summary: Facility Evaluation

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Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Jean Stidman and Cecilia Warren on 5/20/22 at 10am. During the inspection, LPAs met with met with Najon Saina Administrator and inspected the facility inside and out. LPAs reviewed one child's records on site at the facility at 10am. LPAs reviewed three staff personnel files on site at the facility at 10am.. LPAs interviewed three staff on site at 10am. LPAs did not interview any children currently taking psychotropic medication. LPA conducted exit interview with Najon Saina Administrator at 1:00pm and provided the Summary Report upon completion. One deficiency was observed in three out of three staff files reviewed (refer to LIC 809D), the staff files are missing documentation of Initial and Annual Psychotropic Medication training which poses a potential Health, Safety or Personal Rights risk to children in care. Facility cited from the California Code of Regulations, Title 22, 84065(i)(3)(M) and 84065 (j)(4) during the inspection

met_with: Najon Saina Administrator


state: CA

facility_name: KB HOMES LLC

summary: Facility Evaluation

raw_content:
Narrative:
On January 20, 2026, an informal conference was held with Applicant Markiesha Brown of KB Homes, LLC to discuss current Community Care Licensing (CCL) areas of clarification. Present at the meeting were Licensing Program Manager (LPM) Ann Valenzuela, Licensing Program Analysts (LPAs) Charmaine Linley and Stefanie Mutialu and Applicant, Markiesha Brown. The following areas of clarification were addressed: LPM Valenzuela asked Ms. Brown to provide the facility number, address, and telephone number for Stella Morris. Ms. Brown provided the address of Sylmar Drive, Moreno Valley, 92553 and phone number (909) 496-4465. Ms. Brown stated they did not have the facility number and stated the facility is currently not operating right now. LPM Valenzuela asked Ms. Brown to clarify the dates of employment and Ms. Brown stated they worked at the facility from 2021-May 2025. Ms. Brown stated the facility closed in August. LPM asked Ms. Brown if Stella Morris is a Group Home or Short-Term Residential Treatment Program (STRTP) and Ms. Brown stated the facility is a STRTP. LPM Valenzuela asked Ms. Brown to clarify if Lakechia is the same on all the forms submitted to Community Care Licensing (CCL) and Ms. Brown stated Lakechia is the same person and is going to work with Ms. Brown. LPM asked Ms. Brown to clarify if Lakechia is the individual who wrote the letter of employment experience and Ms. Brown said yes. LPM Valenzuela asked Ms. Brown to clarify their role at IHeart Lives and Ms. Brown stated they are a DSP, Direct Support Professional. LPM Valenzuela asked what their responsibilities were and Ms. Brown stated daily activities with the kids. Ms. Brown stated the facility just opened up and Ms. Brown went through the *** LPM Valenzuela asked Ms. Brown to confirm that their resume stated that they were a Direct Support Professional at Stella Morris in Moreno Valley and assisted with independent living skills, medication administration, and behavioral supports for 6 or more children and Ms. Brown confirmed that was correct. LPM Valenzuela asked Ms. Brown for the capacity of the facility and Ms. Brown stated the facility was a capacity of six. LPA Linley asked if the clients were male or female and Ms. Brown stated the clients were female. LPM Valenzuela asked Ms. Brown if Stella Morris is the same as Stella Marris and Ms. Brown stated yes that Stella Moris Growth Center is the same as Stella Moris. LPA Linley asked if Ms. Brown worked with any other supervisors if Lakechia was not available and Ms. Brown stated they mainly worked with Lakechia and stated there was an owner, but could not think of his name. Ms. Brown stated that the Owner's name is Charles Ohaeri and the facility number is 336402176. LPM Valenzuela asked Ms. Brown if they had any questions and Ms. Brown asked if the revisions had been reviewed and LPA Linley said yes. LPA Linley asked Ms. Brown if they could provide proof of employment experience to Community Care Licensing and Ms. Brown said they had paycheck stubs and would email copies of the stubs to LPA by end of business day tomorrow. LPA Linley asked Ms. Brown if the information in this document is accurate, true and correct and Ms. Brown stated yes. An exit interview was conducted and a copy of this report and appeal rights were reviewed and provided to Ms. Brown. whole process to set it up. LPA Linley asked Ms. Brown to clarify what they meant by helping set it up and Ms. Brown stated they were the Administrative Support role and they were doing applications, setting up the Group Home, and completing paperwork. Ms. Brown said they did not do hands on at the facility and the facility received their first two clients this month. LPM Valenzuela stated that Ms. Brown cannot use their experience as an Administrator at KB Homes, LLC or IHeart Lives because the facilities do not have any clients to provide direct services. LPM Valenzuela asked Ms. Brown why they left Stella Morris and Ms. Brown stated the facility closed. LPM Valenzuela asked if they knew the reason why the facility closed and Ms. Brown stated they were not sure and the facility was switching counties. LPM Valenzuela discussed and reviewed documents that were submitted to the Department by Applicant Markiesha Brown on December 14, 2025: On the LIC 215, Ms. Brown listed Lakeisha Brooks as a personal reference and LPM Valenzuela asked Ms. Brown if Lakeisha Brooks is the same person listed on all the documents and Ms. Brown said yes, they are the same person, and it might have been a typo or spelling error. Ms. Brown stated Lakeisha's correct last name is Donald. On the LIC 215, Ms. Brown listed she worked at the Stella Morris Group Home located at Steeplechase Drive Moreno Valley, CA 92555 and Ms. Brown stated the termination reason as "on call," and Ms. Brown stated that must have been a mistake. On the LIC 501, Ms. Brown listed that she worked at Stella Morris as a STRTP and stated the facility was closed and worked there from 06/2021-08/2025 and LPM Valenzuela wanted to confirm the dates of employment. Ms. Brown stated that the facility slowed down in May, they moved to "on-call," and the facility closed in August. On the LIC 501, Ms. Brown stated that Lakeisha Brooks is their reference for past employer and Ms. Brown confirmed that Ms. Donald is their reference for past employment at Stella Morris. ***

