical fights and verbal threats occurred between them. The staff member confirmed he accidentally hit a former client in the face during the commotion. } Our summary of the state's report. The state's own wording follows.

While staff #1 was on the telephone with 911, [Former client 2] caused property damage by punching and kicking the office door. [...] "Staff #1 punched me in my face and ended up with a busted lip and messed up eye." [...] They had stopped fighting but staff #1 kept “talking junk" and punched his brother in the face and they started fighting again. [...] "He [staff #1] would jokingly say how he would hurt me and my brother- how he would choke us out, stab us, shoot us, try to kill, punch us and slam us against the wall. [...] Staff #1 punched [Former client 1] trying to get to him. [...] "[Staff #1] hit my brother to get to me. He (staff #1) hit me and we started fighting." [...] "[Staff #1] called the police." Cc [...] The kid said something about his mom, [staff #1] punch the kid. [Staff #1] don't hit first unless he have to. can't recall the name of the kid." [...] Staff #1 confirmed he did hit [Former client 1] open handed by accident in the face in all the commotion.

From the state's report. Deficiency cited, complaint 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.

In plain words: { summary: During an incident, a child bit a staff member, and the child was later taken to the hospital. A video showed the staff member putting the child in a chokehold. Police later arrested the staff member on charges of cruelty to children and assault. } Our summary of the state's report. The state's own wording follows.

During this process, Resident #2 bit Staff B. Lastly, the IIF stated that Staff B was arrested on cruelty to children allegations and Resident #2 was transported to the hospital for evaluation and treatment. [...] Staff A further stated that Resident #2 stated that Staff B choked Resident #2 and he/she could not breathe. [...] Review on June 10, 2026 of the ring camera video revealed that Staff B was seen on the ground with Resident #2 in what appeared to be a chokehold. [...] Review on June 12, 2026 of the police report, dated April 5, 2026 that at approximately 1900 hours Staff B was arrested on allegations of aggravated assault, cruelty to children in the first degree, and 3 counts of cruelty to children in the 3rd degree for allegedly placing Resident #2 in a chokehold while punching Resident #2 for an extensive period of time in the presence of three juveniles.

From the state's report. Deficiency cited, severity D, incident survey. "[...]" marks text left out between sentences.

In plain words: { summary: Medical and police records showed potential bodily fluid on a child in the program during an exam. The child reported that a staff member gave them a THC vape pen during a sexual assault. The state found that the facility failed to respond to the sexual assault and provide necessary care because four staff members did not report it until the child called for help. } Our summary of the state's report. The state's own wording follows.

A. Maltreatment: Regarding Sexual Abuse Information provided in [the alleged victim]’s medical record and in law enforcement information showed that during [the alleged victim]’s SANE exam, speckled fluorescence appeared under ultraviolet light that indicated potential bodily fluid. [...] Sexual abuse includes threatened sexual abuse.) Regarding Neglect The [the alleged victim] provided consistent information that [the staff person] provided [the alleged victim] with a THC vape pen during the time of the sexual assault. [...] Additionally, given that [the alleged victim] called and reported the sexual assault him/herself, after four staff persons with various levels of authority failed to report the incident, and that without [the alleged victim] reporting the incident him/herself the alleged sexual assault would have not been investigated there was a preponderance of the evidence that the facility failed to respond to a sexual assault and supply [the alleged victim] with necessary care and services.

From the state's report. Maltreatment Determined as to sexual abuse and 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.

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.

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.

The document stated, “The client, [Resident 1], reported an allegation that staff had physically hit [Resident 1] and caused a mark. [Resident 1] further stated that [Resident 1]intended to present this claim at school. [...] On March 31, 2026, at approximately 6:30 AM, during the morning routine at Mattie’s Care House, LLC, [Resident 1] made a concerning statement indicating [Resident 1's] intent to report an allegation of abuse against staff. [Resident 1] stated that [Resident 1] planned to go to school and report [sic] that staff had hit [Resident 1] and caused a mark. [Resident 1] further expressed that [Resident 1] would create the mark [sic] [Resident 1] in order to support this claim. [...] 7. While on site, the Compliance Officer observed [Staff 1] conduct a phone call to the local police department.

From the state's report. Deficiency cited, complaint. Cited: 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.

