summary: Facility Evaluation

raw_content:
Narrative:
On 10/27/2021 at 9:30AM Licensing Program Analyst (LPA) Olivia made an unannounced to Trinity House I for the purpose to conduct the Annual/Required licensing Inspection. LPA Rosas met with Staff#1(S1) who granted access to the facility and an inspection of the facility was conducted together. Individuals mention in this report are identify on the Confidential Names List (LIC811) dated 10/28/21. Temperature and health checks are conducted at the entrance in the sign-in area. LPA met with Staff#1 (S1), who granted access into the home, and who provided a tour of the entire physical plant. This facility has a provisional licensed to provide care and supervision for six (6) children ages 12-17 years old, Ambulatory only. The facility also provides services to non-minor dependents. The facility is in the process of obtaining Accreditation with Joint-Commission. They are in the process obtaining Mental Health Approval. There are no bodies on water on the premises. Staff confirmed that there are no firearms or dangerous weapons in the facility. The facility is current with their annual fees. LPA Rosas inspected the following: This is a one (1) story (STRP) Short Term Residential Therapeutic Program, located in a residential neighborhood. There are three (3) bedrooms, two (2) bathrooms, a living room, dining room, kitchen, staff office, backyard, and an attached garage for storage. There is one (1) facility vehicle parked outside inspected to be in good operating condition. Outdoor Area: There was no swimming pool or bodies of water on the premises. The activity space is free of hazard materials and debris. LPA observed a staff displayed the utility shut-off valves. The facility is surrounded by wooden fence and is observed to be good condition. Report continues on LIC 809-C Page 1 of Garage: The attached garage is used as storage and is kept locked. Laundry Room: The laundry room is located inside of the garage. The laundry is equipped with a washer and dryer unit that was observed to be in good condition. The laundry detergent is made inaccessible to the children and is disputed according the load of the laundry. Disinfectants and chemicals are locked in cabinets made inaccessible. Living Room: There is adequate furniture which appears to be in good condition. There is a television and fireplace that is non-operable. Staff Office: It is equipped office furniture (i.e desk, computers, printers). The medication is triple locked inside of the staff office. All the children prescribed medications are locked in the staff office and children files are kept in a lock cabinet. Staff office is located inside the main facility. The First Aid kit has the required items inside (age-appropriate, and scissors, tweezers, thermometer, and gauzes, antiseptic and First Aid Manual Guide. Dining Area: One table with six chairs is next to the Kitchen: There is a gas stove/oven with four (4) burners, all operating. There is a microwave, refrigerator/freezer and a toaster oven. LPA's observed adequate perishable/nonperishable food supplies. Sharp knives, disinfectants/cleaning solutions made inaccessible to the children locked in cabinets. Water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. Bedroom # 1: Occupied by two (2) clients, the bedroom is equipped two (2) twin sized beds, comfortable mattresses, linen, blankets and pillows; adequate drawer and one (1) wall closet. There is adequate lighting and the windows have horizontal slide locked with curtains observed to be in good condition. This bedroom was a bathroom. Bedroom # 2: Currently occupied by one (1) client, has two (2) twin sized beds and comfortable mattresses, linen, blankets and pillows; adequate drawer and one (1) walk in closet. There is adequate lighting and the windows have horizontal slide locked with curtains observed to be in good condition. Bedroom # 3: Currently occupied by two (2) clients. The bedroom has two (2) twin sized beds and comfortable mattresses, linen, blankets and pillows; adequate drawer and one (1) walk in closet. Report continues on LIC 809-C Page 2 of Bathrooms: There are two (2) bathrooms. Bathroom #1 is the common bathroom for the clients. It is a full-sized bathroom with a toilet, sink, and tub/showers. Bathroom #2 is located inside of Bedroom#1 is full-sized bathroom with a toilet, sink, and shower. Water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. LPA observed a key locked closet that stored hygiene supplies, and cleaning solutions. All windows were in good condition with screens and blinds. There were no security bars on the windows. LPA observed ample towels and linen closet. The passageways and porches are unobstructed. All posting requirements were met, (food menu, regulations, licenses, emergency disaster plan, Children's Personal Rights, and Ombudsman). The facility has a working telephone and youths can use the telephone unless restricted by court order. The Emergency Evacuation Plan is posted on the walls throughout the facility. The Facility operates within license conditions and limitations including capacity limitations. Facility has a current, written plan of operation. Facility personnel are instructed to report violations of personal rights. Licensee will report changes in the plan of operation affecting service to youths. Licensee will report youth injuries requiring medical treatment. A review of Facility's Personnel Report Summary on 10/28/2021 indicates that all personnel have criminal record clearance has obtain the necessary clearances with DOJ, FBI, and Child Abuse Response. LPA Rosas was not able to review youth or staff files during this visit and will return to continue with the annual inspection. Youth were in school during the inspection. LPA Rosas by email the following PINS to S PIN 20-17-CRP: New Background Check Requirements, Assembly Bill 819 (Chapter 777, Statutes of 2019), PIN 21-20-CRP: Statewide Launch of New Inspection Tools for Children's Residential Licensees, PIN 21-05-CRP: The Family Urgent Response System (FURS), Medications Guide TSP 2017-03 (version 08/23/21). There were no deficiencies observed or cited at this time. Exit interview was conducted with S1 and a copy of this report was email to S1 for signature.


state: CA

facility_name: TRINITY HOUSE I

summary: Facility Evaluation

raw_content:
Narrative:
On 01/13/2022 at 10:00AM Licensing Program Analyst (LPA) Olivia made an unannounced to Trinity House 1 for the purpose to verify facility closure. LPA Rosas, knocked the door and waited for response. LPA Rosas, waited and walked around the outdoor perimeter of the home (facility). LPA did not see or hear anyone at the facility. LPA Rosas, contacted CEO via phone and call went to voice mail. LPA, left a voice mail to return phone call to LPA Rosas. LPA Rosas will mail copy of report to the facility mailing address for signature.

report_type: Facility Evaluation

visit_type: Case Management

met_with: CEO


facility_name: TUOLUMNE INN

summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13On October 20, 2021, Licensing Program Analyst (LPA) Eduardo Barragan conducted a complaint inspection at Tuolumne Inn and met with Ramsina Oushana. The purpose of the inspection was to deliver the findings for the above complaint allegations. The Department has investigated the above complaint allegations. LPA Barragan spoke with staff, clients, a Probation Officer and reviewed other predominant documents. Based on documents reviewed, an inspection, and conversations with staff and clients, all the information that was gathered was conflicting. "Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED." An exit interview was conducted with Ramsina Oushana. A copy of this report and appeal rights were provided to Ramsina Oushana. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Eduardo Barragan 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 2

report_type: Complaint Investigation

met_with: Ramsina Oushana

complaint_status: unsubstantiated


raw_content:
Investigation Findings:
13Licensing Program Analysts (LPAs) Lidia Tinoco and Briana Placencia conducted an unannounced visit to the Tuolumne Inn STRTP in order to deliver the findings of the above allegations and met with Monica Alexander. The above allegations were referred to Community Care Licensing for investigation. The investigation included an inspection of the Facility, interviews, and a review of facility and foster children's records. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the allegations occurred. Therefore, the allegations are UNSUBSTANTIATED at this time. A copy of this report was discussed and provided along with appeal rights at the conclusion of the inspection. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lidia Tinoco LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

met_with: Monica Alexander


summary: Facility Evaluation

raw_content:
Narrative:
On 09/03/21, Licensing Program Analysts (LPAs) Eduardo Barragan and Jessica Rodriguez travelled to the above facility to conduct an Annual inspection. LPAs were met by Ramsina Oushana, Administrator. An inspection of the facility was conducted and the following was observed: There are currently four clients in placement. LPAs toured the facility indoors and outdoors. Fire extinguisher charged and up to date. Hot water temperature last measured at 109 degrees. LPAs observed adequate supply of non-perishables. Observed adequate supply of furnishings, linen and storage space for clients. Cleaning chemicals inaccessible to clients. Medication area centrally stored and locked. There are no pets at the facility. Per the Administrator, there are no weapons at the facility. There are no bodies of water at the facility. There have been no deficiencies in the prior 12 months. LPAs will return to the facility at a later date and time in order to complete the annual inspection. No deficiencies cited on this date. LPAs conducted and exit interview with Ramsina Oushana.

