facility_name: PARADISE OAKS - SUNSET

summary: Facility Evaluation

raw_content:
Narrative:
On 06/18/21 at 1: PM, the second collaborative a quarterly meeting with Paradise Oaks Youth Services (POYS) was held to provide technical assistance and collaborative support to assist with and ensure POYS operates a successful program. The first meeting was held on March 19, 2020. POYS consists of nine locations: Olivine, Rosa Vista, Hazel, Hickory, Antelope, Mariposa, Old Auburn, Madison, and Sunset. The current census at all locations is 28. Two locations have closed, Linda Creek on 2/3/21 and Violets on 5/11/21. The following were present on an MS Teams virtual meeting: · CCL: Margo Castaneda, Regional Manager, Jodean Hall, Licensing Program Manager, Robin Sullivan, Licensing Program Analyst. · System of Care (SOC): Marjana Jackson, Stacie Kinney. · Sacramento County: Linda Abdelbaki · Department Health Care Services (DHCS): Brian Keefer · POYS: Robert Pye, CEO, Laynee Kuhn, Executive Director, Stephanie Fisher, Program Director, Thomas Harrer, Clinical Director POYS provided a status update of the CARF evaluation stating the accreditation approval is over two months out due to backlogs from covid. An extension of approval is in effect. The Mental Health review by Dept. of Health Care Service (DHCS) was completed in April 2021 and at this time POYS is working with DHCS in providing the plan of corrections. POYS reports numerous clients recently graduated from high school. Some graduates are enrolled in community college, some are working, some are seeking transitional housing programs, and some are still figuring things out. Distance learning challenges were reported to be with band-width issues both from the schools and at the facilities. Distance learning was embraced by about half of the clientele, with the other half preferring in-person learning. CCL reported a decrease in complaints and incident reports. POYS attribute the decline to a more deliberate intake process and screening for better compatibility with the current clients. They also reported they were revamping their level system. In addition, POYS is training house staff to participate more closely with each client and their overall treatment plan. Staff are eliciting more input from youth on what is working/not working with the program. Youth have responded with more engagement. POYS reported they are resuming a higher level of training for staff as more in-person training become available. They have contracted with Relias Learning for staff training. When asked about the status of overnight staff, POYS reported, they have two roamers that are assigned to three homes each. They also have one floater that helps out as needed or if someone calls out. This model is used both for the day shift and nighttime shift. The roamers and floaters meet regularly with staff to discuss client behaviors and needs. Sacramento County had no specific areas of concern. They complimented the discussed areas of change and the graduation of youth. DHCS discussed the pros/cons of the virtual Mental Health review and was appreciative for POYS' feedback on the process. Clarification on mask wearing requirements for POYS clients and staff will be provided as the Department receives details. POYS will submit an electronic Program Statement to include recent revisions. They next meeting is scheduled for September 17, 2021.

met_with: Executive Management


state: CA

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Cindy Johnson arrived at Paradise Oaks Youth Services Main Office to initiate a Required Annual on 6/23/2021 at 10: AM with Laynee Kuhn, Executive Director, due to this facility not currently having any placements. Areas discussed: annual fees, updated Administrator Certificate, waiver for 40 hours of annual staff training; and updated Emergency Disaster Plan (per H&S Code 1565). The status of other requirements was discussed, and current/updated version is being requested, for the following: · CARF International Accreditation was conducted 4/26/21-4/28/21, new certificate is pending · Mental Health Contract is renewed annually with Sacramento County · Mental Health Program approval- is currently in process of renewal and making corrections. · Emergency Intervention Log, via Board Meeting Minutes for the past 6 months, LPA Johnson followed Ms. Kuhn to POYS- Sunset and conducted the inspection. The following items were observed and evaluated by LPA Johnson: Posted items in the facility: Facility License, Emergency Mass Casualty Disaster Plan, Foster Youth Personal Rights, Foster Youth Ombudsman (other posters), exit routes, COVID-19 hand washing instructions, and health and safety information. Kitchen- a cabinet door is broken off. Five refrigerators (four downstairs) tested below 45 degrees F; one freezer tested at zero degrees. Refrigerators and freezers had various areas that needed cleaning and/or removal of old and expired food (Lactaid Milk- 2 half gallons, cream cheese, various condiments) and butter. Area to post menus is available. Hot water temperature tested within the regulatory range of 105-120 degrees (118 degrees). Knives and Sharps will be stored and locked inside the staff office. However, none are currently present. Dishwasher is operable. There are no refrigerated medications. Trash can has a lid. No disinfectants or cleaners are stored in the kitchen. Living Areas- Furniture is clean and in good repair. Smoke & Carbon monoxide detectors are present and operable. Windows have screens, but the blinds had many missing / broken slats. Carpet/flooring are in good repair. The fireplace screen that had been securely fastened and attached, now has sharp edges that can cut. The screen/blockage needs to be safely secured. Bedrooms- There are 3 client bedrooms with double occupancy; all had the required furnishings, including storage space. The facility has the required items for a bed: mattress pad, fitted sheet, top sheet, pillow and mattress in good repair, even if not on the bed; extra linen supply was present. The window in the master bedroom is missing its screen. Window coverings were adequate. Two holes are in the walls in the master bedroom. Smoke detectors are operable. There are no staff bedrooms. Cabinets in the hallway are missing handles/knobs. Bathroom- There are 2.5 client bathrooms (regular, master & half) and 1 staff bathroom. Hot water temperature tested exceeded the regulatory range of 105-120 degrees: 129, 107, 119 and 127 respectively. All client toilets need cleaning. Tub/showers were clean and operable. Buildings and Grounds- Fire extinguisher was not present. Telephone: Available and in operable condition. Carbon monoxide detector and smoke detector were tested and working. Cleaning & Chemical Supplies were not accessible. Passageways are clean and free of obstructions. Facility has no bodies or water, cameras, or firearms on the premises. Outdoor fencing has a few areas that need additional support. Agency has engaged with the neighbors for repairs. Medication- Medication is stored and locked in the filing cabinets inside the staff office, when it is present. Since no youth are currently placed, no medication or documentation were present to inspect. First aid kit was not available to be inspected. Since this facility is currently not occupied with clients and staff are not assigned to this location, file reviews and interviews were not conducted. Prior to resuming operations of this facility, the following items remain needed: Updated forms: LIC 308, 500, 610C If the administrator is changed, an updated board resolution and valid certificate. Adequate food supply- 2 days of perishable, 1 week of non-perishable and snacks Monthly menus and activity schedule need to be posted. Adequate dishware and cooking utensils. Hygiene supplies. Inspection of facility vehicle Beds have all required items No deficiencies are being cited due to no clients in placement. The agency should address all items prior to resuming the operation of the facility. Exit interview conducted and reports discussed with Laynee Kuhn, Executive Director; copies of documentation were provided to the facility, via email.

