summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Misty Valencia on 09/14/2023 at 8:15am. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Valencia met with Alina Scott, Therapist and inspected the facility inside and out. Facility is under remodeling and not sure when it will be completed to start admitting children again. LPA reviewed zero child's records and two of seven (2 of 7) staff personnel files on site at the facility. There are currently no children in the home. LPA interviewed two of seven (2 of 7) staff on site to discuss the facilities policies and procedures of operation. LPA provided a copy of this licensing report to Alina Scott, Therapist No deficiencies are being cited at this time. LPA conducted exit interview with Alina Scott, Therapist

met_with: Alina Scott, Therapist


state: CA

facility_name: ROP QUALIFYING HOUSE MT. RUBY

summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced annual inspection on 12/20/23 at 11: AM and Monica Guzman, Coach Counselor assisted with the physical plant inspection at the facility. LPA Hill toured the inside of the facility and noted that there are three, dual occupancy client rooms, one office room, and one staff room in the facility. All of the client bedrooms have the required furniture and equipment as required. LPA Hill noted that while the client beds have sheets and blankets, there are no mattress pads on any of the client beds during the inspection. LPA Hill informed Ms. Guzman that this is required and the facility will be cited for not have these as required. LPA Hill observed that the facility had the required supply of perishable and nonperishable food as required by regulation and that the house was clean and tidy. LPA Hill observed that there are two bathrooms accessible to clients in the facility and that the toilets flushed, showers worked and had hot water, and that the sinks were working and had hot water. LPA Hill did observe loofahs in the shower area and did provide an advisory to the facility about labeling them so as to ensure that all clients know what loofahs are theirs so that there is no cross contamination or cross use. LPA Hill toured the inside and outside of this facility and LPA Hill did observe that further progress is being made for the deck on the backside of the facility. LPA Hill noted that while perimeter of the facility was inspected on 12/7/23 by this analyst, the deck was and is still under construction today and there continues to be several potentially dangerous or harmful items scattered throughout the back yard related to the construction of the deck. While the back yard was deemed "off limits" to clients in care since the construction began, the potential for harm continues to be present and these issues continue to present a danger to clients in care. LPA Hill noted that many of the same items are still scattered throughout the back yard and not secured as previously discussed with Ms. Edwards during the 12/7/23 inspection. LPA Hill did cite for this during the annual inspection today. After the tour of the physical plant of the facility, LPA Hill ceased the physical plant inspection and resumed the inspection at the business office in Minden. At this location, LPA Hill conducted staff and client interviews and reviewed staff and client files. LPA Hill requested that the facility provide the following documents to be updated in the facility file: LIC308, LIC500, LIC610. LPA Hill also reminded the facility that the program statement update is due 2/2/16/24. LPA Hill did cite the facility on this date for the following: 87087.2(a) Outdoor Activity Space: The outdoor space behind the house is not safe as it was noted that there were multiple unsafe objects laying out and accessible to youth in care who have a propensity for harm to others and self. These items were left by a contractor working on the back deck of the facility. 87088(c)(2) Fixtures, Furniture, Equipment, and Supplies: LPA Hill observed that all six of the beds were lacking the mattress pads as required by this regulation. 87070(c)(2) Children's Records: LPA Hill observed during the review of the records that there are no Removal or Transfer Policy or Discipline Policy signed by the placing agency. 87068.2(f) Needs and Services Plan: LPA Hill observed that the facility is not obtaining the signature of the placing agency on the Needs and Services document or the modifications when this document is updated, changed, or modified. Exit interview was conducted and documents were provided to Ms. Edwards.

Deficiencies:
87087.2(a): Deficient Practice Statement
1
2
3
4Based on LPA Hill's observation and photos taken during the inspection, the licensee did not comply with the section cited above as it was observed that there were numerous dangerous objects accessible to youth in care lying around the back yard including nailes, screws, braces and brackets which poses an immediate health, safety or personal rights risk to persons in care. (Section 87088(j) also indicates that this is a violation but only one citation can be given.)
POC Due Date: 12/22/2023
Plan of Correction
1
2
3
4

report_type: Facility Evaluation

visit_type: Annual

met_with: Tracy Edwards, Administrator

title:
Outdoor Activity Space

(a) Children shall have access to safe outdoor activity space.

This requirement is not met as evidenced by


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an announced case management annual continuation review at the business offices of Rites of Passage located in Minden, Nevada, on 12/21/23 at 9: AM and met with Tracy Edwards, Administrator who assisted in records review. LPA Hill reviewed staff and client records, reviewed restraint records, and requested board meeting minutes, and conducted interviews. LPA Hill requested the Emergency and Disaster Plan but the needed requirements were not available for review (Technical Violation was provided). LPA Hill conducted the exit interview with Ms. Edwards and documents were provided.

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection to the administrative offices for Rite of Passage and met with Jim Amaral, Program Director. LPA Hill interviewed staff and one youth related to an incident that took place that the facility 1/7/24, and was reported to Licensing. LPA Hill attempted to interview C1 (see LIC811 dated 1/12/24) but C1 declined an interview. LPA Hill interviewed C2 and S1 related to this incident. Additional interviews are necessary. LPA Hill is requesting the agency provide video footage for 1/7/24 from PM to AM 1/8/24 by Tuesday, 1/16/24. LPA Hill requested a copy of the individual incident reports depicting staffs' accounts of the events of the night of 1/7/24, from 3: PM through the incident referenced herein. LPA Hill was informed that Alpine County law enforcement was notified of the incident and have been in contact with youth involved. LPA Hill informed Mr. Amaral that further investigation is needed at this time as LPA Hill still needs to collect additional information and conduct further interviews. Exit interview conducted and document was provided.

met_with: Jim Amaral, Program Director


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 9/20/24 at 10: AM and met with Tracy Edwards, Program Manager. LPA Hill met with Ms. Edwards to discuss an incident report regarding two incidents that happened on 9/16/2024. The first incident happened at the facility between C1 and S1 (see LIC811 dated 9/20/24) and a second incident that took place at the facility with C2. The first incident took place on 9/16/24, at about 8: AM, in front of the facility where there was a confrontation between a client and staff over transportation. The second incident was regarding another client inside the facility and had been ongoing with the client and staff most of the morning. LPA Hill conducted interviews about the incidents during the inspection on this date, obtained documents related to C2, their placement and needs. LPA Hill informed Ms. Edwards that further investigation is needed at this time. Exit interview conducted and documentation provided.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 11/26/24 at 10: AM and initially met with Case Manager Angeline Sunday. Tracy Edwards arrived at the agency and met with this LPA to conclude the inspection. The inspection on this date was made for the purposes of discussing two incident reports regarding youths C1, C2, and C3. The details of the incidents are as follows: 11/12/24 - C1 and C2 collaborated in the taking of an educational staff's phone. C2 was arrested and charged with theft after review of the classroom cameras showed C2 taking the phone. C2 was returned to the program and remains in program at this time. LPA Hill interviewed one staff and one youth related to this incident. One youth was not available to interview due to absconding from the facility and not returning. No further investigation was needed at this time. 11/17/24 - C2 absconded from the facility and it was alleged by another youth in care that S1 assisted youth in absconding. LPA Hill conducted interviews with staff and did inform the agency that further investigation is needed at this time. 11/25/24 - LPA Hill learned of youth absconding from the facility on 11/25/24 and spoke to youth about this incident. At this time, no citations were issued and no further investigation is needed based on the information shared by youth interviewed. LPA Hill did not have a full report for this incident and spoke to youth solely based on their willingness to share what happened. At the time of the inspection, there were citations issued and LPA Hill did conduct an exit interview with Ms. Edwards.

met_with: Tracy Edwards, Program Supervisor


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced annual inspection on 12/10/24 at 10: AM and met with Tracy Edwards, Program Administrator, to conduct the physical plant inspection of the facility as part of the annual inspection. LPA Hill observed that the facility has three dual occupancy bedrooms for clients in care but each of the youth currently are not sharing bedrooms with other youth. LPA Hill observed that the facility was clean, safe and sanitary during the annual inspection. LPA Hill observed that the smoke detectors and carbon monoxide detectors were functioning as required. Fire extinguishers were last inspected 1/23/24. LPA Hill observed two client restrooms that had running hot water, paper towels, flushing toilets, and showers that delivered hot water. LPA Hill observed that the client bedrooms were supplied with proper bedding including mattress cover, fitted sheets, blankets, pillows, closet space, and storage for belongings. LPA Hill observed that the facility had two days perishable food supply and seven days nonperishable food supply appropriate for the youth in care. LPA Hill observed the facility was safe inside and out for youth in care. The deck is new and was very stable and no concerns were noted on the perimeter of the facility. LPA Hill interviewed one youth while at the house as that youth was home sick and not attending school on this date. LPA Hill informed Ms. Edwards that the client interviews were going to be conducted at the agency administrative offices as well as file reviews. LPA Hill interviewed two youth at the administrative office. Document was provided to Ms. Edwards and exit interview was conducted.