report_type: Facility Evaluation

met_with: Markiesha Brown


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On October 21, 2025, Licensing Program Analyst (LPA) Charmaine Linley, met with Applicant, Markiesha Brown, for Component II Orientation for a Group Home. The following questions were discussed and answered: Ms. Brown stated they have previously worked in STRTP facilities and will provide letters of experience for the Administrator qualifications. Ms. Brown stated they received their Administrator Certificate earlier this year and LPA reviewed the qualifications for Ms. Brown to qualify as an Administrator. If Ms. Brown does not meet the qualifications, Ms. Brown can submit an Exception letter to LPA for Administrator qualifications. LPA asked if Ms. Brown or Remia will be living at the facility and Ms. Brown stated they will not be living at the facility and Remia will not be living at the facility. LPA reviewed the LIC 500 and to indicate positions on the LIC 500 so as to be hired to ensure there is adequate coverage for the facility. LPA reviewed some of the budget costs were lower than normal and Ms. Brown will update the monthly budget or provide a statement with an explanation of the costs. LPA provided a copy of the LIC 184, LIC 281, and CRP PIN 24-09, to assist with the revisions needed to the application via email. The revisions are due by November 4, 2025, by 5:00 pm. Overall Notes: Section B documents as noted in the LIC 281 were not provided. Please provide all Section B documents that are identified either at the top of the page or through a cover sheet. *** Section A Documents: A1. Application (LIC 200):  #8: Alternative Public Phone Number needs to be completed.  #10: needs to be completed. A2. Applicant Information (LIC 215):  Education: Please explain if the High School and College are the same schools and completion dates.  References: Addresses need to be completed.  Work Experience: CCRC address needs to be completed. A3. Applicant Information (LIC 308):  Date needs to be filled out.  Facility number needs to be filled out.  Remia Williams needs to be added in Guardian and associated to the facility. A4. Administrative Organization (LIC 309):  Provide the LLC Operating Agreement.  Please explain why Remia Williams is listed on the Secretary of State website as a member and they are not listed on the LIC 309. A7. Monthly Operating Statement (LIC 401):  Provide an explanation of the following areas:  # Transportation is estimated to be very low.  # Salaries and wages seem to be low.  # Insurance - the lease states that the LLC will provide liability insurance, this needs to be indicated on this form and any other types of insurance.  #28 why property taxes are not indicated.  #30 electricity seems to be low.  # 33 and #34 why are there no expenses indicated for repair and maintenance. *** A8.b Balance Sheet (LIC 403):  Remove crossed out sections. A8.c Balance Sheet Supplemental Schedule (LIC 403a):  Provide a copy of the ownership documentation for Property #1 with the purchase price and current value. A10. Personnel Report (LIC 500):  Facility Number needs to be filled out.  Name of the person that prepared form needs to be filled out.  We cannot approve individuals to be working 7 days per week and not have any days off. The facility needs to follow California labor laws. There needs to be enough coverage for all the hours you can put to be hired, however, there is not enough coverage at this time to approve.  Social Worker: days and times needs to be filled out.  Administrator needs to be fully spelled out.  Dates employed needs to be filled out. A11. Personnel Record (LIC 501):  Cross out sections need to be removed.  Information needs to be written legibly or typed.  Facility Number at the top right of the form needs to be completed.  References: Addresses needs to be completed. Remia Williams:  Date needs to be filled out.  Remove crossed out sections.  Information needs to be written legibly or typed.  References: Addresses needs to be completed. LaKechia Donald:  Previous Employment: Addresses needs to be completed. *** A12. Health Screening Report - Facility Personnel (LIC 503):  Markeisha: The Health Screening Report and TB Test are over one year old and cannot be accepted. Please provide a new Health Screening Report and TB test that includes the Duty Statement.  The Physician needs to write out what is "WNL."  Please do not use wite-outs on the forms.  LaKechia: Need original signed Health Screening Report, we cannot accept a photocopy.  The Health Screening Report and TB Test are over one year old and cannot be accepted. Please provide a new Health Screening Report and TB test that includes the Duty Statement.  Types of persons needs to be filled out. A14. Emergency Disaster Plan (LIC 610C, LIC 610D,LIC 610E):  Remove crossed out section.  Information needs to be written legibly or typed.  Administrator needs to be fully spelled out.  Provide letters of permission from both relocation sites with the printed and signed name of the authorized agent. A15. Facility Sketch (LIC 999):  Include the garbage storage areas on this form.  Will the facility have a Ring doorbell or any video cameras? Section B Documents were not provided. B1. Partnership Agreement/Articles of Incorporation/Articles of Organization:  This section was not provided.  Provide a copy of the LLC Operating Agreement in this section. B2. Verification of Administrator Qualifications and Certification:  This section was not provided. ***  Have completed high school, or equivalent, plus at least three years administrative experience or supervisory experience over social work, child care, and/or support staff providing direct services to children in an agency or in a community care facility with a licensed capacity of seven or more.  Written references are to be obtained and submitted to the licensing agency. References are used solely to determine that the experience requirement is met (i.e., the person worked there, in the particular capacity, the specific duties performed, for a specified period of time). The written letter must be submitted by the employer who can speak about the information listed above.  Provide the name and residence and mailing addresses of the facility administrator, a description of the administrator's background and qualifications. B3. Verification of Social Worker Qualifications:  This section was not provided.  This section is missing the documents listed below:  LIC 215: Applicant Information  LIC 501: Personnel Record  LIC 503: Health Screening Report  Verification of education and experience, copy of degree and transcripts, and resume  Photo ID  Copy of First Aid Certificate B4. Job Description - each position:  This section was not provided.  Provide a job description for all positions which corresponds with the LIC 500 to include:  Duties and responsibilities;  Minimum qualifications that correspond to licensing requirements. This is to include any special licenses or certificates or special skills needed to perform the job;  Lines of supervision. B5. Personnel Policies:  This section was not provided. ***  Provide the work hours/shift for documentation of positions to provide coverage with competent staff, to correspond with staff positions and works days and hours listed on all personnel reports.  Describe the abuse reporting procedures:  Describe the types of abuse the facility will report and how it is documented the employees are informed of their responsibilities to report to the licensing agency as well to the policy and child protective services.  Describe how the facility will provide a report to the licensing agency within the agency's next working day during its normal business hours.  Describe how a Supervisor or Administrator does not impede or inhibit the reporting of duties of mandated reporters.  Describe how the facility shall not sanction, punish, or discipline any person for making a report.  Describe how the facility shall not direct an employee or independent contractor to allow their supervisor to file or process a mandated report on their behalf or require an employee to disclose their identity to the employer.  Hiring Practices: Describe the screening of employees for necessary education and experience and informing employees that conditions of their employment include fingerprint clearance, statement of prior criminal convictions, TB clearance, physical examination/health questionnaire, child abuse index check. B6. In Service Training for Staff:  This section was not provided.  Provide a descriptions of the New Employee training and who will be conducting their training along with their qualifications.  Provide the topics to be covered in the ongoing training, along with who will be conducting the training, along with their qualifications.  Include the Administrator continuing education units, how often the training will be documented and include topics specified in the LIC 281. B7. Facility Program Description:  This section was not provided.  Provide a statement of the purpose, goals, and program methods.  Provide the days and hours of operation. ***  Provide a daily schedule of activities to be provided by the facility that needs to state who plans, conducts, and assists clients in participating in these activities.  Provide a one month schedule of planned social, education, and recreational activities that needs to state who plans, conducts, and assists clients in participating in these activities.  Provide a description of basic services provided by the facility.  Describe any optional services listed in the Admission Agreement.  Describe how the facility is going to handle medical emergencies if a client becomes ill or injured  Describe the procedure for handing and assisting clients with self-administered medications.  Describe how the motor vehicles used to transport clients shall be maintained in a safe operating condition.  Describe how the licensee and their staff are prohibited from smoking a tobacco product, or permitting any person from smoking a tobacco product in a motor vehicle that is regularly used to transport children, regardless of when the children are present. This prohibition applies when the motor vehicle is moving or at rest.  Provide a description of list of community resources and consultants to be used by the facility.  Provide the complaint/grievance procedures in this section including, how to submit a grievance/complaint, who responds, the timeframe, how the outcome is documented, where is the procedures documented. B8. Rules of Discipline/Personal Rights:  This section was not provided.  Provide a statement that discipline does not include a violation of personal rights.  Describe the types of discipline that will be used and under what conditions each type will be used. The discipline policies shall also address the following, when appropriate: types of discipline not permitted.  Provide the grounds for planned discharges/unplanned discharges from placement.  Provide a clear statement that there will be no corporal or unusual punishment used.  Describe how the child will sign the personal rights form at intake and each time a new right has been added.  Provide a copy of the discipline policy and describe how the child and Authorized Representative will sign the form. *** B9. Admission Policies:  This section was not provided.  Describe the persons accepted for care, including age range and compatibility determination process, when necessary.  Describe the criteria for assessing appropriateness of placement given an individual client's needs (i.e., interviews, procedures for obtaining and developing the necessary paperwork, etc.)  Describe the needs and services plan.  Provide a statement that clients/residents will be informed of their rights and that client's/resident's rights will not be violated).  Describe the pre-admission appraisal plan in this section.  Describe how the facility will obtain emergency information.  Describe the sign-in and sign-out procedures.  Describe the physical examination requirements/immunization requirements/TB test in this section. B10. Sample Menu:  This section was not provided. The sample menu will include:  Planned meals and snacks for one week, foods used should be from the four basic food groups.  Portion sizes.  Times meals served. B11. Control of Property:  This section was not provided.  Name and address of the owner must be provided.  Proof of ownership must be provided if the applicant is the owner of the property. The licensing agency can verify this by a Property Tax bill, Deed or other related document. The documents provided must contain the facility street address within the document or its' attachments. B12. Bacteriological Analysis of Private Water Supply (When Water for Human Consumption is from a Private Source):  This section was not provided. *** B15. Neighborhood Complaint Policy:  This section was not provided.  Describe the procedure for immediate responses to incidents and complaints.  Include the time when the Licensee or Administrator will be available to meet with neighborhood residents. B16. First Aid Card:  This section was not provided.  Provide a CPR/1st Aid card for the Applicant. B18. Group Home Program Statement:  This section was not provided.  Use the LIC 9106. Program Statement: Sec # Purpose, Methods and Goals {Ref: CCR: 80022(b)(1); MPP11-402.356(a)}.  The ages are not the same age as listed on the LIC 200, please make sure all ages in all sections are the same as listed on the LIC 200.  Describe how the clients will be assessed.  Describe what type of treatment will be provided.  Describe how the results or outcomes will be measured and how often Sec # Planned Activities/Use of Community Resources {Ref: CCR 80022(b)(13),84065(e), 84079}.  Describe the plan for individual child activities and group interaction activities.  Describe which children are involved in the activities.  Provide a list of community resources used by the program that is specific to your area, this area is too vague.  Describe the program's planned educational activities and services. Include: *** • Special Education; • Use of public and/or private schools; • On grounds school; and • Tutoring, if applicable  Provide a sample daily activity schedule for one week, including weekends and holidays. The schedule must include social, recreational, and education activities. Sec. # Special Services/Programs Offered  Describe if the program will provide vocational training, if so describe: • The skills taught; • Goals of the training program; • Hands-on experience received; • Materials provided; • Number of hours per day/days per week training is provided; and • How training is funded. Sec. # Medical and Dental. (Ref: CCR 80075 (a) (1)-(2).  Describe the procedure for handling and assisting children with self-administered medication.  Describe procedures used to identify and handle medical, dental and psychiatric emergencies, outside of calling 911.  Identify staff position(s) responsible for dispensing and destroying medications.  Describe how the facility will obtain a copy of the current court order, or written authorization of the child's parent or guardian, for each psychotropic medication.  Describe the use of Psychotropic Medication Administration Records (PMAR LIC 622B). A separate log for each psychotropic medication prescribed to the child.  Provide a statement that medication errors will need to be reported and documented to CCL, according to the timeframes for reporting requirements.  Provide a statement that any medication refusal by a client is considered a "Special Incident" and a report will be sent to Community Care Licensing. *** Sec. # Transportation (Ref: CCR 80022 (b)(10).  