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
On 09/08/21, Licensing Program Analyst (LPA) Eduardo Barragan travelled to the above facility to continue an Annual Inspection that began on 09/03/2021. LPA Barragan was met by Ramsina Oushana, Administrator. LPA Barragan interviewed two staff members and three clients at the facility. LPA Barragan is going to go to the corporate office to finish the file review today (09/08/2021). LPA Barragan is going to go to one of the clients schools to complete his interview as well today (09/08/2021). There have been no deficiencies in the prior 12 months. No deficiencies cited on this date. LPA Barragan conducted and exit interview with Ramsina Oushana.


summary: Facility Evaluation

raw_content:
Narrative:
On 09/08/21, Licensing Program Analyst (LPA) Eduardo Barragan travelled to the corporate office to continue an Annual Inspection that began on 09/03/2021. LPA Barragan was met by Brandi Boehme. LPA Barragan went to the corporate office to finish the staff file review today (09/08/2021). No deficiencies were cited on this date. LPA Barragan conducted and exit interview with Brandi Boehme.

met_with: Brandi Boehme


summary: Facility Evaluation

raw_content:
Narrative:
On December 1, 2021, Licensing Program Analyst (LPA) Eduardo Barragan stopped at Tuolumne Inn in order to review a few a client files. LPA Barragan met with Ramsina Oushana. No deficiency were noted on todays visit.


summary: Facility Evaluation

raw_content:
Narrative:
On December 13, 2021, an unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Melikian at 10:00AM. During the inspection, LPA met with Ramsina Oushana , Administrator and Monica Alexander, Assistant Program Director and inspected the facility inside and out. LPA reviewed seven children's records and reviewed two staff personnel records for the facility at 10:30AM. A medication count was conducted at 12:00PM. LPA interviewed two staff at 12:30PM. LPA interviewed two children. The remainder of the children were not interviewed as they were at school and will be interviewed at a later date. No deficiencies to be cited at this time. LPA conducted exit interview with Ramsina Oushana, Administrator and Assistant Program Director Monica Alexander at 1:00PM. LPA provided the summary report upon completion.

met_with: Monica Alexander, Ramsina Oushana


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Tamara Melikian and Vanessa Galvan on March 2, 2023 at 9:00AM. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPAs met with Monica Alexander, Administrator and inspected the facility inside and out. LPAs reviewed 3 child's records and 2 staff personnel files on site at the facility. LPAs reviewed 3 child's psychotropic medications and medication records. LPAs interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPAs interviewed one child currently on psychotropic medication as the other children were in school at this time. LPAs provided a copy of the licensing report to Administrator, Monica Alexander. No deficiencies are being cited at this time. LPA conducted exit interview with Monica Alexander, Administrator.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco arrived at the Tuolumne Inn STRTP for the purpose of conducting an unannounced Annual/Random inspection. LPA met with Administrator, Monica Alexander and Assistant Facility Manager, Cassandra Martinez Alvarez and inspected the facility, inside and out. Centrally stored medications are maintained in a locked cabinet. Sharps and Toxic chemicals are kept locked. The facility has a written emergency disaster plan. All facility smoke detectors were tested and appear to be in appropriate working order, carbon monoxide detectors were observed, fire extinguisher is properly charged. Individual beds were observed with appropriate clean linens and are in good repair. There is at least one-week supply of nonperishable and a two-day supply of perishable foods. The facility is maintained at 68 degrees. No firearms or weapons are allowed in the facility. Appropriate staff/client ratios were verified during this inspection. The facility employs Administrator, Head of Service, 1 facility supervisor, 1 assistant facility supervisor and 13 direct care staff and 4 on call staff. Licensee has obtained Mental Health Certification Including the following: Mental Health Program Approval valid through September 24, 2024. Licensee has obtained National Accreditation through CARF (Commission on Accreditation of Rehabilitation Facilities). The Accreditation is valid through September 30, 2026. 5 records of clients were reviewed. Staff interviews were conducted. Staff Files and Children interviews will be conducted on a later date. One deficiency was cited on today's date and a Technical Assistance. A copy of this report was provided at the conclusion of the inspection along with Appeal rights.

Deficiencies:
80026(h): Safeguards for Cash Resources, Personal Property, and Valuables

(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following

met_with: Administrator, Monica Alexander and Assistant Facility Supervisor, Cassandra Martinez Alvarez


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco met with Administrator, Monica Alexander for the purpose of conducting a continuation Annual/Random inspection. LPA Reviewed 5 staff files. Client interviews will be conducted at a later time. Administrator provided LPA with the plan of correction documents for deficiencies issued on 04/29/24 and POC clearance letters were provided at the conclusion of the inspection. No deficiencies were cited on todays visit. A copy of this report was provided at the conclusion of the inspection.

met_with: Administrator, Monica Alexander


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco arrived at the Tuolumne Inn STRTP for the purpose of continuing the Annual inspection and met with Administrator, Monica Alexander. LPA conducted Client interviews. LPA also followed up with the facility manager and Administrator in regards to the allowance. LPA addressed the allowance in a Technical Violation that was issued on today's visit. LPA spoke with Program Director, Brandi Boehme over the phone and it was discussed that the allowance will be addressed in the upcoming program statement revision. A copy of this report was provided at the conclusion of the inspection.

met_with: Administrator, Monica Alexander and Facility Supervisor, Ramsina Oushuna


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco met with Program Director, Brandi Boehme and Administrator, Dawn Lee for the purpose of conducting a 2-year Required Annual Inspection. Administrator, Monica Alexander is present at the facility a minimum of 20 hours a week. The facility employs Social Worker, 2 facility managers and 13 direct care staff. Licensee has obtained Mental Health Certification Including the following: Mental Health Program Approval valid through September 24,2024. Agency had a Mental Health Program Approval inspection the week of September 16-20, 2024 and are pending results. Licensee has obtained National Accreditation through CARF. The Accreditation is valid through September 30, 2026. 5 records of staff were reviewed. (See LIC811 confidential names list). This annual will be completed at a later date. No deficiencies were observed or cited on today's date. A copy of this report was provided at the conclusion of the inspection.

met_with: Brandi Boehme, Dawn Lee


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco arrived at the Tuolumne Inn STRTP for the purpose of continuing the Annual inspection. LPA met with Administrator, Monica Alexander and inspected the facility, inside and out. Centrally stored medications are maintained in a locked cabinet. Sharps and Toxic chemicals are kept locked. The facility has a written emergency disaster plan and provided a copy to LPA. All facility smoke detectors were tested and appear to be in appropriate working order, fire extinguisher is properly charged. A fire department inspection was conducted on 11/07/2023 and marked as passed as verified by documentation reviewed. Individual beds were observed with appropriate clean linens and are in good repair. There is at least one-week supply of nonperishable and a two-day supply of perishable foods. No firearms or weapons are allowed in the facility. 6 records of clients were reviewed (See LIC Confidential Names List). Client and Staff interviews were conducted on this date. No deficiencies were observed or cited on this date. A copy of this report along was provided at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco arrived at the Tuolumne Inn for the purpose of conducting a Case Management Inspection and met with Administrator, Monica Alexander. On December 23, 2024 an incident involving C1 occurred. LPA Tinoco addressed restraints and discipline policies, including, avoiding power struggles. A Technical Violation was issued for ILS, 87072.1(a)(2) Discipline Policies and Procedures. A copy of this report was provided at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Reyna Martinez on April 10, 2025 at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPA met with Monica Alexander, Administrator and inspected the facility inside and out. LPA reviewed 4 child's records and 2 staff personnel files on site at the facility. LPA reviewed 4 child's psychotropic medications and medication records. LPA interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPA was unable to interview any children currently on psychotropic medication on site as they were in school at this time. LPA will attempt interviews with 4 children at a later time. LPA provided a copy of the licensing report to Administrator, Monica Alexander. No deficiencies are being cited at this time. LPA conducted exit interview with Monica Alexander, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analysts (LPAs), Lidia Tinoco and Olivia Medrano arrived at the Tuolumne Inn STRTP for the purpose of conducting an unannounced Case Management inspection and met with Facility Manager, Angelica Espinoza. The purpose of the inspection was to discuss an incident report that occurred on July 10, 2025. The incident involved C1, S1, S2 and S3 (See LIC Confidential Names List). LPA's were informed that the incident was due to a staff miscommunication which resulted in staff not accompanying C1 to the hospital. However, a staff (S3) conducted a follow-up and was able to go pick up C1 from the hospital. LPA's issued a Technical Violation on this date for ILS, Section 87065.1(b)(3)(I) Supervision, Evaluation and Training Requirements. An exit interview was conducted, and a copy of the report was provided at the conclusion of the inspection.

