summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced annual inspection to this facility on 9/23/22 at 10: AM. LPA was unable to immediately conduct the physical plant inspection as there were no staff persons present to accompany LPA on the walk through. LPA placed a call to Haley Randle, Director of Youth Residential Programs and eventually a staff person was sent to the facility to assist in the walk through for the physical plant. LPA toured the facility inside and out and found no issues in the facility or on the exterior or grounds of the facility. LPA then went to the "Golden Plaza" to review staff and client files. LPA reviewed two staff files and the administrator file while at the facility and found that there were no issues with the file review for all staff. LPA also reviewed two client files while at the administrative office and did not observe any violations during the file reviews. LPA did inform the agency that there are other topics still needing review including the facility Disaster Preparedness, Emergency Intervention Plan, Core/Therapeutic Services, as well as additional review of some client and staff and other operational files. These reviews will be conducted another date and time, unannounced by Licensing. LPA did not observe any violations during the physical plant review or the file reviews. Exit interview was conducted and documents were provided via email.


state: CA

facility_name: SUMMITVIEW CHILD AND FAMILY SERVICES - AGAPE

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced continued annual inspection on 10/13/22 at 10: AM and met with Haley Randle, Director of Youth Residential Programs who assisted with the inspection. While at the agency, LPA Hill reviewed staff files, reviewed disaster plan and evacuation drills, board meeting minutes, and other facility files. LPA Hill interviewed one staff from the facility. LPA Hill did conclude the annual inspection during the inspection today. LPA Hill did advise the facility that one advisory was given regarding the client roster. Exit interview was conducted and documentation was provided.

report_type: Facility Evaluation

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPAs) Tamara Hill and Monica Roberts made an unannounced inspection on 1/19/23 at 9: AM and met with Haley Randle, Director of Youth Residential Programs to discuss an incident report. LPA discussed the incident report dated 12/5/22 in which C1 (see LIC811 dated 1/19/23) left the facility unauthorized and law enforcement provided a ride to the local cafe. LPA interviewed C1 and one staff person present for the incident. LPA explained to Ms. Randle that the incident report needed to indicate additional information since the report is not clear about why youth are not given access to wifi in the resident, who called law enforcement, why youth was transported to a local cafe by law enforcement, and how long youth was at the cafe. LPA discussed with staff at the facility other information that is necessary to be in the incident reports (particularly the 24 hour reports) when submitting the reports to Licensing. LPA also discussed with the staff that it has been observed that there is an up-tick in medication incident reports where medications are either not administered or incorrectly administered for doses or medications. LPA advised that the agency needs to do something to ensure that youth are given their medications as prescribed and that missing medications for youth is not acceptable. LPA discussed 24 hour reports with the agency as well. LPA pointed out that there are incidents in which there is little to no information about why a youth is restrained or information is missing that is vital to know on these reports. LPA provided examples of the 24 hour incident reports that need additional information on them so that staff are aware of the missing or incomplete reports. No citations were issued as a result of the inspection and exit interview was conducted.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 5/25/23 at 2: PM and met with Anna Gleason, CEO and Jose Navarrete, Administrator, to discuss an incident report. LPA Hill discussed a medication error that occurred on 5/19/23 for C1 (See LIC811 dated 5/25/23). This incident report details that a youth was not administered a medication on 5/18/23 as a result of a medical appointment in which C1 was not allowed to take the medication prior to the scheduled appointment. LPA Hill asked for more information about the appointment, permission to pass the medication, who gave the authorization to pass the medication at a time different than the regularly scheduled prescription time, and what was done about the "staff" that forgot to pass the medication at the newly authorized time. LPA Hill asked that the facility provide this additional information to Licensing by 5/30/23. Exit interview was conducted with Ms. Gleason and documentation provided at the conclusion of the inspection.

met_with: Anna Gleason, CEO


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 7/20/23 at 2: PM and met with Jessica Maglietta, Administrator and Haley Randle, Director of Youth Residential Programs. LPA Hill discussed an incident report dated 7/14/23 in which C1, C2 and C3 (see LIC811 dated 7/20/23) were all counseled by law enforcement over an incident involving clients destroying the property of others. LPA Hill advised the agency that the incident report is all about what the client(s) did in destroying the clients' room and bathroom but there is nothing in the 24 hour report that details what the staff were doing to deter or stop clients in engaging in the property discussion. In discussing the report with Ms. Maglietta, LPA Hill did advise that the report be updated with the additional information discussed and provided to Licensing by tomorrow, 7/21/23, since that is the seven limit to provide the report. In addition, LPA Hill questioned what the agency did or is planning to do regarding the staff not intervening to redirect the clients or stop the property destruction and did request documentation of any action or re-training provided to the three staff present. Exit interview was conducted and documents were provided.

met_with: Haley Randle, Director of Youth Res Programs


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 10/6/23 at 1: PM and met with Haley Randle, Director of Youth Residential Programs. LPA Hill met with Jessica Maglietta, Administrator, to discuss the incident reports in detail: * 10/2/23 - Facility reported a possible bed bug infestation at the facility after a client presented with some bites that were abnormal. The facility responded appropriately by taking the youth to urgent care for proper diagnosis and second opinion. The facility was proactive in removing all bedding and washed all clients' bedding in hot water and dried on high heat as well as contacting an outside pest control company, Terminax, to come out to the facility for possible treatment. Terminax professional determined that there was no evidence of bed bug infestation in the home but did place traps around the bedding to ensure this. * 8/15/23 - Facility reported that C1 (see LIC811 dated 10/6/23) was struggling as a result of a substance dependency and the facility utilized a harm reduction approach to keep C1 from leaving the facility. LPA Hill advised that the facility maintain written documentation in the client's file, i.e. documentation of acknowledgement from the county social worker. * 8/13/23 and 8/3/23 - Facility provided a report that details C2 being inappropriate in their use of their cell phone in the facility, i.e. taking inappropriate pictures. LPA Hill discussed cell phone appropriateness, education, and usage with facility staff. LPA Hill also discussed another report with the facility that appeared to give C2 more than one consequence for the same violation. LPA Hill cautioned staff about this. * 6/24/23 - Facility provided a report about C3 regularly not sleeping in their own room. Continued on LIC809C * 4/8/23 - Facility provided a report about multiple youth in the facility, (C2, C4, C5) engaging in an inappropriate manner at the facility, including being able to obtain dangerous items and threatening staff with these items. LPA Hill asked the facility about contacting law enforcement. LPA Hill advised that once youth in the facility are able to obtain sharp items and threatening to staff or youth, they should call. LPA Hill also discussed some medication issues reported to Licensing and Ms. Magelietta states that she has worked with the facility staff about putting reminders on, in particular for the mid day medication reminder to ensure that youth are no longer missing medications. LPA Hill did not cite the facility for any of the incident reports discussed as the facility followed protocol and did what was supposed to be done in each of the incidents. Exit interview conducted with Ms. Randle and documentation was provided on 10/6/23.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 4/3/24 at 1: PM to discuss an incident report with Haley Randle, Director of Youth Residential Programs. LPA Hill discussed with Ms. Randle an incident report dated 4/2/24 where staff discovered that C1 (see LIC811 dated 4/3/24) was not administered their prescribed medications on the morning of 4/1/24 when youth returned to the school location from a home pass over the weekend with family. LPA Hill interviewed Ms. Randle, facility Administrator, Jessica Maglietta, and reviewed and obtained medication records while at the agency. LPA Hill informed Ms. Randle that additional investigation is needed at this time. Exit interview conducted with Ms. Randle and documentation was provided.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 4/17/24 at AM and met with Haley Randle, Director of Youth Residential Programs to discuss an incident report regarding medications. The incident report dated 4/15/24 in which C1 (See LIC811 dated 4/17/24) reported taking an excess of medications while on a home visit over the weekend. LPA Hill made the inspection today to discuss the facility's protocol related to medication training for parent(s)/guardian(s) to ensure the health and safety of youth while away from the facility. LPA Hill interviewed C1's therapist who communicated that they were aware of the incident and stated that, due to the seriousness of the incident, was going to go over medication security with the parent(s) this Friday. C1 is not scheduled to go on a home pass this weekend and the therapist states that in addition to them doing education training for the parent(s), they will ensure that Medical Services also reviews the filling out of the form and medication security while C1 is in the home. LPA Hill also spoke with Anna Gleason, CEO about the safety and security of youth in care and with Haley Randle, Director of Youth Residential Programs, about the education of the parent(s) about the medication and medication security. Both state that they will ensure that the facility administrator educates parent(s) about the potential dangers related to youth having access to the medications and the need to have documentation related to refusals as that needs to be discussed with the psychologist as needed. No citations issued during this inspection.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 7/18/24 at 2: PM and initially met with Jose Navarrete, Residential Manager. Mr. Navarrete informed LPA Hill that the administrator of the home was present so LPA Hill worked with the administrator, Jessica Maglietta. Mr. Navarrete signed documentation related to the inspection because Administrator Maglietta needed to get to the residence. LPA Hill discussed the following incidents with Administrator Maglietta: 6/27/24 - C1, C2, C3, C4 were taken on an outing by S1 (see LIC811 dated 7/18/24) and during this outing, S1 made a stop at a store where C1, C3, and C4 were able to abscond with several miniature bottles of alcohol. Further investigation with this incident is necessary and LPA Hill shall return for further investigation at a later date. 7/4/24 - C5 was not administered their 4PM medication on 7/4/24. Administrator states that there was a lot going on at the facility on this date and it was an oversight of staff due to events happening. Administrator states that they did counsel staff responsible and did provide a reminder to staff about the importance of the medication passing. No citations applicable and no further investigation needed. 7/4/24 - C1, C5, C4 were involved in an altercation in the evening of 7/4/24 after C5 escalated over consequences given. C5 may have been in possession of illegal substance(s). "Law enforcement was contacted due to "threats of AWOLing" and "escalation in verbal aggression". LPA Hill issued advisory to agency regarding appropriate calls for services. 7/5/24 - C5 was escalate due to reports of possible possession of illegal substances. Subsequent to a violent outburst causing property damage and assault on staff, law enforcement responded and took C5 to juvenile hall. C5 was not returned to the facility's care. No further investigation needed. 7/8/24 - C4 and C2 involved in an altercation. LPA Hill discussed rooming situation between youth since they share a room. Administrator reports that they moved C4 to another room and that youth continue to be housemates without issue. No citations issued and no additional investigation needed. Exit interview conducted and documentation was provided.