Describe if the staff will be using their own vehicles for transporting the children.  Specify how the program will ensure that vehicles used to transport children are maintained in safe operating condition.  Specify how the program will ensure that vehicle registration and insurance will be maintained.  Specify how the program will ensure that only appropriately licensed program staff and volunteers will transport children. Sec. # Admission/Intake (Ref: CCR 80022(b)(2) 84068.1 84068.2).  Describe the timeframe for responding to referring agencies regarding acceptances or rejection of referral.  Describe the staff position responsible for intake.  Describe the procedures for accepting emergency placements on a time-limited and/or trial basis. Sec. # Needs and Services Plan/Assessment {Ref:CCR 84022(b)(2)}.  Describe who writes the Needs and Services Plan, "qualified staff," is too vague.  Describe the procedures for implementing and modifying the Needs and Services Plan.  Describe the policy regarding participating of the child and their Authorized Representative in developing, updating and modifying the Needs and Services Plan. Sec # Discharge/Removal (Ref: CCR 84068.2, 84068,4).  Provide a copy of the discharge/removal form that the child and Authorized Representative will sign in this section. Sec. # Visitation Rules and Policies (Ref: CCR 80068 (b)(8) 80068,2 (b)(6), 84072).  Describe when and under what circumstances children can be visited at the facility by friends and others.  Include that any supervised visits needs to be documented and signed off in the Needs and Services Plan.  Describe when and under what circumstances the child is permitted to have home visits with relatives.  Describe when and under what circumstances the child is permitted to have overnight visits with relatives, family members, and friends. *** Sec. # House Rules.  Describe the policy of allowing children to be unsupervised away from the facility, including issuing passes to children.  Provide more information on what contraband is considered to be removed.  For belongings to be removed (phones, tablets, etc.,) the reason why must be documented and included in the Needs and Services Plan with signatures from the child and Authorized Representative.  Provide a copy of the house rules the child will sign in this section.  Specify other house rules to include: • Curfew hours on weekends and holidays; • Smoking; • Dating other children in placement; • Completing homework; • Dress Code; • Laundry Sec. # Discipline Policies [Reference: CCR 80072(a)(3), (7) - (8), 84072, 84072.1]  Describe the conditions under which each type of discipline will not be used.  Include a statement that discipline does not violate personal rights.  Describe the provisions for contact with parents and/or placement representatives (conferences).  Include the discipline policy the child and Authorized Representative will sign in this section. Sec .# Emergency Intervention Plan (Ref: CCR 84800(d), 84801, 84802, 84802.1,84803, 84804 and 84808.  Provide the resume and qualification of the individual who designed the Emergency Intervention Plan. 1.Individuals vendored as a behavior management consultant prior to, or as of, December 31, 2006, that have not previously completed twelve semester units in applied behavior analysis, shall have until December 31, 2008 to complete twelve semester units in applied behavior analysis and possess a license and experience as specified in 3. through 7. below. 2.Individuals vendored as a behavior management consultant on, or after, January 1, 2007, shall, prior to *** being vendored, have completed twelve a\semester units in applied behavior analysis and possess a license and experience as specified in 3. through 7. below. 3.Possesses a valid license as a psychologist from the Medical Board of California or Psychology Examining Board; or 4.Is a Licensed Clinical Social Worker pursuant to Business and Professions Code, Sections 4996 through 4998.7; or 5.Is a Licensed Marriage and Family Therapist pursuant to Business and Professions Code, Sections 4980 through 4984.7; or 6.Is any other licensed professional whose California licensure permits the design and/or implementation of behavior modification intervention services. 7. Have two years experience designing and implementing behavior modification intervention services.  Provide a list of the blocking techniques in this section.  Provide the Admission Agreement in this section that must include a written statement regarding the type(s) of emergency interventions that will be used.  Describe how a child does not remain in a manual restraint for more than 15 consecutive minutes, unless written approval to continue the restraint after the initial 15 minutes is obtained from the administrator or administrator's designee and manual restraints must not exceed four (4) cumulative hours in a 24-hour period.  Describe all techniques (including manual restraints), when techniques are NOT used and expected outcomes.  Describe the assessment of underlying or unknown medical or physical condition precluding use of restraints.  Describe the techniques of group and individual behavior management.  Describe the alternative methods of handling aggressive and assaultive behavior.  Describe the techniques for returning the child to planned activity following an emergency intervention.  As a reminder, each use of manual restraints must be reported to the Department and the child's authorized representative by telephone no later than the next working day following the incident.  The Emergency Intervention Staff Training Plan is to be included as a component of the emergency intervention plan. The plan must include the following in this section: *** (1)The type, title, and a brief description of the training that all facility personnel have completed. (2) Training requirements for new personnel. (3) The ongoing training required for existing personnel. (4) Training curriculum as specified in Section 84365(b). (5) Training schedule which identifies when staff training will be offered and provided. (6) The name(s) and qualification(s) of the instructor(s) who will provide the training.  Describe how any report of the use of manual restraints must be reviewed, for accuracy and completeness, and signed by the administrator or administrator's designee no later than the next working day following the incident.  Describe or provide a copy of the monthly log of each use of manual restraints.  Describe the procedures for an internal biannual review of the use of emergency interventions must be developed or provide a copy of the form.  Describe the procedure of when and how to involve Law Enforcement.  Describe the staff training plan and how often staff are trained and where the training is documented.  Describe how the facility shall submit reports to the Department, using form LIC 624-LE or a report containing all the information required in LIC 624-LE, regarding any incident that involves law enforcement contact with a child residing in the facility.  Describe how the licensee shall make an initial report to the Department no later than the next business day following each incident and send a written report within seven days.  Describe how within six months of the incident, the licensee shall provide a follow-up report for each incident that includes the following information: (A) The type of incident. (B) Whether the incident involved an alleged violation of any crime, other than an age-based curfew law, by a child residing in the facility. (C) Whether staff, children, or both were involved in the incident. (D) The gender, race, ethnicity, and age of children involved in the incident. (E) The outcome of the incident, if known, including arrests, removals of children from placement, termination or suspension of staff, the filing of a Welfare and Institutions Codes Section 602 petition for the child, or revocation of or changes to the terms of probation. *** Sec. # Children's Complaint/Grievance Procedures [Reference: CCR 84072.2].  Clarify who is the "designated designee," if the complaint is against the Administrator.  Describe where the outcome of the complaint/grievance is documented.  Describe where the grievance box is located.  Provide a copy of the complaint/grievance policy the child and Authorized Representative will sign in this section. Sec. # Handling Children's Funds, Allowances, and Salaries [Reference: CCR 80022(b)(12), 80025, 80026, 84026].  Provide the amount of allowance in this section.  As a reminder, Personals and Incidentals cannot be used for allowance.  Describe the amount of allowance clients can earn for chores. Sec. # Chores.  Provide a copy of the House Chore Chart in this section. Sec. # Nutrition/Sample Menu  Provide a sample menu which includes one week's worth of planned meals, including snacks from the four basic food groups;  Portion sizes; and  Times meals/snacks are served. Sec. # Staff Schedule  Provide the actual work schedule or LIC 500 in this section, which includes names, classifications, days, and hours worked.  Specify the number of hours the Administrator will be at the facility each week.  Specify the number of facilities for which the Administrator is responsible. Sec. # Staff Qualifications  Provide copies of resumes or job applications for all child care workers, social work staff, administrator, and consultants in this section. If employees have not started work, provide a letter of *** acceptance/commitment for the position.  Specify the number of hours the Administrator will be at each facility each week, performing administrative duties. Sec. # Job Descriptions  Please note the Administrator job descriptions does not have the requirements listed in the regulations for the Administrator and needs to be updated.  Provide a job description for the Social Worker.  Provide duties on all job descriptions. Sec. #24. Inservice Training for Staff/Administrator 1.Please provide the initial and annual training curricula/outline, including the trainers' name/position and their qualifications. 2.List trainers' names and qualifications for the annual training requirements. 3.Describe the 5 hours of the annual training that shall consist of course work from an entity other than the group home such as an accredited educational institution, workshops, seminars, or other direct training provided by a qualified individual, who meets the requirements specified in Section 84065(i)(4)(A)1., who is not affiliated with the group home licensee 4.Describe the training plan for the facility's manager. Please include the course titles and length of each training. 5.Describe or provide a copy of the child care staff assessment within 7 and 30 days of the completion of the 8-hour training and that it will be stored in the personnel record. 6.Describe how special training needs are identified and then training met to address. 7.Describe the training for the Reasonable and Prudent Parent Standard. 8.Describe the initial training that needs to include: (A) Overview of the client population served by the group home; (B) Facility's program and services, including program philosophy, activities and community resources; (C) Facility's policies and procedures, including reporting requirements to the Department and as a mandated child abuse reporter; *** (D) Child care workers' job description, including roles and responsibilities; (E) Child care workers' self awareness; (F) Role of other facility personnel in service delivery, including case staffing; and the role and responsibilities of the onsite staff member designated to apply the reasonable and prudent parent standard as specified in Section 84065 (b)(1); (G) Discipline policies and procedures; (H) Disaster response (I) Medical emergency response; (J) Teamwork and interpersonal communication among facility personnel and clients and client family members; (K) Teamwork and intra-facility communication; (L) The role of placement workers; (M) Medication procedures, assistance with medication, universal precautions, recognition of early signs of illness and the need for professional assistance, and other health related issues ;including oversight and monitoring of psychotropic medications for children in foster care and related topics specified in Section 16501.4(d) of the Welfare and Institutions Code; (N) Group home children's adjustment to group care; (O) Housekeeping and sanitation principles; principles of nutrition, food preparation and storage and menu planning; (P) California Code of Regulations, Title 22; (Q) Availability of community services and resources; and (R) Recreation activities and resources. (S) A child's rights as specified in Welfare and Institutions Code section 16001.9 and Section 84072, including a child's right to have fair and equal access to all available services, placement, care, treatment, and benefits, and to not be subjected to discrimination or harassment on the basis of actual or perceived race, ethnic group identification, ancestry, national origin, color, religion, sex, sexual orientation, gender identity, and gender expression, mental or physical disability, or HIV status. status. (T) Instruction on cultural competency and sensitivity relating to sexual orientation, gender identity and gender expression, and best practices for, providing adequate care to lesbian, gay, bisexual and transgender children in out-of-home care. *** (U) The facility's policies and procedures concerning when and how to involve law enforcement in response to an incident involving a child residing in the facility. 1. The training shall include the right of children in foster care to have law enforcement intervention requested only when there is an imminent threat to the life or safety of a child or another person, or as a last resort after other diversion and de-escalation techniques have been utilized; and to not have law enforcement intervention used as a threat or in retaliation against the child. (V) A child's right to receive sexual and reproductive health care and information. (W) A child's right to have their sensitive health information kept confidential (X) The duties and responsibilities of the assigned case management worker and the licensee to ensure that children can obtain sexual and reproductive health services and information. (Y) Guidance about how to engage and talk with children about healthy sexual development and reproductive and sexual health in a manner that is medically accurate, age or developmentally appropriate, trauma informed, and strengths based. (Z)Information about current contraception methods and how to select and provide appropriate referral resources and materials for information and service delivery. 9.Submit a one-month training schedule and the length of each training. Sec. #25. Administration  Provide a current organizational chart which shows lines of administrative authority; and copies of the articles of incorporation and bylaws. Sec. # Control of Real Property  Will you be living at the facility?  #2 needs to be filled out.  #4 says they will allow clients between ages 6-17, however, you stated on the LIC 200 you will have 5 children between the ages of 18-21. The lease or the LIC 200 needs to be updated so they are the same ages in all sections.  #5 needs to be filled out. *** Sec. # Facility Sketch  Include the garbage storage areas on this form.  Will the facility have a Ring doorbell or any video cameras? A copy of this report was provided to the applicant along with the signed Orientation form indicating Component II has been completed. A copy of this report will be placed in the facility file.

