facility_name: CASA BONITA

summary: Facility Evaluation

raw_content:
Narrative:
On April 11, 2022 at approximately 10: AM, Licensing Program Analyst (LPA) Raymond Wu conducted a visit at the facility for the purposes of initiating a Year Required inspection. LPA met with the representative listed above and discussed the purpose of the visit. During the visit, a walk-through of the facility was conducted. The facility is currently vacant and the last client moved out approximately 2 years ago according to the Administrator. PHYSICAL PLANT A walk-through of the physical plant was conducted at approximately 10: AM. The facility is a single-story home situated in a quiet residential area. The exterior of the facility was observed to be well-maintained and in good repair. After entering the front door, postings, including the License, Emergency Disaster Plan, and Complaint hotline numbers were prominently placed for any potential clients. Towards the left, a living room was observed to be clean, in good repair, and furnished with furniture and entertainment items for potential clients. Moving up, there is a kitchen and dining room. All kitchen cabinets and appliances were observed to be in good repair. No perishable food was observed due to the facility being vacant. There were a total of 3 bedrooms and 2 bathrooms for client use. All rooms were observed to be clean and furniture was observed to be in good repair. Mattresses were outfitted with mattress covers and linens were clean and tidy. Bathrooms were observed to have paper towel dispensers, trash bins with covered lids, and soap for potential client use. Smoke detectors and carbon monoxide detectors were observed to be functional and a fire extinguisher was observed to have been serviced in the past year. Sharp objects, chemicals, and medication were securely stored in the staff office. In the back, there is a secure garage used for storing supplies. All indoor and outdoor passageways were free from obstruction. LPA advised that an annual continuation visit would need to be conducted. No deficiencies were observed or cited during this date.

met_with: Administrator Sergio Castaneda


state: CA

summary: Facility Evaluation

raw_content:
Narrative:
On March 22, 2024 at 9: AM, Licensing Program Analyst (LPA) Juliet Robles conducted a visit at the facility for the purpose of an Annual inspection. LPA met with Luis Tobar, Supervisor and discussed the purpose of the visit. During the visit, a walk-through of the facility was conducted. The facility is currently vacant, with no clients. LPA observes that rooms 1 & 2 flooring needs to be replaced. Per Supervisor, the repair is scheduled after the basement flooring dries up well. The facility Supervisor will email LPA Robles once the repair is completed sometime in Summer. During the inspection, LPA conducted a physical tour (inside and out) and reviewed operational requirements: (physical plant; operations; disaster preparedness; emergency intervention plan and staff files). LPA was provided with the LIC 500, current LIC 610C, LIC 309, LIC 308. The new Group Home Administrator documents will be mailed to the Regional Office. LPA observes postings, after entering the front door. The License, Emergency Disaster Plan and complaint hotline numbers were prominently placed for potential clients. No perishable food was observed due to the facility being vacant. Smoke detectors and carbon monoxide detectors were observed to be functional, and a fire extinguisher was observed. Sharp objects, chemicals, and medication were securely stored in the staff office. In the back, there is a secure garage used for storing supplies. All indoor and outdoor passageways were free from obstruction. LPA reviewed two (2) staff files that were provided by Human Resources staff, Sheila Davis. A review of Guardian and Licensing Information System on 03/21/24, indicates that all facility staff associated with facility have DOJ, FBI, and child abuse index clearances. LPA interviewed one (1) staff at the facility. Based on the physical inspection of the facility and the records review, there are no violations of Title 22, Division 6 of the California Code of Regulations and no deficiencies were cited. An exit interview was conducted with the facility representative and a copy of LIC 809, and LIC 811 were provided to the facility representative Luis Tobar.

report_type: Facility Evaluation

visit_type: Annual

met_with: Luis Tobar


facility_name: CASA DE ESPERANZA

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
The investigation, including confidential interviews with resident and staff members, revealed C1 made sexual abuse allegations a month after they no longer resided at the facility and almost a year after the alleged incidents occurred. Staff were not informed nor observed any sexual activity between C1 and other clients. Interviews produced no additional alleged victims or witnesses to the alleged abuse. As to claims that staff failed to prevent drugs in the facility, the investigation revealed that C1 and other client at the facility would at time smuggle illegal drugs into the facility after they returned from home visits. Clients were also suspected of using the internet to purchase narcotics and have them delivered by the facility's fence area and sidewalk. It was revealed, due to client's personal rights, staff were not able to search clients who were suspected of possibly being involved in drug activity. The investigation did not produce any independent witnesses to the allegation. Observations of the facility physical plant during the investigation on unannounced complaint inspections, found facility grounds in substantial compliance. The facility was observed overall to be clean and or orderly. On site inspections produced no deficiencies concerning a lack of cleanliness. Due to a lack of evidence, the allegations can not be substantiated at this time. Although the allegations may have happened or may be valid, there is not a preponderance of the evidence to prove or disprove the allegations occurred; therefore, the allegations are determined Unsubstantiated. There were no deficiencies cited during the investigation. Exit interview conducted; appeal rights discussed and a copy of this report will be emailed to Facility Administrator.

Investigation Findings:
13On June 29, 2021 at 1: PM, Licensing Program Analyst (LPA), Regina Martin conducted a follow-up complaint inspection to deliver findings concerning the above-mentioned allegations. LPA Martin met with Facility Representative, Lupe Rodriguez to discuss the investigative outcome. The investigation was conducted by the California Department of Social Services (CDSS), Investigator Olivia Spindola of the Community Care Licensing (CCL) Investigations Bureau. On November 6, 2020, CCL received complaint allegations concerning neglect and lack of supervision. It was reported that a lack of supervision resulted in inappropriate interactions between minors in care as Client #1 (C1) was allegedly sexually abuse by another minor resident; that staff failed to prevent drugs in the facility; and that the facility is not clean. (Continued on page LIC9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Regina Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: CASA DE ESPERANZAFACILITY NUMBER: VISIT DATE: 06/29/2021

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

report_type: Complaint Investigation

met_with: Lupe Rodrigriguez, Facility Administrator

complaint_status: unsubstantiated


raw_content:
Narrative:
The investigation, including confidential interviews with staff members and a tour of the facility revealed the ceiling was damaged due to excessive rains and doors were damaged due to clients having anger episodes. Observations of the facility physical plant during the investigation on unannounced complaint inspections, found facility doors to be repaired, however the ceilings have not been repaired in the therapist office or laundry room. Based on observations, AGPA Woodard has determined the preponderance of evidence standard has been met. Therefore, the allegations are found to be substantiated. Deficiencies were cited to the facility for physical plant. Exit interview conducted; appeal rights discussed and a copy of this report will be left at the facility.

Investigation Findings:
13On January 28, 2022 at 11:15AM, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted a followup complaint inspection to deliver findings on the above allegations. Upon arrival, AGPA was greeted by Marina Herrera, Facility Manager. On January 18, CCL received complaint allegations concerning issues with building and grounds. It was reported that the ceiling was falling down in a couple of rooms with insulation, wires and beams exposed. Doors were also off the hinges, there was a pot under the bathroom sink and a hole in the ceiling where a missing bath fan should be. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: CASA DE ESPERANZAFACILITY NUMBER: VISIT DATE: 01/28/2022

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: Marina Herrera


raw_content:
Narrative:
continued from page A query of Zillow resulted that the property at this location is currently on the market and in pending sale status. An official eviction notice was not done (meaning the legal steps for doing an eviction was not taken), however the Landlord did leave a 60-day Notice to Vacate under the front door mat. AGPA Woodard has determined the preponderance of evidence standard has not been met. Therefore, the allegation is found to be unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Investigation Findings:
13On February 19, 2022 at 2: PM, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted a follow-up complaint inspection to deliver findings on the above allegation. Upon arrival, AGPA was greeted by Hassan Kalantari, Mental Health Rehabilitation Specialist. On December 28, 2022, CCL received a complaint allegation concerning an eviction notice given to the facility due to non-payment of the lease. The investigation included confidential interviews with reporting party and staff members. Supporting documentation provided did not support that payment was not received or that it was in fact paid. It was also reported that as a result of non-payment the homes were under foreclosure. AGPA queried the Housing of Urban Development (HUD) website and didn't see the homes listed under properties for sell and/or auction. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: CASA DE ESPERANZAFACILITY NUMBER: VISIT DATE: 02/19/2022

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

met_with: Hassan Kalantari


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
continued from Based on observations and interviews, AGPA Woodard has determined the preponderance of evidence standard has been met. Therefore, the neglect/lack of supervision allegations are found to be substantiated. Deficiencies were cited to the facility for Personnel Duties. Exit interview conducted; appeal rights were discussed, and a copy of this report will be left at the facility.

