summary: Facility Evaluation

raw_content:
Narrative:
On 3/20/25, Licensing Program Manager (LPM) Hillary Hall and Licensing Program Analyst (LPA) Bianca Mendez arrived unannounced at the facility and met with Bob Phillips, Administrator. The purpose of the visit was to conduct a Required Bi-Annual Inspection of the facility. The last Bi-Annual inspection for the facility was on 6/5/2023. LPM and LPA utilized the CARE Tool to complete the inspection. LPM/LPA conducted an inspection of the physical plant, and checked for all necessary requirements. The facility is clean, safe, and sanitary. Facility provides a visitation room and all cleaning chemicals are stored away out of reach. The facility maintained an acceptable room temperature. The facility has five offices for staff. LPM/LPA observed the proper postings including: facility license, complaint hotline, and emergency disaster plan. The restrooms for clients and staff were clean. Smoke alarms were in working order, fire extinguishers were current, and a first aid kit was fully stocked. Evacuation drills for the facility were completed quarterly. LPM/LPA observed client files were stored electronically and in paper form. Electronic files had password protection. Paper files were in a locked cabient. The facility has no outstanding fees. The facility has Non-Minor Dependent clients and zero minor clients. Clients all live in remote site apartments. No client resides more than two hours from the facility. The facility employs Case Managers, and one Administrator. Continued on 809C Continued from LPM/LPA reviewed three case manager files. Case manager files had completed criminal record clearances and met minimum education and experience qualifications. LPM/LPA interviewed three case managers. Case managers were missing training on policies regarding law enforcement contact and sexual and reproductive health. LPM/LPA reviewed five client files. One client was missing signed agreement for discharge and removal policies and Technical Violation 9102 was provided. Client files had current Needs and Service Plans, signed by the client and placing agency. One citation given on this date per Interim Licensing Standards 86065(f)(3,4). A signed copy of this LIC-809, LIC-809C, and LIC-809D report was provided to the Administrator. An exit interview was conducted. Appeal rights were provided *Date on 809 is incorrect as inspection occurred on 3/20/25

met_with: Bob Phillips, Administrator


state: CA

facility_name: KRISTA FOSTER HOMES THPP/THP+FC

summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
During the complaint investigation into the allegation: THP/THPP staff mismanaged client's funds, interviews and records reviewed were consistent. All five interviews reported that during a budget audit, errors were found indicating funds were inaccurate on the client's budget sheet and the client was overpaid. LPA reviewed budget sheets which indicated the dates and amounts where errors were discovered. The agency admitted to the finance errors and the staff who made the errors is no longer with the agency. Based on LPA's interviews which were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. One citation is being issued for violating Interim Licensing Standards: Section 86226(c)(2)(B) SAFEGUARDS FOR CASH RESOURCES, PERSONAL PROPERTY, AND VALUABLES (c) If the cash resources, personal property, and valuables of a nonminor dependent are entrusted to the licensee, these items shall be safeguarded as specified in this subsection. (2) The licensee shall: (B) Maintain accurate records of the cash resources, personal property, and valuables belonging to a nonminor dependent. A signed copy of this LIC-9099 report, the LIC-9099C, and LIC-9099D were provided to the facility. An exit interview was conducted. Appeal rights were provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Lyta Vue arrived unannounced at the facility on this date for the purpose of delivering findings for the complaint investigation. LPA met with Administrator Bob Phillips. LPA Vue conducted the complaint investigation. LPA initiated the investigation with the facility on 03/06/26 and met with Administrator Bob Phillips. During the course of the investigation, LPA interviewed one (1) client, one Administrator, two (2) Case Managers, (1) additional Agency Staff, and one (1) County Social Worker. LPA reviewed records including LIC 500 with staff schedule, client's most recent Needs and Service/IPP, Agency Social Worker case notes, CFT notes, and client cash values/budget sheet. LPA also reviewed county records. Report continued on 9099c SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Hillary Hall LICENSING EVALUATOR NAME: Lyta Vue 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 25-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CHICO - RESIDENTIAL, COHASSET RD., STE. FACILITY NAME: KRISTA FOSTER HOMES THPP/THP+FCFACILITY NUMBER: VISIT DATE: 03/26/2026

report_type: Complaint Investigation

met_with: Administrator Bob Phillips

complaint_status: SUBSTANTIATED


facility_name: LEADING PURPOSE, INC

summary: Facility Evaluation

raw_content:
Narrative:
On November 1, 2022, at 9:00am, Licensing Program Analyst (LPA) Charmaine Linley, conducted a pre-licensing inspection for a change in relocation from Chandon Laguna Niguel, CA 92677 to the above facility address. LPA toured the office with Elizabeth Urenda, Administrator. The office consists of a three storied office building, which is convenient to the public. The building includes a front desk, lobby area, multiple offices, and six conference room. The office is on the second floor of the office building. The Administrator provided a copy of the lease, as well. Emergency Disaster Plan, Personal Rights, Foster Care Ombudsman phone number will be posted in a prominent area for participants to view. The Administrator will take a picture and send to the LPA once the forms are posted. License will be posted as soon as it is issued. Participants files are locked in file cabinets in the office. Staff files are locked in file cabinets in the office. Telephones, computers, fax and copying machines are operable. The bathrooms are located outside the suite. Fire extinguishers are current, there are fire sprinklers, smoke detectors, and carbon monoxide detectors located in each office. A complete first aid kit is readily accessible and located downstairs in the lobby at the front desk. The facility has demonstrated compliance with Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted, Due to printer malfunction, a copy of this report will be emailed to Elizabeth Urenda, Administrator.

report_type: Facility Evaluation

visit_type: Prelicensing

met_with: Elizabeth Urenda, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On February 7, 2023 at 10:10 am, Licensing Program Analyst (LPA) Charmaine Linley made an unannounced post-licensing visit. The purpose of this inspection was to conduct an unannounced post-licensing inspection for a Transitional Housing Placement Program (THPP) for Non-Minor Dependents (NMD). LPA toured the office with Elizabeth Urenda, Administrator. The office consists of a three storied office building, which is convenient to the public. The building includes a front desk, lobby area, multiple offices, and six conference room. The office is on the second floor of the office building. The Emergency Disaster Plan, Personal Rights, Foster Care Ombudsman phone number are posted in a prominent area for participants to view. Participants files are locked in file cabinets in the office. Staff files are locked in file cabinets in the office. Telephones, computers, fax and copying machines are operable. The bathrooms are located outside the suite. Fire extinguishers are current, there are fire sprinklers, smoke detectors, and carbon monoxide detectors located in each office. A complete first aid kit is readily accessible and located downstairs in the lobby at the front desk. Currently the THPP has fifteen NMD's placement's and eight remote site apartments. The remote apartments were all within two hours of the administrative office. LPA reviewed three NMD files. The files were stored in locked cabinets within the Director's office. LPA also reviewed all staff files which was a total of three. The staff files were in a locked cabinet in the Administrator's office. The facility is being cited for Title 22, Division 6 regulations, Health and Safety Codes 1565, and Interim Licensing Standards 86275. The facility has been issued (2) type A and (15) type B citations. Please refer to LIC 809(d). An exit interview was conducted, Due to printer malfunction, a copy of this report, 809(d)'s, LIC 811, and appeal rights will be emailed to Elizabeth Urenda, Administrator.


summary: Facility Evaluation - 4 deficiencies

raw_content:
Narrative:
On July 22, 2024, at 9:30 am Licensing Program Analyst (LPA) Charmaine Linley made an unannounced visit to the facility. The purpose of this inspection was to conduct a Random/ Annual Inspection for the Transitional Housing Placement Program (THPP) for Non-Minor Dependents (NMD). LPA toured the office with Andrew Castillo, Program Director. The office consists of a three storied office building, which is convenient to the public. The building includes a front desk, lobby area, multiple offices, and six conference rooms. The office is on the second floor of the office building. The Emergency Disaster Plan, Personal Rights, Foster Care Ombudsman phone number are posted in a prominent area for participants to view. Participants files are locked in file cabinets in the office. Telephones, computers, fax and copying machines are operable. The bathrooms are located outside the suite. Fire extinguishers are current, there are fire sprinklers, smoke detectors, and carbon monoxide detectors located in each office. A complete first aid kit is readily accessible and located downstairs in the lobby at the front desk. Currently the THPP has sixteen NMD's placed and ten remote site apartments. The remote apartments were all within two hours of the administrative office. LPA reviewed three NMD files. The files were stored in locked cabinets within the Director's office. LPA was unable to review staff files as the Facility Administrator had the employee files located at their residence. LPA reviewed the Personnel Roster and Guardian to ensure that staff had a criminal record clearance, record review indicated that Staff #1 (S1) and Staff #3 (S3) have clearances that were pending and Staff #2 (S2) was not listed on the Guardian website. LPA Linley requested copies of any supporting documents the facility may have and what they provided was incomplete it was only the DOJ clearance. The facility was reminded to send LPA an updated LIC 500 with all individuals associated to the facility and to send LPA a copy of the client roster when there are changes to the roster. *** The facility is being cited for violations of the Title 22, Division 6 regulations, California Code of Regulations 86019(e) Criminal Record Clearance, three individuals were working at the facility and did not have a complete Criminal Record Clearance, 86066(a) Personnel Records, three staff members (S1-3) did not have their personnel files available to review, 86030.5(a), Identification of Transitional Housing Placement Program Participant Living Units, three units did not have a Certificate of Compliance, 86068.3(b), Modifications to Needs and Services and Transitional Independent Living Plans, Client #2 (C2) did not have any dates listed on their Needs and Services Plan and the Authorized Representative did not sign off on the Needs and Services Plan, 86069(a), Participant Medical Assessments, Clients 1-3 (C1-3) did not have written medical assessments or documentation of denial of the medical assessment, and Health and Safety Code 1565(b) Other Provisions, four out of four staff members did not have training on the emergency/disaster plan and shift responsibilities. Please refer to LIC 809(d). An exit interview was conducted, Appeal rights were reviewed. Due to printer malfunction, a copy of this report, 809(d)'s, LIC 811, and appeal rights were emailed to Elizabeth Urenda, Administrator and Andrew Castillo, Program Director.