met_with: Jessica Maglietta, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 9/6/24 at 11: AM and met with Haley Randle, Director of Youth Residential Programs. LPA Hill made this inspection to discuss the finalizing of an open case management inspection initiated on 7/18/24 regarding an incident report dated 6/27/24, where youth were taken on an outing and were able to abscond from a store with alcohol without staff knowledge. LPA Hill interviewed youth in care about how this happened and youth indicated that they planned, in advance, to outnumber staff during outings. LPA Hill found that staff did not know that this was planned and upon seeing it unfold, they got the youth out of the store and returned to the facility. LPA Hill did provide counseling to the agency about conducting searches when situations such as this come about. In addition, LPA Hill advised that the staff, knowing that youth were out of sight during the outing and inside a store where contraband is readily available, call ahead of their return to the facility to allow time for the facility staff to contact responsible parties and obtain permission to search youth prior entering the facility. Exit interview conducted and documentation provided to Ms. Randle.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 7/13/23 at 9: AM and met with Haley Randle, Director of Youth Residential Programs. LPA Hill discussed incident reports and the responsibility of providing reports to Licensing in a timely manner. LPA Hill reviewed incident reporting for the month of June 2023 and informed Ms. Randle that the following reports were either not received for 24-hour notifications or the full report within the seven day period: C1 and C2 (see LIC811 dated 7/13/23) dated 6/2/23 - no 24 hour notice was received. Full report was received 6/7/23. C3 dated 6/23/23 - 24 hour report was received but there was no full report provided. LPA Hill requested this document during the inspection and it was provided via email on 7/13/23. C4 dated 6/16/23 - no 24 hour report was received and full report was received on 6/20/23. As a result of the information reviewed, LPA Hill did cite the facility for General Regulations, Title Section 80061(b) Reporting Requirements. The facility did not provide the 24 hour report and/or the full written report within the seven days as required. Exit interview was conducted with Ms. Randle and documents were provided.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Jean Stidman and Connie Goldie on 12/11/23 at 10am. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9(a)(2). During the inspection, LPAs met with Jessica Maglietta, Administrator and inspected the facility inside and out. LPAs reviewed two child's records and four staff personnel files on site at the facility. LPAs reviewed two child's psychotropic medications and medication records. LPAs interviewed three staff on site to discuss the facilities policies and procedures of operation. LPAs did not interview any children currently prescribed psychotropic medication. During the inspection the LPAs observed deficiencies (see attached 809D), plan of corrections were discussed and appeal rights were provided. LPAs provided a copy of this licensing report to Jessica Maglietta, Administrator. Facility cited Interim Licensing Standards for STRTP Articles 1-10, Regulations 87068.2(a) Needs and Services Plan (NSP), 87068.3(a) and 87068.3(b) Modification to the Needs and Services Plan and 87070(b)(13)(H) Children's Records. LPAs observed one out of two client files reviewed was missing an initial NSP created within 30 days of placement as well as the NSP was not updated every 30 days. LPAs observed two clients file are missing the client's signature for the NSP for November and December 2023. LPAs observed staff initials were missing for two out of two clients psychotropic medication logs for December 2023.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 4/11/24 at 2: PM and met with Haley Randle, Director of Youth Residential Programs. LPA Hill made this case management inspection to discuss the conclusion of an investigation related to an incident report related to C1's return to the facility from a home visit on 4/1/24 and C1 not being given their morning medications upon return. C1 had gone with family for the weekend and when C1 was returned, C1 arrived at the agency's non-public school site, Monday morning, 4/1/24. C1's regularly scheduled medications are to be administered at 8:00 but C1 arrived at the non-public school site after 9:00 am. While the school site staff assumed that the parent/guardian had already given the youth their medication, nobody specifically asked C1 or their parent/guardian which resulted in C1 missing morning medications. LPA Hill discussed this incident with Haley Randle, Director of Youth Residential Programs and did interview the facility administrator and school aid supervisor about C1's arrival at the non-public school site. LPA Hill observed that the agency's policies and procedures are not clear about receiving youth at the non-public school site, who or how youth are to be checked in at the school site, or how to ensure that youth are given their medication(s) upon return. After reviewing the medication transfer documentation, LPA Hill did advise the agency to add some details to this medication transfer documentation to indicate when youth are being given medication by the parent/guardian during their home pass. This documentation would be similar to what the facility is required to do, i.e., date, time and signature of parent/guardian who administers the medication. In addition, LPA Hill advised that on the medication transfer sheet there be a note informing the parent/guardian of the responsibility to administer the medications if they are returning the child after any regularly scheduled medication time. As a result of the interviews conducted and documentation received and reviewed, LPA Hill did not issue any citations during the inspection and investigation related to this incident but did issue a Technical Advisory related to the medication transfer procedure(s) on the attached LIC9102TA. While at the agency on this date, LPA Hill also spoke to the agency regarding another incident involving C1 in which C1 was not administered a prescribed medication on 4/3/24. LPA Hill learned from Ms. Randle that overnight staff are to pack any medications that are to be administered while at the non-public school site for youth but on 4/3/24, this particular medication, being that there had been a change in the administration, was not packed accordingly. While the incident report received indicates that staff responsible, S1 and S2, were counseled and training was to be provided 4/8/24, LPA Hill learned S2, S3, and S4 were all responsible but only S1 was provided the required training. As a result of this, LPA Hill did cite the agency for violation of Interim Licensing Standards, Section 80075(b) h LPA Hill conducted an exit interview related to this incident and provided documentation to Ms. Randle.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 4/30/24 at 11: AM and met with Haley Randle, Director of Youth Residential Programs. LPA Hill made the inspection to discuss an incident report related to an incident report dated 4/23/24 indicating that C1 (see LIC811 dated 4/30/24) had missed their midday prescribed medication. Upon arrival at the administrative site for Summitview Child & Family Services to discuss the issue, LPA Hill met with Alyssa Polk, Special Ed Learning Coach Supervisor who supervises the educational staff. Ms. Polk discussed that last week was a bit of a different scheduled for C1 due to state testing which required C1 to arrive at the administrative site later than normal, causing the missed medication dosage as the required staff were no longer present to administer the medication to C1. When discussing the issue, Ms. Polk indicated that it came to their attention that C1 did not have a refill for this same medication and had missed their medication. Upon further review, it was determined that C1 missed their medications the evening of 4/29/24 and the morning 4/30/24. While the facility has already ordered the medication and it will arrive today, C1 still missed the medication 4/23/24, 4/29/24, and 4/30/24. When asked who is responsible for ordering refills, Ms. Polk states that it is the administrator and while the house administrator was on vacation last week, this did not conflict with or should not have impeded the responsibility to refill the medication. As a result of the information discussed, LPA Hill informed Ms. Randle that due to the repeated missed medications, the facility was cited for Title 22, Division 6, General Regulations, Health Related Services, Section 80075(b). The facility is required to assist clients with self-administration of prescription and nonprescription medications. This did not happen as evidenced by the medication errors 4/23/24, 4/29/24, and 4/30/24. This is a repeat violation within the previous 12 months, resulting in a civil penalty today. Exit interview conducted and documents provided to the agency.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 5/16/24 at 11: AM and met with Haley Randle, Director of Youth Residential Programs. LPA Hill made the inspection to discuss an incident dated 5/3/24 where C1 (see LIC811 dated 5/16/24) disclosed self-harm and showed staff the marks "up and down both right and left legs". C1 was engaged on the phone with a crisis hotline and medical services were summoned to the facility. Ms. Randle states that a room search was conducted after C1 informed staff that they had "gotten rid of" the object they were using to self-harm. Ms. Randle states that the staff in the facility informed C1's social worker that the room search was being completed while C1 was at the hospital. Upon discharge, the agency picked C1 up at the hospital and they were informed that they found "multiple" items hidden in C1's hair that could be used for self-harm and these items were removed by hospital staff. Ms. Randle states that following this information, C1's therapist contacted C1's social worker to request a change in C1's Needs and Services Plan to include wanding C1 when returning from school or is otherwise outside of the facility's supervision. LPA Hill questioned Ms. Randle about the supervision of C1 as indicated in the incident report that the staff that encountered C1 was passing by C1's room to check on another client in care. In review of the cameras in the facility, it was observed that while there were three staff present at the facility, two of the staff were observed to be sitting at the kitchen table for approximately 20 minutes and one staff was in the living room supervising two youth. LPA Hill observed that C1 was not supervised for approximately 30 minutes and no staff were engaging with C1 during this time. The facility was cited for Title 22, Division Six, General Licensing Standards, Responsibility for Providing Care and Supervision, Section 80078(a) as the facility is required to provide care and supervision as necessary to meet the client's needs. The facility was not supervising C1 which resulted in C1 engaging in self harm without staff knowledge. Citation was issued and documentation was provided to Ms. Randle.


