raw_content:
Narrative:
Based on the available information LPA gathered from interviews and observation, the preponderance of the evidence standard has not been met; therefore, the allegation of "Staff do not treat minor(s) with respect" is found to be unsubstantiated. There were no deficiencies cited. An exit interview was completed, and a copy of this report was given.

Investigation Findings:
13On at 1: PM Licensing Program Analyst (LPA) Reagan Cohen arrived at the ROP Harbor City Home and conducted an unannounced complaint inspection. LPA met Facility Manager Lupe Castro and delivered the findings of the investigation for the above allegation. During the course of this investigation, LPA conducted confidential interviews, gathered documentation, and reviewed records. Interviews from clients and staff involved in the event record that the event in question that lead to the allegation that "Staff do not treat minor(s) with respect" was a misunderstanding between staff and a client. All parties have apologized and there have been no further incidents. LPA originally delivered findings, but then conducted more interviews for the investigations. These new interviews with other involved staff and clients concur with the original findings and testimonies. Records review shows that staff are up to date on training in de-escalation and other practices to help with these situations. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Reagan Cohen LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: ROP HARBOR CITY HOMEFACILITY NUMBER: VISIT DATE: 06/11/2025

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

met_with: Facility Manager Lupe Castro


state: CA

facility_name: ROP HARBOR CITY HOME

summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
There was no evidence that staff are not honoring minors rights to visitations/outings while in care. Documentary evidence explained the visitation guidelines for the facility. Each client signed and agreed to the visitation rules that were explained in a CFT meeting which include the facility staff, Social Worker, designated family members, therapist, client, etc. Confidential interviews did not produce evidence that facility is not adhering to these individual guidelines or having "blanket" guidelines that cover all clients. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred; therefore, the above allegation is Unsubstantiated. There are no deficiencies being cited at this time.

Investigation Findings:
13On July 16, 2025 1pm, Licensing Program Analyst (LPA) Donald Martin conducted a follow up complaint inspection and spoke with Facility Manager, Lupe Castro. The purpose of this inspection was to deliver findings for the above complaint allegation. During the investigation LPA conducted confidential interviews and reviewed documentary evidence. The interviews did not produce corroborating evidence to support allegations. Interviews revealed inconsistent statements and no witnesses to suggest allegations occurred. There was no evidence to support that staff are conducting unreasonable searches on minors in care. Confidential interviews indicated that contraband usage spiked in the home which lead to increased searches in the faciilty. There was no evidence that the searches were a written daily part of the facility program. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: ROP HARBOR CITY HOMEFACILITY NUMBER: VISIT DATE: 07/16/2025

report_type: Complaint Investigation

met_with: Lupe Castro-Facility Manager

complaint_status: unsubstantiated


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Confidential interviews were conducted with Y1, Y1's assigned Social Worker and Facility Manager/Administrator. Facility file and placement history were also reviewed. Information obtained revealed that Y1 was placed in multiple facilities from 2020 through 2023. Confidential statements found no disclosures of sexual abuse occurring at ROP Harbor City Home as alleged. Confidential interviews revealed alleged sexual abuse occurring at a separate location involving an unidentified individual who was reportedly not a facility staff member at Rite of Passage. Statements obtained were determined to be inconsistent and vague, and there were no witnesses. Due to the lack of evidence to support the allegation at this time, the assignment was not promoted. Therefore, the allegation is determined to be unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. There are no deficiencies cited per the California Code of Regulations, Title 22, or Interim Licensing Standards (ILS) at this time. An exit interview was conducted and a copy of this report was provided to the Facility Manager/Administrator via email.