met_with: Tracy Edwards, Program Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill conducted an unannounced case management inspection on 2/5/25 at 1: PM and met with Tracy Edwards, Administrator, to discuss the following issues: Cell phone policy. Cell phone policy includes discussions with youth during their Child & Family Team Meetings ensuring the policy is individualized for each youth in the program. When granted, youth must agree to usage policy including not having the phone until schooling, groups, and chores are done. Calling on law enforcement. The agency says they wait 30 minutes after losing sight of youth prior to calling law enforcement to assist, but there are exceptions such as when youth are seen getting into a vehicle or if youth are assessed to be at risk then they call immediately. Educating community partners for youth. LPA discussed how the agency is working and educating community partners about youth in their facilities. Ms. Edwards states they have not had an open of communication to bridge this gap, but is open to productive dialogue in hopes of forming working partnerships for the betterment of the youth served. Ms. Edwards states the agency is open to building a foundation of support within the community to ensure the safety and acceptance of the youth served. Discharge of youth following serious incidents. Ms. Edwards states that if a child has left the facility via law enforcement, they immediately contact the placing county to alert of what has transpired. If a client is deemed unable to return due to Health and Safety concerns with other youth, this is communicated to the placing county. Ms. Edwards reiterated that according to the regulations, they are able to make that determination if they feel it is unsafe for a youth to return to the facility and they make every effort to ensure the placing county is aware of the determination. Reimbursement for Services. LPA Hill spoke to Ms. Edwards about the communication related to unpaid or outstanding services for expenditures by the home county. Ms. Edwards states they have not received any communication from the county about any outstanding expenditures. Ms. Edwards indicated if they do get notification for any outstanding or unpaid expenses, they forward communications to the placing county where those expenditures are taken care of. Night Staffing Solutions. Ms. Edwards states that they are working on solution(s) to ensure situations involving youth during the hours of 10: PM to 6: AM are handled internally. Ms. Edwards hopes to provide viable solutions in the weeks to come. Agency wants to ensure they are following regulations set by statute but also understands the resource limitation. Youth Refuse to Return. Ms. Edwards asked about what happens if youth are walking away from the facility and are refusing to return to the facility despite staff following. Ms. Edwards states they continue to follow and provide support to youth but do not call law enforcement for assistance if they are with the youth or have the youth in sight. They continue to walk with youth and give them time to de-escalate. Should law enforcement happen on scene, they try to get youth to return with staff. Ms. Edwards states staff try to talk to youth while walking, giving support, and ask youth what they need in the moment. Ms. Edwards states they just sometimes need to walk until they are ready to return. There have been situations where youth request to go to juvenile hall refusing to return so some agencies oblige youth as many are in violation of their probation by leaving without authorization. Interventions. Ms. Edwards states they are constantly speaking with youth in an attempt to get them to stay and not leave the facility. Facility staff engage with youth, remind them of the program and goals, follow them so the facility does not have to report them in violation to their placement agencies. Ms. Edwards states a training is planned that would include Managing Runaway Behavior where staff are trained on immediate interventions to de-escalate situations in an attempt to get youth to stay. Collaboration Meeting. Ms. Edwards states the agency is open to working on communication and collaboration with the local law enforcement and Probation Department to provide information about youth served and how better to collaborate and work together on a community solution to issues and solutions that would serve the community while assisting the agency in serving the youth in care. Ms. Edwards states they would greatly appreciate CCL's assistance and attendance to initiate this process with the local law enforcement. Ms. Edwards states the agency is open to bridging gaps in the community and finding viable solutions including bridging gaps in communication and collaboration in all of these identified areas. LPA Hill did request that the agency supply a cell phone policy discussed during this inspection. No citations were issued during this inspection and this document was provided.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill conducted an unannounced case management inspection on 2/18/25 at 10: AM and met with Tracy Edwards, Administrator. LPA Hill conducted the inspection to provide findings related to an incident that took place on 11/17/24 in which it was alleged that S1 (see LIC811 dated 2/18/25) provided C1 a ride away from the facility as S1 was leaving the facility at the end of their shift. Investigation showed that S1 was the overnight staff working at the facility and was set to leave at 8: AM. S1 and the youth in care were awake and getting ready to begin the morning chores when C1 left the facility through their bedroom window and was able to access S1's running and unlocked vehicle. S1's vehicle was on and warming while S1 was inside, not supervising the unlocked vehicle. During this time, C1 was able to get into S1's vehicle and leave the facility with C1 in their vehicle. During an interview with S1, S1 denied planning to leave their vehicle on and unattended to allow C1 to get into their vehicle and take them away from the facility. S1 did admit they did not check their vehicle prior to leaving the facility property, even though they were aware of C1's unauthorized absence. S1 admitted they drove into the nearby town to get an energy drink. S1 noted when returning to their vehicle, items in the back of their vehicle were disturbed. S1 confirmed they suspected C1 was in their vehicle due to the disturbed items, but failed to notify the facility staff or the police of their suspicions until they were contacted by the sheriff's office. An interview with C2 indicates they were present during the conversation between C1 and S1 about C1 leaving the facility and S1 providing the transportation into town as it occurred. In discussion with the administrator, the agency does have a training specifically about not leaving any vehicles unattended and LPA obtained a copy of this training module while at the agency. While there is a training indicating this, S1 failed to follow the training. LPA Hill did provide an advisory to the agency to have this policy included in the agency's Vehicle Safety Policy (see attached Technical Advisory, LIC AN). This concludes the investigation of this matter at this time. Exit interview was conducted and documentation was provided to Ms. Edwards.


summary: Facility Evaluation

raw_content:
Narrative:
A meeting was held via Microsoft Teams on 2/19/25 at 1: PM with representatives of Community Care Licensing, including Angela Carmack, Assistant Program Administrator, Margo Castaneda, Regional Manager, Jodean Hall, Licensing Program Manager, and Tamara Hill, Licensing Program Analyst, and representatives of Rite of Passage (ROP) Qualifying Houses, Lawrence Howell, Executive Director, Rebekah Graham, Regional Director, Jerry Crandall, National Compliance Director, and Tracy Edwards, Administrator. This meeting is being held to collaborate solutions for ongoing community grievances regarding ROP's operation of Short Term Residential Therapeutic Facilities in Alpine County. During this meeting, the following items were discussed: Alpine County District Attorney Public Nuisance - Community Care Licensing did advise the agency of Alpine County's intent to file public nuisance charges against ROP due to the number of calls for services in the county and the limited resources available to assist ROP with these calls. Management and Operations of ROP - The county's concerns for the types of children being accepted at the facility and officers walking into the facilities without knowing what they may encounter. The county was educated on the acuity of youth placed in the facilities and discussed with ROP is what the agency can do to provide collaboration with the county to mitigate some of the calls even follow up after calls. Overnight Staffing and Alternative Plans of Supervision - ROP discussed plans including floater staff between houses, additional overnight staff staying in a facility when youth exhibit escalated behaviors. Law Enforcement Meetings with ROP - The agency is open to collaborative meetings and additional collaboration and follow-up discussions following law enforcement contacts. Ambulance Billing - If CCL gathers information related to any unresolved fiscal responsibilities as indicated by Alpine County, this information will be passed along to ROP for resolution. Next steps will be for CCL to communicate with Alpine County to garner dates to be distributed for a meeting between CCL, Alpine County and ROP. End of meeting.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill conducted a case management inspection at the agency's administrative office on 6/26/25 at 11: AM and met with Tracy Edwards, Administrator to discuss an 24-hour incident report dated 6/2/25. The incident report details that C1 was administered a five panel drug screening as a result of returning from a home pass and this report details that it is in accordance with the "standard protocol for all clients after home visits". LPA Hill advised the agency that this could be perceived as an unnecessary search as just because a youth is returning from a home visit is not sufficient to render it probable cause for such searches. LPA Hill advised that in the absence of a court order explicitly stating that drug testing is required for such events for each youth in care, the agency cannot do this. LPA Hill stressed that this must be by court order and not as ordered by the youths' probation officers. Furthermore, this practice is not in the Program Statement for the agency and cannot be implemented without approval from Licensing. LPA Hill did provide the agency with an Advisory Note - Technical Violation related to Personal Rights and unreasonable searches. LPA Hill also discussed an incident report dated 6/14/25 where C2 was able to abscond from the facility without detection either 6/13/25 or early morning hours of 6/14/25. The incident report details that S1 did not complete the required 15 minute bed checks in that S1 failed to ensure that when conducting a bed check they were seeing skin. As a result, C2 was reported absent from the facility on 6/14/25 from an unknown time and returned 6/15/25 in the evening hours. LPA Hill obtained S1's disciplinary for not performing the appropriate bed checks. Exit interview conducted and documents provided.