Deficiencies:
86019(e): Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility
86066(a): Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information
86068.3(b): Deficient Practice Statement
1
2
3
4Based on record review, the licensee did not comply with the section cited above in Client #2 did not have the dates listed or the Authorized Representative signature on their Needs and Services plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2024
Plan of Correction
1
2
3
4
86069(a): Deficient Practice Statement
1
2
3
4Based on record review, the licensee did not comply with the section cited above in three out of three clients did not have a written medical assessment of the participant, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2024
Plan of Correction
1
2
3
4

visit_type: Annual

met_with: Andrew Castillo

title:
Modifications to Needs and Services and Transitional Independent Living Plans

(b) The licensee shall ensure that each participant's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the participant's file.

This requirement is not met as evidenced by

title:
Participant Medical Assessments

(a) 	Prior to or within 30 calendar days following the acceptance of a participant, the licensee shall obtain a written medical assessment of the participant, as specified in Section 80069(b), which enables the licensee to determine his/her ability to provide necessary health related services to the participant. The assessment shall be used in developing the Needs and Services Plan.

This requirement is not met as evidenced by


facility_name: LEADING PURPOSE, INCORPORATED

summary: Facility Evaluation

raw_content:
Narrative:
On May 3, 2021 at 10: AM, Licensing Program Analyst (LPA) Anastasia Flores met with Leading Purpose, Program Director, Elizabeth Urenda via tele-visit in regard to an application for a capacity increase for a Transitional Housing Placement Program (THPP) for Non-Minor Dependents. The purpose of the visit is to conduct an inspection for a capacity increase for the apartment located at Windridge Apartment, Hidden Hills Road, Laguna Niguel, Ca. 92677. The apartment consists of a living room, two bedrooms, kitchen area, laundry room and each bedroom have a patio accessible by a sliding glass door. The apartment has ample parking space for the residents. The bedrooms are all furnished with two twin size beds, dressers, closets and clean linens. The following items were discussed: LPA advised that this pre-licensing report for a capacity increase. Facility representative will be notified when the capacity increase has taken affect. Facility will be licensed for a capacity of 3 clients. Facility accepts only ambulatory clients. It was discussed the possibility of expansion for the facility license in the future. An exit interview was conducted with facility representative and report was emailed to Elizabeth Urenda for signature. A signed copy of the report will be in facility file.

visit_type: Case Management

met_with: Elilzabeth Urenda


summary: Facility Evaluation

raw_content:
Narrative:
On May 11, Licensing Program Analyst 's (LPA's) Toni Castillo and Darlene Oseguera, arrived at the agency for the purpose of conducting an unannounced post annual licensing inspection for the agency's Transitional Housing Program (THP) LPA's met and inspected the facility with Program Administrator Elizabeth Urenda. Facility utilizes apartment complex housing model. The agency currently has 5 apartments designated for THP+ NMD. There are 10 non minor dependents (NMD) youth who are currently in placement with the agency. LPA's conducted an inspection of the agency. Files are located in locked file cabinets within a locked office. There are no physical plant deficiencies. Staffing: The agency employs the following assigned staff under the THP program. Program Administrator, Elizabeth Urenda and Case Manager Melissa Sandoval. LPA's received updated participant and certified apartment information. Current Personnel Report (LIC 500) and client roster. Staff files were unavailable for review. However LPA's verified Criminal Background and Child Abuse Clearances which are complete and current for all employees. LPA's reviewed 10 non minor dependent files. During client file review, LPA's observed 3 of 10 client files (C1, C2. C3) were missing client and authorized representative signatures on the Needs and Service Plan and 6 out of 10 client files were missing the needs and service plan for C4, C5, C6, C7, C8 and C9. Therefore, the facility is cited under the Non-Minor Dependent regulations, section 86168.3 (f) Needs and Service Plan.The facility is also cited due to having no staff files located at facility for review. An exit interview was conducted and a copy of this report , deficiencies with appeal rights was provided to Program Administrator, Elizabeth Urenda.

met_with: Program Administrator Elizabeth Urenda


summary: Facility Evaluation

raw_content:
Narrative:
On October 7, 2022, at 10:00AM Licensing Program Analyst (LPA) Charmaine Linley conducted an announced pre-licensing inspection with Administrator, Elizabeth Urenda, and was given a tour of the Remote Site Model home located in Costa Mesa. This is a single site facility that is moving over from the Laguna Niguel single site facility. The home is a single story with three bedrooms and two bathrooms. The facility is licensed to have a capacity of six ambulatory clients. The residence has a desk, a large living room, and a recreation room that leads outside to the backyard. The yard also has additional chairs for sitting. The kitchen is equipped with working appliances and stocked with eating utensils, cups, glasses, plates, bowls and dishes and pans for food preparation. The kitchen has a table to eat at. The facility files (clients files and staff files) are going to be held at the corporate office in Irvine. There is ample parking for residents and staff. The garage will hold a washer and dryer for the clients, the washer and dryer has been ordered, and is waiting to be delivered. The facility has ample storage space in the garage. The garage will be emptied prior to accepting clients. The windows had blinds for privacy. The fireplace has been capped and is non-operable, which does not require a barrier at this time. There is a fire extinguisher in the kitchen and the garage. Bedroom 1 has one twin size bed, one dresser, and one closet. The bedroom does not have a mattress as a client in another location will be moving to the facility and will be bringing their mattress with them. At this time, there is only one bed in bedroom one with the capacity to add in another bed to allow two clients to reside in the bedroom. Bedroom 2 has two twin sized beds, two dressers, and a closet. Bedroom 3 has two twin size beds, two dressers, and a closet. All bedroom windows had blinds for privacy. No more than two clients will share any of the bedrooms. *** Prior to clients moving, the facility will obtain a working telephone line and send the invoice of service to LPA Linley. The facility will send photos of the washer, dryer, TV in living room, and pictures of the debris removed from the garage and backyard. Prior to clients moving in, the facility will send an updated LIC 610 form and any other forms with the updated single site address. The facility will post a copy of the license, personal rights, and the contact information for Community Care Licensing in the facility. The facility meets the Regulatory requirements and is ready for licensure at the conclusion of the visit. Exit interview conducted. A copy of this report was emailed to the Administrator and a copy will be placed in the facility file.

met_with: New Single-Site Facility


facility_name: LIVING ARROWS

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove the alleged violations occurred. The Department has decided that the allegation is unsubstantiated but if additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies to be cited at this time. Exit interview conducted and a copy of this report was left at the facility with Angelique Rangel, Administrator.

Investigation Findings:
13On June 29, 2022 at 10: Am., Licensing Program Analyst (LPA), Kuliema Calloway and Licensing Program Manager (LPM), Kevin Sauk arrived at the facility to deliver the findings of the complaint investigations conducted by LPA Enrique Hernandez. LPA and LPM met with Angelique Rangel, Adminstrator and discussed the investigative findings. During the investigation process, confidential interviews revealed that no one has seen any clients being sexually inapproapriate with one another. Although one statement stated otherwise, after the confidential interview the allegation was denied. The social worker has no concern with the facility and was never informed by any of the participants about the allegation. Continued on LIC C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Kuliema Calloway 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 31-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, VENTURA BLVD., STE. WOODLAND HILLS, CA FACILITY NAME: LIVING ARROWSFACILITY NUMBER: VISIT DATE: 06/30/2022

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

met_with: Angelique Rangel, Administrator

complaint_status: unsubstantiated


raw_content:
Investigation Findings:
13On 12/14/22, at 1:10pm, Licensing Program Analyst (LPA) Nancy O'Connell made an unannounced inspection to the above facility for the purpose of concluding the investigation on the above allegations and deliver the findings. LPA spoke with the office assistant and together, discussed the investigative findings. On 8/2/22, the Department received a complaint reporting allegations related to neglect and lack of supervision of transitional aged youth residing in Transitional Housing Placement Program. During the course of investigation, record reviews and interviews were conducted in order to determine findings of allegations. Regarding the provision of supervision of residents in care, record reviews conducted reflect that the licensee maintained the required staffing coverage during the assigned hours within the program. Further review reflects that emergency procedures are established within the program and made available to residents. Upon interview of staff and residents, it was confirmed that case management services are provided on a weekly basis, thereby providing residents with access to support and the opportunity to report concerns and obtain support from staff. Lastly, needs and services plans were reviewed and demonstrate the incorporation of mental health service goals for each resident. Due to the age of residents, all mental health services remain voluntary. There are no deficiencies to be cited at this time. A copy of this report was reviewed with the staff and due to technical difficulties, a copy of the report was emailed to the facility administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Nancy O'Connell LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

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

met_with: Kelly Kennedy, Office assistant


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
to client records, and has operated in the capacity of an employee, while making executive decisions on behalf of the facility management staff. Based on LPA observations and interviews which were conducted along with record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. According to California Code of Regulations, Title 22, one deficiency is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to the office administrator upon exit.