Investigation Findings:
UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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

met_with: Lupe Castro, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On July 19, 2021 at 12:30pm Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for the purpose of conducting a complaint investigation collateral visit. LPA met with the Facility Manager (FM) and requested to speak to C3. LPA made C3 aware of the allegations and An interview was conducted. After a brief interview, it has been determined that further investigation is needed to conclude this complaint investigation. An exit interview was conducted and a copy of this report will be left with the Facility Manager. There are no deficiencies to report at this time.

report_type: Facility Evaluation

met_with: Facility Manger-Raven Morrow


summary: Facility Evaluation

raw_content:
Narrative:
Report Amended to change the facility Name On July 26, 2021, Licensing Program Analyst, LPA Donald Martin made an inspection visit to ROP Harbor City Home for the purpose of concluding a Case Management Investigation. LPA met with Raven Morrow, Facility Manager. The Department received notification from the Department of Children and Family Services requesting a follow up on a CAP put in place for the ROP facilities. Referral Number: 1355-1304-5004-1047667 which was investigated by LPA Regina Martin. The "Second Floor Interactive Supervision Policy" was put in place by ROP to be in compliance with ILS regulation 87088 (e)(2) which states: The following facilities shall maintain a signal system which meets the requirements specified in (e) and (f) below. Such system shall be used by children to summon staff during an emergency: (2) All facilities having separate floors and not providing full-time staff on each floor whenever children are present. During the investigation process, LPA reviewed ROP's Second Floor Interactive Supervision Policy and also walked around the facility. The Policy and home are in compliance at the time of this LPA's visit. No further incident has been reported. A staff re-training on interactive supervision was completed by staff and submitted to the department.

visit_type: Case Management

met_with: Raven Morrow-Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On September 3, 2021 at 11am Licensing Program Analyst (LPA) Donald Martin arrived at ROP Harbor City Home for the purpose of conducting a Case Management Investigation. LPA was met by Facility Manager, Lupe Castro (FM) And allowed into the facility. LPA made FM aware of the details of the Case Management. FM stated that she was not on duty the day of the incident. FM stated that Staff #1 is on suspension until the internal investigation was complete. FM stated that it is to her understanding that Child #1 and Child #2 took Staff #1 cell phone and purse. FM is unaware if the staff left her belongings unattended. The cell phone was returned but the purse was thrown on top of the house but later retrieved by one of the clients and returned to her also. Staff #1 was missing a credit card which was later found in Child #2 possession. Child #1 and Child #2 were are both in police custody and unable to be interviewed at the time of the visit. Their detainment is unrelated to this Case Management. The staff involved in the incident were not on duty at the time of the visit. LPA will visit the other facility to speak with Raven Morrow, Facility Manager to get additional information on the incident. There is nothing further to report at this time. There were no deficiencies to report at the time of the visit. NOTE: Report will be signed by the Quality Assurance staff (Trista Morrow-Coleman) on duty due to FM having to take a client to a medical visit.