summary: Facility Evaluation

raw_content:
Narrative:
On 8/14/2025 at 7: AM, Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced case management inspection at the facility and met with staff Antony Etchison who assisted with the inspection. LPA conducted a walk through of the facility with staff and observed no deficiencies. This was completed by 8: AM. At 10: AM, LPA arrived at the facility's school at a different location to conduct interviews and obtain information. LPA met with Administrator Tracy Edwards who assisted LPA with this part of the inspection. CCL received a 24HR incident report dated 8/3/2025 for which LPA is gathering more information. The staff related to this incident were not available during LPA's inspection. LPA collected staff and child information. Further information is needed to close this case management. An exit interview was conducted with Administrator Tracy Edwards and a copy of this report was provided to her.

met_with: Tracy Edwards


summary: Facility Evaluation

raw_content:
Narrative:
On 8/20/2025 at 9: AM, Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced case management inspection at the agency's administration office/school and met with Administrator Tracy Edwards who assisted with the inspection. This CM inspection is a continuation of the CM opened on 8/14/2025. CCL received a 24HR incident report dated 8/3/2025 for which LPA is gathering more information. LPA interviewed one staff, two clients, and briefly spoke with one more client before they left the school. Further information is needed to close this case management. An exit interview was conducted with National Director of Operations and Culture Peter Woods and a copy of this report was provided to him.

met_with: Tracy Edwards & Peter Woods


summary: Facility Evaluation

raw_content:
Narrative:
On 11/12/2025 at 6: AM, Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced case management inspection at the facility and met with staff Breanna Brown, who assisted with the inspection. LPA interviewed staff, then went to the facility's school/administration office and met with Administrator Tracy Edwards to complete the inspection. This CM inspection is a continuation of the CM opened on 8/14/2025. CCL received a 24HR incident report dated 8/3/2025 for which LPA is gathering more information. LPA interviewed Administrator and collected staff documentation and client information. LPA requested, for the four clients named to Administrator, the following: Needs and Services Plans, Safety Plans, Runaway Plans, and Soothing Plans. Further information is needed to close this case management. An exit interview was conducted with Administrator and a copy of this report was provided to her.

met_with: Tracy Edwards; Breanna Brown


summary: Facility Evaluation

raw_content:
Narrative:
On 12/3/2025 at 12: PM, Licensing Program Analyst (LPA) Alyssa Burgess conducted an announced case management inspection at the agency's administrative office for the purpose of closing the case management investigation initiated on 8/14/2025, regarding an incident dated 8/3/2025. LPA met with Administrator Tracy Edwards who assisted with the inspection. LPA conducted this case management investigation by reviewing the incident report and client records, and conducting confidential interviews with three clients, a Probation Officer, a County Social Worker, two staff, and the Administrator between 8/14/2025 and 11/12/2025. Based on all information and interviews, the facility handled the incident appropriately. This case management investigation is closed. An exit interview was conducted with Administrator and a copy of this report and appeal rights were provided to her.


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
Based on confidential interviews with all individuals, except for the Reporting Party, clients attempted to steal keys from staff; however, staff prevented them from getting the keys. One client distracted the staff when they were getting the client medication that was requested, stealing the medication box and going to a peer's room. The clients then shut the door, keeping staff out, while they broke into the medication box in search of keys. While the clients did have access to the medication, clients and staff denied that the clients took any medication. One client informed LPA that they were only interested in finding car keys. The clients stated they took the money that was also in the medication box, however it was only a few dollars, and it was their own allowances. Based on an interview with one staff, they informed LPA that the staff who was trying to get into the clients' room when they closed the door with the medication box in their possession, was uncomfortable being an opposite gender staff and going into their room alone. One staff felt that staff present at the client's door should have gone in sooner, though they were still engaged and trying to intervene. Seven staff were present during the incident; it is clear that staff did not prevent the youth from gaining access to the medication box, where the cash resources and medications are stored, and failed to appropriately intervene. Based on LPA's observations and conducted interviews, the preponderance of the evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. On this date, the facility is being cited for a violation of the California Code of Regulations, Title 22, Division 6, Chapter 1, Section 80078(a) - Responsibility for Providing Care and Supervision. See the attached LIC 9099D. An exit interview was conducted with Administrator and a copy of this report, confidential names list, and appeal rights were provided to her.

Investigation Findings:
13On 12/3/2025 at 12: PM, Licensing Program Analyst (LPA) Alyssa Burgess conducted an announced complaint investigation inspection at the agency's administrative office for the purpose of delivering the findings of this complaint. LPA met with Administrator Tracy Edwards who assisted with the inspection. LPA investigated this complaint by reviewing the facility incident report, police reports, client records, and by conducting confidential interviews with the Reporting Party, one witness, three clients, a Probation Officer, a County Social Worker, six staff, and the Administrator between 8/14/2025 and 11/12/2025. It is alleged that three clients stole medication and petty cash. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Jensen-Hill LICENSING EVALUATOR NAME: Alyssa M Burgess LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE MT. RUBYFACILITY NUMBER: VISIT DATE: 12/03/2025

report_type: Complaint Investigation

complaint_status: SUBSTANTIATED


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 1/26/24 at 1: PM and met with Alina Scott, Head of Service. LPA Hill informed Ms. Scott that this inspection is a conclusion of the case management inspection conducted originally conducted on 1/12/24, related to the 1/7/24 incident between C1 and C2. LPA Hill informed Ms. Scott that the investigation included collaboration with Riverside County Probation. Investigation included interviews with three staff and C2 (see LIC811 dated 1/26/24). LPA Hill attempted to interview C1 but C1 refused to discuss the incident. LPA Hill and Riverside County Probation officer reviewed camera footage of the incident while at the administrative offices for Rite of Passage on 1/17/24 and conducted interviews of staff. LPA Hill informed Ms. Scott that the investigation showed that S2 took youth on an outing where S2 admittedly did not supervise youth appropriately, causing C2 to steal an alcohol product bringing it into the facility and C1 and C2 consuming the alcohol throughout the evening. When cameras were reviewed, it showed that S1 failed to perform their duties of supervision in the facility in that S1 did not perform the 15 minute bed checks as outlined in the facility's plan of operation even though this was reported via incident report as having been done. In addition, S1 failed to provide adequate supervision of C1 and C2, knowing the youth were awake and engaging in suspicious activities. As a result of the investigation, interviews conducted, and information obtained, it is clear that the facility failed to provide the supervision necessary to meet the needs of the youth in care and the facility was cited for Title General Licensing Regulation 80078(a) Responsibility for Providing Care and Supervision. S2 did not supervise youth while on an outing, allowing youth time to abscond alcohol from a local store, and S1 did not ensure that youth were adequately supervised to prevent an inappropriate interaction between youth. In addition, the incident report that was submitted about this incident included details that were not seen and do not appear to be accurate, including checking on youth every 15 minutes as articulated in the facility's program statement. In review of the program statement and policies of the facility, night staff are expected to conduct bed checks of the youth every 15 minutes and this was not done as required and outlined in the program statement. As a result, LPA Hill cited the facility for 87022.1(b)(2)(A) Program Statement as the facility is required to have and maintain a program statement that describes how the facility will serve the specified population, including interventions used to tailer their services to this specific population, i.e. the 15 minute bed checks necessary in monitoring youth while sleeping. The facility failed to follow this part of their program statement as necessary. LPA Hill also informed Ms. Scott that the licensee is required to provide staff ratios of one awake and on duty direct care staff for every three children at a minimum daily until 10: PM. During the interviews with staff about this incident, it was disclosed that night staff regularly arrives at 9: PM and that the two day staff regularly leave the facility at 9: PM and 9: PM, leaving the night staff alone with the youth in care for a period of 30 minutes when there is a requirement to have staff ratio of one staff to three clients. There were four clients in care at the time of this incident, thereby meaning that there needed to be two staff awake and on duty until 10: PM. When interviewed, staff stated it was regular to leave before 10: PM. The facility was also cited for 87065.5(a)(1) Direct Care Staff/Child Ratios as the facility is required to have one awake and on duty direct care staff for every three children, or fraction thereof, present, at a minimum and this was not being done. Exit interview was conducted and documentation was provided to the facility along with appeal rights.

met_with: Alina Scott, Head of Service


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced inspection to the agency on 12/20/24 and met with Tracy Edwards, Administrator. LPA Hill spoke with Ms. Edwards regarding an incident that occurred on 12/9/24 in which C1 (see LIC811 dated 12/20/24) disclosed an inappropriate sexual contact with C2 at the facility, the evening of 12/8/24. Ms. Edwards states that an internal investigation was conducted and it was discovered that staff on duty, S1, did not conduct the evening bed checks as required. (Internal investigation was obtained) LPA Hill informed Ms. Edwards that the agency is cited for 87078(b) Responsibility for Providing Care and Supervision as the licensee shall provide those services identified in each child's...needs and services plan...including the need for bed checks of every 15 minutes as described in the Licensee's Program Plan. This was not done which left youth unsupervised and not monitored, leading to the inappropriate interaction between C1 and C2. LPA Hill also discussed with the agency changes in the intake procedures for the better assessment of youth being admitted into the facility and how the agency is looking to lower the incidents of calling on law enforcement partners. LPA Hill discussed that calls for law enforcement services has risen in comparison to previous years and requested that the agency provide a written assessment and training plan to address this rise in calls. LPA Hill is requesting that the agency assess how they can work with staff and agency management to mitigate the need for these calls. LPA Hill advised that it is imperative that the agency try to work with staff and local partners to reduce these calls for service. LPA Hill requested that the agency provide updated written intake procedures, update of the Neighborhood Complaint Procedures, and any/all procedures on how staff and management can mitigate the calls for service to Law Enforcement partners in the community. Exit interview was conducted and documents were provided.


