summary: Facility Evaluation

raw_content:
Narrative:
On August 23, 2024, Licensing Program Analyst's (LPA) C. White and J. Armstrong arrived at Ascend Healthcare #7 for the purpose of conducting a Group Home Post Licensing inspection. LPA met with Administrator, Brenda Reyes who granted access to the facility and provided the tour. Ascend Healthcare #7 is a therapeutic treatment program designed to accept "Private Placement's". The facility is licensed to provide care and supervision for six (6) children, ages 12-17 years old; ambulatory only. Currently the census is five (5). The facility is set up as follows: This is a single-story home. There are three (3) bedrooms, five (5) bathrooms, living room, dining room, kitchen, a group room, a classroom, medication room, a clinical room, two (2) offices, laundry room, an attached garage, and outdoor/backyard area. Living room: a sofa, operational gas burning fireplace equipped with security glass, and a door leading to the patio and backyard. Dining room: Is equipped with a wooden table with eight (8) chairs. Kitchen: Is equipped with refrigerator/freezer, a gas stove with six (6) working burners, microwaves, dishwasher, and a pantry. LPA observed a trash can with a fitted lid. There were ample plates, cups, and eating utensils. Sharp knives are stored in a locked bin within a locked kitchen cabinet. Facility had ample non-perishable food items and snacks in pantry at the time of the visit. License ensures clients in care receive three (3) meals and snacks per day. Group Room: One group room has a mirrored wall, chairs, an operational gas burning fireplace equipped with security glass, and wall to floor windows looking out to the backyard. Classroom: The has six (6) desks, chairs, computers, and an operational electric fireplace equipped with security screen. The room also has an attached bathroom. Medication room: was observed to have a standing locked cabinet storing PRN medications with separate bins for prescribed medications for individual children; locked cabinets; complete First Aid supplies; and a locked refrigerator to store medication. Clinical room: has a desk, computer, and two (2) chairs. The room has a door that opens to the backyard. Report continued on LIC 809C Offices: are located near the classroom. Each room has two (2) chairs. Laundry room: is located near the medication room. The room is equipped with one (1) washer, one (1) dryer, a sink and has multiple cabinets which store disinfectants and extra cleaning supplies, all made inaccessible to clients in care. This room also has a door that opens to the garage. Attached Garage: has two (2) additional refrigerators and one (1) standalone freezer. Bedrooms: There are three (3) bedrooms. Bedroom #1 is equipped with two (2) twin beds; Bedroom #2 is equipped with two (2) queen size beds; Bedroom #3 is equipped with two (2) twin beds. All rooms have adequate closet and drawer space and working lights. Bathrooms: There are five (5) bathrooms. One bathroom is located in the classroom; one bathroom is located in bedroom #3; one bathroom is located next to bedroom #2; one bathroom is located in the hallway to the left of the entrance; and one bathroom is located next to the medical room. All bathrooms have a toilet, sink, and a shower. Bathrooms were found to be clean and in working order. Outdoor Area: The property is fenced in. The backyard has a gated pool and jacuzzi that meet regulations. There is an outside seating area that contains a gas grill, a small refrigerator, a table with eight (8) chairs, and a sofa. There is an enclosed garden, a chicken coop, a shed used to store animal food and supplies, and a large, detached garage which is used for storage. LPA observed the home to have ten (10) regulation fire extinguishers. The smoke detectors and carbon monoxide alarm were tested and found to be operating properly. There are no security bars on the windows. There are no firearms or dangerous weapons in the home. Facility appears to be clean, safe, sanitary, and in good repair. Passageways and porch were clean and in good repair. The front and back yard were free of debris and hazardous material. LPA reminded the Administrator to ensure Children in care are accorded personal rights. Children are to be supported, encouraged to participate in extracurricular activities. Children are allowed to contact the licensing agency. Children are to be supervised and protected at all times. Children are to be accorded dignity in personal relationships with others in the home. Children will not be restricted in telephone use except by court order. Staff working in the facility have DOJ/FBI criminal record clearances, and Child Abuse Index Checks. Facility meets posting requirements. There were no deficiencies cited at this time. LPA concluded the Post License Inspection. An Exit interview was conducted, and a copy of this report was emailed to the Administrator.

met_with: Brenda Reyes - Administrator


state: CA

facility_name: ASCEND HEALTHCARE 7

summary: Facility Evaluation

raw_content:
Narrative:
On May 28, 2025, Licensing Program Analyst (LPA) C. White arrived at Ascend Healthcare #7 for the purpose of conducting an Annual/Required inspection. LPA met with Facility Manager, Barbara Gonzalez who granted access to the facility and provided the tour. Ascend Healthcare #7 is a therapeutic treatment program designed to accept "Private Placement's" for a length of 45 to 90 days. The facility is licensed to provide care and supervision for six (6) children, age 12-17 years old; ambulatory only. Currently the census is six (6). The facility is set up as follows: This is a single-story home. There are three (3) bedrooms, five (5) bathrooms, living room, dining room, kitchen, a group room, a classroom, medication room, a clinical room, two (2) offices, laundry room, an attached garage, and outdoor/backyard area. Living room: has a sofa, operational gas burning fireplace equipped with security glass, and glass doors leading to the patio and backyard. Dining room: Is equipped with a wooden table with eight (8) chairs. Kitchen: Is equipped with refrigerator/freezer, a gas stove with six (6) working burners, two (2) microwaves, dishwasher, and a pantry. LPA observed ample plates, cups, and eating utensils. Sharp knives are kept in a locked box in a locked cabinet next to the stove. The facility had ample non-perishable and perishable food items and snacks in the pantry. The Licensee ensures clients are provided with three (3) nutritious meals and snacks daily. Group Room: Is equipped with eight (8) chairs, has an operational gas burning fireplace equipped with security glass, mirrored walls, exercise mats, and glass doors leading to the backyard. Report continued on LIC 809C (Page 1 of 3) Classroom: Is located near the client bedrooms and is equipped with a wooden table and six (6) chairs, six (6) computer desks, chairs, computers, and an operational electric fireplace equipped with security screen. The room also has an attached bathroom, which remains locked at all times, and contains a storage closet for classroom equipment. There is also a patio door leading to the backyard. Medication room: LPA observed multiple locked and labeled cabinets; a complete First Aid kit; a small, locked refrigerator for use to store medication; a standing locked cabinet for use to store PRN medications and separate bins for prescribed medications for individual clients; a built in desk, chair, and a computer. Clinical room: has a desk, chair, and two (2) chairs. The room has a door that opens to the backyard. Offices: Both are located near the classroom. One room has a desk, two (2) chairs, and storage cubies. One room has a desk, computer, and a chair. Laundry room: is located near the medication room. The room is equipped with one (1) washer, one (1) dryer, and a sink. The room has multiple cabinets, which remain locked, and are used to store laundry detergent and other cleaning supplies. The room has a door that opens to the garage. Attached Garage: is used to store disinfectants, extra cleaning supplies, and has two (2) freezers that contain surplus food supplies. The garage is made inaccessible to children in care. Bedrooms: There are three (3) bedrooms. Bedroom #1 is equipped with two (2) twin beds; Bedroom #2 is equipped with two (2) queen size beds; Bedroom #3 is equipped with two (2) twin beds and has an attached bathroom. All rooms have adequate closet and drawer space, windows, and working lights. Bathrooms: There are five (5) bathrooms. One bathroom is located in the classroom; one bathroom is located in bedroom #3; one bathroom is located next to bedroom #2; one bathroom is located in the hallway to the left of the entrance; and one bathroom is located next to the medical room. All bathrooms have a toilet, sink, and a shower. Bathrooms were found to be clean and in working order. Outdoor Area: The entire property is fenced in. The front lawn has grass and trees. The backyard has a pool and a jacuzzi enclosed with a gate that meet regulations. There is an outside seating area that contains a gas grill, a small refrigerator, a table with eight (8) chairs, and a sofa. Report continued on LIC 809C (Page 2 of 3) There is an enclosed garden, an equine farm with goats, sheep, horses, and a pig; a pig pin, a shed used to store animal food and supplies, and a large, detached garage that is used for storage. LPA observed the home to have multiple regulation fire extinguishers. The smoke detectors and carbon monoxide alarm were tested and found to be operating properly. There are no security bars on the windows. There are no firearms or dangerous weapons in the home. The gas shut off valve is located in the back of the house, the water shut off valve is in the front of the home, and the electric shut off panel is located in the attached garage. Facility appears to be clean, safe, sanitary, and in good repair. Passageways and porch were clean and in good repair. The front and back yard were free of debris and hazardous material. LPA reminded the Facility Manager to ensure clients in care are accorded personal rights. Clients are to be supported, encouraged to participate in extracurricular activities. Clients are allowed to contact the licensing agency. Clients are to be supervised and protected at all times. Clients are to be accorded dignity in personal relationships with others in the home. Clients will not be restricted in telephone use except by court order. Facility meets posting requirements. LPA reiterated the importance of reporting and submitting Incident Reports, Law Enforcement contact, and reporting all changes within the facility to Community Care Licensing and any other appropriate agencies. The Administrator will ensure the Unusual Incident Report LIC 624, and LIC 624LE forms are utilized to document incidents. Clients Records are electronically stored in the facilities online Portal with Kipuworks.com Staff Records are electronically stored in the ISolved system. Facility Manager provided LPA with a copy of the Personnel Report (LIC 500) and a current Client Roster (LIC 9020). LPA will return at a later date to review client and staff records. There are no deficiencies observed or cited at this during this inspection. Exit interview was conducted with the Facility Manager, and a copy of this report was left at the facility. (Page 3 of 3)

report_type: Facility Evaluation

visit_type: Annual

met_with: Barbara Gonzalez - Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On June 5, 2025, Licensing Program Analyst (LPA) C. White, made an unannounced visit to Ascend Healthcare 7, for the purpose of conducting a Case Management Annual Continuation Inspection. LPA met with Administrator, Brenda Reyes and was granted access to the facility and provided the requested information. The facility keeps clients records electronically stored in an online system call KIPUERM and staff Records are electronically stored in the ISolved system. LPA reviewed the following records during the inspection: Client Records: The program currently has a total of six (6) clients. LPA reviewed a total of three (3) client records and found each record to meet required regulations. Staff Records: The program currently has a total of twenty-five (25). LPA reviewed a total of five (5) staff records and confirmed files contained staff qualifications, current CPR/First Aid cards, health screening, and TB test results. LPA obtained the LIC 500 to verify Staff to Client ratio. LPA reviewed the Facility Profile and Personnel Report and confirmed that personnel have required criminal record clearance: DOJ, FBI and Child Abuse; which meet qualification. This inspection included an overview of required Core Services and Supports and based upon inspection of facility records and interviews of staff and clients. Licensee is meeting all requirements. PER California Code Regulations, TITLE 22, DIVISION 6, CHAPTERS 5, General Licensing Regulations the following deficiency was observed and cited at the time of this inspection. (See LIC 809D). A copy of this report was emailed to the Administrator.