Investigation Findings:
13This is an amended Report On March 25, 2022 at 11: AM, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted a follow-up complaint inspection to deliver findings on the above allegations. Upon arrival, AGPA was greeted by Marina Herrera, Facility Manager. On November 22, CCL received complaint allegations concerning issues with a resident setting a fire at the facility on November 13, 2021. The resident was arrested, and the judge released him. On November 20, 2021, another fire was started with a pile of clothing on the side yard of the facility which borders a neighbor's house. The Police and Fire Department were called. Staff was unaware a client was home. Clients also jump the neighbor's fence all the time and drink alcohol and do drugs. There are numerous occasions where there are no staff watching the minors or the staff are aloof. The investigation included confidential interviews with staff members and clients, and a review of supportive documentation. The minor who allegedly started the fires was unavailable for interview. A tour of the facility was conducted and burn areas were inspected during the unannounced complaint inspections. AGPA received copies of before and after photos of the fence in the backyard. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: CASA DE ESPERANZAFACILITY NUMBER: VISIT DATE: 03/25/2022

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

complaint_status: SUBSTANTIATED


raw_content:
Investigation Findings:
13On March 25, 2022 at 11: AM, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted a follow-up complaint inspection to deliver findings on the above allegations. Upon arrival, AGPA was greeted by Marina Herrera, Facility Manager. On November 18, CCL received complaint allegations concerning a child who is being verbally sexually harassed by his peers at his current group home. The child did not provide examples of his concerns and stated that he did not want to talk about it. The child also did not disclose if group home staff are aware his peers were sexually harassing him. The investigation included confidential interviews with staff members and clients, and a review of supportive documentation. The alleged victim declined to be interviewed and there were no witnesses who corroborated the alleged incident. Based on the above, AGPA Woodard has determined the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to support the allegation of a violation of client's personal rights. An exit interview was conducted, and a copy of this report was left with the facility representative. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard 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:
13On June 21, 2022, at Licensing Program Analyst (LPAs) Enrique Hernandez and Nanacy O' Connell arrived at the facility to deliver the findings of a complaint investigation. LPA Hernandez met with Marina Herrera Facility Manager (FM) and discussed the investigative findings. On July 8, 2021, the Department received a complaint alleging Staff member is having an inappropriate relationship with group home minor(s). During confidential interviews and documentation obtained, there was insufficient evidence to substantiate the allegation, although there were some statements claiming that a client and staff had a relationship, the two denied the allegation. Other confidential interviews denied seeing or hearing anything inappropriate between the client and the staff. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. The Department has decided that the allegation is unsubstantiated, but if any additional information is received this complaint can be amended and findings can be changed. Exit interview was conducted and a copy of this report was left with FM UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, This is an official report of an unannounced visit/investigation of a complaint received in our office on 07/08/2021 and conducted by Evaluator Enrique M Hernandez COMPLAINT CONTROL NUMBER: 34-CR- FACILITY NAME:CASA DE ESPERANZAFACILITY NUMBER: ADMINISTRATOR:LUPE L. RODRIGUEZFACILITY TYPE: ADDRESS: QUINTA VISTA DRIVETELEPHONE: (805) 496- CITY:THOUSAND OAKSSTATE: CAZIP CODE: CAPACITY:6CENSUS: 5DATE: 06/21/ UNANNOUNCEDTIME BEGAN: 03: PM MET WITH:Facility Manager TIME COMPLETED:05: PM 91) Staff members' conduct were inimical to the care of group home minors. INVESTIGATION FINDINGS: 13On June 21, 2022, at 3:30pm Licensing Program Analyst (LPAs) Enrique Hernandez and Nancy O' Connell arrived at the facility to deliver the findings of a complaint investigation. LPA Hernandez met with Marina Herrera Facility Manager and discussed the investigative findings. On July 8, 2021, the Department received a complaint alleging Staff members' conduct were inimical to the care of group home minors During confidential interviews conducted with all parties involved and information collected, the above allegation is substantiated, as all relevant parties confirmed that a staff member had a verbal altercation with one of the clients. Additionally, LPA Hernandez received a recording of the actual verbal altercation and staff can be heard yelling at the client. Based on the interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Exit interview was conducted and a copy of this report was left at the facility SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 2 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: CASA DE ESPERANZAFACILITY NUMBER: 565800460

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

met_with: Facility Manager


raw_content:
Narrative:
support presence of C1's missing gold chain, and facility inventory document that does not list gold chain as reported upon CI'1 admission into the facility. Additionally, LPA observed during inspection that facility staff office is kept locked with no presence of residents in the office. Although C1 and the RP have reported that C1's personal items were missing while in care, there was no evidenced provided by C1 to show that the gold chain existed or that C1 left the belonging in the care of facility staff. Therefore, it must be concluded that an allegation of personal rights violation cannot be substantiated at this time. Per Title 22, There are no deficiencies to be cited at this time. Exit Interview conducted, and a copy of this report was left at the facility.

Investigation Findings:
13On June 21 2022, at 03:45pm, Licensing Program Analyst (LPA) Nancy O'Connell and Enrique Hernandez made an unannounced inspection to the above facility for the purpose of concluding the investigation on the above allegation and deliver the findings. LPA spoke with Marina Herrera and together, discussed the investigative findings. During the investigative process by Licensing program Analyst (LPA), Nancy O'Connell, all relevant parties have been accounted for. Based on the interviews conducted and documents obtained, the above allegation is found to be Unsubstantiated, meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Supporting evidence includes: conflicting interviews with facility staff attesting to policies related to safeguarding, lack of evidence to UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Nancy O'Connell LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: CASA DE ESPERANZAFACILITY NUMBER: VISIT DATE: 06/21/2022

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

met_with: Marina Herrera, Facility Manager


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Based on the interviews conducted and documents obtained, the above allegation is found to be Unsubstantiated, meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. There are no deficiencies to be cited at this time. Exit Interview conducted, and a copy of this report was left at the facility with the Facility Manager.