met_with: Angelica Espinoza


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analysts (LPAs), Lidia Tinoco and Olivia Medrano arrived at the Tuolumne Inn STRTP for the purpose of conducting an unannounced Case Management inspection and met with Facility Manager, Angelica Espinoza. The purpose of the inspection was to discuss an incident report that occurred on July 14, 2025. The incident included C1, S1 and S2 (See LIC Confidential Names List). Staff went hands on to bring C1 back to the facility. LPA's addressed that restraints should not be used to bring youth back to the facility unless it is approved and specified on the runaway plan. Facility Manager stated that they will address this at the next staff meeting on July 29, 2025. The Department determined this to be a immediate risk to health and safety of the children in care at this time, therefore ILS, Section 87095. Emergency Interventions Prohibition is being cited on the attached LIC809D. An exit interview was conducted, and a copy of the report and appeal rights were provided at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco arrived at the Tuolumne Inn STRTP for the purpose of conducting an unannounced Case Management inspection and met with Facility Administrator, Monica Alexander. The purpose of the inspection was to discuss an incident report that occurred on September 27, 2025. The incident included two youth in the facility engaging in inappropriate interactions while in care. LPA Tinoco discussed with Administrator staff supervision. LPA Tinoco was informed that Staff supervision was increased in the hallway. 2 staff are now to be in the hallway. Supervision was addressed via email on 9/29/25 to all staff, as well as in person during the staff meeting on 9/30/25. LPA was provided copies of the meeting notes. The Department determined this to be a immediate risk to health and safety of the children in care at this time, therefore the California Code of Regulations (CCR), Section 80078(a) Responsibility for Providing Care and Supervision is being cited on the attached LIC809D. Deficiencies were cleared on 10/10/25 and a copy of the Clearance letter was provided. An exit interview was conducted, and a copy of the report and appeal rights were provided at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPA's) Lidia Tinoco and Vanessa Galvan conducted an unannounced visit to the Foster Family Agency Creative Alternatives in order to conduct a Case Management regarding an incident report that was received through the incident report email and met with Assistant Program Director, Monica Alexander. LPA discussed with Monica the importance of following the needs and services plan and that there will be a meeting with the facility supervisor to discuss the incident. The plan of corrections will include, a house meeting facilitated by the facility supervisor with all facility staff and will take place 11/29/2021. Monica will provide proof to LPA of meeting. Facility was cited for the Interim Licensing Standards Version Articles 1 through Section 87068.2(c) Needs and Services Plan. A copy of this report was left with Monica Alexander.


summary: Facility Evaluation

raw_content:
Narrative:
On March 13, 2024, Licensing Program Analyst (LPA) Lidia Tinoco met with Administrator, Monica Alexander and Program Director, Brandi Boehme for the purpose of conducting a Case Management. The purpose of the inspection is to discuss incidents dated 2/24/24, 2/25/24, 2/26/24, 3/2/24, 3/11/24 and 3/12/24 that indicated medication errors made by staff. LPA Tinoco reviewed incident reports from the Tuolumne Inn Facility (See LIC812 for details). LPA Tinoco discussed with Administrator the incidents. LPA highlighted the importance of administering medications appropriately. Administrator stated that the errors were caused due to lack of communication between staff. Staff responsible for the errors have been issued counseling forms and have been met with to discuss the errors. The agency plans to bring on a nurse that will begin conducting audits and meeting with small groups of staff for a period of time to potentially reduce the errors. As a result of the incidents mentioned above, The Agency is being cited for the Interim Licensing Standards Section 87075(c) Health Related Services. An exit interview was conducted, and a copy of the report and appeal rights were provided to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On April 09, 2024, Licensing Program Analyst (LPA) Lidia Tinoco met with Administrator, Monica Alexander for the purpose of conducting a Case Management. The purpose of the inspection is to discuss an incident dated 04/04/24, that indicated a medication error made by staff. LPA Tinoco discussed with Administrator the incident. LPA highlighted the importance of administering medications appropriately. The incident report stated that S1 (See LIC Confidential Names List) did not administer C1's medication on one occurrence. Administrator stated that the S1 was verbally counseled and a written counseling form will be addressed about the medication errors by the POC due date. The agency has brought in a nurse that conducts the medication audits and will potentially be meeting with small groups of staff for a period of time to potentially reduce the errors. As a result of the incident mentioned above, The Agency is being cited for the Interim Licensing Standards Section 87075(c) Health Related Services. The Agency was also issued a Civil Penalty for Repeat Violation. An exit interview was conducted, and a copy of the report and appeal rights were provided to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On April 29, 2024, Licensing Program Analyst (LPA) Lidia Tinoco met with Administrator, Monica Alexander for the purpose of conducting a Case Management. The purpose of the inspection is to discuss incidents dated 04/10/24 and 04/24/24, that indicated a medication error made by staff. LPA Tinoco discussed with Administrator the incidents. LPA highlighted the importance of administering medications appropriately. On 04/17/24, LPA Tinoco was was provided a Plan of correction which included the staff acknowledgement for the Medication Key Holder Responsibilities. On 4/24/24, LPA Tinoco was notified of the Medication Error dated 4/24/24. On 4/30/24, the agency will have a facility meeting where all the staff present will be retrained on medication administration and responsibilities. Additionally, the nurse will be conducting small group training to go over medications until all staff have been retrained. As a result of the incidents mentioned above, The Agency is being cited for the Interim Licensing Standards Section 87075(c) Health Related Services. The Agency was also issued a Civil Penalty for Repeat Violation. An exit interview was conducted, and a copy of the report and appeal rights were provided to the facility.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco arrived at the Tuolumne Inn STRTP and met with Administrator, Monica Alexander for the purpose of conducting a Case Management inspection. LPA addressed the following incident reports: An incident report dated 10/24/24 involving C1 (See LIC Confidential Names List). The incident involved C1 grabbing a cleaning spray and threatening to spray staff. Per Administrator, the staff was actively cleaning when the incident occurred. All other cleaning supplies was locked and not accessible to youth in care. An incident report dated 10/29/24 involving C1. The incident involved C1 getting restrained due to Non-compliance. Administrator Alexander met with the staff involved and discussed that the restraint was not needed for this incident. Administrator provided LPA Tinoco a letter stating that they met with staff. An incident report dated 10/23/24 involving C2. The incident involved C2 not receiving a medication (not psychotropic) due to an issue with insurance. The agency is actively working with the social worker to transfer services to Stan. County. An incident report dated 10/26/24 involving C1. The incident involved C1 not receiving a medication (not psychotropic) due to not having a refill available and C1 refusing physical. Administrator met with the staff and stated that moving forward staff should call the pharmacy or go to the emergency room if no prescription is available. LPA issued one type A deficiency for the incident dated 10/29/24, See LIC809D. Deficiency cleared on this date. A copy of this report along with appeal rights was provided at the conclusion of the inspection.

Deficiencies:
87095.01(c): (1) Punishment or discipline.
(2) Replacement for on-duty direct-care staff.
(3) Convenience of staff.
(4) As a substitute for, or as part of a treatment program.

title:
1
2
3
4
5
6
787095.01(c) Manual restraints must never be used for the following purposes


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco met with Administrator, Dawn Lee for the purpose of conducting a Case Management inspection. LPA Tinoco addressed an incident report dated 3/16/26 involving a medication error. LPA Tinoco issued a Technical Violation for 87075(b) Health Related Services on the attached LIC9102. Per the Administrator, a plan of correction was put in place and completed on 3/17/26. LPA Tinoco was provided proof of plan of correction at the time of the inspection. This report was discussed during the visit. A copy of this report was provided at the conclusion of the inspection.

met_with: Dawn Lee


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Confidential interviews reported that law enforcement was called for assistance. C1 was taken to a hospital for assessment and discharged from the hospital on May 8, 2021. On May 10, 2022, C1 was observed with several cuts on the left wrist, which were self-inflicted. However, LPA was unable to determine if the cuts were done while at the facility or at the hospital. The interviews that were provided to the LPA were not consistent regarding the allegation of lack of supervision and interviews did not provide any further specific details. Based on interviews and record reviews the allegation that staff did not adequately supervise C1, may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Diana Bustamante.