Investigation Findings:
13On March 16, 2023 at 3:00pm, Licensing Program Analyst (LPA) Nancy O'Connell made unannounced inspection to the above-listed facility for the purpose of concluding the investigation on the above allegations and deliver the finding. LPA O'Connell met with the Office administrator and discussed the investigative finding. On 1/25/23, the Department received a complaint alleging there was an uncleared adult on premises interacting with participants. During the investigative process, LPA O'Connell conducted confidential interviews with all relevant parties and collected information on the above allegation. After reviewing all the statements and the information obtained, the above allegation is supported, as the confidential interviews confirmed that P1 has been in the facility office, maintained access Continued on LIC9099C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Nancy O'Connell 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 31-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, VENTURA BLVD., STE. WOODLAND HILLS, CA FACILITY NAME: LIVING ARROWSFACILITY NUMBER: VISIT DATE: 03/16/2023

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

met_with: Kelly Kennedy, Office Administrator (OA)


raw_content:
Narrative:
Based on the documentary evidence, interviews, and statements obtained during the investigation process, LPA was unable to determine if the above said allegations occurred therefore the allegations are determined to be unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. There are no deficiencies to be cited at this time. Exit interview was conducted and a copy of this report was left with the facility bookkeeper.

Investigation Findings:
13On 12/20/2023 at 09: Licensing Program Analyst (LPA) Jhane Haynes made an unanounced follow up visit to Living Arrows for the purpose of concluding the investigation and deliver findings on the above allegations. LPA met with Bookkeeper (BK) Alaina Upthegrove in leui of FA's absence and together discussed the investigative findings. During the investigation LPA Phillips interviewed and accounted for all available relevant parties; and gathered pertinent information regarding the allegations. Staff denied the allegations listed above and reported no client information was being shared with former staff. Confidential interviews revealed residents have not been charged fees after relocating. Interviews conducted and documentary evidence, stipend log, email correspondence, and program policy regarding clients moving out the information gathered did not produce corroborating evidence to support the allegations. (Continued to LIC9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Jhane Haynes 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 31-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION WOODLAND HILLS S.Ro, Ventura Blvd., STE. WOODLAND HILLS, CA FACILITY NAME: LIVING ARROWSFACILITY NUMBER: VISIT DATE: 12/20/2023

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

met_with: Alaina Upthegrove Bookkeeper(BK)


raw_content:
Narrative:
It was reported that the facility failed to provide medical assistance to C1 during the incident involving Client #2 (C2). At the time of the verbal altercation between C1 and C2. Staff 1 (S1) was present and was trying to de-escalate the situation between them. C1 had already called 911 before S1 contacted the paramedics after C2 threw a can of aerosol at C1's stomach. Statements indicated that there had been no prior incidents between C1 and C2. Following this incident, C2 was removed from the home for violating the participant manual. The Department has decided that the allegation is unsubstantiated but if additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies to be cited at this time. Exit interview was conducted and a copy of this report will be emailed to the Facility Administrator.

Investigation Findings:
13On 11/8/2024 at 11:15am Licensing Program Manager (LPM) Enrique Hernandez made an unannounced inspection to Living Arrows to conclude the investigation on the above allegations and deliver the findings. LPA spoke with Facility Administrator Marylou Escoto and together discussed the investigative findings. During the investigative process by Licensing Program Manager (LPM) Enrique Hernandez, all relevant parties were accounted for. Based on all of the interviews conducted, the Department has concluded that the above allegations to be Unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Supporting evidence includes the following: Although the facility could have improved communication with Client #1(C1) regarding who would provide transportation for them, there needed to be better communication regarding C1's transportation to their baby shower.C1 changed their mind about who would take them, contributing to the confusion. Continue on LIC9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Enrique M Hernandez 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 31-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, VENTURA BLVD., STE. WOODLAND HILLS, CA FACILITY NAME: LIVING ARROWSFACILITY NUMBER: VISIT DATE: 11/08/2024

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


summary: Facility Evaluation

raw_content:
Narrative:
On July 29, 2021 at 9:00am Licensing Program Analyst (LPA) Enrique Hernandez made an unannounced visit inspection to Living Arrows THPP Administrative Office located at E Main Street, #116, Ventura, CA 93001 for the purpose of conducting an Annual/Required Inspection. LPA met with CEO Kris Hart who granted access to the Administrative Office and together toured the office. The office building and is set up as follows: The administrative office Suite #116 accommodates only THPP staff and consists of entrance with a code to get into the office. LPA observed a station with a sign in sheet and temperature check. The office is a two-room office with a bathroom in good working order at the time of the inspection. The building is equipped with a large conference room that can be used for meetings or training to maintain social distance. The main office space consists of two desks and chairs and a small side table with informational packets for clients. The second room is an attached conference room available with two desks and two computers licensee states is available to conduct private interviews and a small group of training. Staff and client records are maintained in the Administrative Office inside locked cabinets. All posting requirements were met. The facility is licensed to provide Transitional Housing Placement plus Foster Care (THP + FC) and Non-Minor Dependents (NMD) to 74 participants ages eighteen (18) through twenty-one (21). There are currently four (4) participants in placement in the Ventura County. Facility has hired Social Workers (1 per 12 participants) and Social Worker Supervisor (1 per Social Workers). The facility is currently operating within staff ratio. Continue on LIC809-C A review of staff records on 7/28/2021 indicates that all individuals who require background checks have received criminal record and child abuse index check clearances or exemptions. Except for two people (Shannon Dobler and Ashley Rufener). CEO stated that they are not currently working until they get cleared. LPA Hernandez together with THP CEO and (Administrator/ Case management) conducted a collateral inspections (see 812's dated 7/29/2021) to the following remote site to ensure compliance to Title Regulations. Due to time constraint LPA Hernandez will return and continue with the annual inspection to be able to review reviewed staff records and client records. There were no deficiencies observed or cited during today's inspection. Exit interview was conducted and a copy of this report was left with the administrator of the facility whose signature on this form confirm receipt of this document.

met_with: Licensee


summary: Facility Evaluation

raw_content:
Narrative:
On 09/09/2021 at 9:15am, Licensing Program Analyst (LPA) Enrique Hernandez conducted an unannounced inspection, at the above-said facility, for the purpose of conducting a Case Management Annual Continuation Inspection. LPA was met by the Facility Administrator Angelique Rangel and Kelly Kennedy and CEO Kris Hart, who granted access into the Administrative Office LPA Hernandez interviewed and reviewed three staff files (S1, S2, and S3) LPA Hernandez conducted the file review for six clients (C1, C2, C3, C4, C5, and C6 [See Confidential Names form (LIC811), dated 09/09/2021, for names.] During the file review of the staff LPA also observed that the job duties for two staff were not in their file. Also during the client's file review LPA observed and was told by the Administrator Angelique that they do not conduct a examination for communicable tuberculosis. The administrator stated that they test participants for COVID-19. The CEO stated that they will begin testing clients upon arrival for tuberculosis. Exit interview was conducted and a copy of this report was left with the administrator of the facility whose signature on this form confirm receipt of this document.


summary: Facility Evaluation

raw_content:
Narrative:
On 08/30/2023 at 9:30am Licensing Program Analyst (LPA) Nancy O'Connell and LPA Jhane Haynes made an unannounced visit inspection to Living Arrows THPP Administrative Office located at E Main Street, #116, Ventura, CA 93001 for the purpose of conducting an Annual/Required Inspection. LPA met with Marylou Andrade, facility administrator and Judith Rodriguez Case Manager, who granted access to the Administrative Office and together toured the office. The office building and is set up as follows: The administrative office Suite #116 accommodates only THPP staff and consists of entrance with a code to get into the office. LPA observed a station with a sign in sheet and temperature check. The office is a two-room office with a bathroom in good working order at the time of the inspection. The building is equipped with a large conference room that can be used for meetings or training. The second room is an attached conference room available with two desks computers. Staff and client records are maintained in the Administrative Office inside locked cabinets and through electronic record. All posting requirements were met. The facility is licensed to provide Transitional Housing Placement plus Foster Care (THP + FC) and Non-Minor Dependents (NMD) to 74 participants ages eighteen (18) through twenty-one Continued on LIC809C. (21). There are currently nine (9) participants in placement in the Ventura County. During the time of inspection, LPA O'Connell and Haynes conducted an inspection of the physical plant, emergency preparedness, and operations procedures. As part of the annual inspection, LPA O'Connell and LPA Haynes traveled to THPP remote site #1 in order to conduct a site inspection. LPA O'Connell and LPA Haynes inspected the property and observed functional carbon monoxide detectors, required posted documents, locked files, and emergency procedure binder. The kitchen was inspected and the refrigerator maintained required amount of food for clients. The backyard was clean, and orderly and free of obstructions or safety hazards. The interior portion of the facility was clean, and orderly. Due to time constraints, LPA O'Connell will return to complete the annual review. There were no deficiencies observed or cited during today's inspection. Exit interview was conducted and a copy of this report was emailed to the administrator of the facility.