report_type: Facility Evaluation

visit_type: Annual

met_with: Laynee Kuhn, Executive Director


summary: Facility Evaluation

raw_content:
Narrative:
On 09/17/21 at 1: PM, the third collaborative quarterly meeting with Paradise Oaks Youth Services (POYS) was held to provide technical assistance and collaborative support to assist with and ensure POYS operates a successful program. POYS consists of nine locations: Olivine, Rosa Vista, Hazel, Hickory, Antelope, Mariposa, Old Auburn, Madison, and Sunset. The current census at all locations is 27. Three locations: Madison, Sunset and Old Auburn currently have no foster youth placed. The following were present on an MS Teams virtual meeting: · CCL: Jodean Hall, Licensing Program Manager, Robin Sullivan, Licensing Program Analyst (LPA), Cindy Johnson, LPA, Tammy Hill, LPA · System of Care (SOC): Marjana Jackson, Stacie Kinney. · Sacramento County: Linda Abdelbaki · Department Health Care Services (DHCS): Brian Keefer · POYS: Robert Pye, CEO, Laynee Kuhn, Executive Director, Stephanie Fisher, Program Director POYS reported a staff and family moved into Sunset after their home burned down approximately 2 weeks ago. Annual inspections were completed for all their facilities in June and July, resulting in Technical Advisory/Advisory Notes and no deficiencies cited. CCL will provide the electronic program statement revisions to System of Care. Program statement revisions for the SAY population was submitted but still needs to be reviewed and approved. LPA Marla Horne will review by October 20, 2021. Incident reports regarding smoking on grounds was discussed. Both trauma-informed practices and harm reduction protocols were discussed. Harm reduction practices have not been approved by the Department. POYS is reminded that incident reports should document interventions including staff discouraging youth from smoking. CCL pointed out youth smoking in the backyard is still smoking on grounds which may require additional case management inspections. CCL requested program statement revision to Transportation services to add details of exceptions to provide transportation to youth when extreme weather, youth not feeling well or after hours. CCL requested incident reports be typed due to the difficulty of reading the handwritten reports. At this time there are multiple POYS staff that still hand write reports. This has been an ongoing conversation between POYS and CCL. CCL requests all reports be typed by November 1, 2021. POYS declined this request. CCL requested all youths' names be included in one incident report rather than referring to other involved youth as "peer". CCL recommended using a legend to submit the report to CCL and redacting the names for POYS purposes. POYS declined the request due to confidentiality. The CCL request was requested and approved through upper management and noted not to be a HIPPA violation. CCL requested incident reports and timeframes be more specific. Antecedent information is specific and thorough, yet more follow up details or resolution information is needed and requested. CCL recommended POYS to Technical Support Program (TSP) for incident report writing. POYS approved the recommendation. Sacramento County had no specific areas of concern. DHCS had no specific areas of concern. Due to the upcoming impact of FFPSA on program statements, a deadline for the revisions was not determined and will be included at the time of the FFPSA changes. No further meetings are scheduled.

visit_type: Case Management

met_with: Robert Pye, CEO, Laynee Kuhn, Executive Director, Stephanie Fisher, Program Director,


summary: Facility Evaluation - 2 deficiencies

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Alyssa Burgess and Shawndra Miles made an unannounced annual inspection at the facility and met with a Paradise Oaks Youth Services (POYS) Administrator, Jovan Metoyer, who assisted with this inspection. After the walk-through, LPAs continued their inspection at the POYS Administration Office where we met with Stephanie Fisher, Program Director and Laynee Kuhn, Executive Director. LPAs conducted a walk-through of the facility inside and out. There were no clients present during the inspection as the facility has not been in use since 2020. There are three bedrooms, three bathrooms, a staff office, living room, den, kitchen and garage. LPA inspected and/or reviewed the following: Posting of license and Children's Personal Rights checked; Disinfectants/Cleaning solutions were found to be kept in the kitchen area of the facility. The refrigerator's temperature was read at 40 degrees Fahrenheit; the freezer temperature was at 0 degrees Fahrenheit. There was not an adequate supply of perishable and non-perishable foods as required. The only food present was purchased by the Administrator for the Administrator's personal use. There is a working landline telephone at the facility. All carbon monoxide and smoke detectors were checked with the assistance of the POYS Administrator. There was one carbon monoxide detector installed in the hallway outside of the clients' bedrooms, which was non-functional. The smoke detectors throughout the facility were working as required. There was no first aid kit at the facility. This was previously addressed with the facility on 6/30/2021, at which time they received an advisory note. An adequately sized common room was available. The dining area had enough space to accommodate clients. LPAs observed holes in the walls of the dining area and in the hallway leading to the garage. There were no medications on-site. An expired fire extinguisher was observed in the kitchen and the meter indicated it needed to be recharged. The refrigerators and freezers were not cleaned and had expired food from 2020 to Feb 2022. This was previously addressed with the facility on 6/30/2021, at which time they received an advisory note. Sinks, baths, and shower fixtures were all in good repair. The toilets were not cleaned and the water had evaporated due to limited use. Provisions of soap, paper towels, and other personal hygiene were observed in the master bathroom only. The laundry area was clean; required linen and furnishings were found to be present and in working order in the linen closets. There were no facility service vehicles on-site. There was no indication of the facility campus having any pest infestation. The facility was unclean and in disrepair in several parts: surfaces, doors, walls, and carpets were dirty with smears, crumbs, etc. there were holes in the wall in the bathroom near the garage/kitchen, broken moulding and no door on the hallway closet, a missing light bulb in one bathroom, garbage on counter in kitchen, dirty dishes in sink, general clutter and debris throughout whole house. Administrator's bedroom messy, piles of dirty linens/towels in the garage. Staff office had a foul odor. The facility has a Disaster and Mass Casualty plan that is up-to-date and readily available. LPAs instructed the facility to amend the plan to indicate how refrigerated medication will be stored. Currently, the facility is not conducting drills, as there are no clients. LPA's observed an POYS Administrator residing at the facility. During the course of the inspection the Administrator admitted to having a firearm with a loaded magazine and ammunition improperly stored on the premises. The firearm was in a locked box, which the Administrator unlocked for LPAs to show an unloaded firearm, with two magazines next to it, one of which was loaded. The Administrator also had two boxes of additional ammunition, which was kept unlocked, in a bag. LPA let Administrator know those cannot be stored in that manner, and how to store them properly. Administrator removed the ammunition from the magazine and took all ammunition to his car to be secured. Additionally, there was curved knife that was in the Administrator's bedroom, which he stated was confiscated from a client. The Administrator's room smelled of marijuana, showed presence of marijuana, and smoking paraphrenia, to which the Administrator admitted to owning. There were various other things missing or incorrect, which LPA detailed in the attached Technical Violation Advisory Notes, which are not citations: 80076(a)(17,19-20), 80088(e)(3), Interim Licensing Standards 87076(c)(4), Health & Safety Code 1565(a)(7)(e). On this date, the facility is being cited for violations of the California Code of Regulations (CCR), Title 22, Division 6, Sections: 80087(d), 80087(g)(3), 80087(a),80087(c), 80076(a)(18), 87076(c)(1), 80075(g), 80088(c). An exit interview was conducted with the Administrator and a copy of this report was emailed to her with appeal rights and read receipt which will serve as the record of receipt.

Deficiencies:
80088(c): Deficient Practice Statement
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4Based on observation, the licensee did not comply with the section cited above when the protective screen of both fireplaces were in disrepair.
80075(g): Deficient Practice Statement
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4Based on observation, the licensee did not comply with the section cited above when there was no First Aid Kit on the premises.

met_with: Jovan Metoyer, Administraor; Stephanie

title:
Fixtures, Furniture, Equipment and Supplies

(c) Fireplaces and open-faced heaters shall be inaccessible to clients to ensure protection of the clients' safety.

This requirement is not met as evidenced by

title:
(g) If the facility has no medical unit on the grounds, first aid supplies shall be maintained and be readily available in a central location in the facility.

This requirement is not met as evidenced by


summary: Facility Evaluation

raw_content:
Narrative:
On January 27, Licensing Program Manger (LPM) Dara Campos, Regional Office Manager Margo Castaneda, and Licensing Program Analyst (LPA) Stephannie Verna held an Informal Conference Meeting from 1: PM to 2: PM to discuss concerns. The meeting was facilitated by LPM Campos. Attendees included (in-person) Paradise Oaks Youth Services staff, Laynee Kuhn (Executive Director), Stephanie Fischer (Administrator), Amanda Lee (administrator) and Board Member Al Werner, as well as (Via Teams Meeting), Shawn Wade Fresno County Social Worker, Julie Leong, Case Manager Mateo County Behavioral Health, Khoa Nguyen Stanislaus County Social Worker, and Tia Carter Sacramento County Social Worker. The topics discussed included: Absent without Permission Temporary Release (TR) Communication with local law enforcement Cancelling Missing Person reports Incident Report details No deficiencies were cited during today's meeting. A copy of this report was provided to Laynee Kuhn, Executive Director.


facility_name: PEACOCK ACRES

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

raw_content:
Narrative:
On 03/16/2021 and 06/07/ LPA Segura observed that the facility has a defunct intercom system installed in the home. What appears to be the main control in the kitchen; has a faceplate that is no longer secure to the wall and falls down onto the counter. LPA Segura was able to use their state issued iphone to capture photos of the intercom. During todays inspection the facility repairman used a sensor to show that there were live wires in the wall of this intercom; although they were capped with plastic electrical caps. Further inspection of the home on 03/16/2021 and 06/07/2021, LPA Segura observed there were multiple faceplates missing from electrical and phone outlets in the home. LPA was able to use their state issued iphone to capture pictures of the missing faceplates. Some of the faceplates appear to be missing in areas the facility has had to patch the walls due to residents damaging the walls and outlets. On todays date, 06/07/ LPA observed that the living room sliding door windows are in need of repairs. The part of the sliding doors that is are not meant to slide have been pushed away from the wall creating a half inch opening to the outside. Further one of the sliding doors has come off the rail creating a half inch opening to the outside. Both items have allowed cold air and insects to come into the home. Based on observation and photographic evidence obtained, there is a preponderance of the evidence to prove that the facility is in need of repair and deep cleaning. Therefore, the above allegations are substantiated. Appeal Rights were provided and discussed with the Andrew Sandoval and deficiencies were cited. Exit interview conducted and a copy of the report was left Andrew Sandoval.

