summary: Facility Evaluation

raw_content:
Narrative:
On December 12, 2023 at 9: AM, Licensing Program Analyst (LPA) Jacob Salem arrived at the above facility's administrative office for the purpose of conducting an annual inspection. LPA met with Verenna Huerta, Administrator and explained the purpose of the visit. The inspection CARE tool was inoperable during LPA's visit, such that the spreadsheet cells that indicate compliance could not be selected. LPA used the CARE tool as a guide only during his inspection and contacted IT support to rectify the technical issue. LPA began by conducting an inspection of the office's physical plant. The office consists of a large main room with four desks, and two private offices that can be used for confidential interviews. Client files are kept in a locked file cabinet in the main room. LPA observed the facility license to be prominently posted near the entrance. LPA reviewed five staff files (S1-S5) which were provided upon request.The staff files have the required background information and health screenings, criminal record clearances, staff qualifications, and mandated reporting acknowledgements. LPA also reviewed the facility's emergency disaster plan. LPA conducted a review of five client files (C1-C5), which were also provided upon request. All client files reviewed contained the signed admission agreement and discharge policies, as well as signed and up-to-date Needs and Services Plans. LPA observed that C2 did not have a written medical assessment within thirty days of entering the program, but record of the case worker's attempts to facilitate the assessment are documented in the client's file. Based on observations made during the inspection, there were no deficiencies cited at this time. An exit interview was conducted with Verenna Huerta, Administrator and a signed copy of this report was provided.


state: CA

facility_name: STABILITY THROUGH ENHANCED PEER SUPPORT S.T.E.P.S

summary: Facility Evaluation

raw_content:
Narrative:
On December 14, 2023, at 4: PM, Licensing Program Analyst (LPA) Jacob Salem arrived at the facility to conduct an annual continuation. The purpose of the inspection was due to computer malfunction during the inspection conducted on 12/12/23; the CARE Tool was not operable at the time of inspection. LPA returned to complete the inspection tool. Based on observations there are no deficiencies noted. A copy of this report was discussed and provided to Verenna Huerta, Administrator.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Verenna Huerta, Administrator


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove facility staff member ran over resident's foot with a car, resident was illegally evicted, facility did not provide a healthful environment for resident and facility did not ensure safety of resident's money while in care, therefore the above allegation is unsubstantiated. Exit interview conducted with FM and LPA left report at the facility.

Investigation Findings:
13Licensing Program Analyst (LPA) Christopher Rollins conducted a follow-up complaint inspection at Stability Through Enhanced Peer Support and met with Larry Hickman Administrator. The purpose of the inspection was to deliver the findings for the above complaint allegation. During the course of investigating the allegation, LPA Rollins conducted confidential interviews with facility staff, clients, social workers and conducted clients file review. Confidential interviews reveal conflicting stories about facility staff member ran over resident's foot with a car & resident was illegally evicted. Confidential interviews reveal conflicting stories about facility did not provide a healthful enviroment for resident & facility staff did not ensure safety of resident's money while in care. Based on interviews and documentation there was not enough evidence to prove facility staff member ran over resident's foot with a car, resident was illegally evicted, facility did not provide a healthful enviroment for resident and facility did not ensure safety of resident's money while in care . UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: Christopher Rollins LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, TRAEGER AVE., SUITE FACILITY NAME: STABILITY THROUGH ENHANCED PEER SUPPORT (STEPS)FACILITY NUMBER: VISIT DATE: 01/05/2022

report_type: Complaint Investigation

met_with: Larry Hickman- Administrator

complaint_status: unsubstantiated


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
day notice. In addition, (P1's) authorized representative and attorney requested a written notice from (S1) on several occasions. However, the facility failed to submit it and did not obtain a copy to LPA Mendoza upon request. LPA Mendoza obtained a copy of the facilities agreement around termination from the program and reviewed the facilities program statement. The facility failed to follow its policies around discharge and removals. Furthermore, the facility did not arrange a CFT meeting with (P1) and (P1's) authorized representatives. On allegation, the facility did not provide (P1) infant supplementation. Based on confidential interviews and documentation. The facility received several checks from the county. Unfortunately, the facility cashed the checks without knowing what the money was or to whom the money was owed too. In addition, the facility was unable to provide the exact figure to (P1). Due to the facility's negligence, (P1) hired an attorney and was able to get the facility to pay (P1) a total of $3,483.00 for (P1's) infant supplementation from August 2021 to December 2021. Based on the information obtained, there is a preponderance of the evidence to prove, (P1) was illegally evicted and the facility did not provide NMD's infant supplementation. Therefore, the above allegation is substantiated. Appeal Rights were provided and discussed with the facility, and deficiencies were cited and a copy of the report was left with the licensee.

Investigation Findings:
13Licensing Program Analyst (LPA) Isabel Mendoza conducted a follow-up complaint inspection at Stability Through Enhanced Peer Support and met with Larry Hickman, Administrator. The purpose of the inspection was to deliver the findings for the above complaint allegation. During the course of the investigation, LPA Mendoza conducted confidential interviews with staff members, participants, authorized representatives, and reporting parties and obtained documentation from the facility and other sources. Based on interviews and documentation submitted to LPA. Interviews and documentation revealed that (P1's) authorized representative only received a 7-day notice. Furthermore, the 7-day notice did not give specific facts about any circumstance or event which resulted in (P1) getting a 7-day (Please refer to LIC 9009-C...) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: Isabel Mendoza LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, TRAEGER AVE., SUITE FACILITY NAME: STABILITY THROUGH ENHANCED PEER SUPPORT (STEPS)FACILITY NUMBER: VISIT DATE: 04/29/2022

met_with: Larry Hickman

complaint_status: SUBSTANTIATED


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Investigation Findings:
13On 1/3/2023 at 2: PM, Licensing Program Analyst (LPA) Alyssa Ng conducted a complaint inspection at Stability Through Enhanced Peer Support (STEPS) and spoke with Claudia Nelson, Program Manager. The purpose of the inspection was to deliver the findings for the above complaint allegations. During investigation, interviews were conducted, and incident reports were reviewed, and it was determined that minor was assaulted by another minor in care, minor had access to alcohol, and facility refrigerator is in disrepair. Based on LPA's interview with staff, client, and record review(s), the preponderance of evidence standard has been met, therefore the above allegations, minor was assaulted by another minor in care, minor had access to alcohol, and facility refrigerator is in disrepair is found to be SUBSTANTIATED. Facility is being cited for violation of California Code of Regulations (CCR), Title 22, Division 6 & Chapter 1: 80087(a) Buildings and Grounds. Please refer to attached 9099D. At this time, one deficiency was given. An exit interview was conducted, appeal rights provided and discussed, and a copy of this report was sent to Claudia Nelson, Program Manager. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Alyssa Ng LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, TRAEGER AVE., SUITE FACILITY NAME: STABILITY THROUGH ENHANCED PEER SUPPORT (STEPS)FACILITY NUMBER: 015650121

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

met_with: Claudia Nelson


facility_name: STABILITY THROUGH ENHANCED PEER SUPPORT (STEPS)

raw_content:
Investigation Findings:
13On 4-17-24 10:47AM, Licensing Program Analyst (LPA) George Karkazis made and unannounced inspection at Stability Through Enhanced Peer Support (STEPS), and met with Isela Sahagun, Case Worker/ Social Worker. The purpose of the inspection was to deliver the findings for the above allegations. The investigation was conducted by Community Care Licensing (CCL) Investigation Branch (IB), Investigator Blake Williams. The complaint alleged that staff did not prevent a minor from sustaining a burn while in care, and staff did not prevent a client from being attacked while in care. During the course of the investigation, IB conducted confidential interviews with staff, clients, witnesses, and authorized representatives. IB obtained documentation, police reports, medical records, facility records and communication records. Confidential interviews and document research conducted provided conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the allegations occurred. Therefore, the allegations are UNSUBSTANTIATED. A Technical Assistance was issued. A copy of this report was given to Isela Sahagun, Case Worker/ Social Worker. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: George Karkazis LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Christopher Rollins conducted an Case Management with Larry Hickman. The reason for the case management visit was to go over the age exception that was submitted on July 7. LPA and Administrator went over age exception and corrected the areas of question that the LPA had. Administrator provided LPA with an updated age exception letter and the county support letter. LPA will review documents and provide feedback to Administrator for approval or denial.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Christopher Rollins made an unannounced required Annual inspection to Stability Through Enhanced Peer Support (STEPS) Administrative office. LPA met with Larry Hickman Administrator. The Transitional Housing Placement Plus Foster Care program (THP-FC) services non-minors dependents. At 10: AM, LPA did a walk through inspection with Administrator of the office. The office has sufficient space for confidential meetings, all participant files and staff files are located in a locked cabinet in a secure location. The agency has their license posted in their office. The office is in compliance with Community Care Licensing (CCL) regulations. LPA spoke with Administrator and Social Workers on site about the residential units. Administrator and Social Workers stated that all residential units have at least one toilet, sink and tub in working order. Administrator and Social Workers stated that all disinfectants and cleaning supplies are locked up and inaccessible. Administrator and Social Workers notified LPA that the program provides all participants with household essentials and that there are no weapons or firearms stored in the apartment units. At 11: AM, LPA reviewed 8 participants files and 6 staff files with Administrator. LPA observed Participants files to be complete and found no deficiencies. All documents are complete and up to date. LPA observed 6 staff files to be complete, all documentation is up to date and all staff training were up to date/current. At 12: PM, LPA conducted staff interviews with two Social Workers who were present. During inspection, LPA receive a updated copy of the LIC Personnel Report to maintain their file current. LPA receive an updated Certificate of Compliance for Apartment units. A review of Licensing Information System on September 2, 2021 indicates that all facility staff associated to the program has DOJ, FBI and child abuse index check clearances. Per Title Regulations, no deficiencies were cited during this inspection. Exit interview conducted and a copy of the report was left at the facility.