Investigation Findings:
13On March 10, 2022 at , Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera conducted an unannounced inspection to the facility to deliver the findings of the above allegation. LPA met with Diana Bustamante. LPA Jesus Cervantes conducted a tele-inspection of the facility on May 20, 2021 at 9:30 am and no immediate deficiencies were observed. Four of four children (C1, C2, C3, C4), three staff and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that staff did not adequately supervise C1. Confidential staff interviews reported that on May 7, 2021, C1 became upset when C1 asked staff to go outside for a walk. Confidential interviews disclosed staff did not allow C1 to go outside because of the time (12:00am). Staff encouraged C1 to stay indoors or stay on the patio. Confidential interviews reported that C1 ignored staff directives and left the facility. Confidential interviews reported that C1 ran towards the main street, as staff followed C1. C1 laid down on the street, into oncoming traffic. Confidential interviews reported that staff attempted to use de-escalation techniques on C1 but was unsuccessful. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Darlene Almaraz 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 22-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: TUSTIN FAMILY CAMPUS QUALIFYING HOUSE-FEMALEFACILITY NUMBER: VISIT DATE: 03/10/2022

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

met_with: Diana Bustamante


raw_content:
Narrative:
Confidential interviews reported that C4 is not using or getting any drugs from C1, C2 or C3. Staff is following all proper protocols when dealing with the minors using drugs/marijuana and monitoring the minors. The interviews that were provided to the LPA were not consistent regarding the allegations of lack of supervision and minors are not accorded dignity in relationships with other persons. Based on interviews and record reviews the allegations staff is not properly supervising minors, minors used marijuana and minors are not accorded dignity in relationships with other persons, may have occurred, however is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Diana Bustamante.

Investigation Findings:
13On March 10, 2022 at 12:31pm, Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera conducted an unannounced inspection to the facility to deliver the findings of the above allegations. LPA met with Diana Bustamante. LPA Jesus Cervantes conducted an inspection of the facility on June 22, 2021 at 10:30 am and no immediate deficiencies were observed. Four of four children (C1, C2, C3, C4), four staff and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that staff is not properly supervising minors, minors used marijuana and minors are not accorded dignity in relationships with other persons. Confidential staff interviews reported that on June 13, 2021, staff took C1, C2 and C3 on a hike. Confidential staff interviews reported that when they returned to the van from the hike the van had an odor of marijuana. Confidential interviews reported that all three clients denied smoking marijuana. Confidential staff interviews reported that once they arrived to the facility, C1 and C2 handed over a bag of marijuana and a vape pen. Additional confidential interviews reported that C4 awol's (absent without leave) from the facility and has returned to the facility under the influence. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Darlene Almaraz 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 22-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: TUSTIN FAMILY CAMPUS QUALIFYING HOUSE-FEMALEFACILITY NUMBER: VISIT DATE: 03/10/2022

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


raw_content:
Narrative:
supervision. Specifically, it was reported that S1 grabbed C1 and that there was not enough supervision resulting in C1 going AWOL . It was also reported that C1 was observed with bruising on the forearm and hands due to staff having C1 clean toilets at the facility. During confidential interviews it was revealed that there were no observations made of S1 hitting or grabbing C1. Confidential interviews revealed that the residents are given chores to do but are always offered protective equipment such as gloves to perform these chores if the clients wish to use it. Confidential interviews revealed that the clients are never asked to clean the toilets. Additionally, confidential interviews revealed that when a client is threatening to AWOL the staff tries to will verbally redirect them and convince them to stay at the facility. If the clients leave the facility staff attempts to follow the client and take a description of what they are wearing, then an incident report is filed. No information could be obtained from C1 because their bed was closed due to the AWOL status and current whereabouts are unknown at this time. LPA was unable to obtain additional information regarding the allegations and there were lack of witnesses to the alleged incidents. Based on confidential interviews and record review, the allegations that Resident was sustained bruising while in care, Staff grabbed the resident, and Staff did not provide adequate supervision may have occurred, however they are not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. A copy of this report and Appeals Rights were provided and explained to Facility Administrator, Diana Bustamante.

Investigation Findings:
13On March 23, 2022 at 11:25 a.m. Licensing Program Analyst (LPA) Sarah Smith met with Tustin Family Campus Qualifying House Short Term Residential Therapeutic Program (STRTP) Facility Administrator, Diana Bustamante to deliver the findings of the complaint investigation for the above allegations. LPA Cervantes conducted a health and safety inspection of the facility on 10/25/2021 at 10:15 a.m. and no immediate deficiencies were observed. During the course of investigating the allegations, LPA Smith conducted confidential interviews with two staff, one client (C2), and County Social Worker (CSW). LPA Smith was unable to interview C1 because they never returned from being Absent With Out Leave (AWOL) and C3 refused to be interviewed. LPA Smith reviewed reports and records for the facility and clients (C1, C2, and C3). On October 19, 2021, a complaint was received by Community Care Licensing (CCL) that a Resident was sustained bruising while in care, Staff grabbed the resident, and Staff did not provide adequate UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Sarah Smith 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 22-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, THE CITY DR., SUITE FACILITY NAME: TUSTIN FAMILY CAMPUS QUALIFYING HOUSE-FEMALEFACILITY NUMBER: VISIT DATE: 03/23/2022

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

met_with: Diana Bustamante, Faciilty Administrator


raw_content:
Narrative:
revealed that the client was told they were being recorded as the client charged toward them with an unknown object in their hand. LPA reviewed the video which did show the client picking up an unknown object off the ground, walking towards staff, and hitting staff, and the video recording ended at that point. Based on confidential interviews, the preponderance of evidence standard has been met regarding the allegation that S1 video recorded C1 without minors' consent. This posed a potential Health, Safety, or Personal Rights risk to C1 in care, the facility will be cited for violating Interim Licensing Standards, STRTP, Article 06, 87072(c)(10) Personal Rights. A copy of this report was provided to and reviewed with Diana Bustamante, Facility Administrator, along with the appeal rights and the LIC 811. A signed copy of the report will be kept in the Facility file. Based on interviews that S1 spoke inappropriately to C1 while in care, which may or may not have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Diana Bustamante, Facility Administrator. A copy of the report will be placed in the facility file.

Investigation Findings:
13On June 24, 2022, at 9:50 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility and met with Diana Bustamante, Facility Administrator, of Tustin Family Campus Qualifying House-Female to discuss the investigative findings for the allegation noted above. LPA conducted an inspection of the facility on June 8, 2022, at 3: PM. No deficiencies were observed. During the investigation, LPA interviewed one of one client (C1) and one of one staff (S1). LPA reviewed video recording. On June 2, 2022, Community Care Licensing (CCL) received an allegation that Staff video recorded minors without minors' consent. Confidential interviews revealed that the client was recorded on a cell phone as they were leaving the facility without permission and was triggered by the recording. Confidential interviews revealed staff was asked not to record the client as the video recording was triggering for the client. Confidential interviews revealed that the video recording started when the client picked up an unknown object on the ground and walked toward the staff. Confidential interviews SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley 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 22-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, THE CITY DR., SUITE FACILITY NAME: TUSTIN FAMILY CAMPUS QUALIFYING HOUSE-FEMALEFACILITY NUMBER: VISIT DATE: 06/24/2022

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


raw_content:
Narrative:
Confidential interviews also revealed that inappropriate noises were heard when S2 was locked in the bathroom or staff office when S2 goes to the bathroom or staff office. Additional, confidential interviews revealed that S2 stands at the foot of the bed staring at the clients, which causes clients to feel uncomfortable. Based on confidential interviews and record review, the preponderance of evidence standard has been met, and the allegations that staff (S2) hit minor (C1) while in care and staff (S2) is engaging in inappropriate behavior are substantiated. The facility is being cited for Interim Licensing Standards (ILS) Version 4, Personal Rights (c) (10). The facility did not ensure their dignity was accorded with staff while in care. An exit interview was conducted, and a copy of this report LIC 9099 and the appeal rights were discussed and provided to Administrator Diana Bustamante. Other confidential interviews denied staff not preventing clients from being absent from care and reported staff communicating the importance of not being absent without permission. Per confidential interviews, the staff is doing all they can to prevent clients from leaving the facility, and if clients do leave, staff will follow the clients to encourage them to return to the facility. Based on confidential interviews and record review, the allegation that there is no prevention made for clients to AWOL may have occurred, however, this is not supported by evidence. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report LIC 9099 and the appeal rights were discussed and provided to Administrator Diana Bustamante.

