raw_content:
Narrative:
allegation of wrongful eviction and that the facility has always provided care for dependents that are on probation or wards of the court. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegations are found to be unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. No title 22 regulations were cited during today's inspection. Exit interview conducted and a copy of this report was left with Paige Woodard Deputy Program Director.

Investigation Findings:
13Licensing Program Analyst (LPA) Jean Stidman conducted an unannounced inspection to the facility on 8/24/22 at 3:30pm to deliver complaint allegation findings. LPA met with Paige Woodard Deputy Program Director and discussed the above allegations. During the investigation of minor's are not being provided a safe environment while in care and wrongful eviction, LPA Ignacia Villapudua-Soto toured the facility with Deputy Director, Paige Woodward on 2/17/22. On 3/21/22 and 8/17/22 and LPA Stidman obtained documentation for the complaint investigation of ROP Removal or Transfer Policies and Procedures, letter of explanation on mixing probation and child protective services clients, list of 15 clients terminated or arrested between February 2021-February 2022 which included documentation from each client's termination or arrest packet. This documentation showed the facility terminated the client when the facility determined they were unable to meet the client's needs, or the placing agency did not request the client return to the facility which is consistent with the facility's Plan of Operation Sections F and H and the Program Statement Section 1. Records reviewed and confidential interview revealed no clients terminated from the facility in the last 12 months prior to the complaint met the criteria described in the UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jean Stidman LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: ROP ATCS SIERRA RIDGE TREATMENT CENTERFACILITY NUMBER: VISIT DATE: 08/24/2022

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

met_with: Paige Woodard Deputy Program Director


state: CA

facility_name: ROP ATCS SIERRA RIDGE TREATMENT CENTER

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Because there is no supporting statements or physical evidence, the allegations are determined to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to provide the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No title 22 regulations were cited during today's inspection. An exit interview was conducted, and a copy of the report and appeals process were provided.

Investigation Findings:
UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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

report_type: Complaint Investigation

met_with: Deputy Program Director

complaint_status: unsubstantiated


raw_content:
Investigation Findings:
13On 5/4/2023 at 12: PM Licensing Program Analyst (LPA) Robyn Word arrived unannounced at the facility to deliver complaint findings. LPA spoke with Paige Woodard, Deputy Director, to discuss the findings of the complaint investigation and allegations stated above.During the course of the investigation, LPA Word inspected the facility and reviewed records. Facility records provided to LPA included: Client register, Staff Roster, staff applications, staff training records, staff schedules and timecards for November and December 2022 and staff contact Information. Confidential interviews were conducted with three facility staff, two clients, Deputy Director, and Executive Director. LPA was informed by the Executive Director that if a staff calls out and is unable to work their assigned shift, the facility will utilize their on-call procedure. If that fails, the facility will then pull a staff member that is trained in childcare to cover the shift. Based on inconsistent statements in interviews, observation, and record review, the LPA was unable to determine if the above allegations occurred. As a result of the investigation, the complaint finding is UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Exit interview was conducted, and a copy of the 9099 and appeal rights was provided to Paige Woodard, Deputy Program Director. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Hillary Hall LICENSING EVALUATOR NAME: Robyn Word LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

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


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Shoua Xiong conducted an unannounced inspection visit to the facility on 8/20/21 beginning at 3: PM. LPA met with Christopher Essary, Program Director, and explained that LPA was conducting a Case Management regarding an incident report the Department received. This report documented an altercation between two clients which occurred on 8/05/21. On today's date, LPA discussed the incident with Program Director and reviewed security footage for the date and time of the incident with Paige Woodard, Deputy Program Director. No deficiencies were cited on today's date. No further follow-up needed. Exit interview conducted and a copy of this report was given to Program Director, Christopher Essary.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Christopher Essary, Program Director


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Shoua Xiong, LPA Rob Sandles, LPA Shawndra Miles, and LPA Maignacia Villapudua-Soto arrived to the facility on 9/16/21 beginning at 10: AM. LPAs met with Chris Essary, Program Director, and explained the purpose of today's visit was to conduct a REQUIRED Annual inspection. On today's date, a health and safety inspection of the facility grounds were conducted. The STRTP currently has two dorms currently occupied, Sierra and Yosemite that houses about 50 clients. Currently in placement are 25 clients. Each client is afforded their own private bedroom, equipped with beds and adequate linen and furniture that are in good repair. The passageways, including pathways to egresses, were unobstructed and free of clutter. LPA observed bathrooms and showers to be clean, safe, sanitary and in good repair. The facility has a cafeteria on the grounds. The cafeteria was observed to have the required two days' worth of perishable food supply and seven days' worth of non-perishable food supplies. Potential toxic or harmful cleaning detergents and other chemicals are handled by a facility staff. Medications are stored within a cabinet located in a locked and dedicated medication room. Smoke detectors and carbon monoxide detectors was observed throughout the facility and was in working condition. Water temperature was checked throughout the facility and within the required range. LPAs reviewed ten client files and ten staff files but were not able to complete the review process. LPA(s) will return on a different date and time to complete the inspection. Exit interview conducted with Program Director, Chris Essary. LPAs informed facility that they will return on a different date and time to complete the annual inspection. A copy of this report was provided to the facility.

visit_type: Annual

met_with: Chris Essary, Program Director


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Shoua Xiong conducted an unannounced visit to the facility on 9/22/21 beginning at 11: AM. LPA met with Program Director, Chris Essary, and explained the purpose of the visit was to continue the Annual/Required inspection visit that had began on 9/16/21. On today's date, LPA continued reviewing files for ten staff members. LPA was unable to complete the Annual Inspection and will return on another date and time to complete the inspection process. No deficiencies were cited on today's date. Exit interview conducted and a copy of this report was given to the Program Director, Chris Essary.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
Licensing Program Analyst (LPA) Shoua Xiong and LPA Shawndra Miles conducted an unannounced inspection visit to the facility on 9/30/21 beginning at 10: AM. LPAs met with Chris Essary, Program Director, and explained the purpose of the visit was to continue the Annual Inspection which began on 9/16/21. On today's date, LPAs proceeded to finish the annual inspection. LPAs conducted separate interviews with five clients and three staff members. During the annual inspection process, it was observed that the facility did not maintain a monthly log documenting each use of manual restraints. The facility is cited on the attached LIC9099-D for violations of the Interim Licensing Standards (ILS) section 87095.61(f) Documentation and Reporting Requirements: The licensee must maintain a monthly log of each use of manual restraints. The log must include: (1) Name of each child (2) Date and time of intervention (3) Duration of the intervention (4) Name(s) of facility staff member(s) who participated in the manual restraint (5) Description of the intervention and type used (6) Result of licensee review. Exit interview conducted and a copy of this report, along with appeal rights, was given to Chris Essary, Program Director.

Deficiencies:
87095.61(f): Documentation and Reporting Requirements

(f) The licensee must maintain a monthly log of each use of manual restraints. The log must include


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 4/29/22 and met with Paige Woodard, Deputy Program Director to discuss an incident. LPA received documentation from the facility which included a grievance form in which C1 alleged that C1 was "choked out by staff in a restraint" (see LIC811 dated 4/29/22). Staff identified in this incident was S1. LPA interviewed C1 while at the facility on 4/29/22 and requested facility documentation related to the alleged incident, including video footage. LPA also requested copies of S1's staff training and job application. LPA also discussed an incident report dated 4/21/22 where C2 was assaulted and was taken to the local hospital where C2 was discovered to have suffered a broken nose. LPA reviewed video footage of this incident while at the facility. S2 was present during this incident. LPA informed the agency that additional investigation is needed at this time for both incidents.