met_with: Marylou Escoto, Facility Administrator (FA)


summary: Facility Evaluation

raw_content:
Narrative:
On 9-12-23, at 10:00am, Licensing Program Analyst (LPA) Nancy O'Connell and Licensing Program Manager (LPM) Kevin Sauk met with the management team for 4kids2kids- Safe House (STRTP) and their related facility, Living Arrows-Transitional Housing Placement Program (THPP). The purpose of this meeting was for Community Care Licensing Division (CCLD) to address operational issues for both facilities as well as matters related to qualifications of current/former staff. individuals in attendance: Marylou Escoto- Facility Administrator (FA), for 4kids2kids-Safe House (STRTP) and Living Arrows (THPP) Yazmine Sepulveda- Facility Manager (FM), for 4kids2kids-Safe House (STRTP) Christina Mengrahani- Head of Services (HOS), for 4kids2kids- Safe House (STRTP) Alaina Upthegrove- Bookeeper for Living Arrows (THPP) and (pending approval by CCLD) assigned "designee" for THPP Topics of discussion: a. Access to facility records - applicable regulation was reviewed and discussed due to recent inspections involving a delay/inability in accessing facility records by CCLD staff . LPM Sauk discussed the related requirement (Section Inspection Authority of the Licensing Agency:) to allow CCLD staff to have access to all facility records, including medication logs during unannounced inspections. b. Fingerprint clearance of staff prior to working at facility- LPM Sauk informed FA of the requirement to ensure that staff are reflected as fingerprint cleared in Guardian, prior to working at the facility. LPM Sauk inquired about who has the authority to to grant new staff permission to work on the facility premises after verifying clearance. FA communicated that she is responsible for verifying all new staff are fingerprint cleared prior to anyone working within the facilities. LPM Sauk noted that FA is reflected as a "corporate board member" in Guardian and this inaccuracy would need to be corrected- FA agreed to update Guardian record. Continued on LIC809C LPM Sauk addressed the inaccuracies in staff still showing as associated to the facilities in Guardian, but are being reported as "former" employees. LPM Sauk instructed FA that staff who are no longer employed by the organization, will need to be dis-associated from the Guardian rosters. c. Maintenance of required documentation- LPM Sauk addressed the substantial delays in providing the LIC500 to Licensing staff during inspection and informed the FA that the LIC500 (Personnel Report) shall be provided to CCL upon request. LPM further communicated that If the facilities choose not to use an LIC500 form, they may use a form of their own, which shall include all of the same information on the LIC500 at a minimum. Further, the LIC500 provided to CCL should be current and have the date of the LPA's visit. LPM Sauk referenced the related regulatory requirements: Section 80066(e),Section 80066 (c), Section 80066 (f). d. Communication issues between the facilities and CCLD- due to ongoing communication issues in contacting the FA as well as and barriers in obtaining information for both facilities, LPM Sauk inquired about the point of contact for both facilities. FA confirms that she is the administrator for both the STRTP and THPP, but is supported by the FM (assigned to the STRTP) along with a newly assigned designee (assigned to support the THPP). FA explained that both the bookkeeper and FM can be contacted in the event of FA's absence. LPM Sauk gathered details about the newly assigned designee's/bookkeeper's role in the facility, her qualifications, and scope of duties. A review of the bookkeeper's qualifications will be conducted prior to granting approval as the new designee for the facility. LPA O'Connell communicated the need to engage in transparent communication and requested that all communication between the organization and CCLD include the FA. LPA O'Connell communicated instance where incidents have occurred and the FA communicated that she did not have awareness or was informed of the situation. FA agreed to communicate request to entire staff/board member group. e. Required staff and their qualifications- LPM Sauk inquired about who the identified Social Work Supervisors and Social Worker personnel are for the THPP. FA identifies that there is one Supervising Social Worker who reviews documentation. LPM Sauk requested additional information on the Social Work Supervisor to ensure qualifications. FA agreed. LPM Sauk referenced the following related regulatory requirement: Sections 86065.4 (Social Work Supervisor/Social Worker Ratio), 86065.2 (Social Worker Supervisor), 86065.3 (Social Work Personnel). Continued on LIC809C f. Physical Plant of THPP facility- LPM Sauk informed FA that in 2022, the administrative assistant for the THPP reported that the second back-room office at the Living Arrows office would no longer be used as part of the facility, but CCLD recently found out that the office is still available for use. LPM Sauk inquired about the use of the space, as well as the function. FA reports that she did not have awareness of any plans to relinquish use of the space and the second adjoining office at the THPP remains part of the facility property. FA reports that the space is used to conduct meetings amongst staff and meet with clients as needed. g. Recent Deficiencies- due to the recent inspections of the STRTP facility, concerns regarding food storage and the physical plant cleanliness were addressed. LPM Sauk communicated awareness that the facility utilizes food pantry donations to supplement grocery store purchases for clients and communicated that food must be inspected regularly to ensure it is safe for consumption and not expired. LPM Sauk also communicated the need to maintain the facilities in a cleanly condition at all times, per regulatory requirements. FA acknowledged and agreed to address issue immediately. LPM Sauk concluded the meeting and communicated that a copy of this report would be provided to the FA for review and signature.

met_with: Marylou Escoto, FAcility Administrator (FA)


summary: Facility Evaluation

raw_content:
Narrative:
On 9-27-23, Licensing Program Analyst Nancy O'Connell arrived at the facility for an unannounced Annual Inspection- Continued. Alaina Upthegrove, Bookkeeper (BK), granted access to the facility. The purpose of the inspection is to continue with the Annual Inspection initiated on 8-30-23. During the time of inspection, LPA O'Connell and BK reviewed items related to the Operations and Emergency Plan and Staffing requirements. BK searched for items requested, but contacted FA via telephone in order to obtain specific information about the location of forms/information. LPA discussed organizational practices and ways to organize files and information that must be centrally stored in the facility. BK was unable to locate documents related to emergency disaster preparedness and House Parent Training records for S1 and S2, and communicated that documents are kept on file within the individual living units. During the course of the inspection, Marylou Escoto, Facility Administrator (FA) arrived at the facility to conclude the Annual. LPA and FA reviewed Social Worker requirements and found that the facility does not employ a Social Worker that is on call 24hours a day, and current "case manager" staff do not meet the Social Worker Personnel requirements. FA communicated that she was unaware of the requirements and agreed to develop a plan to obtain compliance with the regulation. LPA O'Connell provided FA with assistance in obtaining training materials (CARE Tool) to clarify regulatory requirements for the THPP facility. Due to time constraints LPA O'Connell will return on a different day to complete the inspection. PER California Code Regulation, TITLE 22, DIVISION 6, CHAPTERS 1, General Licensing Regulations, 2 deficiencies will be cited today. See LIC809D for details. An exit interview was conducted and a copy of this report was provided to FA upon exit.

met_with: Alaina Upthegrove, bookkeeper (BK), and Marylou Escoto, FAcility Administrator (FA)


summary: Facility Evaluation

raw_content:
Narrative:
On 8/13/25 at 10:00am, Licensing Program Analyst (LPA) Nancy O'Connell, Bernice Karnsrithong, Community Care Licensing Division Regional Manager (RM), and Kevin Sauk, Community Care Licensing Division Program Manager (LPM) met with Valerie Amparan, 4kids2kids Board of Directors member (BODM) and Paulette Melina, 4Kids 2kids Head of Services (HOS) for the purpose of conducting an informal meeting. The Department was informed that the Board of Directors President, Lori Vos would not be in attendance. The meeting was held at the Children's Residential local unit office located in Woodland Hills. During the meeting, the following items were discussed: Administrator Qualifications- Requirements for a Short Term Residential Therapeutic Program (STRTP) administrator including the required Administrator certification training that is also found on the Administrator Certification Bureau Website. The website lists all the required training and training vendor information for STRTP administrators. Required training hours were verified. Board of Director Member (BODM) Valerie Amparan has informed the Department that their administrator will be attending the STRTP Training on 08/14/2025 to 08/24/2025 and will take the required exam after. The BODM stated that once their administrator training is completed, BODM will send email confirmation that they have submitted the STRTP administrator certification requirements to Administrator Certification Bureau, to the Department. Requirements for Transitional Housing Placement Program (THPP) Administrator was also discussed including the following training requirements pertaining to sexual and reproductive rights of children in foster care that includes the following topics: Page 1 of 4, Continued on LIC809C (1) Children's right to receive sexual and reproductive health care and information, pursuant to Section 86172(b)(21) and (24). (2) Children's right to have their sensitive health information kept confidential, pursuant to Sections 86170(d) and 86172(b)(25). (3) The duties and responsibilities of the assigned social worker and the administrator to ensure that children can obtain sexual and reproductive health services and information. (4) Guidance about how to engage and talk with children about healthy sexual development and reproductive and sexual health in a manner that is medically accurate, age or developmentally appropriate, trauma-informed, and strengths-based. (5) Information about current contraception methods and how to select and provide appropriate referral resources and materials for information and service delivery. The Department also reviewed the working experience of the THPP candidate and determined that the resume needs to include job titles to ensure that the THPP candidate meets the Administrator requirements based on the THPP regulations ( Administrator Qualifications and Duties). BODM and HOS has informed the Department that they will speak with the THPP Administrator to revise their resume to be in compliance with the THPP Administrator requirements. The Department also informed BODM that they will provide them with information regarding the required THPP Administrator trainings via email. Facility Manager Requirements: STRTP Facility Manager requirements were also discussed during the meeting. According to the Interim Licensing Standards, the facility manager must meet one of the following requirements prior to employment: (1) Have a bachelor of arts or sciences degree. (2) Two years of full-time experience, or its equivalent, working with the population to be served, or equivalent education or experience, as determined by CDSS. Experience shall be verified as having been Page 2 of 4. Continued on LIC809C performed as a paid or volunteer staff person whose duties required direct supervision and care of the population served. (3) Two years' experience as a member of the social work staff in a group home or short-term residential therapeutic program. LIC500- The Department requested that management update the LIC Personnel Report and indicate current roles, job titles with schedules and contact information. BODM and HOS agreed to update and provide a copy within the week with the updated form. Board Minute Meetings: The requirement for STRTP to provide board minute meetings at least every quarter must be updated and available during on-site inspections. The Department has provided BODM and HOS the information needed to be included in the Board Minute Meetings and have agreed to not include confidential staff and management information. LIC200- The Department has informed BODM and HOS that the current facility email address belongs to their previous administrator who no longer works for the facility. The Department requested that management update the LIC Facility Application and provide an updated email address. BODM agreed to generate a new shared email that can be accessed by the management team and submit an updated LIC200 within a week. BODM informed the Department that she will send this electronically. Technical Support Program (TSP) referral- During the meeting, the TSP referral was discussed. BODM and HOS reported that the TSP services have been halted due to the recent personnel transition. Staff report that they will resume services at a later time when needed. BODM requested supplemental information regarding administrator training requirements. The Department has agreed to contact TSP and inform them that the facility would like to continue with their referral. STRTP Plan of Operations:During the meeting, information regarding the required program statement requirements based on the Interim Licensing Standards (ILS) is to include job descriptions for all the STRTP employees and information pertaining to consultants the facility plans to use. This will also include the scope of work for these consultants they plan to use for their program. BODM and HOS have agreed to submit this Page 3 of 4. Continued on LIC809C Continued- Page 4 of 4 information and provide updates to their program statement in compliance with ILS Version 5. BODM agreed to complete the updates and submit to the Department within the next thirty (30) days. During the meeting, the Department went over the recent plan of corrections that were issued between March 2025 to July 2025 and discussed the facilities plan to be in compliance. During the meeting, all parties agreed to follow up within 1 month to discuss the progress of the required action items needed to clear the program's plan of corrections. A meeting date and time will be scheduled in the future and will be provided to facility. There are no deficiencies to be cited at this time. A copy of this report was provided to the facility staff for signature and a signed copy is retained on file.