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
On September 11, 2025, Licensing Program Analyst (LPA), Emelyn Sanchez P. made an unannounced visit to Ascend Healthcare 7 for the purpose of conducting a Follow-up Case Management- Incident visit regarding a medication error. LPA Sanchez P. met with Regional Operations Manager, Brenda Reyes to discuss the incident. The special incident report was reported to the Department on 09/04/2025. The incident occurred on 09/02/2025. The incident stated a client was given the PM dosage of Psychotropic medication instead of the AM dosage of the Psychotropic medication. Based on the information provided, and interviews conducted, it was confirmed that a medication error occurred on 09/02/2025. The Department has concluded, based on the preponderance of the evidence obtained, that staff failed to administer the client's medication as prescribed. LPA informed Regional Operations Manager, Brenda Reyes that the facility would be cited. The following deficiency is being cited for violating California Code of Regulations Title 22, Division Regulation 80075(b)(5)(B) Health Related Services. (see page D). Exit interview was completed and copy of the report and appeal rights were discussed and provided to Regional Operations Manager, Brenda Reyes.

met_with: Regional Operations Manager- Brenda Reyes


facility_name: ASCEND HEALTHCARE 8

summary: Facility Evaluation

raw_content:
Narrative:
On April 24, 2025 at 10: AM, Licensing Program Analyst (LPA) Charmetha White made an announced visit to Ascend Healthcare #8 for the purpose of completing the Group Home Pre-Licensing Inspection. LPA met with Administrator, Jaqueline Marshall Waldron, and Facility Manager, Brenda Reyes and was granted access to the facility. This facility will be licensed to provide care and supervision for six (6) children ages 12-17 years old, ambulatory only. Current census is zero (0). The facility is set up as follows: This is a two-story home located in a residential neighborhood. There are four (4) bedrooms, five and one half (5 ½) bathrooms, living room, dining room, kitchen, group room, lounge room, medication office, four (4) office rooms, classroom area, laundry area, an attached garage, and backyard area. Living room: Is equipped with a sectional sofa, two (2) chairs, a mounted TV, and an operational gas burning fireplace equipped a retractable glass security door. The room has windows, working lights and opens to the dining room. Dining room: Is equipped with a wooden table with eight (8) chairs, and a glass chandelier. The room has windows, working lights, and opens to the kitchen. Kitchen: Is equipped with a double door refrigerator/freezer, double ovens, a kitchen island with a five (5) burner gas cooktop (all operational at the time of the inspection), a microwave, dishwasher, and trash compactor. LPA observed a wooden table with two (2) benches, a covered trash can, two (2) locked pantries, plenty of cabinet space, ample plates, cups, and eating utensils. Sharp knives are stored in a locked cabinet located next to the sink and made inaccessible. A weekly menu was posted, and food will be prepared by a private chef and delivered to the home. The applicant will ensure that three (3) nutritious meals and snacks will be provided to the clients in care. Group Room: is equipped with eight (8) chairs, window, and working lights. The room has patio doors which lead to the side of the house containing the equine therapy farm. Report Continued on LIC 809C (Page 1 of 3) Lounge Room: is equipped with a couch, two (2) chairs, a small wooden coffee table, an operational gas burning fireplace equipped with an iron screen, windows, working lights, and a patio door leading to the backyard. This room will be used for visitation. Medication Office: is located off the kitchen next to a staircase leading the second floor. The room is equipped with multiple built in locked cabinets, which store PRN medications, first aid supplies, separate bins for prescribed medications for individual clients, and a locked bock for additional sharps. The room also contains a small combination lock refrigerator to store medications, a sink, windows, working lights, and a door that leads to the backyard. Offices: One office is located to the left of the lounge room and will be used for therapy. The is equipped with a desk and chair, a sofa, two (2) additional chairs, a small wooden coffee table, and a bookshelf. The room opens to the Second office which will be used for therapy. This room is equipped with a mounted TV. The Third office is attached to the group room. This office is equipped with a sofa, two (2) chairs, a desk and chair, a mounted TV, a operational gas burning fireplace equipped a retractable glass security door, windows, working lights, and built in shelves. The Forth office is located on the second floor to next to the classroom area and will be used for staff. The room is equipped a desk, chair, built in cabinet space, and contains the WiFi and cable connections. Classroom Area: This area is located on the second and is equipped with six (6) computers, six (6) wooden desk and chairs, a wooden table with five (5) chairs, a pool table, and multiple windows. There is a locked storage closet at the top of the stairs which will be used to store classroom supplies. Additionally, this closet has an unlocked crawl space door leading the homes insulation. Laundry area: is located inside the attached garage and has a washer/dryer. LPA observed locked cabinets above the appliances which contain additional disinfectants and laundry supplies. Attached Garage: This is a 3-car garage which will be used for storage. LPA observed an additional refrigerator, freezer, mattresses, and boxes in this area. Backyard area: contains a ½ court basketball area, a hooded grill, a fenced and gated pool/jacuzzi that meets regulations, a enclosed trampoline, a small garden, a wooden table with two (2) attached benches, and a working firepit. On the side of the home is small equine therapy farm that has 4 goats, chickens, and a small barn. The barn contains a chicken coop, built in storage cabinets that store animal supplies, two (2) desk, and two (2) chairs. Bedroom #1: is equipped with two (2) twin size beds, built in storage shelves with four (4) drawers, and two (2) nightstands. Bedroom #2: is equipped with two (2) full size beds, built in storage shelves with four (4) drawers. The room also has a walk-in closet that will remain locked at all times and not be used due to access to a crawl space that lead to the homes insulation. Bedroom #3: is equipped with one (1) full size bed, a dresser, and two (2) closets with built in shelves. Report Continued on LIC 809C (Page 2 of 3) Bedroom #4: is equipped with one (1) full size bed, a dresser, and a walk-in closet that has separate locked door leading the hallway. All bedrooms were all observed to have mattresses, bed linen, blankets, pillows, windows, and working lights. Bathrooms: Three bathrooms are located on the first floor. Two bathrooms are located on the second floor. The bathrooms contain a toilet, sink, and shower. There is also a ½ bathroom located near the front entrance that contains a toilet and a sink. All bathrooms were checked and found to be in working order. The hot water was tested, and the temperature was found to be between 105 -120 (F). LPA observed the home to have eight (8) regulation fire extinguishers. The smoke detectors and carbon monoxide alarm were tested and found to be operating properly. The First Aid kit was checked and found to be complete with scissors, tweezers, thermometer, and gauzes, antiseptic and First Aid Manual Guide. Extra linens, hygiene supplies, and disinfectants were stored in locked hallway closets. There are no security bars on the bedroom windows. There are no firearms or dangerous weapons in the home.Facility appears to be clean, safe, sanitary, and in good repair. Passageways and porch were clean and in good repair. The front and back yard were free of debris and hazardous material. Applicant showed LPA were the gas shut-off valves, the electrical panel, and water shut off valves were located. The following was discussed with the facility Administrator: Children will be accorded personal rights. Children in care will be supported, encouraged to participate in extracurricular activities. Children in care will be able to contact the licensing agency. Children will be supervised & protected at all times. Children will be accorded dignity in personal relationships with others in the home. Children will not be restricted in telephone use except by court order. Applicant will provide and ensure three nutritious meals, snacks, and special diets. Applicant will ensure to have written authorization to obtain medical and dental care. Applicant will ensure to have personal rights forms in children's files. Applicant acknowledges abuse reporting requirements. Staff working in the facility will have DOJ/FBI criminal record clearances, and Child Abuse Index Checks. Facility will operate within license conditions & limitations including capacity limit. Facility meets posting requirements, including COVID-19 best practices signs and emergency telephone numbers are in prominent locations. The facility will use a Honda, Odyssey to transport youth to appointments and offsite extra curriculum recreational activities. LPA inspected the vehicle and found horn, lights, and all seatbelts in working order. The vehicle is equipped with a complete First Aid Kit, and Roadside emergency kit. LPA observed the vehicle to have valid car insurance through Ace Property & Casualty Insurance Company. LPA concluded the Pre license Inspection. An Exit interview was conducted, and a copy of this report was left at the facility with the Program Administrator. (Page 3 of 3)