met_with: Paige Woodard, Deputy Program Director


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 8/18/22 at 2: PM and met with Paige Woodard, Deputy Program Director to finalize incidents related to a case management inspection that occurred on 4/29/22. LPA Hill advised Ms. Woodard that this investigation involved a grievance form that was received alleging that S1 "choked out" C1 during a restraint. LPA Hill informed Ms. Woodard that C1 was interviewed and C1 did state that they felt that they were unfairly treated by S1 during an incident where S1 restrained C1. C1 did not feel that S1 choked C1 on purpose but C1 did feel that during the one person restraint S1's arm moved to their neck area, choking C1. When LPA Hill interviewed S1, they stated that during the incident S1 didn't touch C1 any where near the neck and thereby could not have choked C1 as alleged. LPA Hill informed Ms. Woodard that the investigation is complete as there is no evidence that C1 was choked. This report concludes the investigation for this incident. There are no citations issued and the investigation is closed. LPA Hill also interviewed C2 related to another incident investigation initiated on 4/29/22 where C2 was taken to the emergency room due to a broken nose. LPA Hill reviewed incident reports previously obtained and after interviewing C2, is closing the investigation without citation as C2 indicates that this injury took place while playing basketball and denied being assaulted by another youth in care. C2 also indicated that they feel safe in the facility at this time. LPA Hill did discuss telephone use with the facility during this inspection and did remind Ms. Woodard that youth cannot be restricted from phone use nor can phone use be restricted to specific dates and/or times. LPA Hill does understand the complexity in trying to find appropriate times to meet this need given the volume of youth in care but did advise the facility to discuss and document appropriate phone times and days during Child and Family Team meetings and in the Needs and Services to ensure that no violation of personal rights occur. Exit interview conducted and document was provided via email.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Robyn Word made an unannounced case management inspection on 10/14/22 at 11: AM and met with Paige Woodard, Deputy Program Director to discuss an incident that occurred on 10/12/22.The incident is related to FC1 (see LIC811 dated 10/14/22) telling the staff he was in a relationship with his probation officer (PO) and made comments of sexual acts they perform together. LPA Word conducted an interview with FC1 and staff. FC1 stated that he did not make that statement. FC1 stated that he is never alone with his PO. FC1 stated that nothing inappropriate has happen between himself and his PO. The Program Director stated that the POs are generally not alone when on our campus meeting the youths. The Case Manager is present in most cases. Due to statements in interview the case management requires no future investigation. A copy of this report was provided to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Shoua Xiong conducted an unannounced inspection visit to the facility on 9/2/21 beginning at 12: PM. LPA met with Christopher Essary, Program Director , and explained the purpose of the visit was to conduct a Case Management regarding concerns that were discovered during an investigation. During the course of complaint investigations, LPA met and interviewed facility residents and staff members. During this investigation process, it was revealed during interviews with both residents and staff that the facility requires residents to remove their tennis shoes from their bedrooms and have it secured in a designated area in the lounge room. Consistent statements were made from interviewed staff members that this is done in order to prevent residents from going AWOL and for resident's safety. Consistent statements were also made that the shoes were then taken and locked into the closet. The facility is being cited for a violation of the Short Term Residential Therapeutic Program Interim Licensing Standards Version 3.1, Sections 87072(d)(6)(A) Personal Rights: ... the licensee shall ensure that each child is accorded the following personal rights: To be provided with and allowed to possess and use adequate personal items...which includes: Clothing items... The facility is also being assessed an Immediate Civil Penalty Fee of $250 on today's date for a repeat violation. Failure to correct the violation will also result in a continuing civil penalty fee of $100 per day for each day that the violation is not corrected. Exit interview conducted and a copy of this report along with appeal rights was given to Christopher Essary, Program Director.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Jean Stidman on 12/17/21 at 9;15am. During the inspection, LPA Jean Stidman met with Christopher Essary Program Director and inspected the facility inside and out. All files, medication documents and a medication count was also conducted on this date. LPA reviewed ten of child's records on site at the facility at 9:15am. LPA reviewed four staff personnel files on site at the facility at 9:15am. LPA interviewed four staff on site at 9;15am. LPA interviewed eight children currently taking psychotropic medications. Facility citation violation of California Code of Regulations, Interim Licensing Standards regulation 87068.3. Modifications to the Needs and Services Plan. Facility has not updated Needs and Services plans updated at least every 30 days for seven out of 10 clients files reviewed. Facility citation violation of California Code of Regulations, Interim Licensing Standards regulation 87075(c) Health Related Services Psychotropic medications shall be used only in accordance with authorization requirements specified in Sections 369.5(a)(1) and 739.5(a)(1) of the Welfare and Institutions Code and Section 87070(b)(11). Facility does not have court written authorization giving parental authorization for one clients psychotropic medication. Facility citation violation of California Code of Regulations, Health and Safety Code 1507.6(b)(2)(B) (vi) The facility is missing staff initials for several dates for six out of ten clients Psychotropic Medication Administration Records. LPA conducted exit interview with Christopher Essary Program Director at 5:30pm.. LPA provided the Summary Report to Christopher Essary, Program Director upon completion on this date

met_with: Christopher Essary Program Director


summary: Facility Evaluation - 2 deficiencies

raw_content:
Narrative:
On 2/17/ Licensing Program Analyst (LPA) Maignacia Villapudua-Soto conducted a Case Management Inspection for LPA Jean Stidman with Paige Woodward, Deputy Program Director. Facility failed to submit written reports of incidents by the next working day, the 24-hour reports and the full reports within seven days following the occurrence. The facility was informed of the issue via email from LPA Jean Stidman on 1/25/22. The facility failed to report incidents dated 1/23/22, 1/27/22, 1/30/22, 1/31/22, 2/5/22 and 2/26/22 until 1/25/22, 2/3/22, 2/4/22, 2/3/22, and 2/9/22 respectively. The facility is cited on the attached LIC 809D under the California Code of Regulations Title 22, Division 6, Chapter 1, 80061(b) Reporting Requirements. Facility failed to maintain coverage by direct care staff on 2/8/22 at 8:05am of at least one awake and on duty direct care staff present at the facility for every four children, or fraction thereof, present at the facility. An Incident Report regarding this incident was submitted on 2/14/22 by Paige Woodard, Deputy Program Director (DPD), who observed the incident. On 2/14/ LPA Stidman spoke with DPD by telephone. DPD stated eight clients were unsupervised upstairs as the only staff was downstairs supervising another client. The facility is cited on the attached LIC 809D under the Short-Term Residential Therapeutic Program, Interim Licensing Standards version 4, 87065.5(b)(1)(C) Direct Care Staff/Child Ratios. Refer to 809D for Title 22 deficiencies cited. Exit interview was conducted. A copy of LIC 809 willl be emailed to Deputy Director **Appeal Rights**

Deficiencies:
80061(b): 1
2
3
4
5
6
7Deputy Director will train head of service on reporting requirements and review the reports on a timely manner. Deputy Director will document and send LPA a copy of the training by 03/17/22.
8
9
10
11
12
13
14
87065.5: during the hours of 7 am to 10 PM: when there are five or more children present at the facility, there shall be at least one awake and on duty direct care staff present at the facility for every four children, or fraction thereof, present at the facility.

met_with: Paige Woodward, Deputy Director

title:
1
2
3
4
5
6
780061 Reporting Requirements 80061(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours.  In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.
** This requirement is not met as evidenced by

title:
1
2
3
4
5
6
787065.5 Direct Care Staff/Child Ratios 87065.5(b)(1)(C) In a facility with a licensed capacity of seven or more children, there shall be coverage by direct care staff as follows