met_with: Valerie Amparan, Board of Director member


summary: Facility Evaluation

raw_content:
Narrative:
On 9/11/2025 at 10:00am Licensing Program Analyst (LPA) Nancy O'Connell made an unannounced visit inspection to Living Arrows THPP Administrative Office for the purpose of conducting an Annual/Required Inspection. LPA met with Ashley Giles, Compliance Officer, who granted access to the Administrative Office. During the time of inspection, LPA O'Connell experienced technical problems, which prevented the initiation of the Annual inspection Care Tool. LPA informed S1 that the Annual would be conducted at a later time. LPA discussed Guardian access and requested that S1 remove staff from roster that are no longer associated with the program. S1 reported that she has access to Guardian and will update the roster by 9/15/25. No deficiencies cited today. A copy of this report was sent via email to the Administrator.

met_with: Ashley Giles, Compliance Officer (S1)


summary: Facility Evaluation

raw_content:
Narrative:
On 10/22/25 at 9:20am Licensing Program Analyst (LPA) Nancy O'Connell made an unannounced visit inspection to Living Arrows THPP Administrative office for the purpose of conducting an Annual Random Inspection. LPA met with Jose Alvarado, Facility Administrator, who granted access to the Administrative Office and together toured the office. The office building and is set up as follows: The administrative office Suite #116 accommodates only THPP staff and consists of entrance with a code to get into the office. The office is a two-room office with a bathroom in good working order at the time of the inspection. The second room is an attached conference room available with two desks computers. Staff and client records are maintained in the Administrative Office inside locked cabinets and through electronic record. All required postings were observed including the facility license. There is also a functional facility telephone available for confidential phone calls. The facility is licensed to provide Transitional Housing Placement plus Foster Care (THP + FC) and Non-Minor Dependents (NMD) to 74 participants ages eighteen (18) through twenty-one (21). There are currently 6 participants in placement in the Ventura County. LPA inquired about the current census, requested the Register of Clients, and a staff roster. LPA requested to interview selected staff and staff files. See LIC811, dated 10/22/25, for names. Client/Staff File reviews: LPA conducted file reviews for: FA, SW, HP1, HP2, CM, C1, C2, C3, C4, C5, and C6. Upon review of Needs and Services Plan documents, LPA observed that documents were not signed by the authorized representation for C1, C2, C3, C4, C5, and C6. FA confirmed that he did not obtain signatures for NSPs. Client/Staff Interviews: LPA conducted a confidential interview with: FA Continued on LIC809C During the time of inspection, LPA O'Connell completed the following sections of the THPP Care Tool: physical plant, operational requirements, disaster preparedness, staffing records, and clients records. Based on California Code of Regulations, there were 1 deficiency cited during today's inspection. See LIC809D for details. Due to time constraints, LPA will return tomorrow, 10/23/25 to complete the Annual Review. Exit interview was conducted and a copy of this report was emailed to the administrator of the facility.

met_with: Jose Alvarado, Facility Administrator (FA)


summary: Facility Evaluation

raw_content:
Narrative:
On 10/23/25 at 9:00AM Licensing Program Analyst (LPA) Nancy O'Connell made an unannounced visit to the above-listed facility for the purpose of conducting a Case Management - Annual Continuation inspection. LPA was met by Samantha Cahill, administrator (Adm). LPA was informed that there are 6 clients in care at this time. LPA met with Adm and informed them that the purpose of the visit is to complete the Annual Inspection. LPA inquired about the current census, requested the Register of Clients, and a staff roster. LPA requested to interview selected staff and staff files. See LIC811, dated 10/23/25, for names. During the time of the visit, LPA and Adm traveled to remote site #1 and remote site #2 in order to complete the physical inspection component of the review. LPA toured each remote site and observed the sites to be in orderly and fully functioning condition. Client/Staff Interviews: LPA conducted a confidential interview with: HP1, Adm, C5, and C6. C1, C2, C3, and C4 declined to be interviewed. Per California Code Regulation, TITLE 22, DIVISION 6, CHAPTERS 1, General Licensing Regulation, there are no deficiencies cited during this inspection. An exit interview was conducted, and staff was informed that the annual inspection was complete. A copy of this report was sent to the administrator via email.

met_with: Samantha Cahill, adminsitrator (adm)


summary: Facility Evaluation

raw_content:
Narrative:
On 7/22/2025, at 1:00PM Licensing Program Analyst (LPA) Nancy O'Connell made an unannounced visit to the above-listed facility for Case Management- deficiency inspection. LPA met with Jose Alvarado, House Parent (HP1) who granted access to the facility. The facility is licensed to care for a capacity of Non-minor Dependents. LPA requested and obtained a copy of the LIC500 along with the client roster for Department records. On 6/11/2025, LPA Nancy O'Connell and Licensing Program Manager (LPM), Kevin Sauk received an email from the facility Interim Board President (BP), Lorie Vos, communicating that the facility no longer has a Facility Administrator (FA), effective 6/11/25. LPM Sauk immediately requested additional information related to a plan for proposed coverage while a new FA is hired and/or trained. On 6/16/25, the BP submitted a "transition plan" that included proposed coverage for an interim FA to be completed by HP1. LPA O'Connell conducted a thorough review of the submitted documents for HP1. Based on category specific regulations listed in California Code Regulation, TITLE 22, DIVISION 6, CHAPTERS 1 and 7, General Licensing Regulation, the Facility Administrator must meet education and/or experiential requirements and have the knowledge of the requirements for providing the type of care and supervision needed by clients...", and "...the ability to comply with applicable law and regulation." Additionally, all Transitional Housing Placement Program (THPP) administrators must complete additional training related to sexual and reproductive rights of children in fostercare. Based on review of HP1's documentation along with an interview of HP1, there is no previous supervisor work history of oversight of regulatory responsibilities within a position previously held. Further, HP1 does not currently meet training requirements related to sexual reproductive health rights for THPP administrators. Due to these reasons, the Department was unable to approve HP1 as an interim FA for the facility. Further, LPA O'Connell conducted a review of records for clients in care for C1, C2, C3, C4 , C5 and C6 (See Confidential names list, dated 7/22/25, for names). LPA O'Connell reviewed intake documents along with Needs and Services Plans(NSP), and verified that NSP documents are required to be completed monthly. LPA found the following: C1- there is 1/ NSPs completed and signed since admission. C2- there were 0/ NSPs on file since admission. C3- there were 0/ NSPs on file since admission. C4- there were NSPs due at the time of inspection and 0 on file. C5- there were 0/ NSPs on file since admission. C6-there is 1/ NSPs on file and signed since admission. Upon interview. HP1 reported that he does not have knowledge of the former Administrator's process for completion of NSPs. HP1 was informed of regulatory requirement, which he agreed to and acknowledged. Per California Code Regulation, TITLE 22, DIVISION 6, CHAPTERS 1 and 7, General Licensing Regulation, there are two deficiencies to be cited at this time.See LIC809D for details. Exit Interview was conducted with staff, and a copy of this report was provided to the facility via email.