Deficiencies:
92501: Kb Homes Llcfacility Number: 366000054 Visit Date: 10/21/2025 Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 A8.b 	Balance Sheet (LIC 403):
	Remove crossed out sections.

   A8.c Balance Sheet Supplemental Schedule (LIC 403a):
	Provide a copy of the ownership documentation for Property #1 with the purchase price and current value.

   A10. Personnel Report (LIC 500):
	Facility Number needs to be filled out.
	Name of the person that prepared form needs to be filled out.
	We cannot approve individuals to be working 7 days per week and not have any days off.

title: Facility Name


facility_name: KELLY'S HOME

summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13On 9/27/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a complaint investigation visit regarding the above allegation. LPA met with Administrator Rochelle Rivera and informed of the purpose of the visit. Based on confidential interviews, observations, and record review, two youth in care are above the licensed age range. The facility has provided support letters for age exceptions but had not provided a written request for age exceptions meeting licensing requirements. Licensing records reflect previous contacts, but interviews with management reflect not being aware further action was needed. Additionally, the facility is currently nearing the end of the licensure process to become an adult residential facility and has kept the licensing agency up to date on their progress with this. The preponderance of evidence standard has been met, and therefore the above allegation is substantiated. LPA determined that the violation is considered a technical violation, and no citation is being issued at this time. Administrator submitted the age exception requests on 9/26/24. An exit interview was conducted, appeal rights were provided, and a copy of this report was left with Administrator. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Mariah Hawkins 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 SAN BRUNO RO, TRAEGER AVE., SUITE This is an official report of an unannounced visit/investigation of a complaint received in our office on 08/14/2024 and conducted by Evaluator Mariah Hawkins PUBLICCOMPLAINT CONTROL NUMBER: 14-CR- FACILITY NAME:KELLY'S HOMEFACILITY NUMBER: ADMINISTRATOR:ROCHELLE RIVERAFACILITY TYPE: ADDRESS: SHOREVIEW AVENUETELEPHONE: (650) 375- CITY:SAN MATEOSTATE: CAZIP CODE: CAPACITY:6CENSUS: 2DATE: 09/27/ UNANNOUNCEDTIME BEGAN: 01: PM MET WITH:Administrator Rochelle RiveraTIME COMPLETED:01: PM 9Staff are overmedicating resident INVESTIGATION FINDINGS: 13On 9/27/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a complaint investigation visit regarding the above allegation. LPA met with Administrator Rochelle Rivera and informed of the purpose of the visit. Based on confidential interviews, observations, and record review of medication administration records (MARs), centrally stored medication records, and other medical records, some discrepancies were found. One discrepancy was found that could reflect an overadministration of medication. The MARs reflected administration of a discontinued medication. However, inspection of the resident's medication bin, centrally stored medication records, and pharmacy orders showed that the medication had not been filled since May 2024 and was not maintained in the bin. It is not clear that this medication was administered or that an overadministration occurred. Although the allegation may have happened or is valid, based on LPA's observations and interviews, there is not a preponderance of the evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. An exit interview was conducted, appeal rights were provided, and a copy of this report was left with Administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Mariah Hawkins 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 3

report_type: Complaint Investigation

met_with: Administrator Rochelle Rivera

complaint_status: unsubstantiated


summary: Facility Evaluation

raw_content:
Narrative:
At 9: AM Licensing Program Analysts (LPA) Isabel Mendoza made an unannounced inspection to this facility to conduct an annual required inspection. LPA met with Direct Care staff John Yap and Lead Staff Daisy Garcia. Shortly after Administrator Rochelle Rivera arrived. The facility currently has a census of 3 clients. All clients were in school during todays inspections. At 9: AM LPA and the Administrator toured the facility inside and out. The facility is clean, safe and sanitary and in good repair. All passageways are unobstructed. All disinfectants, cleaning solutions and poisons are locked in the laundry room. Per Administrator, there are no firearms in the facility. The kitchen is clean and sanitary. The facility has sufficient two day perishable and seven day nonperishable food supply. The inspected bedrooms were furnished accordingly. LPA noticed that two bedrooms (bedrooms 2 and 3) ceilings and walls had several stains/markings, so LPA advised the facility to do a good cleaning on the walls/ceiling. During inspection at 11: AM staff started wiping down the walls in both bedrooms. There is an outdoor space for the clients, and no hazards or broken items. The facility has another house/detachment which is separate from the facility. This area is prohibited from clients and is used by staff members/live-ins. LPA advised the facility to submit an updated fire clearance sketch and include the backyard detachment house. The facility will submit the sketch no later than 10/01/21. There are no pools or bodies of water. LPA inspected medications, and they appeared fine. Medications are located in the kitchen area [ PLEASE REFER TO LIC C...] in a locked cabinet. All items are fully documented. LPA noticed that the facility was using MAR LIC A for psychotropic medication. LPA gave a copy of LIC B to the Administrator so the facility can separate non-psychotropic from psychotropic MARS per requirements. The facility ensured they will start incorporating the LIC 622B, and make all necessary changes. LPA Mendoza reviewed all three client files. All files were organized and had all required documents. LPA found a few items were documents were not fully complete, so LPA reminded the facility to ensure that all LIC forms must be completed and if an item does not apply to write "N/A". At 12: PM LPA inspected three staff files and (S1), (S2), and (S3) (Please refer to LIC 811, dated 09/17/21 for confidential names) did not have Health Screening or TB test results on file. The administrator confirmed that all three staff member have not and they will make an appointment. All staff have required training on file. The Administrator (S4) certificate expired back in 2018 and the Administrator stated that she tried to renew it in 2019 but did not complete the correct administrator courses, so was unable to get it renewed. LPA obtained copies of all documentation that was submitted back in 2019. During inspection, the Administrator confirmed she is currently registered for a recertification class that will be on 09/22/21 and submitted proof to LPA. LPA went over Guardian association list that was printed on 09/16/21 with Administrator, and (S5) Daisy Garcia is not showing associated. The facility confirmed that (S5) has worked at the facility for about 5 months. During inspection, LPA obtained a copy of criminal record transfer request, which was submitted to CCL main office back in April. LPA advised the facility to resubmit form to CCL main office again, and LPA obtained a copy and will take back to the office for processing. LPA Mendoza also introduced Administrator to CCL's new background portal called Guardian. LPA obtained copies of LIC 500, LIC 610, LIC 309, and Administrative documents for Rochelle Rivera. Per Title 22 regulations, deficiencies were cited at this visit, and three LIC Technical Violations, and one Technical Assistance was issued. Exit interview conducted, appeal rights printed, and a copy of this report was left with the Administrator.