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection to the facility on 5/20/22 to discuss a serious incident that took place in the facility 5/18/2022. LPA met with Paige Woodard, Deputy Program Director to discuss the incident. LPA Hill and Ms. Woodard discussed the incident that happened at the facility on 5/18/2022 that included C1 (see LIC811 dated 5/20/2022) being beat up by a group of youth while C1 was in their room. LPA Hill, Jodean Hall, Licensing Program Manager, Ms. Woodard, Galey Betzler, ROP Compliance Director, and representatives from San Bernardino County Probation all met on 5/19/2022 to discuss the incident via video technology. During this video conference, Ms. Woodard was able to share the video of the incident where it was observed that S1 left the dorm to make a phone call, leaving that wing of the dorm unsupervised for a period of approximately four minutes. In that time, two youth were observed to enter C1's bedroom and be in C1's bedroom for a few seconds, then the youth and C1 came out of the room. It appears that while the youth are in the hallway, words were exchanged amongst all the youth. C1 eventually returned to their bedroom and a few seconds later, three youth went into C1's room while one youth stayed in the doorway watching the door that staff had exited out of. LPA Hill conducted an interview with C1 via video technology on 5/19/2022. LPA Hill interviewed S1 on 5/20/2022 while at the facility. LPA also obtained additional documentation for staff and clients while at the facility. C1's account of events revealed that they were punched, hit and kicked repeatedly by the youth during both incidents. C1 allegedly called out for staff to assist but none responded to help C1. It was also noted that C1 reported not feeling well following the incident and that C1 had a headache but refused being taken for medical assessment. C1 was not seen or assessed until 5/19/2022. LPA Hill informed Ms. Woodard that the findings of the investigation reveal that the facility was not in ratio at the time of the incident in that there were 14 youth in the dorm and only three staff. There was another staff on the facility grounds supervising four additional youth in the dining area but that still left the facility out of ratio. At the time of the incident, there were 18 youth total living in the facility and this meant that the facility was required to have five staff present but there were only four. In this hallway, it was observed via video surveillance that there was only one staff for this hallway. During the interview with S1, S1 acknowledged that they were aware that six youth were assigned this area, in that hallway and that one additional youth had come from the youth lounge that was not assigned this area. As a result of the investigation of this incident, the facility is cited for violation of the Interim Licensing Standards Version 4, 87065.5(b)(1)(C): Direct Care Staff/Child Ratios and 87072(c): Personal Rights. Staff interviews, video surveillance review, and client interview demonstrate that staff did leave the dorm unattended for approximately four minutes allowing two fights to take place in the dorm. In addition, the evidence supports that the facility was out of compliance on this night by having only three staff in the dorm with 14 youth. In addition, the personal rights of youth were violated in that youth has a right to have a safe environment in which to live. By staff leaving their area of supervision without ensuring that additional staff was there to cover, youth was not accorded these personal rights. Facility was assessed civil penalties for a violation of the same subsection within the previous 12 months. Exit interview with Ms. Woodard and documentation provided on 5/20/2022.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection to the facility on 7/21/22 at AM and met with Paige Woodard, Administrator to discuss an incident. LPA Hill learned that a youth was assaulted (C1) by another youth (C2) (see LIC811 dated 7/21/22) on 6/24/22, after the youth returned to the dorm following breakfast, at approximately 7: AM. LPA reviewed camera footage and observed that C2 went into C1's room and a fight ensued. LPA observed that there are two staff present in the hallway - positioned at either end of the hallway. One staff was by the exit door (S2) and the other staff (S1) was near the restrooms with another youth, not involved in the incident. Review of the camera shows that S2 was standing in the hallway watching and observed C2 go into C1's room but did not react to this. S1 was seen to come down the hallway and stop in front of C1's room and observed an altercation taking place in the room between the youth. It is observed that the fight actually starts to spill into the hallways twice within seconds of one another but S2 who was standing in the hallway did not intervene. It is unclear if anything was said by S2 to stop the youth from fighting. It then appears that S1 motioned for a youth (C3) to go into the room to stop the youth fighting. C3 then emerges from the room following C2. S1 never entered the room to stop C1 and C2 from engaging or stopping the situation already in progress. Ms. Woodard states that C3, S2 and S1 were interviewed by her and it was reported that S1 did tell C3 to go in and stop the fight. As a result of review of this incident with Ms. Woodard, LPA Hill did cite the facility for 80065(j) Personnel Requirements as clients shall not be used as substitutes for required staff. During this incident, the cameras indicated that S1 told or motioned to C3 to go into C1's room to stop the fight happening in C1's bedroom. Exit interview was conducted and documentation was provided with appeal rights.

met_with: Paige Woodard, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 8/18/22 at 11: AM and met with Paige Woodard, Deputy Program Director to discuss an incident that occurred on 4/11/22. The incident is related to a S1 (see LIC811 dated 8/18/22) supervising youth in the facility dorm and while supervising, did leave his post in the dormitory leaving all youth in his direct care and supervision unsupervised for an undisclosed amount of time, while reportedly short in duration. In the time that the youth were unsupervised, C2 was able to enter C1's room and assault C1. This incident was also reviewed by the Ms. Woodard, LPA Hill and other staff from the agency via camera review. In review of the final incident report submitted to Licensing, S1 stated that the incident was observed by S1 but investigation and camera review shows that this was not possible as S1 left the youth unsupervised in the hallway for a short time. In light of this information, LPA did request that the agency update the reports and provide them to Licensing as this information documented is not accurate. LPA advised the agency that all incident reports need to be complete and accurate before submitting them to Licensing and placing agencies. LPA Hill also discussed ratios of staff to clients during this case management inspection as well. With the varied incident investigations and complaint investigations happening in recent months, it has come to the attention of Licensing that facility staff are not adhering to the ratios required by Interim Licensing Standards (ILS), specifically one staff to every four clients. LPA Hill was leaving the facility on 5/20/22 and observed that one staff left the dormitory with six clients, in violation of this regulation. LPA did advise Ms. Woodard of this observed violation via email on 5/20/22. In addition, while reviewing camera footage related to the various incidents in recent months, there were several occasions where staff were observed to be out of the required ratio. LPA did inform Ms. Woodard and Galey Betzler, Compliance Director during the camera reviews of the observed violations. Based on the review of footage provided and shown to LPA and information obtained during investigations related to complaints and incident reports, the facility is cited for violation of Interim Licensing Standards Section 87065.5(b)(1)(C) Direct Care Staff/Child Ratios as it was observed that during the incident on 4/11/22, S1 did leave youth unsupervised; on 5/20/ LPA Hill observed one staff leave the dormitory at approximately 6: PM with six youth; and there were observations noted during camera reviews with ROP staff that direct care staff were entering or exiting the dorm with five or six youth and only one staff. While S1 was provided a disciplinary report for leaving their post on 4/11/22, this and the other noted violations are violations of the same Interim Licensing Standards regulation as noted and the standards that the facility is required to adhere to ensure the health, safety and personal rights of the youth at all times while in the facility. Exit interview was conducted with Ms. Woodard and documents were provided to the facility via email.


facility_name: ROP EMANCIPATION HOME

summary: Complaint Investigation - Substantiated - 1 deficiency - 1 allegation

raw_content:
Investigation Findings:
13On July 21, 2021 at 12pm LIcensing Program Analyst (LPA) Donald Martin arrived at the above facility to deliver finidings from the above allegation. LPA met with Raven Morrow, Facility Manager. During the investigation, LPA met with staff and clients and reviewed documentary evidence pertaining to the allegation. Staff #1 stated that during the time the incident occurred, she was alone supervising 4 clients. The clients interviews also supported Staff #1's statement. There was photo of the neighbor's broken window and an invoice provided for the repairs to LPA. As a result, the allegation is Substantiated. Facility is being Cited for violation of 87065. Direct Care Staff/Child Ratio's (a) In a facility with a licensed capacity of six or fewer children, there shall be coverage by direct care staff as follows: (1) During the hours of 7 am to 10 pm, there shall be one awake and on duty direct care staff for every three children, or fraction thereof, present, at a minimum. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin 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 34-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, N. Continental Blvd. #290B FACILITY NAME: ROP EMANCIPATION HOMEFACILITY NUMBER: 198209644

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

Deficiencies:
87065.5: (1) 	During the hours of 7 am to 10 pm...one awake and on duty direct care staff for every three children, or fraction thereof...1
2
3
4
5
6
7Licensee is instructed to provide LPA proof of training on Supervision of Clients by submitting a sign off sheet after training is conducted.
8
9
10
11
12
13
14

met_with: Raven Morrow-Facility Manager

complaint_status: SUBSTANTIATED

title: Direct Care Staff/Child Ratio's (a) six or fewer children, there shall be coverage by direct care staff as follows


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Due to lack of evidence and inconsistent information obtained during the investigation, LPA determines that the allegation is Unsubstantiated at the this time meaning, although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove or disprove a violation occurred. There were no deficiencies cited at this time. Exit interview was conducted and appeal Rights and a copy of this report will be emailed to Raven Morrow, Facility Manager.