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Isabel Mendoza made an unannounced required Annua/Required inspection to Stability Through Enhanced Peer Support (STEPS) Administrative office. LPA met with Larry Hickman Administrator and Claudia Nelson Program Manager. The Transitional Housing Placement Plus Foster Care program (THP-FC) services non-minors dependents. At 9: AM, LPA did a walk through inspection with Administrator of the office. The office has sufficient space for confidential meetings, all participant files and staff files are located in a locked cabinet in a secure location. The agency has their license posted in their office. LPA spoke with Program Manager about the residential units, and obtained copies of all Certificate of Compliances. The facility currently has 18 sites. The administrator confirmed that all residential units have at least one toilet, sink and tub in working order. LPA obtained a copy of all sites Certificate of compliance for all 18 sites. At 9: AM, LPA reviewed 8 participants files and 6 staff files along with staff training. LPA observed 8 participants files to be complete and found no deficiencies. LPA reminded the facility to complete all items on the LIC 601 (Identification and Emergency Information). The form is to be filled out completely. LPA found several participants that were missing items. However, during inspection, the Program Manager and Social Worker completed missing items. LPA observed 6 staff files to be complete, all documentation is up to date and all staff training were up to date/current. During inspection, LPA obtained a copy of the LIC 610 and LIC 500. The facility currently has a balance due of $1,931.00. (Please refer to LIC 809-C continuation page). The Administrator informed LPA that this was not correct and the facility has been trying to get these fees corrected, because CCL possibly made an error after the change of location. The Administrator noticed the error started in January of 2020. The administrator submitted copies of cashed checks along with email correspondence with former LPA to LPA Mendoza. LPA Mendoza will take this information back and will follow-up with the Administrator. No deficiencies were cited during todays inspection. An exit interview was conducted and a copy of the report was left with the Administrator.

met_with: Claudia Nelson and Larry Hickman


summary: Facility Evaluation

raw_content:
Narrative:
On 4/24/2023 at 12:45PM, Licensing Program Analyst (LPA) Selena Hood conducted a visit to the office of the above agency. On 4/24/2023, Community Care Licensing (CCL) was informed that an 18 year old resident of the facility had died by shooting on 4/23/2023 in Richmond, California. LPA met with Claudia Nelson, Program Manager. LPA collected copies of the Transitional Independent Living Plan and Needs and Services Plan for the resident. LPA discussed the details of the incident and the who had reported the incident with Program Manager (see LIC812). The resident's probation officer and biological mother have been informed. The facility has begun informing other residents in the home. Program Manager is checking in with the other residents and offering grief counseling today, 4/24/2023. The facility is also working with the resident's mother to receive their belongings. LPA conducted an exit interview with Claudia Nelson, Program Manager at 1:01PM. Facility will provide the incident report when they have been granted more information about the location and circumstances of the incident.


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with Vicky Taylor, Administrator at 2: PM on 7/29/24. Based on confidential interviews conducted it was determined that the allegations listed above are Substantiated. Witnesses interviewed stated that during the summers their apartments too hot. Although, their apartments have a through-the-wall AC, it only cools one area of the apartment and doesn't reach clients' rooms. Witnesses stated that they are unable to sleep in their rooms at night because it was too hot. One witness stated that their apartment gets up to 95 degrees during the day. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. As a result of this visit, there is one General Licensing Standards violation ( Furniture, Fixtures, Equipment, and Supplies(a)(1))The facility will be cited (see 809-Ds for details). Appeal rights were discussed and provided. Exit interview was conducted and a copy of this report was emailed to Vicky Taylor, Administrator. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN JOSE RO, N. First Street, Ste. FACILITY NAME: STAR TRANSITIONAL HOUSING PLACEMENT PROGRAMFACILITY NUMBER: 435202144

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

met_with: Vicky Taylor, Administrator


raw_content:
Investigation Findings:
13On 9/27/2024 at 8: AM, Licensing Program Analyst (LPA) Shikya Belfield, conducted an unannounced inspection at the above facility. The purpose of this inspection is to inform the facility representative of the findings of the complaint investigation that was conducted for the allegations listed above. LPA met with Supervisor Carina Oliva who assisted with the inspection. Based on confidential interviews conducted and supportive documentation to include but not limit; maintenance receipts, pest control service logs, and staff files. Participant units have damaged or broken items that were not repaired in a timely manner. Based on a review of staff files, staff are missing the required training's outlined in the programs plan of operation. It was confirmed that although he facility does have roaches, the program has be proactive in maintaining pest control service and will continue to monitor the ongoing issue and address it. The preponderance of the evidence has been met. Therefore, these allegations are Substantiated. Facility issued technical assistance advisory for California Code Regulations, Title 22, Division Six, Section 80022(k) plan of operation and Welfare and Institutions Code section 16001.9(a)(1) Personal Rights, as described on the following page LIC 9102TV. An exit interview was conducted and a copy of this report was left with Supervisor Carina Oliva. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Shikya Belfield LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. This is an official report of an unannounced visit/investigation of a complaint received in our office on 04/08/2024 and conducted by Evaluator Shikya Belfield PUBLICCOMPLAINT CONTROL NUMBER: 26-CR- FACILITY NAME:STAR TRANSITIONAL HOUSING PLACEMENT PROGRAMFACILITY NUMBER: ADMINISTRATOR:STEUART SAMUELSFACILITY TYPE: ADDRESS: SHERMAN OAKS AVENUETELEPHONE: (669) 300- CITY:SAN JOSESTATE: CAZIP CODE: CAPACITY:36CENSUS: 10DATE: 09/27/ UNANNOUNCEDTIME BEGAN: 08: AM MET WITH:Carina OlivaTIME COMPLETED:09: AM 9Staff violated client rights. INVESTIGATION FINDINGS: 13On 09/27/2024 at 8: AM, Licensing Program Analyst (LPA) Shikya Belfield, conducted an unannounced inspection at the above facility. The purpose of this inspection is to inform the facility representative of the findings of the complaint investigation that was conducted for the allegations listed above. LPA met with Supervisor Carina Oliva who assisted with the inspection. Based on confidential interviews conducted and supportive documentation to include but not limit; maintenance receipts, pest control service logs, and staff files. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, this allegation is Unsubstantiated. There were no violation of the California Code Regulations, Title 22, Division Six cited cited during this inspection. An exit interview was conducted a copy of this report was left with Supervisor Carina Oliva. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Shikya Belfield LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 2 of 2

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

met_with: Carina Oliva


facility_name: STAR TRANSITIONAL HOUSING PLACEMENT PROGRAM

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Vaishali Singh-Sood made an unannounced inspection on 6/3/2021 to the above listed facility via face-time, and met with Case Manager, Christina Winn, at 3: PM. This agency serves as a 726 - Transitional Housing Placement Program (THPP). LPA Singh-Sood explained that the purpose of the inspection was to conduct a Case Management as a follow up to the incident that occurred on 12/20/2020 at THPP unit 3. On January 25, 2021, LPA Carolyn Flynn conducted an unannounced inspection at the facility. Additionally, LPA Flynn requested copies of the involved client's file (assessment, admission paperwork, case plan, incident reports, and medication list), AWOL log for client, copy of the staff schedule, staff training tracker logs - certificates in binder in office, staff contact information, Google note from staff that conducted check at 5: PM on 12/20/20, Incident Report that they sent to the County with more details, Certificates of Approval for each of the four units, residents of the unit and their contact information. LPA also interviewed ED and ED agreed to send LPA Google Notes where the staff document their check-in notes and copies of the training certificates for the staff that were working on 12/20/2020 for the past year. The Incident was then investigated by the Investigations Bureau (IB), who conducted interviews with the foster children, facility staff, and other confidential parties and reviewed relevant documents. Based on the documents reviewed regarding the interviews conducted, and documents attached, there is no evidence that there were any violations for neglect/lack of care and supervision and/or personal rights. This agency has investigated the above complaint allegation and found that it was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of the report was emailed to Ms. Winn at 4: PM .