Type of Incident: "suicide attempt, suicide gestures, self-harm, aggression, property damage;" [...] At approximately 1:55 PM, law enforcement arrived and assumed control of the scene. [...] At approximately 2:05 PM, Emergency Medical Services (EMS) arrived. Law enforcement escorted the client to he ambulance. [...] AP arrived at the facility when [Client #1] was getting ready to be transported by EMS to the local hospital on 1/4/26; "She (Executive Director/Licensee) told me to tell the police that the other staff was gone to get something to eat" on 1/4/26;

Psychiatric hospitalization or crisis stabilization admission; [...] On 1/4/24, Staff #1 was at the facility alone with Client #1, when she started to have Cc aggressive behaviors, and inflicted self- harm by cutting herself with glass. [...] EMS transported client to local hospital.

From the state's report. Deficiency cited, complaint survey, Type A1 violation. Cited: V 296] 27G .1704 Residential Tx. Child/Adol - Min.; V 293} 27G .1701 Residential Tx. Child/Adol - Scope. "[...]" 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.

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 ....

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.

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 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.

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.

Each youth provided a statement to police about the alleged incident. [...] Resident #3 further stated that Staff B told them to hit the blunt.

From the state's report. Deficiency cited, severity D, incident survey. "[...]" marks text left out between sentences.

(GA00184433) Findings Include: Review on September 7, 2025 at 10:30 a.m. of the Intake Information form for intake GA00184433 revealed that Resident #1 rushed Staff A and Staff A slammed Resident #1 into the wall to stop Resident #1 from lunging into him/her. [...] Finally, Staff B stated that Resident #1 was brought back to the group home by law enforcement. [...] Finally, Resident #2 stated that Resident #1 left the group home and was brought back by the police. [...] The investigation revealed that upon resident interview, staff interviews and documentation review, Staff A engaged in a confrontation with Resident #1 that resulted in corporal punishment being used by Staff A against Resident #1.

From the state's report. Deficiency cited, severity D, incident survey. "[...]" marks text left out between sentences.

In plain words: Records showed residents earned money for cleaning. A child reported hearing rumors about a staff member and another child having a sexual relationship. An incident report noted a child wrapped a fan cord around their neck while staff were busy, leading to a restraint. During that restraint, a child reported a staff member twisted their wrist and forced them to the ground. Our summary of the state's report. The state's own wording follows.

[Resident 5]'s and [Resident 10]'s pages documented that on May 25, 2025 and June 7, 2025, [Resident 5] and [Resident 10] earned $20 per day each for "cleaning apartment," and $10 each on June 3, 2025 for "cleaning feet." 7.In an interview, [Resident 3] stated [Resident 5] is [Staff 1]'s "number one worker," and that [Resident 3] has heard rumors from multiple people regarding [Resident 5] and [Staff 1] being in a sexual relationship. [...] 9.In an interview, [Resident 5] reported other residents have made comments to [Resident 5] about [Resident 5] and [Staff 1] being in a sexual relationship.

A review of [Resident 4]'s medical record revealed a document titled, "Incident Report Form," dated May 25, 2025, which stated, "..There was a situation going on that had staff a bit pre-occupied and peer...went to talk to [Resident 4] and found [Resident 4] with a standing fan cord wrapped around [Resident 4's] neck. [Peer] yelled for staff...[Resident 4's] peer...came out of the room carrying the standing fan...[Resident 2] was sitting on the bed and [Staff 7] moved into escort [Resident 4]...[Resident 4] was put into a PCS restraint to escort [Resident 4] down the hall..." 7. [...] During this restraint [Resident 2] reported staff twisted [Resident 2]'s wrist and put [Resident 2] down to the ground, stating "it hurt." [Resident 2] also stated staff will use their hands or knee to hold the residents down on the floor "like police grabbing you." 10.

From the state's report. Deficiency cited, complaint. Cited: R9-10-716.A.7.a. Behavioral Health Services A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings ...; 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.

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.

A staff did not provide youth with a safe environment when he engaged in inappropriate sexual activity with children in their care. Staff confessed to law enforcement that he took the youth to Walmart, sexually abused them, and had naked photos of the girls on his phone.

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

It was alleged that [Staff 1] hit [Child 1] back and attempted to restrain [Child 1] during this interaction. Immediately following the interaction, [Staff 1] called law enforcement and reported they had been assaulted in the facility.