visit_type: Annual

met_with: Adminstrator, Rochelle Rivera


summary: Facility Evaluation - 2 deficiencies

raw_content:
Narrative:
On 9-29-22 10:10AM, Licensing Program Analysts George Karkazis conducted an unannounced Annual/Required inspection at the listed facility. LPA's met with Co-Administrator Adora Ancheta and toured the facility inside and out. Safety precautions were taken, including screening call and mask-wearing. The Group Home is licensed to serve 6 clients. Present during the inspection were two staff and no clients present. All clients were at school and all clients are non-verbal. At 11:03AM, LPA Karkazis toured the facility. LPA Karkazis observed five bedrooms and three bathrooms. LPA observed the facility license, personal rights, facility sketch, meal menu, and other forms posted on the walls throughout the facility. LPA Karkazis tested the water temperature and found it to be 110 degrees, which is within range. The thermostat read 68 degrees which is within range. Sharps were locked, and chemicals were safely stored. There were two days of perishable foods and seven days of non-perishable foods present. The medication was also stored and locked cabinet. LPA checked medication and found no issues. The facility is in good repair and clean. LPA Karkazis interviewed two staff and no clients. At 12:20PM LPA Karkazis toured the backyard. There were no open bodies of water. The backyard was in good repair and clean. At 1: PM LPA Karkazis reviewed client and staff files. Client files were complete and had all required documents. LPA Karkazis reviewed staff files and the following items were missing: (S1) did not have a current CPR training certificate, (S2) had no first aid training, fingerprint clearance, no education history, no personnel record, no job application, no health screening, no medical training, no tuberculosis clearance. (S3) had no first aid training certificate, valid fingerprint clearance, education history, health screening, employee rights, medical training, and tuberculosis clearance. (S4's) CPR certificate expired. (S5)had no first aid certificate, personnel record, no health screening, no training record, no education history, and no tuberculosis clearance. Also, staff (S3) was present at the facility and was not associated to the facility. The Co-Administrator showed LPA a copy of the DOJ Applicant Fingerprint Response sheet, however, (S3) was not showing associated to the facility nor had a profile on Guardian. At this time, there were deficiencies cited, Title Group Home Regulations 84365(d)(1), 84365(d)(1)(A Emergency Staff Intervention Training, 84365(d)(1)(B), 84365(d)(1)(C) Emergency Staff Intervention Training, 80066(a)(3),80066(a)(10) Personnel Records, 80066(a)( Health Related Services, 80075(f) Personnel Records, 80066(a)(5, 80066(a)(6) Personnel Records, and 80019(e) Criminal records clearance, civil penalty assessed. An exit interview was conducted, appeal rights discussed, and a copy of this report was given to Adora Ancheta, Director.

Deficiencies:
80075(f): Deficient Practice Statement
1
2
3
4Based on record review,the licensee did not comply with the section cited above, have not received first aid training from qualified agencies,which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2022
Plan of Correction
1
2
3
4All staff shall  have qualified first aid training, with certificates on file.
80019(e): Deficient Practice Statement
1
2
3
480019(e) Criminal Record Clearance-All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility.

met_with: Adora Ancheta, Director

title:
Health-Related Services

(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by


summary: Facility Evaluation

raw_content:
Narrative:
On 8/31/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a required annual inspection. LPA met with Administrator Rochelle Rivera, and informed of the purpose of the visit. The CARE Inspection Tool was used to completed this inspection. During inspection, LPA toured the facility site and inspected facility records. LPA observed the facility to be clean. No hazards were observed. The kitchen is fully stocked with food within date. Bedrooms have clean linens. Bathrooms are maintained in sanitary condition. A continuation visit is required to complete this inspection. LPA observed the following deficiencies during today's inspection: - Staff S1 (See LIC Confidential Names) does not have a background clearance. - The facility has not completed emergency drills in at least 8 months. - All four residents are above the licensed age range, and the facility has not been granted age exceptions. - There was no current register/roster of residents, and licensee needed to generate a new one. - The facility manager (S1) personnel file did not include facility manager training, and administrator stated the training plan in the plan of operation (POO) was not followed. - The personnel file for staff S2 did not reflect 20 hours of annual training nor any training since January 2022. - The file for resident R4 did not contain medical consent forms nor a medical assessment/physician's report. LPA is issuing citations of Health and Safety Code, Section 1565(c) and (e) and California Code of Regulations, Title 22, Sections 80019(e), 80010, 84065(d) and (j), 84070(b), and 80069. See attached LIC 809-D pages. Additionally, LPA is assessing a civil penalty of $3000, pursuant to Section 80019, for the second criminal record clearance violation in 12 months. See LIC 421BG. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Rochelle Rivera, whose signature on this form confirms receipt.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 9/7/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted an annual continuation inspection, continuing from the 8/31/23 inspection. LPA met with Administrator Rochelle Rivera and informed of the purpose of the visit. During visit, LPA interviewed two staff and reviewed four client files and 1 staff file. Using the CARE Inspection Tool to complete this inspection, LPA observed the following deficiencies: - Medication administration was not logged on 9/6/23 or 9/7/ AM. Medication counts and staff statements reflect that medication was administered. - Staff S3 (See LIC Confidential Names, dated 9/7/23) file did not contain a LIC 501, a LIC 503, or mandated reporter acknowledgement form. Record review and interview indicated that mandated reporter training and first aid training are needed. - The administrator does not have a valid group home administrator certificate, and evidence of completion of the 40 hours of administrator continuing education could not be supplied during visit. The facility was previously cited for administrator certification on 09/17/2021. - Resident files were missing required documentation. R1 and R2 cash resources logs were blank for August 2023, and the cash balances did not match the last logged amount, even accounting for August receipts. Additionally, the personal property and valuables logs were missing for R1 and R4 and had not been updated since 2017 for R2 and R3. R1, R2, and R3 files did not contain current care plans (IPP/ISP), and R4's file did not contain any plans. Administrator supplied a current plan for one resident, but there was no evidence it had been trained on and implemented due to needing to be located in email. LPA is issuing citations for the above deficiences of Title 22, Sections Children's Records, Personnel Records, Personnel Requirements, Health-Related Services, Administrator Qualifications and Duties, Client Records, and 84068. Modifications to Needs and Services Plan. See attached LIC 809-D pages. Additionally, due to repeat violations within 12 months of sections 80075(f), 80066(a)(6), and 80066(a)(10), LPA is assessing civil penalties of $250 for each violation, totaling $750. See LIC 421FC pages. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Rochelle Rivera, whose signature on this form confirms receipt.

Deficiencies:
84068.3(a): Modifications to Needs and Services Plan

(a) The needs and services plan specified in Section 84068.2 shall be updated at least every six months to determine the following

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
On Monday, September 25, 2023 (09/25/23), a scheduled office meeting was held with the licensee to discuss the licensee's current population and the facility's plan to either transition the residents to adult homes or convert the facility into an adult residential facility (ARF). In attendance were Licensing Program Manager (LPM) Lidia Tinoco, Licensing Program Analyst (LPA) Mariah Hawkins, Administrator Rochelle Rivera, Director Adora Ancheta, and Golden Gate Regional Center (GGRC) Social Workers Martha Tercero, Anita Yen, and Blanca Rivera del Valle. The facility currently has three residents in care whose ages exceed the facility's licensed age range. The licensee was instructed to submit age exception requests with placement agency support letters, and all were received this month. The licensee stated they will be converting the home into an adult home. The licensee agreed to complete the following: 1) By Friday 10/27/23, the licensee will submit their ARF application to the CCLD Adult & Senior Care Program Centralized Application Bureau. 2) Following submission of the ARF application, the licensee will send LPA the assigned license number for the ARF application so that LPA may check in internally on the application review. 3) The licensee will continue to provide monthly updates until the ARF has been licensed. A copy of this report was provided to Administrator Rochelle Rivera, whose signature on this form confirms receipt.

met_with: Director Adora Ancheta, Administrator Rochelle Rivera


summary: Facility Evaluation

raw_content:
Narrative:
On 03/14/24 at 9:45AM, Licensing Program Analysts (LPAs) Celeste Aparicio and Mariah Hawkins conducted a quarterly case management inspection, per the agreed upon terms of the December 2023 noncompliance conference (NCC). LPAs met with Licensee Adora Ancheta and acting Administrator Rochelle Rivera and informed both on the purpose of this visit. Per the NCC terms, the facility was to be subject to quarterly inspections at which personnel and resident records will be reviewed for completion. In addition, the facility was to designate a qualified and currently certified administrator, and to implement interview review of records conducted by the licensee or director with documentation of the review available on site. Lastly, the facility is to maintain overall compliance with applicable regulations. At visit, LPAs reviewed all personnel and resident records and observed them to be complete. Administrator Rivera agreed to submit R3's current IPP and ISP to LPA Aparicio by 3/15/24 at 4:30PM. LPAs observed that Administrator Rivera has completed the required administrator continuing education hours and submitted an administrator recertification application to the Department in October 2023, which the Department has not yet processed. LPAs advised the licensee that technically the acting administrator is not currently certified. See LIC 9102. An exit interview was conducted, appeal rights were discussed, and a copy of this report was left with Administrator Rochelle Rivera, whose signature on this form confirms receipt.