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Youth and staff interviews failed to identify any witnesses to the alleged hit. Further interviews with staff to whom the disclosure was made indicated that when C1 made this disclosure, C1 had no bruises or marks to indicate being hit. As a result of the information obtained, interviews conducted and documentation obtained, the allegation that C1 was hit by S1 is UNSUBSTANTIATED at this time meaning the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. The allegation that staff deny youth time away is related to staff not allowing youth to take space during the schooling hours at the facility. LPA Hill conducted confidential interviews with staff and youth present at the facility during schooling hours and it was revealed that the agency is temporarily providing educational services in the residential facility until their educational site, same as the administrative site, has completed their construction to allow youth to move back to this site for educational instruction. S1 and S2 indicated that on most days they are the primary staff responsible for educational services to youth in care as well as the supervision of youth during the schooling hours. Staff indicated that this facility is a tri-level facility and that having youth on different levels presents a challenge for supervision during the educational hours so they typically keep all youth in the lower level of the facility during schooling hours. Staff state they typically have five or six youth attending the educational services provided at this location with two to three staff present to supervise and assist. Staff interviews indicate they are responsible for supervision of youth during these hours, including maintaining visual of youth. While staff try to give youth options of taking space when feeling overwhelmed or agitated, it is restricted to direct line of sight of staff. Staff states that when the staffing allows for additional staffing at the facility during schooling hours they can accommodate walk-abouts or other services youth request. Confidential interviews with youth also indicated that they can walk outside if they want to take space or need a break as long as they remain in sight of staff supervising. As a result of the information obtained and interviews conducted, the allegation that staff deny youth time away is UNSUBSTANTIATED at this time meaning the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted with Ms. Maglietta and documentation was provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint investigation inspection on 1/29/25 at 3: PM and met with Jessica Maglietta, Administrator, to discuss the findings of the complaint investigation related to the allegations stated. LPA Hill informed Ms. Maglietta that the complaint investigation included an initial inspection at the facility on 9/18/24 where the facility was inspected and interviews were conducted. LPA Hill also conducted a collateral inspection at the administrative office to collect client documents. Confidential interviews were conducted from 9/18/24 to 1/29/25 of direct care staff, administrative staff, and youth in care. The allegation that staff hit a minor in care is related to an alleged disclosure that S1 hit C1 (see LIC811 dated 1/29/25) on their arm some time in August 2024. During an interview conducted with C1, C1 alleges they, S1 and C1, were not within the camera's view at the facility so there would be no proof via camera footage. Confidential interviews were conducted with staff and youth identified as being present and/or witness to this incident. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: SUMMITVIEW CHILD & FAMILY SERVICES - SUGAR PINEFACILITY NUMBER: VISIT DATE: 01/29/2025

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

report_type: Complaint Investigation

complaint_status: unsubstantiated


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Administrative staff indicated that while this is not explicitly stated in the personnel policies, it is discussed in staff meetings, and in other forums with staff from the time of initial employment throughout staffs employment with the agency. Confidential interviews with staff working at the facility, indicated they are aware of this policy and are aware of the expectation to adhere to the dress code polices due to the nature of the behaviors and histories of the youth in care. Confidential interviews with youth in care indicate that it was pointed out to S1 by youth shortly after S1 arrived at the facility for their shift. As a result of the investigation including interviews conducted and documentation obtained, the allegation that staff was inappropriately dressed is SUBSTANTIATED at this time meaning the "preponderance of the evidence" standard has been met. The facility was cited for violation of the STRTP Interim Licensing Standards, Section 87065(g)(1)(B) Personnel Requirements. Investigation showed that staff are to demonstrate knowledge, skills and abilities to engage and develop a rapport with children who have diverse backgrounds. S1 was not able to do this as S1 did not adhere to the same policies youth are required to adhere to, compromising their ability to develop that rapport. Exit interview was conducted with Ms. Gleason and documentation was provided to the facility including appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill conducted a complaint inspection on 2/25/25 at 3: PM and met with Anna Gleason, Chief Executive Officer, to provide findings for to the allegation stated. LPA Hill informed Ms. Gleason that the complaint investigation included an initial inspection at the facility on 11/21/24 where five youth and three staff were interviewed. Subsequent interviews of two staff were conducted on 1/24/25 as well as collection of documentation related to an electronic message exchange between S1 (see LIC811 dated 2/25/25) and Haley Randle, Director of Youth Residential Programs. The allegation about staff not being dressed appropriately is related to an allegation that S1 arrived for their shift at the facility on 11/13/24, not wearing an undergarment. While the facility does have a dress code policy for youths in care, the same policy does not exist for staff. However, administrative staff state it is an implied policy that staff adhere to the same requirements as youth, including the dress code. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: SUMMITVIEW CHILD & FAMILY SERVICES - SUGAR PINEFACILITY NUMBER: VISIT DATE: 02/25/2025

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

met_with: Anna Gleason, Chief Executive Officer

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
During LPA Hill's initial inspection at the facility, LPA Hill did observe youths' lunches that were being provided and they were sack lunches that had a sandwich, an apple, a granola bar, string cheese, and a bag of chips. Interviews with youth in care indicated that they are all given opportunities to pack their own lunches the night prior and these lunches are brought to the house where youth are attending educational services. Youth indicated that if they forget to pack their lunch, run out of time, or just do not want to, the overnight staff packs youths' lunches for them and it typically includes the items listed. While the lunches meet regulatory requirements, youth indicated they are tired of the "same thing" every day and would prefer other things, including hot lunches. When interviewing staff, they indicated this is not possible due to staffing as the youth are split in different houses for educational programs. Staff indicated that they will be transitioning to the nonpublic school site as soon as the remodel and approvals are granted and they do not have the facilities for preparing hot meals for youth there either. Youth indicated there are not alternatives provided for youth, except a different kind of sandwich. As a result of the investigation related to the staff not providing adequate food service to minor(s) in care, the complaint is UNSUBSTANTIATED at this time meaning the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. LPA Hill did issue an advisory about providing alternative meals for youth in care or involving youth in the planning of meals. See LIC9102-TA.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill conducted a complaint inspection on 2/25/25 at 3: PM and met with Anna Gleason, Chief Executive Officer, to provide findings for to the allegation stated. LPA Hill informed Ms. Geason that the complaint investigation included an initial inspection at the facility on 11/12/24 where eight youth and three staff were interviewed. The allegation that staff did not provide adequate food service to minor(s) in care is related to the youths' lunches they are provided daily. Interviews included youth attending the educational services at the facility, not just the youth who reside in the facility. Youth indicated that they were displeased with the choices of food being provided for their lunches, indicating that it is the same every day. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: SUMMITVIEW CHILD & FAMILY SERVICES - SUGAR PINEFACILITY NUMBER: VISIT DATE: 02/25/2025