From the state's report. Substantiated. Cited: 87072(c)(1). The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

Furthermore, the evidence shows [Staff 4] physically assaulting [Child 1] by wrestling and throwing [Child 1] to the ground resulted in [Child 1]'s broken arm. [...] Moreover, based on the evidence, [Staff 4] was arrested for PC 243(D)- Battery with serious bodily injury and PC 273a(a)- child abuse with possible great bodily injury.

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.

At 4:12 AM, the patient was found unresponsive. [...] Staff called Emergency Medical Services (EMS), and they arrived around 2:50 AM. EMS took the patient’s vitals, and the patient refused to be transported to the ER. [...] Staff called 911 and administered Narcan to the patient. [...] The document showed that EMS responded and worked on the patient for 15 minutes and got a pulse. The patient was stabilized and transported to the local hospital. [...] Law enforcement responded to the scene and investigated the incident.

Failure to monitor access and egress to the facility can result in a lack of oversight of the facility and poor patient outcomes, including death. [...] The document showed that Emergency Medical Services (EMS) responded and worked on the patient for 15 minutes and got a pulse. The patient was stabilized and transported to the local hospital.

From the state's report. Deficiency cited, complaint investigation. Cited: WAC 246-337-080 – Resident care services (2)(h)(i)(ii) The licensee must address serious illness, medical emergencies, or threat to life; WAC 246-337-075 – Resident rights (2)(g) Each resident has the right to have a safe and clean environment.. "[...]" marks text left out between sentences.

Law enforcement arrived to assist facility with ensuring safety of clients. Furthermore, interviews also confirmed that [Child 1] was pushed by [Staff 2] into the wall when [Child 1] was running towards [Staff 2] during the crisis.

From the state's report. Substantiated (one of several allegations). Cited: 87072(C)(16). The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

Entity #2 informed Human Rights Advocate via letter dated October 31, 2024, that it was determined the disposition was Founded, Level One, for Sexual Abuse. Entity #2 reported to Human Rights Advocate that Employee #1 was charged with 7 felony counts of VA Code 18.2-370.1, Taking Indecent Liberties with Child by Person in Custodial or Supervisory Relationships.

From the state's report. Non-compliance, DBHDS investigation. Cited: 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation..

In plain words: A staff member sexually abused a child in the program, sending graphic TikTok messages and arranging meetings in the group home bathroom, and also left other children unattended during the abuse, sometimes in the same bedroom while they slept. The state determined the abuse was substantiated. Our summary of the state's report. The state's own wording follows.

Provider substantiated for sexual abuse and psychological abuse based on the following: Provider found inappropriate TikTok messages between Employee #1 and Individual #1 on Individual #1's phone that were sexually graphic in nature and which discussed meeting up in the group home bathroom on more than one occasion, along with references to sexual interactions which included oral sex and sexual intercourse. [...] While Employee #1 engaged in sexually abusing Individual #1, Employee #1 failed to provide services necessary to the health, safety, and welfare of other minor individuals residing in the group home, leaving those individuals unattended during the sexual encounters with Individual #1, and, at times, engaging in the abuse in the same bedroom with other individuals while they were sleeping. ?

From the state's report. Non-compliance, DBHDS human rights inspection. Cited: 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.. "[...]" marks text left out between sentences.

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.

In plain words: The state found that a staff member had inappropriate sexual relations with children in care. Staff also neglected supervision, which led to a child getting a staff member's firearm and being arrested. Additionally, staff left children alone at the facility and gave a child keys to access medications and other prohibited areas. Our summary of the state's report. The state's own wording follows.

During the inspection, it was determined a staff member had inappropriate sexual relations with children in care; staff was neglectful in supervision resulting in a child gaining access to, and being arrested for the possession of, staff's firearm; and staff being neglectful in supervision by leaving children in care alone and unsupervised at the facility while providing a child keys which access medications, supplies, and other prohibited areas.

From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation. The state recorded it as corrected at the inspection.

The investigation revealed, reported allegations of Youth #1 being inappropriately touched by former staff member ([Staff 1]) was previously investigated by the San Luis Obispo Police Department in February 2020 and the matter was closed. In September of 2020, the same allegation of being inappropriately touched by [Staff 1] was investigated by CCL Investigator Mariana Lomeli and substantiated regarding [Staff 1] sexually abusing minors in care.