met_with: Rochelle Rivera


summary: Facility Evaluation

raw_content:
Narrative:
On 6/7/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management inspection. LPA met with Facility Manager Dela Luna at the facility and Administrator Rochelle Rivera over the phone and informed of the purpose of the visit. Per the December 2023 noncompliance conference (NCC), the following conditions apply and/or shall be met: 1) The facility shall be subject to quarterly case management inspections. Today is the facility's 2nd quarterly inspection. 2) Personnel records shall be complete with background clearance documentation, initial training, annual training, intervention training, first aid training, mandated reporter training. LPA observed all staff listed on the LIC 500 to have a background clearance. All files were complete, and all staff have valid first aid and CPI intervention certifications and have complete annual, initial, and other required training. 3) Resident records shall be complete with accurate cash/valuables records and current care plans updated at least every 6 months. LPA observed all resident files to be complete, including care plans updated within the last 6 months and detailed and accurate cash/P&I records. 4) Monthly reviews, beginning January 2024, of all personnel and resident records conducted by the director/licensee shall be documented and available on site. LPA observed all personnel and resident files to be complete and the main facility binder to be current and up to date. Administrator agreed to create a specific checklist to document the administrative review by Administrator and/or Director. See Lic 809-c. 5) Administrator shall have complete training and certification. Administrator has a valid administrator certificate reflecting complete administrator training. 6) The facility shall be maintained in compliance. The licensee was required by the fire department to complete work on the physical plant. An inspection was conducted by the fire department on 5/29/24, and per Administrator, only small corrections are still needed. Administrator agreed to send LPA the list of needed corrections once received. Lastly, all residents in care are above the facility's licensed age range. However, age exception requests are pending, and the facility is actively working towards adult residential facility licensure. No deficiencies were observed during the tour of the facility and grounds nor during review of facility records. No citations were issued at today's visit. An exit interview was conducted, and a copy of this report was left with Facility Manager Conrado Dela Luna, whose signature on this form confirms receipt.

met_with: Facility Manager Conrado Dela Luna


summary: Facility Evaluation

raw_content:
Narrative:
On 9/19/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a required annual inspection. LPA met with Licensee Adora Ancheta and informed of the purpose of the visit. LPA toured the physical plant. LPA observed the facility to be clean and organized. Bedrooms and living spaces are tidy. Kitchen and bathrooms are maintained in sanitary condition. The bathroom is accommodating for the population served. There are 3 double-occupancy bedrooms. Both residents are nonverbal, and residents are currently not sharing a room. The outdoor space is well-maintained, and no immediate or potential hazards were observed. Using the CARE Inspection Tool, no deficiencies in physical plant were observed. LPA inspected facility records. LPA observed 5 staff files to be complete. All files have documentation of valid background clearance, required certifications, and 20 hours of annual training in the past year. LPA observed resident files to be complete. All files have current and accurate documentation for medications and care plans. Using the CARE Inspection Tool, no deficiencies in facility records were observed. LPA interviewed Licensee and Facility Manager and observed both residents. No citations were issued at today's visit. An exit interview was conducted, and a copy of this report was left with Licensee.

met_with: Licensee Adora Ancheta


summary: Facility Evaluation

raw_content:
Narrative:
On 9/27/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit. LPA met with Administrator Rochelle Rivera and informed of the purpose of the visit. Per the December 2023 noncompliance conference (NCC), the following conditions apply and shall be met: 1) The facility shall be subject to quarterly case management inspections. Today is the facility's 3rd quarterly inspection. 2) Personnel records shall be complete with background clearance documentation, initial training, annual training, intervention training, first aid training, mandated reporter training. LPA observed that all staff listed on the LIC 500 have a background clearance and that all files were complete with valid first aid and CPI intervention certificates and complete training records. 3) Resident records shall be complete with accurate cash/valuables records and current care plans updated at least every 6 months. LPA observed that the resident files for both residents in care are complete and contain current care plans and inventory logs. Resident cash resources were counted and observed to be accurate to the records. 4) Monthly reviews, beginning January 2024, of all personnel and resident records conducted by the director/licensee shall be documented and available on site. LPA observed all personnel and resident files to be complete and the main facility binder to be current and up to date. Administrator agreed to create a specific checklist to document the administrative review by Administrator and/or Director. 5) Administrator shall have complete training and certification. LPA observed that Administrator has completed the 40-hour administrator training program. However, Administrator has not yet received the renewal certificate. Administrator submitted the application in June 2024 and is showing on the pending renewal list published to the Administrator Certification Bureau's site. 6) The facility shall be maintained in compliance. The residents in care are currently above the facility's licensed age range. The final submission needed for the age exceptions was received on 9/27/24, and the facility is nearing the end of the adult residential facility licensure process. No deficiencies were observed, and no citations were issued at today's visit. An exit interview was conducted, and a copy of this report was left with Administrator Rochelle Rivera, whose signature on this form confirms receipt.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 8/31/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit at the facility to follow-up on a submitted incident report. LPA met with Administrator Rochelle Rivera and informed of the purpose of the visit. During the visit, LPA conducted 1 staff interview with Administrator and observed footage from facility staff of the incident detailed in the incident report. In the footage, a staff member is shown restraining a resident in the prone position with their hands behind their back and with the staff member seated on top of the resident. Administrator initially stated she did not believe this was a restraint and confirmed that the program prohibits staff from performing restraints. LPA explained that this was a restraint and that it was prohibited in the plan of operation. LPA also discussed the dangers of the type of restraint performed and how it is a personal rights violation. Additionally, on 8/15/23, LPA requested a revised/supplemental report be submitted, as not all required information for the restraint incident was included in the original report. On 8/29/23, Administrator stated that no restraint was performed and so the requested information was not submitted to LPA, including the type of restraint used. Lastly, no correction or retraining of staff has been completed yet. LPA is issuing citations of California Code of Regulations, Title 22, Sections Personal Rights, Emergency Intervention Staff Training, Reporting Requirements, and Plan of Operation. See attached LIC 809-D pages. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Rochelle Rivera, whose signature on this form confirms receipt.

Deficiencies:
84061: (C) Description of what manual restraints were used, and how long the child was restrained.

title: Reporting Requirements (h)(6) When the Incident Report is used to report the use of manual restraints, the report must include the following


summary: Facility Evaluation

raw_content:
Narrative:
On 01/18/24 at 11:30AM, Licensing Program Analyst (LPA) Celeste Aparicio conducted a case management inspection at the facility to follow-up with a health and safety check due to the information provided by San Mateo County's fire inspection conducted on 12/12/23. LPA met with Administrator Rochelle Rivera and informed her on the purpose of the visit. LPA conducted an interview with the Administrator, a walk through of the facility, and requested documentation regarding recent incident reports. During the facility walk through, LPA observed sharp plastic and cement debris in the backyard that was accessible to clients. LPA also observed mold around a broken ceiling vent inside one of the clients bedroom. LPA is issuing two citations of California Code of Regulations, Title 22, section Buildings and Grounds. An exit interview was conducted, and a copy of this report was left with Administrator Rochelle Rivera, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 01/23/24, Licensing Program Analyst (LPA) Celeste Aparicio made a visit to the facility and observed deficiencies for which this case management report was generated. LPA met with Licensee Adora Ancheta and informed on of the purpose of the visit. During the visit, LPA observed construction and alterations made to the back house. LPA explained to the licensee that prior to construction or alterations, licensee shall notify the licensing agency of the proposed change and secure a building permit. LPA is issuing citations of California Code of Regulations, Title 22, section Alterations to Existing Building or New Facilities. An exit interview was conducted, appeal rights provided, and a copy of this report left with Licensee Adora Ancheta, whose signature on this form confirms receipt.

met_with: Adora Ancheta


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 9/27/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit in order to deliver notice of deficiency(ies) found during the course of an investigation at the facility. LPA met with Administrator Rochelle Rivera and informed of the purpose of the visit. Based on confidential observations, interview, and record review, the facility did not maintain a current medication administration record due to logging the administration of a medication (Doxycycline) despite not administering this medication, as it is no longer prescribed nor maintained in the resident's current medication bin. LPA issued a citation of California Code of Regulations (CCR), Title 22, Section 80070(b)(10). LPA discussed this matter with Administrator and reviewed the medication records. Administrator confirmed observing the mistake and correcting staff. Administrator stated the mistake was discussed with staff and staff write-ups will be issued. LPA observed the records to have been corrected, the old records maintained for recordkeeping purposes, and the pharmacy medication orders reflecting the medication had not been ordered to be maintained with the records. LPA identified one additional area, food services and menus, in which technical support may be beneficial. See attached LIC 9102. An exit interview was conducted, appeal rights were provided, and a copy of this report was left with Administrator.