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


raw_content:
Narrative:
While C1 left the facility on an unauthorized absence and upon apprehension by law enforcement, was taken for further assessment. Youth were told by staff that C1 would not be returning and to move on and not speak about the events. C1 returned to the facility prior to youth waking up in the morning and without warning to youth in care. Other youth in care reported that they did not feel safe with C1 returning to the facility due to the magnitude of the events that took place. Following such events happening in the facility, youth typically have access to an on-call therapist, via teleservices but youth in care expressed that there was a need to be able to process the events of the incident as a group but this was not offered or conducted. Confidential interviews indicated that youth did not feel that staff could keep them safe due to the seriousness of the incident with C1 returning to the facility without preparing youth in care and without providing youth the ability to process the incident in a trauma informed manner. Additional confidential interviews further indicated that the seriousness of this incident scared both, youth and staff, and brought about past traumatic experiences that youth would have benefitted from having a therapist present to assist in processing the events immediately following the incident. Confidential interviews indicated that youth and staff alike expressed that having a therapist come to the facility when an incident of this magnitude occurs would allow the youth to process as a group and assist youth in feeling safe, heard, and supported. It was further discussed that telling youth to stop talking about the event and not giving youth an avenue to discuss the events of the incidents in a safe and supportive space, is not trauma informed and does not allow youth to process their past traumatic experiences brought up by incidents of this nature. Confidential interviews further indicated that having the therapist available via a video chat is not the same as the in-person collaboration and youth tend to not engage in the video collaboration offered. As a result of the investigation conducted, including confidential interviews, the allegation that staff did not provide a safe environment for youth in care is SUBSTANTIATED at this time meaning that the "preponderance of the evidence" standard has been met. The facility was cited for violation of Short Term Residential Therapeutic Programs, Interim Licensing Standards, Section 87078.2(a)(3) Trauma-Informed Interventions and Treatment Practices as staff are required to understand the types of trauma experienced by children..., how to provide care and supervision that is trauma informed..., and how to reduce risk of re-traumatization. The youth were not provided the trauma informed care necessary following a serious incident that would have allowed youth to process their trauma experiences and move forward in a trauma informed manner.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill conducted an unannounced complaint inspection on 5/1/25 at 9: AM and met with Haley Randle, Director of Youth Residential Programs to discuss the findings of the allegation as noted. LPA Hill informed Ms. Randle that the complaint inspection included an initial inspection to the facility on 1/29/25 where two youth were interviewed. LPA Hill interviewed three youth on 3/27/25 and conducted interviews with staff from 3/26/25 through 4/18/25. Three youth refused to be interviewed during the initial inspection on 1/29/25. The allegation that staff did not provide a safe environment for minors is related to an incident that occurred at the facility on 1/21/25, where C1 (see LIC811 dated 5/1/25) got upset at other youth in care and made threats to staff and youth. C1 caused substantial property damage trying to get at youth in care causing staff and youth to barricade themselves in rooms to keep C1 from going after staff and youth. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: SUMMITVIEW CHILD & FAMILY SERVICES - SUGAR PINEFACILITY NUMBER: VISIT DATE: 05/01/2025

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


raw_content:
Narrative:
note also indicates that if C1 were to call, "make sure no one knows it's me" indicating that S1 knew this was against agency policy to be in contact with clients outside of their shift. Another note (date unknown as it is not dated or signed) believed to have been written by C1 followed by a note written by S1 at the bottom of the same page. While C1 denied writing this letter, acknowledges that the writing at the bottom is S1's writing. S1's writing on this note details wanting to kiss and hold C1. This note also states C1 should not tell anybody and to be patient, "one day we'll be together". S2 and S3 called S1 into the administrative office to discuss the allegation and while S1 acknowledged it was their handwriting on at least one of the notes, denied the note(s) being for C1. S1 denied having any inappropriate conversations or interactions with C1. S1 was dismissed from the agency upon discovery of the correspondence. When contacted as part of the investigation, S1 declined to provide a statement regarding the allegation. As a result of the investigation, interviews conducted, and documentation obtained, the allegation that staff had inappropriate contact with minor in care is SUBSTANTIATED at this time meaning the "preponderance of the evidence" standard has been met. Facility was cited for violation of Short Term Residential Therapeutic Program, Interim Licensing Standards, Section 87072(c)(16) Personal Rights as youth in care have the right to be free of...emotional...abuse including...exploitation...or coercion. S1 was secretly corresponding with a youth in care in an effort to exploit C1's vulnerability. Exit interview conducted with Ms. Randle, and documents provided along with appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill conducted an unannounced complaint inspection on 6/10/25 at 10: AM and met with Haley Randle, Director of Youth Residential Programs, to discuss the findings of the allegation as stated. LPA Hill informed Ms. Randle that the complaint investigation included an initial inspection at the facility on 5/29/25 with a collateral inspection conducted on the same date to collect documentation related to S1 and C1 (see LIC811 dated DATE) and spoke to administrative staff about the allegations. LPA Hill also obtained letters written by S1 to/for C1 while working in the facility. LPA Hill contacted S1 on 6/4/25 tried to schedule an interview but S1 declined. LPA Hill interviewed C1 on 6/5/25. The allegation that staff had inappropriate contact with a minor in care is related to S1's hand written communication(s) with C1. One note appeared to be written by S1 and it is believed to be intended for C1, there are no names on the letter but is signed "love" and gives S1's phone number followed by "XOXO". This SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: SUMMITVIEW CHILD & FAMILY SERVICES - SUGAR PINEFACILITY NUMBER: VISIT DATE: 06/10/2025

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


facility_name: SUMMITVIEW CHILD & FAMILY SERVICES - SUGAR PINE

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an announced Pre-Licensing Inspection on 6/27/24 at 8: AM and met with Haley Randle, Director of Youth Residential Programs. LPA Hill toured the facility inside and out and observed the following in this home: * Main floor of the home has the kitchen area, dining area with seating for eight, living room area, one half restroom, staff room where chemicals and client files are to be stored. The dining room has a cabinet where the medications are to be stored and this cabinet has a two lock system for all medications and first aid supplies to be stored in. * Second floor of the home has two dual occupancy rooms and two single occupancy rooms that have all of the required furniture. Additional furniture, bedding and other needed supplies are coming with the relocation of the youth for their current location. This floor also has one restroom centrally located and accessible to youth and the other restrooms is in the master bedroom. These are full restrooms, including showers, sinks, toilets, and other necessary storage. Since the cabinets in the restrooms cannot lock, there will be nothing stored in these restrooms that cannot otherwise be accessible to youth in care. * Basement floor of the home is where the youth will be doing schooling, therapy or other activities in the home. This floor has a restroom as well as storage closets that will not be accessible to youth. There are desks in the garage that will be placed in this space for therapists and/or youth to use for schooling. * Linens and other excess items will be stored in the garage area. Laundry area is in the garage. * Outdoor area of the facility was observed to have rubbish from trees and log/wood piles that all need to be removed. Ms. Randle informed maintenance that this needs to be attended to immediately. LPA Hill also observed tree rounds in the yard and suggested possibly a seating area be designed for youth to sit outside on using these rounds but if the facility is not going to utilize them then they need to be removed. * Smoke detectors were functioning and carbon monoxide detectors are on every floor. LPA Hill and Ms. Randle discussed the submission of the Program Statement and Plan of Operation by 7/1/24. LPA Hill observed that the facility is ready for licensure and will provide the recommendation as needed to the management. End of document.

visit_type: Prelicensing


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill conducted an unannounced case management inspection on 8/16/24 at 11: AM and met with Jose Navarrete, Residential Manager. LPA Hill conducted the inspection on this date as a follow up regarding an incident report dated 8/14/24 where C1 (see LIC811 dated 8/16/24) went on a 1:1 visit with a staff member at the agency and where youth gained access to unauthorized medications. When interviewed staff states that they watched C1 enter the restroom during their outing but did not clear the restroom prior to allowing youth to enter. In the restroom were several first aid supplies and a bottle of pills marked "pain killers" but staff did not think to clear the restroom prior to allowing youth to enter. Staff has only been working with the youth and agency for two months and was provided subsequent training immediately after this incident about clearing public restrooms or asking youth to wait until they return to the facility if clearing is not possible. LPA Hill provided the documentation and advisory note (TA) to Mr. Navarrete.

met_with: Jose Navarrete, Residential Manager


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 8/23/24 at 12:40 and met with Joy Rose, Learning Coach/MHS II. LPA Hill made the case management inspection to discuss an incident dated 8/19/24 that allegedly took placed at this house during the facility's schooling hours. While the youth (C1, see LIC811 dated 8/23/24) does not reside in this house, C1 attends schooling and group hours at this location. LPA Hill spoke with S1 who spent time with C1 outside of the classroom on 8/19/24 and did participate in one of C1's coping mechanisms while C1 was struggling. Youth was not available during the case management inspection today due to another incident that took place that removed youth from the agency. End of documentation.

met_with: Joy Rose, Learning Coach/MHS II


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 1024/24 at 1: PM and met with Sarah Rodriguez, Administrator to discuss some incidents at this facility. LPA Hill discussed the following with the administrator: Incident report dated 10/23/24 where C1 (see LIC811 dated 10/24/24) threatened to report an inappropriate touch for removing C1's cell phone from their bedroom following a consequence being given for inappropriate use in the facility. LPA Hill informed the agency that further investigation is needed at this time and no conclusion was indicated. Incident report dated 10/8/24 where C2 was administered an incorrect dosage of medication. LPA Hill learned that the staff administering the medication was not the typical house staff but was responsible for transportation on the date of the incorrect dosage provided. LPA Hill obtained the medication transfer sheet and will follow up on this incident as further investigation is needed. Incident report dated 9/23/24 where C2 was sent home from public school due to a behavior and being placed on "sick day protocol" which included being in their room and secluded from peers and staff for the day. LPA Hill cautioned the facility about being excessively punitive regarding behaviors as this type of consequence does not appear to be trauma-informed. LPA Hill informed the agency that further investigation is needed at this time. Exit interview was conducted with Ann Barlett and documentation was provided.