Investigation Findings:
13On September 30, 2022, Licensing Program Analysts (LPAs) Leslie Covarrubias and Jose Gonzalez met with Administrator Diana Bustamante to deliver the compliant findings to the allegations listed above. LPA Covarrubias conducted a health and safety inspection on 03/23/2022 at 12: PM, and no immediate health and safety concerns were observed. During the course of the investigation, LPA Covarrubias conducted confidential interviews with Staff #1(S1), Staff #3 (S3), and Clients (C1, C3, C5, C6, C7). LPA obtained copies of Special Incident Reports (SIRs), the client roster and staff roster, the night supervision policy, staff investigation documents, and written statements from staff and clients. LPA was unsuccessful in interviewing S2 as S2 was unavailable. On 03/17/2022, Community Care Licensing (CCL) received an allegation that staff #2 (S2) tapped client #1 (C1) hard, and S2 engaged in inappropriate behavior. Some confidential interviews revealed that S2 poked them during night checks to check if clients were physically in bed. Confidential interviews revealed that staff is not to touch the clients physically. (Continue on next page...) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Leslie Y Covarrubias 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 22-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, THE CITY DR., SUITE FACILITY NAME: TUSTIN FAMILY CAMPUS QUALIFYING HOUSE-FEMALEFACILITY NUMBER: VISIT DATE: 09/30/2022

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

met_with: Administrator, Diana Bustamante


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

raw_content:
Narrative:
Confidential interviews and documents reviewed indicated that C1's belongings were not searched upon returning to the facility which was required per the NSP. Based on confidential interviews and record review, the preponderance of evidence standard has been met regarding the allegations that the Staff allowed C1 to be transported for a visit in an unsafe manner and staff did not follow search protocol., therefore the allegations are substantiated. This poses an immediate Health, Safety, or Personal Rights risk to the children in care. The facility will be cited for violating the California Code of Regulations, Short Term Residential Treatment Program Interim Licensing Standards (ILS) Version 4, 87022(f) Plan of Operation, and 87068.2(c)(1) Needs and Services Plan. An exit interview was conducted, and a copy of this report LIC 9099 and the appeal rights were discussed and provided to Facility Representative Charon Mitchell and Administrator Diana Bustamante.

Investigation Findings:
13On 08/25/2023, Licensing Program Manager (LPM), Ann Valenzuela, Licensing Program Analysts (LPAs), Jacqueline Garcia, and Guadalupe Munoz met with Facility Representative, Charon Mitchell and Administrator Diana Bustamante via telephone to deliver the compliant findings to the allegations listed above. On June 29, 2023, at 11:50 am LPAs conducted a health and safety inspection, and no immediate health and safety concerns were observed. During the investigation, LPA's conducted confidential interviews with five Staff (S1-S5) and Client #1 (C1). LPAs obtained copies of Special Incident Reports (SIRs), the client roster and LIC 500 staff roster, the Needs and Services Plan (NSP), copies of communication logs, and email correspondence. On 06/26/23, Community Care Licensing (CCL) received a complaint that alleges staff allowed C1 to be transported for a visit in an unsafe manner and staff did not follow search protocol. Confidential interviews and documents reviewed revealed that the Facility did not follow its Plan of Operation: C1 left the facility with their mother for an unsupervised visit without providing the required insurance information. **cont'd on next page SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Jacqueline Garcia 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 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY NAME: TUSTIN FAMILY CAMPUS QUALIFYING HOUSE-FEMALEFACILITY NUMBER: VISIT DATE: 08/25/2023

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

Deficiencies:
87022(f): Plan of Operation

met_with: Charon Mitchell and Diana Bustamante

complaint_status: SUBSTANTIATED

title: Plan of Operation


raw_content:
Narrative:
allegations with a preponderance of evidence. Based on confidential interviews and records reviewed the allegations that due to neglect, staff did not prevent C1 from coming into contact with drugs and staff did not seek C1 timely medical attention which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Destiny Ledesma. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights were emailed to Destiny Ledesma. A copy of this report will be placed in the facility file.

Investigation Findings:
13On April 8, 2024, at 11:20 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Destiny Ledesma, Facility Administrator, to discuss the investigative finding for the allegations noted above. LPA conducted an inspection of the facility on March 1, 2024, at 4:30 pm and no deficiencies were observed. The investigation was conducted by the Department's Investigations Branch (IB), assigned to Investigator Thomas Smith. Investigator Smith interviewed three clients (C1-3), six staff (S1-6), and one County Social Worker (CSW). During the investigation, Investigator Smith conducted a comprehensive review of C1's hospital medical records. On February 26, 2024, Community Care Licensing (CCL) received allegations that due to neglect, staff did not prevent C1 from coming into contact with drugs and staff did not seek C1 timely medical attention. Disclosures during the interviews were inconsistent with the allegations. The investigation could not determine if C1 had illicit drugs in their system. Thus, confidential interviews did not corroborate the UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley 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 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: TUSTIN FAMILY CAMPUS QUALIFYING HOUSE-FEMALEFACILITY NUMBER: VISIT DATE: 04/08/2024

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

met_with: Destiny Ledesma


raw_content:
Narrative:
Based on confidential interviews and records reviewed the allegation that S1 smoked marijuana with clients, which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Destiny Ledesma. Due to printer difficulties, a copy of this report and appeal rights were emailed to the Facility Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On December 2, 2024, at 11:30 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Destiny Ledesma, Facility Administrator, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on October 21, 2024, at 3:28 pm and no deficiencies were observed. LPA interviewed four clients (C1-3, C6), two clients declined to interview (C4-5), and LPA interviewed six staff (S1-6). The following documents were reviewed during the investigation: Staff Roster, Staff Schedule, S1's Employee Application, S1's Training Records, S1's Termination Notice, and Special Incident Reports. On October 14, 2024, Community Care Licensing (CCL) received an allegation that staff smoked marijuana with clients. It was reported that C1, C2, and C3 were at the park smoking marijuana with S1. Confidential interviews revealed conflicting statements. Thus, confidential interviews did not corroborate the allegation with a preponderance of evidence. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley 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 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: TUSTIN FAMILY CAMPUS QUALIFYING HOUSE-FEMALEFACILITY NUMBER: VISIT DATE: 12/02/2024

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


raw_content:
Narrative:
during this time period. LPA was unable to interview all individuals, although multiple attempts were made, thus, confidential interviews could not confirm or deny the allegation. Confidential interviews did not corroborate the allegation with a preponderance of evidence. Based on confidential interviews and records reviewed the allegation that staff did not adequately supervise C1 resulting in C1 leaving the facility, which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report, LIC 811, and appeal rights were provided to Charon Mitchell. A copy of this report will be placed in the facility file.

Investigation Findings:
13On May 5, 2025, at 10:10 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Charon Mitchell, Senior Coach to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on February 13, 2025, at 3:15 pm, and no deficiencies were observed. LPA interviewed one Client (C1), four Staff (S1-4), and LPA was unable to interview one Staff (S5), despite multiple attempts to contact them. LPA reviewed the facility documents during the investigation. On February 6, 2025, Community Care Licensing (CCL) received an allegation that staff did not adequately supervise minor resulting in minor leaving the facility. It was reported that during the weekend of February 1, 2025, C1 ran away from the facility for a few days. Confidential interviews revealed conflicting statements. Some interviews and records reviewed indicated C1 ran away on January 31, 2025, and staff noticed C1 was not in their bedroom while conducting room checks. While other interviews could not recall if C1 ran away UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley 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 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: TUSTIN FAMILY CAMPUS QUALIFYING HOUSE-FEMALEFACILITY NUMBER: VISIT DATE: 05/05/2025

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

met_with: Charon Mitchell


facility_name: TUSTIN FAMILY CAMPUS QUALIFYING HOUSE-FEMALE

summary: Facility Evaluation

raw_content:
Narrative:
On September 13, 2021, at 9: AM Licensing Program Analyst (LPA) Jesus Cervantes conducted an unannounced annual inspection. The facility converted from a Group Home to a STRTP (Short Term Therapeutic Program) on September 24, 2018. LPA was met at the facility by Facility Administrator, Sylvia Arballo. There are currently five residents in placement. LPAs toured the facility inside and out at 9: AM. The facility consists of a common area, kitchen, pantry, laundry room, three client bedrooms, two client bathrooms, one staff bedroom, and one staff bathroom. The client bedrooms are set up so there are two clients to a bedroom and one client per bed. There is adequate closet and drawer space for client's belongings. The bathrooms were clean and in good repair. The hot water was tested in client bathroom #1 at 10: AM and registered at 118.2 degrees Fahrenheit which is within the appropriate range of 105 degrees to 120 degrees Fahrenheit. Cleaning solutions and hazardous items were observed to be stored in a locked cabinet in the staff's office. Sharp knives were observed to be inaccessible and stored in a locked cabinet in the staff's office. Medications are stored in a locked cabinet inside the staff's office. The facility's smoke and carbon monoxide detectors are electrically hard wired and observed to be operable. The fire extinguishers are properly charged and serviced. There are no guns or weapons in the facility as stated by the administrator. LPAs observed facility posted items in the hallway that included: Disaster Plan, Personal Rights, Grievance Procedures, and Foster Care Ombudsman poster. Client's medications were observed to be inaccessible and stored inside a locked cabinet in the staff's office. Medication records were reviewed and observed to be completed with dates and staff initials on dispensing records. LPAs observed a minimum 7-day non-perishable and a 2-day perishable supply of food. See Page Two The facility outside grounds was also inspected and it was observed to be clean and well maintained. There are no bodies of water located on the premises. Emergency exits were free from obstruction. One facility staff was interviewed during the inspection. Five clients were interviewed during the inspection. Due to the need to complete the inspection and continue staff/client file reviews, this inspection will need to be continued at later date. An exit interview was conducted, and a copy of this report was provided to Sylvia Arballo.