Deficiencies:
80070(b): (10) Record of current medications, including the name of the prescribing physician, and instructions, if any, regarding control and custody of medications.

title: Each record must contain information including, but not limited to, the following


summary: Facility Evaluation

raw_content:
Narrative:
On 10/28/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a visit to the facility. LPA met with Administrator Rochelle Rivera and informed of the purpose of the visit. During the visit, LPA became aware that an incident occurred on 10/17/24 where an intervention method constituting a manual restraint was performed by staff. LPA observed that no incident report had been submitted for this incident, and no incident report was located in the resident's records. Administrator confirmed that no report had been generated. After discussion with Administrator, LPA clarified that due to the restriction of the resident's movement during the intervention, the intervention method used constituted a restraint. LPA is issuing a citation of California Code of Regulations, Title 22, Division 6, Chapter 5, Subchapter 3, Article 8, Section Documentation and Reporting Requirements. See attached LIC 809-D. An exit interview was conducted, and a copy of this report and the licensee's appeal rights were provided to Administrator Rochelle Rivera, whose signature on this form confirms receipt.


facility_name: KEY HOUSING

summary: Facility Evaluation

raw_content:
Narrative:
On 09/28/2021 at 9: AM Licensing Program Analyst (LPA) Zena Phillips made an unannounced visit to Key Housing for the purpose of an Annual/Required Licensing Inspection. LPA Phillips met with Artis Carhee 111/Program Director and conducted a tour of the facility. There is currently 1 child placed in the facility. The program accepts clients from Private Placement's. This GH is licensed to serve 6 children ages 13-17 years of age, ambulatory only. The facility is located in a residential area a two story residence , 3 bedrooms, 3 1/2 bathrooms, kitchen/dining room, 1 laundry room , den area with ample outdoor space. There was adequate closet and storage space for the clients. Overall, the facility appeared clean, safe and sanitary. The building is in good repair. The Facility has Office space for the Administrator and staff. All beds are in good repair. Each client has adequate closet and ample clothing. Each client has complete sets of towels, sheets, blankets and bedspreads. There is adequate hygiene and grooming supplies in client's bedroom. The kitchen is sanitary and in good repair. A physical plant inspection was completed and included the following checks: Facility is clean, safe, sanitary and in good repair. LPA Phillips conducted confidential interview with Program Director and resident present at facility. There were no deficiencies cited at this time. LPA will return to interview additional staff and that were not present during the initial inspection. Exit Interview was conducted and a copy of this report was left at facility

met_with: Artis Carhe/Program Director


summary: Facility Evaluation

raw_content:
Narrative:
On 09/29/2021 at 10:10AM, Licensing Program Analyst (LPA) Zena Phillips made an announced visit to Key Housing for Annual Continuation licensing Inspection. LPA met with Artis Carhee 111, Program Director who granted access to the facility. LPA Phillips reviewed the following during the inspection: Staff records review and client record review.. LPA Phillips observed first aid kit, fire extinguisher, and private bathroom. Facility vehicles was operable, clean, free of damage and had current registration and insurance. LPA reviewed Criminal Records and confirmed that all current staff were cleared. LPA Phillips reviewed staff records and client records. LPA interviewed staff present during this inspection. Only i staff file had mandatory reporter training and current CPR card. All other staff files did not have complete required documents. LPA Phillips advised Artis Carhee Program Director of the missing required documents for staff files. LPA Phillips advised training certificates, job duties . Program Director stated would update filed immediately and add required documents to file.


summary: Facility Evaluation

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Narrative:
On 11/16/2023 at 09: AM, (LPA) Licensing Program Analyst - Dennis Jarmin made an unannounced visit to Key Housing Group Home to conduct the annual required inspection. LPA met with Jack Muldoon, Program Director, who granted access to the facility. LPA then inspected the entire physical plant of the facility. The Group Home is licensed and provides care and supervision for six (6) children, ages 12-17, Ambulatory only. There are no bodies of water on the premises and security camera surveillance are placed outside area of the home. The Group Home Administrator confirmed that there are no guns or weapons stored on the premises. The facility is a two story home with 3 bedrooms and 3 full bathrooms plus 2 (1/2) bath. LPA observed the facility clean and sanitized with clean linens, appropriate drawer storage and closet available for clients clothing. The 3 and 2 (1/2) bathrooms were observed clean and sanitary with the required hot water temperature within the regulation. The dining room and living room area had appropriate seatings, and furniture were in good repair condition. The facility has central air conditioning unit that provides suitable air temperature throughout the home with appropriate lighting. LPA observed all the windows in good condition and observed 5 window screens that had tears but a work order to replace the screens today was submitted today. There were no bars on the windows in the event of an emergency evacuation and all passageway, stairs and porches were clear of obstruction and debris. All required posting were met (meal plan, daily activities, required licenses and regulations, personal rights and emergency disaster plan) that are posted in the common area readily accessible to clients. LPA observed cleaning supplies solutions, bleaches and disinfectants are properly stored under the sink that is locked. Sharp knives were also observed locked and inaccessible on a separate cabinet. All the clients prescribed medications are in locked cabinet in the administrative office. LPA observed 8 battery operated smoke detectors and Carbon Monoxide, tested by the facility manager to be operable and audible. The garage is use for inside activity area and there is an on-site laundry area to the rear side of the house that is maintained cleaned and sanitized. The facility has a working telephone and clients can use the telephone when needed. There are appropriate supply of perishable (2 days) and (7 days) non perishable food. Clients are accorded dignity in personal relationships with staff and others. The Facility operates within license conditions and limitations including capacity limitations. Facility has a current, written plan of operation. Facility personnel are instructed to report violations of personal rights. Licensee will report changes in the plan of operation affecting service to clients. Licensee will report client injuries requiring medical treatment and other incidents. LPA conducted two (2) Staff interviews and no Client interviews due to clients are all in school. LPA reviewed eight (8) Personnel files and five (5) Client records. During this inspection, LPA observed the facility to be clean, safe and sanitary. There were no deficiencies cited at this time only technical advisory. Exit Interview was conducted, and a copy of this report will be emailed to Evan Powell.

met_with: Jack Muldoon


facility_name: KEY TREATMENT 1, LLC

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Statements indicated that the property owner is currently working with the City of Malibu to make the corrections and add a garage to the facility. There were no witnesses or statements to corroborate that Licensee was made aware of conversion or citation issued. Due to lack of evidence obtained during the investigation, LPA determines that the allegation is Unsubstantiated. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that a violation occurred. There are no deficiencies cited at this time. An exit interview was conducted, and a copy of this report was left at the facility with the Program Director Matthew Cox Program.

Investigation Findings:
13On July 18, 2024, 11: AM, Licensing Program Analyst (LPA), Rosslyn Gray made an unannounced visit to conclude the complaint investigation. Prior to entering the facility LPA Gray conducted a health and safety risk assessment. During the investigation, LPA Gray conducted confidential interviews, reviewed documentary evidence and photos. Licensee denied knowledge of the allegation. Based on confidential interviews and review of documentary evidence, statements were inconsistent. Documentary evidence indicated that during the pre-licensing inspection and fire inspection no garage was observed, and the facility was not found to have any compliance or safety concerns. Statements indicated that the property owner did not disclose to the Licensee that the garage was converted into a sound room when facility was leased. Statements indicated that the property owner completed this conversion without authorization from the City of Malibu and received a citation December 12, 2022. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Rosslyn Y. Gray LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: KEY TREATMENT 1, LLCFACILITY NUMBER: VISIT DATE: 07/18/2024

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

met_with: Mathew Cox Program Director


raw_content:
Investigation Findings:
13On July 17, 2025, at 1:15PM, Licensing Program Analyst, (LPA), Justine Armstrong conducted an unannounced visit to the Key Treatment 1, LLC facility for the purpose of delivering findings for a complaint investigation alleging, 1) Staff did not provide adequate supervision, resulting in minors having inappropriate sexual interactions. 2) Staff did not intervene when minors had altercations with each other, and 3) Staff made an inappropriate comment to a minor. This complaint was received by the Department on February 7, 2024. Upon arrival, LPA was granted access to the facility by the Executive Director Elnaz Mayeh. This amended report reflects the original findings that were previously reviewed with and signed by the facility on January 23, 2025. The report is now being issued as the official version. The investigation conducted by LPA K.Dear included confidential interviews, as well as a review of incident reports, supervision logs, and other relevant documentation. Concerning the supervision issues, both interviews and documents did not support the claim that staff failed to adequately monitor clients. The statements provided were inconsistent and lacked corroborating evidence. Additionally, the allegation that staff failed to intervene during peer altercations was not substantiated; both records and interviews indicated that staff responded appropriately to these incidents. Lastly, the claim that a staff member made an inappropriate comment to a minor could not be confirmed. The statements were conflicting, and no witnesses were able to verify the allegation. Based on the confidential interviews and review of documentary evidence collected by LPA K.Dear, the Department has decided that the allegations are Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. If any additional information is received, this complaint can be amended, and the findings can be changed. An exit interview was conducted with Facility Executive Director, and a copy of this report was provided. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Enrique M Hernandez LICENSING EVALUATOR NAME: Justine Armstrong LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Elnaz Mayeh


raw_content:
Investigation Findings:
13On July 17, 2025, at 1:15PM, Licensing Program Analyst, (LPA), Justine Armstrong conducted an unannounced visit to the Key Treatment 1, LLC facility for the purpose of delivering findings for a complaint investigation alleging, (1) Staff forced minor in care to sleep on the floor (2) Staff did not provide adequate services to minor in care. This complaint was received by the Department on January 16, 2025. Upon arrival, LPA was granted access to the facility by the Facility Executive Director Elnaz Mayeh. The investigation conducted by LPA J. Armstrong included confidential interviews with staff and relevant documentation.Documentary evidence confirmed that staff did not force the minor in care to sleep on the floor. Furthermore, the allegation that staff did not provide adequate services to the minor was not supported, as records and interviews revealed inconsistent statements that could not be corroborated by evidence. The conflicting statements provided did not have any witnesses to verify the allegations. Based on the confidential interviews and review of documentary evidence collected by LPA J. Armstrong, the Department has decided that the allegations are Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. If any additional information is received, this complaint can be amended, and the findings can be changed. An exit interview was conducted with Facility Executive Director, and a copy of this report was provided. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Enrique M Hernandez LICENSING EVALUATOR NAME: Justine Armstrong LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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