Investigation Findings:
13On June 18, 2021 at 10am Licensing Program Analyst (LPA) Donald Martin conducted a follow-up complaint inspection and spoke with Raven Morrow, Facility Manager and delivered findings from the above complaint allegation. During the course of investigating the allegation for staff hit a minor while in care, LPA conducted interviews and collected several documents pertaining to the investigation. Interviews and documentary evidence did not produce corroborating evidence to support allegation. LPA was presented with Doctors visit information that shows the client complained about a back injury prior to stating he was struck by staff. The Doctors visit after the incident was inconclusive. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin 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 34-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, N. Continental Blvd. #290B FACILITY NAME: ROP EMANCIPATION HOMEFACILITY NUMBER: VISIT DATE: 08/18/2021


raw_content:
Narrative:
Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or disprove that a violation occurred; therefore, the above allegation is Unsubstantiated. There are no deficiencies being cited at this time.

Investigation Findings:
13On October 28, 2022 at 1pm Licensing Program Analyst (LPA) Donald Martin arrived at the above facility. The Purpose of this visit is to deliver finding for the above allegations. LPA met with , Raven Morrow, Facility Manager and was allowed into the facility. During the course of investigating the allegations for facility staff provided alcohol to minor and facility staff are not properly supervising minors, interviews were conducted. The interview did not produce corroborating evidence to support said allegations. Interviews revealed inconsistent statements and no witnesses to suggest allegations occurred. There was no evidence that facility staff provided alcohol to a minor or that facility staff are not properly supervising minors. Child #1 recanted his story that staff provided alcohol to him. Staff was unable to supervise client due to allegation appearing to have occurred while client was on an approved mandatory outing. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin 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 34-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, N. Continental Blvd. #290B FACILITY NAME: ROP EMANCIPATION HOMEFACILITY NUMBER: VISIT DATE: 10/28/2022


raw_content:
Narrative:
There was no evidence that facility is not meeting the health care needs of the children, facility does not have complete personnel files, facility does not have complete children's files, children in care were not advised of their personal rights, and facility is not in good repair. The facility was inspected by The Department of Los Angeles County Probation which prompted the allegations. The facility made all necessary repairs and file updates according to my inspection. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or disprove that a violation occurred; therefore, the above allegation is Unsubstantiated. There are no deficiencies being cited at this time.

Investigation Findings:
13On October 28, 2022 at 12pm Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for to deliver findings to the above faclity. LPA met with , Facility Manager and was allowed into the facility. During the course of investigating the allegations for facility is not meeting the health care needs of the children, facility does not have complete personnel files, facility does not have complete children's files, children in care were not advised of their personal rights and facility is not in good repair, interviews were conducted, files were reviewed and documents were obtained. The interview did not produce corroborating evidence to support said allegations. Interviews revealed inconsistent statements and no witnesses to suggest allegations occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin 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 34-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, N. Continental Blvd. #290B FACILITY NAME: ROP EMANCIPATION HOMEFACILITY NUMBER: VISIT DATE: 10/28/2022

met_with: Facility Manager


raw_content:
Narrative:
Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or disprove that a violation occurred; therefore, the above allegation is Unsubstantiated. There are no deficiencies being cited at this time.

Investigation Findings:
13On October 28, 2022 at 12pm Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for to deliver findings to the above facility. LPA met with Charise Evans, Facility Manager and was allowed into the facility. During the course of investigating the allegations for staff did not prevent youths from engaging in altercations and staff is not providing a safe environment for youths, interviews were conducted. The interview did not produce corroborating evidence to support said allegations. Interviews revealed inconsistent statements and no witnesses to suggest allegations occurred. There was no evidence that staff did not prevent youths from engaging in altercations and staff is not providing a safe environment for youths. Child #1 refused to discuss with LPA the details of the altercation. No client interviewed expressed that they did not feel safe at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin 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 34-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, N. Continental Blvd. #290B FACILITY NAME: ROP EMANCIPATION HOMEFACILITY NUMBER: VISIT DATE: 10/28/2022

met_with: Charise Evans-Facility Manager


raw_content:
Narrative:
Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or disprove that a violation occurred; therefore, the above allegation is Unsubstantiated. There are no deficiencies being cited at this time.

Investigation Findings:
13On November 17, 2023 at 1:30pm, Licensing Program Analyst (LPA) Donald Martin conducted a follow up complaint inspection and spoke with Facility Manager, Charise Evans. The purpose of this inspection was to deliver findings for the above complaint allegation. During the course of investigation the allegation for Staff did not ensure that sharp objects were inaccessible to minor, interviews were conducted. The interviews did not produce corroborating evidence to support said allegations. Interviews revealed inconsistent statements and no witnesses to suggest allegations occurred. There was no evidence that Staff did not ensure that sharp objects were inaccessible to minor. Child #1 sustained the cuts while on elopement from the facility. Facility keeps the sharps in a lock box in the office and document when sharps are distributed and returned to staff for disposal. Child #1 refused to speak with LPA. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin 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 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: ROP EMANCIPATION HOMEFACILITY NUMBER: VISIT DATE: 11/17/2023

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


raw_content:
Narrative:
Confidential interviews, statements confirmed that S1 became intimately involved with C1 (former client) resulting in the birth of their child. Confidential statement revealed S1 and C1's relationship began after C1 left the ROP Emancipation Home. Statements further revealed S1's acknowledgement of violating ROP Emancipation Home policy and procedure (Anti-Fraternization Policy) as S1 was terminated in January 2024, for admitting to having a relationship with a former resident that resulted in the birth of a child. Based on confidential interviews and documentary evidence the preponderance of evidence standard has been met, and therefore the above allegation is Substantiated. The facility is cited per Health and Safety Code Persons prohibited from employment; dismissal or removal. The investigation including review of facility file/records, and confidential interviews of C1, S1, Program Manager, and contact with Department of Children and Family Services-Out of Home Care, revealed C1 resided at the facility from October 2021 to July 2022. S1 began employment with ROP Emancipation Home in March 2022 through January 2024. Information obtained from confidential interviews, revealed denial of sexual abuse by S1 towards C1. While statements disclosed confirmation of a sexual relationship between S1 and C1, statements maintain denial of C1 being underage or engaging in a sexual relationship or intimately involved while C1 resided in the facility. Confidential interviews revealed that S1 and C1 became intimately involved after C1 was discharged from the facility. Statements further contend that the intimate relationship between S1 and C1 was consensual. The Department's investigation determined, although the allegation may have happened or is valid, the allegation is not supported or proven by the evidence gathered. Therefore, the allegation that S1 sexually abused C1 while at ROP Emancipation facility, is determined unsubstantiated at this time. An exit interview was conducted, and a copy of this report was provided to the Facility Representative, Facility Senior Manager.

Investigation Findings:
13On August 27, 2024, at 11: AM, Licensing Program Analyst (LPA), Regina Martin conducted a subsequent complaint inspection to deliver findings concerning the above-mentioned allegation. LPA Martin met with Facility Manager and further spoke with facility Administrator by phone to inform the investigative outcome. The investigation was conducted by Community Care Licensing (CCL) Investigations Branch, Investigator Laura Garcia. On February 14, 2024, CCL received an allegation alleging that Staff (S1) engaged in a sexual relationship with a former resident resulting in staff becoming pregnant. The investigation including review of facility file/records, and confidential interviews of former client (C1) former staff member (S1), Program Manager, and contact with Department of Children and Family Services-Out of Home Care, revealed C1 resided at the facility from October 2021 to July 2022. S1 began employment with ROP Emancipation Home in March 2022 through January 2024. (Continued on page LIC9099-C) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Regina Martin 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 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: ROP EMANCIPATION HOMEFACILITY NUMBER: VISIT DATE: 08/27/2024