Investigation Findings:
13The purpose of the inspection was to deliver the findings for the above complaint allegations. On March 11, 2021, The department recevied a complaint regarding the cleanliness and good repair of the facility. Based physical evidence, observed on March 16, 2021 and June 7, 2021 it was determined that the facility is in disrepeair and in need of deep cleaning. On 03/16/2021 at 10:30am LPA Segura observed the facility garage had excrement and urine of the facility pert dog. Once in the home LPA observed that the walls and baseboards throughout the home are in need of deep cleaning as they were observed to have buildup of liquid spills, dust and dirt. On todays date 06/07/ LPA Segura observed that the garage is clean and did not observe any urine or feces; however, the inside is still in need of deep cleaning of surfaces, walls and baseboards. LPA was able to take pictures of the items in need of cleaning on 03/16 and 06/07. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Joel Segura LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: PEACOCK ACRESFACILITY NUMBER: 270702624

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

Deficiencies:
00871: Based on photo evidence and observation of the1
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7

report_type: Complaint Investigation

met_with: Andrew Sandoval

complaint_status: SUBSTANTIATED

title:
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7(a)	The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement is not met as evidenced by


summary: Complaint Investigation - Substantiated - 1 deficiency

raw_content:
Narrative:
On 06/07/ LPA Segura observed that the facility has a defunct intercom system installed in the home. What appears to be the main control in the kitchen; has a faceplate that is no longer secure to the wall and falls down onto the counter. LPA Segura was able to use their state issued iphone to capture photos of the intercom. During todays inspection the facility repairman used a sensor to show that there were live wires in the wall of this intercom; although they were capped with plastic electrical caps. Further inspection of the home; LPA Segura observed there were multiple faceplates missing from electrical and phone outlets in the home. LPA was able to use their state issued iphone to capture pictures of the missing faceplates. Some of the faceplates appear to be missing in areas the facility has had to patch the walls due to residents damaging the walls and outlets. On todays date, 06/07/ LPA observed that the living room sliding door windows are in need of repairs. The part of the sliding doors that is are not meant to slide have been pushed away from the wall creating a half inch opening to the outside. Further one of the sliding doors has come off the rail creating a half inch opening to the outside. Both items have allowed cold air and insects to come into the home. Based on observation and photographic evidence obtained, there is a preponderance of the evidence to prove that the facility is in need of repair and deep cleaning. Therefore, the above allegations are substantiated. Appeal Rights were provided and discussed with the Andrew Sandoval and deficiencies were cited. Exit interview conducted and a copy of the report was left Andrew Sandoval.

Investigation Findings:
13The purpose of the inspection was to deliver the findings for the above complaint allegations. On June 1, 2021, the department recevied a complaint regarding the good repair of the facility. Based physical evidence, observed on June 7, 2021 it was determined that the facility is in disrepeair and in need of deep cleaning. In the course of inspecting the home, LPA observed that the walls and baseboards throughout the home are in need of deep cleaning as they were observed to have buildup of liquid spills, dust and dirt. LPA was able to take pictures of the items in need of cleaning 06/07. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Joel Segura LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: PEACOCK ACRESFACILITY NUMBER: 270702624

Deficiencies:
00871: Based on photo evidence and observation of the1
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3
4
5
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7

met_with: Andrew Sondoval


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that there is vermin in the home. The client and staff have not reported seeing them in the home. Appeal Rights were provided and discussed with Andrew Sandoval. No deficiencies were cited. Exit interview conducted and a copy of the report was left with the Andrew Sandoval.

Investigation Findings:
13The purpose of the inspection was to deliver the findings for the above complaint allegations. On June 3, 2021, the department recevied a complaint regarding there being vermin in the home. Based physical evidence, interview of C1, and observation on June 7, 2021 it was determined that the facility may have vermin. (C1, Client 1, see confidential name list LIC 811 dated 06/07/2021). In the course of inspecting the home, LPA did not observe any evidence of there being vermin in the home. C1 stated that they have never seen any vermin in the home, rather they have heard them in the attick. The facility provided a bill showing there is monthly pest control service to the home. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Joel Segura LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: PEACOCK ACRESFACILITY NUMBER: VISIT DATE: 06/07/2021

complaint_status: unsubstantiated


raw_content:
Narrative:
Interviews conducted with S5, S7 and S8 revealed that they had been trained and participate in annual refresher courses. Trainer S7 stated that he conducts regular training to for staff specifically for the nonviolent crisis interventions, other training's are conducted by the facility manager or self-paced online training by outside providers. The interview with S7 revealed that the runaway training is not part of the Nonviolent Crisis Intervention (NCI) and Emergency Intervention Plan training. Eric stated that the NCI training only touches on runaways when a hold is necessary not prevention. Eric indicated that due to personal rights the facility mostly tries to talk children out of running away and only ever conduct a hold on a child if they are being a danger to themselves or others such as attempting to run into traffic. Interviews conducted with staff revealed that staff felt as if they could not do anything to prevent a child from running away; however, did admit that they attempt to talk children out of running away by following them when they attempt to walk away and conduct bed checks overnight to ensure they are still in bed. Staff also report calling non-emergency number for the Monterey Sheriff's office to report a missing child. A review of the facility Program Statement revealed that although the facility does have a Runaway Plan, there is no indication that facility staff are trained in the plan. LPA Segura reviewed at hire training list and new hire training checklists for five staff. None of the documents showed that the facility is training staff on the runaway plan. An interview conducted with S8 confirmed that although staff knows some of the steps of the runaway plan, they had not seen the plan before LPA showed them a copy on 09/17. A brief review was conducted with administrator Andrew Sandoval of the facility training documents and confirmed that the Runaway Plan is not listed on any of the checklists or training materials. Based on observation and photographic evidence obtained, there is a preponderance of the evidence to prove that the facility staff were not trained in the agency Runaway Plan. Therefore, the above allegations are substantiated. Appeal Rights were provided and discussed with the Andrew Sandoval and deficiencies were cited. Exit interview conducted and a copy of the report was left Andrew Sandoval.