met_with: Christina Winn


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Shikya Belfield made an unannounced case management inspection to the above facility on 7/6/2022 at 4:00PM. LPA Belfield met with Program Administrator Vicky Taylor, who assisted with the inspection. The purpose for this case management inspection is to obtain information regarding an incident involving a non-client death( see LIC811 dated 7/6/2022) that occurred at the Transitional Housing Placement Program (THPP) residential apartment. On July 2, 2022, facility staff emailed this LPA and informed the department that a death occurred of a 16-year-old female guest of a participant in the THPP, who passed away due to an overdose. Program case manager went to the participant's apartment on July 1, 2022, and met with the participant regarding their visitor policy and following the rules of the program. On July 2, 2022 the THPP staff reviewed surveillance camera footage displaying firefighters arriving to the apartment unit for the participants. A third party notified law enforcement. The participant left the apartment. At 1: PM a parent (mother) arrived at the apartment and stated that her daughter was inside (second guest of the participant). Staff looked in the apartment and found the youth in another participants bedroom. Due to her being pale and her lips were blue in color, staff contacted law enforcement and the youth was taken to the hospital. Participant returned to the apartment and was met by the staff to check in. Participant was discharged from the program on 7/5/2022. Follow up: Case manager checked in with the remaining clients in the unit. A plan is in place to increase the checks being done on the apartments. Participants have not requested any services, however a plan is in place to follow up again by 7/7/2022 with participants regarding counseling services and other resources available. Due to other friends of the participant having the codes to access to the apartment and these friends entering the apartment without permission, the locks have been changed and additional cameras were installed in the outside common areas. Administrator Vicky Taylor states that Incident Reports will be submitted by Friday 7/8/2022 or no later than Monday 7/11/2022 regarding the incident. There were not citations issued. An exit interview was conducted a copy of this report will be sent to administrator Vicky Taylor.

met_with: Vicky Taylor


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Shikya Belfield conducted an unannounced inspection to the facility on 10/6/2022 at 10:30AM. The purpose for the inspection is conducting the Required Annual Inspection. LPA Belfield met with Administrator Vicky Taylor who assisted with the inspection. During a walk-through of the facility LPA Belfield observed the appropriate forms posted and the files kept in a locked cabinets. During this inspection, staff files were reviewed and all files were observed by this LPA kept locked to ensure confidentiality. This THPP currently has 18 clients in placement. The administrator Vicky Taylor stated there are no weapons or bodies of water at the facility. At this time the inspection could not be completed and will be completed on a later date. There were no violations of California Code of Regulations, Title 22, Division Six or Interim Licensing Standard cited during this inspection.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Manager Angela King and Licensing Program Analyst Michelle Kyane conducted a case management inspection on October 20, 2022 at 11:20AM, based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 7 out of Direct Care Staff and 8 out of 18 youth files were reviewed. 1 out of Direct Care Staff and 2 out of 18 youth were interviewed. (See the Confidential Names List, LIC 811, dated October 20, 2022. The Plan of Operation including policies and procedures were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments,THPP Interview Questions, and safety plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPM Angela King observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. The licensee is contacting law enforcement in accordance to their emergency intervention plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Christina Faraone Transitional Aged Youth Program Coordinator.

met_with: Christina Faraone


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Shikya Belfield made an unannounced case management inspection to the above facility on 1/25/23 at 1:15PM. LPA Belfield met with Program Program Coordinator Christina Faraone, who assisted with the inspection. The purpose for this case management inspection is to obtain information regarding an incident involving a client overdose ( see LIC811 dated 1/25/2023) who resides at the Transitional Housing Placement Program (THPP) residential apartment. The department received information regarding a participant C1, who was reported as runaway on 1/22/2023 at 11PM. On 1/23/2023 case manager Amy was notified by the probation officer via text and email stating that the client was found and is in the hospital recovering from an overdose. As of today the program continues to be in contact with the probation officer. Client's mother is with them in the hospital and the mother notifies probation of updates. Client is currently under a 14 day notice for violation program rules and behavior contracts regarding possession of fire arm and ammunition, hit and run with client's vehicle, smoking and violating visitation policies. LPA Belfield will attempt to speak to C1. A CFT was scheduled for Tuesday 1/24/2023 however Client's was in the hospital. Proper notice was given to participants social worker and probation officer on 1/20/2023 prior to the current incident. There were not violations cited during this inspection. An exit interview was conducted and a copy of this report will be sent to Program Coordinator Christina Faraone and administrator Vicky Taylor.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Vaishali Singh-Sood conducted an unannounced inspection to the facility on 3/7/2025 at 11: AM. The purpose for the inspection was to conduct the Required Annual Inspection. LPA Singh-Sood met with Administrator Vicky Taylor who assisted with the inspection. During a walk-through of the facility LPA Singh-Sood observed the appropriate forms posted and the files kept in a locked cabinets. During this inspection, staff and client files were reviewed. Additionally, all files were observed by this LPA kept locked to ensure confidentiality. This THPP currently has nine clients in placement. The administrator Vicky Taylor stated there are no weapons or bodies of water at the facility. There were no violations of California Code of Regulations, Title 22, Division Six or Interim Licensing Standard cited during this inspection. At 4: PM, an exit interview was conducted with Ms. Taylor.


summary: Facility Evaluation

raw_content:
Narrative:
On 06/11/21 at 9: AM, Licensing Program Analyst (LPA), Zena Phillips and Licensing Program Manager (LPM) Lakescia Smith made an unannounced visit to the St Anne Maternity Home THPP to conduct a required annual inspection. LPA Phillips met with Mayra Velasco Director, who granted access to facility. State of CA license was posted along with occupancy self certification of units. Personnel files were requested and. LPA Phillips conducted review of staff and clients files. Will conduct an inspection of living units at a later date. A review consisted of the following: At admission each participant and his/her authorized representative, shall be personally advised of the and given a copy of personal rights. THPP participant's records contain copies of school records, immunization records and medical records. THPP documents that personnel meet education and experience requirements THPP maintains records of annual personnel performance evaluations THPP license and staff have criminal record clearance. THPP license and staff have child abuse index checks THPP licensee request fire clearance for participants living units prior to residence of non- ambulatory individuals. THPP has Certificates of Compliance for participants living units. THPP administration offices, staff residential and participants living units have telephone service at all times. LPA Phillips advised Mayra of the following: update personnel report. The following documents were obtained today, client and staff roster. There are no deficiencies cited during today's visit. Exit interview completed

met_with: Director Mayra Velasco


summary: Facility Evaluation

raw_content:
Narrative:
On 12/07/23 at 9: AM, Licensing Program Analyst (LPA), Zena Phillips made an unannounced visit to the St Anne's Maternity Home THPP to conduct a required annual inspection. LPA Phillips met with Marianna Oganesyan/ VP of Housing, who granted access to facility and provided census. State of CA license was posted along with occupancy self certification of units. Personnel files were requested for staff and client. LPA Phillips conducted review of three (3) staff and three (3) clients files. Will conduct an inspection of living units at a later date. A review consisted of the following: At admission each participant and their authorized representative, shall be personally advised of the and given a copy of personal rights. THPP participant's records contain copies of school records, immunization records and medical records. THPP documents that personnel meet education and experience requirements THPP maintains records of annual personnel performance evaluations THPP license and staff have criminal record clearance. THPP license and staff have child abuse index checks THPP licensee request fire clearance for participants living units prior to residence of non- ambulatory individuals. THPP has Certificates of Compliance for participants living units. THPP administration offices, staff residential and participants living units have telephone service at all times The following documents were obtained today, client and staff roster. Each THPP participant's records include a personalized Needs and Services plan. Personnel records include documentation that THPP personnel meet the education and experience requirements. Employees responsible for direct care and supervision of participants have current training, from persons qualified to provide such training, in CPR and First Aid (see confidential names list, LIC 811). There are no deficiencies cited during today's visit. Exit interview completed

met_with: Marianna Oganesyan/VP of Housing


summary: Facility Evaluation

raw_content:
Narrative:
On 12/18/23 at 9: AM, Licensing Program Analyst (LPA), Zena Phillips made an unannounced visit to the St Anne's THPP-NMD to conduct continuation of required annual inspection. LPA Phillips met with Marianna Oganesyan/ VP of Housing; LPA Phillips toured physical plant which included participant living units. LPA Phillips was able to tour one occupied unit RM# 108, and one empty unit RM#109. There is a separate office that provides privacy for confidential interviews, which is next to the laundry room. The laundry room has two washers and two dryers for residence use. There are nine participants and ten children placed in the program. There are two kitchens on the floor for residence use. The kitchen has a four burner stove, double sink, refrigerator with upper and lower cabinets. LPA observed the refrigerator with ample food supply and food stored in plastic containers or original bags from purchase. LPA Phillips was allowed by resident to tour RM#101. The resident has twin bed and crib with clean linens, cabinet with shelves for storage, adequate closet space for clothing. There is a working refrigerator in room with ample food supply. There is a round table with two chairs and dresser for personal belongings. The room has on suite bathroom with shower sink and toilet. Resident confirmed bathroom has hot water. LPA did not observe any cleaning or disinfectant supplies in the living units of residents. THPP participants and their minor children are provided with household essentials including, but not limited to: cooking utensils, furniture, equipment, supplies and linens. Facility has one or more functioning carbon monoxide detectors that meet the statutory requirements. LPA Phillips observed two wall mounted fire extinguishers fully charged. cont on 809 c LPA Phillips conducted one client interview, other client declined interview due to sleeping. The facility is sanitary and in good repair for the safety and well-being of clients, employees, and visitors. LPA Phillips observed two pans with grease on stove and advised clients had not cleaned up after using kitchen. During inspection. LPA was advised that maintenance staff would be coming to clean the kitchen. No deficiencies were observed or cited at the time of this inspection. Exit interview was completed and copy of this report will be provided to Marianna Oganesyan/ VP of Housing.