summary: Facility Evaluation

raw_content:
Narrative:
On 1/28/26 at 12: PM , Licensing Program Analyst (LPA) Aleza Ruiz conducted an unannounced case management inspection at the agency's administrative office and met with Tracy Edwards, who assisted with the inspection. LPA Ruiz is providing this case management inspection on behalf of LPA Alyssa Burgess as the result of an investigation conducted regarding an incident investigated by LPA Burgess. Statements obtained by LPA Burgess from facility staff revealed the facility did not submit a Suspected Child Abuse Report per the Mandated Reporting requirements, nor did they report the incident to CCL as required, when they found evidence to suggest inappropriate contact between a staff member (S2) and a client may have occurred, as confirmed by the Administrator. LPA Burgess also found that one staff (S7) did not properly conduct room checks at least on one occasion, resulting in a client leaving the facility unauthorized during the night and not being discovered until the following morning. The client did not return for multiple days, their whereabouts unknown. On this date, the facility is being cited for violations of the Short Term Residential Therapeutic Program Interim Licensing Standards, Version 5, Sections 87065.2(b)(1) - Personnel Requirements, 87022.1(d) - Program Statement, and a violation of the California Code of Regulations, Title 22, Chapter 1, Section 80061(b)(1)(E) - Reporting Requirements. An exit interview was conducted with Tracy Edwards, Program Manager and a copy of this report, confidential names list, and appeal rights were provided to Tracy Edwards, Program Manager.

met_with: Tracy Edwards, Program Manager


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Manager (LPM) Tamara Hill conducted a case management inspection on 3/9/26 and met with Tracy Edwards, Administrator. The purpose of the inspection was to discuss a discovery made after a child (C1 - see LIC811 dated 3/9/25) left the facility on an unauthorized discharge June 15,2025. While the staff was packing up the child's belongings, a letter or journal entry was found that raised suspicions about S1's interactions with C1. The facility staff reported their suspicions related to the letter and the agency reports that a Suspected Child Abuse Report was provided but was not able to provide proof that this was completed. As a result, the agency was cited for Title 22, Division 6, General Regulations Reporting Requirements 80061(b)(E). The agency is responsible for reporting incidents that are suspected of threatening the physical or emotional health or safety of a client and meets the criteria specific for mandated reporting in Penal Code section 11166(a). This regulation requires the mandated reporter to make an initial report by telephone to the agency immediately or as soon as is practicably possible, and shall prepare and send, fax, or electronically transmit a written follow-up report within 36 hours of receiving the information concerning the incident to local child welfare agency and local law enforcement agency. The facility is also reminded of the importance of the mandated reporter's role and of the requirements should such a report be warranted. Exit interview conducted and documents provided.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Manager (LPM) Tamara Hill conducted an unannounced case management inspection on 3/16/25 at 11:30 am and met with Tracy Edwards, Administrator to discuss the case management investigation findings. LPM informed Ms. Edwards that this case management is a result of an investigation related to S1's (see LIC811 dated 3/16/25) inappropriate interactions with youth in care while at the facility and at the school site as observed by several staff personnel. The information obtained during the investigation relates to S1 crossing several boundaries and participating in inappropriate behavior. The Licensing Program Manager (LPM) informed the agency that eight of the 13 staff interviewed reported awareness of S1's inappropriate interactions with the client. At least two staff indicated they had previously addressed the issue directly with S1 and instructed them not to be alone with clients. The agency is being cited today for violation of the STRTP Interim Licensing Standards section 87072(c) Personal Rights as the licensee is required to ensure that each child is accorded the personal rights specified in Welfare and Institutions Code Section 16001.9 including the right to live in a safe, healthy, and comfortable home where they are treated with respect and this did not happen when S1 interacted in inappropriate ways with youth in the facility. Exit interview was conducted with Ms. Edwards and documentation was provided.


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
The allegation that staff inappropriately touched client is related an incident where S1 allegedly grabbed a client's arm "really hard" and touched their bottom while the client accessed the staff room attempting to get items not authorized for youth to have. Confidential interviews were unable to corroborate S1 inappropriately touched the client as there were no other witnesses. Regarding the allegation that staff did not afford client privacy, it was alleged that S1 walked in on a youth changing in their room and S1 looked through client bedroom windows when the youth barricaded themselves in their rooms or would otherwise refuse to open their bedroom door. Information obtained through confidential interviews was inconsistent and this allegation could not be corroborated. The allegation that staff did not treat client with dignity is related to an incident involving law enforcement where client allegedly asked for a female officer to conduct a "pat down" and that S6 was laughing at client having to be pat down by the male officer instead of advocating for youth to have a female officer present. Both staff present denied this allegation or denied client asked for a female officer. There were no other witnesses to this incident. As a result of the interviews conducted, documents reviewed, and investigation, the allegations that staff did not afford client privacy, staff inappropriately touched a client, and staff did not treat clients with dignity, the Department finds that the allegations are unsubstantiated at this time meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted with Tracy Edwards, Program Manager, and a copy of this report and appeal rights were provided to Tracy Edwards.

Investigation Findings:
13This document was amended on 3/26/26 by Licensing Program Manager Tamara Hill. On 1/28/26 at 12: PM, Licensing Program Analyst (LPA) Aleza Ruiz conducted an unannounced complaint investigation inspection at the agency's administrative office for the purpose of delivering the findings of this complaint. LPA met with Tracy Edwards, Program Manager who assisted with the inspection. LPA Alyssa Burgess investigated this complaint by reviewing incident reports, client records, staff records, and by conducting confidential interviews with five clients, a Probation Officer, two County Social Workers, nine staff, a drug counselor, a case manager, the Head of Service, and the Administrator between 8/20/2025 and 1/21/2026. LPA Burgess was unable to speak with two staff despite multiple attempts to reach them. LPA Burgess also attempted to speak with a youth but the youth declined an interview. The Department's Investigations Branch (IB) Investigator Austin Blatnick, made multiple attempts to speak with one staff but staff did not respond to IB's calls or texts. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Danielle Walker-Flores LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE MT. RUBYFACILITY NUMBER: VISIT DATE: 01/28/2026