Investigation Findings:
13On 9/21/22, LPA O'Connell delieved a finding for an amended report which supercedes the origional delievered on 6/21/22. Based on evidence related to misuse of facility funds, Community Care Licensing Division has initiated a Solvency Audit to look further into possible financial issues. During the investigative process by Licensing Program Analyst (LPA), Nancy O'Connell, all relevant parties have been accounted for. Supporting evidence includes: review of LIC500, client roster, interviews with the Reporting party, staff, client, and a public service agency. Interviews with facility staff and a resident, report that the facility provides for all basic needs and meets the required licensing standards. Further, an interview with a public service agency confirms that the facility is current on required service payment. Continued on LIC90099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Nancy O'Connell LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: CASA DE ESPERANZAFACILITY NUMBER: VISIT DATE: 06/21/2022


raw_content:
Investigation Findings:
13On June 25, 2022 at 11: AM, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard met with Lupe Rodriguez to deliver findings on the above allegation(s). Licensing Program Analyst (LPA) Enrique Hernandez and Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted the investigation into the above allegations. LPA Hernandez conducted the initial 10-day complaint inspection on February 25, 2022 and conducted confidential interviews with three staff, and on March 22, 2022 conducted a subsequent visit at the facility. AGPA Woodard conducted subsequent visits to the facility on April 8, 2022 and May 20, 2022; confidential interviews were conducted with three staff members, and one client. Additional phone interviews were conducted on May 20th and 21st, 2022. Confidential interviews revealed that a rock was not thrown at the minor and the minor threw a rock breaking a window in the rear of the home. After the incident minor AWOLed as soon as Law Enforcement arrived; it is unknown if minor returned and was not let into the house. Staff follow AWOL protocol and will do a debriefing with the residents prior to being allowed in the home. Staff deny the allegation that they do not allow minor's back into the home. Staff deny slamming a minor's arm and foot in a door, and there have not been any injuries reported. Based on confidential interviews and review of supportive documentation, AGPA Woodard determined the personal rights allegations that staff threw a rock at a minor, staff did not prevent a minor from AWOLing, and staff member slammed a minor's arm and foot in a door, the allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the findings are unsubstantiated. A copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B This is an official report of an unannounced visit/investigation of a complaint received in our office on 02/22/2022 and conducted by Evaluator Tonya Barnes-Woodard COMPLAINT CONTROL NUMBER: 34-CR- FACILITY NAME:CASA DE ESPERANZAFACILITY NUMBER: ADMINISTRATOR:LUPE L. RODRIGUEZFACILITY TYPE: ADDRESS: QUINTA VISTA DRIVETELEPHONE: (805) 496- CITY:THOUSAND OAKSSTATE: CAZIP CODE: CAPACITY:6CENSUS: 5DATE: 06/25/ UNANNOUNCEDTIME BEGAN: 11: AM MET WITH:Lupe RodriguezTIME COMPLETED:12: PM 9Staff member hit a minor INVESTIGATION FINDINGS: 13This is an amendment report On June 25, 2022 at 11: AM, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard met with Lupe Rodriguez to deliver findings on the above allegation. Licensing Program Analyst (LPA) Enrique Hernandez and Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted the investigation into the above allegation. LPA Hernandez conducted the initial 10-day complaint inspection on February 25, 2022 and conducted confidential interviews with three staff, and on March 22, 2022 conducted a subsequent visit at the facility. AGPA Woodard conducted subsequent visits to the facility on April 8, 2022 and May 20, 2022; confidential interviews were conducted with three staff members, and one client. Additional phone interviews were conducted on May 20th and 21st, 2022. Based on confidential interviews and review of supportive documentation, the Staff member admitted to hitting a minor in self-defense when he was being attacked by four minors, therefore the preponderance of evidence standard has been met, and the personal rights allegation is substantiated. Per California Code Regulation, Title 22, Division 6, CHAPTERS 1, General Licensing Regulations, and Short Term Residential Therapeutic Program (STRTP) Interim Licensing standards (ILS), the following deficiency was cited. (See LIC9099-D) Exit interview conducted; appeal rights discussed and a copy of this report will be left at the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard 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 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: CASA DE ESPERANZAFACILITY NUMBER: 565800460

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

met_with: Lupe Rodriguez


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

raw_content:
Investigation Findings:
13This is an amended report On June 25, 2022 at 11: AM, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard met with Lupe Rodriguez to deliver findings on the above allegation(s). Licensing Program Analyst (LPA) Enrique Hernandez and Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted the investigation into the above allegations. LPA Hernandez conducted the initial 10-day complaint inspection on February 25, 2022 and conducted confidential interviews with three staff. AGPA Woodard conducted subsequent visits to the facility on April 8, 2022 and May 20, 2022; confidential interviews were conducted with three staff members, and one client. Additional phone interviews were conducted on May 20th, 21st, and June 15th, 2022. Confidential interviews revealed that there are two staff present for each shift, including NOC. The day of the incident there were two staff on shift. While staff person was being attacked by four clients, one client blindsided staff and punched staff in the face. In return, Staff punched one of the boy's in their chest who was not the alleged victim. In interview with the minor who was punched in the chest, minor didn't disclose the attack against staff or that he was punched by staff but referenced another staff member who swung on the alleged victim. The alleged victim has a history of verbally going after staff as well as physically assaulting staff and people in the community. After staff didn't receive any support from other staff member at the facility, staff gathered his items and left the facility to report the incident to the police, leaving the staff person with five clients temporarily until additional staff arrived. Based on confidential interviews and review of supportive documentation, the Staff member admitted to hitting a minor in self-defense when he was being attacked by four minors, and leaving the facility to report it with Law Enforcement, which left one staff alone with five clients, therefore the preponderance of evidence standard has been met, and the personal rights and lack of supervision allegations are substantiated. Per California Code Regulation, Title 22, Division 6, CHAPTERS 1, General Licensing Regulations, and Short Term Residential Therapeutic Program (STRTP) Interim Licensing standars (ILS), the following deficiencies are cited. (See LIC9099-D) A copy of this report was left, and appeal rights were discussed SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: CASA DE ESPERANZAFACILITY NUMBER: 565800460

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

Deficiencies:
87065.2: (1) 	Supervision, protection, and care of children at all times, individually and in groups.

title:
Personnel Duties
(b) 	Direct care staff shall perform the following duties


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account. The balance from both joint accounts was eventually paid to C3's adult sister (A1), and there is no evidence that any money was withheld from C3. Whether or not A1 returned C3's money to C3 could not be determined. Based on LPA's interviews and documents obtained, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. There are no deficiencies to be cited at this time. Exit interview was conducted, and a copy of this report was left at the facility.

Investigation Findings:
13On 7/20/22, at 2022, Licensing Program Analyst (LPA) Nancy O'Connell conducted an unannounced inspection at the above facility for the purpose of delivering findings, regarding the above allegation. LPA met with the Facility Administrator (ADM), who granted access into the facility. During the investigative process, all relevant parties have been accounted for, and LPA obtained bank statements, as well as a series of text message screenshots between the Facility Administrator (ADM) and the client's (C3's) adult sister (A1) were obtained. Confidential interviews confirmed that the ADM held both a joint checking account, and a joint savings account with C3, even though C3's Deputy Probation Officer (DPO) did not approve of these joint bank accounts. C3 was discharged from the facility, on 08/18/2021, and an outstanding balance remained on both joint bank accounts, until December 2021, when C3 and C3's adult sister (A1) requested that the balance be paid to A1's Zelle UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Nancy O'Connell LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: CASA DE ESPERANZAFACILITY NUMBER: VISIT DATE: 07/20/2022

met_with: Lupe Rodriguez, Facility administrator


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clients reside, despite directives to not engage with clients until background clearance is obtained. Multiple staff and clients corroborate S3's presence and interaction with residents in the facility since January 2022. Based on all interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Per California Code Regulation, Title 22, Division 6, Chapter 1, General Licensing Regulations, and Short Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS), Chapter 7. Version 4, a deficiency: 80019(e)(1), will be be cited at the time of this inspection. (See attached LIC9099D) Exit Interview conducted, and a copy of this report was left at the facility.