met_with: Jose Alvarado, House Parent


summary: Facility Evaluation

raw_content:
Narrative:
On 1-14-26, at 9:30AM Licensing Program Analyst (LPA) Nancy O'Connell made an unannounced visit to the above-listed facility for Case Management-Other inspection. LPA met with Jose Alvarado, Staff 1 (S1, who granted access to the facility. This visit is a followup to the case-management visit conducted on 7-22-25, during which time, the facility was cited for operating without an approved administrator. Since the visit conducted on 7-22-25, LPA O'Connell has made various attempts to obtain the required administrator documentation needed to approve a new qualified administrator for the facility. Requests have been made to the licensee via email as recent as 1-8-26 to finalize the approval process. Although the licensee submitted some of the required documents to approve a new administrator, the following required documents have not been submitted: LIC308- Designation of Facility Responsibility, LIC309- Administrative Organization, and the LIC200- Application providing name of the newly assigned administrator (S1) Additionally, upon inspection of the staff file assigned to conduct administrator duties (S1), there is no signed job duties description, outlining the assigned administrator duties. Further, Board Meeting minutes were requested and reviewed for the facility for the year of 2025 (dated: 3/12/25, 3/25/25,4/15/25, 6/25/25, 8/12/25, and 8/27/25) and there is no indication that a new administrator. LPA confirmed that there were no additional board meetings conducted for the year of 2025, and S1 reported that he provided all meeting minutes which he had access to at the time of inspection. LPA inquired about the status of submitting the required documents, and S1 communicated that the licensee has not provided completed documents for submission as of 1-14-26. Due to incomplete documentation needed to approve a new administrator, LPA informed S1 that the facility will be cited today for Administrator Qualifications CCR 86064(a)(c)(e). S1 acknowledged the information and agreed with the decision. Based on the California Code of Regulation, there is one deficiency to be cited. See LIC809D for details. Exit interview was conducted and a copy of this report along with appeal rights were provided to S1 and the licensee via email.

met_with: Jose Alvarado, Staff 1 (S1)


summary: Facility Evaluation

raw_content:
Narrative:
On 1-28-26 at 1:30pm, Licensing Program Analyst (LPA) Nancy O'Connell and Licensing Program Manager (LPM) Kevin Sauk conducted a virtual, scheduled office meeting with Valerie Amparan, Board of Directors President for 4kids2Kids. The purpose of the meeting was to provide the findings of an audit conducted by the California Department of Social Services (CDSS)-Audits Section. Meeting attendees: Nancy O'Connell, Licensing Prorgam Analyst (LPA)- CDSS, Community Care Licensing Division (CCLD) Kevin Sauk, Licensing Program Manager (LPM)-CDSS, Community Care Licensing Division (CCLD) Benjamin Benahene, Auditor- CDSS, Audits Section Valerie Amparan- Board of Directos President, 4Kids2Kids Heather Howard- Bookkeeper, 4kids2Kids Jose Alvarado- Staff, 4kids2kids An audit was conducted to determine whether the facilities had solvency issues, and whether they maintained an adequate financial plan as required by California law (Title 22 regulations). The following are key findings from the Solvency Audit: 1. Profit & Loss statements confirmed significant financial net losses 2. Expenses far exceeded income 3. Rent appeared underreported 4. Facilities lacked sufficient cash reserves. 4. Financial records were incomplete and not reliable, due to limited supporting documentation. 5. Most utilities were paid, but records show that some payments were occasionally missed. Continued on LIC809-C Based on the Solvency Audit, the Department found that the licensee had experienced serious financial instability in the month of June 2025, that the licensee does not have an adequate financial plan in place, and that improvements are needed to ensure solvency and compliance. As a follow-up to the findings of the Solvency Audit, the Licensee has been informed that a 6-month financial monitoring period will take place. The purpose of the financial monitoring period is to ensure compliance, demonstrate solvency, to see if the facility is maintaining accurate financial records, and to see if the facilities are maintaining a financial plan sufficient to meet operating costs. Further details of this financial monitoring will be provided on a later date. No deficiencies were cited today. A copy of this report was sent to the licensee on 1/29/26, and a copy of the report along with an electronic signature are retained on file.


summary: Facility Evaluation

raw_content:
Narrative:
On 2-3-26, at 9:30am Licensing Program Analyst (LPA) Nancy O'Connell conducted an unannounced visit to the above listed facility in order to conduct a Case Management- Plan of Correction (POC). LPA O'Connell met with Jose Alvarado, Staff 1(S1),who provided access to the facility. During the time of inspection, LPA O'Connell reviewed the required documents related to the POC issued on 1-14-26. LPA reviewed the following: LIC308- Designation of Facility Responsibility- assigning S1 as the designee for the facility LIC309- Administrative Organization- signed by an authorized board member (BP) LIC200- Application providing name of the newly assigned administrator (S1) LIC500- Personnel report reflecting S1 as the facility administrator Board meeting minutes dated 1-27-26, reflecting a board resolution to assign S1 as the new facility administrator Upon review, LPA O'Connell found that the LIC308, LIC309, LIC200, and LIC500 have been completed and signed as required, by an authorized member of the board of directors. LPA O'Connell cleared the related POC, dated 1-14-26. No deficiencies cited at this time. An exit interview was conducted, and a copy of this report was emailed to the administrator

met_with: Jose Alvarado, Staff1


summary: Facility Evaluation

raw_content:
Narrative:
On 2-3-26, at 9:30am LPA Nancy O'Connell conducted an unannounced Case Management inspection at the above listed facility. LPA was met by Jose Alvarado, Facility Administrator (FA) who provided access to the facility. During the time of inspection, LPA requested a copy of the LIC500-Personnel Report and found that the roster reflected an unknown staff member, P1. LPA inquired about the role of P1 and when the staff was hired. FA reported that the staff was a previous employee but has not been scheduled for work in an extended period of time. FA confirmed that P1 is still reflected as associated to the facility in Guardian, but there is no current facility personnel report for P1. A review of P1's file in Guardian shows that she was associated to both Living Arrows and 4kids2kids SAfe House in 2021, and then disassociated from 4kids2kids Safe House in 2023, but not disassociated from Living Arrows. LPA O'Connell informed FA that updated records would be required to reflect P1's current employment and clearance status. FA agreed and immediately updated the Guardian roster to reflect P1 as disassociated from the facility. FA also provided an updated LIC500 and Guardian roster reflecting P1 as removed from the rosters. LPA provided technical assistance to FA regarding management of Guardian and offered suggestions to update the facility roster in Guardian when staff are no longer employed with the organization. LPA also provided guidance on ways of maintaining an updated LIC500 roster to ensure that all individuals working in the facility maintain an active criminal background clearance. No deficiencies cited at this time. An exit interview was conducted and a copy of this report was provided to the Administrator.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 2-12-26, Licensing Program Analyst (LPA) Nancy O'Connell conducted an unannounced Case Management-Deficiencies inspection for the above listed facility. LPA O'Connell was met by Ryan Brunett, Mental Health Rehab Specialist (MHRS) who served as the acting representative for the facility. This visit is a follow-up from a previous office meeting held with the licensee on 1-28-26. On 1-28-26, LPA O'Connell met with FA and the facility Board of Directors President (BP) during a scheduled office meeting, to deliver the outcome of a Solvency audit, conducted by the Department. The audit was conducted in order to determine whether the facility had solvency issues and if it has been able to maintain an adequate financial plan as required by California law (Title 22 regulations). The following are key findings from the Solvency Audit: 1. Profit & Loss statements confirmed significant financial net losses 2. Expenses far exceeded income 3. Rent appeared under-reported 4. Facilities lacked sufficient cash reserves. 4. Financial records were incomplete and not reliable, due to limited supporting documentation. 5. Most utilities were paid, but records show that some payments were occasionally missed. Based on the Solvency Audit and the recommendation provided by the assigned investigator, the facility will be cited per Title 22 80062(a)- Finances. The licensee has been informed that a plan of correction will include the recommended 6-month financial monitoring plan. Continued on LIC809C The purpose of the financial monitoring period is to ensure compliance, demonstrate solvency, and to see if the facility is maintaining accurate financial records, and to see if the facility is maintaining a financial plan sufficient to meet operating costs. Details of the financial monitoring plan were sent directly to the licensee via email on 2/6/26, and are as follows: The licensee will submit the following documents that covers July, August, and September of 2025 for the facility: · For each of the three months, July, August, September 2025, we need the following for each facility: o Profit & Loss Section (lic401, lic 401a) Revenue: Profit & Loss statement, with supporting documents, such as rent roll, copies of revenue deposits o Expenses: Rent, supporting document showing payments of rents or mortgages for each of the 3 months mentioned above Payroll: Total wage & salary expenses incurred with the supporting documents such as copies of checks, third party payroll summary report for each of the three months. Utilities: Utilities statements for Electricity, Gas, Phone, sewer, waste management, etc and all supporting documents for all amounts entered on the P&L expenses section o Financial position Section (LIC 403, LIC 403A) Balance sheet prepared with supporting documents for all the amounts( Assets, liabilities) entered on the LIC 403, LIC 403A Cash reserve: Bank statements from all accounts used during the months of July, August, September 2025. Additionally, any accounts or supporting documents for the facilities serving as cash reserves should in case of emergency o Insurance reports Certificate of Liability Insurance & Certificate of Workers compensation for each of the 3 months. Documents will be sent to LPA O'Connell via email at Nancy.oconnell@dss.ca.gov, by 2/23/ Based on California Code of Regulations, the facility will be cited with one deficiency today. See LIC809D for details. An exit interview was conducted and a copy of this report was provided to administrator via email.