Investigation Findings:
13The purpose of the inspection was to deliver the findings for the above complaint allegations. LPA Segura met with administrator Anrew Sandoval. On March 11, 2021, The department received a complaint regarding untrained staff. LPA Segura interviewed staff S4 on 04/07/21 at 4:15pm, S5 on 08/25/21 at 10:15am, S6 on 08/20/21 at 10am, S7 on 09/01 at 4:15pm, S8 and S2 on 09/17 at 11:00am. See confidential names list LIC 811 dated 09/21/ LPA Segura obtained staff training records at the facility on 08/25/2021 at approximately 10am. Five staff training documents were reviewed for new hire training. LPA Segura observed that all five staff had evidence that they were trained in accordance with the facilities training plan including Non violent Crisis Intervention and Emergency Intervention Plan. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Joel Segura LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: PEACOCK ACRESFACILITY NUMBER: VISIT DATE: 09/21/2021

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

Deficiencies:
87076.11: Based on staff interviews and records review the1
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7Plan of Correction due 09/22/21.

title:
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7(C)(3)(C) Facility's policies and procedures, including reporting requirements to the Department and as a mandated reporter; This requirement is not met as evidences by


raw_content:
Narrative:
RP further indicated that this occurred due to the food meant for the meal had been consumed prior to the menu planned day. LPA Segura conducted an interview with staff S8 (Staff 8, see confidential names list LIC 811 dated 09/21/21) on 09/17 at approximately 11am and S2 on 09/14 at approximately 12:30pm. Interview with S8 confirmed that there are times when clients want to eat a meal prior to the planned date on the menu and they have to improvise if the ingredients are used prior to the planned meal day. S8 denied that there were times that there was not enough food. S8 stated that there is always sufficient food. Interview with S2 revealed that the facility staff do attempt to stick to the posted menu; however, clients sometimes want something different or want the meal sooner than posted. S2 indicated that in those cases staff have to choose a different meal to provide clients. S2 stated that if they are missing ingredients or were used up, the staff calls the office to request the items be brought to the home. Interview was conducted with C1 (Client 1, see confidential names list LIC 811 dated 09/21/21) on 09/17/2021 at 12:30 pm. C1 stated denied there was insufficient food in the home. An interview was conducted with C2 on 09/14/21 at 1:20 pm. C2 indicated that they had sufficient food and had no complaints to report about food. On 09/ LPA Segura conducted an inspection of the facility menu and confirmed that the facility had the ingredients necessary to cook meals listed on the Menu. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that there was insufficient food service in the home; therefore, the above allegations are unsubstantiated. Appeal Rights were provided and discussed with Shaniz Beza. No deficiencies were cited. Exit interview conducted and a copy of the report was left with Shaniz Beza.

Investigation Findings:
13Licensing Program Analyst (LPA) Joel Segura conducted a follow-up complaint investigation to the STRTP (Short Term Residential Therapeutic Program) and met with Shaniz Beza. The purpose of the inspection was to deliver the findings for the above complaint allegation. On March 11, 2021, an anonymous reporting party (RP), reported to the department that the facility failed to provide adequate food service to clients in care. The RP reported that the facility does not follow the menu and often does not have enough food. An interview conducted by LPA Segura with RP on 08/18 at 3pm confirmed the reported information that the facility does not follow the posted menu. RP also indicated that although there were times when the menu item was not available, the facility had food to cook for clients in care. Continued on 9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Joel Segura LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: PEACOCK ACRESFACILITY NUMBER: VISIT DATE: 09/24/2021

met_with: Shaniz Beza


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced complaint inspection at the above facility on 3/21/2022. The purpose for this inspection is to deliver the findings for the above allegations. Based on interviews conducted with staff and supportive documentation to include but not limit; photos from facility website.The facility is currently not operational and no clients reside there as repairs are being done. during this investigation it was determined that, although there may have been incidents that were unreported to the department, there are no specific incidents, dates, or times that can be tracked or located to know if they did or did not happen. It was also determined that some of the photos on the website were found to be stock photos from the internet, there were two photos with no known source. The facility was not able to provide contact information or a statement from person who created the website. Therefore these allegations are Unsubstantiated. There were no violations of California Code of Regulations, Title 22, Division Six or Interim Licensing Standards cited during this inspection. An exit interview was conducted and a copy of this report will be sent to Shaniz Beza at 1: PM UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Shaniz Beza, Executive Director


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with Ana Hernandez, TAY Program Manager at 10: AM on 9/13/24. Due to this incident occuring sometime between 2010 and 2012, LPA was unable to find enough evidence to determine if the facility violated any regulations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was emailed to Ana Hernandez, TAY Program Manager. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Ana Hernandez, TAY Program Manager


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
On September 24, 2021, the Department received a complaint alleging clients engaged in sexual interactions by cuddling/spooning with each other and staff did not provide supervision to meet the needs of the clients. Based on confidential interviews and documents reviewed, Peacock Acres did not provide close supervision as his Needs & Services Plan stated and C1 and C2 cuddled/spooned with each other, without staff supervision. C1 has a history of behaviors that Peacock Acres felt needed the additional staff support. Peacock Acres did not follow C1's Needs & Services Plan as required, which led to the inappropriate client interactions. Additional staff support and staff supervision was needed. Based on confidential interviews conducted and documents reviewed, there is a preponderance of evidence that clients engaged in sexual interactions while in care and staff did not provide supervision to meet the needs of the clients. Therefore, the above allegations, are substantiated.

Investigation Findings:
13Licensing Program Analyst (LPA) Monica Pavia conducted a complaint investigation. LPA Joel Segura initiated a complaint investigation with Executive Director, Shaniz Beza with Peacock Acres on, 9/24/21 at 9:30am. Investigations Bureau Investigator (INV) Mariana Lomeli conducted confidential interviews with clients, staff, Monterey County Sheriff's Department, and county social workers. LPA Pavia conducted interviews with staff and reviewed client Needs & Services, client incident reports and staff training. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Monica Pavia 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: 3 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: PEACOCK ACRESFACILITY NUMBER: VISIT DATE: 11/09/2021


facility_name: PEACOCK ACRES GROUP HOMES INC.

raw_content:
Narrative:
S1 stated there were no other staff in the immediate area when C1 began to hit S1. S1 indicated that he was attempting to block C1 from hitting him and eventually made it out to the living room where other staff were present and intervened. Staff S3 and S2 intervened and escorted the client to the couch. Interview with former staff S3 on 09/08/21 at 1:45 pm, revealed that C1 had sat down on the couch and appeared to have calmed down. S3 indicated that C1 stood up, still appearing to be calm and then suddenly ran into the kitchen where S1 was attempting to keep distance from C1. S3 indicated that all she witnessed was S1 attempting to deflect C1 from hitting him and pushed C1 away in a further attempt to stop the attack. S3 indicated that again her and S2 escorted the client outside to try and calm him down. S3 indicated that she did not observe any injuries on C1; but did hear C1 say "how could a grown man do that to a little boy". S3 indicated she did not know what C1 was referring to, and assumed it was S1 attempting to push client away. S3 indicated that she did not hear S1 making any inappropriate statements to C1. An interview was conducted with S2 on 08/20/21 at approximately 10:15am. The interview with S2 revealed that C1 was trying to punch and hit S1. S2 stated he did not see S1 hit, handle in a rough manner or hear S1 state anything inappropriate to C1. S2 indicated that C1 did have a negative opinion of S1. A review of the CPS report made regarding this incident did contain a statement from C1 indicated that S1 had hit C1 and had made inappropriate comments toward C1. C1 was taken into custody by juvenile hall and had run away various times since removal from the facility. A review of county welfare database indicates that as of 06/25/ C1 has been missing therefore no interview was conducted. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that C1 was hit, handled in a rough manner or inappropriate comments were made; therefore, the above allegations are unsubstantiated. Appeal Rights were provided and discussed with Nate Garner. No deficiencies were cited. Exit interview conducted and a copy of the report was left with Nate Garner.

Investigation Findings:
13Licensing Program Analyst (LPA) Joel Segura conducted a follow-up complaint investigation to the STRTP (Short Term Residential Therapeutic Program) and met with the facility manager Nate Garner. The purpose of the inspection was to deliver the findings for the above complaint allegations. On 03/18/21 the department received an anonymous complaint alleging that staff S1 had hit, handled in a rough manner and made inappropriate comments to C1 (Child 1, Staff 1, see confidential names list dated 09/14/2021). An interview was conducted with S1 on 04/07/21 at approximately 3pm. S1 indicated that C1 had a behavior incident due to being denied a late evening outing to a store. S1 denied having hit the youth, handling in a rough manner or making any inappropriate comments to C1. S1 indicated the youth was highly agitated and he had encountered the youth in the darkened hallway outside of the staff office. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Joel Segura LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. San Jose, CA Facility Name: Peacock Acres Group Homes INC.FACILITY NUMBER: VISIT DATE: 09/14/2021