summary: Facility Evaluation

raw_content:
Narrative:
On February 8, 2023 @ 10: AM Licensing Program Analyst (LPA) Zena Phillips conducted Component II - Face to Face meeting with KEY TREATMENT 1, LLC at the El Segundo Regional Office. The purpose of the meeting was to discuss the review of the Program Statement. The following individuals were present: Zena Phillips, Licensing Program Analyst and Evan Powell, Applicant. The Program Statement has been reviewed. Revisions are required as outlined below. Please make the required revisions and submit additional documents by February 22, 2023, unless arrangements for an extension are made prior to that date. Section 4: List of Community Resources, provide daily activity schedule for one week including weekends Section 6: Medical: Provide details on destroying medications Section 13: Discipline Policy: Level System: Provide details on time frame staff will transition to another level. Include the name and qualifications of who designed Emergency Intervention Plan. Section 15: Runaway Plan: Must notify CCL by submitting incident report. If Law Enforcement contacted must submit Law Enforcement report to CCL. Section 16: Children's Complaint/ Grievance Procedures: Can a complaint be filed anonymously? Please explain. continued on 809 c Section 19: Nutrition/Sample Menu: Provide sample menu. Section 21: Staff Schedule: Specify number of hours program administrator will be at the facility. Section 22: Staff Qualifications: Provide copies of resume for administrator. Provide number of hours administrator will be at each facility performing administrator duties. Resubmit LIC 500 with job titles should match LIC 500. Section 24: In Service Training for Staff : Please explain who will do training. Initial training and annual training with curricula. Describe training plan for facility manager. . Missing documents: . Submit Surety Bond with seal First Aid Certificate: A copy of applicants driver's license was made during visit. Provided information for Group Home Orientation contact for Riverside office. Provided administration required documentation. Advised applicant will conduct pre licensing inspection visit tentatively on March 2, 2023. .

met_with: Evan Powell/ Applicant


summary: Facility Evaluation

raw_content:
Narrative:
On 03/02/2023 @ 9: AM Licensing Program Analyst (LPA) Zena Phillips made an announced visit to KEY TREATMENT 1, LLC for the purpose of conducting Pre Licensing inspection. LPA Phillips was greeted by Evan Powell/ Administrator who granted access and provided a tour of the entire facility. The facility is a two story structure with five (5) bedrooms and three and half bathrooms (3.5) located in a residential neighborhood. Current census is 0. Facility kitchen has double sink with garbage disposal, dishwasher, adequate cabinet and drawer space for dishes, utensils, and food storage. There is a large refrigerator and freezer combo in the kitchen with sample menu posted next to refrigerator. The sharps will locked away in the staff office and used the facility chef. The stove top has six (6) burners and LPA Phillips observed all burners functioning properly. There is a working hardline phone located in the kitchen, one of four fire extinguishers located on west facing wall of dining area. Next to the kitchen there is small staff dining area with seating for six (6) and LPA Phillips observed laminated and wall mounted personal rights poster. Emergency Disaster Plan posted on staff dining room wall. There is common area with covered non- operable fireplace. LPA Phillips observed large sofa and chairs, tables, lamps with adequate seating for twelve (12). There is half bathroom downstairs for staff use. LPA Phillips observed next to front door storage closet with adequate hygiene products, paper goods. There is second locked storage room for cleaning supplies to the right of the stairs. The first bedroom downstairs has two (2) double beds with clean linens, lamps, table, wall mounted television and six (6) drawers with adequate closet space for storage. cont on 809 c Report amended on 03/09/2023 to correct wording of pool gate lock. Laundry room has washer, dryer and additional refrigerator and freezer combo storage. This room is locked with locked cabinets for medicine storage and three (3) first aide kits including thermometer. There is working sink with counter adequate storage for laundry products. Second bedroom has two (2) double beds with clean linens, table, lamps, wall mounted television. LPA Phillips observed two full bathrooms downstairs to have tub and shower combo, toilet and sink. Water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. LPA Philips observed the upstairs bedroom with two(2) double beds with clean linens, six (6) drawers, tables, lamps, full bathroom attached, and adequate closet space for storage. LPA Phillips observed the facility's eight (8) working smoke and carbon monoxide detector. LPA Phillips requested Administrator test of alarm and confirmed working. LPA Phillips observed water shut off valve to the left of the front door. The gas line is down the path to the right of the from entrance clearly marked. The front entrance is landscaped, and clear of any debris. The rear of the facility has large wooden deck with tables and chairs with adequate seating for twelve (12) or more. The lower deck to the right facing the ocean has seating for eight (8) with large lounge chairs and table. The lower desk to the left facing the ocean has seating for eight( 8) with large lounge chairs. There is an additional upper deck to the left of facility with seating for six (6). All windows are in good repair with screens and blinds. LPA Phillips observed the facility has four (4) fire extinguishers fully charged and wall mounted. The facility has a pool with self- latching gate and sel closes and LPA Phillips observed gate height to be within compliance requirements .LPA observed facility exterior grounds to be landscaped, maintained and clear of all debris. LPA Phillips observed the facility to clean , safe and sanitary and license ready. An exit Interview was conducted, and a copy of this report will be emailed to the Evan Powell/ Administrator.

visit_type: Prelicensing

met_with: Evan Powell/ Adminstrator


summary: Facility Evaluation

raw_content:
Narrative:
On 06/08/2023 @ 10: AM Licensing Program Analyst (LPA) Zena Phillips made an unannounced visit to KEY TREATMENT 1, LLC for the purpose of conducting Post Licensing inspection. LPA Phillips was greeted by Matthew Cox/ Program Director who granted access and provided the current census. LPA Phillips requested LIC 500 and client roster. The facility is a two story structure with five (5) bedrooms and three and half bathrooms (3.5) located in a residential neighborhood. Current census is 6. During the inspection LPA Phillips conducted four (4) confidential interviews, reviewed five (5) staff files, and five (5) client files. LPA Phillips observed files to be in compliance. Facility kitchen has double sink with garbage disposal, dishwasher, adequate cabinet and drawer space for dishes, utensils, and food storage. There is a large refrigerator and freezer combo in the kitchen with weekly menu posted next to refrigerator. The sharps are locked away in the staff office and used the facility chef. The stove top has six (6) burners and LPA Phillips observed all burners functioning properly. There is a working hardline phone located in the laundry room, one of four fire extinguishers located on west facing wall of dining area. Next to the kitchen there is small staff dining area with seating for six (6) and LPA Phillips observed laminated and wall mounted personal rights poster. Emergency Disaster Plan posted on staff dining room wall. Complaint box to submit anonymously concerns located near staff dining area/multi purpose room. There is common area with covered non- operable fireplace. LPA Phillips observed large sofa and chairs, tables, lamps with adequate seating for twelve (12). There is half bathroom downstairs for staff use. LPA Phillips observed next to front door storage closet with adequate hygiene products, paper goods. There is second locked storage room for cleaning supplies to the right of the stairs. . cont on 809 c The first bedroom downstairs has two (2) double beds with clean linens, lamps, table, wall mounted television and six (6) drawers with adequate closet space for storage Laundry room has washer, dryer and additional refrigerator and freezer combo storage. This room is locked with locked cabinets for medicine storage and four (4) first aide kits including thermometer. There is working sink with counter adequate storage for laundry products. Second bedroom has two (2) double beds with clean linens, table, lamps, wall mounted television. LPA Phillips observed two full bathrooms downstairs to have tub and shower combo, toilet and sink. Water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. LPA Philips observed the upstairs bedroom with two (2) double beds with clean linens, six (6) drawers, tables, lamps, full bathroom attached, and adequate closet space for storage. LPA Phillips observed the facility's eight (8) working smoke and carbon monoxide detector. LPA Phillips requested test of smoke detector and confirmed operational. LPA Phillips observed fire drill roster with date and participants. All windows are in good repair with screens and blinds. LPA Phillips observed the facility has four (4) fire extinguishers fully charged and wall mounted. LPA Phillips requested Board Meeting minutes to be emailed at a later date, Program Director agreed to email. The facility has a pool with self latching locked gate and LPA Phillips observed gate height to be within compliance requirements LPA observed facility exterior grounds to be landscaped, maintained and clear of all debris. LPA Phillips observed the facility to clean, safe and sanitary. An exit Interview was conducted, and a copy of this report will be emailed to the Evan Powell/ Administrator.

met_with: Matthew Cox/Program Director


summary: Facility Evaluation

raw_content:
Narrative:
On 12/27/2023 @ 11: AM Licensing Program Analyst (LPA) Zena Phillips made an unannounced visit to KEY TREATMENT 1, LLC for the purpose of conducting Case Management Inspection due to incident dated 11/04/2023. LPA Phillips was met by Matthew Cox/Program Director who granted access to the facility. During this inspection LPA Phillips verified placement status and requested documents including, incident reports for November 2023 concerning Client #1 (refer to LIC Confidential Names form, dated 12/27/2023). LPA Phillips conducted one confidential interview, all other will be interview at a later date. Please email requested information to LPA Phillips at zena.phillips@dss.ca.gov. LPA Philips further requested a copy of Client Roster (obtained during visit) Personnel Schedule (LIC 500 to emailed). This case management requires further investigation. A copy of this report will be emailed to Matthew Cox/Program Director.