Deficiencies:
80062(a): 1
2
3
4
5
6
7Finances-(a)The licensee shall meet the following financial requirements


facility_name: LOVE FOCUS YOUTH OUTREACH

summary: Facility Evaluation

raw_content:
Narrative:
On the above date, a virtual component II orientation is conducted by LPA (Licensing Program Analyst) Lisa Slusher with Administrator and Board member Margaret Mungai. LPA forwarded letter with requested corrections on 8/18/21. Corrections ( Pages) were submitted on 8/22. LPA is reviewing corrections at this time. Discussed Fingerprinting and the Guardian system, and the need for the agency to create an account. Agency will in the meantime send associations for appropriate staff to this LPA, and will have staff fingerprint if required. Discussed Foster Care Rates Status. Pre-licensing inspection tentatively scheduled for 9/2/21 at the Facility in Merced, CA.

met_with: Margaret Mungai


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analysts Eduardo Barragan and Lisa Slusher travelled to the CTC THP + NMD office in Merced CA . LPAs were met by Administrator Margaret Mungai, for the purpose of a scheduled pre-licensing inspection for an initial licensure for a THP + NMD program.. A general overview of their program and a tour of the facility was provided. This facility has a reception area, waiting area, and office space for staff. Observed fixtures and furniture, equipment and supplies necessary for this operation. Also observed locked cabinets for client and staff files in order to ensure confidentiality and a fully stocked first aid kit. Discussed daily ongoing functions including incident reports. Initial incident reports are to be submitted by the next working day to CCLFresnoIncidents@dss,ca,gov. A full report shall follow within 7 days. There is sample confidential space for meeting with clients on an as needed basis. Agency has received Administrative approval to manage background clearances through Guardian, and will ensure that all staff are appropriately cleared and associated prior to presence in the facility. Agency has contacted the FCARB (Foster Care Rates and Audits Bureau) about obtaining funding. Once licensed, LPA will forward information to FCARB. LPAs observed staff files and sample participant files. The above licensee is recommended for licensure on this date as a THP+NMD serving clients age 18-21 in Merced county and other counties within a two hour radius, pending approval of program Statement updates. . On a quarterly basis, facility is to submit a roster of THP+NMD clients that includes client names, dates of birth, county worker and current address of placement as well as a current LIC 500. Discussed possible exception for a Social Work Supervisor/Social Worker Supervisor. Agency will send transcripts (Masters and Doctorate) for SWS as well as documentation of requirements for becoming a registered addiction specialist along with the exception request for regulation sections 86065.2 (Social Worker Supervisor) and 86065.3 (Social Work).


summary: Facility Evaluation

raw_content:
Narrative:
On this date, an unannounced annual inspection is conducted by Licensing Program Analyst (LPA) Rachel Bruce who was met at the facility by Executive Director, Margaret Numgai and Office Manager Carolyne Njogu. The agency currently has no clients but maintains a 5 bed facility at Childs Ave, Merced, CA. Employed currently is one social worker, two LCSW, a social worker intern, a volunteer who maintains the facility, Office Manager, CEO and Executive Director. Staff interviews conducted during visit. A general overview of their program and a tour of the facility was provided. This facility has a reception area, waiting area, and office space for staff. LPA Bruce observed fixtures and furniture, equipment and supplies necessary for this operation. Also observed locked cabinets for client and staff files in order to ensure confidentiality. When living units are occupied, inspections will be conducted monthly to ensure the facility is meeting required guidelines. Regardless of occupancy, the facility will ensure that firearms or other weapons are not stored in THP living units and that fire extinguishers and carbon monoxide detectors are in proper working order. There are no participant files to review on this date. Paid staff and volunteer files were reviewed. No citations issued at today's visit. A review of personnel records on this date indicates that facility personnel are appropriately fingerprint cleared. Exit interview conducted with Margaret Numgai, and a copy of this report along with appeal rights was provided to the agency.

met_with: Margaret Numgai, Executive Director


summary: Facility Evaluation

raw_content:
Narrative:
On this date, an unannounced annual inspection was conducted by Licensing Program Analyst (LPA) Brinae Pointer who was met at the facility by Office Manager Carolyne Njogu. LPA was informed by the staff of them being an Enhanced Care Management Community Support facility, and the THPP+NMD having no clients at the time. LPA was informed by staff of Director Margaret Mungai, being more capable of answering any questions related to the THPP, and they would be arriving to the facility in the next 15-30 minutes. Director Margaret arrived at 11:50AM. The agency currently has no clients but is currently seeking grants in efforts of building housing on the previously acquired land. The Director reports there have been no clients in care for more than a year. Director reports they have since written to CDSS to report the program is not closed, but will house youth when they have a facility. Currently, there are no staff employed to operate the facility, due to there being no facility or youth housed by the agency. A general overview of their program and a tour of the facility was provided. This facility has a reception area, waiting area, and office space for staff. LPA Pointer observed fixtures and furniture, equipment and supplies necessary for this operation. LPA also observed locked cabinets for client and staff files in order to ensure confidentiality. Employed currently is the Office Manager and Director. There are no participant files to review on this date. Directors files were reviewed on this date indicating that personnel are appropriately fingerprint cleared. Director noted they will provide proof of 1st aide/ CPR renewal completion to LPA via email. Staff interviews conducted during visit. There are no deficiencies cited upon the conclusion of this inspection.

met_with: Margaret Mungai, Director


facility_name: LOVE NEVER FAILS

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Monica Pavia made an announced prelicensing inspection, on above date. LPA met with applicant, Vanessa Russell and toured the office building. The applicant is applying for a Transitional Housing Placement Program (THPP) license. The office has sufficient space for confidential meetings with participants, if needed. Files will be kept locked in a filing cabinet in an office, on site. The THPP has a Community Engagement Center/training center at this location for participants to utilize. All staff at the participant living unit will be fingerprint cleared prior to accepting any admissions. Background cleared staff will accompany all participants to the Community Engagement Center, located at the address listed above. LPA is waiting for the granted fire clearance from Hayward Fire Department. This facility is ready for licensure once the fire clearance is received and Licensing Program Manager (LPM), has reviewed and approved the application. LPA will notify you of licensure date and email facility license.

met_with: Vanessa Russell


summary: Facility Evaluation

raw_content:
Narrative:
On 08/25/23 at 10: AM, Licensing Program Analyst (LPA) Alyssa Ng made an unannounced Post Licensing Inspection to Love Never Fails Administrative office. LPA met with Vanessa Russell, Administrator. At 10: AM, LPA did a walk through inspection with Administrator of the office. The office has sufficient space for confidential meetings, all participant files and staff files are located in a locked cabinet in a secure location. The agency has their license posted in their office. The office is in compliance with Community Care Licensing (CCL) regulations. LPA spoke with Administrator about the residential unit. Administrator stated that the residential units have all working toilets, sinks and tubs. Administrator notified LPA that the program provides all participants with household essentials. At 11: AM, LPA reviewed 1 participant file with Administrator. The participant was in the program for 2 days so there was insufficient information. LPA discussed the forms needed to be maintained in the client, staff, and the facility file. At 12: PM LPA observed 3 staff files to be complete, all documentation is up to date and all staff training were up to date/current. LPA Ng interviewed 2 staff. During inspection, LPA requested a updated copy of the LIC Personnel Report to maintain their file current. A review of Licensing Information System on August 25th, 2023 indicates that all but one facility staff associated to the facility had DOJ, FBI and child abuse index check clearances. The facility have been in contact with Guardian regarding that one staff. Administrator assured me that the staff member who is not cleared have not been around any participants. Per Title Regulations, 0 deficiencies were cited during this inspection. Exit interview conducted and a copy of the report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On 5/7/2024 at 1: PM, Licensing Program Analyst (LPA) Jasmine Cardeno and LPA Mona Lam made an unannounced visit to Love Never Fails Administrative Office to conduct a required annual inspection. The Facility Love Never Fails currently has no clients in care as of 5/7/2024. During the time of the inspection, there was 1 facility staff and 2 office staff members that were present. At 1: PM, LPA Cardeno met an office staff member (ITBIC Outreach and CEC Manager), Viviana Soto, and notified her that she will be conducting a required annual inspection for the THPP, and will need to meet with Facility Administrator, Vanessa Russell, on-site at the Love Never Fails Administrative Office. At 1: PM, LPA Cardeno contacted Facility Administrator, Vanessa Russell, via telephone call and left a voicemail message to let Vanessa Russell know that the Facility Administrator will need to meet at the office on-site in order to conduct the required annual inspection. At 2: PM, Vanessa Russell notified LPA Cardeno via text message, that she was on the way to Love Never Fails Administrative Office to meet with LPAs. At 2: PM, LPA Cardeno and LPA Lam met with Facility Administrator, Vanessa Russell, who helped facilitate the inspection and do a walk-through of the office. The Love Never Fails Office has sufficient space for confidential meetings and staff files are located in a locked cabinet in a secure location. The agency has their license posted in a prominent location in their office. The office is in compliance with Community Care Licensing (CCL) regulations. Vanessa Russell stated that the Love Never Fails Transitional Housing Placement Program currently does not have clients in care as of 5/7/2024. LPA Cardeno reviewed 1 staff file to be complete with all documentation being up to date and current. LPA Cardeno discussed the forms needed to be maintained in the facility files including the posting of the up to date Certificate of Compliance. LPA Cardeno conducted 1 staff interview. There were 0 deficiencies cited during this inspection. An exit interview was conducted, and a copy of the report was given to Facility Administrator, Vanessa Russell, whose signature on this from confirms the receipt.

met_with: Vanessa Russell, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 5/22/2024 at 12: PM, Licensing Program Analyst (LPA) Celeste Aparicio made an unannounced visit to Love Never Fails Administrative Office to conduct a required annual inspection. LPA met on site with office staff member ITBIZ Program Manager, Viviana Soto, and informed them on the purpose of the visit. LPA then spoke over the phone with Business Operations Manager/HR, Huda Alawi and Administrator Vanessa Russell who helped facilitate the inspection via telephone. During the inspection, Administrator Vanessa Russell stated that there are no current participants in the Love Never Fails Transitional Housing Placement Program (THPP). It was found that since being licensed the THPP has never had clients in care. The CARE Tool was used to conduct this inspection. LPA conducted a walk through of the Administrative office and observed sufficient space for confidential meetings and supplies. The agency has their license posted in a prominent location in their office. Using the CARE Tool LPA reviewed the Physical Plant, Operations, Staff Files, and Disaster Preparedness. Staff files are maintained electronically, LPA was able to view the staff files through a shared google document. LPA observed staff files to be complete and up to date. At this time, no deficiencies were observed or cited. An exit interview was conducted, and a copy of the report was given to ITBIZ Program Manager, Viviana Soto whose signature on this from confirms the receipt.