met_with: Sylvia Arballo


summary: Facility Evaluation

raw_content:
Narrative:
On September 16, 2021, at 8: AM, Licensing Program Analysts (LPA), Jesus Cervantes continued the unannounced annual inspection, which was started on September 13, 2021. LPA met with Compliance Manager, Crystal Maxwell at the ROP Corporate Office located at N. Tustin Ave. Suit #120. Santa Ana, CA 92705. At 8: AM, LPA reviewed sample of seven staff files. All files did not contain the necessary documents per Title Regulations and ILS. Technical Advisory notes were issued for the following: Staff records indicate that staff only receive yearly Emergency Intervention Staff Training. As specified in Interim Licensing Standards (ILS) 87095.65(e), Staff must receive on-going training to maintain certification. One of five client records did not have results of an examination for communicable tuberculosis as specified per California Code of Regulations (CCR) 80069(c)(1). Two of five client records had incomplete psychotropic medication logs, as specified in ILS 87070(b)(12)(F), (b) The following information regarding the child shall be obtained and maintained in the child's record: (12) A separate log for each psychotropic medication prescribed to a child documenting all of the following: (F) The date and time of each dose taken by the child. Per a review of the Community Care Licensing Information System (LIS), all staff met DOJ/FBI criminal record clearances and Child Abuse Index Check requirements. All staff have proof in file of acknowledging the child abuse reporting requirements. Technical Advisory notes were issued and no citations at this time. Due to the need to complete staff interviews, this inspection will be completed on a later date. A copy of this report and LIC AT were reviewed and given to Compliance Manager, Crystal Maxwell.

met_with: Crystal Maxwell


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst, Dahl Larios conducted a case management inspection on October 7, 2021, at 10:07 am, based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. 5 out of Direct Care Staff and 6 out of 6 youth files as identified on the LIC 811 confidential names dated October 7, 2021, were reviewed. 4 out of Direct Care Staff and 4 out of 6 youth were interviewed. The Plan of Operation including policies and procedure were reviewed. A copy of this report was discussed and provided to Sylvia Arballo, Administrator.

met_with: Sylvia Arballo - Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) David Torres conducted a case management inspection September 13, 2022 at 9:10 am based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 10 out of Direct Care Staff and 6 out of 6 youth files were reviewed. 3 out of Direct Care Staff and 0 out of 6 youth were interviewed. (See the Confidential Names List, LIC 811, dated September 13, 2022). The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, youth case plans, quarterly assessments, and crisis intervention plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA David Torres observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Diana Bustamante, Administrator.

met_with: Diana Bustamante, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On September 22, 2022 at 11: AM, Licensing Program Analysts (LPAs) Leslie Covarrubias and Jose Gonzalez, arrived unannounced at Tustin Family Campus Qualifying House- Female STRTP and met with Administrator, Diana Bustamante. LPAs conduced interviews for previous complaint. Exit interview was conducted and a copy of this report was provided to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Latricia Rogers and Licensing Program Manager Angela King conducted a case management inspection July 12, 2023 based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 5 out of Direct Care Staff and 5 out of 5 youth files were reviewed. 2 out of Direct Care Staff and 2 out of 5 youth were interviewed. (See the Confidential Names List, LIC 811, July 12, 2023). The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, and Self Soothing Plan, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Rogers and LPM King observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Diana Bustamante- Program Manager/Administrator.

met_with: Diana Bustamante- Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On September 7, 2023, at 11:30AM, Licensing Program Analyst (LPA) Guadalupe Munoz made an unannounced case management visit to interview one youth that recently moved to this location. LPA met with Charon Mitchell, Senior Coach. LPA interviewed one youth at today's visit. LPA did not observe any deficiencies. Exit interview was conducted with Charon Mitchell, Senior Coach and a copy of this report will be provided via email.


summary: Facility Evaluation

raw_content:
Narrative:
On October 9, 2023, at 8: AM Licensing Program Analyst's (LPA's) Charmaine Linley and Guadalupe Munoz conducted an unannounced annual inspection. LPA's were met at the facility by House Parent, Flor Perez, and Program Manager, Destiny Ledesma. There are currently 5 residents in placement. LPA's toured the facility inside and out. The facility consists of a common area, kitchen, pantry, laundry room, three client bedrooms, two client bathrooms, one staff bedroom, and one staff bathroom. The client bedrooms are set up so there are two clients to a bedroom and one client per bed. There is adequate closet and drawer space for the client's belongings. The bathrooms were clean and in good repair. The hot water was tested in client bathroom #1 at 9: AM and registered at 105 degrees Fahrenheit and the kitchen was tested at 9: AM and registered 117 degrees Fahrenheit, which is within the appropriate range of 105 degrees to 120 degrees Fahrenheit. Cleaning solutions and hazardous items were observed to be stored in a locked cabinet in the staff's office. Sharp knives were observed to be inaccessible and stored in a locked cabinet in the staff's office. Medications are stored in a locked cabinet inside the staff's office. The facility's smoke and carbon monoxide detectors are electrically hard wired and observed to be operable. The fire extinguishers are properly charged and serviced. There are no guns or weapons in the facility as stated by the administrator. LPA's observed facility posted items in the hallway that included: Disaster Plan, Personal Rights, Grievance Procedures, and Foster Care Ombudsman poster. Client's medications were observed to be inaccessible and stored inside a locked cabinet in the staff's office. Medication records were reviewed and observed to be completed with dates and staff initials on dispensing records. LPA's observed a minimum 7-day non-perishable and a 2-day perishable supply of food. The facility outside grounds were also inspected and it was observed to be clean and well maintained. There are no bodies of water located on the premises. Emergency exits were free from obstruction. *** Two staff were interviewed during the inspection. Two clients were interviewed during the inspection. LPA's left the facility at 10: AM, drove to the main office at Tustin Ave Santa Ana, CA 92705 and arrived at 10: AM and reviewed a sample of five staff files. Per a review of the Community Care Licensing Information System (LIS), all staff met DOJ/FBI criminal record clearances and Child Abuse Index Check requirements. All staff have proof in file of acknowledging the child abuse reporting requirements (S1-5) (SEE LIC 811). LPA's left the office at 12: PM and arrived at the facility at 1: PM. LPA's reviewed five out of five client files. Client files were reviewed and all files did not have the necessary documents required per Title 22 regulations. The facility was cited for California Code of Regulations (CCR) Physical Plant 87075(b) Five of five clients did not have a Centrally Stored Medication Record completed. The facility was also cited for California Code of Regulations (CCR) Client Records 80069(a) five out of five clients did not have a medical assessment with the required information completed. An exit interview was conducted and a copy of this report and appeal rights was reviewed with Destiny Ledezma. Due to printer malfunction, a copy of this report will be emailed to Destiny. A copy of this report will be placed in the facility file.


summary: Facility Evaluation

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Narrative:
On 05/01/25, at 10: AM, Licensing Program Analyst (LPA) Gilbert Marquez met with Administrator, Destiny Ledesma, for the purpose of conducting an annual inspection of the facility. The Facility is licensed to serve six ambulatory children ages 12-17 years-old and non minor dependents. The current census is six children. The Facility is current with their licensing fees. The Facility is a single story dwelling. A physical plant inspection was completed with Charon Mitchell, Senior Coach and included the following checks: kitchen, medication room, dining room, living room, den, one staff office, one leased vehicle, three bedrooms, a facility apartment for the house parents, and outdoor living space. All beds were observed with appropriate bedding and mattress in good repair. Bedrooms contained adequate drawers and closet space. No bedroom occupied more than two clients and not used for other purposes. All required forms are posted including Grievance Procedures, Visitation Policies, Personal Rights form, Foster Care Ombudsman poster, and the Emergency Disaster Plan. Clients' medications were observed to be inaccessible and stored in the medication room. **Continued on LIC809** **Continued from LIC809** Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. All facility smoke detectors and carbon monoxide detectors are monitored through Tustin Family Campus; fire extinguishers are properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. LPA observed a minimum seven-day non-perishable and two-day perishable supply of food. Individual beds were observed with clean linens, pillows, comforters, and mattress in good repair. All three bedrooms contain two twin beds. The water temperature was tested in bathroom one which measured 110 degrees Fahrenheit which is within the appropriate range of 105 degrees to 120 degrees Fahrenheit. The first aid kit was accessible to all staff and had all required supplies. All client files are stored and maintained on a secure internet database. LPA reviewed five client files out of six (C1 - C5) to ensure clients had all required documents per Title 22. LPA reviewed five client medication records. Per a review of Guardian, all staff listed on LIC500 dated 4/30/25 have a criminal record clearance. Staff files are stored and maintained on a secure internet database at another location called The Hub, N Tustin Avenue, Santa Ana. LPA conducted three staff interviews(S1 - S3) and two client interviews(C3 and C5). Per facility staff, no firearms or weapons are allowed in the facility. No deficiencies cited during today's inspection. Due to time constraints LPA will return on another day to conduct staff file reviews at "The Hub" in Santa Ana. An exit interview was conducted, and a copy of this report was provided to Destiny Ledesma. A copy of this report will be placed in the facility file.