met_with: Sarah Rodriguez, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 11/21/24 at 2: PM and met with Haley Randle, Director of Youth Residential Programs, to discuss some incidents at this facility. LPA Hill discussed the following with Ms. Randle: Incident report dated 10/23/24 where C1 (see LIC811 dated 10/24/24) threatened to report a staff for inappropriately touching them for removing C1's cell phone from their bedroom while sleeping and that C1 was placed on a cell phone restriction due to "multiple violations". LPA Hill advised the agency that when writing incident reports, the staff need to be detailed on what violations the youth violate that caused the restriction from the phone. Staff should not be writing "multiple violations" as this is too vague and could lead to further allegations/investigations related to personal rights violations. This concludes the investigation related to this incident report. No citations was issued. Incident report dated 10/8/24 where C2 was administered an incorrect dosage of medication. LPA Hill was unable to obtain the medication transfer sheet, but did obtain proof of staff retraining related to this medication error. This concludes the investigation related to this incident. No citations were issued. Incident report dated 9/23/24 where C2 was sent home from public school due to a behavior and being placed on "sick day protocol" including being in their room and secluded from peers and staff for the day. LPA Hill advised the agency about being excessively punitive regarding behaviors as this does not appear to be trauma-informed. Ms. Randle states that they are send a memo to all staff indicating that no youth should be placed on "sick day protocol" unless truly sick and/or displaying symptoms that may deem youth contagious. Ms. Randle to provide the written direction put out to staff. No citation issued. Youth closing bedroom doors - LPA Hill discussed with the agency youth being in their rooms when alone and being able to close their bedroom doors. While the Department is sympathetic with the nature of the program, the agency has an obligation to look at each youth as individuals and develop individual treatment plans and needs and service plans for each youth to meet their individual needs. and not implement blanket type policies that could be interpreted as personal rights violations. Each youth should be assessed individually, and if deemed safe, be able to utilize the time away as a coping skill as long as individual youth safety could be ensured. If safety cannot be maintained, this should be noted in their Needs and Services Plan and a plan to achieve this should be expressed. No citations were issued at this time. Cell phone policy for youth. LPA Hill discussed that the cell phone policy should not include staff going into client bedrooms to remove or retrieve youths' cell phones if they fail to turn cell phones in per their cell phone policy. LPA Hill advised that review of the cell phone policy, as well as other policies youth sign upon admission, should include frequent review of the policies to ensure youths' understanding of policies signed upon admission and are required to follow. This policy is under review at this time by Licensing as it is part of the agency's Program Statement submitted during relocation of the facility. No citations were issued at this time. LPA Hill concluded the inspection and exit interview was conducted with Ms. Randle.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill conducted an unannounced case management inspection on 2/6/25 at 2: PM to the administrative offices for the agency and met with Haley Randle, Director of Youth Residential Programs to discuss incident reports. LPA Hill discussed an incident report dated 1/31/25 in which C1 was given a double dose of their prescribed medication due to staff error. LPA Hill did obtain the counseling and/or disciplinary documentation for S1 and S2 related to the medication error. LPA Hill was advised and provided proof that both staff were also provided additional training to ensure this does not happen again in the future. LPA Hill advised the agency that the number of medication errors are becoming alarming and the agency needs to be reviewing policies and procedures to ensure that future medication training meets the expectations so as to lessen incidents related to medication errors. Exit interview conducted and documents provided.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill conducted an unannounced case management inspection on 3/7/25 at 11: AM and met with Haley Randle, Director of Youth Residential Programs, to discuss an incident report. LPA Hill conducted the inspection to discuss an incident report dated 1/30/25 regarding a medication error. During the inspection LPA Hill obtained documentation related to the medication error, including the Master Medication Schedule and Medication Administration Record (MAR) which identified that the pharmacy provided a different medication strength than what the child had been taking. While the MAR was correct, the previous MAR indicated a different instruction. It is not clear if the staff person(s) read the old MAR and administered the medications based on that instead of the new MAR. LPA Hill was informed that counseling and/or training was provided to the staff responsible for the medication error. Staff responsible for the counseling were not available to provide proof so LPA Hill requested that the documentation be provided when available. LPA Hill observed that the agency is preparing for an Open House to commemorate their move to their new administrative office and schooling program location. LPA Hill informed the agency that further investigation is needed regarding this incident. End of documentation regarding this incident.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill conducted an annual inspection on 7/23/25 at 1: PM and met with Haley Randle, Director of Youth Residential Programs, who assisted with the inspection. LPA Hill toured the facility and observed the following: Facility is a tri-level facility with client bedrooms on the top floor, kitchen, living room, and dining room on the middle floor and extra rooms used for relaxation and visitations with family. The middle floor is considered the main floor of the house and is the main entrance of the facility. The facility has an attached garage that is storage for freezer and another fridge, holiday decorations, art supplies, sports equipment and other supplies for the house including additional linens. The facility has a large property filled with numerous trees and bushes but no grass. The facility has three fire extinguishers that were last serviced on 1/20/25. There are three restrooms accessible to youth on the main floor and upstairs. The client bedrooms had required bedding, storage space, and closet space for youths' belongings. There are two dual occupancy client rooms and two single occupancy client rooms. The restrooms were stocked with paper towels, toilet paper, and had the covered trash can. The smoke alarms and carbon monoxide detectors in the facility were tested and functioning. There are carbon monoxide detectors on each floor of the facility. The kitchen is stocked with the appropriate perishable and non-perishable food as required with additional supplies in the garage. The sharps in the facility are locked and stored under the kitchen sink where youth do not have access. The agency was issued two Advisory Notes during the physical plant inspection. The Advisories were issued for the master bathroom sink was not clean and one of the beds in the mast bedroom did not have the fitted sheet as required. LPA Hill and Ms. Randle discussed a pending change of location for this facility to their current adult facility and the adult facility to be moved to this location. Ms. Randle states that this would be submitted to the Department by the end of the month of July 2025. No citations were issued at the time of the inspection and exit interview was conducted with Ms. Randle and documents were provided.

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
On Thursday, August 21st, 2025, Licensing Program Analyst (LPA) Brittany Crass, arrived Unannounced at the Agency's Administrative Office to continue an annual inspection which began on 7/23/25. LPA met with Anna Gleason who assisted with the inspection. LPA reviewed 5 staff files. All five staff members are fingerprint cleared. LPA observed all staff have current and valid CPR certificates. LPA viewed one Facility Manager's Prudent Parent Standard training. LPA viewed staff Mandated Reporter training's. LPA discussed annual, 40 hour training requirements, and issued one Technical Advisory, which is not a citation, to clarify training requirements. LPA will need to return on another date to complete the inspection. Exit interview conducted with Anna Gleason. A copy of this report and appeal rights were given.

announced_status: Unannounced

met_with: Anna Gleason


summary: Facility Evaluation

raw_content:
Narrative:
On Wednesday, August 27th, 2025, Licensing Program Analyst (LPA) Brittany Crass, arrived Unannounced at the Agency to continue an Annual Inspection. LPA met with Director, Haley Randle, who assisted with the inspection. LPA reviewed 5 client files. LPA observed: up to date Needs and Services plans for all clients, medical consent forms, and signed discharge policy forms. The Director will email LPA the Room Sharing Compatibility assessments which were locked in the office of a staff member who was not present. LPA advised the Director to add the assessments to the clients files going forward. LPA is giving the Agency one Technical Violation, which is not a citation, for ILS Section 87070(b)(13) Children's Records. This completes the facilities annual inspection. Exit interview conducted with Haley Randle. A copy of this report and appeal rights were given.