visit_type: Prelicensing

met_with: Jaqueline Marshall Waldron - Administrator, and Brenda Reyes - Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On July 30, 2025, Licensing Program Analyst (LPA) C. White arrived at Ascend Healthcare #8 for the purpose of conducting a Group Home Post Licensing Inspection. LPA met with the Facility Manager, Brenda Reyes and who granted access to the facility and provided the tour facility. Ascend Healthcare #8 is a therapeutic treatment program designated to accept "Private Placement's". The facility is licensed to provide care and supervision for six (6) children ages 12-17 years old, ambulatory only. Current census is five (5). The facility is set up as follows: This is a two-story home located in a residential neighborhood. There are four (4) bedrooms, five and one half (5 ½) bathrooms, living room, dining room, kitchen, group room, lounge room, medication office, four (4) office rooms, classroom area, laundry area, an attached garage, and backyard area. Living room: Is equipped with a sofa, a mounted TV, and an operational gas burning fireplace equipped a retractable glass security door. The room has windows, working lights and opens to the dining room. Dining room: Is equipped with a wooden table with eight (8) chairs. The room has windows, working lights, and opens to the kitchen. Kitchen: Is equipped with a double door refrigerator/freezer, double ovens, a kitchen island with a five (5) burner gas cooktop (all operational at the time of the inspection), a microwave, dishwasher, and a trash compactor. The room has a wooden table with two (2) benches, a covered trash can, two (2) locked pantries, and ample plates, cups, and eating utensils. Sharp knives are stored in a locked cabinet next to the sink and made inaccessible to children in care. A weekly menu was posted, and food is prepared by a private chef then delivered to the home. Licensee ensures children in care receive three (3) nutritious meals and snacks. Report continued on LIC 809C (page 1 of 4). Group Room: is equipped with eight (8) chairs, has a window, and working lights. The room has patio doors that lead to the left side of the house. Lounge Room: is equipped with a couch, chairs, a wooden coffee table, an operational gas burning fireplace equipped with an iron screen, windows, working lights, and a patio door leading to the backyard. Medication Office: is located off the kitchen. The room is equipped with built-in locked cabinets, which store PRN medications, first aid supplies, separate bins for prescribed medications for individual clients, and a locked box for additional sharps. The room also contains a small combination lock refrigerator to store medications, a sink, windows, working lights, and a door that leads to the backyard. Offices: One office located to the left of the lounge room, is used for therapy; the room is equipped with a desk and chair, a sofa, two (2) additional chairs, a wooden coffee table, and a bookshelf. The room opens to a Second office which is also used for therapy; this room is equipped with a mounted TV. The Third office is attached to the group room; this office is equipped with a sofa, two (2) chairs, a desk and chair, a mounted TV, an operational gas burning fireplace equipped a retractable glass security door, windows, working lights, and built in shelves. The Forth office, located on the second floor, is being used by staff; the room is equipped with a desk, chair, built in cabinet space, and contains the WiFi and cable connections. Classroom Area: This area is located on the second floor and is equipped with six (6) computers, six (6) wooden desks and chairs, a wooden table and chairs, and multiple windows. There is a locked storage closet at the top of the stairs which will be used to store classroom supplies. Additionally, this closet has an unlocked crawl space door leading to the homes' insulation. Laundry area: is located inside the attached garage and has a washer/dryer. LPA observed locked cabinets above the appliances which contain additional disinfectants and laundry supplies. Attached Garage: This is a 3-car garage which will be used for storage. LPA observed an additional refrigerator, freezer, mattresses, and boxes in this area. Backyard area: contains a ½ court basketball area, a hooded grill, a fenced and gated pool/jacuzzi that meets regulations, an enclosed trampoline, a small garden, a wooden table with two (2) attached benches, and a working firepit. On the side of the home is an equine therapy farm that has 4 goats, chickens, and a small barn. The barn contains a chicken coop, built in storage cabinets that store animal supplies, two (2) desks, and two (2) chairs. Bedroom #1: is equipped with two (2) twin size beds, built in storage shelves with four (4) drawers, and two (2) nightstands. Report continued on LIC 809C (page 2 of 4) Bedroom #2: is equipped with two (2) full size beds, built in storage shelves with four (4) drawers. The room also has a walk-in closet that will remain locked at all times and not be used due to access to a crawl space that leads to the home's insulation. Bedroom #3: is equipped with one (1) full size bed, a dresser, and two (2) closets with built-in shelves. Bedroom #4: is equipped with one (1) full size bed, a dresser, and a walk-in closet that has separate locked door leading the hallway. All bedrooms were all observed to have mattresses, bed linen, blankets, pillows, windows, and working lights. Bathrooms: Three bathrooms are located on the first floor. Two bathrooms are located on the second floor. The bathrooms contain a toilet, sink, and shower. There is also a ½ bathroom located near the front entrance that contains a toilet and a sink. All bathrooms were checked and found to be in working order. The hot water was tested, and the temperature was found to be between 105 -120 (F). LPA observed the home to have regulation fire extinguishers. The smoke detectors and carbon monoxide alarm were tested and found to be operating properly. The First Aid kit was checked and found to be complete. Extra linens, hygiene supplies, and disinfectants were stored in locked hallway closets. There are no security bars on the bedroom windows. There are no firearms or dangerous weapons in the home. Facility appears to be clean, safe, sanitary, and in good repair. Passageways and porch were clean and in good repair. The front and back yard were free of debris and hazardous material. The following was discussed with the facility Administrator: Children will be accorded personal rights. Children in care will be supported, encouraged to participate in extracurricular activities. Children in care will be able to contact the licensing agency. Children will be supervised & protected at all times. Children will be accorded dignity in personal relationships with others in the home. Children will not be restricted in telephone use except by court order. Licensee acknowledges abuse reporting requirements. Staff working in the facility have DOJ/FBI criminal record clearances, and Child Abuse Index Checks. Facility operates within license conditions & limitations including capacity limit. Report continued on LIC 809C (page 3 of 4). LPA reviewed the LIC Personnel Report and Guardian Roster. LPA informed, Facility Manager, Brenda Reyes that the following 10 staff members: Brenda Reyes, Kyle Difulvio, Laura Hubbard, Gabriel Andrade, Xena Blair, Larissa Perez, Erika Gomez, Kayla Holcolm, Spencer Bartlett, and Kayle Yi, who were working and present in the facility at the time of the inspection, were not associated to the facility per licensing regulations. Additionally, the facility does not have a Facility Manager for every shift and does not have a certified Administrator. LPA informed Facility Manager, Brenda Reyes, that the facility would be cited. PER California Code Regulations, TITLE 22, DIVISION 6, CHAPTERS 5, General Licensing Regulations the following deficiencies were observed and cited at the time of this inspection, 80019(e)(3) Criminal Record Clearance; 84065(d) Personnel Requirements; 84064(b) Administrator Qualifications and Duties. (See LIC 809D). LPA will return at a later date to review client files and complete Staff file review. An exit interview was conducted, and a copy of this report was emailed to the Facility Manager, Brenda Reyes. (Page 4 of 4).