met_with: Destiny Ledesma, Adminstrator


summary: Facility Evaluation

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Narrative:
On 05/08/25, at 9: AM, Licensing Program Analyst (LPA) Gilbert Marquez met with Todd Cutchlow, Site Trainer, for the purpose of continuing an annual inspection of the facility listed above. The Facility is licensed to serve six ambulatory children ages 12-17 years old, and non minor dependents. The current census is six clients. The Facility is current with their licensing fees. The initial inspection occurred on 05/01/25 at the facility. Today, LPA visited the Headquarters at North Tustin Avenue, Suite 120, Santa Ana to review staff files which are stored in file folders only accessible by a select group of individuals at Rite of Passage. LPA reviewed five staff files to ensure staff had all required documents per Title 22 regulations. Per a review of Guardian, all staff have a criminal record clearance. No deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were provided to Todd Cutchlow, Site Trainer. A copy of this report will be placed in the facility file.

met_with: Todd Cutchlow, Site Trainer


summary: Facility Evaluation

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Narrative:
On December 3, 2025, at 2: PM, Licensing Program Analyst (LPA) Stefanie Mutialu conducted an unannounced case management inspection of the facility. LPA Mutialu met with Program Manager, Destiny Ledesma. LPA conducted a walkthrough of the facility, and no deficiencies were observed. On November 19, 2025, the Department received information that a client's Personal Rights may have been violated. LPA requested documentation from facility and client records. LPA conducted two client interviews(C1, C2) and one staff (S1).. Due to the need to gather additional information this case management investigation is being extended. The Facility is reminded that they are prohibited from informing other parties of an impending and unannounced site visit and reminded not to discuss the ongoing investigation with any interested parties. An exit interview was conducted and a copy of this report, and Confidential Names (LIC 811), were provided to Program Manager, Destiny Ledesma.

met_with: Program Manager, Destiny Ledesma


summary: Facility Evaluation

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Narrative:
On July 30, 2025, at 11:15 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Destiny Ledesma, Facility Administrator. The purpose of this inspection is for a case management involving an incident with Staff (S1), and two Clients (C1, C2). On July 24, 2025, Community Care Licensing observed a video involving S1, C1, and C2. The video footage was taken of the Cottage's back patio with windows and glass doors that were uncovered and allowed a clear view into the inside of the Cottage living area. LPA observed that on June 5, 2025, at 12:00 am, C1 knocked on the patio doors and entered the Cottage with a scooter. C1 began to ride the scooter in the living room area and S1 grabbed the scooter and C1 and S1 struggled over the scooter and S1 pulled the scooter with enough force that C1 stumbled on their feet. A few seconds later, S1 engaged in a restraint with C1, which led to C1 and S1 falling onto the ground and struggling with each other until S1 got up and walked away from C1. Based on LPA's observation of the video recording, S1 did not ensure that C1 was accorded dignity within their personal relationships with staff, due to grabbing the scooter away from C1 and engaging in a struggle over the scooter which resulted in C1 stumbling on their feet and based on LPA's observation of the video footage showing S1 mishandled C1 when S1 swept C1's leg causing C1 to transition onto the floor during the encounter which led to C1 and S1 struggling on the ground and S1 turning C1 on their back and held down until S1 got away from C1, the facility is being cited for one deficiency. The facility is cited for violating Interim Licensing Standards, STRTP, Article 06. Continuing Requirements, 87072(c)(15) Personal Rights. *** An exit interview was conducted. A copy of this report and appeal rights were provided to the facility. A signed copy of the report will be placed in the facility file.


summary: Facility Evaluation

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Narrative:
On 08/25/2023, at 12:00 pm, Licensing Program Analyst (LPAs) Guadalupe Munoz and Jacqueline Garcia, and Licensing Program Manager (LPM) Ann Valenzuela conducted an unannounced inspection at the facility and met with Facility Representative Charon Mitchell and Administrator Diana Bustamante via telephone. The purpose of the inspection is to conduct a case management on a serious incident that occurred on 6/22/2023. Community Care Licensing (CCL) became aware that an incident occurred with Client #1 [refer to Confidential Names (LIC 811) dated 08/25/2023] on 6/22/2023 and was not reported to CCL till 6/26/2023. LPM Valenzuela stressed the importance of reporting incidents in a timely manner. This process is necessary to ensure the welfare and well-being of all residents that are in care. The agency is in violation of regulation 80061(b)(E) Reporting Requirements. Please refer to LIC 809-D for detailed deficiency information. An exit interview was conducted appeal rights were reviewed and a copy of this report was provided to Administrator Diana Bustamante.

met_with: CHaron Mitchell and Diana Bustamante


summary: Facility Evaluation

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Narrative:
On January 28, 2025, at 3: PM, Licensing Program Analyst (LPA) Stefanie Mutialu conducted an unannounced case management continuation inspection of the facility. LPA Mutialu met with Sandra Rodarte, Senior Coach. LPA conducted a walkthrough of the facility, and no deficiencies were observed. On November 19, 2025, the Department received information that a client's Personal Rights may have been violated this is a continuation visit for the purposes of gathering additional information. LPA conducted one client interview(C5). Due to the need to gather additional information this case management investigation is being extended. The Facility is reminded that they are prohibited from informing other parties of an impending and unannounced site visit and reminded not to discuss the ongoing investigation with any interested parties. An exit interview was conducted and a copy of this report, and Confidential Names (LIC 811), were provided to Sandra Rodarte, Senior Coach.

met_with: Sandra Rodarte, Senior Coach


summary: Facility Evaluation

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Narrative:
On February 17, 2025, at 4: PM, Licensing Program Analyst (LPA) Stefanie Mutialu conducted an unannounced case management continuation inspection of the facility. LPA Mutialu met with Destiny Ledesma, Administrator.LPA conducted a walkthrough of the facility, and no deficiencies were observed. On November 19, 2025, the Department received information that a client's Personal Rights may have been violated this is a continuation visit for the purposes of gathering additional information. LPA attempted to conduct client interview. C4 declined interview. Due to the need to gather additional information this case management investigation is being extended. The Facility is reminded that they are prohibited from informing other parties of an impending and unannounced site visit and reminded not to discuss the ongoing investigation with any interested parties. An exit interview was conducted and a copy of this report, and Confidential Names (LIC 811), were provided to Destiny Ledesma, Administrator. Due to technical difficulties copy of this report was emailed at time of inspection.

met_with: Destiny Ledesma, Administrator


summary: Facility Evaluation

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Narrative:
On March 5, 2025, at 1: PM, Licensing Program Analyst (LPA) Stefanie Mutialu conducted an unannounced case management inspection of the facility. LPA Mutialu met with Program Manager, Destiny Ledesma. LPA conducted a walkthrough of the facility, and no deficiencies were observed. On November 19, 2025, the Department received information that a client's Personal Rights may have been violated. LPA reviewed documentation. LPA conducted five client interviews and (C1, C2, C3, C5, C6) and two staff interviews (S1, S2). C4 declined to be interviewed. Confidential interviews revealed that the Facility was in compliance as the client's personal rights were not violated. An exit interview was conducted and a copy of this report, and Confidential Names (LIC 811), were provided to Program Manager, Destiny Ledesma. Due technical difficulties this report was emailed at the time of inspection.


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Narrative:
Confidential interviews and documents obtained revealed the facility staff conducts searches of clients within the scope of the minors Personal Rights. However, conflicting confidential interviews revealed that drugs are still being smuggled into the facility by a minor in care. Confidential interviews and documents reviewed revealed the facility has been proactively addressing the issue of a minor supplying other minors with drugs. Based on confidential interviews and record review, the allegation that a minor is supplying other minors with drugs while in care may have occurred; however, it is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this report along with appeal rights was provided to Diana Bustamante.