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: Facility Representative #1


summary: Facility Evaluation

raw_content:
Narrative:
Report Amended to change the facility Name On July 26, 2021, Licensing Program Analyst, LPA Donald Martin made an inspection visit to ROP Emancipation Home for the purpose of concluding a Case Management Investigation. LPA met with Raven Morrow, Facility Manager. The Department received notification from the Department of Children and Family Services requesting a follow up on a CAP put in place for the ROP facilities. Referral Number: 1355-1304-5004-1047667 which was investigated by LPA Regina Martin. The "Second Floor Interactive Supervision Policy" was put in place by ROP to be in compliance with ILS regulation 87088 (e)(2) which states: The following facilities shall maintain a signal system which meets the requirements specified in (e) and (f) below. Such system shall be used by children to summon staff during an emergency: (2) All facilities having separate floors and not providing full-time staff on each floor whenever children are present. During the investigation process, LPA reviewed ROP's Second Floor Interactive Supervision Policy and also walked around the facility. The Policy and home are in compliance at the time of this LPA's visit. No further incident has been reported. A staff re-training on interactive supervision was completed by staff and submitted to the department.


summary: Facility Evaluation

raw_content:
Narrative:
On November 19, 2021 at 10:30am Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for the purpose of conducting an Annual/Required inspection. LPA was met by Administrator, Raven Morrow, and allowed into the facility. The facility is licensed to provide care and supervision to six (6) children, ages 12 through 17, ambulatory only. This facility also provides services to Non-minor Dependents pursuant to W&I code 16501.1(C)(1).There are no bodies of water on the premises. LPA will conduct the facility inspection inside and out and review 3 client files on this visit. The home is set up as follows: This is a two story house with three (3) bedrooms, two (2) bathrooms, living room, staff office, kitchen/laundry area, dining area, and outdoor space. Living Room: There is adequate furniture which appears to be in good condition there is a sofa with a center table and a covered fire place. Next to the living room is a desk set up for clients to use with a computer. Dining Area: One table with five (5) chairs. Kitchen: There is a stove/oven with four (4) burners, all working at this time. There is a microwave and refrigerator/freezer. The food service in the home is adequate with perishable/nonperishable food supplies. There is a fire extinguisher mounted onto the wall. Trash can has a tight lid on. All cleaning supplies are kept locked in laundry area cabinet. The knives and medications are locked in the closet that is located under the staircase and made accessible only to employees supervising stored medications. Client files are also kept locked inside a file drawer in the kitchen. Laundry Area: Is located towards the back of the kitchen. There is a washer/dryer available. Staff Office: Is located upstairs. There are two desks with a desk chairs. The staff office is kept locked at all times. Bedroom #1: Is located downstairs. The room is equipped with two twin size beds. There are adequate drawers, closet space, and lighting in this room. Bedroom #2: Is located downstairs. The room is equipped with two twin size beds. There are adequate drawers, closet space, and lighting in this room. Bedroom #3: Is located upstairs. The room is equipped with two twin size beds. There are adequate drawers, closet space, and lighting in this room. Cont. 809-C Bathrooms: There are two (2) bathrooms. One (1) bathroom is downstairs and the other bathroom is located upstairs. The bathroom located downstairs is only used by the clients in care and the upstairs bathroom is used by both facility staff and clients. All bathrooms were checked and were in operating conditions. The faucets that are used by the children were tested and delivered hot water at a safe temperature range. There are no security bars on the windows. Outdoor Space: The entrance area and backyard to be free of debris and hazardous materials. There is an outdoor shed that is used for storage and the garage is used for clients therapeutic services and two freezers are kept inside to store extra food. The home was inspected and the following was observed: The facility is clean, safe, sanitary, and in good repair. Medicines, disinfectants, and cleaning solutions are inaccessible to children in care. No more than two (2) children share a bedroom. Children have comfortable mattresses, clean linens, blankets, and pillows which are all in good repair. Outdoor activity space is free of obstructions. The facility smoke detectors are in appropriate working order, fire extinguishers are properly charged and serviced. There are no weapons in the facility. Sharp knives are stored in a locked cabinet inside a locked box and inaccessible to children. Staff conduct a sharps count to ensure all sharp objects are returned and locked in the lock box. Adequate supervision is provided for children in care. Staff ensure three nutritious meals and snacks. Food supply is ample in the home. Children are accorded personal rights. All posting requirements were met. Children in care are not restricted in telephone use except by court order. There is a working telephone line available for clients to use. The home operates within capacity and limitations of license. Facility Van: Dodge Caravan, registration and insurance all current and up to date. The Van appears to be clean and in good working condition. The facility is in the process of being slightly renovated. The carpet was pulled up in the living room, two bedrooms have been painted and the third is scheduled to be painted on Monday. Note: Administrator was advised to send LPA notification when extensive work is being performed at the facility in the future. Review of Staff files and interviews will be conducted on the next visit. No deficiencies were found at the time of the visit. A copy of this report will be left with Raven Morrow, Administrator.

met_with: Raven Morrow-Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On December 2, 2021 at 11:30 am Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for the purpose of conducting an Annual Continuation Inspection. LPA was met by Administrator, Raven Morrow and allowed into the facility. LPA interviewed Staff, Client and reviewed Staff files during the visit. LPA also reviewed the Needs and Services Plans for each client. No deficiencies were found at the time of the visit. A copy of this report will be emailed to The Administrator, Raven Morrow.


summary: Facility Evaluation

raw_content:
Narrative:
On April 20, 2022 at 11am Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for the purpose of conducting an inspection of the Garage Area. LPA was met by Charisse Evans, Senior Coach and allowed into the facility. LPA inspected the garage area and noticed one large desk with four chairs and two smaller desks with one chair each. There was no signs of anyone using the garage as a living space. Senior Coach stated that the garage is only used for Therapy meetings. Staff was advised to add the staff office to the facility sketch. There were no deficiencies noted at the time of the visit. Nothing further to report at this time.

met_with: Charisse Evans-Senior Coach


summary: Facility Evaluation

raw_content:
Narrative:
On 04/20/2022 @ 1:30PM Licensing Program Analyst (LPA) Zena Phillips made an unannounced visit due complaint at different facility. LPA Phillips was greeted by Charisse Evans , Facility Manager who granted access to the facility. LPA Phillips conducted interview with Child #2. Exit interview was conducted and complaint report was left with Charisse Evans, Facility Manager .

met_with: Charisse Evans/Facility Manger


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Sethany Yem conducted a case management inspection on 5/3/23 at 11:30am 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, 5 out of Direct Care Staff and 5 out of 5 youth files were reviewed. 2 out of Direct Care Staff and 1 out of 5 youth were interviewed. (See the Confidential Names List, LIC 811, 5/3/23). The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, youth case plans, quarterly assessments, and crisis intervention 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. LPA Yem observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. 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 Administrator Raven Morrow.

met_with: Administrator Raven Morrow


summary: Facility Evaluation

raw_content:
Narrative:
On November 21, 2023 at 10am Licensing Program Analyst (LPA) Donald Martin arrived for the purpose of conducting an Annual/Random facility inspection. LPA was met by Facility Manager, Charise Evans an allowed into the facility. The facility is licensed to provide care and supervision to six (6) children, ages 12-17, ambulatory only. This facility also provides services to Non-minor Dependents pursuant to W&I code 16501.1(C)(1).There are no bodies of water on the premises. The home is set up as follows: This is a two story house with three (3) bedrooms, two (2) bathrooms, living room, staff office, kitchen/laundry area, dining area, and outdoor space. Living Room: All furniture is in good condition. There is 2 sofas with a center table and a covered fire place. Next to the living room is a desk set up for clients to use with a computer. Dining Area: One table with five (5) chairs. Kitchen: There is a stove/oven with four (4) burners, all working at this time. There is a microwave and refrigerator/freezer. The food service in the home is adequate with perishable/nonperishable food supplies. There is a fire extinguisher mounted onto the wall that has been recharged until 2024. Trash can has a tight lid on. All cleaning supplies are kept locked in laundry area cabinet. The knives and medications are locked in the closet that is located under the staircase and made accessible only to employees supervising stored medications. Client files are also kept locked inside a file drawer in the office. Laundry Area: Is located towards the back of the kitchen. There is a washer/dryer available. Staff Office: Is located upstairs. There are two desks with desk chairs. The staff office is kept locked at all times. Bedroom #1: Is located downstairs. The room is equipped with two twin size beds. There is drawers space, closet space, and lighting in this room. Bedroom #2: Is located downstairs. The room is equipped with two twin size beds. There is drawer space, closet space, and lighting in this room. Bedroom #3: Is located upstairs. The room is equipped with two twin size beds. There is drawer space, closet space, and lighting in this room. Cont. 809-C Bathrooms: There are two (2) bathrooms. One (1) bathroom is downstairs and the other bathroom is located upstairs. The bathroom located downstairs is only used by the clients in care and the upstairs bathroom is used by both facility staff and clients. All bathrooms were checked and were in operating conditions. The faucets that are used by the children were tested and delivered hot water at a safe temperature range. There are no security bars on the windows. Outdoor Space: The entrance area and backyard to be free of debris and hazardous materials. There is an outdoor shed that is used for storage and the garage is used for clients therapeutic services and two freezers are kept inside to store extra food. The home was inspected and the following was observed: The facility is clean, safe, sanitary, and in good repair. Medicines, disinfectants, and cleaning solutions are inaccessible to children in care. No more than two (2) children share a bedroom. Children have comfortable mattresses, clean linens, blankets, and pillows which are all in good repair. Outdoor activity space is free of obstructions. The facility smoke detectors are in appropriate working order, fire extinguishers are properly charged and serviced. There are no weapons in the facility. Sharp knives are stored in a locked cabinet inside a locked box and inaccessible to children. Staff conduct a sharps count to ensure all sharp objects are returned and locked in the lock box. Adequate supervision is provided for children in care. Staff ensure three nutritious meals and snacks. Food supply is ample in the home. Children are accorded personal rights. All posting requirements were met. Children in care are not restricted in telephone use except by court order. There is a working telephone line available for clients to use. The home operates within capacity and limitations of license. Facility Van: Dodge Caravan, registration and insurance all current and up to date. The Van appears to be clean and in good working condition. There no deficiencies cited at the time of the visit.