summary: Facility Evaluation

raw_content:
Narrative:
On April 21, 2026 at 9:25am, Licensing Program Analyst (LPA) Emelyn Sanchez P. made an unannounced visit to Ascend Healthcare 8 for the purpose of conducting a Annual/Required inspection visit. LPA Sanchez P. met with Brenda Reyes, Administrator who granted access to the facility. LPA Sanchez P. toured the interior and exterior of the facility. The facility is licensed to provide care and supervision services for up to six (6) male and female children, ages 12-17 years old, ambulatory only. There is a swimming pool on the premises which meets licensing regulations. The census at the time of the inspection was six (6). The facility is set up as follows: This is a two-story home located in a residential neighborhood. There are four (4) bedrooms, four and one half (4 ½) bathrooms, living room, dining room, kitchen, group room, lounge room, medication office, four (4) office rooms, classroom area, an attached garage/laundry space, and backyard area/farm. Living room: Is equipped with a sofa, a mounted TV, and an operational gas burning fireplace equipped a retractable glass security door. The room has windows, working lights and opens to the dining room. Dining room: Is equipped with a wooden table with seven (7) chairs. The room has windows, working lights, and opens to the kitchen. Kitchen: Is equipped with a double door refrigerator/freezer, double ovens, a kitchen island with a five (5) burner gas cook top (all operational at the time of the inspection), a microwave, dishwasher, and a trash can. Report Cont. on LIC 809-C. Pg. 1 of The kitchen has a wooden table with two (2) benches, two (2) locked pantries, and ample plates, cups, and eating utensils. Sharp knives are stored in a locked cabinet next to the sink and made inaccessible to children in care. A weekly menu was posted, and food is prepared by a private chef then delivered to the home. Licensee ensures children in care receive three (3) nutritious meals and snacks. Group Room: is equipped with eight (8) chairs, has a window, and working lights. The room has patio doors that lead to the left side of the house. Lounge Room: is equipped with a couch, chairs, a wooden coffee table, an operational gas burning fireplace equipped with an iron screen, windows, working lights, and a patio door leading to the backyard. Medication Office: is located off the kitchen. The room is equipped with built-in locked cabinets, which store PRN medications, first aid supplies, separate bins for prescribed medications for individual clients, and a locked box for additional sharps. The room also contains a small combination lock refrigerator to store medications, a sink, windows, working lights, and a door that leads to the backyard. Offices: One office located to the left of the lounge room, is used for therapy; the room is equipped with a desk and chair, a sofa, two (2) additional chairs, a wooden coffee table, and a bookshelf. The room opens to a Second office which is also used for therapy; this room is equipped with a round table and chairs. The Third office is attached to the group room; this office is equipped with a sofa, two (2) chairs, a desk and chair, a mounted TV, an operational gas burning fireplace equipped a retractable glass security door, windows, working lights, and built in shelves. The Forth office, located on the second floor, is being used by staff; the room is equipped with a desk, chair, and built in cabinet space. The fifth office is also located on the second floor and is equipped it a desk and chair. Classroom Area: This area is located on the second floor and is equipped with six (6) computers, six (6) wooden desks and chairs, a wooden table and chairs, and multiple windows. There is a locked storage closet at the top of the stairs which will be used to store classroom supplies. Additionally, this closet has a locked crawl space door leading to the home's insulation. Report Cont. on LIC 809-C. Pg. 2 of Attached Garage/Laundry Space: This is a 3-car garage which will be used for storage. LPA Sanchez P. observed an additional refrigerator, freezer and boxes in this area. There is also a washer and dryer. LPA Sanchez P. observed locked cabinets above the appliances which contain additional disinfectants and laundry supplies. Backyard area: contains a ½ court basketball area, a hooded grill, a fenced and gated pool/jacuzzi that meets regulations, an enclosed trampoline, a small garden and a fire pit. On the side of the home is the farm that has 2 goats, 4 ponies, 1 sheep, chicken coop, and a shed with built in storage cabinets that store animal supplies, two (2) desks, and two (2) chairs. Bedroom #1: is equipped with two (2) twin size beds, built in storage shelves with four (4) drawers, and two (2) night stands. Bedroom #2: is equipped with two (2) twin size beds, built in storage shelves with four (4) drawers. The room also has a walk-in closet that will remain locked at all times and not be used due to access to a crawl space that leads to the home's insulation. Bedroom #3: is equipped with one (1) full size bed, a dresser, and two (2) closets with built-in shelves. Bedroom #4: is equipped with one (1) full size bed, a dresser, and a walk-in closet that has separate locked door leading the hallway. All bedrooms were all observed to have mattresses, bed linen, blankets, pillows, windows, and working lights. Bathrooms: Two full bathrooms are located on the first floor. Two full bathrooms are located on the second floor. The bathrooms contain a toilet, sink, and shower. There is also a ½ bathroom located near the front entrance that contains a toilet and a sink. The bathrooms were clean and in operating condition. Water temperature was observed to be within 105 - 120 degrees Fahrenheit. Report Cont. on LIC 809-C. Pg. 3 of Transportation: The facility uses a Honda Odyssey to transport children in care. LPA Sanchez P. inspected the vehicle and found it to be in good repair. LPA Sanchez P. observed the vehicle to have current registration and valid insurance. The carbon monoxide and smoke detectors were tested and found to be in working order. The facility has six (6) regulation fire extinguishers. The facility has a working telephone readily accessible. Temperatures in client rooms and common areas are maintained by a central air and heating system and the home was found to be between 68 - 85 degrees (F). Overall LPA Sanchez P. observed the home to be clean, safe, sanitary, and in good repair. The front yard and outdoor spaces were clean and free of debris. The home has a linen closet located on the second floor which stores additional towels and sheets. Disinfectant and cleaning solutions are locked in a storage closet located in the kitchen and made inaccessible to the clients. There are no firearms or dangerous weapons located in the home. Licensee ensures that individuals supervising children in the pool area are Water Safety trained. The facility operates within license conditions and limitations including capacity limitations. All posting requirements for Group Home Licensure, including the Emergency Plan, Personal Rights, and Grievance Procedures were met and posted on the wall. LPA Sanchez P. discussed the following: Children are accorded their Personal Rights. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. LPA Sanchez P. reiterated the importance of reporting and submitting Incident Reports, Law Enforcement contact, and reporting all changes within the facility to Community Care Licensing and any other appropriate agencies. The Administrator will ensure the Unusual Incident Report LIC 624, and LIC 624LE forms are utilized to document incidents. LPA Sanchez P. was provided with a copy of the Personnel Report (LIC 500) and Client Register (LIC 9020). The facility keeps client files and documents in digital system called KIPU. The facility keeps staff files and documents in digital system called Isolved. Report Cont. on LIC 809-C. Pg. 4 of LPA Sanchez P. reviewed the following records during the inspection: Client Records: The program currently has a total of six (6) clients. LPA Sanchez P. reviewed three (3) client records and found each record to meet licensing requirements. LPA Sanchez P. will return at a later date to review staff files and to conduct interviews with staff and clients. There are no deficiencies observed or cited at this time during this inspection. An exit interview was conducted with Brenda Reyes, Administrator, and a copy of this report was left at the facility. Pg. 5 of 5

met_with: Brenda Reyes, Administrator


facility_name: ASCEND HEALTHCARE #6

summary: Facility Evaluation

raw_content:
Narrative:
On December 8, 2022 at 9: AM, Licensing Program Analyst (LPA) Charmetha White made an announced visit to Ascend Healthcare #6 for the purpose of conducting a Group Home Pre-Licensing Inspection. LPA met with Administrator, Jaqueline Marshall Waldron, Facility Compliance Manager, Dave Trice, and Director of Facilities, Zackary Hale and together toured the interior and exterior of the facility. This facility will be licensed to provide care and supervision for six (6) female children ages 12-17 years old, ambulatory only. Current census is zero (0). The facility is set up as follows: This is a single-story home located in a residential neighborhood. There are three (3) bedrooms, four (4) bathrooms, living room, dining room, kitchen, group room, medication room, two (2) offices, laundry area, an attached garage (which will be used as the classroom), and backyard area. Living room: Is equipped with two (2) sofas and two (2) chairs, a mounted TV, multiple shelves, and an operational gas burning fireplace equipped with a security screen. The room has patio doors which lead to the backyard. Dining room: Is equipped with a wooden table with 10 chairs, a mounted TV, and an operational gas burning fireplace equipped with a security screen. There is an additional table located off the kitchen that has six (6) chairs. The room has patio doors which lead to the backyard. Kitchen: Is equipped with an electric temperature controlled refrigerator, two (2) freezer drawers, a gas stove with six (6) working burners, a microwave, and dishwasher. LPA observed a covered trash can with a mechanical foot closing device, a pantry, plenty of cabinet space, ample plates, cups, and eating utensils. Sharp knives are stored in a locked cabinet located next to the stove and made inaccessible. Food will be prepared by a private chef and a weekly menu was posted. LPA observed ample perishable food items in the refrigerator and the pantry is fully stocked with non-perishable food items. The applicant will to ensure that three (3) nutritious meals and snacks will be provided to the youth. Group Room: is equipped with six (6) chairs, a mounted TV, a white board, yoga matts, and an operational gas burning fireplace equipped with a security screen. The room has patio doors which lead to the backyard. Medication room: was observed to a desk, chair, multiple locked cabinets which store PRN medications, separate bins for prescribed medications for individual youth, a sink, a First Aid kit, and two refrigerators. LPA observed one refrigerator to have a lock and it will be used to store medication. Report continued on LIC 809C (page 1 of 3) Offices: The first office is located to the right of the entrance and will be used as a staffing office. The room is equipped with a desk, chair, printer, and lamp. The second office is located off the kitchen and will be used as a therapy room. The room is equipped with a desk, chair, sofa, a mounted TV, and has ample closet space which will be used for storage. The room has an attached bathroom that includes a sink, toilet, and shower. Laundry area: is located inside a hallway closet left of the entrance. LPA observed the area to have a washer, dryer and two (2) cabinets used for storage. The laundry detergent and other cleaning supplies are stored in separate locked closet located adjacent to laundry area. Attached garage (Classroom): The garage is being converted into a classroom. Currently this area is unfurnished and not equipped. The Fire Clearance will be reviewed to ensure the space has been permitted for use as a living space. Backyard area: has a combination basketball/tennis court, a grill, small refrigerator, a fenced and gated pool/jacuzzi that meets regulations, a small detached room which will be used for therapy, and storage bin on the side of the home. The therapy room was unfurnished, and storage bin was observed to be empty. Applicant will ensure all individuals supervising youth in the pool area is Water Safety trained. Bedroom #1: is equipped with two (2) twin size beds, each with two (2) pull out drawers. The room has built in shelves, a window, and an attached bathroom (equipped with toilet, sink, shower/tub combination). LPA observed the room to have a locked closet used to store the facility's internet system and ADT system. Bedroom #2: is equipped with two (2) twin size beds, each with two (2) pull out drawers. The room has a closet with ample space, a window, and shares a Jack and Jill bathroom with Bedroom #3. Bedroom #3: is equipped with two (2) twin size beds, each with two (2) pull out drawers. The room has a closet with ample space, a window, and shares a Jack and Jill bathroom with Bedroom #2. All bedrooms were all observed to have mattresses, bed linen, blankets, pillows, and working lights. Bathrooms: All bathrooms were checked and found to be in working order. The hot water was tested and the temperature was found to be between 105 -120 (F). LPA observed the home to have three (3) regulation fire extinguishers. The smoke detectors and carbon monoxide alarm were tested and found to be operating properly. The First Aid kit was checked and found to be complete with scissors, tweezers, thermometer, and gauzes, antiseptic and First Aid Manual Guide. Extra linens, hygiene supplies, and disinfectants were stored in locked hallway closets. There are no security bars on the bedroom windows. There are chimes on the exit doors. There are no firearms or dangerous weapons in the home. Report continued on LIC 809C (page 2 of 3) Facility appears to be clean, safe, sanitary, and in good repair. Passageways and porch were clean and in good repair. The front and back yard were free of debris and hazardous material. Administrator showed LPA were the gas shut-off valves, the electrical panel, and water shut off valves were located. The following was discussed with the facility Administrator: Children will be accorded personal rights. Children in care will be supported, encouraged to participate in extracurricular activities. Children in care will be able to contact the licensing agency. Children will be supervised & protected at all times. Children will be accorded dignity in personal relationships with others in the home. Children will not be restricted in telephone use except by court order. Applicant will provide and ensure three nutritious meals, snacks, and special diets. Applicant will ensure to have written authorization to obtain medical and dental care. Applicant will ensure to have personal rights forms in children's files. Applicant acknowledges abuse reporting requirements. Staff working in the facility will have DOJ/FBI criminal record clearances, and Child Abuse Index Checks. Facility will operate within license conditions & limitations including capacity limit. Facility meets posting requirements, including COVID-19 best practices signs and emergency telephone numbers are in prominent locations. The following is needed for license approval: The classroom needs to be furnished. A facility vehicle to transport the youth to appointment and off site extra curriculum recreational activities. The program statement was not reviewed during the review process, due to no changes being implemented to the program statement. If any changes or modifications are implemented to the program statement, the provider should submit the changes to the LPA for review and approval before implementing new changes. LPA will conduct a follow up visit once all requirements have been met. An exit Interview was conducted, and a copy of this report was left with the Administrator. (page 3 of 3)