From the state's report. Substantiated (one of several allegations). The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

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.

In plain words: A staff member bit a child on the shoulder to make the child let go of the staff member thumb. The child reported that the staff member put him in a chokehold and threw him on a bed, and that the child bit the staff member to get away. Another staff member called the police, and the child went to the hospital. Our summary of the state's report. The state's own wording follows.

Staff #1 bit Client #1 on the left shoulder to get Client #1 to release his bite on Staff #1's right thumb. [...] "According to [Client #1], [Staff #1] tried to put him in a chokehold and he (Client #1) bit [Staff #1] in an attempt to get out of the chokehold Vv 514 iss Mir flo( MX 25, hon (Kasi yeahs CDK911 If continuation sheet 5 of 9 Cc when [Staff #1] bit his shoulder." " don't believe he (Staff #1) bit [Client #1] maliciously." Interview on 7/9/24 with Staff #2 revealed: [...] Called the police and Client #1 was transported to a local hospital for a mental health evaluation for his aggressive behavior [...] In an attempt to get Client #1 to release his bite, Staff #1 bit Client #1 on the left shoulder.

"He (Client #1) said [Staff #1] pulled him by the shirt and threw him on the bed, breaking the bed, then he (Client #1) grabbed a piece of wood from the broken bed and defended himself against [Staff #1]." "According to [Client #1], [Staff #1] tried to put him in a chokehold and he (Client #1) bit [Staff #1] in an attempt to get out of the chokehold Client on Cc when [Staff #1] bit his shoulder." " don't believe he (Staff #1) bit [Client #1] maliciously." Interview on 7/9/24 with Staff #2 revealed:

From the state's report. Deficiency cited, complaint survey, Type A2 violation. Cited: V514 ugetn; V 514) 27E .0102 Client Rights - Prohibited Procedures Vv 514. "[...]" 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.

Based on confidential interviews and record reviews, the allegation of sexual abuse had maintained consistent through multiple interviews. [...] The allegations were also investigated by the Alameda County Sheriff's Office. [...] Based on the confidential interviews and record review, the allegation that staff sexually abused a youth in care has met the preponderance of doubt and is therefore substantiated.

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

In plain words: An administrator failed to notify the state in writing within one working day about a resident's death from a reported drug overdose. Our summary of the state's report. The state's own wording follows.

Based on documentation review and interview, the administrator failed to provide written notification to the Department of a resident's death, if the resident's death was required to be reported according to A.R.S. § 11-593, within one working day after the resident's death. [...] The e-mail from O1 was dated September 27, 2023 and stated "I received a call from Durango Detention and they informed me a medical examiner [O2] called them and they identified a youth that has an ankle monitor that has been deceased...I asked if [O3] knows what happen and [O3] stated early in the morning, a witness stated [Resident 1] was seen smoking a unknown substance at a QT off [street name] and [Resident 1] was taken to the emergency room where [Resident 1] died of a drug overdose..." 3. A review of Department documentation revealed the administrator failed to provide written notification to the Department of [Resident 1]'s death.

From the state's report. Deficiency cited, complaint. Cited: G. An administrator shall provide written notification to the Department of a resident's: 1. Death, if the resident's death is required to be reported .... "[...]" 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 child in the program reported that a staff member made sexual comments, flirted, and touched them inappropriately. Another staff member reported the allegations to child protective services and law enforcement. The state report notes that the staff member was later charged with two counts of child molestation. Our summary of the state's report. The state's own wording follows.

Review of a facility document titled, “Incident Report”, dated 08/23/23, showed that Staff B, Milieu Manager, contacted CPS to report sexual assault allegations made by Patient #1. [...] It showed that Staff Q captured detailed statements Patient #1 was making to law enforcement about the alleged sexual assault by Staff A. e. [...] 19. Review of an email exchange between Investigator #1, Staff D, Executive Director of Intensive Youth Services, and Individual #2, Detective, on 01/02/24, showed: “[Staff A] has been charged with two counts of Child Molestation in the 3rd Degree”. [...] On or around 08/19/23, Patient #1 disclosed during a “casual conversation” with a milieu staff that Staff A had inappropriately touched them. b. [...] On a second occasion, there was an inappropriate touching event with Staff A in the facility’s laundry room.