met_with: Viviana Soto


facility_name: MARY'S HELP THPP/THP+FC

summary: Facility Evaluation

raw_content:
Narrative:
On 06/23/2021, at approximately PM, Licensing Program Analyst (LPA) Chad Cabigon attempted to conduct the Required Annual Inspection for this Transitional Housing Placement Program. LPA first contacted Vivi Smally over the phone to do a COVID-19 screening--Mrs. Smally was not at the program's office and stated that she was not available this day due to having personal appointments. LPA informed Mrs. Smally that the inspection will be re-attempted either by the end of this week or early next week. Mrs. Smally stated that the program currently has two clients. On 06/30/2021, starting at approximately PM, Licensing Program Analyst (LPA) conducted an onsite Annual/Required inspection of this Transitional Housing Placement Program (THPP). LPA met with Office Administrator Vivi Smally in the program office located at the above address. Two client files, staff records, and the participant unit's Certificate of Compliance were reviewed. Personnel criminal record clearances were also verified by LPA. A tour of the participant unit's interior and exterior areas was conducted; this unit was a detached two-story single-family residence located at Oakwood Ave., Vallejo 94591. The THPP's two non-minor ambulatory dependent clients are the only residents of this house, each having their own room. There is a full bathroom on the first floor, another full bathroom on the second floor, and a third en-suite full bathroom located in the master bedroom. All bathrooms were inspected and found to have toilets, sinks, and bathtubs or showers in working order. The refrigerator was stocked with perishable goods sufficient for at least three days. There was a landline telephone located in a common area. No indication of firearms or any other weapons were observed by LPA; the common areas, including the yards, were free from clutter, and the egresses were unobstructed. The house was equipped with appropriate furnishings and supplies. No citations were issued as a result of this inspection. Exit interview conducted; a copy of this report is being provided to Mary's Help.

met_with: Vivi Smally


facility_name: MY BROTHER'S KEEPER TRANSITIONAL HOUSING

summary: Facility Evaluation

raw_content:
Narrative:
On June 7,2023, at 10: AM., Licensing Program Analyst (LPA) Carol Anderson conducted an announced pre-licensing inspection to the above facility. LPA Anderson met with President Antwone O'Quinn. LPA Anderson toured the administrative office for the Transitional Housing Placement Plus Foster Care (THP+FC). The participants' apartment units will be in within a two hour radius from the Administration office. LPA Anderson inspected the office. The following areas were observed: The Administrative Office located in the Emerald Plaza Building in San Diego. There is reception area/waiting room located in suite 400. There are three conference rooms in suite 400 that will be used to conduct confidential interviews. All participants' and staff files will be locked in file cabinets inside suite 400. Staff desk will be in suite 400. All documents have been received and the physical plant meets the minimum requirements of Title 22 regulations. An exit interview was conducted, a copy of this report was discussed and left with President Antwone O'Quinn.

met_with: Antwone O'Quinn


summary: Facility Evaluation

raw_content:
Narrative:
On May 14, 2024, at 12:30PM, Licensing Program Analyst (LPA) Carol Anderson conducted an unannounced annual/required inspection. There was no one at the facility at the time. LPA contacted Execute Director President Antwone O'Quinn via telephone stated that he will be there in 30 minutes. At 1:30PM, LPA Anderson toured the administrative office for the Transitional Housing Placement Plus Foster Care (THP+FC), with Antwone O'Quinn. Currently there are 11 participants' living in apartments throughout San Diego County. The Administrative Office is in the Emerald Plaza Building in San Diego. There is a reception area/waiting room located in the lobby area and staff break room. There are three conference rooms to conduct confidential interviews. The administrative office consists of several staff workstations. Emergency Disaster Plan, Personal Rights, Foster Care Ombudsman are posted in a prominent area for participants to view inside the administrative office. Telephones, computers, fax and copying machines are operable. LPA reviewed six participants' files and three staff files. Fire extinguishers are current, there are fire sprinklers, smoke detectors, and carbon monoxide detectors located in the building. A complete first aid kit readily accessible located inside the administrative office. A review of Guardian on May 14, 2024, indicates that all facility staff associated to the facility had DOJ, FBI, and child abuse index check clearances. There were no deficiencies cited for today's inspection. An exit interview was conducted, a copy of this report was discussed and left with President Antwone O'Quinn.


summary: Facility Evaluation

raw_content:
Narrative:
On August 15, 2024, at 10:30AM, Licensing Program Analyst (LPA) Carol Anderson met with Executive Director Antwone O'Quinn for purpose to conduct an announced, licensee initiated case management inspection. The above-named agency is requesting a capacity increase for the Transitional Housing Placement Program (THPP). The Transitional Housing Placement Program is currently licensed to serve 30 participants. The agency is requesting an increase from 30 participants of a total of capacity of 100 participants. Agency staff provided verification there will be social workers among this caseload to serve these participants. According to Transitional Housing Placement: Section 86020 -Fire Clearance. The THPP shall secure and maintain for each THPP participant living unit any fire clearance required by and approved by the fire authority having jurisdiction. The THPP shall request a fire clearance for the THPP participant living unit prior to residence of a non-ambulatory individual. The non-ambulatory individual may be the participant, persons approved by the licensee and authorized by the licensing agency to remain in the apartment, the child of a THPP participant, a THPP employee, or the employee's child(ren). The increase of capacity is approved as of August 15,2024.

met_with: Antwone O'Quinn, Executive Director


facility_name: MY HOME AT THE LYONS HOUSE

summary: Facility Evaluation

raw_content:
Narrative:
On October 30, 2024, at AM, a Component II and III Office Visit was held to discuss the application received for My Home At The Lyons House Eugenia Place, Suite Carpinteria, CA 93013. Attending Component II and III were the following individuals: Jennifer Heinen-Stiffler , Applicant, Erika Butler. Licensing Program Analyst, and JoAunne Griffin, Licensing Program Manager. The purpose of this Component II and III meeting was to review and discuss the incomplete application and Program Statement and to resolve any outstanding concerns that may have existed. The following incomplete application forms were discussed at the meeting: 1. Fingerprint clearance and associations. 2. Staff Schedule - Section 21 3. Program Forms and Requirement Pre Licensing Inspection will be scheduled within the next 14 to 21 days. A copy of this report was provided to Applicant, Jennifer Heinen-Stiffler, COO.

met_with: Jennifer Heinen-Stiffler, COO


summary: Facility Evaluation

raw_content:
Narrative:
On November 18, 2024, at 10:00 am, Licensing Program Analyst (LPA) Nestor Gomez and Licensing Program Manager (LPM) Kevin Sauk conducted an announced visit for the purpose of a pre-licensing inspection for the above-mentioned facility. Licensing staff met with the COO (Chief Operating Officer) Jennifer Heinen-Stiffler who granted access, and who provided a tour of the office for the inspection. The office is located at Eugenia Place, Suite 104, Carpinteria, CA 93101. The program only has one single site location that is 20 minutes away from this administrative office. This single site location is currently still under construction. The office is set up as follows: Suite 104 is located on the first floor of a two story commercial building. This suite contains a large conference room for large and private meetings, as wells as a copy room, server room, storage room and an exercise room. There are a total of eight cubicles in the office space. Four cubicles are located on the left side and 4 on the right side of the office space. There are a total of 10 offices in the suite. Exit interview was conducted and a copy of this report was emailed to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On 3/26/25, at 9:45am, Licensing Program Analyst (LPA) Nancy O'Connell conducted an unannounced visit for the purpose of a Post-Licensing inspection for the above-listed facility. LPA was granted access to the facility office and was met by Amy Tovias, Facility Administrator, at 10:50am. FA granted access, and who provided a tour of the entire suite for the inspection. The office is set up as follows: The office is located in a two-story commercial building in suite #104. The Transitional Housing Placement Program (THPP) administrative office is located within the suite that maintains additional offices for the YMCA organization. The THPP office is located near the front entrance of the suite and to the right of the exercise room. The program only has one single site location that is 20 minutes away from this administrative office. This suite contains a large conference room that can be used for confidential meetings, as wells as a copy room, server room, storage room and an exercise room. Four cubicles are located on the left side and 4 on the right side of the office space. There are a total of 10 offices in the suite. LPA observed the following: · Client/personnel records are stored electronically and FA maintains access to all records · Required signage postings were observed in administrative office · There is designated space for clients to conduct confidential meetings with social workers/authorized representatives within the designated THPP office as well as in the conference room. Continued on LIC809C.r · LIC500 was reviewed and all staff were confirmed to have a criminal records clearance · Client roster was reviewed and contained all required information Administrator was informed that the administrative office is the licensed location for the facility and where all required visits will be conducted. LPA O'Connell explained that the remote site, where youth reside, will be visited and inspected as necessary only. The licensee is required to ensure that the remote site is maintained according to county/state requirements. Exit interview was conducted and a copy of this report was emailed to the facility administrator.

met_with: Amy Tovias, Facility Administrator (FA)