met_with: Administrator, Jaqueline Mashall Waldron, Facility Compliance Manager, Dave Trice, and Director of Facilities, Zackary Hale


summary: Facility Evaluation

raw_content:
Narrative:
On December 12, 2022 at 9: AM, Licensing Program Analyst (LPA) Charmetha White made an announced visit to Ascend Healthcare #6 for the purpose of completing the Group Home Pre-Licensing Inspection. LPA met with Administrator, Jaqueline Marshall Waldron, Facility Compliance Manager, Dave Trice, and Director of Facilities, Zackary Hale and was granted access to the facility. This facility will be licensed to provide care and supervision for six (6) female children ages 12-17 years old, ambulatory only. Current census is zero (0). The facility is set up as follows: This is a single-story home located in a residential neighborhood. There are three (3) bedrooms, four (4) bathrooms, living room, dining room, kitchen, group room, medication room, two (2) offices, laundry area, an attached garage (which will be used as the classroom), and backyard area. Living room: Is equipped with two (2) sofas and two (2) chairs, a mounted TV, multiple shelves, and an operational gas burning fireplace equipped with a security screen. The room has patio doors which lead to the backyard. Dining room: Is equipped with a wooden table with 10 chairs, a mounted TV, and an operational gas burning fireplace equipped with a security screen. There is an additional table located off the kitchen that has six (6) chairs. The room has patio doors which lead to the backyard. Kitchen: Is equipped with an electric temperature controlled refrigerator, two (2) freezer drawers, a gas stove with six (6) working burners, a microwave, and dishwasher. LPA observed a covered trash can with a mechanical foot closing device, a pantry, plenty of cabinet space, ample plates, cups, and eating utensils. Sharp knives are stored in a locked cabinet located next to the stove and made inaccessible. Food will be prepared by a private chef and a weekly menu was posted. LPA observed ample perishable food items in the refrigerator and the pantry is fully stocked with non-perishable food items. The applicant will to ensure that three (3) nutritious meals and snacks will be provided to the youth. Group Room: is equipped with six (6) chairs, a mounted TV, a white board, yoga matts, and an operational gas burning fireplace equipped with a security screen. The room has patio doors which lead to the backyard. Medication room: was observed to a desk, chair, multiple locked cabinets which store PRN medications, separate bins for prescribed medications for individual youth, a sink, a First Aid kit, and two refrigerators. LPA observed one refrigerator to have a lock and it will be used to store medication. Report continued on LIC 809C (page 1 of 3) Offices: The first office is located to the right of the entrance and will be used as a staffing office. The room is equipped with a desk, chair, printer, and lamp. The second office is located off the kitchen and will be used as a therapy room. The room is equipped with a desk, chair, sofa, a mounted TV, and has ample closet space which will be used for storage. The room has an attached bathroom that includes a sink, toilet, and shower. Laundry area: is located inside a hallway closet left of the entrance. LPA observed the area to have a washer, dryer and two (2) cabinets used for storage. The laundry detergent and other cleaning supplies are stored in separate locked closet located adjacent to laundry area. Attached garage (Classroom): The garage has been converted into a classroom. LPA observed the room to be equipped with six (6) computers, six (6) desk, eight (8) chairs, classroom supplies, and ample cabinets which will be used to store additional classroom supplies. LPA observed the to have a regulation fire extinguisher hung in towards the back of the garage, and a combination smoke detector/carbon monoxide alarm that is connected to the smoke alarm system in the house. The smoke detector was tested and found to be in working order. The Fire Inspector conducted an additional inspection on 12/09/2022 and confirmed the space was permitted for use. Backyard area: has a combination basketball/tennis court, a grill, small refrigerator, a fenced and gated pool/jacuzzi that meets regulations, a small detached room which will be used for therapy, and storage bin on the side of the home. The therapy room was unfurnished, and storage bin was observed to be empty. Applicant will ensure all individuals supervising youth in the pool area is Water Safety trained. Bedroom #1: is equipped with two (2) twin size beds, each with two (2) pull out drawers. The room has built in shelves, a window, and an attached bathroom (equipped with toilet, sink, shower/tub combination). LPA observed the room to have a locked closet used to store the facility's internet system and ADT system. Bedroom #2: is equipped with two (2) twin size beds, each with two (2) pull out drawers. The room has a closet with ample space, a window, and shares a Jack and Jill bathroom with Bedroom #3. Bedroom #3: is equipped with two (2) twin size beds, each with two (2) pull out drawers. The room has a closet with ample space, a window, and shares a Jack and Jill bathroom with Bedroom #2. All bedrooms were all observed to have mattresses, bed linen, blankets, pillows, and working lights. Bathrooms: All bathrooms were checked and found to be in working order. The hot water was tested, and the temperature was found to be between 105 -120 (F). LPA observed the home to have three (3) regulation fire extinguishers. The smoke detectors and carbon monoxide alarm were tested and found to be operating properly. The First Aid kit was checked and found to be complete with scissors, tweezers, thermometer, and gauzes, antiseptic and First Aid Manual Guide. Extra linens, hygiene supplies, and disinfectants were stored in locked hallway closets. There are no security bars on the bedroom windows. There are chimes on the exit doors. There are no firearms or dangerous weapons in the home. Report continued on LIC 809C (page 2 of 3) Facility appears to be clean, safe, sanitary, and in good repair. Passageways and porch were clean and in good repair. The front and back yard were free of debris and hazardous material. Administrator showed LPA were the gas shut-off valves, the electrical panel, and water shut off valves were located. The following was discussed with the facility Administrator: Children will be accorded personal rights. Children in care will be supported, encouraged to participate in extracurricular activities. Children in care will be able to contact the licensing agency. Children will be supervised & protected at all times. Children will be accorded dignity in personal relationships with others in the home. Children will not be restricted in telephone use except by court order. Applicant will provide and ensure three nutritious meals, snacks, and special diets. Applicant will ensure to have written authorization to obtain medical and dental care. Applicant will ensure to have personal rights forms in children's files. Applicant acknowledges abuse reporting requirements. Staff working in the facility will have DOJ/FBI criminal record clearances, and Child Abuse Index Checks. Facility will operate within license conditions & limitations including capacity limit. Facility meets posting requirements, including COVID-19 best practices signs and emergency telephone numbers are in prominent locations. The facility uses a Honda, Odyssey to transport youth to appointments and offsite extra curriculum recreational activities. LPA inspected the vehicle and found horn, lights, and all seatbelts in working order. The vehicle is equipped with a complete First Aid Kit, and Roadside emergency kit. LPA observed the vehicle to have valid car insurance through Farmers Insurance. Clients Records will be electronically stored in the facilities online Portal with Kipuworks.com electronically stored. Staff Records are electronically stored in the ISolved system. LPA reviewed three (3) the records of active primary staff; Program Administrator, Director of Facilities and the Facility Manager. There were no deficiencies cited at this time. LPA-White recommended for a provisional license based the inspection of the entire physical plant, inside and out. All Pre-Licensing administrative conditions were viewed and met. This facility is within Title 22 regulation standards and is placement ready. LPA concluded the Pre license Inspection. An Exit interview was conducted, and a copy of this report was left at the facility with the Program Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On April 7, 2023, Licensing Program Analyst (LPA) Charmetha White made an unannounced visit to Ascend Healthcare 6, for the purpose of conducting a Post Licensing Inspection. LPA met with Assistant Facility Manager, Aida Hernandez who granted access to the facility and together a tour of the entire interior and exterior physical plant was conducted. The facility is a private pay Group Home running a therapeutic treatment program licensed to provide care and supervision services for up to six (6) female children, ages 12-17 years old, ambulatory only. The facility acquired a Rehabilitation Facilities Joint Commission Accreditation which is valid through 03/20/2024. The census at the time of the inspection was six (6). The Group Home is set up as follows: This is a three (3) bedroom, four (5) bathroom single-story home located in a residential neighborhood, which includes living room, dining room, kitchen, group room, medication room, two (2) offices, a laundry area, an attached garage converted into a classroom, and a backyard. Living room: is equipped with sofas and chairs, a mounted TV, and an operational gas burning fireplace equipped with a security screen. The room has multiple shelves for books and games and has patio doors that open to the backyard. Dining room: is equipped with a wooden table with ten (10) chairs, a mounted TV, an operational gas burning fireplace equipped with a security screen, and patio doors that open to the backyard. There is an additional table located off the kitchen that has six (6) chairs. Kitchen: is equipped with an electric temperature controlled refrigerator, with two (2) freezer drawers below, a gas stove with six (6) working burners, a microwave, and dishwasher. LPA observed two (2) covered trash cans with a mechanical foot closing device, a pantry, plenty of cabinet space, ample plates, cups, and eating utensils. Sharp knives are stored in a locked cabinet located next to the stove and made inaccessible to clients in care. Food is prepared by a private chef and the weekly menu was posted. LPA observed ample perishable food items in the refrigerator and the pantry is fully stocked with non-perishable food items. Group Room: is equipped with six (6) chairs, a mounted TV, a white board, yoga matts, an operational gas burning fireplace equipped with a security screen, two (2) storage closets, an attached bathroom (equipped with a toilet, sink, shower, tub, and a closet used for storage, and patio doors that open to the backyard. All closets remain locked at all times. Report continued on LIC 809C. Medication room: is equipped with a desk, chair, multiple locked cabinets which store PRN medications, separate bins for prescribed medications for individual youth, a sink, a First Aid kit, and a locked refrigerator which is used to store medication that required refrigeration. Offices: The first office is located to the right of the entrance and is used by the Clinical Director. The room is equipped with a desk, three (3) chairs, and small book shelve. The second office is located off the kitchen and is used as a therapy room. The room is equipped with a desk, chair, sofa, a mounted TV, and has ample closet space which will be used for storage. The room has an attached bathroom that includes a sink, toilet, and shower. Laundry area: is located inside a hallway closet left of the entrance and it contains a washer, dryer and two (2) cabinets used for storage. Laundry detergent and other cleaning supplies are stored in separate locked closet located adjacent to laundry area. Attached Garage (Classroom): The garage has been converted into a classroom. LPA observed the room to be equipped with six (6) computers, six (6) desk, a long wooden table with eight (8) chairs, classroom supplies, and ample cabinets to store additional classroom supplies. LPA observed the to have a regulation fire extinguisher hung in towards the back of the garage, and a combination smoke detector/carbon monoxide alarm that is connected to the smoke alarm system in the house. Backyard area: has a combination basketball/tennis court, a grill, small refrigerator, a fenced and gated pool/jacuzzi that meets regulations. There is also a small detached shed that is used for therapy, and a storage bin on the side of the home. LPA observed the therapy room to equipped with a desk and chair. The storage bin was observed to be empty. Bedrooms: Bedroom #1: is equipped with two (2) twin size beds, each with two (2) pull out drawers. The room has built in shelves, a window, and an attached bathroom (equipped with toilet, sink, shower/tub combination). LPA observed the room to have a locked closet used to store the facility's internet system and ADT system. Bedroom #2: is equipped with two (2) twin size beds, each with two (2) pull out drawers. The room has a closet with ample space, a window, and shares a Jack and Jill bathroom with Bedroom #3. Bedroom #3: is equipped with two (2) twin size beds, each with two (2) pull out drawers. The room has a closet with ample space, a window, and shares a Jack and Jill bathroom with Bedroom #2. All bedrooms were all observed to have mattresses, bed linen, blankets, pillows, and working lights. Bathrooms: Bathroom #1: is located off of the dining room. Bathroom #2: is located inside bedroom #1. Bathroom #3: is located inside the group room. Report on continued on LIC 809C. Bathroom #4: is a jack and jill bathroom accessible through bedroom #2 and bedroom #3. Bathroom #5: is located inside the therapy room. All bathrooms were checked and found to be in working order. The hot water was tested, and the temperature was found to be between 105 -120 (F). LPA observed the home to have three (3) regulation fire extinguishers. The carbon monoxide and smoke detectors were tested and found to be in working order. The First Aid kit was checked and found to be complete. Extra linens, hygiene supplies, and disinfectants were stored in locked hallway closets and made inaccessible to clients in care. There are no security bars on the bedroom windows. There are chimes on the exit doors. There are no firearms or dangerous weapons in the home. LPA observed the facility to be clean, safe, sanitary and in good repair. The outdoor spaces were clean and clear of hazards. Passageways, open porches, and all exits were observed to be unobstructed. Licensee ensures that individuals supervising children in the pool area is Water Safety trained. The facility operates within license conditions and limitations including capacity limitations. LPA discussed and advised the Licensee to ensure the following: Children are afforded their Personal Rights. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. All posting requirements for Group Home Licensure, including the Emergency Plan, and grievance procedure were met and posted on the wall. The LPA reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. Licensee will ensure to utilize the Unusual Incident Report LIC 624, and LIC 624LE to document incidents. Facility Manager provided LPA with a copy of the Personnel Report (LIC 500). There are no deficiencies observed or cited at this during this inspection. Exit interview was conducted with the Assistant Facility Manager, and a copy of this report was left at the facility.