Investigation Findings:
13On July 20, 2022 at 03:15pm Licensing Program Analyst (LPA) Nancy O'Connell made unannounced inspection to the above said facility for the purpose of concluding the investigation on the above allegation and deliver the findings. LPA O'Connell met with Lupe Rodriguez (FA) and discussed the investigative finding. On 04/14/2022 the Department received a complaint alleging that an uncleared adult is providing care for minors. [See Confidential Names form (LIC811) dated 07/20/2022, for names] During the investigative process, LPA O'Connell conducted confidential interviews with all relevant parties and collected information on the above allegation. After reviewing all of the statements and the information obtained, the above allegation is supported, as the confidential interviews confirmed that S3 has made multiple contacts at the facility where CONTINUED ON LIC9099D SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Nancy O'Connell LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: CASA DE ESPERANZAFACILITY NUMBER: VISIT DATE: 07/20/2022

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

met_with: Lupe Rodriguez, Facility Administrator


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interviews confirmed that BOD was present in the facility and carried out an unauthorized restraint on a minor (staff was not trained to perform restraint), resulting in a physical altercation. A report obtained by law enforcement reflects that BOD and the minor sustained bodily injuries due to an unauthorized restraint initiated by BOD. Further, LPA O'Connell reviewed database records and found that the licensee did not submit a report to CCLD regarding this incident. Upon interview with the licensee, LPA O'Connell made an additional request to obtain evidence of submission of a serious incident report, and was informed that a report was not available for the date in question. Further confidential interviews revealed that staff present in the facility did not have the training needed to deescalate C1 and required additional support of BOD who was not approved as a direct care provider, or a staff authorized to conduct restraints. In addition, the licensee did not inform the authorized representative or CCLD about the incident and did not take steps to review actions taken to mitigate future occurrences of this nature. Based on LPA interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Based on California Code of Regulations, Title 22, 2 deficiencies are being cited on the attached LIC 9099D. See 9099D for details. A copy of this report was discussed with the Operations Manager and emailed to the facility.

Investigation Findings:
13On September 21, 2022 at 9:00am, Licensing Program Analyst (LPA) Nancy O'Connell made unannounced inspection to the above said facility for the purpose of concluding the investigation on the above allegations and deliver the findings. LPA O'Connell met with Operations Manager, and discussed the investigative findings. On 8/26/22, the Department received a complaint alleging that a staff member had an altercation and that the licensee did not report the serious incident to the authorized representation nor community Care Licensing Division (CCLD). During the investigative process, LPA O'Connell conducted confidential interviews with all relevant parties and collected information on the above allegations. After reviewing all the statements and the information obtained, the above allegation is supported, as the confidential Continued on LIC9099C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Nancy O'Connell LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: CASA DE ESPERANZAFACILITY NUMBER: VISIT DATE: 09/21/2022

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

met_with: Wanda Nelson, Operations Manager (OM)


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continued from 9099 (unsubstantiated findings) During confidential interviews conducted with clients and staff, and a review of supportive documentation that was obtained, there was insufficient evidence to substantiate the allegations. The alleged victim C1 (6' tall, 249 lbs) attempted to assault a female staff (S9), and C3 intervened by pushing C1 out of the way so he wouldn't hurt S9. C1 called Law Enforcement (L/E) and reported he was being attacked. C1 threw a big rock towards a C3 who was sitting outside with a staff, almost hitting the client in the face. C3 got up and began chasing C1, caught him and pinned him against the facility van. Staff separated the boys. C1 then proceeded to vandalize staff (S8)'s vehicle. L/E arrived and attempted to de-escalate the situation. C1 was given a citation for vandalism. C1 was assessed and transported to the hospital by emergency services. According to the 'Patient Visit Information' sheet, C1 was assessed for a closed head injury, cervical strain, and left knee contusion; SIR stated C1 required medical treatment for hurt left knee, head injury, cervical strain and headache from emotional state, and other documentation states C1 was transported to the hospital to tend to a hurt ankle by running and was checked out at the hospital for his neck and knee hurting. According to citation (A448614) the date of violation was 05/25/21 at 1637 (approximately 4: PM). C1 was released at 6:30AM and returned back to the facility by Ventura County Sheriff's Deputy and Child Welfare Social Worker. There is not a preponderance of evidence to prove the allegations occurred, therefore the Department has decided that the allegations are unsubstantiated. If any additional information is received this complaint can be amended and findings can be changed.

Investigation Findings:
13On September 23, 2022 at 11: AM, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted a follow-up complaint inspection to deliver findings on the above allegation. Upon arrival, AGPA Woodard was greeted by Christopher Thompson, Mental Health Rehabilitation Specialist (MHRS). AGPA met with Lupe Rodriguez, Facility Administrator and discussed the investigative finding. On May 26, 2021, the Department received a complaint alleging that on May 25, 2021 a minor sustained injuries after being attacked by an unidentified 16-year-old resident at Casa de Esperanza while staff were present. The minor appeared to have a possible fractured/swollen jaw, loose permanent teeth, and one of his knees were swollen from the attack, and staff were not at the hospital. It was also reported that the minor gets beat up at least once a week at the group home and refuses to return to the facility and he has a history of running away from the facility. The Reporting Party is concerned for the minor's immediate safety and for the safety of group home staff as well. On 05/22/2021, the minor took a large log and smashed one of the group home staff member's vehicle and he was cited for vandalism. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: CASA DE ESPERANZAFACILITY NUMBER: VISIT DATE: 09/23/2022

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


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Investigation Findings:
13On September 23, 2022 at 11: AM, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted a follow-up complaint inspection to deliver findings on the above allegations. Upon arrival, AGPA Woodard was greeted by Christopher Thompson, Mental Health Rehabilitation Specialist (MHRS). AGPA met with Lupe Rodriguez, Facility Administrator and discussed the investigative findings. On March 19, 2021, the Department received a complaint alleging staff (S1) and client (PC5) engaged in a verbal altercation that escalated to a physical altercation. [See Confidential Names form (LIC811), dated 09/23/2022 for names.] During confidential interviews conducted with clients and staff, and a review of supportive documentation that was obtained, it was discovered these allegations were previously reported on February 11, 2021 and findings were substantiated on February 23, 2021. Due to being previously cited on February 23, 2021, no new citations will be given at this time. Therefore, the preponderance of the evidence standard has been met. An exit interview was conducted, and a copy of this report was left at the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard 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:
- SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:


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continued from 9099-A (unsubstantiated findings) During confidential interviews conducted with clients and staff, and a review of supportive documentation that was obtained, there was insufficient evidence to substantiate the allegations. Although there were some statements claiming that clothes received are donated and don't fit, calling licensing is frowned upon and not encouraged, and statements that food is received from the food bank currently, there is not a preponderance of evidence to prove the allegations occurred in March 2021. Therefore, the Department has decided that the above allegations are unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. If any additional information is received this complaint can be amended and findings can be changed. Exit interview was conducted and a copy of this report was left at the facility. continued from 9099 (substantiated findings) Interviews indicated allowance was not received on time, and facility records concluded that weekly allowances were paid late (example: March 19-25, 2021 allowance wasn't paid until April 2, 2021). Therefore, the Department has determined the above allegation to be substantiated, meaning that the preponderance of the evidence standard has been met. An exit interview was conducted, and a copy of this report was left at the facility.