complaint_status: unsubstantiated


facility_name: ROP QUALIFYING HOUSE TALLAC

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA Tamara Hill made an unannounced annual inspection on 11/30/21 at 12: AM and met with Tracy Edwards, Program Manager, who assisted with the inspection. LPA Hill conducted a walk-through of the facility inside and out. There were no clients present and this facility is currently closed due to lack of clients at this time. LPA observed three, dual occupancy client bedrooms, two bathrooms accessible to clients, and one staff room with staff bathroom during the inspection. LPA Hill inspected and/or reviewed the following: Postings of facility license, Personal Rights Poster Disinfectants/Cleaning solutions were inaccessible There are two refrigerators but neither are plugged in at this time due to no clients There are no nonperishable or perishable foods present due to no clients Working telephone was present Carbon monoxide detectors and Smoke Detectors were functioning First Aid Kit was present and had all required components Common Room (living room) was available as was a separate room for relaxing/recreation Dining area with enough seating was present and in good condition Medication was centrally stored, locked/inaccessible but there are currently none at this time LPA observed a locked staff office/sleeping area. All documentation and equipment in the staff room is locked as is the staff room. Hot Water was between 105 -120 degree F Fire Extinguishers were observed to be last inspected on 2/8/21 and 4/1/21 (there were two present) Toilets, wash basin, bath and shower fixtures appeared to be in good repair, no leaks and delivering hot water. LPA observed there to be soap and paper towels available in the bathrooms. Laundry Facilities were available even though there are no clients Bedrooms appeared to be clean and organized with required linen and furnishings Motor Vehicle was not present due to the lack of clients Facility appeared to be free of vermin LPA observed no citations during the physical plant inspection. There are currently no staff or client files to review. Exit interview conducted and documentation provided to Ms. Edwards.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an announced annual inspection on 2/7/23 at 9: AM and met with Tracy Edwards, Administrator, to conduct the inspection. LPA Hill toured the facility inside. LPA Hill did not tour the outside of the facility due to the volume of snow surrounding the building. LPA Hill observed that the facility is currently not occupied and there are no clients in care at this time. LPA observed that the smoke detectors were functioning as required and that there is a carbon monoxide detector on the second level of the home. LPA Hill observed that the fire extinguishers were last serviced on 2/2/23 and there is one on the first floor near the kitchen and the other is upstairs at the top of the stairs. LPA Hill observed that the mental health certificate is on display at the front door and is current for year 2022 to 2023. At this time, this facility does not have any clients in care. LPA Hill observed that the facility is ready for clients should the need arise. LPA Hill observed that the bedrooms are equipped with appropriate furnishing and that beds are made and ready for clients. LPA Hill observed that the water is within the required temperature. LPA Hill observed that there is no food at the house - perishable or nonperishable due to there being no clients in care. The freezer and refrigerator are unplugged at this time due to them not being in use. LPA Hill advised the facility that if clients are placed in the facility that the administrator notify licensing so that we are aware that clients are no occupying the facility. There were no citations issued during the inspection today and exit interview was conducted with Ms. Edwards. Documentation was provided at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced collateral inspection to the agency's administrative office in Minden, Nevada and met with Tracy Edwards, Program Director, on 6/6/23 at 12: PM. LPA Hill informed Ms. Edwards that the purpose of the inspection was to discuss a program design addendum regarding overnight staffing that was sent to LPA Hill on 5/28/23. The addendum from the agency outlines that this facility will not have an awake night staff person but would have a staff person present at the facility sleeping while the three youth sleep. LPA Hill informed Ms. Edwards that the regulations for Short Term Residential Therapeutic Programs (STRTP) Interim Licensing Standards (ILS) requires "During the hours of 10 pm to 7 am, there shall be one awake and on duty direct care staff for every six children, or fraction thereof, present, at a minimum. [86065.5]" This means that the Department cannot accept this addendum and the facility shall provide the awake night staff as required. Further discussing, Ms. Edwards requested an exception for the three youth currently present in the facility to not have the awake night staff as required as the youth have completed their requirements as STRTP clients and are awaiting AB 12 transition and/or transitional housing acceptance. LPA Hill informed Ms. Edwards that an exception would need to be in writing and submitted to the Department for review/approval. LPA Hill informed Ms. Edwards that if they would like to proceed, they can submit the required written documentation to the Department for review. Ms. Edwards stated that she would work on the necessary paperwork this week to get it to the Department for review. End of inspection.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an announced annual inspection on 12/22/23 at 9: AM and met with Tracy Edwards, Administrator. LPA Hill conducted an announced inspection as the facility is currently not operating and does not currently have clients in care or staff. This facility currently does not have an administrator as the named administrator has been redirected to programs outside the state of California. The agency will not populate the home or operate this location until a qualified administrator can be hired and trained. LPA Hill conducted the physical plant inspection of the facility and observed that the facility is a split level home with two client rooms upstairs and one client room downstairs. There are two client bathrooms in the facility and that there was hot water in all faucets and sinks. There is currently no food in the house as the facility is not sure when they will be able to fill the home as they are still recruiting for an administrator and Head of Service for this house. LPA Hill observed that the carbon monoxide detector and smoke alarms are all working as required. LPA Hill observed a fire extinguisher that was last inspected in November 2022. LPA Hill observed that the facility meets all requirements according to the Interim Licensing Standards and there were no citations observed during the inspection. Exit interview conducted with Ms. Edwards and document provided.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced annual inspection on 12/10/24 at 9: AM and met with Tracy Edwards, Program Administrator, to conduct the physical plant inspection of the facility as part of the annual inspection. LPA Hill observed that the facility has three dual occupancy bedrooms upstairs, one downstairs and two upstairs, for clients in care, but there are currently no youth in care at this time. LPA Hill observed that the facility was clean, safe and sanitary during the annual inspection. LPA Hill observed that the smoke detectors and carbon monoxide detectors were functioning as required. Fire extinguishers were last inspected 1/23/24. LPA Hill observed one client restroom upstairs that had running hot water, paper towels, a flushing toilet, and a shower that delivered hot water. The other restroom is downstairs and also has hot water, paper towels, flushing toilet, and a shower that delivers hot water. LPA Hill observed that the client bedrooms were supplied with proper bedding including mattress cover, fitted sheets, blankets, pillows, closet space, and storage for belongings. LPA Hill observed that the facility did not have the required perishable or non perishable food supply as there were no clients in care at this time. LPA Hill observed that the facility did have the appropriate cook ware and dining supplies and can make ready this facility for clients should there be a need. LPA Hill observed that the facility was safe for youth, inside and out, if needed for client placement. No interviews were conducted for staff or clients as there are no clients in care. End of inspection. Document was provided to Ms. Edwards and exit interview was conducted.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill conducted a case management inspection at the agency's administrative office on 6/26/25 at 11: AM and met with Tracy Edwards, Administrator to discuss an incident report dated 6/18/25. The incident report details that C1 received a probation visit on 6/18/25 where C1 was drug tested by the probation officer. C1 tested positive for a substance(s) that are prohibited which prompted the probation officer to then search C1's bedroom, finding another prohibited item(s). As a result of the drug test and contraband found in C1's possession, C2 and C3 were also tested and their rooms searched. When discussing this incident with Ms. Edwards, LPA Hill advised the agency to be careful as this may be perceived as an unnecessary search of C2 and C3's persons simply because they share the house with C1. LPA Hill advised that there did not seem to be any behavior(s) that prompted C2 or C3 to be tested or their rooms searched nor was it documented that approval from their placing agency was obtained prior to conducting said drug testing or rooms search(es). Ms. Edwards stated that permission was obtained from the placing agencies for C2 and C3, for the drug testing and the room searches, but did not document it on the incident report. In addition to this, it is noted on the incident report that the agency will "continue to randomly drug test all three [youth]". LPA Hill advised that without a court order explicitly stating that random drug testing is required, the agency cannot do this. LPA Hill stressed that this must be by court order and not as ordered by the youths' probation officers. LPA Hill did provide the agency with an Advisory Note - Technical Violation related to Personal Rights and unreasonable searches. Exit interview conducted and documents provided.


facility_name: RUBICON RANCH

summary: Facility Evaluation

raw_content:
Narrative:
On Friday, December 19th, 2025 at 10AM, Licensing Program Analyst (LPA) Brittany Crass and Licensing Program Manager (LPM) Tamara Hill, met with applicant Alexis Thrasher at the Community Care Licensing office for a Component II meeting. LPA discussed Administrator Qualifications, receipt of Sacramento County letter, Facility Sketch, Training, Removal Procedures, Personal Rights, Medications, Mental Health Approval, and more. LPA discussed needing all required forms for the corporation such as Board of Directors, LIC 309, and others. During the meeting, licensing documents were reviewed and requested they be updated. Component III will be scheduled in January 2026. Date and location to be determined by email. Exit interview conducted with Applicant, Alexis Thrasher and a copy of this report was provided.

met_with: Alexis Thrasher


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Investigation Findings:
13On 10-6-22 9: AM Licensing Program Analysts Karkazis conducted a complaint investigation with REFUGE and met with Sylvia Smith, Administrator. The purpose of this inspection was to deliver the findings for the above complaint allegations. The complaint was taken by Community Care Licensing's (CCL's) Investigative Branch (IB)and assigned to investigator Megan Mullen. During the investigation, it was discovered that the alleged staff member had an argument with the client. During the investigation, through document research and confidential interviews with staff and clients, no one made any disclosures regarding observing firearms in the facility or staff talking about firearms. Child and Family Services (CFS) conducted an investigation and were provided with conflicting information.. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that staff threatened a minor with a firearm while in care. Therefore, the above allegation is UNSUBSTATIATED. An exit interview was conducted, and a copy of this report was given to Sylvia Smith, Administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Mendoza LICENSING EVALUATOR NAME: George Karkazis LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

Allegations:
- UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:

met_with: Sylvia Smith Administrator


raw_content:
Narrative:
continued from LIC An exit interview was conducted and a copy of this report was given to Dwayne White, Facility Administrator.

Investigation Findings:
13On 1-6-23 2:57PM, Licensing Program Analyst (LPA) George Karkazis conducted an unannounced follow up inspection at the REFUGE I, and met with Dwayne White, Facility Administrator. The purpose of the inspection was to deliver the findings for the above complaint allegation. Regarding the allegation of staff yelling at minors: During the course of the investigation, LPA Karkazis conducted confidential interviews and documentation research. There was no evidence of staff yelling at minors in document research. Staff and clients interviewed stated that they have never heard staff yelling at clients in a derogatory manner. S1 stated that she speaks in a loud tone regularly and may raise her voice occasionally if clients cannot hear her. LPA interviewed residents of neighboring homes, stated that they have never heard staff yelling at minors. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that staff are yelling at minors. Therefore, the allegation is UNSUBSTANTIATED. continued on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Mendoza LICENSING EVALUATOR NAME: George Karkazis LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CENTRAL COAST SC/RES, TRAEGER AVE., Suite San Bruno, CA Facility Name: R.E.F.U.G.E.FACILITY NUMBER: VISIT DATE: 01/06/2023

Allegations:
- UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:

met_with: Dwayne White, Facility Administrator


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
continued from LIC Appeal Rights were provided and discussed with the facility, and deficiencies were cited. The facility was cited for Health and Safety Code 1568. Conduct Inimical. At this time, the case is being reviewed for enhanced civil penalties. An exit interview was conducted and a copy of this report was given to Dwayne White, Facility Manager.