met_with: Assistant Facility Manager - Aida Hernandez


summary: Facility Evaluation

raw_content:
Narrative:
On April 7, March 30, 2023, at 1: PM, Licensing Program Analyst (LPA) Charmetha White made an unannounced visit to Ascend Healthcare #6 for the purpose of conducting a Case Management for Special Incident Report regarding BCIA 8572. The incident report was received by the Department on 03/23/2023. LPA met with Administrator Jacqueline Marshall Waldron. During this visit, confidential interviews were conducted. LPA requested a copy of Client #1 (C1) intake paperwork, shift notes regarding C1, and Staff #2 employee file and training record. This incident needs further investigation. Based on information obtained during this visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. Exit interview was conducted, and a copy of this report was left with the Administrator.

met_with: Administrator - Jacqueline Marshall Waldron


summary: Facility Evaluation

raw_content:
Narrative:
On December 11, 2023, Licensing Program Analyst (LPA) C. White made an announced visit to Ascend Healthcare #6 for the purpose of conducting an Annual/Required Inspection. LPA met with Facility Manager, Emely Hernandez, and Administrator Jaqueline Marshall Waldron and was granted access to the facility. This facility is licensed to provide care and supervision for six (6) female children ages 12-17 years old, ambulatory only. Current census is five (5). This three (3) bedroom, four (4) bathroom single-story home located in a residential neighborhood. The facility includes the following: living room, dining room, kitchen, group room, medication room, two (2) rooms designated as office space, laundry area, an attached garage (utilized as a classroom), and backyard area. Living room: has sofas, chairs, a mounted TV, multiple shelves that store books and games, a gas burning fireplace equipped with a security screen, and patio doors that open to the backyard. Dining room: has a wooden table with ten (10) chairs, a mounted TV, a gas burning fireplace equipped with a security screen, and patio doors that open to the backyard. Kitchen: has a refrigerator, two (2) freezer drawers, a six (6) burner gas stove (all operational at the time of the inspection), a dishwasher, and a microwave. The kitchen has a pantry stocked with snacks, seasonings, and non-perishable food. Additionally, food is prepared by a private chef. Sharp knives are stored in a combination lock wooden box that is located in a locked kitchen cabinet next to the stove and made inaccessible. There is an additional table equipped with six (6) chairs to the right of the kitchen. Group Room: has eight (8) chairs, a mounted TV, a movable white board, multiple shelves that store yoga matts, a gas burning fireplace equipped with a security screen, and patio doors that open to the backyard. The contains two (2) closets. Additionally, the room has a bathroom equipped with a toilet, sink, shower, tub, and a closet used for storage. LPA observed that all closets in this room remain locked at all times. Medication room: has a desk, chair, multiple locked cabinets for PRN medications, a sink, a First Aid kit, and two (2) small refrigerators, one is used to store medication requiring refrigeration. Report continued on LIC 809C (Page 1 of 3) Offices: The first office is located near the entrance of the facility and is used by the clinician. This office has a desk, chair, printer, and lamp. The second office is located to the right of the kitchen and is used as a therapy room. The room has a desk, chair, sofa, a mounted TV, and a closet used for storage. There is an attached bathroom that is equipped with a sink, toilet, and shower. Laundry area: is located to the left of the entrance along the hallway and it is equipped with a washer, dryer and two (2) storage cabinets. The laundry detergent and cleaning supplies are stored in locked closet adjacent to laundry area. Attached garage (Classroom): The garage has been converted into a classroom. The classroom is equipped with six (6) computers, six (6) desk, eight (8) chairs, classroom supplies, and ample cabinets which is used to store classroom supplies. The room contains a regulation fire extinguisher and a combination smoke detector/carbon monoxide alarm that is connected to the smoke alarm system in the house. The Fire Inspector confirmed the space was permitted for classroom use. Backyard area: contains a combination basketball/tennis court, a grill, a fenced and gated pool/jacuzzi that meets regulations, two (2) detached therapy rooms, and storage bin. Bedroom #1: is equipped with two (2) twin size beds, each containing two (2) pull out drawers. The room has built in shelves, a window, and an attached bathroom (equipped with toilet, sink, shower/tub combination). LPA observed the room to have a locked closet used to store the facility's internet system and ADT system. Bedroom #2: is equipped with two (2) twin size beds, each containing two (2) pull out drawers. The room has a closet with ample space, a window, and shares a Jack and Jill bathroom with Bedroom #3. Bedroom #3: is equipped with two (2) twin size beds, each containing two (2) pull out drawers. The room has a closet with ample space, a window, and shares a Jack and Jill bathroom with Bedroom #2. All bedrooms were all observed to have mattresses, pillows, bed linens, blankets, and working lights. Bathrooms: All bathrooms were checked and found to be in working order. The hot water was tested, and the temperature was found to be between 105 -120 (F). LPA observed the home to have regulation fire extinguishers. The smoke detectors and carbon monoxide alarm were tested and found to be operating properly. The First Aid kit was checked and found to be complete with scissors, tweezers, thermometer, and gauzes, antiseptic and First Aid Manual Guide. Extra linens, hygiene supplies, and disinfectants were stored in locked hallway closets. Temperatures in client rooms and common areas were found to be between 68 - 85 degrees (F). Disinfectants/cleaning solutions and poisons are stored and inaccessible to clients. There are no security bars or screens on the windows. There are chimes on the exit doors. There are no firearms or dangerous weapons in the home. Report continued on LIC 809C (Page 2 of 3) LPA observed the facility to be clean, safe, sanitary and in good repair. The outdoor spaces were clean and clear of hazards. Passageways, open porches, and all exits were observed to be unobstructed. Licensee ensures that individuals supervising children in the pool area are Water Safety trained. The gas shut-off valves are located in the back of the home, the water shut off valve is located in the front the home near the garage, and the electrical panel is located on the side of the home near the driveway. The facility operates within license conditions and limitations including capacity limitations. LPA discussed and advised facility staff to ensure the following: Children are afforded their Personal Rights. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. All posting requirements for Group Home Licensure, including the Emergency Plan, and grievance procedure were met and posted on the wall. The LPA reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. Licensee will ensure to utilize the Unusual Incident Report LIC 624, and LIC 624LE to document incidents. Transportation: The facility uses a Honda, Odyssey to transport youth to appointments and offsite extra curriculum recreational activities. LPA inspected the vehicle and found horn, lights, and all seatbelts in working order. The vehicle is equipped with a complete First Aid Kit, and Roadside emergency kit. LPA observed the vehicle to have valid car insurance through Farmers Insurance. Facility staff provided LPA with a copy of the Personnel Report (LIC 500) and Current Client Roster (LIC 9020). Clients Records are electronically stored in the facilities online Portal with Kipuworks.com and Staff Records are electronically stored in the facilities online iSolve system. LPA will return at a later date to review staff and client files. There are no deficiencies observed or cited at this during this inspection. An exit interview was conducted with the Administrator, and a copy of this report was left at the facility. (Page 3 of 3)