Investigation Findings:
13On September 23, 2022 at 11: AM, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted a follow-up complaint inspection to deliver findings on the above allegation. Upon arrival, AGPA Woodard was greeted by Christopher Thompson, Mental Health Rehabilitation Specialist (MHRS). AGPA met with Lupe Rodriguez, Facility Administrator and discussed the investigative finding. On March 15, 2021, the Department received a complaint alleging clients were not receiving their allowance in a timely manner. The facilities plan of operation states that allowances will be distributed by Saturday morning of each week. During confidential interviews conducted with clients and staff, and a review of supportive documentation that was obtained from the facility, there was sufficient evidence to substantiate the allegation. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B This is an official report of an unannounced visit/investigation of a complaint received in our office on 03/15/2021 and conducted by Evaluator Tonya Barnes-Woodard COMPLAINT CONTROL NUMBER: 34-CR- FACILITY NAME:CASA DE ESPERANZAFACILITY NUMBER: ADMINISTRATOR:LUPE L. RODRIGUEZFACILITY TYPE: ADDRESS: QUINTA VISTA DRIVETELEPHONE: (805) 496- CITY:THOUSAND OAKSSTATE: CAZIP CODE: CAPACITY:6CENSUS: 5DATE: 09/23/ UNANNOUNCEDTIME BEGAN: 11: AM MET WITH:Lupe RodriguezTIME COMPLETED:03: PM 9Facility staff do not provide youths with a clothing allowance Facility staff do not allow youths to buy the clothing of their choice Facility staff do not allow youth to contact Licensing Facility staff speak inappropriately to youths Facility staff do not provide a good quality of food INVESTIGATION FINDINGS: 13On September 23, 2022 at 11: AM, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted a follow-up complaint inspection to deliver findings on the above allegations. Upon arrival, AGPA Woodard was greeted by Christopher Thompson, Mental Health Rehabilitation Specialist (MHRS). AGPA met with Lupe Rodriguez, Facility Administrator and discussed the investigative findings. On March 15, 2021, the Department received a complaint alleging a youth went without a clothing allowance for several months, was not allowed to go to the store to pick out clothing of his choice, when another youth wanted to contact licensing, the staff hung up the phone, staff treat the youths poorly by saying "who gives a fuck, call licensing", and the food at the facility is all expired and has expiration dates from "last month". continue on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard 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 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: CASA DE ESPERANZAFACILITY NUMBER: VISIT DATE: 09/23/2022

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:


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continued from 9099-A (unsubstantiated findings) During confidential interviews conducted with clients and staff, and a review of supportive documentation that was obtained, there was insufficient evidence to substantiate the allegations. In statements from staff, a client (PC1) was triggered when they heard a staff make a comment about them being gay which resulted in the client destroying property (no record of SIR). In other interviews it was reported that they never heard staff speak inappropriately about a youth. Staff will put gas in the vehicle and air in the tires. The facility van was terrible and didn't have a rearview mirror. In other staff interviews, the Facility Administrator brought a mechanic to fix it. Eventually the facility had a new car, but then there was an accident and they changed cars. Staff will hear of 14-day notices but were never part of the conversation and are unsure if clients were present. Staff reported false statements and/or documentation such as fake Covid 19 test results to say negative from previous Head of Services and false documentation where the facility manager wrote in an SIR that a client attacked a staff with a spatula when it was a knife/blade 8-10" long and gave statements to police as an eye witness to events when she was in the office with the door closed. During confidential interviews regarding a misuse of funds, no statements were given about issues that occurred last year. There is not a preponderance of evidence to prove the allegations occurred in April 2021, therefore, the Department has decided that the allegations are unsubstantiated. If any additional information is received this complaint can be amended and findings can be changed. continued from 9099-A (unsubstantiated findings) continued from 9099 (Substantiated findings) It was also reported that the facility is severely understaffed, and that upper management hire unqualified staff and lie about their credentials, saying that a master's student (MFT) is a licensed therapist, and that the Head of Services and MFT are providing services, which are not actually being provided. The Facility Administrator provided documentation that the staff performing the duties as a Residential Therapist was an Associate Marriage & Family Therapist. In other interviews another staff (S2) was asked to be the Residential Therapist, however declined, due to not yet being licensed. Therefore, the Department has determined that the above allegations to be Substantiated, meaning that the preponderance of the evidence standard has been met. An exit interview was conducted, and a copy of this report was left at the facility.

Investigation Findings:
13On September 23, 2022 at 11: AM, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted a follow-up complaint inspection to deliver findings on the above allegations. Upon arrival, AGPA Woodard was greeted by Christopher Thompson, Mental Health Rehabilitation Specialist (MHRS). AGPA met with Lupe Rodriguez, Facility Administrator and discussed the investigative findings. On April 12, 2021, the Department received a complaint alleging staff/upper management telling a youth that expired food was "ok to eat", and staff bringing in food they know is expired. It was also alleged that facility staff are not qualified and are not sufficient to meet the youths' needs. Based on all interviews and documents obtained there was sufficient evidence to substantiate the allegations. Interviews indicated that staff are forced to go to the food bank and get donated food for the facility; food from the food bank usually has a 3-day window of expiration. If clients make a big deal about it, they are told it's ok to eat because it's been in the freezer. continued on LIC 9099-C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B This is an official report of an unannounced visit/investigation of a complaint received in our office on 04/12/2021 and conducted by Evaluator Tonya Barnes-Woodard PUBLICCOMPLAINT CONTROL NUMBER: 34-CR- FACILITY NAME:CASA DE ESPERANZAFACILITY NUMBER: ADMINISTRATOR:LUPE L. RODRIGUEZFACILITY TYPE: ADDRESS: QUINTA VISTA DRIVETELEPHONE: (805) 496- CITY:THOUSAND OAKSSTATE: CAZIP CODE: CAPACITY:6CENSUS: 5DATE: 09/23/ UNANNOUNCEDTIME BEGAN: 11: AM MET WITH:Lupe RodriguezTIME COMPLETED:03: PM 9Facility staff spoke inappropriately to youths Facility vehicle is not maintained in a safe operating condition Facility staff threatened youths with termination of services Facility staff provided false information to licensing Facility staff misused facility funds INVESTIGATION FINDINGS: 13On September 23, 2022 at 11: AM, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted a follow-up complaint inspection to deliver findings on the above allegation. Upon arrival, AGPA Woodard was greeted by Christopher Thompson, Mental Health Rehabilitation Specialist (MHRS). AGPA met with Lupe Rodriguez, Facility Administrator and discussed the investigative finding. On April 12, 2021, the Department received a complaint alleging the licensee didn't ensure the facility vehicle was functioning properly, the Facility Administrator (FA) made homophobic comments to an unknown youth, utilized 14-day notices as a scare tactic with youths, provided false information to outside stakeholders about the status of the facility, nature and frequency of services provided at the facility, and her involvement in the program development. The complaint also alleges that the Facility Administrator misused holiday gift resources intended for youth(s) and company funds as an apology for any given incident of harassment. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard 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: 5 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: CASA DE ESPERANZAFACILITY NUMBER: VISIT DATE: 09/23/2022

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:


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PER California Code Regulation, TITLE 22, DIVISION 6, CHAPTERS 1, General Licensing Regulations, and Short Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS), Chapter 7. Version 4, a deficiency will be cited at this time. Exit Interview conducted, and a copy of this report was emailed to the FA.

Investigation Findings:
13On 9/30/2022 at 12:30pm, Licensing Program Analyst (LPA) Nancy O'Connell, made an unannounced inspection to the above-listed facility, and met with the Facility Administrator (FA), who granted access to the facility. The purpose of this inspection is to conduct an initial complaint investigation inspection regarding the above allegations. During the time of the inspection,LPA conducted confidential interviews with FA, and FM. [See Confidential Names form (LIC811), dated 9/30/22, for names]. At the time of interview, information gathered from confidential interviews confirm that C1 was left unattended at a medical appointment on 9/20/22 by FM. Further, FM confirmed that she could not pick up C1 from the medical appointment once C1 was ready, resulting in C1 leaving the appointment location. Continued on LIC9099C. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Nancy O'Connell LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: CASA DE ESPERANZAFACILITY NUMBER: VISIT DATE: 09/30/2022

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

met_with: Lupe Rodriguez, Facility Adminsitrator (FA), and Kristin Reynolds (FM).