Law enforcement determines whether a crime was committed and therefore the facility may not limit or prohibit external reporting activities. [...] 12. During an interview with Staff D, on 09/21/23, they stated that no one from the facility had contacted law enforcement to report the sexual assault allegations made by Patient #1 on 08/18/23. They stated that after a conversation with Staff L, Chief Administrative Officer, they realized that they had the responsibility of reporting allegations of sexual assault to law enforcement.

The documents contained the following information: a. “[Staff A] has been making sexual comments like, “age is just a number” and [they] slap my ass. [They] also been looking down girls' shirts and has been making all of us uncomfortable.” b. “[Staff A] flirts with us kids. [They] tell them age is just a number, winks at them, touches them in places like their butts, gives them flowers, and overall is just really taken. [They] need to not work in a place where people have been sexually assaulted.

From the state's report. Deficiency cited, complaint investigation. Cited: WAC 246-337-075 Resident rights.; WAC 246-337-065 Safety and security.; WAC 246-337-048 Quality improvement program.; WAC 246-337-048 Quality improvement program.. "[...]" marks text left out between sentences.

In plain words: A child in the program reported that a staff member made sexual comments and touched them inappropriately. Another child made a similar report and called law enforcement, and records showed staff failed to report the first allegation to the police. Our summary of the state's report. The state's own wording follows.

On or around 08/19/23, Patient #1 disclosed during a “casual conversation” with a milieu staff that Staff A had inappropriately touched them. b. [...] The documents contained the following information: a. “[Staff A] has been making sexual comments like, “age is just a number” and [they] slap my ass. [They] also been looking down girls' shirts and has been making all of us uncomfortable.” b. “[Staff A] flirts with us kids. [They] tell them age is just a number, winks at them, touches them in places like their butts, gives them flowers, and overall is just really taken. [They] need to not work in a place where people have been sexually assaulted. [...] On 09/05/23 law enforcement responded to a lewd conduct call [lewd conduct is a type of criminal charge] from Patient #2 after they reported they’d been inappropriately touched by Staff A. b.

12. During an interview with Staff D, on 09/21/23, they stated that no one from the facility had contacted law enforcement to report the sexual assault allegations made by Patient #1 on 08/18/23. They stated that after a conversation with Staff L, Chief Administrative Officer, they realized that they had the responsibility of reporting allegations of sexual assault to law enforcement. [...] 9. A Teams message exchange between Staff D, Executive Director, and Staff E, Counselor, dated 09/28/23, showed Staff D messaging Staff E, saying “The detectives are wanting the documentation around your conversation about the sexual misconduct.

5. During an interview on 09/21/23 at 09:15 AM, Staff D, Executive Director of Intensive Youth Services, stated that an allegation of staff sexual misconduct was made by Patient #1 on or around 8/18/23. [...] 7. Review of law enforcement records and internal facility records showed that Patients #1 and #2 repeatedly reported they were prevented from using the telephone to call 911 and the non-emergency law enforcement number to report sexual misconduct by a staff inside the facility 8.

Staff S wrote:” Did anyone tell [Patient #4] that a DCR [designated crisis responder] would be coming to assess [them] and that due to [their] recent self-harm and blade to [their] neck indicating suicide risk that [they] would be likely detained for 6.5 months? [...] PYR will determine which outside entity needs to be reported to (DOH, Law Enforcement, CPS) and will determine the next steps.

From the state's report. Deficiency cited, complaint investigation. Cited: WAC 246-341-0600 Individual rights.; WAC 246-341-0410 Agency administration—Administrator key responsibilities.; WAC 246-341-0420 Agency policies and procedures.; WAC 246-341-1133 Evaluation and treatment services—Service standards.. "[...]" marks text left out between sentences.

A. Respondent has obstructed external oversight and intervention by impeding Program investigations and failing to cooperate with DCYF/CPS and law enforcement in connection with complaints of employee misconduct, child abuse and neglect, and criminal acts at the facility. [...] M2022-552 (lead) M2022-553 (consolidated) C. Respondent has demonstrated a pattern of indifference to the mental and physical well-being of patients by failing to report sexual abuse and professional misconduct. Furthermore, individuals in supervisory capacities, in at least two instances, attempted to cause credentialed providers to downgrade serious conduct such as “grooming” and “sexual assault” to protect the agency from external scrutiny.

From the state's report. Findings of fact, summary action order. "[...]" marks text left out between sentences.