met_with: Administrator - Jacqueline Marshall Waldron and Facility Manager - Emely Hernandez


summary: Facility Evaluation

raw_content:
Narrative:
On 12/14/2023, Licensing Program Analyst (LPA) C. White, made an visit to Ascend Healthcare 6, for the purpose of conducting a Case Management Annual Continuation Inspection. LPA met with Administrator, Jacqueline Marshall Waldron and was granted access to the facility and provided the requested information. The facility keeps clients records electronically stored in an online system call KIPUERM and staff Records are electronically stored in the ISolved system. LPA reviewed the following records during the inspection: Client Records: The program currently has a total of six (6) clients. LPA reviewed all six client records and found each record to meet required regulations. Staff Records: The program currently has a total of thirty staff. LPA reviewed a total of five (5) staff records and confirmed files contained staff qualifications, current CPR/First Aid cards, health screening, and TB test results. LPA obtained the LIC 500 to verify Staff to Client ratio. LPA reviewed the Facility Profile and Personnel Report and confirmed that personnel have required criminal record clearance: DOJ, FBI and Child Abuse; which meet qualification. LPA conducted interviews with three (3) clients and a total of three (3) staff. This inspection included an overview of required Core Services and Supports and based upon inspection of facility records and interviews of staff and clients. Licensee is meeting all requirements. PER California Code Regulations, TITLE 22, DIVISION 6, CHAPTERS 5 no deficiencies were cited. An exit interview was conducted, and a copy of this report was left with the Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On June 14, 2024, Licensing Program Analyst (LPA) C. White made an unannounced visit to Ascend Healthcare #6 for the purpose of conducting a Case Management for Special Incident Report. The incident occurred on 06/09/2024 and the report was received by the Department on 06/13/2024. LPA met with Assistant Facility Manager, Aida Hernandez. During this visit, confidential interviews were conducted. LPA requested a copy of LIC 500, Client Roster, Client #1 (C1) intake paperwork and medical documentation, Facility seizure protocol, and Incident documentation. Based on the information obtained, this incident needs further investigation. There were deficiencies cited per Title Regulations on this date. Exit interview conducted and a copy of the report was left with Assistant Facility Manager.


summary: Facility Evaluation

raw_content:
Narrative:
On December 10, 2024, Licensing Program Analyst (LPA) C. White made an unannounced visit to Ascend Healthcare #6 for the purpose of conducting an Annual/Required Inspection. LPA met with Facility Manager, Emely Hernandez and was granted access to the facility. This facility is licensed to provide care and supervision for six (6) female children ages 12-17 years old, ambulatory only. Current census is six (6). The facility is operated out of a three (3) bedroom, five (5) bathroom single-story home located in a residential neighborhood. The facility includes the following: living room, dining room, kitchen, group room, medication room, two (2) office rooms, laundry area, an attached garage (utilized as a classroom), and backyard. Living room: has ample seating, a TV, multiple shelves that store books and games, a gas burning fireplace equipped with a security screen, and patio doors that open to the backyard. Dining room: has a wooden table and ample seating, a TV, a gas burning fireplace equipped with a security screen, and patio doors that open to the backyard. Kitchen: has a refrigerator with two (2) freezer drawers, a gas stove top with six (6) burners (found to be operational at the time of the inspection), double ovens, a dishwasher, a microwave, and a pantry stocked with snacks, seasonings, and non-perishable food. Additionally, food is prepared at the Ascend Healthcare #2 location by a private chef and brought over to the home. Sharp knives are stored in a combination lock wooden box located in a locked kitchen cabinet next to the stove top and made inaccessible to children in care. There is an additional table and chairs to the right of the kitchen. Group Room: has multiple chairs, a TV, multiple shelves, a gas burning fireplace equipped with a security screen, and patio doors that open to the backyard. The room contains two (2) closets one stores holiday supplies and one that stores games and activities. Additionally, the room has a bathroom equipped with a toilet, sink, shower, tub, and a closet used to store supplies and extra disinfectants. LPA observed that the bathroom and all closets in this room remain locked at all times. Medication room: has a desk, chair, multiple locked cabinets for PRN medications, a sink, a First Aid backpack kit, and two (2) small refrigerators, one is used to store medication requiring refrigeration. Report Continued LIC 809C (page 1 of 3) (2) Offices: The first office is located near the entrance of the facility and is used by the clinician. This office has a desk, chair, printer, and lamp. The second office is located to the right of the kitchen and is used as a therapy room. The room has a desk, chair, sofa, a TV, and a closet used for storage. There is an attached bathroom that is equipped with a sink, toilet, and shower. Laundry area: is located to the left of the entrance along the hallway and it is equipped with a stacked washer/dryer and two (2) storage cabinets. The laundry detergent and cleaning supplies are stored in locked closet adjacent to laundry area. Attached garage (Classroom): The garage has been converted into a classroom. The classroom is equipped with six (6) computers, six (6) desk (all along the wall), ample seating, a refrigerator that stores extra food, and ample cabinets used to store classroom supplies. The room contains a regulation fire extinguisher and a combination smoke detector/carbon monoxide alarm that is connected to the smoke alarm system in the house. Backyard area: contains a combination basketball/tennis court, a grill, a fenced and gated pool/jacuzzi that meets regulations, a ping pong table, two (2) detached sheds used as therapy rooms, and storage bin. (3) Bedrooms: All bedrooms located along the hallway to the left of the entrance. All bedrooms are equipped with two (2) twin size beds, each containing two (2) pull out drawers; closets with ample space; windows; and working lights. All bedrooms were all observed to have mattresses, bed linen, blankets, and pillows. (5) Bathrooms: Bathroom #1: is located off of the dining room. Bathroom #2: is located inside bedroom #1. Bathroom #3: is located inside the group room. Bathroom #4: is a jack and jill bathroom accessible through bedroom #2 and bedroom #3. Bathroom #5: is located inside the therapy room. Bathrooms are equipped with toilet, sink, showers. All bathrooms were checked and found to be in working order. The hot water was tested, and the temperature was found to meet regulation requirements. LPA observed the home to have three (3) regulation fire extinguishers. The smoke detectors and carbon monoxide alarm were tested and found to be operating properly. The First Aid kit was checked and found to be complete. Extra linens, hygiene supplies, and disinfectants were stored in locked hallway closets. Temperatures in client rooms and common areas were found to be between 68 - 85 degrees (F). Disinfectants/cleaning solutions and poisons are stored and inaccessible to clients. There are no security bars or screens on the windows. There are chimes on the exit doors. There are no firearms or dangerous weapons in the home. Report Continued on LIC 809C (page 2 of 3) LPA observed the facility to be clean, safe, sanitary and in good repair. The outdoor spaces were clean and clear of hazards. Passageways, open porches, and all exits were observed to be unobstructed. Licensee ensures that individuals supervising children in the pool area are Water Safety trained. The gas shut-off valves are located in the back of the home; the water shut off valve is located in the front the home near the garage; the electrical panel is located on the side of the home near the driveway. The facility operates within license conditions and limitations including capacity limitations. LPA discussed and advised facility staff to ensure the following: Children are afforded their Personal Rights. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. All posting requirements for Group Home Licensure, including the Emergency Plan, and grievance procedure were met and posted on the wall. The LPA reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. Licensee will ensure to utilize the Unusual Incident Report LIC 624, and LIC 624LE to document incidents. Transportation: The facility uses a Honda, Odyssey to transport children in care. LPA inspected the vehicle and found it to be in good repair. LPA observed the vehicle to have current registration and valid insurance through 02/08/2025. Facility staff provided LPA with a copy of the Personnel Report (LIC 500) and Current Client Roster (LIC 9020). Clients Records are electronically stored in the facilities online Portal with Kipuworks.com and Staff Records are electronically stored in the facilities online iSolve system. LPA will return at a later date to review staff and client files. There are no deficiencies observed or cited at this during this inspection. An exit interview was conducted with the Administrator, and a copy of this report was left at the facility. (page 3 of 3)