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Narrative:
continued from page 1 (LIC 9099A) Therefore, the Department has decided that the above allegation is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. If any additional information is received this complaint can be amended and findings can be changed. continued from page 2 (LIC 9099C) Based on interviews and supporting documentation, although the bathrooms were repaired, the toilets sometimes didn't work; plumbing was backed-up/clogged and clients had to go to the gas station down the street to use the restroom or would go to the backyard. Based on recordings on C6's cellphone, the Deputy Probation Officer (DPO) viewed recordings of the facility having incomplete repairs, lacking furniture, and C6 pouring water into the tank to flush the toilet. DPO also observed incomplete construction on the back patio and a video of clients jokingly placing their arm under the blade and stating that it could cause an injury. Through AGPAs investigation it was noted that the completed construction occurred in late October/early November 2021, however during a heavy rain in December, the ceiling collapsed in both room additions. AGPA Woodard verified that building permits were not pulled for the alterations to the facility. C6 has a standing appointment in person at the clinic every Tuesday at 10:30AM with the Behavioral Health Clinician (BHC). Both the facility staff and C6 are aware. In the month of July 2021, C6 last attended therapy on July 6th. On July 13th, the BHC walked into the lobby to see if C6 was there for his regularly scheduled appointment. BHC called the facility and spoke with staff (S4), who stated that C6 had to work. S4 was informed on July 13th that C6 has not been participating in therapy and there were no future appointments scheduled or contact made by group home staff or C6. BHC states that therapy sessions were cancelled on July 13th, 20th, and 27th. On August 13th, C6 had a medication appointment with psychiatrist (DR). DR shared with BHC that the follow-up was done by phone instead of in-person per the group homes manager's request due to the facility remodel. DR phoned S4 and S4 reported that C6 was taking a shower and not available for an interview. continue on page 4 (LIC 9099-C) continued from page 1 (LIC 9099) C6 has a history of drug and alcohol abuse and has been caught with drug paraphernalia in his room and/or personal property. CDE did not provide adequate supervision when C6 and client (C9) were placed off-site at a motel during the time the facility was going through renovations and being repaired; this is evident by the change of motel due to clients smoking marijuana in the room and on the property by the pool. During a room check at 2:30AM, staff noticed C6 was not in the room. It was also reported that when staff (S3) left the clients in the room and went to the restroom somewhere outside of the room, and upon S3's return, S3 was locked out, and could not get back in. There were conflicting stories as to whether staff stayed in the motel room with the two clients or stayed outside the door. SIR dated 08/08/2021 states that staff (S5) took C6 and C9 to the facility to pick up more clothes. S5 stayed in the vehicle with C6, while C9 was allowed to enter the facility during the time construction workers were doing renovations. Upon entering the facility, C9 was upset that his belongings were dirty and blamed construction workers. C9 became enraged and destroyed facility property as well as power tools. The Facility Administrator (FA) requested that clients be taken off-site between August 4, 2021 to August 8, 2021 during the time the facility was being repaired. FA provided the repair list which included: painting the inside of the house, fixing the broken cabinets and adding granite, updating flooring, adding new cabinetry in the hallway, fixing both bathrooms, adding new appliances and furniture in client's rooms, and adding an extension for a new therapy room. The repairs took longer than expected, and the clients did not return until August 17, 2021. continue on page 3 (LIC 9099C) continued from page There have been ongoing concerns with Casa De Esperanza not providing adequate supervision, concerns with their lack of communication with the Department, Placement Agencies, and Behavioral Health, as well as their ability to ensure clients in placement are receiving needed services in a timely manner. Therefore, the Department has determined the above allegations are substantiated, meaning that the preponderance of the evidence standard has been met. The following deficiencies have been cited. (See LIC 9099D)

Investigation Findings:
13On October 21, 2022 at 10: AM, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted a follow-up complaint inspection at Casa De Esperanza (CDE), to deliver findings on the above allegations. Upon arrival, AGPA Woodard was greeted by Christopher Thompson, Mental Health Rehab Specialist, and discussed the investigative findings. On August 19, 2021, the Department received allegations that were investigated by AGPA Woodard and LPA Olivia Rosas. During confidential interviews conducted with clients and staff, and a review of supportive documentation, there was sufficient evidence to substantiate that client (C6) was heavily intoxicated to a point that his judgment was impaired, and staff (S2 and S8) did not seek medical attention for him. [See Confidential Names for (LIC 811), dated 10/21/2022 for names] continue on LIC 9099C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: CASA DE ESPERANZAFACILITY NUMBER: 565800460

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: Christopher Thompson


raw_content:
Narrative:
After reviewing all the statements and records obtained, the above allegation is supported, as the confidential interviews confirmed that medication for C3 was not disbursed as prescribed, and a medication log was not created or maintained for C3 even though a prescription medication was observed within the secured area designated for medications. On 9/21/22, LPA noted that a prescription medication for C3 was obtained within the last seven days, but zero pills had been disbursed to C3, as evidenced by observation of a full pill count within precription container. Upon further interview, the facility manager could not produce records showing that medication had been disbursed to C3 and C3 reported that he had not received any medication related to identified prescription. Further confidential interviews revealed that there is no single identified facility staff responsible for the oversight of administration of medications for residents. Based on LPA observations, record reviews and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A deficiency is being cited on the attached LIC 9099D.

Investigation Findings:
13On November 3, 2022 at 10:00am, Licensing Program Analyst (LPA) Nancy O'Connell made an unannounced inspection to the above said facility for the purpose of concluding the investigation on the above allegation and deliver the finding. LPA O'Connell met with the facility administrator and discussed the investigative finding. On 9/15/22, the Department received a complaint alleging that facility staff mismanaged the minor's medication. During the investigative process, LPA O'Connell conducted confidential interviews with all relevant parties and collected information on the above allegation. Continued on LIC9099C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Nancy O'Connell LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: CASA DE ESPERANZAFACILITY NUMBER: VISIT DATE: 11/03/2022

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

met_with: Lupe Rodriguez, Facility Administrator (FA)


raw_content:
Investigation Findings:
13On November 3, 2022 at 10:00am, Licensing Program Analyst (LPA) Nancy O'Connell made an unannounced inspection to the above said facility for the purpose of concluding the investigation on the above allegation and deliver the findings. LPA O'Connell met with the facility manager and discussed the investigative findings. During the investigative process by Licensing program Analyst (LPA), Nancy O'Connell, all relevant parties have been accounted for. Supporting evidence includes: conflicting interviews related to allegations and lack of supporting evedence to determine that violations occurred. Futher, during interviews with relevant parties, no witnesses were identified that could support in corroborating the allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. No deficiencies are being cited at this time. Exit Interview conducted, and a copy of this report was emailed to the licensee. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Nancy O'Connell LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

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


raw_content:
Investigation Findings:
13On November 3, 2022, at 10:00am, Licensing Program Analyst (LPA) Nancy O'Connell made an unannounced inspection to the above facility for the purpose of concluding the investigation on the above allegation and deliver the findings. LPA spoke with the facility administrator and together, discussed the investigative findings. During the investigative process by Licensing program Analyst (LPA), Nancy O'Connell, all relevant parties have been accounted for. Supporting evidence includes: conflicting interviews with house residents and staff related to allegations. LPA interviewed all relavant parties and determined that witnesses were not available to corroborate allegations listed above. Further, during the investigation,LPA observed that the facility maintained the required amount of food neccessary to meet licensing requirements (obsevation of persihables and non-perishables). Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. No deficiencies are being cited at this time. Exit Interview conducted, and a copy of this report was emailed to the licensee. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Nancy O'Connell LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

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

met_with: Lupe Rodriguez, Facility Administrator, FA


raw_content:
Narrative:
In addition, a Solvency Audit was completed by the Community Care Licensing Division Audit Section on 3/24/23, and findings from that report revealed that the facility bank records showed that there should have been enough funds to cover necessary facility expenses, but there was "excessive spending including foreign transfer fees, restaurants, and excessive amounts at Costco." Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 1, are being cited on the attached LIC 9099D. Exit Interview conducted, and a copy of this report was emailed and mailed to the administrator.