summary: Facility Evaluation

raw_content:
Narrative:
On 07/19/24 at 10: AM, Licensing Program Analyst (LPA), Zena Phillips and Licensing Program Analyst (LPA) Kim Dear made an unannounced visit to the St Anne Maternity Home THPP-NMD to conduct a required annual inspection. LPAs met with Freddie Gallegos/Program Manager, who granted access to the facility. State of CA license was posted along with occupancy self certification of units. Personnel files, LIC 500 and client roster were requested. The current census at time of inspection 12. LPAs conducted review of staff and clients files. and living units. A review consisted of the following: At admission each participant's authorized representative, shall be personally advised of the and given a copy of personal rights. THPP participant's records contain copies of school records, immunization records and medical records. THPP documents that personnel meet education and experience requirements THPP maintains records of annual personnel performance evaluations THPP license and staff have criminal record clearance. THPP license and staff have child abuse index checks THPP licensee request fire clearance for participants living units prior to residence of non- ambulatory individuals. THPP has Certificates of Compliance for participants living units. THPP administration offices, staff residential and participants living units have telephone service at all times. During today's inspection included five (5) staff files and five (5) client files all were in compliance. LPAs conducted confidential interviews with two (2) staff and one (1) client. cont on 809c The following documents were obtained today, client and staff roster. LPAs requested copy of fire drill log to be emailed to LPA's by Tuesday July 2023. There are no deficiencies cited during today's visit. Exit interview completed. Report will be emailed to Anna Chow/Contract Analyst & Carlos Tobar/Quality Assurance Director

met_with: Freddie Gallegos/Program Manager


facility_name: SUCCESS IN RECOVERY, INC

summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analysts Lisa Slusher and Vanessa Galvan traveled to the Success in Recovery office in Visalia CA.. LPA was met by Administrator Brad Harness and Compliance Specialist Clint King for the purpose of a scheduled pre-licensing inspection for a THP + NMD. A general overview of their program and a tour of the facility was provided. This facility has a reception area, waiting area, and office space for staff. Observed fixtures and furniture, equipment and supplies necessary for this operation. Also observed locked cabinets for client and staff files in order to ensure confidentiality. Discussed daily ongoing functions including incident reports. There is ample confidential space for meeting with clients on an as needed basis. Agency is in the process of setting up a Guardian account to transfer and associate appropriate staff. Agency to provide to LPA Galvan association requests and copies of current identification for any staff to be associated prior to Guardian account approval. Agency provided requested updates for review. Agency will submit program updates electronically following this inspection. The agency is still waiting on verification of First Aid Card for Administrator and a current bond for the facility. LPAs will review this information. The above licensee meets the requirements to be licensed as a THP+NMD serving clients age 18-21 within a two hour driving radius pending approval of updates requested during the component II orientation. . On a quarterly basis, facility is to submit a roster of THP+NMD clients that includes client names, dates of birth, county worker and current address of placement.

visit_type: Prelicensing

met_with: Brad Harness


summary: Facility Evaluation

raw_content:
Narrative:
On February 10, 2023, Licensing Program Analyst (LPA) Vanessa Galvan traveled to the Success in Recovery, INC. and met with Administrator Brad Harness, Social Worker Joseph Lovett, and Compliance Officer Clint King. The purpose of the inspection is to conduct a post-licensing inspection. LPA Galvan conducted a physical plant inspection and included the following observation and checks: Client and staff files are kept in locked filing cabinets. The agency has adequate confidential meeting space and space for Social Workers to complete job duties. The facility has a current copy of the license posted in a common area. The agency's office is located within two hours of travel time of the THPP participants living units. The agency has a client roster, with the unit addresses, and contact numbers. The agency employs one social worker, one social worker supervisor, one Administrator, and one Executive Director. LPA Galvan reviewed two staff files. A review of their staff files on this date indicates that all facility staff has received child abuse index clearances and fingerprint clearances. Agency staff meets the requirements of respective job descriptions. Staff files meet regulatory standards. The agency currently has THPP NMD participants. LPA Galvan reviewed two THPP NMD Participant files on this date. Participants' files meet regulatory standards. LPA obtained an updated LIC 500, roster of clients, and certified THPP units certificated. LPA discussed the participant's medical assessments and the assessment to be used to help develop the client's needs and services plans. No deficiencies were noted on this date. An exit interview was conducted, and a copy of this report was provided to Joseph Lovett at the conclusion of the inspection.

met_with: Brad Harness, Joseph Lovett, and Clint King


summary: Facility Evaluation

raw_content:
Narrative:
On July 5, 2023, Licensing Program Analyst (LPA) Vanessa Galvan traveled to the Success in Recovery, INC. THPP in Visalia, CA and met with Program Director Assistant (PA), Elizabeth Reynaga. The purpose of the inspection is to conduct an Annual Required inspection. The agency has a capacity of 6 with 3 participants on this date. The agency's accreditation is current and expires April 30, 2026. LPA Galvan conducted a physical plant inspection and included the following observation and checks: Client and staff files are kept in locked filing cabinets. The agency has adequate confidential meeting space and space for Social Workers to complete job duties. The facility has a current copy of the license posted in a common area. The agency's office is located within two hours of travel time of the THPP participants living units. The agency has a client roster, with the unit addresses, and contact numbers. The agency employs one social worker, one social worker supervisor, one Executive Director/Administrator, and one Assistant THP Administrator. LPA Galvan reviewed three staff files. A review of the staff files on this date indicates that all facility staff has received child abuse index clearances and fingerprint clearances. Agency staff meets the requirements of respective job descriptions. Staff files meet regulatory standards. The agency currently has three THPP Non-Minor Dependents (NMD) participants. LPA Galvan reviewed three THPP NMD Participant files on this date and files meet regulatory standards. A technical assistance was provided on today's visit. (See attached LIC 9102.) No deficiencies were noted on this date. An exit interview was conducted, and a copy of this report was provided to Elizabeth Reynaga at the conclusion of the inspection.

met_with: Elizabeth Reynaga


summary: Facility Evaluation

raw_content:
Narrative:
On 7/12/2023, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Success in Recovery THP in Visalia, CA, to conduct an unannounced visit and met with Assistant Program Director, Elizabeth Reynaga. The purpose of the visit was to complete the annual inspection (Start date 7/05/2023) by conducting staff interviews. LPA conducted interview with 4 staff. No deficiencies were issued or observed at this time. A copy of this report was provided to Elizabeth Reynaga at the conclusion of this inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On July 19, 2023, Licensing Program Analyst (LPA) Vanessa Galvan traveled to the Success in Recovery, INC. THPP in Visalia, CA and met with Program Director Assistant (PA), Elizabeth Reynaga. The purpose of the inspection was to conduct an Annual Required inspection. The agency has a capacity of six with four participants on this date. The agency's accreditation is current and expires April 30, 2026. LPA Galvan conducted a physical plant inspection and included the following observation and checks: Client and staff files are kept in locked filing cabinets. The agency has adequate confidential meeting space and space for Social Workers to complete job duties. The facility has a current copy of the license posted in a common area. The agency's office is located within two hours of travel time of the THPP participants living units. The agency has a client roster, with the unit addresses, and contact numbers. The agency employs one social worker, one social worker supervisor, and one Executive Director/Administrator. LPA Galvan reviewed three staff files. A review of the staff files on this date indicates that all facility staff has received child abuse index clearances and fingerprint clearances. Agency staff meets the requirements of respective job descriptions. LPA reviewed three staff files. Staff files meet regulatory standards and have all required documentation. The agency currently has four THPP Non-Minor Dependents (NMD) participants. LPA Galvan reviewed four THPP NMD Participant files on this date and files meet regulatory standards. One deficiency for 86069(a) Participants Medical Assessment and one Technical Violation 86069(a)(1). An exit interview was conducted, and a copy of this report was provided to Elizabeth Reynaga at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On 08/07/2024, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Success in Recovery THP in Visalia, CA, to conduct an announced visit and met with Assistant Program Director, Elizabeth Reynaga. The purpose of the visit was to complete the annual inspection by conducting staff and client interviews. LPA conducted interview with 2 staff and 3 clients. No deficiencies were issued or observed at this time. A copy of this report was provided to Brad Harness at the conclusion of this inspection.