met_with: Nate Garner


raw_content:
Narrative:
On this date LPA used their state issued iPhone to take pictures of the grounds at the facility. Pictures consisted of the linoleum near resident bedrooms in need of mopping and sweeping, stained carpets, power outlets missing face plates, missing floor board, visible patches, a small section of the homes siding appeared to have been torn off, cabinets in need of wiping from hand grease, kitchen cabinets with stuck on food particles and spills, and patches that seem to have been damaged again. During the 03/24 inspection, LPA observed that the facility had installed new windows to replace the previously broken ones. Note that although patches are not visually pleasing, they are not an immediate health and safety risk to clients in care and are fixes to damaged walls. LPA Segura interviewed staff S4 on 04/07/21 at 4:15pm, S5 on 08/25/21 at 10:15am, S6 on 08/20/21 at 10am, S7 on 09/01 at 4:15pm, S8 and S2 on 09/17 at 11:00am. See confidential names list LIC 811 dated 09/21/21. LPA Segura obtained staff training records at the facility on 08/25/2021 at approximately 10am. Five staff training documents were reviewed for new hire training. LPA Segura observed that all five staff had evidence that they were trained in accordance with the facilities training plan including Non violent Crisis Intervention and Emergency Intervention Plan. Interviews conducted with S5, S7 and S8 revealed that they had been trained and participate in annual refresher courses. Trainer S7 stated that he conducts regular training to for staff specifically for the nonviolent crisis interventions, other trainings are conducted by the facility manager or self-paced online training by outside providers. The interview with S7 revealed that the runaway training is not part of the Nonviolent Crisis Intervention (NCI) and Emergency Intervention Plan training. S7 stated that the NCI training only touches on runaways when a hold is necessary not prevention. S7 indicated that due to personal rights the facility mostly tries to talk children out of running away and only ever conduct a hold on a child if they are being a danger to themselves or others such as attempting to run into traffic. Continued on 9099C Interviews conducted with staff revealed that staff felt as if they could not do anything to prevent a child from running away; however, did admit that they attempt to talk children out of running away by following them when they attempt to walk away and conduct bed checks overnight to ensure they are still in bed. Staff also report calling non-emergency number for the Monterey Sheriff's office to report a missing child. A review of the facility Program Statement revealed that although the facility does have a Runaway Plan, there is no indication that facility staff are trained in the plan. LPA Segura reviewed at hire training list and new hire training checklists for five staff. None of the documents showed that the facility is training staff on the runaway plan. An interview conducted with S8 confirmed that although staff knows some of the steps of the runaway plan, they had not seen the plan before LPA showed them a copy on 09/17. A brief review was conducted with administrator Andrew Sandoval of the facility training documents and confirmed that the Runaway Plan is not listed on any of the checklists or training materials. Based on observation and photographic evidence obtained, there is a preponderance of the evidence to prove that the facility was in need of repair and deep cleaning and staff were not trained in the agency Runaway Plan. Therefore, the above allegations are substantiated. Appeal Rights were provided and discussed with the Andrew Sandoval and deficiencies were cited. During todays inspection LPA Segura was given a tour of the facility ground and observed all windows have been repaired, floors cleaned and swept, carpets cleaned and siding of the home repaired and painted. Deficiencies were cleared as of todays inspection. Exit interview conducted and a copy of the report was left Andrew Sandoval

Investigation Findings:
13The purpose of the inspection was to deliver the findings for the above complaint allegations. On March 11, 2021, The department received a complaint regarding the cleanliness, good repair of the facility and untrained staff. Based physical evidence, observed on March 16, 2021 and March 24, 2021 it was determined that the facility was in disrepair and in need of deep cleaning. On 03/16/2021 at 3:30pm LPA Segura was given a virtual tour of the home by facility manager Nate Garner. A tour of the home revealed that the facility had several broken windows that were caused by a resident on the previous Friday 03/12/21; on 03/14/2021 resident had also destroyed several light fixtures which had been repaired by the inspection on 03/14. On March 24, 2021 at 12:00pm, LPA Segura returned to the facility to conduct a facility inspection. Continued on 812C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Joel Segura LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. San Jose, CA Facility Name: Peacock Acres Group Homes INC.FACILITY NUMBER: VISIT DATE: 09/21/2021

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

Deficiencies:
87065.11: Based on staff interviews and records review the1
2
3
4
5
6
7Plan of Correction due 09/22/21.


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with Shaniz Beza , Executive Director (ED) at 11: AM on 6/8/22. On 05/17/2022, the San Jose Children's Residential Regional Office (RO) received a complaint regarding the above allegations. The RO referred this case to the Investigations Branch on 05/17/2022, and Investigations Branch Investigator (IB) Maria Barragan was assigned to interview individuals involved with the allegations and they denied the allegations were true. IB Barragan conducted confidential interviews from 5/24/22-5/25/22. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was provided to Shaniz Beza, ED. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

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

met_with: Shaniz Beza, Excutive Director


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
Bathroom floors were dirty and needed to be mopped. One of the bathrooms had a broken cabinet door that needed to be repaired. A light fixture in the hallway was broken. The TV stand was dirty and had a dead flower with lots of pedals on it. LPA took photos of these observations and will document them in a LIC 813. Based on these observations there is a Buildings and Grounds violation. Based on confidential interviews conducted during the initial visit on 5/20/22 the problem has to do with staffing issues. The combination of new employees, low staffing numbers, and loss of a key employee that handled a lot of the cleaning responsibilities has led to the facility not being maintained. The complaint allegations, staff do not properly maintain the facility and facility is in disrepair, are valid because the preponderance of the evidence standard has been met As a result of this visit, there is one title Regulation and General Licensing Standards Buildings and Grounds (a) violation observed. The facility will be cited (see 809-D for details). Appeal rights were discussed and provided to ED. Exit interview was conducted and a copy of this report was provided to Shaniz Beza, ED whose signature on this form confirm receipt of these documents.

Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed complaint. LPA met with Shaniz Beza , Executive Director (ED) at 11: AM on 6/8/22. On 5/20/ LPA made an initial visit to open this complaint. During the visit the following was observed: Carpets were stained and trash was on the ground, it doesn't look like it has been vacuumed in a while. Laundry room floor was dirty, and it looks like it hasn't been cleaned/mopped in a while. clients rooms were all messy, clothes and trash were on the floors. One of the client's room had dirty dishes, food that was not properly stored, food stains/possibly throw up on the floor, a broken light fixture, carpet needed to be vacuumed, carpet need to be cleaned, and dresser/drawers that are broken and need repair. Another client's room had a broken door that needed repair. All the client's rooms needed the carpet to be vacuumed and cleaned. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. San Jose, CA Facility Name: Peacock Acres Group Homes INC.FACILITY NUMBER: VISIT DATE: 06/08/2022


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with Clarissa Joseph, Residential Manager (RM) and Steisha Monderoy, Strategic Project Director (SPD) at 12: PM on 7/29/22. On 3/1/2022, the San Jose Children's Residential Regional Office (RO) received a complaint regarding the above allegations. The RO referred this case to the Investigations Branch on 3/1/2022, and Investigations Branch Investigator (IB) Ruben Munoz was assigned to investigate this allegation on 3/2/22. Based on IB Munoz's investigation and confidential interviews conducted 3/9/22-3/14/22. There was not enough evidence to prove the above allegations occurred. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations . Therefore the above allegations are unsubstantiated. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was to Clarissa Joseph, Residential Manager (RM) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