A. Respondent has obstructed external oversight and intervention by impeding Program investigations and failing to cooperate with DCYF/CPS and law enforcement in connection with complaints of employee misconduct, child abuse and neglect, and criminal acts at the facility. [...] M2022-552 (lead) M2022-553 (consolidated) C. Respondent has demonstrated a pattern of indifference to the mental and physical well-being of patients by failing to report sexual abuse and professional misconduct. Furthermore, individuals in supervisory capacities, in at least two instances, attempted to cause credentialed providers to downgrade serious conduct such as “grooming” and “sexual assault” to protect the agency from external scrutiny.

From the state's report. Findings of fact, summary action order. "[...]" marks text left out between sentences.

[Former client 6] was hospitalized and sustained a "broken jaw a deep gash over her eye as well as an injury to the back of her head." Review on 5/2/23 of police report revealed: [...] "[Sheriff Deputy] was never dispatched to disturbance here. [...] Three staff (she, staff #3 and [Former staff 8]) were working at the sister facility A when [Former client 6] was hit by the car. [...] The fourth staff member who should have been working was at the store when [Former client 6] was hit by a car.

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

Page The Department received a complaint alleging a client was injured during an altercation with staff and staff restrained a minor. [...] In addition to the above information, the investigation revealed staff admitted to law enforcement that a client was restrained during the incident and informed a placing agency investigator the restraint took place on the floor. [...] Record review and confidential interviews corroborated a client sustained an injury to his cheek after being restrained in a prone position.

From the state's report. Substantiated. Cited: 87072(c)(11). "[...]" marks text left out between sentences.

[Staff 3] contacted non-emergency numbers and Oxnard Police Department. [...] At 6:30pm Oxnard Police Department arrived and detained minor [Child 1]. Oxnard Police Department notified [Staff 2], [Staff 3] that [Child 1] would be placed on a 72-hr hold/5150 at St. John's Regional Medical Center stating he was threatening the staff, children and destroying property. Based on witness, and video footage [Staff 2] conducted inappropriate restrain hold to [Child 1] to prevent from harming himself and others.

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 December 8, 2021, Community Care Licensing (CCL) received a complaint alleging neglect/lack of supervision as Youth #1 was reportedly sexually assaulted by another youth resident while in care (see LIC811, dated October 11, 2022). [...] On October 28, 2020, LAPD responded to Adolescent Growth, Inc. concerning an alleged sexual assault between [Youth 1] and Youth #2 reportedly occurring on October 27, 2020, for which [Youth 2] was subsequently arrested.

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.

In plain words: A staff member sexually abused a child in the facility on May 12, 2022. The state investigation concluded the allegation was substantiated and cited the facility for violating the child's personal rights. Our summary of the state's report. The state's own wording follows.

The allegation that staff sexually abused a minor while in care is related to an incident that took place at the facility on 5/12/2022 involving [Staff 1] and [Child 1] (see LIC811 dated 8/26/22). [...] Based on information obtained and interviews conducted by the Investigations Branch, the allegation that a staff sexually abused a minor while in care is SUBSTANTIATED meaning the "preponderance of the evidence" standard has been met. The facility is being cited for Personal Rights section 87072(c)(11) as the licensee shall ensure that each child is accorded the personal rights specified in Welfare and Institutions Code Section 16001.9, including the right to be free of physical, sexual, emotional, or other abuse as it pertains to [Staff 1] engaging in a sexual relationship with a client while in the facility.

From the state's report. Substantiated. Cited: 87072(c)(11). "[...]" 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 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.

Investigator Barajas conducted the investigation in conjunction with El Dorado County Sheriff Department. Investigation with the Department showed that [Staff 1] (see LIC811 dated 7/15/22) and [Child 1] engaged in a sexual relationship, including oral sex and sexual intercourse, while [Child 1] was residing in the facility and continued after [Child 1] left the program. The sexual relationship began while [Child 1] was under the age of 18. Investigator Barajas and El Dorado County Sheriff also conducted additional interviews with two additional clients of the facility ([Child 2] and [Child 3]) who disclosed that they exchanged nude photos with [Staff 1] and that [Staff 1] made sexually explicit statements to them, including wanting to meet up with the youth and have sexual relations with the youth.

From the state's report. Substantiated. Cited: 87072(c)(11). The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.