met_with: Director, Haley Randle


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Aleza Ruiz conducted an unannounced case management inspection on 11/21/25 at 10: AM to continue follow up regarding a prior case management on 11/20/2025. LPA interviewed 2 youth regarding the incident. No citations were given on this date. A signed copy of this LIC-809 report was provided to Anna Gleason, CEO. An exit interview was conducted.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill conducted an unannounced case management inspection on 5/21/25 at 12: PM and met with Haley Randle, Director of Youth Residential Programs. LPA Hill conducted the inspection for the purposes of following up on a referral provided to Licensing involving C1 (see LIC811 dated 5/21/25). It was reported that C1 was provided a vaping device by S1 while C1 was in care and that S1 and S2 may have been providing devices to other youth in care for some time. Discussion with Ms. Randle and the Human Resources Generalist indicated that S1 admitted to agency staff that the allegation was valid but that S2 denied the allegation. S2 was terminated from employment on 5/20/25 and S1 resigned their employment from the agency on 5/20/25. As a result of the internal investigation conducted, C2, C3, C4 also alleged that S1 and S2 were providing contraband to youth in care. The agency was alerted by youth interviewed that S3, S4, and S5 either provided vaping devices to youth in care and/or had knowledge of this happening but this information could not be confirmed. LPA Hill conducted interviews with Human Resources Generalist, Ms. Randle, and S3 and obtained relevant hire documents for S1 and S2. LPA Hill advised that the agency was being cited for violation of Interim Licensing Standards, section 87072(c)(1) Personal Rights as youth have a right to live in a safe environment. S1 and S2 provided vaping device(s) to youth in care that are working a program for mental health issues and/or substance abuse issues when they need to be free from undue stress related to these devices in the program. Exit interview was conducted with staff and documents were provided to Ms. Randle, along with appeal rights.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill conducted an unannounced case management inspection on 7/3/25 at 1: PM and met with Anna Gleason, CEO, to discuss an incident report dated 6/28/25 involving C1, C2, and C3 (see LIC811 dated 7/3/25). LPA Hill conducted the inspection to discuss this incident report regarding inappropriate interactions between youth from 6/28/25. During the inspection LPA Hill discussed the documented lack of supervision including the ability for youth to be in other youths' rooms and/or be in their own rooms with other youth and staff not be in the vicinity to supervise as required and as detailed in the agency's Plan of Operation. As a result of this, the facility was cited for violation of Title Regulations Section 80065(a) Personnel Requirements as facility staff was not competent to provide the services necessary to meet the individual client needs and were not sufficient in number were not provided the supervision necessary to ensure youth needs are being met. This was observed by staff not being sufficient in number at the facility on 6/28/25 to provide the supervision necessary to prevent inappropriate interaction(s) between youth in care. End of documentation regarding this incident.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Aleza Ruiz conducted an unannounced case management on 11/20/25 at 2: PM regarding an incident report dated 11/02/2025 that involved a youth missing their prescribed medications due to staff "not set[ting] their medication alarm." There was also a second incident report received by the department involving a separate youth missing their medication on 11/01/2025. LPA met with Anna Gleason, CEO regarding the incident reports. The facility is being cited for ILS 84675(c) due to staff failing to administer medications. See LIC-809D for more information. A signed copy of this LIC-809 and LIC-809D report was provided to Anna Gleason, CEO. Appeal rights were provided and an exit interview was conducted.


facility_name: HATHAWAY-SYCAMORES CHILD AND FAMILY SERVICES

summary: Facility Evaluation

raw_content:
Narrative:
On 03/04/2022 at 9am, Licensing Program Analyst (LPA) Bernice Karnsrithong arrived at the facility for the purpose of conducting a pre-licensing inspection. LPA met with Administrator, Daisy Delgado who granted tour and access to the facility. LPA Karnsrithong conducted the health and safety risk assessment upon arriving at the facility. There are currently no clients in the facility. There are no bodies of water in the premises. The facility is located in a residential neighborhood. The entire campus is fenced in and gated. The Administrative Office is located in the front part of the campus. Covid- Health and Safety checks are conducted in the front reception area. The facility is to provide care and supervision for male youth ages eleven (11) to seventeen (17) and non-minor dependents with a capacity up to sixteen (16) clients. LPA Karnsrithong has observed the following during the Pre-Licensing Inspection: The facility composes of three (3) cottages: Baldwin, Swartzott and Hutter. Baldwin Cottage: This cottage has four (4) bedrooms, three (3) bathrooms, a staff office, dining room, kitchen, laundry area, living room and laundry room. It has one (1) storage rooms to store supplies for the cottage. The utility shut-off valve for this cottage is at the back. There is a separate laundry room in this cottage equipped with storage cabinets and individual lockers. It has a working washer and dryer unit. Bedrooms: Each bedroom is equipped with a twin-size bed with linens, a cabinet with a locker, adequate lighting, a desk and a chair. There is a window with screens that is in good condition. One bedroom next to the Living Room is currently being used by the other STRTP for one (1) client. It has one bed with mattress and linens, a desk, a cabinet with a locker, and adequate lighting. (Page 1 of 3) Bathrooms: One full size bathroom is being used by staff. It has a toilet, sink, and shower all in good working condition. There is one bedroom that has a half bathroom with toilet and sink. All bathrooms are clean and water temperature are in safe range. There are cabinets to be used for storage in all bathrooms. Kitchen/Dining Area: The kitchen and dining area is next to the Living Room. It has a table and chairs to be used for meals and for studying. It has a full-size kitchen with a four (4) gas stove oven with a hood range, a microwave, dishwasher, and toaster. There is sufficient cabinet space for non-perishable food items and dry goods. There is a French door style refrigerator in the kitchen. There is fire extinguisher in the kitchen area. Living Room: The living room is next to the Kitchen/Dining Area. It is equipped with a television, a coffee table, couches, a media center with books and a video game console. Licensing postings and children's rights are posted in the Living Room area. There is fire extinguisher in the living room. Swartzott Cottage: This cottage has four (4) double bedrooms, two (2) bathrooms, living room and kitchen. The utility shut-off valve for this cottage is at the back. There is no laundry room for this cottage. Bedrooms: All bedrooms are equipped with twin size mattress, with linens, two (2) cabinets and one (1) desk and a chair. There is a window with screens that is in good condition Bathrooms: There are two (2) full sized bathrooms in this cottage. It is equipped with toilet, sink, and shower all in good working condition. All water temperatures are in safe range. There are cabinets to be used for storage in all bathrooms. The showers in this cottage have shower doors instead of shower curtains. Kitchen: The kitchen is equipped with a four (4) burner gas stove, a microwave, French door style refrigerator, toilet, sink, and dishwasher. There is adequate cabinet space for kitchen items and food supplies. There is a working fire extinguisher in the kitchen area. All food preparation area is clean and well maintained. Living Room: The living room is next to the kitchen. It is equipped with a television cabinet, coffee table, media center, and couches. There is a fire extinguisher in the Living Room area. (Page 2 of 3) Hutter Cottage: This cottage has four (4) bedrooms, two (2) bathrooms, kitchen, laundry room and living room. The utility shut-off valve for this cottage is out in the front. There is a laundry room in this cottage that has a separate door entrance outside. It has a working washer and dryer. Bedrooms: All bedrooms are equipped with twin size mattress, with linens, two (2) cabinets and one (1) desk and a chair. There is a window with screens that is in good condition. Bathrooms: There are two (2) full sized bathrooms in this cottage. It is equipped with toilet, sink, and shower all in good working condition. All water temperatures are in safe range. There are cabinets to be used for storage in all bathrooms. The showers in this cottage have shower doors instead of shower curtains. Kitchen: There is a fire extinguisher in the kitchen area to be used in case of emergencies. It is equipped with a gas stove, a microwave, French door style refrigerator, toilet, sink, and dishwasher. There is adequate cabinet space for kitchen items and food supplies. There is a working fire extinguisher in the kitchen area. There is trash can with a tight fitted lid in the kitchen. Living Room: The living room is next to the kitchen. It is equipped with a television cabinet, coffee table, media center, and couches. There is a fire extinguisher in the Living Room area. All clients have access to outdoor space. The campus has patio seating and tables throughout. It has a outdoor garden next to Hutter Cottage, a recreational hall, a basketball court, exercise equipment, swing set that is all securely bolted in to the ground. There is a pergola with patio furniture next to the other STRTP campus. The facility has an Emergency Disaster Plan in place. All staff are regularly trained for emergency safety quarterly. Each cottage has its own basic first aid supplies. Most medical and first aid supplies and equipment are stored in the nurse's office. The facility has its on-site nurse that provides basic medical care and administers medication for clients as needed. All medication is centrally stored in the nurses office. Medication logs for clients are stored in the nurse office and available for review and audit if needed. LPA Karnsrithong reviewed ten (10) staff files. All staff assigned to this facility have criminal background clearance. There are no deficiencies cited at this time. Exit interview was conducted with Administrator, Daisy Delgado. A copy of this report will be provided to the facility. (Page 3 of 3)

met_with: Daisy Delgado, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 12/29/2022, Licensing Program Analyst (LPA) Bernice Karnsrithong arrived at the facility at 11am for the purpose of case management verifying cottages being used by the Sycamores Short Term Residential Therapeutic Program (STRTP) South Campus. Health and safety risk assessment was conducted upon arriving at the facility. LPA Karnsrithong met with Daisy Delgado, Director of Residential Programs who granted tour and access to the facility. This facility is licensed to provide care and supervision to up to sixteen (16) children ages six (6) to seventeen (17) ambulatory only and to Non-Minor Dependents (NMD). The current census for the facility during the visit is ten (10). The facility is composed of two (2) cottages that are being utilized by clients, Hutter and Swartzott. Hutter Cottage has four (4) bedrooms and two (2) bathrooms. Each bedroom has two (2) twin sized beds, closet space, a desk and adequate lighting. Each bathroom has its own toilet and shower. This cottage also has its own laundry room and a kitchen/dining and living room area. The current census for Hutter Cottage is five (5). Swartzott Cottage has four (4) bedrooms and two (2) bathrooms. Each bedroom has two (2) twin sized beds, closet space, a desk and adequate lighting. Each bathroom has its own toilet and shower. This cottage also has its own laundry room and a kitchen/dining and living room area. The current census for Swartzott Cottage is five (5) during the visit. Currently Family Cottages and Baldwin Cottage is being used for isolation for COVID-19. Baldwin Cottage is also being used for storage. The isolation areas are labeled "Red Zone" when it is in use. The facility has updated its program statement to reflect the changes regarding the facility's designated isolation area and storage.