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


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with Clarissa Joseph, Residential Manager (RM) and Steisha Monderoy, Strategic Project Director (SPD) at 12: PM on 7/29/22. The allegation was investigated by the Investigations Branch (IB). Please refer to LIC 9099 7/29/ CONTROL NUMBER 26-CR-20220301131245 which entails this: On 3/1/2022, the San Jose Children's Residential Regional Office (RO) received a complaint regarding the above allegations. The RO referred this case to the Investigations Branch on 3/1/2022, and Investigations Branch Investigator (IB) Ruben Munoz was assigned to investigate this allegation on 3/2/22. Based on IB Munoz's investigation and confidential interviews conducted 3/9/22-3/14/22. There was not enough evidence to prove the above allegations occurred. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations . Therefore the above allegations are unsubstantiated. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was to Clarissa Joseph, Residential Manager (RM) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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


raw_content:
Narrative:
On 1/27/22, the County received a 14-day notice for a client residing at Peacock Acres. A County representative (CR) claimed they were told the reasoning for this is because Peacock Acres did not have enough staff to safely provide supervision for the client. CR said that the facility mentioned an altercation the youth in question had to show this. This led to the allegations that Peacock Acres does not have sufficient staff, does not provide a safe environment, and a youth was involved in an altercation with another youth while in care. RCR felt that the 14-day notice was unjustified because they felt the client in question was making progress and that they should not be given a 14-day notice because of lack of staffing. On 3/3/22 when LPA Simien asked Peacock Acres about the client's issues and why a 14-day notice was issued. Peacock Acres explained, since placement, the client has struggled with several behavioral challenges that the program is unable to effectively address. These challenges have continued to impede Client's ability to make progress towards his treatment goals and have continued to pose a risk to safety of staff and other residents of the program. Included in these challenges are ongoing property destruction, continuing to store and smoke marijuana in the home, verbal threats to kill and/or harm both staff and other residents, theft of Peacock Acres and other resident's property with intention to sell, and, inciting and provoking another resident to become physically assaultive, punching another resident several times, and ongoing harassment of another resident (refusing to let that resident use the kitchen or exit his room), purposely destroying other resident's property and stalking other residents around the home while posturing and yelling threats and homophobic/transphobic slurs, throwing items at other residents resulting in property damage. The client has been unresponsive to lower level interventions instead requiring police intervention, has been unable to commit to maintaining the ongoing safety of the home and other residents, and voiced his ongoing intention to try to harm other residents. His behaviors have resulted in marked increases in the mental health symptoms of other residents, required Peacock Acres to temporarily place residents in another lower level home to ensure their safety, and have prevented clinical staff from implementing therapeutic components of the program (ex: providing group therapy) due to the need for increased staff ratios to help stabilize the client and maintain safety in the home. When LPA Simien mentioned to Peacock Acres the allegation of not having sufficient staff and that CR claimed that they said they didn't have enough staff, they said that they are maintaining proper staff-to-client ratios based on ILS V.4 standards. They also mentioned that the client in question is much larger than the average client and that it would take more than one staff member to subdue and redirect the client in question. They said they could not risk the whole program for one client. At the time of LPA Simien's inspection of Peacock Acres on 2/16/22 they had the proper client-to staff ratio. Based on the review of staff schedules from 1/1/22-1/31/22 it showed that Peacock Acres did have the proper client-to-staff ratio, although there is no way LPA Simien can confirm staff worked those shifts. CR said that because Peacock Acres does not have enough staff and the altercations the client in question is having, Peacock Acres does not provide a safe environment. When LPA Simien brought up the allegation that the facility does not provide a safe environment, staff responded by saying they felt they provide a safe environment for clients. They mentioned that some of the clients (including the client in question) behaviors and actions create an unsafe environment. Based on confidential interviews LPA conducted with clients on 2/26/22 clients felt that Peacock acres provided a safe environment and only other clients make them feel unsafe. The clients LPA Simien interviewed mentioned the client in question as creating an unsafe environment. LPA Simien asked clients "Has there been any time you have felt or observed yourself, staff, or other kids being in danger at Peacock?". They responded, only when the client in question gets upset, this individual tends to physically attack people. They also mentioned that the client in question bullies and attacks them and because of this they do not like the client in question. When LPA Simien brought up the allegation that a youth was involved in an altercation with another youth while in care, staff responded that although altercations happen between clients, they respond to them within CCL regulations. They also mention that the client in question is usually the aggressor in these altercations with other clients. Staff pointed out an incident that occurred on 2/5/22 where the client in question attacked another client in which they had to call law inforcment and the client in question was booked in juvenile hall. On 2/16/ LPA Simien asked clients, "do you feel like there are enough staff to stop physical altercations?". The clients' responses were mixed. They responded, "yes, staff put a stop to bullying" and "kind of, staff attempts to stop altercations." Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations . Therefore, the above allegations are unsubstantiated. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was to Clarissa Joseph, Residential Manager (RM).

Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with Clarissa Joseph, Residential Manager (RM) and Steisha Monderoy, Strategic Project Director (SPD) at 12: PM on 7/29/22. During the investigation, LPA Simien conducted confidential interviews. They were conducted on 2/26/22, 3/3/22, and 7/7/22. LPA Simien reviewed and obtained copies of client files, needs and service plans, treatment plan, safety plan for clients, a copy of the staff schedule from 1/1/22-1/31/22, current phone list, graveyard time punch log (staff check in every 30 minutes) from 1/1/22-1/31/22, sleep chart documents for the weeks of 1/1/22 through 1/31/22 for clients, daily mental health progress notes for clients from 1/1/22-1/31/22 and house notes from 1/1/22-1/31/2022, police report numbers and name of responding officers, incident reports for clients for December 2021 and January 2022. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. San Jose, CA Facility Name: Peacock Acres Group Homes INC.FACILITY NUMBER: VISIT DATE: 07/29/2022