Investigation Findings:
13On November 24, 2021, at 10: AM, Licensing Program Analyst (LPA) Jesus Cervantes made an unannounced visit at the facility. LPA met with Administrator Diana Bustamante, to issue the investigative finding of the allegation listed above. On April 28, 2021, Licensing Program Analyst (LPA), Jesus Cervantes, conducted an unannounced inspection of the facility, and no deficiencies were noted. LPA Cervantes conducted interviews with five of five foster children (C1, C2, C3, C4, C5) and two of two staff (S1 and S2). During the investigation, LPA reviewed facility records and obtained copies of the following documents: Incident Reports and Facility Policy and Procedures. On April 26, 2021, Community Care Licensing received the allegation that a minor is supplying other minors with drugs while in care. Confidential interviews revealed conflicting statements regarding a minor supplying other minors with drugs. SEE PAGE TWO UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Jesus Cervantes 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 22-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, THE CITY DR., SUITE FACILITY NAME: TUSTIN FAMILY CAMPUS QUALIFYING HOUSE-MALEFACILITY NUMBER: VISIT DATE: 11/24/2021

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

met_with: Diana Bustamante


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Narrative:
facility and attempted to get in through a window and a staff body slammed them and carried them outside of the facility, causing scratches to their forearm. Confidential interviews revealed conflicting statements, some interviews indicate that S3 told C1 they needed to turn in the aerosol cans before entering the facility. Other interviews indicate that staff was waiting for Law Enforcement to arrive and assist as C1 had thrown a patio chair at the window. As far as the allegation of staff mishandling C1, confidential interviews revealed that S1 held C1's arms at their side, walked them out of the facility, and held them in a single-person restraint while waiting for law enforcement to arrive. Conflicting interviews revealed that S1 picked up and slammed C1 to the ground. Other interviews indicated that C1 hit S3 several times and C1 guided them out of the facility to the front porch and while S3 was trying to restrain C1, both individuals fell onto the grass. Based on confidential interviews and records reviewed that staff denied C1 access to the facility and staff mishandled C1 while in care which may or may not have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted and appeal rights explained.. Due to printer malfunction, a copy of this report and appeal rights will be emailed to the Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On August 26, 2022, at 11:05 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility and met with Vickie Rogers, Facility Manager, to discuss the investigative findings for the allegations listed above. LPA Linley conducted an inspection of the facility on 07/13/2022 at 12:15 pm. No deficiencies were observed. During the investigation, LPA Linley interviewed four out of four clients (C1-4), four out of four staff (S1-4), and one County Social Worker (CSW1). (See LIC 811 for confidential names). LPA Linley also reviewed the following documents: S Resume, application, and training records, Staff Contact list, Client roster, Special Incident Report, dated 07/06/2022, C1 daily progress notes, dated 07/06-07/2022, and copies of the house log, dated 07/06-07/07/2022. On July 8, 2022, Community Care Licensing received allegations that staff denied minor access to the facility and staff mishandled a minor while in care. It was reported that the minor was denied entry to the UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley 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 22-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, THE CITY DR., SUITE FACILITY NAME: TUSTIN FAMILY CAMPUS QUALIFYING HOUSE-MALEFACILITY NUMBER: VISIT DATE: 08/26/2022

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

met_with: Vickie Rogers, Facility Manager


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Other confidential interviews revealed that C1 phone calls with the biological parent are monitored per court order. Additional confidential interviews indicated that FS allows C1 to make and receive phone calls. Confidential interviews revealed that FS allows C1 privacy when making calls that FS does not monitor. CSW stated that C1 phone calls with C1's parent are monitored per court order. The Department also received an allegation that client #1 (C1) mental health needs are not being met. Additional confidential interviews indicated that C1 was provided therapy sessions at the facility. Confidential interviews disclosed that C1s refuse to participate in therapy. Other confidential interviews indicated that the home offered C1 different therapeutic groups and therapists. Confidential interviews disclosed that C1 was not receiving therapy. Additional confidential interviews indicated that C1 wanted to participate in therapy with a licensed therapist. It was disclosed that the facility offered C1 a therapist. It was also disclosed that C1 refused to participate in therapy. Confidential interviews reported that CSW provided C1 with an outside therapist and C1 continued to refuse. The confidential witness denied the allegation of mental health needs not being met. The Department received an allegation that Facility Staff (FS) caused client #1 (C1) to miss a scheduled court date. Confidential interviews revealed that C1 and FS arrived late to court. Additional confidential interviews indicated that the judge was upset with C1 for arriving late to court. Other confidential interviews revealed that C1 arrived at court on time. Additional confidential interviews indicated that C1 returned late to the second court session due to C1 still eating C1 lunch. A confidential witness stated that C1 never missed a court date. Additional confidential interviews disclosed that the facility did everything possible to meet C1 needs. Based on inconsistent confidential interviews, the allegations that Facility Staff (FS) are interfering with client #1 (C1) telephone visits, C1's mental health needs are not being met, and FS caused C1 to miss a scheduled court date may have occurred, however, are not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Administrator (AD) Diana Bustamante.

Investigation Findings:
13On September 30, 2022, at 11: 12 am, Licensing Program Analysts (LPAs) Jose Gonzalez and Leslie Covarrubias met with Administrator (AD) Diana Bustamante to deliver the findings for the above-stated allegations. LPA conducted a health and safety inspection on January 14, 2022, at 9:25 am, and no immediate health and safety hazards were observed. LPA also reviewed six clients' records. During the investigation, interviews were conducted with three out of six clients (C1, C5, and C6), Administrator (AD), Staff #1 (S1), Head of Service (HS), and County Social Worker (CSW), clients (C2, C3, and C4) refused to be interviewed. The Department received an allegation on January 10, 2022, that Facility Staff (FS) are interfering with client #1 (C1) telephone visits. Confidential interviews disclosed that FS interfered with C1 phone conversations. Additional confidential interviews indicated that FS listens in on C1 phone conversations. Confidential interviews disclosed that the FS is not allowing C1 privacy during C1 phone calls. Additional confidential interviews indicated that C1 phone calls are not monitored.R- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: TUSTIN FAMILY CAMPUS QUALIFYING HOUSE-MALEFACILITY NUMBER: VISIT DATE: 09/30/2022

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

met_with: Administrator (AD) Diana Bustamante


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Narrative:
Confidential interviews disclosed that C1 slept under the covers, and it's the facility policy to ensure that clients are physically seen and that pillows are not placed over clients' faces. Confidential interviews also revealed that S5 retaliated against C1 by demonstrating an attitude toward C1 and treating C1 disrespectfully. Other confidential interviews revealed that S5 treated C1 well by S5 attempting to speak with C1, and C1 would ignore S5 by not communicating back. Confidential interviews stated that the allegations were false. Based on the inconsistent confidential interviews, the allegations that staff inappropriately touched minor (C1) and staff (S5) are retaliating against minor (C1) for making complaints may have occurred, however, this is not supported by evidence. Therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report LIC 9099 and the appeal rights were discussed and provided to Administrator Diana Bustamante.

Investigation Findings:
13On September 30, 2022, Licensing Program Analysts (LPAs) Leslie Covarrubias and Jose Gonzalez met with Administrator Diana Bustamante to deliver the compliant findings to the allegations listed above. LPA Valerie Wilson conducted a health and safety inspection on 12/29/2021 at 10: AM, and no immediate health and safety concerns were observed. During the course of the investigation, LPA Covarrubias conducted confidential interviews with Staff #1(S1), Staff #2 (S2), Staff #3 (S3), Staff #4 (S4), Staff 6 (S6), Staff 7 (S7), and Clients (C1, C2, C3, C4, C5). LPA obtained copies of Special Incident Reports (SIRs), the client roster and staff roster, and the training record/ documents for one staff. On 12/20/2021, Community Care Licensing (CCL) received an allegation that staff inappropriately touched C1, and the staff (S5) is retaliating against C1 for making complaints. Confidential interviews reported that S5 would poke clients to verify they were physically there. Other confidential interviews revealed that S5 did not poke the clients (C2-C5). (Continue on next page...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Leslie Y Covarrubias 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 22-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, THE CITY DR., SUITE FACILITY NAME: TUSTIN FAMILY CAMPUS QUALIFYING HOUSE-MALEFACILITY NUMBER: VISIT DATE: 09/30/2022

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

met_with: Administrator, Diana Bustamante