met_with: Elizabeth Reynaga & Brad Harness


summary: Facility Evaluation

raw_content:
Narrative:
On July 10, 2024 @ 3: PM Licensing Program Analyst (LPA) Zena Phillips and Licensing Program manager (LPM) Lakescia Smith conducted Component II - Face to Face meeting for S.T.E.P.S. at the El Segundo Regional Office. The purpose of the meeting was to discuss the review of the Application and Program Statement. The following individuals were present: Zena Phillips, Licensing Program Analyst, Licensing Program Manager (LPM) and Lawrence Hickman, Applicant/Executive Director. LPA Phillips and LPM Smith discussed the following items missing from the application: Rental agreement needs to completed and resubmitted Personnel report listing facility association for Chanda Delifus as social worker. Applicant must submit transfer request LIC 9182 request for applicant and Chanda Delifus Submit copy of Chanda Delifus' transcript/degree and LIC Chanda Delifus TB result & Health screening for both applicant and Chanda Delifus Provide LIC 508 for both Lawrence Hickman & Chanda Delifus Operating budget updated with more accurate estimate Criminal record statement needed for applicant and Chanda Delifus Provide LIC 610C Emergency disaster plan cont on 809c Per Program Statement review the following concerns were reviewed: Page #31 utilizing community resources in San Diego and additional counties Page #33 update residents visitors hours and how many visitors allowed Page #37 need to add Los Angeles address Page #38 update phone number contact for Los Angeles to Chanda Delifus Page #49 remove "smoking responsibly" Page #50 update phone # for emergency contact & who is emergency contact Page # 51 update internal grievance policy. Provide more details about complaint process. Who is responsible for resolving complaint. Pre Licensing is scheduled for Friday July 12, 2024 and deadline to submit revision by July 17, 2024. Exit interview was conducted and copy of report was provided to Lawrence Hickman/Executive Director.

met_with: Lawrence Hickman/Executive Director


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Zena Phillips & Licensing Program Manager (LPM) Lakescia Smith made an announced visit S.T.E.P.S. Transitional Housing Placement Program Administrative office. The administrative office is located at CENTER DR., STE 695, Los Angeles, CA 90045. The purpose of the visit was pre licensing of Administrative office. Chanda Delifus advised LPA and LPM she will be Administrator and Social Worker Supervisor. LPA & LPM observed the office suite to have two desk and two chairs. The file cabinet has two drawer and locked with a key. There is an inoperable phone line located on one of the desk. The office suite has main door with frosted glass window next to the door. LPA & LPM requested the square footage of office suite and information was not available and will be provided at a later date. The office lacks printer and no computers were present at time of inspection. LPM inquired about staff laptops. Chanda Delifus/Administrator stated she has received work laptop and other staff will receive laptops but no laptops have been issued at time of inspection. Their plan is to have a room designated for confidential interviews by reservation only in a conference room down the hall. LPA and LPM observed the conference room Earhart on the 6th floor. LPA and LPM observed room to have table and six chairs, large television, projector, small cabinets with frosted glass doors. LPA & LPM reminded Chanda Delifus that all participants records shall be maintained in a secure area or a locked file cabinet in the administrative office. cont on 809c The office suite is accessed by security desk granting access to elevator with key card. Receptionist grants access to the office hallway to the office suite. Follow up is needed regarding status of the building and status of the conference room. Due to the capacity and the small size of the suite to accommodate the needs of the clients. The conference room is down the hallway behind the receptionist area only accessible by reservation. LPA and LPM discussed the office not being completely set up. Exit interview was conducted report and confidential names list will be emailed to Lawrence Hickman/Executive Director

met_with: Chanda Delifus/Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On August 14, 2024, at AM, Licensing Program Analyst (LPA) Erika Butler, Cheri Wilkerson, and Licensing Program Manager (LPM) JoAunne Griffin arrived at S.T.E.P.S. Transitional Housing Placement Program (THPP) administrative office located at Midvale Ave. Suite Los Angeles, CA 90034 for the purpose of conducting a Pre-Licensing inspection. LPAs and LPM conducted a walkthrough of the administrative office with Lawrence Hickman, Licensee. A health and safety assessment was conducted. LPAs and LPM observed the office suite to be located in an office building on the second floor. The office space is 250 square feet. The office suite was accessed by using the elevator located on the first floor. LPAs and LPM were met at the front entrance by Lawrence Hickman who granted access into the office space. The building is accessible via a call pad. This call pad has not been updated with administrative office information. The office suite is separated into two spaces by a door. The first space is where staff workspace is located. The space consist of a L-shaped desk, four chairs, computer monitor, laptop, printer and scanner. Lighting was sufficient and smoke detector was observed. Second space is accessed through a door and was observed to have five drawer file cabinet with the ability to lock. Lighting was sufficient. Space Continued on 809C will be used as a confidential space for clients. Space was also observed to have an air conditioning unit and a window that does not open. Phone service was observed and provided through Spectrum. Chairs and a table will be ordered and placed in space. Emergency exits are located on the east and west end of the building. Bathrooms are located directly outside of office suite. Chanda Delifus has been identified as the Administrator/Social Worker for location. Mr. Hickman was advised that all staff will need to associated to location. An exit interview was conducted and a copy of this report will be emailed to Mr. Hickman

met_with: Lawrence Hickman


summary: Facility Evaluation

raw_content:
Narrative:
On August 29, 2024, at AM, Licensing Program Analyst (LPA) Cheri Wilkerson, and Licensing Program Manager (LPM) JoAunne Griffin arrived at S.T.E.P.S. Transitional Housing Placement Program (THPP) administrative office located at Midvale Ave. Suite Los Angeles, CA 90034 for the purpose of conducting a Pre-Licensing follow-up inspection. LPA and LPM conducted a walk through of the administrative office with Chanda Delifus, Administrator. A health and safety assessment was conducted. LPA and LPM observed the office suite to be located in an office building on the second floor. The office space is 250 square feet. The office suite was accessed by using the elevator located on the first floor. The building is accessible via a call pad and the code is 60. The office suite is separated into two spaces by a door. The first space is where staff workspace is located. The space consists of a L-shaped desk, four chairs, computer monitor, laptop, printer and scanner. Lighting was sufficient and smoke detector was observed. Second space is accessed through a door and was observed to have five drawer file cabinet with the ability to lock. Lighting was sufficient. Space also included a table and four chairs. Space will be used as a confidential space for clients. Space was also observed to have an air conditioning unit and a window that does not open. Phone service was observed and provided through Spectrum. Emergency exits are located on the east and west end of the building. Bathrooms are located directly outside of office suite. Chanda Delifus has been identified as the Administrator/Social Worker for location. An exit interview was conducted, and a copy of this report will be emailed to Chanda Delifus, chanda.Delifus@questprograms.org.

met_with: Chanda Delifus, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On January 22, 2025, at 9: AM, Licensing Program Analyst, (LPA) Kim Dear arrived at the S.T.E.P.S. Transitional Housing Placement Program, (THPP) administrative office located at Midvale Ave. Suite # Los Angeles, CA 90034 for the purpose of conducting a unannounced, Post Licensing inspection. LPA was met at the front entrance of office by Chanda Delifus, who granted access into the office space. Chanda Delifus has been identified as the Administrator/Case Manager for this location. LPA conducted a walk through of the administrative office with Chanda Delifus, the Program Administrator. A health and safety assessment was conducted. LPA requested A copy of the current LIC500 and the Client Roster, which was provided to LPA. LPA observed the office suite located in an office building on the second floor. The office space is 250 square feet. The office suite was accessed by using the stairs to the first floor. The building is accessible via a call pad. Dial 60 on cell pad to call administrative office. The office suite is separated into two spaces by a door. The first space is where staff workspace is located. The space consists of a Shaped desk, four chairs, computer monitor, laptop, printer, and scanner. Lighting was sufficient and smoke detector was observed. See LIC809-C Page 2 of continued Second space is accessed through a door and was observed to have a five drawer, file cabinet with the ability to lock. Space will be used as a confidential space for clients. Lighting was sufficient. Space was also observed to have an air conditioning unit and a window that does not open. Phone service was observed and provided through Spectrum. Chairs and a table will be ordered and placed in space. Emergency exits are located on the east and west end of the building. Bathrooms are located directly outside of office suite. (5) Five staff and (3) three client files were reviewed. Mr. Hickman was advised that all staff will need to associated to this location. An exit interview was conducted, and a copy of this report was provided for Mr. Hickman

met_with: Chanda Delifus


facility_name: TRANSITION AGE YOUTH HOUSING PROGRAMS

summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Brian Bertoli met with Assistant Program Director Nancy Campbell and Housing Director Vanessa Guevara at the facility office. The purpose of the inspection was to deliver the findings for the above complaint allegations. During the course of the investigation, the LPA reviewed records and conducted confidential interviews. It was confirmed that the Resident Advisor was intoxicated in the home, made inappropriate comments, made the residents uncomfortable, offered residents illegal substances, and showed inappropriate photos to residents. Based on the information obtained, there is a preponderance of the evidence to prove that the Resident Advisor did not ensure that residents were able to live in a safe, healthy, and comfortable home. Therefore, the above allegations are substantiated. Title 22 deficiencies were cited and Appeal Rights were provided and discussed. Advisory Notes were issued. An exit interview was conducted, and a copy of the report was given to the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lidia Tinoco LICENSING EVALUATOR NAME: Brian Bertoli LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 21-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SANTA ROSA RO, NEOTOMAS AVENUE, STE. FACILITY NAME: TRANSITION AGE YOUTH HOUSING PROGRAMSFACILITY NUMBER: 496803445

met_with: Nancy Campbell and Vanessa Guevara


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Brian Bertoli conducted an unannounced inspection to the THPP/THP+FC Administrative office to conduct an Annual/Required inspection. LPA met with Administrative Assistant Casha Cory and was joined later by Housing Director Vanessa Guevara. The THPP has a capacity of 60 and service both THPP and THPP+FC participants and THPP Plus contracted through the County. There are currently 27 participants in care (Three minors and NMDs). The facility uses a scattered site model and currently has both host homes and apartment units. LPA reviewed six Certificate of Compliances and they were valid. LPA inspected the THPP office, which has two stories and a basement. The first floor has a reception area, open meeting room, kitchen/lunch room, and restroom. The second floor has private offices and a restroom, and the basement has private meeting spaces. The license and Emergency Disaster Plan (LIC610C) forms are posted. LPA's reviewed participant records - three minor files and three Non-Minor Dependents. All participant files are acceptable. Staff records are maintained at the TLC administrative office on Gravenstein Hwy North in Sebastopol. Facility was able to coordinate with Human Resources Manager Amanda Atkinson to acquire staff records promptly electronically. A review of Licensing Information System on June 16, 2021, indicates that all facility staff associated to the facility had DOJ, FBI and child abuse index check clearances. During inspection, LPA's reviewed three staff files and all files were complete and had all required documents and required training. There were no Title 22 deficiencies cited during todays inspection. Exit interview was conducted and a copy of the report was left at the facility .