Investigation Findings:
13On June 6, 2023, at 2:50pm, Licensing Program Analyst (LPA) Nancy O'Connell contacted the former administrator Lupe Rodriguez due to the facility being closed on 1-5-23 for the purpose of concluding the investigation on the above allegation and deliver the finding. LPA O'Connell spoke with Lupe Rodriguez and discussed the investigative finding. On 2/1/23 the Department received a complaint alleging that staff behavior poses as a risk to the minors. During the investigative process, LPA O'Connell conducted confidential interviews with relevant parties and reviewed a completed Solvency Audit report for the facility organization. After reviewing all the statements and the information obtained, the above allegation is supported, as the confidential interviews confirmed that staff P1 was withdrawing facility funds for unapproved/personal expenses during his time of operation as the Board of Directors President for the facility. Also, the administrator confirmed that P1 was a primary signor of the facility bank account and was removing funds from the facility bank account for personal use. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Nancy O'Connell LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: CASA DE ESPERANZAFACILITY NUMBER: VISIT DATE: 06/06/2023

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


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Olivia Rosas made an announced inspection to Casa de Esperanza on 08/11/21 at 10:00 am for the purpose of conducting an Annual/Required Inspection. LPA Rosas met with Staff#1 (S1) who granted access to the facility. The facility is licensed to care for six (6) male clients, ages 13-17 years, ambulatory only (See confidential name list LIC 811 dated 08/11/21). There is no swimming pool or any other bodies of water on the premises The entire physical plant was not inspected due to an approved contraction in the facility. LPA Rosas, will return to the facility to conduct a physical plant inspection. LPA Rosas, was not able to interview clients or staff as they were off site. Staff and Client files were not reviewed due of being store in different facility due to the construction. LPA Rosas, will return to the facility to conduct review files. LPA Rosas provided S1 a copy of PIN 21-20-CPR Statewide Launch of New Inspection Tools for Children's Residential Licensees with a copy of Compliance and Regulatory Enforcement (CARE) Tools inspection for Short-Term Residential Therapeutic Program (STRTP) Inspection Tool. LPA Rosas, explained the CARE tools and how the annual inspection process. In addition, LPA Rosas provided a link to CDSS Forms, and STRTP Interim Licensing Standards (ILS) Version 3.1. A review of Facility's Personnel Report Summary on 08/09/2021, indicates that all personnel have criminal record clearance has obtain the necessary clearances with DOJ, FBI, and Child Abuse Response. There were no deficiencies cited at this time. Exit interview was conducted and a copy of this report will be emailed to A#1 to obtain signature.

met_with: Staff#1 (S1)


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) David Torres, and Licensing Program Manger (LPM) Angela King conducted a case management inspection August 2, 2022 at 9:00 am based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 9 out of Direct Care Staff and 3 out of 3 youth files were reviewed. 2 out of Direct Care Staff and 3 out of 3 youth were interviewed. (See the Confidential Names List, LIC 811, dated August 02, 2022). The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the youth case plans, and crisis intervention plans, the licensee does not always use trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. LPA David Torres and LPM Angela King did not observe documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Lupe Rodriguez, Administrator.

visit_type: Case Management

met_with: Lupe Rodriguez, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On August 16,2022 at 9:30am Licensing Program Analyst (LPA) Nancy O'Connell conducted an unannounced annual inspection at the above-listed facility. Licensing staff was met by Christopher Thompson, Mental Health Rehab Specialist (MHRS) and Marina Herrera, Facility Manager (FM). Census was reported to be 5 residents (4 in the facility and 1 on a home pass). LPA observed the following during inspection: Living Room: there was enough seating on the couch for all residents and additional staff. All furniture appeared to be in good repair. There is no fireplace or open faced heater. Rugs were being cleaned outside of the facility. The living room is used as an area for relaxation. The main facility door is located in living room. The facility telephone is cordless and is accessible to clients to use within this space. Kitchen: Equipped with a refrigerator, functional stove, microwave, pantry area with limited non-perishables. LPA observed that there were enough dishes, and utensils for number of residents. Kitchen was clean, and orderly. Trashcan was secured with a lid. Refrigerator was at correct 45degree temperature to prevent spoilage and contamination. There was enough perishable food to last required amount of time. Sharps were stored in locked box in garage storage and inaccessible to clients. A weekly menu was posted in clear view but did not have a date. All appliances appeared to be in working condition. · Upon entering the kitchen, and inspecting the refrigerator contents, LPA observed multiple Continued on LIC809C food items that were not dated or were expired. LPA inquired about reason for missing date and FA stated "yes, staff should have dated that." LPA directed FA to dispose of expired food prior to continuance of inspection. Dining Room: equipped with a a large table with 5 chairs and separate seating (3 can occupy table and 2 can occupy the counter table adjacent to kitchen). There is not enough seating for additional staff. Garage: is being utilized as facility storage and contains items that are not currently in use. there is an additional refrigerator, and freezer that store additional food items for residents. Knives are stored in this area and are inaccessible to clients. At time of inspection, LPA observed cleaning supplies left on cabinet adjacent to garage freezer. FM communicated that staff was using the supplies and didn't put them away. Hallway: there is a linen cabinet that contains additional bedsheets and linens, but not enough observed to accommodate all residents. There is also a medication closet that is locked and inaccessible to clients. Medication closet was observed and contained locked and labeled medications. First aid kit was observed to contain all required supplies. · Smoke detector were observed to be missing from kitchen/hallyway location and smoke detector adjacent to client bedrooms was non-functional. · Fire extinguishers (3) were observed and appeared to be charged. Fire extinguishers were located in kitchen, garage, and hallway. Laundry area: equipped with a washer and dryer and no space for storage. LPA observed dust and rags on floor on left side of washing machine. Additional rags and clothes were laying on the ground adjacent to dryer. Continued on LIC809C Bedroom #1 is occupied by two clients with two twin size beds on each side of the room, adequate closet and drawer space. Closet did not have doors or enclosures for items in closet. Bed #1 did not have a fitted sheet or pillow. Bedroom walls were observed to be in disrepair, with stains and dirt markings/graffiti. Bedroom #2 is occupied by two clients it has two twin size bed, adequate closet and drawer space.Closet did not have doors or enclosures for items in closet. Walls were observed to be in disrepair and buckling away from foundation. Bedroom #3 is occupied by one client; it has two full twin size beds and drawer space. Bathrooms- 1 full bathroom is located in the main hallway. LPA observed bathroom to be in disrepair with strong odor, collection of dust at perimeter of flooring, rust stains in tub, and cracked interior of tub. There is a second bathroom adjacent to the kitchen and is used solely for staff, and for residents if necessary. Staff bathroom maintains cabinet that holds cleaning supplies and laundry detergents. At time of inspection, LPA observed cabinet to be unlocked but inaccessible to clients due to lock on bathroom door. Backyard/Front yard- LPA observed broken gate that could not latch on left side of home. LPA also observed item intended for disposal in backyard (punching bag), and broken sewage lids in ground, where clients have access to walk across. Facility Vehicle: Car was inspected to be in good repair and with functional lights, blinkers, emergency lights, and headlights. Registration and insurance was verified. PER California Code Regulation, TITLE 22, DIVISION 6, CHAPTERS 1, General Licensing Regulations, and Short Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS), Chapter 7. Version 4, there are deficiencies to be cited at this time. Refer to 809D for details. Due to time constraints, the annual inspection will be completed on another day. A copy of this report was discussed with the facility manager and appeal rights, along with copy of this report was left at the facility.

met_with: Marina Herrera, Facility Manager, (FA), Chris Thompson, Mental Health Rehab Specialist (MHRS)


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 8/31/22 at 9:00am, Licensing Program Analyst (LPA) Nancy O'Connell conducted an unaannouced Annual Inspection (continuation) at the above-listed facility. LPA was met by Kristin Reynolds (FM) who granted access to the facility grounds and confidential files. the purpose of this visit was to continue the annual required inspection initiated on 8/16/22. All files available are centrally stored in the facility with only approved staff having access to records. During the time of inspection, LPA O'Connell reviewed the personal rights documents, client roster, LIC500. Emergency Preparedness Plan, disaster plan, facility new-hire training records, board of directors documents, and records related to maintaining cash resources. LPA completed the remainder of inspection regarding physical plant and observed deficiencies regarding bedding/linen. Due to time constraints, LPA will return to the facility to complete the annual inspection. PER California Code Regulation, TITLE 22, DIVISION 6, CHAPTERS 1, General Licensing Regulations, and Short Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS), Chapter 7. Version 4, there are deficiencies to be cited at this time. Refer to 809D for details. Pictures of all deficiencies were retained for LPA records. An exit interview was conducted, and a copy of appeal rights were discussed and provided to the FA. A copy of this report was discussed with the FA and left at the facility.