Investigation Findings:
13On 3-1-23 3:35PM, Licensing Program Analyst (LPA) George Karkazis made an unannounced inspection to REFUGE and met with Dwayne White, Facility Manager. The purpose of the inspection was to deliver the findings for the above allegation. The investigation was conducted by Community Care Licensing (CCL) Investigation Branch (IB), Investigator Jorge Martinez. During the course of the investigation, (IB) conducted interviews with staff members, clients, witnesses, and authorized representatives. Based on confidential interviews by (IB), (S1) (see LIC 811 confidential names dated 9-27-22) sexually assaulted (C3) on three separate occasions, that occurred in a location outside of the facility. Based on the information obtained, there is a preponderance of the evidence to prove that staff had a sexual relationship with a foster child. Therefore, the above allegation is SUBSTANTIATED. continued on LIC 9099-C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: George Karkazis LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CENTRAL COAST SC/RES, TRAEGER AVE., Suite San Bruno, CA Facility Name: R.E.F.U.G.E.FACILITY NUMBER: VISIT DATE: 03/01/2023

Allegations:
- SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

met_with: Dwayne White, Facility Manager


raw_content:
Narrative:
The allegations that staff are performing inappropriate searches on minors while in care. may or may not be true. The allegations have not met the preponderance of doubt and are therefore unsubstantiated. No deficiencies were cited at this time. LPA conducted an exit interview with Administrator, Mr. White, at 1: PM.

Investigation Findings:
13On 06/5/2023 at 10:00AM, Licensing Program Analyst (LPA) Vaishali Singh-Sood conducted a visit to the above agency to deliver the findings on the listed allegation. LPA met with Administrator, Mr. White. At the time of the visit, there were 2 staff, and 2 clients present in the facility. During the course the investigation, LPA conducted confidential interviews with reporting party member, clients, social workers, and resource parents. According to confidential interviews, records reviews, and a walkthrough of the facility, LPA Singh-Sood concluded, the allegation had inconsistent support. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated, and no Title 22 deficiencies were observed. (Continued on LIC 9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Vaishali Singh-Sood LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: R.E.F.U.G.E.FACILITY NUMBER: VISIT DATE: 06/06/2023

Allegations:
- UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:

met_with: Dwayne White


raw_content:
Narrative:
The allegations that staff inappropriately handled a child in care and staff inappropriately pushed on a child to fall down the stairs. may or may not be true. The allegations have not met the preponderance of doubt and are therefore unsubstantiated. No deficiencies were cited at this time. LPA conducted an exit interview with Administrator, Mr. White, at 1: PM.

Investigation Findings:
13On 06/5/2023 at 10:00AM, Licensing Program Analyst (LPA) Vaishali Singh-Sood conducted a visit to the above agency to deliver the findings on the listed allegation. LPA met with Administrator, Mr. White. At the time of the visit, there were 2 staff, and 2 clients present in the facility. During the course the investigation, LPA conducted confidential interviews with reporting party member, clients, social workers, and resource parents. According to confidential interviews, records review, and a walkthrough of the facility, LPA Singh-Sood concluded, the allegation had inconsistent support. It is further noted the client involved in the allegations refused to return a callback to this LPA. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated, and no Title 22 deficiencies were observed. (Continued on LIC 9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Vaishali Singh-Sood LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: R.E.F.U.G.E.FACILITY NUMBER: VISIT DATE: 06/06/2023

Allegations:
- UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:


raw_content:
Investigation Findings:
13On 10-27-23 11:47, Licensing Program Analyst (LPA) Karkazis conducted an unannounced inspection at REFUGE and met with Arireisea Adanandus, Facility Manager, who helped with the inspection. The purpose of the inspection was to deliver the complaint findings. The complaint alleged that staff handled a foster child in a rough manner, staff do not accord foster child with dignity and respect, staff leave tools accessible to foster children, staff leave cleaning supplies accessible to foster children, and facility is in disrepair. Licensing Program Analyst (LPA) Karkazis conducted confidential interviews with staff, clients, representatives, and conducted document research, in which inconsistent information was provided. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegations occurred. Therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was given to Arireisea Adanandus, Facility Manager. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lidia Tinoco LICENSING EVALUATOR NAME: George Karkazis LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

Allegations:
- UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:

met_with: Arireisea Adanandus, Facility Manager


raw_content:
Investigation Findings:
13On 1-31-24 1:49PM, Licensing Program Analyst (LPA) George Karkazis conducted an unannounced inspection at REFUGE 1, and met with Dwayne White, Administrator, who helped with the inspection. The purpose of the inspection was to deliver the complaint findings. The complaint alleged that staff did not prevent minors from stealing other minor's personal belongings and staff did not adequately supervise minor resulting in minor leaving the facility. LPA Karkazis conducted confidential interviews and document research, in which inconsistent information was provided. LPA could not locate the victim/client for their statement. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the allegations occurred. Therefore, the allegations are UNSUBSTANTIATED. A copy of this report was given to Dwayne White, Administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: George Karkazis LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

Allegations:
- UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:

met_with: Dwayne White, Administrator


summary: Facility Evaluation - 2 deficiencies

raw_content:
Narrative:
Licensing Program Analyst (LPA) Christopher Rollins made an unannounced annual required inspection to REFUGE Short Term Residential Therapeutic Program (STRTP). LPA met with Sylvia Smith Administrator, Geneva Morgan Facility Manager and Jason Henderson Director. The STRTP is licensed to served 6 clients ages 13-17. The facility consists of three bedrooms (3 for clients) and Bathrooms. The facility is a one story home with a side office. The facility is licensed for 6 residents and currently 4 clients reside in facility. No more than two clients share a bedroom. At 11: AM, LPA, Administrator and FM conducted a walk through of the facility and office. LPA observed the kitchen to be clean. The hot water in the bathroom, shower and kitchen measured 110 degrees F which is currently between 105 - 120 degrees. The facility has plenty of nonperishable and perishable food supply. Medication, knives and cleaning supplies is locked away. There are enough folks, spoons, plates and cups. All passageways are unobstructed. All smoke detectors are update and working. The home is clean, safe, and sanitary. There are no firearms on the property. The fire extinguisher has been checked and is up to date. There are no bodies of water on the property. The home is maintained at a comfortable temperature. Personal rights, floor plan, food menu and Emergency disaster forms were posted and in clear view. At 12: PM, LPA reviewed four clients files with Administrator, FM and Director. LPA observed all four clients files to be missing Authorized Representative signatures for Needs and Services Plans, Medical Consent Form and clients' personal rights documents. LPA also observed that all four clients TB Test, Immunization Records and Medical Assessment form were not up to date. At 1: PM, LPA reviewed six staff files with Administrator, FM and Director. LPA observed all six staff files to be complete and found no deficiencies. LPA observed all staff files to have the correct up to date documentation and all staff were up to date with their staff training for the year. Per Title Regulations and Interim Licensing Standards regulations were cited and exit interview was conducted. A Copy of the report and deficiencies were left at the facility.

Deficiencies:
87068.3(a): Modifications to The Needs And Services Plan

(a) The needs and services plan specified in Section 87068.2 shall be updated at least every 30 days to determine the following
87068.2: (2)

met_with: Sylvia Smith-Administrator, Geneva Morgan- Program Manager and Jason Henderson-Director


summary: Facility Evaluation

raw_content:
Narrative:
On Monday February 28, 2022 at 11: AM Regional Manager, Nelson Martinez, Licensing Program Managers (LPM) Carolyn Flynn, Helga Wong and Licensing Program Analyst (LPA) Isabel Mendoza conducted a Office meeting virtually via Microsoft Teams due to the COVID-19 pandemic. Community Care Licensing (CCL) met with Executive Director Jason Henderson, Consultant Jeff Rackmil, DHCS Representatives, Sandi Snelgrove and DSS Representative, David Gutierrez. The purpose of this meeting was to discuss the Mental Health Status Approval (MHSA) Update, and the required items for permanent licensure for R.E.F.U.G.E. The facility has not submitted their MHPA yet to DHCS and the facilities 24 month expires on April 10, 2022. DHCS provided the facility all required documents for submission. During this meeting the following options were discussed; withdrawal of STRTP application by the program, this would prevent CCL (Community Care Licensing) from taking legal action against the program. The facility was informed that if the program is not able to obtain their Mental Health approval by the date of April 10, 2022 the department will have to take legal action. The facility was also informed that they could withdraw their STRTP application and submit a plan of closure. At this time, the facility will be working on submission and agrees to have a follow-up meeting on 3/9/22 at AM. The meeting was concluded, and a copy of this report will be sent to Executive Director, Jason Henderson.