met_with: Casha Cory


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Brian Bertoli conducted an unannounced inspection to the THPP/THP+FC Administrative office to conduct an Annual/Random inspection. LPA met with Administrative Assistant Casha Cory. The THPP has a capacity of 60 and service both THPP and THPP+FC participants and THPP Plus contracted through the County. There are currently 27 participants in care (one minor and NMDs). The facility uses a scattered site model and currently has both host homes and apartment units. LPA reviewed six Certificate of Compliances and they were valid. LPA inspected the THPP office, which has two stories and a basement. The first floor has a reception area, open meeting room, kitchen/lunch room, and restroom. The second floor has private offices and a restroom, and the basement has private meeting spaces. The license and Emergency Disaster Plan (LIC610C) forms are posted. LPA reviewed participant records - one minor's file and nine Non-Minor Dependent's files. All participant files are acceptable. LPA Bertoli interviewed two staff persons. Staff records are maintained at the TLC administrative office on Gravenstein Hwy North in Sebastopol and reviews will be done at a later date, as will additional staff interviews. All facility staff are associated to the facility and had DOJ, FBI and Child Abuse Index check clearances. There were no Title 22 deficiencies cited during todays inspection. An exit interview was conducted and a copy of the report was left at the facility .


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA) Brian Bertoli conducted an unannounced inspection for the purposes of continuing a Post-Licensing Inspection and met with HR Manager Amanda Atkinson, who assisted with records. The visit was conducted at the organization's administrative office at Gravenstein Hwy North in Sebastopol. A pre-screening call was done with Brittany Burns prior to arrival, and there were no changes since last visit. Five staff records were reviewed and found to be acceptable. All staff have the required Criminal Background Clearance. No deficiencies were cited at this visit. This concludes the Annual inspection. An exit interview was conducted with Amanda Atkinson and a copy of the report was left at the facility.

met_with: Amanda Atkinson


summary: Facility Evaluation

raw_content:
Narrative:
On the above date Licensing Program Analyst (LPA) Brian Bertoli conducted an unannounced inspection at the facility and met with Casha Cory, Resource Center Manager in person and Nancy Campbell, PsyD (see LIC 812 dated 4/5/24) by phone regarding two Special Incident Reports (SIRs) that were submitted to Community Care Licensing. The first incident took place on 04/03/2024 and the SIR was written to report an incident regarding the participant being arrested for domestic battery on her boyfriend. The second incident was on 4/2/24 and was for a participant being arrested for possession of narcotics, firearms, ammunition, and controlled substances. LPA Bertoli discussed the incident with Dr Campbell. In the course of reviewing the incident, the Administrator stated that they were still reviewing the incidents and would share whatever information became available. LPA Bertoli will order police reports on the incidents and review further details with the facility. Nancy Campbell inquired about Law Enforcement Contacts being reported even when they are incidental occurrences not requested by the facility. LPA Bertoli stated that all contacts need to be reported regardless of the initial source. LPA Bertoli also reviewed the 24-hr or next business day notification requirement for incident reports. This section was not discussed at the previous meeting with Administrator Shelby Means, but will be adhered to by the facility. No deficiencies were cited and an exit interview was conducted and a copy of the report was provided to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Brian Bertoli conducted an unannounced inspection to the THPP Administrative office to conduct an Annual/Random inspection. LPA met with Interim Program Director Vanessa Guevara. The THPP has a capacity of 60 and service both THPP and THPP NMD participants and THPP Plus contracted through the County. The facility uses a scattered site model and currently has both host homes and apartment units. LPA reviewed Certificate of Compliances and they were acceptable. LPA inspected the THPP office, which has two stories and a basement. The first floor has a reception area, open meeting room, kitchen/lunch room, and restroom. The second floor has private offices and a restroom, and the basement has private meeting spaces. The license and Emergency Disaster Plan (LIC610C) forms are posted. LPA reviewed participant records and all participant files reviewed are acceptable. LPA Bertoli conducted confidential staff interviews. Staff records are maintained at the TLC administrative office on Gravenstein Hwy North in Sebastopol and LPA met with HR Assistant Kelly Yelapi and CFO Jen Koliba and reviewed staff files. All facility staff are associated to the facility and had DOJ, FBI and Child Abuse Index check clearances. There were no Title 22 deficiencies cited during todays inspection. An exit interview was conducted and a copy of the report was left at the facility .

met_with: Vanessa Guevara, Jen Koliba and Kelly Yelapi


facility_name: TRANSITION AGE YOUTH PROGRAM

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Shikya Belfield conducted a change of location inspection with the new facility office. LPA met with administrator Meg Clark who assist with the tour of the office. The purpose of this Pre-licensing inspection is due to the change of location, the previous location was Ocean St Suite B Santa Cruz Ca 95060. The new location is now located at Encinal St, Suite 200, Santa Cruz Ca 95060. This program a Transitional Housing Placement Program(THPP). The program is licensed to provide services and Transitional Housing Placement plus Foster care ( THPP+FC) services to Non-Minor Dependents. The new office location was toured and the following areas were observed: - Reception Area was observed with the proper guidelines being followed regarding the pandemic with the following; plastic dividers / separators placed on the counter tops, masks are worn inside, signs are posted with emergency exists and floor plans on every doorway. Administrator states that all protocols for COVID are in place including taking temperature of all who enter and recording it. - Offices spaces; Due to the Pandemic, there are no private offices spaces and there are three private conference rooms that are available for use upon scheduling. - Storage: Client files are kept double locked by key box and the file cabinets are stored in the main office area in the center of building. No clients enter in this area unless absolutely necessary. There are no work stations for staff at this location and all files are kept locked. - Conference Rooms / Board Rooms: meetings are located at Encinal St, Suite 200, Santa Cruz Ca, 95060. This location has adequate space to conduct meetings and training's. - Office floor space/ plan has sufficient space for the staff, file cabinets and desks / works stations. There are three bathrooms. First aid supplies are located nest to the file cabinets in the main building. There are two fire extinguishers at this location and both are currently out of date and need to be serviced ( expiration dates are April 2020). Administrator Clark states they will schedule the servicing of the new fire extinguishers or purchase new extinguishers as soon as possible and will send photographs to this LPA. Upon receipt of this information the inspection shall be complete. An exit interview was conducted and a copy of this report will be sent to Administrator Meg Clark.

met_with: Meg Clark


summary: Facility Evaluation

raw_content:
Narrative:
On 5/18/2022 at 2:00PM, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the above facility. The purpose of this visit was to begin the required annual inspection. LPA met with Meg Clark, Program Manager, and conducted a walk through of the office. The current census for the program is five clients, and they are scatter-site operated. LPA observed the posted license, locked staff and client files, and multiple rooms with sufficient privacy for counseling sessions. LPA reviewed the emergency plan binder, Program of Operations, and the packet delivered to clients. LPA interviewed one staff member. LPA reviewed two staff files. No deficiencies were cited during this visit. LPA conducted an exit interview with Meg Clark, Program Manager, at 3:30PM, whose signature confirms the receipt of this document.


summary: Facility Evaluation

raw_content:
Narrative:
On 5/27/2022 at 11:30AM, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the above licensed facility. The purpose of this visit is to conduct the required annual inspection. LPA met with Annalisa Morris, Program Assistant who provided LPA access to the files. LPA reviewed three staff files and five client files. The facility currently has five clients within their program and function on a scatter site model. LPA delivered three Technical Violations for Title California Code of Regulations 86071(a)(1)(B) and 86068.3(b), as well as Interim Licensing Standard 86268.3(c)(1) (see LIC 9102s). LPA delivered deficiencies and appeal rights. LPA conducted an exit interview with Annalisa Morris, Program Assistant at 1:00PM whose signature confirms the receipt of this document.