met_with: Emely Hernandez - Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On December 2, 2025, at 9:25am Licensing Program Analyst (LPA) Emelyn Sanchez P. made an unannounced visit to Ascend Healthcare #6, for the purpose of conducting an Annual/Required inspection visit. LPA Sanchez P. met with Jaqueline Waldron, Administrator/Director of Operations who granted access to the facility. LPA Sanchez P. toured the interior and exterior of the facility. The facility is licensed to provide care and supervision services for up to six (6) children, ages 12-17 years old, ambulatory only. There is a swimming pool on the premises which meets licensing regulations. The census at the time of the inspection was five (5). The facility is a single-story house that includes four (4) bedrooms, five 5 bathrooms, a living room, dining room, kitchen, laundry space, an attached garage (utilized as a classroom), and backyard. The facility is set up as follows: Living room: has ample seating, a TV, multiple shelves that store books and games, a gas burning fireplace equipped with a security screen, and patio doors that open to the backyard. Dining room: has a wooden table with 7 chairs, a TV, a gas burning fireplace equipped with a security screen, and patio doors that open to the backyard. Kitchen: has a refrigerator with freezer drawers which are not operating at this time, a gas stove top with six (6) burners (found to be operational at the time of the inspection), double ovens, a dishwasher, a microwave, and a pantry stocked with snacks, seasonings, and non-perishable food. Report Cont. on LIC 809-C. Pg. 1 of Additionally, food is prepared at the Ascend Healthcare (1) by a private chef and brought over to the facility. Sharp knives are stored in a combination lock wooden box located in a locked kitchen cabinet next to the stove top and made inaccessible to children in care. There is additional table and chairs to the right of the kitchen. Group Room: has multiple chairs, a TV, multiple shelves, a gas burning fireplace equipped with a security screen, and patio doors that open to the backyard. The room contains two (2) closets used for storage. Additionally, the room has a bathroom equipped with a toilet, sink, shower, tub, and a closet used to store supplies. LPA Sanchez P. observed that the bathroom and all closets in this room remain locked at all times. Medication Room: has a desk, chair, multiple locked cabinets for PRN medications, a sink, a First Aid backpack kit, and two (2) small refrigerators, one is used to store medication requiring refrigeration. Laundry Space: is located to the left of the entrance along the hallway and it is equipped with a stacked washer/dryer and two (2) storage cabinets. The laundry detergent and cleaning supplies are stored in the locked cabinet. Bedrooms: All bedrooms were all observed to have mattresses, bed linen, blankets, and pillows. Bedroom #1: is equipped with two (2) twin sized beds. The room has adequate drawer space, closet space and working lights. Bedroom #2: is equipped with two (2) twin sized beds. The room has adequate drawer space, closet space and working lights. Bedroom #3: is equipped with one (1) twin size bed. The room has adequate drawer space, closet space and working lights. Bedroom #4: is equipped with one (1) twin size bed. The room has adequate drawer space, closet space and working lights. Bathrooms: Bathroom #1: is located off of the dining room. Bathroom #2: is a jack and jill bathroom accessible through bedroom #2 and bedroom #3. Report Cont. on LIC 809C. Pg. 2 of Bathroom #3: is located inside Bedroom #1. Bathroom #4: is located inside the group room. Bathroom #5: is located inside Bedroom # Bathrooms are equipped with toilet, sink, and showers. All bathrooms were checked and found to be in working order. The hot water temperature was tested and found to be between 105-120 degrees (F). (3) Offices: The first office is located near the entrance of the facility and is used by the Clinical Director. This office has a desk, chairs, and bookshelves. The second office is a converted shed located to the side of the Medication Room which is used as a Therapy Office. The third office is a converted shed located at the back of the house. Attached Garage (Classroom): The garage has been converted into a classroom. The classroom is equipped with computers, desks (all along the wall), ample seating, a refrigerator/freezer that stores extra food, and ample cabinets used to store classroom supplies. The room contains a regulation fire extinguisher and a combination smoke detector/carbon monoxide alarm that is connected to the smoke alarm system in the facility. Backyard Area: contains a combination basketball/tennis court, a grill, a fenced and gated pool/jacuzzi that meets licensing regulations, a ping pong table, out door seating space, and a chicken coop. Transportation: The facility uses a Honda, Odyssey to transport children in care. LPA Sanchez P. inspected the vehicle and found it to be in good repair. LPA Sanchez P. observed the vehicle to have current registration and valid insurance. The carbon monoxide and smoke detectors were tested and found to be in working order. The facility has three (3) regulation fire extinguishers. The facility has a working telephone readily accessible. Temperatures in client rooms and common areas are maintained by a central air and heating system and the home was found to be between 68 - 85 degrees (F). Report Cont. on LIC 908C. Pg. 3 of Overall LPA Sanchez P. observed the facility to be clean, safe, sanitary and in good repair. The front yard and outdoor spaces were clean and free of debris. Passageways, open porches, and all exits were observed to be unobstructed. There were no security bars on the windows. Licensee ensures that individuals supervising children in the pool area are Water Safety trained. The facility operates within license conditions and limitations including capacity limitations. All posting requirements for Group Home Licensure, including the Emergency Plan, Personal Rights, and Grievance Procedures were met and posted on the wall. LPA Sanchez P. discussed the following: Children are accorded their Personal Rights. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. LPA Sanchez P. reiterated the importance of reporting and submitting Incident Reports, Law Enforcement contact, and reporting all changes within the facility to Community Care Licensing and any other appropriate agencies. The Administrator will ensure the Unusual Incident Report LIC 624, and LIC 624LE forms are utilized to document incidents. LPA Sanchez P. was provided with a copy of the Personnel Report (LIC 500) and Client Register (LIC 9020). The facility keeps client files and documents in digital system called KIPU. LPA reviewed the following records during the inspection: Client Records: The program currently has a total of five (5) clients. LPA Sanchez P. reviewed two (2) client records and found each record to meet licensing requirements. LPA will return at a later date to review staff files and to conduct interviews with staff and clients. There are no deficiencies observed or cited at this during this inspection. An exit interview was conducted with Jaqueline Waldron, Administrator/Director of Operations and a copy of this report was left at the facility. Pg. 4 of 4

met_with: Jaqueline Waldron, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On December 3, 2025 at 9:20am, Licensing Program Analyst (LPA) Emelyn Sanchez P. made an unannounced visit to Ascend Healthcare #6 for the purpose of conducting a Case Management- Annual Continuation Inspection visit. LPA Sanchez P. met with Jaqueline Waldron, Administrator/Director of Operations. LPA Sanchez P. was granted access to the facility. The facility keeps staff and client files and documents in digital system called KIPU and Isolved. LPA reviewed the following records during the inspection: Client Records: The program currently has a total of five (5) clients. LPA Sanchez P. reviewed three (3) client records and found each record to meet licensing requirements. Staff Records: The program currently has a total of thirty-eight (38) staff. LPA reviewed a total of two (2) staff records and found records to be out of compliance per licensing requirements. LPA Sanchez P. obtained the LIC 500 to verify staff to client ratio. LPA Sanchez P. reviewed the Facility Profile and Personnel Report and confirmed that personnel have required criminal record clearance: DOJ, FBI and Child Abuse; which meet licensing requirements. LPA Sanchez P. conducted interviews with two (2) clients and a total of two (2) staff. The following deficiency is being cited for violating California Code of Regulations Title 22, Division Regulation 80066 (a)(10) Personnel Records. (see page D). An exit interview was conducted, and a copy of this report was left with Jaqueline Waldron, Administrator/Regional Operations Manager


summary: Facility Evaluation

raw_content:
Narrative:
On June 14, 2024, Licensing Program Analyst (LPA) C. White conducted an unannounced case management inspection at the above facility. Upon arrival, LPA was greeted by Louis Perez Langlois, Lead Mentor, who granted access to the facility. Assistant Facility Manager, Aida Hernandez arrived at a later time to meet with LPA. During today's inspection, LPA C. White observed the following: There was no facility manager present at the facility. Three beds in bedroom 1, which occupies 3 clients (see LIC 811) One bed in the office adjacent to the medication office, which occupies 1 client (see LIC 811) At time of inspection, LPA took pictures of the deficiencies. Per California Code Regulation, Title 22, Division 6, CHAPTERS 5, General Licensing Regulations the following deficiencies were observed and cited at the time of this inspection. (See LIC 809-D). An exit interview was conducted, and a copy of this report was left with Assistant Facility Manager.


facility_name: ASHCROFT HOME

summary: Facility Evaluation

raw_content:
Narrative:
On 01/27/2022, an unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Tamara Melikian and Vanessa Galvan at 10:00AM. During the inspection, LPAs met with Nanci Luna, House Manager and inspected the facility inside and out. LPA reviewed two children's records and reviewed two staff personnel records for the facility at 10:15AM. A medication count was conducted at 11:00AM. LPA interviewed one staff at 11:20AM. LPA did not interview any children in the home as the children are at school and will be interviewed at a later date. No deficiencies to be cited at this time. LPAs conducted exit interview with Nanci Luna, House Manager at 12:00PM. LPAs provided the summary report to Nanci Luna, House Manager upon completion.

met_with: Nancy Luna


summary: Facility Evaluation

raw_content:
Narrative:
On January 21, 2022, licensee provided Licensing Program Analyst (LPA) with a closure plan for the Ashcroft Home effective February 5, 2022. At the time the plan was provided two clients were at the facility. On February 4, 2022, licensee submitted a waiver request to maintain a client past their 18th birthday pending transfer to another facility. Licensee wanted the request until February 7, 2022 and indicated the facility would move forward with closure once the client was moved. On February 8, LPA contacted the licensee to confirm the client was moved. Licensee confirmed the client was moved from the facility on February 5, 2022. The licensee indicated they were unsure if they would be moving forward with closure and would provide LPA with an update of a plan with the facility; however, indicated they would not be taking any new clients. On March 15, 202, licensee sent LPA an email indicating they would be moving forward with the closure effective February 7, 2022. On March 21, 2022, the licensee forfeited their license to the Children's Residential Office. On March 23, 2022, LPA Jessica Rodriguez arrived at the facility to confirm its closure. Upon arrival, LPA observed the property has a "for sale" sign outside. No vehicles were in the driveway. LPA knocked on the door and there was no answer. LPA observed all signage that was previously at the front door regarding COVID-19 had been removed. LPA will move forward with completing closure paperwork.