summary: Facility Evaluation

raw_content:
Narrative:
On 11/21/2023, at 9: AM, Licensing Program Analyst (LPA) Regina Martin conducted a Case Management - Incident inspection at ROP EMANCIPATION HOME and met with Charisse Evans, Facility Manager in response to a Special Incident Report submitted to Community Care Licensing (CCL) on 11/17/2023. The incident, reports in part, alleged neglect/lack of supervision and conduct inimical as a facility staff reportedly contributed alcohol and marijuana to the delinquency of minors. During this inspection, LPA Martin informed the incident has been referred to CCL Investigations Branch, Investigator Lorraine Patterson. Upon completion of the investigation, the investigation findings will be delivered and discussed. LPA Martin requested and/or obtained the following documents from subject Staff and Client files: Client Roster (obtained during visit), Personnel Report (Schedule) LIC500, facility Staff #1 job description, Date of Hire, Personnel Application, criminal record clearance, current contact information, last performance evaluation; training; past reprimands (if applicable), Client Needs and Services Plans for subject clients (see LIC811, dated 11/21/2023). Please submit requested documents to LPA Regina Martin at regina.martin@dss.ca.gov The incident requires further investigation. Upon completion, the Department's findings will be issued and discussed. There are no deficiencies cited per California Code of Regulations, at this time. Exit Interview conducted, and a copy of this report was left with Facility Manager .

met_with: Charisse Evans, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On December 8, 2023 at 2pm Licensing Program Analyst (LPA) Donald Martin arrived above facility. The purpose of this visit is the continuation of the Annual/Random facility inspection. LPA was met by Facility Manager, Katherine Machuca an was allowed into the facility. The facility is licensed to provide care and supervision to six (6) children, ages 12-17, ambulatory only. This facility also provides services to Non-minor Dependents pursuant to W&I code 16501.1(C)(1).There are no bodies of water on the premises. There are currently 2 clients at the facility. LPA will be reviewing staff and client files and interviewing staff and clients. LPA reviewed three client files and 3 staff files. The medication log and Allowance log were both up to date. Client and staff interviews were conducted. LPA advised Facility Manager, Katherine Machuca to send an email to LPA regarding an age exception for C2 and C4 who are 18yrs of age. Inspection is complete. There were no deficiencies cited at the time of the visit.

met_with: Katherine Machuca-Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On June 25, 2024, at 12pm, Licensing Program Analyst (LPA) Donald Martin initiated a Case Management Incident inspection in response to self-reported incident involving Client #1 (C1) death. LPA spoke with Administrator, Faaputu Vaafuti (S1). The self-reported incident report was submitted to Community Care Licensing (CCL) on June 24, 2024. The incident, occurred on June 22, 2024. C1 and C2 left the facility on June 22, 2024, at 12: PM on an unauthorized absence. Facility staff filed a missing person report for C1 and C2 with the Torrance Police Department. Facility staff received information on June 23, 2024, that C1 and C2 attended a pop-up carnival in Culver City, California and C1 was stabbed to death. Facility staff spoke with LAPD Pacific Division Officer Ramirez #36911 and confirmed C1 death. C2 returned to the facility on June 24, 2024, at 11: AM. During inspection LPA spoke with S1. LPA was informed S1 last spoke to C1 on June 22, 2024. S1 was notified of the incident from S2. S2 , while working the overnight shift was approached by C3 who was distraught. C3 stated he just received a phone call from C2 stating that C1 was just stabbed. Additionally, LPA was informed that S3 got information from C1's girlfriend who stated C1's last location was in the Palms area. This information was possibly disclosed by C3. Staff has notified all pertinent parties regarding both C1 and C2 and Incident is being investigated by LAPD Pacific Division Homicide Detectives. LPA requested the following information from Client #1's files: Placement Agreement, Intake Paperwork, Transitional Independent Living Plan (TILP), Case Management Notes, a copy of the police report, and a copy of Client #1's death certificate once the document is made available. This incident requires further investigation. A copy of this report was provided to Administrator, Faaputu Vaafuti. There were no deficiencies cited at this time.

met_with: Faaputu Vaafuti-Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Sethany Yem conducted a case management inspection on 9/10/24 at 12:10pm 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, 5 out of Direct Care Staff and 6 out of 6 youth files were reviewed. 2 out of Direct Care Staff and 2 out of 6 youth were interviewed. (See the Confidential Names List, LIC 811, 9/10/24). The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, and progress notes, 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. LPA Yem observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. 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 Administrator Faaputu Vaafuti.

met_with: Administrator Faaputu Vaafuti


summary: Facility Evaluation

raw_content:
Narrative:
On 7/22/25, Licensing Program Analyst (LPA) Reagan Cohen made an unannounced visit to the above facility for the purpose of a Case Management for Special Incident Report #1359317. LPA met with Program Manager (PM) Faaputu Vaafuti. During this visit, confidential interviews were conducted with staff and clients. LPA requested and received a copy of both an up to date staff drivers license and insurance/registration for the facility vehicle. LPA requested and received a copy of the staff and client roster. LPA observed and examined the facility vehicle. LPA observed and examined the intersection and site of the accident. LPA observed that the facility vehicle had a dash cam and requested a copy of the video. Facility requested it from the insurance and will provide a copy when able. LPA informed PM that further investigation is needed and LPA would continue to investigate and conduct more interviews. Exit interview was conducted, and a copy of this report was given to the program manager.

met_with: Faaputu Vaafuti Program Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 7/22/25, Licensing Program Analyst (LPA) Reagan Cohen made an unannounced visit to the above facility for the purpose of a Case Management for Special Incident Report #1359317. LPA met with Facility Manager Emily Kavea. During this visit, confidential interviews were conducted with staff. Facility Manager will follow up on getting LPA acess to dash cam and, one on one contact info, and drug test results. LPA informed FM that further investigation is needed and LPA would continue to investigate, conduct more interviews, and records review. Exit interview was conducted, and a copy of this report was given to the Facility manager.

met_with: Emily Kavea Facility Manager


raw_content:
Narrative:
There was no evidence that staff are not honoring minors rights to visitations/outings while in care. Documentary evidence explained the visitation guidelines for the facility. Each client signed and agreed to the visitation rules that were explained in a CFT meeting which include the facility staff, Social Worker, designated family members, therapist, client, etc. Confidential interviews did not produce evidence that facility is not adhering to these individual guidelines or having "blanket" guidelines that cover all clients. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred; therefore, the above allegation is Unsubstantiated. There are no deficiencies being cited at this time.