met_with: Annalisa Morris


summary: Facility Evaluation

raw_content:
Narrative:
On 8/30/2022 at 9:15AM, Licensing Program Analyst (LPA) Selena Hood conducted a change of location inspection with the new facility office. LPA met with Program Manager, Meg Clark, Jose Sanchez, Housing Manager, and Rene Fuentes, Program Assistant who assisted with the tour of the office. The purpose of this Pre-licensing inspection is due to the change of location, the previous location was Encinal Street Santa Cruz, CA 95060 . The new location is now located at Dubois St., Santa Cruz Ca 95060. The program licensed to provide services and Transitional Housing Placement plus Foster care ( THPP+FC) services to Non-Minor Dependents. LPA observed the facility to have a small foyer with an entrance desk and lockers for youth's to store their belongings. Within the initial lobby there is another set of lockers to store youth's mail. LPA observed an open conference room with standing desks and sitting areas for staff members. There are five rooms, which are used for therapy, quiet time, file storage, and staff workspaces. There is a large youth space that includes a kitchen, sitting areas, and two outdoor sitting areas. The sharps from the kitchen are stored in a locked closet. The kitchen has gates that block it off from the rest of the sitting area. There is one staff bathroom, three youth bathrooms, and three shower areas. LPA observed all bathrooms to have hand soap and paper towels. LPA observed that the fire extinguishers were within compliance, emergency plan was posted, and the facility sketch outlining the escape routes was posted as well. LPA conducted an exit interview with Meg Clark, Program Manager, at 9:55AM, whose signature confirms the receipt of this document.


facility_name: TRANSITIONAL AGE YOUTH PROGRAM

summary: Facility Evaluation

raw_content:
Narrative:
On 10/14/2022 at 10:00AM, Licensing Program Analyst (LPA) conducted an unannounced visit to the above licensed facility. LPA conducted a The purpose of this Post-licensing inspection is due to the change of location, the previous location was Encinal Street Santa Cruz, CA 95060 . The new location is now located at Dubois St., Santa Cruz CA 95060. The program licensed to provide services and Transitional Housing Placement plus Foster care (THPP+FC) services to Non-Minor Dependents. LPA met with Rene Fuentes, Program Assistant and Maricela Avoytes, Resource Center Manager, who helped in obtaining the files and the online training. The facility has a current census of five youth. LPA reviewed two client files and two staff files. LPA observed the files and training to be sufficient. There are five rooms, which are used for therapy, quiet time, file storage, and staff workspaces. There are also locker's for youth to store their belongings, and standing or sitting areas for staff members. There is a large youth space that includes a kitchen, sitting areas, and two outdoor sitting areas. The sharps from the kitchen are stored in a locked closet. There is one staff bathroom, three youth bathrooms, and three shower areas. LPA observed all bathrooms to have hand soap and paper towels. LPA observed that the fire extinguishers were within compliance, emergency plan was posted, and the facility sketch outlining the escape routes was posted as well. LPA conducted an exit interview with Rene Fuentes, Program Assistant, at 11:40AM whose signature confirms the receipt of this document.

met_with: Rene Fuentes


summary: Facility Evaluation

raw_content:
Narrative:
On 10/25/23, an unannounced annual inspection was conducted by LPA (Licensing Program Analyst) Celeste Aparicio and Licensing Program Analyst (LPA) Paul Simien at Transitional Age Youth Program and met with Administrator Johanna Molnar. LPA inspected the facility, inside and out. LPA Aparicio and LPA Simien reviewed five staff and five client files, conducted physical plant inspection, and reviewed the disaster preparedness plan. All personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Personnel Files are maintained on-site in locked cabinets. At this time the inspection is not complete, LPA Aparicio and LPA Simien will return to complete the inspection. No deficiencies were cited at this time. LPA conducted an exit interview with Johanna Molnar, Administrator, at 4: PM.

met_with: Johanna Molnar


summary: Facility Evaluation

raw_content:
Narrative:
On 10/31/23 at 9: AM, Licensing Program Analyst (LPA) Celeste Aparicio and Licensing Program Analyst (LPA) Paul Simien conducted an unannounced visit to the above facility. The purpose of this visit was to complete the required annual inspection. LPA's met with Johanna Molnar, Administrator, at the above facility to conduct the required annual inspection. LPA's reviewed the facilities operations, disaster preparedness plan, and conducted an interview (only one staff available). LPA discussed the following with the Administrator: client files, staff files, disaster preparedness plan, operations, Needs and Services Plans, and Compliance Certification requirements. Two deficiencies (HSC 1565(b) and ILS 86270(a)(2)(c)), seven technical violations, and two technical assistance were cited at this time. The facility will be cited (see 809-Ds for details). Appeal rights were discussed and provided. Exit interview was conducted and a copy of this report was provided to Johanna Molnar, Administrator whose signature on this form confirm receipt of these documents.


summary: Facility Evaluation

raw_content:
Narrative:
On 10/28/24, an unannounced annual inspection was conducted by LPA (Licensing Program Analyst) Jonathan Medina and Licensing Program Analyst (LPA) Paul Simien at Transitional Age Youth Program and met with ILP Manager, Jake Dunbar. LPAs inspected the facility, inside and out. Using the CARE inspection tool, LPA Medina and LPA Simien reviewed five staff and five client files, conducted physical plant inspection, and reviewed the disaster preparedness plan. All personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Personnel Files are maintained on-site in locked cabinets. At this time the inspection is not complete, LPA Medina and LPA Simien will return to complete the inspection. No deficiencies were cited at this time. LPAs conducted an exit interview with ILP Manager, Jake Dunbar, at 4: PM.

met_with: Jake Dunbar


summary: Facility Evaluation

raw_content:
Narrative:
On 10/29/24 at 10: AM, Licensing Program Analyst (LPA) Jonathan Medina and Licensing Program Analyst (LPA) Paul Simien conducted an unannounced visit to the above facility. The purpose of this visit was to complete the required annual inspection. LPA's met with Program Coordinator, Rene Fuentes at the above facility to conduct the required annual inspection. LPA's reviewed the facilities operations, disaster preparedness plan, and conducted two confidential interviews(Only two Staff available). No clients were available to interview. The inspection is complete and no citations were issued at today's visit. An exit interview was conducted and a copy of this report was left with Program Coordinator, Rene Fuentes.

met_with: Rene Fuentes - Program Coordinator


summary: Facility Evaluation

raw_content:
Narrative:
On 10/30/25 at 9: AM, Licensing Program Analyst (LPA) Paul Simien conducted an unannounced visit to the above facility. The purpose of this visit was to complete the required annual inspection. LPA met with Johanna Molnar, Administrator (ADM) at the above facility to conduct the required annual inspection. LPA reviewed five staff and five client files, conducted physical plant inspection, reviewed the disaster preparedness plan, facility operations, disaster preparedness plan, and conducted three confidential staff interviews. No clients were available to interview. The inspection is complete and no citations were issued at today's visit. An exit interview was conducted and a copy of this report was left with ADM.

met_with: Johanna Molnar, Administrator


facility_name: TRIDENT LIVING

summary: Facility Evaluation

raw_content:
Narrative:
On February 7, 2024, at 9: AM, Licensing Program Analyst's (LPA's) Darlene Almaraz-Oseguera and Emina Preciado arrived at Trident Living, Transitional Housing Placing Program (THPP). LPAs met with, Facility Administrator, Monique Bautista. The purpose of the visit was to conduct a pre-licensing inspection of the facility. LPAs did a tour of the facility with Monique Bautista for a pre-license of a Transitional Housing Placement Program (THPP) for Non-Minor Dependents (NMD). There are four bedrooms, four bathrooms, and one office. LPAs observed two living rooms furnished with couches and chairs. The common areas for residents are the kitchen, two sitting areas, a living room with ample sitting space, television, and a fireplace with proper coverings for safety. There is ample parking for residents and staff. The facility has Wi-Fi accessibility. Downstairs: The administrative office is located downstairs. The office is equipped with a desk, a locked file cabinet, and a printer/scanner. Client and personnel records will be kept electronically, and physical copies will be stored and available for review at the administrative office. The administrative office is in the process of being relocated. Upstairs: Four bedrooms and three bathrooms. LPAs observed there are clean mattresses, linens, pillows, and beds in good repair. The participant bedrooms have locks placed on the bedroom doors and each participant will have their own key to their room. The administrator will keep a master key in case of emergencies. The windows had shutters for privacy. The laundry room is equipped with a washer and dryer. The facility outside grounds were also inspected and it was observed to be clean and well maintained. LPAs observed an underground pool and spa. * LIC 809-C* During the inspection the following was discussed: During the meeting component II and component III were discussed. LPA's discussed Post Licensing visits that Community Care Licensing (CCL) may provide, solutions to problematic areas, overview of Title 22, THPP regulations, personal fingerprint requirements, abuse reporting requirements, and licensing fees. LPAs communicated about LPA's responsibility; Special Incident reporting requirements, for LIC624, CC: internal procedures, AB388 reporting form 624LE. The facility will be notified once they are provisionally licensed as a THPP/NMD facility. The license will expire one year from effective date. Facility will be licensed for a capacity of 4 participants. Facility accepts only ambulatory clients. It was discussed that the administrative office is in the process of being relocated to be utilized for storage of pertinent records, staff trainings, and meetings with participants; As well as the possibility of future expansion for the facility license as stated in the program statement. LPA provided applicant with a copy of the special incident report and provided applicant the email address and directions on reporting incidents to Community Care Licensing, Riverside North office. The certificates of compliance will also be submitted to LPA. After a final file review, the facility will be submitted for licensure. Exit interview conducted a copy of this report was provided to Licensee.