summary: Facility Evaluation

raw_content:
Narrative:
On March 28, 2023, at 9: AM, Licensing Program Analyst (LPA) Charmetha White made an unannounced visit to Sycamores STRTP South Campus, for the purpose of conducting a Post Licensing Inspection. LPA met with the Vice President of Sycamores, Gina Peck-Sobolewski, who granted access to the facility and together a tour of the entire interior and exterior physical plant was conducted. The facility is a Short Term Therapeutic Residential program that provides care and supervision for up to sixteen (16) male youth ages 11 - 17 years old, and non-minor dependents, ambulatory only. The census at the time of this inspection was 9. The Facility is located in a residential neighborhood and is composed of three (3) cottages: Swartzott, Hutter, and Baldwin. Each cottage is set up as follows: Swartzott Cottage houses 8 clients and it is composed of the following: Living room, Kitchen, four (4) bedrooms, and two (2) bathrooms. The cottage census at the time of this inspection was four (4). Living room: is equipped with couches, a coffee table, a mounted enclosed television cabinet, a TV, and a regulation fire extinguisher. Kitchen: is equipped with refrigerator/freezer, a four (4) burner gas stove, a dishwasher, a microwave, a regulation fire extinguisher, and a trash can with a lid. LPA observed the cottage to use paper plates, cups, and plastic utensils. Food is prepared in the main dining area of the facility and brought over to the cottage. Bedrooms: each bedroom is equipped with two (2) twin beds, two (2) cabinets, working lights, and windows. LPA observed each bed to have clean linens and pillows. Bathrooms: one (1) bathroom is located at the end of the hallway near bedroom #1, and one (1) bathroom is located inside of bedroom #3. Each bathroom is equipped with a toilet, sink, and a shower all in working order. The water temperature was tested and found to be between 105 -120 degrees F. Hutter Cottage houses 8 clients and it is composed of the following: Living room, Kitchen, Laundry room, four (4) bedrooms, and two (2) bathrooms. The cottage census at the time of this inspection was five (5). Report continued on LIC 809C (Page 1 of 3). Living room: is equipped with couches, a coffee table, a mounted enclosed television cabinet, a TV, and a regulation fire extinguisher. Kitchen: is equipped with refrigerator/freezer, a five (5) burner gas stove, a dishwasher, a microwave, a regulation fire extinguisher, and a trash can with a lid. LPA observed the cottage to use paper plates, cups, and plastic utensils. Food is prepared in the main dining area of the facility and brought over to the cottage. Laundry room: is located adjacent to bedroom #4 and accessible from the outside. It is equipped with a washer and dryer. Bedrooms: each bedroom is equipped with two (2) twin beds, two (2) cabinets, working lights, and windows.LPA observed bed to have clean linens and pillows. Bathrooms: are side by side and are located along the hallway. Each bathroom is equipped with a toilet, sink, and a shower all in working order. The water temperature was tested and found to be between 105 -120 degrees F. Baldwin Cottage is used as the facility's isolation area and satisfies ILS regulation 87075(e): it is composed of a Dining room, Living room, Kitchen, Conference room/Staff office, Laundry room, four (4) bedrooms, three (3) bathrooms, and a Storage room. There were zero (0) clients in isolation at the time of this inspection. Dining room: is equipped with a table and chairs. Living room: is equipped with couches, a coffee table, a mounted enclosed television cabinet, a TV, video game console, and a regulation fire extinguisher. Kitchen: is equipped with refrigerator/freezer, a four (4) burner gas stove, a dishwasher, a microwave, a regulation fire extinguisher, and a trash can with a lid. Conference room/ Staff office: is located next to the laundry room and accessible from outside. The room is equipped with a table and multiple chairs. Laundry room: is located outside next to the conference room/staff office and it is equipped with a washer and dryer. Storage room: LPA observe this room to be empty. Bedrooms: each bedroom is equipped with two (2) twin beds, two (2) cabinets with built in lockers, working lights, and windows. Bathrooms: one (1) bathroom is located inside bedroom #2 and it is equipped with a toilet and sink; one (1) bathroom is located in the hallway next to bedroom #3 and it is equipped with a toilet, sink, and shower; one (1) bathroom is located next to the dining room, and it is equipped with a toilet, sink, and shower. All bathrooms were observed to be in working order. The water temperature was tested and found to be between 105 -120 degrees F. Report continued on LIC 809C (Page 2 of 3). Smoke alarms and carbon monoxide detectors were tested and found to be in working order. First Aid kits checked and found to be complete. LPA observed the cottages to have cameras in the common areas and on the outside perimeter of the buildings. The cameras are monitored by the administrative staff and the IT Department. There is a camera waiver on file. Disinfectants/cleaning solutions are stored in the maintenance room and made inaccessible to clients. All medication is centrally stored in the nurse's office and the facility has an on-site nurse that provides medical care and to administer medication. Medication logs for clients are stored in the nurse office and available for review and audit as needed. Overall LPA observed the facility to be clean, safe, sanitary and in good repair. Clients have access to the following outdoor space: an outdoor garden next to Hutter Cottage, basketball court, recreational hall, swing set, and exercise equipment. The facility operates within license conditions and limitations including capacity limitations. The facility has an Emergency Disaster Plan in place. LPA discussed and advised the Licensee to ensure the following: Children are supported and encouraged to participate in extracurricular activities. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. LPA reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. Emergency Plan, Personal Rights, and menus were posted in each of the cottages. Transportation: The facility has a total of 7 vehicles to transport clients. LPA inspected 3 out of 7 vehicles and found seat belts and horn in working order, travel first aid kits, and current registration and insurance. Vehicles are insured by Nonprofit Insurance Alliance of CA and expire 11/1/2023. There are no deficiencies observed or cited at this during this inspection. An exit interview was conducted with the Vice President, and this report was left at the facility. (Page 3 of 3).