Deficiencies:
87063(a): Accountability

(a) The board of directors or other governing body including, but not limited to, an individual natural person who is a licensee, shall be active in ensuring oversight and accountability, and shall perform, at a minimum, the following duties

met_with: Kristin Reynolds, Facility Manager, (FM) and Lupe Rodriguez, Facility Administrator (FA)


summary: Facility Evaluation

raw_content:
Narrative:
On September 21, 2022, at 09:00am, Licensing Program Analyst (LPA) Nancy O'Connell made an unannounced inspection to the above facility for the purpose of delivering the documentation related to a recent Non-Compliance Conference (NCC) held with the provider, Operations Manager, Board of Director President, Community Care licensing Staff, and county representatives, at the office. LPA was met by FM and OM and together, they discussed the results of the NCC. On 9/14/2022, Community Care Licensing Division held a meeting with the Licensee (and her management team), as well as county placing referrals agencies (Ventura County, San Bernadino County, Santa Barbara County, and San Luis Obispo County) to address an ongoing pattern of concerns related to multiple topics. The NCC meeting was conducted at the Woodland Hills RO to go over the categories (1. fire clearance denial, 2. notice of rate termination, 3. Unfingerprinted staff / unassociated staff, 4. Expired Accreditation for over 2 years, 5. Mental Health Program Approval denials, 6. Reporting Requirements, 7. Insufficient/Expired foods, 8. Facility Administrator duties and responsibilities, 9. Staffing issues and training, 10. Solvency Issues and Misuse of Funds, 11. Many Physical Plan Citations). Due to ongoing noncompliance issues, the matter of conducting an administrative review on the licensee's provisional license will be presented to the department's legal counsel. Exit Interview conducted, and (due to technical difficulties with printer) a copy of this report will be emailed to the Operations Manager.

met_with: Wanda Nelson, Operations Manager (OM) and Kristin Reynolds, Facility Manager (FM)


summary: Facility Evaluation

raw_content:
Narrative:
On November 3, 2022, Licensing Program Analyst (LPA) Nancy O'Connell made an unannounced case management inspection to the above facility for the purpose of inspecting the rear portion of the facility. LPA was met by the facility administrator and provided a tour of the facility. During the inspection, LPA conducted a walkthrough of the facility and inspected the rear portion of the facility, adjacent to the backyard. LPA observed that the room that was previously used as a therapy room and laundry room has been demolished. LPA inquired about date of completed demolition and FA reported that it was completed on 10/22/22 . LPA retained pictures for records. No deficiencies will be cited at this time. Due to technical difficulties, a copy of this report was emailed to the licensee.

met_with: Lupe Rodriguez Facility Administrator (FA)


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Olivia Rosas on December 6, 2022 at 8:30am. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Rosas met with Lupe Rodriguez, Facility Administrator and inspected the facility inside and out. LPAs reviewed #3 of child's records and #3 of staff personnel files on site at the facility. LPAs reviewed #3 of child's psychotropic medications and medication records. LPAs interviewed #3 of staff on site to discuss the facilities policies and procedures of operation. LPAs interviewed #0 of the children currently prescribed psychotropic medication. LPAs provided a copy of this licensing reports to Lupe Rodriguez, Facility Administrator. No deficiencies are being cited at this time. LPA conducted exit interview with Lupe Rodriguez, Facility Administrator.

met_with: Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On February 25, 2022, at 12:40 pm Licensing Program Analyst (LPA) Enrique Hernandez made an unannounced inspection to the above said facility for the purpose of conducting a Case Management Inspection to address concerns regarding reporting requirements. On 2/16/2022 the Department received multiple incident reports dated back from December 2021 to January 2022. LPA informed the facility manager the importance of submitting unusual incident reports in timely matter PER California Code Regulation, TITLE 22, DIVISION 6, CHAPTERS 1, General Licensing Regulations, and Short Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS), Chapter 7. Version 4, The following deficiency is to be cited See page 809-D Exit interview was conducted, and a copy of this report will be emailed to the Facility Administrator due to technical difficulties with the printer

met_with: Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On February 25, 2022, at 10:00 am Licensing Program Analyst (LPA) Enrique Hernandez, conducted an unannounced Case Management- inspection to Casa De Esperanza Short Term Residential Therapeutic Program (STRTP) located at the above address. Marina Herrera Facility Manager (FM) granted access into the facility and together conducted a tour of the entire facility, inside and out. The facility is licensed to care for six (6) male clients, ages 12-17 years, ambulatory only (See confidential name list LIC-811 dated 02/25/2022). During the inspection the following was observed: Outdoor: · Broken window not boarded up at the time of the inspection with sharp edges exposed and broken pieces on the ground of the backyard of the facility. · Metal BBQ rack in backyard of facility · Nonfunctional dirty BBQ in the backyard of the facility. · Window screens of the client's room broken and lying on the floor of the facility, · Pieces of wood laying on backyard grass · A metal bed frame on the side of the back yard · A mattress on the side of the backyard · Rocks lying down in the backyard · Parts of the backyard grass is one foot tall · Missing pieces of wood on the backyard fence · Graffiti in the front entrance of the facility and on the backyard Continue on LIC809-C LPA took pictures of all the deficiencies observed during the time of the inspection. Per California Code Regulation, Title 22, Division 6, CHAPTERS 1, General Licensing Regulations, and Short Term Residential Therapeutic Program (STRTP) Interim Licensing standars (ILS), the following deficiencies were observed and cited at the time of this inspection. (See LIC809-D) A copy of this report was discussed with the facility manager and will be email to the facility due to technical difficulties with the LPA's printer


summary: Facility Evaluation

raw_content:
Narrative:
On March 17, 2022, at 11:50 am Licensing Program Analysts (LPAs) Nancy O'Connell and Enrique Hernandez, conducted an unannounced Case Management- inspection to Casa De Esperanza Short Term Residential Therapeutic Program (STRTP) located at the above address. Marina Herrera Facility Manager (FM) Lupe Rodriguez Facility Administrator granted access into the facility. During the time of the inspection LPAs were conducting confidential interviews at the dining room table, near the living room couch, and wall outlet with computer charger could be heard surging. LPA O'Connell could smell the area near the outlet burning. The FM confirmed the smell of something burning and proceeded to unplug the charger from the outlet. LPA took pictures of all the deficiency observed during the time of the inspection. Per California Code Regulation, Title 22, Division 6, CHAPTERS 1, General Licensing Regulations, and Short Term Residential Therapeutic Program (STRTP) Interim Licensing standards (ILS), the following deficiency is observed and cited at the time of this inspection. (See LIC809-D) A copy of this report was discussed with the facility and will be emailed to the facility due to technical difficulties with the LPA's printer

met_with: Facility Administrator