met_with: Monique Bautista, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On February 16, 2024 at 8:59 am Licensing Program Analyst (LPA), Emina Preciado, arrived at Trident Living, Transitional Housing Placing Program (THPP). LPA met and did a walk through of the facility with Facility Administrator, Monique Bautista. The purpose of the visit was to conduct a second pre-licensing inspection of the facility for a Transitional Housing Placement Program (THPP) for Non-Minor Dependents (NMD) due to a change of location. The administrative office is located at: Cherry Ave Suite Fontana, CA 92335. Upon entrance into the office building, there are two stories and multiple businesses with private suites. The administrative office is located on the second floor and is equipped with a desk, a locked file cabinet, and a printer/scanner. The administrative office has Wi-Fi accessibility and a telephone. Client and personnel records will be kept electronically, and physical copies will be stored and available for review at the administrative office. On the first floor, there is a staff break room equipped with a refrigerator and microwave. There is a conference room is equipped with desks, chairs, white board, and television and can be utilized for staff trainings and meetings with participants on the first floor. The restrooms are located downstairs inside the building. The facility outside grounds were also inspected and it was observed to be clean and well maintained. An initial pre-licensing inspection was conducted on February 7, 2024. During the initial pre-licensing meeting on 02/07/ Component II and Component III were discussed. The facility will be notified once they are provisionally licensed as a THPP/NMD facility. The license will expire one year from the effective date. The facility will be licensed for a capacity of 4-6 participants and will accept only ambulatory participants. * LIC 809-C* The facility meets the Regulatory requirements and will be ready for review for licensor at the conclusion of the visit. Exit interview conducted a copy of this report was provided to Licensee.

met_with: Administrator, Monique Bautista


summary: Facility Evaluation

raw_content:
Narrative:
On August 7, 2024 at 9:00 am Licensing Program Analyst (LPA), Emina Preciado, arrived at Trident Living, Transitional Housing Placing Program (THPP) for Non-Minor Dependents (NMD). LPA met with Facility Administrator, Monique Bautista. The purpose of the visit was to conduct a post-licensing inspection. The administrative office is located in a retail business establishment. Upon entrance into the office building, there are two stories and multiple businesses with private suites. On the first floor, there is a staff break room equipped with a refrigerator and microwave. There is a conference room equipped with desks, chairs, a white board, and television that can be utilized for staff trainings and private meetings with participants on the first floor. The restrooms are located downstairs inside the building. The administrative office is located on the second floor in Suite 205 and is equipped with a desk, telephone, printer/scanner, and Wi-Fi accessibility. There is a file cabinet located inside the office, near a bookshelf and office printer, that is locked and can be accessed using a key that is used to store confidential documents. Participant and personnel records are kept electronically, and physical copies were available for LPA to review during the inspection. Currently, the THPP has one Participant and three remote sites. The remote sites are within two hours from the office location in the cities of: Murrieta, Rialto, and Fontana. During the inspection, LPA completed one staff interview and reviewed one participant file and one staff file. One of one staff file reviewed had a completed health screening/tuberculosis (TB) test result. One of one staff file reviewed had FBI, DOJ, and Child Abuse Index Check clearances available for review. One of one staff record reviewed had completed a minimum of one hour training in child abuse identification and met the minimum qualifications as required by the Department. One of one participant file reviewed had an admission agreement, signed personal rights and grievance procedures, medical/education history, immunization records, an initial/current Needs and Services Plan (NSP), pre-placement appraisal and met the minimum qualifications as required by the Department. Operational and disaster preparedness documents are maintained at the administrative office and were available for LPA to review. * LIC 809-C* Staff was informed that each Evolution Coach should maintain a 1 to 12 ratio, which should not be exceeded. Staff is aware of submitting unusual incident reports as needed to the Department and to include all Law Enforcement contacts. Two technical violations of California Code of Regulations (CCR) are being issued for sections: 86069(a) and 86069(b)(1) pertaining to Participant 1 (P1) obtaining a medical assessment within 30 days of admission into the program and results of an examination for communicable tuberculosis and other contagious/infectious diseases. Based on observation and record review, the facility is in compliance and no deficiencies were noted at this time. Exit interview conducted and a copy of this report was provided to Facility Administrator, Monique Bautista.

met_with: Administrator, Monqiue Bautista


summary: Facility Evaluation

raw_content:
Narrative:
On July 14, 2025, at 8:25 am Licensing Program Analyst (LPA), Raina Perez-Diaz, arrived at Trident Living, Transitional Housing Placing Program (THPP) for Non-Minor Dependents (NMD). LPA met with Facility Administrator, Monique Bautista. The purpose of the visit was to conduct an annual inspection. The administrative office is located in a retail business establishment. Upon entrance into the office building, there are two stories and multiple businesses with private suites. On the first floor, there is a staff break room equipped with a refrigerator and microwave. There is a conference room equipped with desks, chairs, a white board, and television that can be utilized for staff trainings and private meetings with participants on the first floor. The restrooms are located downstairs inside the building. The administrative office is located on the second floor in Suite 205 and is equipped with a desk, telephone, printer/scanner, and Wi-Fi accessibility. There is a file cabinet located inside the office, near a bookshelf and office printer, that is locked and can be accessed using a key that is used to store confidential documents. Participant and personnel records are kept electronically, and physical copies were available for LPA to review during the inspection. Currently, the THPP has no participants and three remote sites. The remote sites are within two hours from the office location in the cities of: Riverside, Murrieta, and Fontana. The LIC 500 was reviewed, the Administrator is the sole employee; therefore, she is also the facility's Social Worker with an availability of Monday through Friday 8AM to 5PM. Administrator was informed, should they accept a client into care she will need to be available around the clock unless she is to hire an additional staff member. Operational and disaster preparedness documents are maintained at the administrative office and were available for LPA to review. LPA inquired to the lack of Trident Living identifying signs for the THPP office space. Administrator reported she does have a sign available and will be placing it on the office door. **Continue on LIC 809-C Additionally, the Administrator was asked about the previous visit attempt which a therapist was conducting a therapy session in the THPP office. The administrator reported she was not aware of the therapist utilizing the THPP office space for therapy sessions and will discuss it with the administrator of Edge TLC to ensure therapists are not utilizing the THPP office space due to the office being licensed for the THPP program. Based on the facility inspection and the current census being zero, LPA did not review any staffing or client files at the time of this inspections and there are no deficiencies cited at this time. LPA informed the Licensee to notify the Department at the time of receiving their first client in care. The Department will return to conduct staff and client file reviews at the facility. Exit interview conducted and a copy of this report was provided to Facility Administrator, Monique Bautista

met_with: Administrator- Monique Bautista


facility_name: UMOJA

summary: Facility Evaluation

raw_content:
Narrative:
On 9/11/25 at 11AM, Licensing Program Analyst (LPA) Mariah Hawkins met with Applicant Umoja for the scheduled Component II Face-to-Face meeting. In attendance were Administrator/Director Cassandra Waller-Mims, Social Work Supervisor Cassandra Abram, and Program Director Theresa Coleman. During the meeting, the following topics were discussed: Goal/Purpose of the Facility Basic Services Transitional Independent Living Plans (TILPs) Care and Supervision Policies Emergency Intervention Policies Emergency Disaster Procedures Reporting Requirements Background Clearance/Guardian Process At the conclusion of the meeting, LPA discussed that the prelicensing inspection will be scheduled upon receipt of the fire clearance. LPA thanked Applicant representatives for attending the meeting. A copy of this report was provided to Director.

met_with: Administrator/Director Cassandra Waller-Mims; Social Work Supervisor Cassandra Abram; Program Director Theresa Coleman


summary: Facility Evaluation

raw_content:
Narrative:
On 12/8/25 at 11: AM, Licensing Program Analysts (LPA) Paul Simien and Omar Sawyer conducted an announced visit to the above facility. The purpose of this visit was to conduct the required Prelicensing inspection. LPA met with Cassandra Waller-Mims, Administrator (ADM) at the above facility to conduct the required annual inspection. LPA completed the plant, operations, and disaster preparedness sections of the THPP prelicensing CARE tool. LPA Simien advised the facility to implement the following before accepting clients: Dressers for client rooms, install washer and dryer, post visible signage in areas monitored by cameras, and instructions utility shut off for staff. License shall be granted pending staff/board member background clearances and resubmission of LIC 500, LIC 610C, and job description of live-in staff. At this time, the inspection is complete. LPA conducted an exit interview with ADM.

met_with: Cassandra Waller-Mims, Administrator


facility_name: UNITY CARE GROUP

summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
under the influence and smoking paraphernalia in the home. Also, text messages of dates when participants were using drugs and alcohol. (P1) and (P2) authorized representatives received a 7-day notice via email. Also, LPA Mendoza obtained a copy of the email correspondences between the facility and authorized representatives, and both representatives requested the facility to submit a proper written notice. The facility never submitted a 7-day notice/letter. Based on interviews and documentation, the preponderance of evidence standard has been met, and therefore the above allegations are found to be Substantiated. There are two citations. California Code of Regulations, Title 22, Section Responsibility For Providing Care and Supervision and and Section 86168. Removal Or Discharge Procedures. An exit interview was conducted and copy of the report was provided to Administrator.

Investigation Findings:
SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

met_with: Adminstrator- Dyese Hunt