Investigation Findings:
13On November 6, 2025 2pm, Licensing Program Analyst (LPA) Donald Martin conducted a follow up complaint inspection and spoke with Facility Manager,Brittany Scott The purpose of this inspection was to deliver findings for the above complaint allegation. During the investigation LPA conducted confidential interviews and reviewed documentary evidence. The interviews did not produce corroborating evidence to support allegations. Interviews revealed inconsistent statements and no witnesses to suggest allegations occurred. There was no evidence to support that staff are conducting unreasonable searches on minors in care. Confidential interviews indicated that contraband usage spiked in the home which lead to increased searches in the faciilty. There was no evidence that the searches were a written daily part of the facility program. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin 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 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: ROP EMANCIPATION HOMEFACILITY NUMBER: VISIT DATE: 11/06/2025

met_with: Brittany Scott-Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Emelyn Sanchez P. and Andrew Upshaw on January 14, 2026 at 8:55am. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs Sanchez P. and Upshaw met with Faaputu Vaafuti, Administrator and inspected the facility inside and out. LPAs reviewed 0 of child's records and 5 of staff personnel files on site at the facility. LPAs reviewed 0 of child's psychotropic medications and medication records. LPAs interviewed 2 of staff on site to discuss the facilities policies and procedures of operation. LPAs interviewed 0 of children currently prescribed psychotropic medication. LPAs provided a copy of this licensing report to Faaputu Vaafuti, Administrator. No deficiencies are being cited at this time. LPA conducted exit interview with Faaputu Vaafuti, Administrator and a copy of the report was left at the facility.

met_with: Faaputu Vaafuti, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 9/3/25, Licensing Program Analyst (LPA) Reagan Cohen made an unannounced visit to the above facility for the purpose of a Case Management for Special Incident Report #1359317. LPA met with Facility Manager Brittany. On 7/16/ S2 was driving clients 4 clients and 2 staff to get there laundry done. After exiting the driveway, when turning the facility vehicle was involved in an accident where it his the back of another car. All staff and client testimonies stated that the other vehicle cut in front of the facility vehicle, and it was the other drivers fault. All staff and clients reported to being physically fine after the accident. No one requested medical attention. Shortly after the incident S2 was taken to get a drug test. The drug test stated that S2 tested positive for Marijuana during the incident. The facility stated that the test did not differentiate between psychoactive cannabis and non-psychoactive. Because of the positive drug test for S2, the facility is in violation of ILS 87065. Personnel Duties. See LIC 809-D. Exit interview was conducted, and a copy of this report and the appeal rights was given to the Facility Manager.

met_with: Brittany Scott Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
To Amend the LPA arrival date On July 21, 2021 at 12:30pm Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for the purpose of conducting a Case Management investigation. LPA met with Raven Morrow, Facility Manager. Brief Summary: On 07/08/ 2021, the Department received a Special Incident Report stating that on 07/06/2021 a Staff member left two 15 years old male clients and one 16 years old male client alone in facility van with keys while he used the restroom at a local park. Upon returning, the facility van and clients were gone. Staff searched perimeter of park, but van nor clients were found. Staff contacted Torrance Police Department to file police report. Additional staff also canvassed the neighborhood in search of van and clients. All clients returned to facility approximately three hours later. Upon arrival, clients stated no injuries were sustained while away from the facility. 16 years old male client was arrested due to becoming combative with Torrance Police Department officer. An Addendum pending for safe return of all residents and vehicle located. No further information provided. During the investigation process, LPA reviewed Special Incident Report #763271 and interviewed Facility Manager (FM) and Child #1. Statements were consistent that on July 6, 2021 at 2:45pm Staff #2 left 3 clients in a running van while he went to use the bathroom. Staff #2 came back to where the van was and noticed it was gone. After interviewing Child #1 he stated that the client who drove the van was Child #2The van was located downtown Los Angeles after the client driving crashed into another vehicle. No one was injured in the crash. Staff #2 was suspended that day and eventually terminated on July 19, 2021. A review of facility's personnel summary on July 21, 2021 indicates that all staff required to have a criminal record clearance have obtained the necessary clearances with DOJ, FBI and Child Abuse Response. Facility is being Cited for Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.

met_with: Facility Manager-Raven Morrow


summary: Facility Evaluation

raw_content:
Narrative:
On 4/22/ LPA arrived at the above facility for the purpose of conducting a Case Management Incident visit, to preform an IR Follow-Up regarding an incident where clients were rough housing and busted a window. LPA met with Senior Coach Counselor Brittany Scott and informed them of the Follow-Up. During the follow-up LPA interviewed involved staff and clients regarding the situation. All interviews stated that while the incident did happen, clients were horse playing and staff were discouraging the horse play. Clients shared that they were not angry at each other but just wanted to mess around and while staff was trying to discourage and break up the play they ignored it. All interviews shared that the clients were offered immediate medical attention but the clients declined. All interviews also shared that medical attention was also offered the following morning but again clients declined. Staff shared that the proper documentation and reports were made and submitted including to the clients Social Workers. Staff shared that the clients were talked to after regarding horse play and the consequences were reviewed of this type of activity to discourage any future incidents. Clients shared that they felt safe and healthy and declined the need for any medical attention or follow-ups. LPA observed the area where the incident happened and the replacement window that is already set up. LPA determined that the facility had the proper response to the situation discouraging and trying to de-escalate the horse play and offering medical attention and follow-ups after the incident, while also making the proper documentation and reports. Based on interview and records review evidence, the facility is not at fault and there is no deficiency citations. Exit interview conducted. A copy of this report was given to Senior Coach Counselor Brittany Scott.

met_with: Senior Coach Counselor Brittany Scott


facility_name: ROP HARBOR CITY HOME

raw_content:
Narrative:
review of medical records, facility internal investigation and review of related reports from the Los Angeles Police Department (LAPD) did not provide enough evidence to support allegation. Information provided by Client #1 to LAPD, Investigator Hector and facility staff show a pattern of inconsistency. Moreover, staff members working on the alleged date of the incident confirm no incidents occurred. Residents corroborate denial of witnessing alleged incident and agree that staff provide continual supervision and monitoring in the facility. Client #2 denied the allegation. There were no witnesses or documentary evidence to support or prove that the allegation occurred. As to claims of Client #3 being AWOL since August 2020, a review of records indicates on 08/21/2020, Client #3 left the facility without permission. At that time, staff followed procedures and AWOL Protocols were completed including, but not limited to, notifying required parties. Due to a lack of evidence, alleged lack of supervision leading to sexual abuse, and client AWOL cannot be substantiated. Therefore, it has been determined that the allegation is Unsubstantiated at this time meaning, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or disprove that a violation occurred. There were no deficiencies cited during the investigation. Exit interview conducted. A copy of this report and appeal rights was emailed to Facility Administrator.

Investigation Findings:
UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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

met_with: Tamia Tolson, Facility Manager


raw_content:
Narrative:
Child one was unable to produce the actual name the overnight staff that slept on duty. Due to lack of evidence and inconsistent information obtained during the investigation LPA determines that the allegations are Unsubstantiated at this time meaning, although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove or disprove that a violation occurred. There were no deficiencies cited at this time. Exit interview was conducted and appeal Rights and a copy of this report will be left with Raven Morrow, Facility Manager.

Investigation Findings:
13On August 18, 2021 at 12pm Licensing Program Analyst (LPA) arrived at the above facility to conduct a follow-up complaint inspection and spoke with Raven Morrow, Facility Manager and delivered findings for the above complaint allegations. During the course of investigating the allegations for staff not allowing resident to retrieve personal belongings, staff sleeping during shift, staff threatened minor and lack of supervision resulting in a minor having access to another minor's personal belongings, LPA conducted interviews. Interviews did not produce corroborating evidence to support allegations. Child #1 was a client at the facility between June 2020 and August 2020. The complaint was filed in march. Child #1 belongings were retrieved by someone from Orange County September 17, 2020. Clients said to be involved were no longer residents of the above facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin 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 34-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, N. Continental Blvd. #290B FACILITY NAME: ROP HARBOR CITY HOMEFACILITY NUMBER: VISIT DATE: 08/18/2021

met_with: Raven Morrow-Facility Manager


raw_content:
Narrative:
There were no deficiencies cited at this time. Exit interview was conducted and appeal Rights and a copy of this report will be left with Tamia Tolson, Facility Manager.