met_with: Jason Henderson


summary: Facility Evaluation

raw_content:
Narrative:
On Wednesday March 09, 2022 at 11: AM Regional Manager, Nelson Martinez, Licensing Program Managers (LPM's) Carolyn Flynn, Helga Wong and Licensing Program Analyst (LPA) Isabel Mendoza conducted a follow-up office meeting virtually via Microsoft Teams due to the COVID-19 pandemic. Community Care Licensing (CCL) met with Executive Director Jason Henderson, Consultant Jeff Rackmil, Clinicial Director, Jacqueline Smith, California Alliance, Chris Stoner-Mertz, DHCS Representatives, Pat Coyle, Kelsie Martinez, and DSS Representative, David Gutierrez. The purpose of this meeting was to follow-up on 2/28/22 office meeting regarding the Mental Health Status Approval (MHSA) Update. At this time, the facility submitted there application to DHCS on 3/6/22, and the application is currently under review. Per DHCS current review, the facility did not submit all required documents. Multiple items will be needed and revisions will be required. DHCS will complete their full review by next week 3/15/22, and will send out a notice. Also, will be coordinate a meeting with the provider to discuss all necessary changes. The meeting was concluded and CCL will follow-up with the provider towards the end of the month regarding the MHPA review. In addition, CCL reminded the provider withdrawal of STRTP application by the program, will prevent CCL from taking legal action against the program. The facilities 24 month expires on 4/10/22. An exit interview was conducted and a copy of the report was emailed to Executive Director, Jason Henderson for signature.

met_with: Jason Henderson, Executive Director.


summary: Facility Evaluation

raw_content:
Narrative:
On 8-30-23 3:00PM, Licensing Program Analyst (LPA) George Karkazis conducted an unannounced inspection at REFUGE to open a complaint dated 8-25-23 #14CR-20230825103959. LPA met with Administrator Dwayne White (DW). While reading the second page of the complaint, LPA observed that C1 (see LIC 811 confidential names list) has their eighteenth birthday tomorrow, 8-31-23. LPA has not received an age exception request letter from REFUGE or the Administrator. DW stated that he was not aware of the regulation that requires a request letter of age exception within 30 days of a client's 18th birthday, which must be sent to CDSS. DW told LPA Karkazis that he was trying to place C1 in REFUGE's Tay Adult Extended Foster Youth Program. DW stated that C1's behavior was poor in the last few weeks and would not recommend C1 for the Tay Adult Extended Foster Youth Program. DW stated that C1 could still apply for the TAY Adult Extended Foster Youth Program, but without a recommendation. DW also stated that C1 could no longer stay at REFUGE after he turns 18 years old, but was trying to find a placement for him, notifying C1's social worker of the situation. The facility is being issued a Technical Violation, 80010(a) Title 22, Division 6, Chapter 1, Article 02, Limitations of Capacity and Ambulatory Status. An exit interview was conducted and a copy of this report was given to Dwayne White, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On 4-24-24 9:15AM, Licensing Program Analysts George Karkazis conducted an unannounced Annual/Random inspection at listed facility. LPA met with Dwayne White, Administrator, and toured the facility inside and out. The Short Term Therapeutic Program is licensed to serve 6 clients. Present during the inspection were 1 staff and 0 clients. Dwayne White informed me that there have been no clients in care for the past 2.5 months at this facility. LPA requested copies of LIC 500,610, and 309. At 9:25AM, LPA Karkazis reviewed staff files, which were complete and in good order. There are no clients in care, therefore no client files were reviewed. At 10:15AM, LPA Karkazis toured the facility. LPA Karkazis observed 3 bedrooms and 2 bathrooms. LPA observed facility license, personal rights, facility sketch, and other forms posted on the walls throughout the facility. LPA Karkazis tested the water temperature and found it to be 105 degrees which is in range. The thermostat read 72 which is within range. Sharps were locked and chemicals were safely stored. There are no clients in care, there was not two days of perishable foods and seven days non-perishable foods present. The medication (none) was also stored and locked in the kitchen cabinet. The facility is in good repair and clean. LPA Karkazis interviewed 1 staff and 0 clients. At 10:30AM, LPA Karkazis toured the backyard. There were no open bodies of water. The backyard was in good repair and clean. At this time the facility is being cited for National Accreditation ILS 87089(a). An exit interview was conducted, appeal rights discussed and a copy of this report was given to Dwayne White, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On October 9, 2025, at 9:45AM Licensing Program Analyst's (LPA's) Omar Sawyer and LPA Vaishali Singh-Sood made an unannounced Case Management inspection at the above facility regarding an Incident Report (IR) Follow-up. LPA's Sawyer and Singh-Sood met with, Dwayne White, Administrator. There are currently 2 clients in care, but only one was present during the inspection. The purpose of the inspection was to obtain more information from the Short Term Residential Therapeutic Program (STRTP) regarding an incident report that was submitted to Community Care Licensing (CCL) by the STRTP on 09/29/25. LPA Sawyer reviewed the current Staff Roster/schedules. LPA Sawyer reviewed Staff files and Staff training. Additionally Mr. White was interviewed, and the client present refused to be interviewed. Mr. White and LPA Sawyer discussed facility protocol when a client is about to AWOL. Mr. White advised that usually clients and staff discuss plans, safety precautions, and the consequences of leaving the facility. Mr. White was explained that all incident reports involving AWOL's should contain pertinent information regarding clients leaving, and staff attempting de-escalation techniques/consequences for AWOL behaviors. An exit interview was conducted at 10: AM with Administrator, Mr. White. A copy of this signed report was printed and left with Mr. White, whose signature confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst's (LPA) Shikya Belfield and LPA Lisa Schlembach made an unannounced inspection to the above facility on 5/25/2022 at 10: AM. The purpose for this inspection is to conduct a case management. LPA's Belfield and Schlembach met with Administrator who assisted with the visit. During a visit conducted on 4/22/ LPA's met with Sylvia Smith. During that visit a walk though was conducted with staff Issac as part of an annual inspection. During that inspection it was confirmed by staff interviews that incident reports were not being reported to the department. Due to technical issues with LPA Belfield's computer the forms were not able to be printed and given to the staff. During this inspection LPA discussed with staff that all incident reports have still not been reported regarding the clients in care. Facility is cited for violation of Interim Licensing Standards 87061(j)(1) Reporting Requirements. During the inspection conducted on 4/22/ LPA's Belfield and Schlembach were informed that staff Sylvia Smith is the administrator for Refuge I. LPA Belfield discussed with staff Smith that they would look into the requirements for them to be the administrator as well as the information that CCL had in the system. During a walk through of the facility LPA Belfield and Administrator Smith had a discussion regarding the bedframes being used for the clients. LPA will refer to the regulations for clarification and conduct a follow up with administrator Smith on whether or not the black frames being used should be changed. During a staff file review it was observed that one staff is not qualified to be the facility manager for the facility. LPA Belfield discussed with administrator Smith regarding applying for an exception request. Facility cited for violation of Interim Licensing Standards Version 4, Section 87061(j)(1) Reporting Requirements. An exit interview was conducted and a copy of this report will be sent to administrator Sylvia Smith.

met_with: Sylvia Smith


summary: Facility Evaluation

raw_content:
Narrative:
On July 12, 2022, at 10: AM, LPA's George Karkazis and Alyssa Ng, made an unannounced inspection and met with Kurmonie Govan, direct care staff. Upon arrival, we discovered that there was no Facilty Manager nor House Manager present. At 11: AM, Silivia Smith (Facility Manager) arrived. Silvia stated that she had to leave for an appointment that could not be cancelled. There is a current census of four clients. Two clients are on AWOL and three clients were present. LPA Karkazis is issuing a citation of Short-Term Residential Program (STRTP) Interim Licensing Standards (ILS) Section 87065(f) Personnel Requirements. See attached LIC 809-D. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Silvia Smith, whose signature confirms this receipt.

met_with: Silvia Smith, Adminstrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPA) Karkazis made an unannounced case management inspection at REFUGE on 10-6-22 10:00AM, and met with Sylvia Smith, Administrator. The purpose of this inspection was to discuss the complaint investigation control number 14-CR-20220708100610, dated 07/08/22. LPA Karkazis conducted a walk through inspection of the facility with Sylvia Smith, Administrator. LPA Karkazis observed that the facility was clean and in good repair. On 8/8/2022, Investigator Megan Mullen was interviewing Administrator Sylvia Smith (S1), please refer to LIC 811, 7-12-22, and requested a copy of the incident report and (S1) could not provide a copy of the report within the required timeframe. It took (S1) four days to provide the report. On 8/8/2022, Investigator Megan Mullen requested the client's file and was not readily accessible. (S1) stated that the client files were located at the facility office and did not have access to the office and could not find anyone who has access. The following deficiencies were cited, Title 22, Division 6, Chapter 1, Art. 6, Section 80061(b) Client Records, and Title 22, Division 6, Article 4, Section 80044(c)(c) Inspection Authority. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Sylvia Smith, Administrator, whose signature on this form confirms receipt.