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


raw_content:
Narrative:
On 1/27/22, the County received a 14-day notice for a client residing at Peacock Acre and had a preservation CFT meeting with the facility. The facility explained that the reason for the 14-day notice was that they felt the client question could no longer make therapeutic progress in an environment with peers with behavioral issues and that they became a health and safety risk for clients and staff. Peacock Acres suggested that the client would benefit from being placed in an ITFC resource foster home. CFT Facilitator for the County stated that this was not an option for the client unless they could demonstrate sustained progress for 3 months or longer and that ITFC resource foster homes were in short supply and it was unlikely the County would be able to find one. Peacock Acres also suggest maybe placing the client in Texas to be closer to their Mother. The County responded that they legally could not place client in Texas. When LPA Simien talked to a County representative (CR) about the CFT meeting they claimed they were shocked by the 14-day notice and that Peacock Acres said that the client in question was doing well and progressing clinically. When LPA Simien brought this up to Peacock Acres, they acknowledge that the client did well one-on-one with clinical team but regressed with behavioral issues while with other peers with behavioral issues. On 3/3/22 when LPA Simien asked Peacock Acres about the client's issues and why a 14-day notice was issued. Peacock Acres explained, since placement, the client has struggled with several behavioral challenges that the program is unable to effectively address. These challenges have continued to impede Client's ability to make progress towards his treatment goals and have continued to pose a risk to safety of staff and other residents of the program. Included in these challenges are ongoing property destruction, continuing to store and smoke marijuana in the home, verbal threats to kill and/or harm both staff and other residents, theft of Peacock Acres and other resident's property with intention to sell, and, inciting and provoking another resident to become physically assaultive, punching another resident several times, and ongoing harassment of another resident (refusing to let that resident use the kitchen or exit his room), purposely destroying other resident's property and stalking other residents around the home while posturing and yelling threats and homophobic/transphobic slurs, throwing items at other residents resulting in property damage. The client has been unresponsive to lower level interventions instead requiring police intervention, has been unable to commit to maintaining the ongoing safety of the home and other residents, and voiced his ongoing intention to try to harm other residents. His behaviors have resulted in marked increases in the mental health symptoms of other residents, required Peacock Acres to temporarily place residents in another lower level home to ensure their safety, and have prevented clinical staff from implementing therapeutic components of the program (ex: providing group therapy) due to the need for increased staff ratios to help stabilize the client and maintain safety in the home. Peacock Acres said they would try to preserve placement if the County could take back the client while they tried to find more staff to be better equipped to handle the client's behavior issues. The County said that was not possible. Based on conversations with Peacock Acres and CR, there was a miscommunication/misunderstanding regarding the plan of action for the client. Both said that there was an agreement that the client would stay with their mother for two weeks (starting on 2/10/22) while the County found a new placement (with County providing updates). Peacock Acres would attempt to hire more staff to accommodate the client's behavioral issues. The misunderstanding/miscommunication stems from what would happen after the client's stay with their mother. The County said there was an expectation that the client would go back to Peacock Acres if no placement was found. Peacock Acres says there was no agreement to accept back the client after their stay with their mother. On 2/18/22, Peacock Acres received an email from the client's Social Worker stating no placement had been found for client, providing return date for the client and expectations for him to be picked up at the airport. On 2/20/22, Peacock Acres sent an email to the client's Social Worker informing them of the decision not to accept the client back into the facility following return from home visit due to ongoing safety issues presented by doing so. Peacock Acres provided LPA Simien a screen shot of the email with time stamps to confirm that the email was sent to the Social Worker on 2/20/22. Peacock Acres said they didn't get a response back from the client's social worker On 2/22/22, Peacock Acres sent an email with the client's discharge summary to client's Social worker. Peacock Acres provided LPA Simien a screen shot of the email with time stamps to confirm the email was sent on 2/22/22. On 2/23/22, Client and their Social Worker flew to San Jose with the expectation that Peacock Acres were going to pick up them up. The County said that Peacock Acres refused to pick up client because of previous 14-day notice and left the client and Social Worker stranded. Once they realize that Peacock Acres was not going to pick up the client, The County tried calling various staff members of Peacock Acres, but no one answered. This event lead to the allegations: minor was abandoned while in care, wrongful eviction, minor is being deprived of their possessions, staff are not responsive to requests for communication, and facility's phone went unanswered. When LPA Simien mentioned to Peacock Acres the allegation minor was abandoned while in care, they mentioned the emails they sent to the client's Social Worker (mentioned above). They said despite them informing the Social Worker they were not taking back the client and the discharge summary, The County still sent the client and Social Worker to San Jose. When LPA Simien mentioned to Peacock Acres the allegation of wrongful eviction, they said they had a consultation on 2/15 with an Alliance representative regarding the legality of not accepting client back into placement following his two week home visit. Based on this consultation it was determined that the client would not be accepted back following visitation with mother as the County had stopped paying for client's placement after his departure to home visit. The Days to find placement had passed and there was no prior agreement with the County that Peacock Acres would continue placement of client after 14 days. Given client's behaviors prior to leaving on visit and additional events that had occurred in the house, client was increasingly likely to pose ongoing safety risks to the other residents of the home if they returned back. Also, increased staffing beyond required 1:3 staff to client ratio could not be secured to manage this risk. LPA Simien reviewed Peacock Acres Discharge Policy and it states, "Reasons for an unplanned discharge, removal, or transfer include but are not limited to 1. Repeated program violations, 2. Health and safety of other residents is endangered by the child's or youth's continued presence 3. Repeated or prolonged absences from the facility (AWOLs) 4. If it is determined the facility can no longer meet the needs of the child or youth". Peacock Acres determined the client triggered reasons two and four for unplanned discharge, removal, or transfer. On 3/3/ LPA mentioned the allegations facility's phones are not answered, staff are not responsive to requests for communication, and minor is being deprived of their possessions. Peacock Acres said that although they missed the County's calls on 2/23/22 they had eventually contacted them and were working on sending the rest of the client's belongings. On 7/7/ LPA Simien contacted CR regarding Peacock Acres claims regarding the allegations against them. Based on this conversation, CR stated that Riverside County had an arrangement with Peacock Acres to meet the client and Social Worker at the airport and gave no indication they were not going to take back the client. CR said that on 2/23/22 none of the various staff members they attempted to contact answered. LPA Simien encouraged CR to send him any correspondence between them and Peacock Acres. As of 7/29/ CR has only sent LPA a copy of the client's placement history which showed the County paying for the client's placement at Peacock Acres until 3/1/22. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations.Therefore, the above allegations are unsubstantiated. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was to Clarissa Joseph, Residential Manager (RM).

Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with Clarissa Joseph, Residential Manager (RM) and Steisha Monderoy, Strategic Project Director (SPD) at 12: PM on 7/29/22. During the investigation, LPA Simien conducted confidential interviews. They were interviews on 3/3/22, and 7/7/22. LPA Simien reviewed and obtained copies of the 14-day notice, facility's 14-day notice policy, initial 30-day evaluation, clinical progress reports/logs, needs, service plans, treatment plan, safety plan for client, daily mental health progress notes for client, and the client's social worker information, and all correspondence the facility had with the County starting from when the initial 14-day notice was given (text messages and emails). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. San Jose, CA Facility Name: Peacock Acres Group Homes INC.FACILITY NUMBER: VISIT DATE: 07/29/2022

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


facility_name: PENNACLE FOUNDATION INC

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Narrative:
**This is an amended report of the original dated January 19, 2022** adequately supervise minors in care, facility staff allow C2 to smoke cigarettes while in care, and facility does not provide C1 a safe environment. Specifically, it was reported that C2 has been punching C1 in the stomach daily for two weeks and when this is brought to staff's attention, staff don't do anything to stop C2 from doing this. Additionally, it was reported that C2 smokes cigarettes outside the STRTP and staff are aware but do not do anything about this. It was also reported that C2 has threatened to hit C1 more if C1 tells staff that C2 is hitting C1. Per allegation details, a witness does not feel safe in the STRTP. While a witness maintains all of the allegation details are true and occurred as reported, another witness denies all allegations. FM confirmed C2 would intentionally hit C1 on occasion, however, this was not due to lack of supervision, as staff was supervising the clients when this occurred. This was C2's behavior when arrived at the STRTP. Staff redirected C2 and separated C2 from C1 immediately in each incident. Staff confirmed C2 will look for used cigarette butts while on outings and will sneak them into the STRTP to attempt to smoke them. Staff corroborate that they confiscate the cigarette butts when this occurs as C1 knows this is against STRTP rules. Staff corroborate clients are supervised on a continuous basis due to their behaviors and conditions, however, C2 is more independent and does push STRTP boundaries regardless of staff supervision. LPA reviewed C2's needs and service plan and observed there is nothing in the plan stating C2 requires constant supervision. Staff corroborate they have never witnessed C2 threaten C1. Additionally, staff corroborate that C1 has never mentioned the above allegations to staff to be addressed. Also, CSW states C1 has never reported allegations to CSW and CSW has never had concerns with the care being offered at the STRTP. A couple of witnesses confirm they feel safe in the STRTP despite the allegations reported. Based on interviews conducted and information obtained, the allegations that C1 is getting hit by C2 while in care without staff intervening, staff do not adequately supervise minors in care, facility staff allow C2 to smoke cigarettes while in care, and facility does not provide C1 a safe environment, may have occurred, however, they are not supported or proven by evidence. The allegation is, therefore, UNSUBSTANTIATED. There are no deficiencies to be cited. An exit interview was conducted and a copy of this report, LIC 811, and appeal rights, were provided to Ms. Watishi Turner for original signature. Signed report will be placed in facility file.

Investigation Findings:
13**This is an amended report of the original dated January 19, 2022** On January 19, 2021 at 9: AM, Licensing Program Analyst (LPA) Carmen Escobar conducted an unannounced inspection at the Short Term Residential Therapeutic Program (STRTP) in order to issue the investigative findings for the above allegations. During the investigation, LPA requested documents from client 1 (C1), client 2 (C2), and client 3 (C3's) files including placement agreements, copy of needs and service plans, and special incident reports involving the allegations reported. LPA also obtained a copy of STRTP client roster and staff roster. LPA Escobar conducted interviews with facility manager (FM), staff 1 (S1), C1, client 2 (C2), client 3 (C3), and C1's county social worker (CSW). LPA Escobar completed the initial ten-day inspection at the facility to initiate the complaint on 10/25/21 at 12: PM. No safety concerns were observed. It was alleged that on or around 10/18/21, C1 is getting hit by C2 while in care, staff do not UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Carmen Escobar 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 19-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, MAIN ST., SUITE FACILITY NAME: PENNACLE FOUNDATION INCFACILITY NUMBER: VISIT DATE: 01/19/2022