Investigation Findings:
13On September 29, 2022 at 12pm LIcensing Program Analyst (LPA) Donald Martin arrived at the above facility. The purpose of the visit is to deliver findings for a Complaint investigation. LPA met with Tamia Tolson, Facility Manager and was allowed into the facilty. During the course of investigating the allegations for staff are not providing adequate supervision to minors, LPA conducted interviews. Interviews did not produce corroborating evidence to support allegations. Clients said to be involved were no longer residents of the above facility. Due to lack of evidence and inconsistent information obtained during the investigation LPA determines that the allegations are Unsubstantiated at this time meaning, although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove or disprove that a violation occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin 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 34-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, N. Continental Blvd. #290B FACILITY NAME: ROP HARBOR CITY HOMEFACILITY NUMBER: VISIT DATE: 09/29/2022

met_with: Tamia Tolson-Facility Manager


raw_content:
Narrative:
There was no evidence that facility is not meeting the health care needs of the children, facility does not have complete personnel files, facility does not have complete children's files, children in care were not advised of their personal rights, and facility is not in good repair. The facility was inspected by The Department of Los Angeles County Probation which prompted the allegations. The facility made all necessary repairs and file updates according to my inspection. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or disprove that a violation occurred; therefore, the above allegation is Unsubstantiated. There are no deficiencies being cited at this time.

Investigation Findings:
13On December 16, 2022 at 12pm Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for to deliver findings to the above faclity. LPA met with Raven Morrow, Administrator and was allowed into the facility. During the course of investigating the allegations for facility is not meeting the health care needs of the children, facility does not have complete personnel files, facility does not have complete children's files, children in care were not advised of their personal rights and facility is not in good repair, interviews were conducted, files were reviewed and documents were obtained. The interview did not produce corroborating evidence to support said allegations. Interviews revealed inconsistent statements and no witnesses to suggest allegations occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin 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 34-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, N. Continental Blvd. #290B FACILITY NAME: ROP HARBOR CITY HOMEFACILITY NUMBER: VISIT DATE: 12/16/2022

met_with: Raven Morrow-Administrator


raw_content:
Narrative:
There was no evidence that staff made inappropriate comments about residents. There was no name of the actual staff involved provided. Staff interviewed denied the allegation. There was no evidence that staff do not follow menu. Menu was provided to LPA and reasons for meal substitution. Although Child #1 was injured and was involved in a physical altercation, there was no evidence that staff instigated the fight or caused the injury to Child #1. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or disprove that a violation occurred; therefore, the above allegation is Unsubstantiated. There are no deficiencies being cited at this time.

Investigation Findings:
13On February 2, 2023 at 10am Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for the purpose of delivering findings for the above complaint allegations. LPA was met by and allowed into the facility. During the course of investigating the allegations for, resident sustained injury while in care, youth engaged in physical altercation, staff make inappropriate comments about residents and staff do not follow menu interviews were conducted, files were reviewed and documents were obtained. The interview did not produce corroborating evidence to support said allegations. Interviews revealed inconsistent statements and no witnesses to suggest allegations occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin 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 34-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, N. Continental Blvd. #290B FACILITY NAME: ROP HARBOR CITY HOMEFACILITY NUMBER: VISIT DATE: 02/02/2023

met_with: Facility Manager


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
Facility cited for violation 84172 (5)(2) The licensee shall ensure that every child admitted to a community treatment facility is informed and afforded the personal rights as specified...To be free from physical, sexual, emotional, or other abuse, or corporal punishment. A copy of this report is being left with Administrator, Raven Morrow.

Investigation Findings:
13On February 2, 2023 at 9am Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for the purpose of delivering findings for the above complaint allegation. LPA was met by Administrator, Raven Morrow and allowed into the facility. During the course of investigating the allegation of staff spoke inappropriately to residents, interviews were conducted and documentation collected. Interviews determined that staff in fact did speak inappropriately to a client in care which is a violation of his personal rights. Staff #1 admitted to speaking inappropriately and did receive a write up and mandatory training. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin 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 34-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, N. Continental Blvd. #290B FACILITY NAME: ROP HARBOR CITY HOMEFACILITY NUMBER: VISIT DATE: 02/02/2023


raw_content:
Narrative:
There was no evidence that Facility staff member had a physical altercation with minor while in care. LPA collected several incident reports stating that Child #1 attacked several staff. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or disprove that a violation occurred; therefore, the above allegation is Unsubstantiated. There are no deficiencies being cited at this time.

Investigation Findings:
13On April 18, 2023 at 4pm Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for the purpose of delivering findings for the above complaint allegations. LPA was met by Facility Manager, Lupe Castro and allowed into the facility. During the course of investigating the allegations for facility staff member had a physical altercation with minor while in care. interviews were conducted, files were reviewed and documents were obtained. The interview did not produce corroborating evidence to support said allegations. Interviews revealed inconsistent statements and no witnesses to suggest allegations occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin 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 34-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, N. Continental Blvd. #290B FACILITY NAME: ROP HARBOR CITY HOMEFACILITY NUMBER: VISIT DATE: 04/18/2023

met_with: Lupe Castro-Facility Manager


raw_content:
Narrative:
There was no evidence that staff are not providing adequate supervision to minor in care. Staff followed elopement procedures and confiscated the packages sent to Child #1 before the client could get them in his possession. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred; therefore, the above allegation is Unsubstantiated. There are no deficiencies being cited at this time.

Investigation Findings:
13On September 6, 2024 at 12pm Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for the purpose of delivering findings for the above complaint allegations. LPA was met by Administrator, Faaputu Vaafuti and allowed into the facility. During the course of investigating the allegations for staff are not providing adequate supervision to minor in care, interviews were conducted and files were reviewed. The interview did not produce corroborating evidence to support said allegations. Interviews revealed inconsistent statements and no witnesses to suggest allegations occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin 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 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: ROP HARBOR CITY HOMEFACILITY NUMBER: VISIT DATE: 09/06/2024

met_with: Faaputu Vaafuti-Program Manager


raw_content:
Investigation Findings:
13On October 25, 2024 at 1:00 pm Kenrick Ellis, Licensing Program Analyst (LPA), conducted an unannounced visit to ROP Harbor City Home for the purpose of concluding a complaint investigation of the above allegations. LPA met with Lupe Castro, Administrator to discuss the investigations findings. During the investigation, LPA conducted confidential interviews with five staff members and two clients. LPA reviewed personnel Report (LIC500), client roster and administrator interviews of the alleged incident on July 23, 2024. The interviews conducted did not produce evidence to support the allegations. The interviews revealed inconsistent statements. Statements indicated that Staff 1 (S1) was not observed to punch Client 1 (C1) in the throat or speak to Client 1 (C1) inappropriately. C1 was observed by multiple staff members to not have any injuries on neck consistent with being punched. There were no witnesses, physcial or documentary evidence to support allegations. There were no deficiencies cited at time. Exit interview was conducted, and a copy of this report and appeal rights were printed and given to Lupe Castro, Administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Kenrick Ellis LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Lupe Castro, Administrator


raw_content:
Investigation Findings:
13On 4/28/25 at 11: AM Licensing Program Analyst (LPA) Reagan Cohen arrived at the ROP Harbor City Home and conducted an unannounced complaint inspection. LPA met with with Direct Care Staff (DCS) Faizon Morrow and deliverd the findings of the investigation for the above allegation. During the course of this investigation, LPA conducted confidential interviews, gathered documentation, and reviewed records. Interviews from clients and staff record that the event in question was a misunderstanding and all parties have apologized with no further hurt feelings. Records review shows that staff are up to date on training in de-escscalation and other practices to help with these situations. Based on the available information LPA gathered from interviews and observation, the preponderance of the evidence standard has not been met, therefore the allegation of "Staff do not treat minor(s) with respect." is found to be unsubstantiated. There were no deficiencies cited. An exit interview was completed, and a copy of this report was given. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Reagan Cohen LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Faizon Morrow Direct Care Staff