met_with: Sylvia Smith, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 8-28-24 4:34PM, Licensing Program Analyst (LPA) George Karkazis conducted an unannounced inspection at REFUGE 1. The purpose of the inspection was to conduct interviews. While conducting interviews, LPA Karkazis discovered that a facility manager was not on duty while three clients were present. The facility is being cited for Interim Licensing Standards (ILS) Section Personnel Requirements 87065(f). An exit interview was conducted, appeal rights provided, and a copy of this report was left with Kendall Winfrey, Direct Care Counselor, whose signature confirms this receipt.

met_with: Kendall Winfrey, Direct Care Counselor


summary: Facility Evaluation

raw_content:
Narrative:
On 1-31-25 1:53PM, Licensing Program Analyst (LPA) George Karkazis conducted an unannounced case management at REFUGE 1 and met with Dwayne White, Administrator. During the course of complaint investigation 14-CR-20241002171400 dated 10-2-24, it was discovered that four client (C1) AWOL incident reports were not reported. They occurred 9-12-24, 9-16-24, 9-19-24, and 10-6-24. The facility is being cited for Title 22, Division 6, Chapter 1, Article 6, Continuing requirements, Reporting Requirements 80061(b), Type B. An exit interview was conducted, appeal rights provided, and a copy of this report was given to Dwayne White, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On Wednesday, April 15th 2026, Licensing Program Analyst (LPA) Mariah Hawkins and Licensing Program Manager (LPM) Isabel Diego visited the facility for an annual/2-year inspection. The facility's last 2-year inspection was in April 2024. LPA and LPM met with Administrator Dwayne White and Program Manager Marla Anderson and informed of the purpose of the visit. Administrator Dwayne White and Program Manager Marla Anderson arrived shortly after. During inspection, three clients were in care and appeared in good spirits. At 11AM, LPA and LPM toured the facility and observed that it was clean, free of obstructions, and appeared to be in good repair. Facility has lounge space and a supply of games and activities. Sharp objects and medications were secured in a locked cabinet. Smoke detectors and carbon monoxide detectors were observed to be working. The kitchen had supply of fresh and pantry food items to meet the needs of clients in care. The first aid kit was observed to be complete. Personal rights and facility license were posted. At 11:05AM, LPA and LPM observed multiple cleaning solutions in an unlocked cabinet under the kitchen sink, including a jug of bleach, a can of Ajax, and window cleaner. LPA and LPM issued a citation of California Code of Regulations (CCR), Title 22, Section 80087(g). See attached LIC 809-D. At 11:30AM, LPA and LPM observed that hot water measured 144. F and F, which are above the permitted range, and no warning signs were posted. LPA and LPM issued citations of CCR, Title 22, Section 80088(e)(1) and 80088(e)(2). See attached LIC 809-D. See Page 2 / Lic 809-c PAGE At 11:35AM, LPA and LPM observed that the facility had insufficient hygiene supplies due to no hair products available for the clients in care. LPA and LPM observed only shared bar soap in both bathrooms. LPA and LPM issued citation of CCR, Title 22, Section 87088(c)(3). See attached LIC 809-D. At 11:30AM, LPA and LPM discussed the facility changing program model. Additionally, LPA and LPM observed multiple cameras on the facility site. The cameras were located by the front door, in the backyard, in the living room, in the dining room, and in the kitchen. LPA and LPM discussed with Administrator and Program Manager the need to update the plan of operation to reflect these changes. LPA and LPM issued a citation of CCR, Title 22, Section 87022(b). See attached LIC 809-D. LPA and LPM also provided at visit a copy of PIN 24-09-CRP on surveillance cameras. At 12PM, LPA and LPM reviewed personnel files for 6 staff. LPA and LPM observed the portion of the files reviewed to be mostly complete. Files reflected that the administrator has a valid administrator certificate. LPA and LPM initiated review of client files but were unable to complete this review. A continuation visit will be conducted in order to complete the record review and interview portions of the inspection. At 4PM, LPA and LPM observed that 3 of 6 personnel files were missing a complete LIC Health Screening or similar documentation. LPA and LPM issued a citation of CCR, Title 22, Section 80066(a)(10). See attached LIC 809-D. At 4PM, LPA and LPM observed that 4 of 6 personnel files contained first aid certificates from a training program that does not meet regulatory requirements due to not being approved by the State Emergency Medical Services Authority. LPA and LPM issued a citation of CCR, Title 22, Section 87065.1(e)(8)(A). See attached LIC 809-D. An exit interview was conducted, and a copy of this report, the attached LIC 809-D pages, the LIC Confidential Names, and the licensee's appeal rights were provided to Direct Care Counselor Tyrone Anderson.

met_with: Administrator Dwayne White; Direct Care Counselor Sheena Moore; Direct Care Counselor Tyrone Anderson


raw_content:
Narrative:
Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that facility staff speaks inappropriately to client in care and facility staff did not ensure that clients in care prescriptions were filled in a timely manner, therefore the above allegation is unsubstantiated. Exit interview conducted with Adminstrator and report was e-mail to Administrator for signature.

Investigation Findings:
13Licensing Program Analyst (LPA) Christopher Rollins conducted a tele-visit follow-up complaint inspection with REFUGE II and spoke with Sylvia Smith Administrator. The purpose of the inspection was to deliver the findings for the above complaint allegations. During the course of investigating the allegation, LPA Rollins conducted confidential interviews with staff, clients, support staff, Social Workers, received documentation and conducted clients' file review. Confidential interviews reveal conflicting stories on if facility staff speaks inappropriately to client in care. Confidential Interviews reveal conflicting stories on if facility staff did not ensure that clients in care precriptions were filled in a timely manner. Based on interviews and documentation there was not enough evidence to prove that facility staff speaks inappropriately to client in care and facility staff did not ensure that clients in care prescriptions were filled in a timely manner. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: Christopher Rollins LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, TRAEGER AVE., Suite San Bruno, CA Facility Name: R.E.F.U.G.E.IIFACILITY NUMBER: VISIT DATE: 05/12/2021

met_with: Sylvia Smith- Administrator


raw_content:
Narrative:
Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that facility staff did not refill client in care medication resulting in client attempting suicide and clients' in care safety needs are not properly met in the facility, therefore the above allegation is unsubstantiated. Exit interview conducted with Adminstrator and report was e-mail to Administrator for signature.

Investigation Findings:
13Licensing Program Analyst (LPA) Christopher Rollins conducted a tele-visit follow-up complaint inspection with REFUGE II and spoke with Sylvia Smith Administrator. The purpose of the inspection was to deliver the findings for the above complaint allegations. During the course of investigating these allegations, LPA Rollins conducted confidential interviews with staff, clients, support staff, Social Worker, received documentation and conducted client file review. Confidential interviews reveal conflicting stories on if facility staff did not refill client's in care medication resulting in client in care attempting suicide. Confidential Interviews reveal conflicting stories on if clients' in care safety need are not properly met in the facility. Based on interviews and documentation there was not enough evidence to prove that facility staff did not refill client in care medication resulting in client attempting suicide and clients in care safety need are not properly met in the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: Christopher Rollins LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, TRAEGER AVE., Suite San Bruno, CA Facility Name: R.E.F.U.G.E.IIFACILITY NUMBER: VISIT DATE: 05/12/2021


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Christopher Rollins conducted a tele-visit follow-up complaint inspection with REFUGE II and spoke with Sylvia Smith Administrator. The purpose of the inspection was to deliver the findings for the above complaint allegations. During the course of investigating these allegations, LPA Rollins conducted confidential interviews with staff, clients, support staff, Social Worker, received documentation and conducted client file review. Confidential interviews reveal conflicting stories on if facility staff abandoned client in care. Confidential Interviews reveal conflicting stories on if facility staff failed to meet clients in care needs. Based on interviews and documentation there was not enough evidence to prove that facility staff abandoned client in care and facility staff failed to meet clients in care needs. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that facility staff abandoned client in care and facility staff failed to meet clients in care needs, therefore the above allegation is unsubstantiated. Exit interview conducted with Adminstrator and report was e-mail to Administrator for signature. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: Christopher Rollins LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Sylvia Smith-Administrator


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Christopher Rollins conducted a tele-visit follow-up complaint inspection with REFUGE II and spoke with Sylvia Smith Administrator. The purpose of the inspection was to deliver the findings for the above complaint allegation. During the course of investigating these allegations, LPA Rollins conducted confidential interviews with staff, clients, support staff, Social Worker, received documentation and conducted client file review. Confidential interviews reveal conflicting stories on if client in care sustained unexplained injuries while in care. Based on interviews and documentation there was not enough evidence to prove that client in care sustained unexplained injuries while in care. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that client in care sustained unexplained injuries while in care, therefore the above allegation is unsubstantiated. Exit interview conducted with Adminstrator and report was e-mail to Administrator for signature. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: Christopher Rollins LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2