met_with: Vice President of Sycamores - Gina Peck-Sobolewski


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On September 28, 2023, Licensing Program Analyst (LPA) C. White made an unannounced visit to Sycamores STRTP South Campus, for the purpose of conducting an Annual/Required Inspection. LPA met with the Administrator, Daisy Delgado, who granted access to the facility and together a tour of the entire interior and exterior physical plant was conducted. The facility is a Short Term Therapeutic Residential program that provides care and supervision for up to sixteen (16) male youth ages 11 - 17 years old, and non-minor dependents, ambulatory only. The census at the time of this inspection was zero (0). The Facility is located in a residential neighborhood and is composed of three (2) cottages: Swartzott and Hutter. Each cottage is set up as follows: Swartzott Cottage houses 8 clients; it is composed of the following: Living room, Kitchen, four (4) bedrooms, and two (2) bathrooms. The cottage census at the time of this inspection was zero (0). Living room: is equipped with couches, a coffee table, a mounted enclosed television cabinet, a TV, and a regulation fire extinguisher. Kitchen: is equipped with refrigerator/freezer, a four (4) burner gas stove/oven (all burners were operational at the time of this inspection), a dishwasher, a microwave, a regulation fire extinguisher, and a trash can with a lid. LPA observed there were no dishes or utensils in the cottage at the time of the inspection. All food is prepared and served in the main dining area located on the facility's premises. Bedrooms: each bedroom is equipped with two (2) twin beds, two (2) cabinets, working lights, and windows. LPA observed there were no pillows, or linens in any of the bedrooms. Bathrooms: one (1) bathroom is located at the end of the hallway near bedroom #1, and one (1) bathroom is located inside of bedroom #3. Each bathroom is equipped with a toilet, sink, and a shower all in working order. The water temperature was tested and found to be between 105 -120 degrees F. Hutter Cottage houses 8 clients; it is composed of the following: Living room, Kitchen, Laundry room, four (4) bedrooms, and two (2) bathrooms. The cottage census at the time of this inspection was zero (0). Report continued on LIC 809C (Page 1 of 3). Living room: is being used for storage. LPA observed several large wooden cabinets with built in lockers, a mounted television enclosure, a metal storage shelve with boxes, and a few wooden desk stored in this area. Kitchen: is equipped with refrigerator/freezer, a five (5) burner gas stove/oven (all burners were operational at the time of this inspection), a dishwasher, a microwave, a regulation fire extinguisher, and a trash can with a lid. LPA observed there were no dishes or utensils in the cottage at the time of the inspection. All food is prepared and served in the main dining area located on the facility's premises. Laundry room: is located adjacent to bedroom #4 and accessible from the outside. It is equipped with a washer and dryer. Bedroom #1: is being used for storage. LPA observed several large wooden cabinets, several mattresses, and a chair stored in this room. Bedroom #2 & #3: is equipped with two (2) twin beds, two (2) cabinets, working lights, and windows. LPA observed there were no pillows, or linens in any of the bedrooms. Bedroom #4: is being used for storage. LPA observed several wooden desks, a large wooden cabinet, two small round tables, a few plastic storage bins, extra fans, and a vacuum stored in this room. Bathrooms: are side by side and are located along the hallway. Each bathroom is equipped with a toilet, sink, and a shower all in working order. The water temperature was tested and found to be between 105 -120 degrees F. Smoke alarms and carbon monoxide detectors were tested and found to be in working order. First Aid kit is located in the nurse's office. LPA observed the cottages to have cameras in the common areas and on the outside perimeter of the buildings. The cameras are monitored by the administrative staff and the IT Department. There is a camera waiver on file. LPA did not observed any disinfectants/cleaning solutions stored in either of the cottages. All medication is centrally stored in the nurse's office and the facility has on-site nurses that provide medical care and administer medication. Medication logs for clients are stored in the nurse office and available for review and audit as needed. The outdoor space consists of the following: a garden next to Hutter Cottage, a basketball court, a recreational hall, a swing set, and exercise equipment. The facility has an Emergency Disaster Plan in place. LPA reminded Licensee to ensure the following when children are in placement: Children are supported and encouraged to participate in extracurricular activities. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the facility. LPA reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. Emergency Plan, Personal Rights, and menus were posted in each of the cottages. Report continued on LIC 809C (Page 2 of 3). Transportation: The facility has a total of 7 vehicles to transport clients. LPA inspected 3 out of 9 vehicles and found seat belts and horn in working order, travel first aid kits, and current registration and insurance. Vehicles are insured by Nonprofit Insurance Alliance of CA and expire 11/1/2023. Administrator Daisy Delgago is present at the facility with a minimum of 20 hours a week, as verified by staff schedule. Licensee is in the process of obtaining Mental Health Certification, the application and Mental Health Plan was submitted to DHCS on 4/19/23. Licensee has obtained National Accreditation through The Joint Commission. The Accreditation is valid through July 17th, 2024. The facility has a camera waiver that is meeting the terms and conditions that approved when the facility was a licensed group home. There were deficiencies cited per California Code of Regulations and Interim Licensing Standards. Exit interview was conducted, Appeal Rights and a copy of this report was given to the Administrator. (Page 3 of 3)

Deficiencies:
87088: (1) An individual bed maintained in good repair; equipped with good springs and a clean mattress; and supplied with pillow(s) which are clean and in good repair.

met_with: Administrator - Daisy Delgado

title: Fixtures, Furniture, Equipment, and Supplies (c)The licensee shall provide and make readily available to each child the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene


summary: Facility Evaluation

raw_content:
Narrative:
On October 27, 2023, Licensing Program Analyst (LPA) C. White arrived at Sycamores STRTP South Campus, for the purpose of conducting a Plan of Correction (POC) inspection in order to clear the deficiencies cited during the Annual/Required visit, conducted on 09/28/2023. LPA met with Administrator, Daisy Delgado who granted access to the facility. The deficiencies previously cited were: Type B - There were no pillows in any of the bedrooms. Section. 87088(c)(1). Type B - There were no linen in any of the rooms. There were no bath towels, hand towels, or wash cloths in any of the cottages. Section 87088(c)(2). Type B - There were no personal hygiene products in either of the cottages. Section. 87088(c)(3). Type B - The Living room, Bedroom #1, and Bedroom #4 in Hutter's cottage is being used for storage. Section. 87087.3(a). During this inspection, LPA was provided a tour of Swartzott Cottage and Hutter Cottage. LPA observed all bedrooms in each cottage to have pillows and new linen. Each cottage was equipped with a supply of personal hygiene products, bath towels, wash clothes, and hand towels. Additionally, all storage items had been removed from the living room, Bedroom #1 and Bedroom #4 in Hutter's Cottage. All deficiencies were cleared at the time of this inspection. LPA printed out the Deficiency Clearance Letter and provided it to the Administrator. There are no deficiencies cited California Code Regulation, TITLE 22, DIVISION 6, CHAPTERS 1, General Licensing Regulations, and Short Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS). Exit interview was conducted and a copy of this report was left with the Administrator.

met_with: Daisy Delgado - Administrator


raw_content:
Narrative:
Additionally, confidential interviews stated that FC2 was angry at FC1 and hit FC1. Other Confidential interviews confirmed that FC1 and FC2 were horseplaying prior to the incident and FC1 and FC2 were prompted to stop. Additional interviews reported that there were no other witnesses to this alleged incident. LPA received inconsistent information regarding the allegation. Based on confidential interviews, the allegation that FC1 sustained a fracture while in care due to a lack of supervision may have occurred, however, it is not supported or proven by evidence. Therefore, the above allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Facility Administrator Trina Sanford.

Investigation Findings:
13On November 24, 2021 at 3:00PM, Licensing Program Analyst (LPA) Adaleyci Caballero met with S.A.M.'s Facility Administrator Trina Sanford to discuss the investigative finding for the above stated allegation for foster child #1. LPA Carol Anderson began the investigation at the facility on April 9, 2021 at 2:00PM. LPA Adaleyci Caballero conducted a collateral visit to interview Foster Child #1, #2, #3, #4, and Staff #1. Facility Administrator Trina Sanford was interviewed via telephone. LPA reviewed previous incident reports. Community Care Licensing received information on April 7, 2021 alleging that foster child #1 (FC1) sustained a fracture while in care. It was specified that foster child #2 (FC2) hit FC1 on the nose causing it to bleed and possibly dislocated/broken it. Confidential interviews stated that both FC1 and FC2 were horseplaying and it was caused on accident. Confidential interviews stated that FC1 nose was not dislocated or broken. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Adaleyci Caballero 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: S.A.M.'SFACILITY NUMBER: VISIT DATE: 11/29/2021

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

met_with: Trina Sanford


facility_name: REFUGE, THE

raw_content:
Narrative:
All interviewees denied Y2 or another youth in care has received a concussion. Staff reported that when the verbal altercation started between Y1 and Y2, staff utilized various de-escalation techniques. Staff reported the incident occurred very quickly. According to staff interviews, as Y1 was leaving the area, Y1 picked up the drying rack and threw the drying rack at Y2. Staff reported that S1 was able to deflect the drying rack however the object hit Y2. All staff interviews denied any of the youth in care received a concussion. One CSW reported they had no concerns regarding the physical altercation while another CSW reported they were unaware of the physical altercation. LPA's record review documented this was the only physical altercation at the facility. Based on confidential interviews the allegation that staff (S1, S2) failed to protect youth (Y2) from being harmed by other resident (Y1) may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, a copy of this report and appeal rights were emailed to Administrator Amaneece Harrison. A copy of the signed report will be placed in the facility file.

Investigation Findings:
13On June 16, 2021 at 04:00pm Licensing Program Analyst (LPA) Kendal Zirbes met with Administrator Amaneece Harrison to deliver the investigative finding for the above stated allegation. During the investigation, LPA interviewed three of three youth, two County Social Workers (CSW), one Facility Manger, the Administrator, Therapist, and two Direct Care staff members. Furthermore, LPA completed a review of the facility records. LPA Zirbes completed a virtual safety inspection of the STRTP on March 9, 2021 at 10:15am, there were no deficiencies noted. On March 1, 2021, the Department received an allegation that on an unknown date, youth 1 (Y1) gave two unknown youth concussions. Confidential interviews reported there was one physical altercation that occurred at the facility. According to the confidential interviews, youth 2 (Y2), youth 3 (Y3), Y1, staff 1 (S1) and staff 2 (S2) were present during the altercation. Confidential interviews reported Y1 threw a drying rack at Y2, which hit Y2 on the side of the head. Confidential interviews reported the staff utilized de-escalation techniques and could not have prevented the altercation. Other confidential interviews reported that if the staff had intervened sooner, Y1 may have been prevented from throwing the drying rack. Report continued on page two UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Christina Barnes LICENSING EVALUATOR NAME: Kendal Zirbes 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, METROPOLITAN DR. # FACILITY NAME: REFUGE, THEFACILITY NUMBER: VISIT DATE: 06/16/2021

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

met_with: Administrator, Amaneece Harrison