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

met_with: Facility Manager-Watishi Turner


summary: Complaint Investigation - Substantiated - 1 allegation

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Narrative:
while in care. Specifically, it was reported that C1 turned up the TV because staff shift change was happening and C1 could not hear the TV. S1, allegedly, became upset and turned off the TV. C1 became angry and turned the TV back on. It was then reported that S1 got in C1's face, telling C1 to leave the TV alone. C1 requested for S1 to "get out of (C1's) face" and shoved S1 when S1 did not remove self from C1 personal space. There was a power struggle between C1 and S1 as C1 pushed S1 and S1 attempted to redirect C1. They were witnessed to have ended up wrestling near the couch and landed on the floor of the facility living room. Allegedly, S1 proceeded to push C1 down the hallway in an effort to put C1 in C1's room. Several corroborating statements confirm S1 was raising S1's voice while attempting to get C1 to go to C1's room. Confidential witnesses state S1 attempted to restrain C1 during the altercation. Several witnesses corroborate seeing S1 put hands on C1 in an attempt to redirect and restrain C1 from potentially hitting S1. Other witnesses corroborate hearing C1 yell, several times, "Get your hands off me!" to S1. During the investigation, S1 confirmed S1 put hands on C1, stating S1 attempted to put C1 in a child pose, one-arm restraint, which S1 states S1 is trained to conduct. S1 also confirmed S1 tried to physically turn C1 around to redirect C1 to C1's room, however, was only able to "maintain control of (C1's) forearms". Corroborating statements confirm that eventually S1 and C1 released their holds on each other and C1 retreated to C1's room. Another confidential witness confirms seeing S1 restrain C1's arms as C1 yelled, "Get your hands off me!" and both of them struggling with each other like they were going to fall on the floor during the incident. Based on confidential interviews, information gathered, and review of the facility's program statement which states restraints are not to be used on clients, the allegation that S1 engaged in a physical altercation with C1 while in care is SUBSTANTIATED because the preponderance of evidence standard has been met for the allegation. This poses a potential health, safety, or personal rights risk to clients in care. The facility is being cited under Interim Licensing Standards (ILS) section 87095, General Provisions. An exit interview was conducted and a copy of this report, LIC 811, and appeal rights, were provided to FM Ayla Losoya, for signature. Signed report will be placed in facility file.

Investigation Findings:
13On April 20, 2022, at 11: AM, Licensing Program Analyst (LPA) Carmen Escobar made contact with short term residential therapeutic program (STRTP) facility manager (FM), Ayla Losoya. LPA Escobar conducted a facility risk assessment with FM and proceeded to continue with the facility inspection to issue the investigative finding for the above allegation. During the investigation, LPA requested documents from client 1 (C1's), client 2 (C2's), and client 3 (C3's) files including placement agreements, copy of C1's needs and service plan, and special incident reports involving C1. LPA also obtained a copy of the STRTP client roster and staff roster. LPA Escobar conducted interviews with three staff members, C1's county social worker, C1, C2 and C3. LPA Escobar conducted an in-person inspection of the STRTP on 02/28/22 at 2: PM, no health or safety concerns were observed at the time. It was alleged that on or around 02/28/22, S1 engaged in a physical altercation with C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Carmen Escobar 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 19-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, MAIN ST., SUITE FACILITY NAME: PENNACLE FOUNDATION INCFACILITY NUMBER: VISIT DATE: 04/20/2022

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

met_with: Facility Manager (FM)-Ayla Losoya


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Narrative:
the pills were vitamins and there was also nothing mentioned by authorized representative that the pills were vitamins. Even though C1 advised S2 the pills were vitamins, S2 could not confirm this information and for C1's safety, flushed the vitamins down the toilet. S2 was unaware of a proper way to dispose of drugs/pills and later participated in staff training that provided instructions on proper disposal of medication/pills/drugs and also proper documentation. Another witness observed the actual flushing of the vitamins and became upset with S2 at time of incident. Other witnesses corroborate that even though they did not witness the flushing of the vitamins, they were made aware by upper administration/management, that this incident had occurred prior to the staff training that was completed. Based on confidential interviews and information gathered, the allegation that S2 flushed C1's vitamins while in care is SUBSTANTIATED because the preponderance of evidence standard has been met for the allegation. This poses a potential health, safety, or personal rights risk to clients in care. The facility is being cited under Interim Licensing Standards section 87072, Personal Rights. An exit interview was conducted and a copy of this report, LIC 811, and appeal rights, were provided to FM, Candice Caldwell, for signature. Original signed reports will be placed in facility file. Specifically, it was reported that C1 has been denied access to C1's phone book. Several witnesses corroborate this is not true and C1 has constant access to any phone numbers C1 might need, including CSW's, county representatives, legal entities, etc. It was also detailed that S1 gets in C1's face and yells at C1, however, no details of this were reported. It was further reported that S1 will say things such as, "If (C2) sticks (C2's) thumb up your (C1's) butt, you're gay right?" While two witnesses corroborate these two allegations, all other witnesses state this has never been observed and S1 does not yell at clients or says things as indicated on report. Several other witnesses state these incidents have never been reported to them during C1's time at the facility. It was also reported S1 refuses to make C1 food, however, all witnesses corroborate that while several staff, including S1, do not cook for the clients in the facility at times, staff will order food or pick up fast food for clients. While S1 states S1 does not cook and does not like to cook, S1 states S1 will buy clients fast food or will order food for clients, including C1. Several other witnesses corroborate this information, some even stating they would rather eat fast food than eat food cooked by staff. Again, other witnesses advise this has not been reported to them during C1's time at the facility. It was then detailed that S1 threatened to make C1 food with a dirty plate or food that is contaminated. S1 denies this allegation stating C1 can be unhygienic and S1 will have to remind C1 to not touch C1's private parts and then touch plates in the kitchen, or food in the kitchen, as it will contaminate items with unhygienic germs. Another witness denies this occurring. Several witnesses corroborated this incident, advising S1 was not threatening C1, but was advising of proper hygiene when eating and preparing food. This incident was also not shared with other parties and, therefore, not witnessed. It was further detailed that C1 does not have access to TV or WiFi in the facility, causing C1 to be bored. Several staff deny this allegation and advise the TV and internet are always available to C1 as long as C1 has completed chores and has not lost privileges. While a witness maintains this continues to occur, several other witnesses deny this allegation, stating the TV is always on and staff usually allow clients to use the WiFi when requested. Finally, it was also reported that C1 has not been enrolled in school, however, the facility provided documentation of the ongoing enrollment process which has taken longer than usual, but not due to lack of effort by the facility, simply issues with school district in regards to C1's educational needs and behavioral issues. While a witness maintains this was the case initially, the facility has now been able to enroll C1 into school. S1 denies all allegations related to S1 and C1. While another witness maintains the allegations are true, several witnesses deny ever observing these allegations occur. Based on interviews conducted, the allegations that S1 denied C1 access to phone book, S1 yells at C1 while in care, S1 makes inappropriate comments towards C1, S1 refused to make food for C1 while in care, S1 threatened C1 while in care, staff deny C1 access to activities while in care, and C1 is not enrolled into school while in care may have occurred, however, they are not supported or proven by evidence. The allegations are, therefore, UNSUBSTANTIATED. There are no deficiencies to be cited. Exit interview was conducted and a copy of this report and appeal rights, were provided to FM for original signature. Report will be put into facility file.

Investigation Findings:
13On September 30, 2022, at 10: AM, Licensing Program Analyst (LPA) Carmen Escobar arrived at the short term residential therapeutic program (STRTP) facility and met with facility manager (FM), Candice Caldwell. LPA Escobar conducted a facility risk assessment with FM and proceeded to continue with the facility inspection to issue the investigative finding for the above allegation. During the investigation, LPA requested documents from client 1 (C1's), client 2 (C2's), and client 3 (C3's) files including placement agreements, copy of C1's needs and service plan, and special incident reports involving C1. LPA also obtained a copy of the STRTP client roster and staff roster. LPA Escobar conducted interviews with three staff members, C1, C2, C3, and C1's county social worker (CSW). LPA Escobar conducted an in-person inspection of the STRTP on 03/09/22 at 10: AM, no health or safety concerns were observed at the time. It was alleged that on or around 03/01/22, S2 flushed C1's vitamins while in care. Specifically, it was reported that when C1 arrived to the facility for placement, S2 flushed C1's vitamins down the toilet. Several witnesses corroborate this. S2 stated vitamins were flushed because they were not in a container indicating SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Carmen Escobar 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 19-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, MAIN ST., SUITE FACILITY NAME: PENNACLE FOUNDATION INCFACILITY NUMBER: VISIT DATE: 09/30/2022

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

met_with: Facility Manager-Candice Caldwell