summary: Facility Evaluation

raw_content:
Narrative:
On December 6, 2021 at 10:30am Licensing Program Analyst (LPA), Donald Martin made an unannounced visit to ROP Harbor City Home for the purpose of conducting an Annual/Required inspection. The facility is licensed to provide care and supervision to six (6) clients ages 12 through 17. Ambulatory only. There are no bodies of water on the premises. The facility also provides services to non-minor dependents. The home is set up as follows: This is a two story house with three (3) bedrooms, two (2) bathrooms, front patio, living room, staff office, family room/laundry area, dining area, kitchen, and outdoor space. Front Patio: There is ample seating space, one table with six (6) chairs and extra chairs. Living Room: There is adequate furniture which appears to be in good condition there are two sofas with a center table and a covered fire place. Dining Area: One table with eight (8) chairs. Kitchen: There is a stove/oven with four (4) burners, all working at this time. There is a microwave and refrigerator/freezer and a locked storage freezer. The food service in the home is adequate with perishable/nonperishable food supplies. There is a fire extinguisher located to the left side of the door entering the family room. Trash can has a tight lid on. All cleaning supplies are kept locked in a storage room off of the living room. The knives and medications are locked in the closet that is located to the right once entering the office and made accessible only to employees supervising stored medications. Client files are also kept inside the closet locked. Office/ Laundry Area: There is a washer/dryer located inside a closet in the office. Laundry detergent is kept in the locked closet off of the living room. There is a staff bathroom entrance also located in the staff office and a door that leads to the back yard. Bedroom #: Is located upstairs. The room is equipped with two twin size beds. There are adequate drawers, individual closet space, and lighting in this room. Bedroom #2: Is located upstairs. The room is equipped with two twin size beds. There are adequate drawers, closet space, and lighting in this room. Bedroom #3: Is located upstairs. The room is equipped with two twin size beds. There are adequate drawers, closet space, and lighting in this room. Report Cont. on LIC 809-C. Bathrooms: There are two (2) bathrooms available for client use. One (1) bathroom is downstairs and has a shared entrance to the staff bathroom. The other bathroom is located upstairs in the hallway and is shared by all clients. All bathrooms were checked and were in operating conditions. The faucets that are used by the children were tested and delivered hot water at a safe temperature range. There are no security bars on the windows. The hallway window upstairs will be used as an emergency exit with an emergency escape ladder available. Outdoor Space: LPA observed the entrance area and backyard to be free of debris and hazardous materials. The home was inspected and the following was observed: The facility is clean, safe, sanitary, and in good repair. Medicines, disinfectants, and cleaning solutions are inaccessible to children in care. No more than two (2) children share a bedroom. Children have comfortable mattresses, clean linens, blankets, and pillows which are all in good repair. Outdoor activity space is free of obstructions. Facility has one or more functioning carbon monoxide detectors that meet statutory requirements. There are no weapons in the facility. Sharp knives are stored in a locked cabinet inside a locked box and inaccessible to children. Staff conduct a sharps count to ensure all sharp objects are returned and locked in the lock box. Adequate supervision is provided for children in care. There is a desk upstairs in the hallway available for staff to supervise the children when they are upstairs. Staff ensure three nutritious meals and snacks. Food supply is ample in the home. Children are accorded personal rights. Children in care are supported and encouraged to participate in extracurricular activities. Children in care can contact the licensing agency or Group Home Ombudsman person in confidence without threats or punishment for making complaints. All posting requirements were met. Children in care are not restricted in telephone use except by court order. There is a working telephone line available for clients to use. All smoke detectors and carbon monoxide are operable. The home will operate within capacity and limitations of license. LPA observed age appropriate First Aid supplies. Fire extinguishers were fully charged. There was no deficiencies cited at this time of the visit. Exit Interview was conducted, and a copy of this report was left at the facility.

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Dahl Larios conducted a case management inspection April 21, 2022 at 9:15 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 5 out of 5 youth files were reviewed. 5 out of Direct Care Staff and 4 out of 5 youth were interviewed. (See the Confidential Names List, LIC 811, dated April 21, 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 youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Dahl Larios 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 Program Director Dana Centanni.

met_with: Program Manager - Raven Morrow


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Sethany Yem conducted a case management inspection on 4/26/23 at 11:30am 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 3 out of 5 youth were interviewed. (See the Confidential Names List, LIC 811, 4/26/23). 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, 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 youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Yem 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 Administrator Raven Morrow.

met_with: Administrator Raven Morrow


summary: Facility Evaluation

raw_content:
Narrative:
On December 19, 2023 at 12p Licensing Program Analyst (LPA) arrived at the above facility for the purpose of conducting an Annual/Random inspection. LPA was in formed that C1 tested positive for Covid-19 and refuses to quarantine or wear a mask. LPA decided not to enter the facility and reschedule the Inspection to a later date. On December 27, Licensing Program Analyst (LPA) Donald Martin made a visit to ROP Harbor City Home for the purpose of conducting an Annual/Required inspection. The facility is licensed to provide care and supervision to six (6) clients ages 12 through 17. Ambulatory only. There are no bodies of water on the premises. The facility also provides services to non-minor dependents. LPA was met by Facility Manager, Lupe Castro (FM) and together we walked through the facility. The home is set up as follows: This is a two story house with three (3) bedrooms, two (2) bathrooms, front patio, living room, staff office, family room/laundry area, dining area, kitchen, and outdoor space. Front Patio: There is one table with six (6) chairs and additional seating against the wall. Living Room: There are two sofas with a center table and a covered fire place. Dining Area: One table with eight (8) chairs. Kitchen: There is a stove/oven with four (4) burners, all working at this time. There is a microwave and refrigerator/freezer and a locked storage freezer. The food service in the home is adequate with perishable/nonperishable food supplies. There is a fire extinguisher located to the left side of the door entering the family room that was currently charged. Trash can has a tight lid. All cleaning supplies are kept locked in a storage room off of the living room. The knives and medications are locked in a closet that is located in the office and made accessible only to employees supervising stored medications. Report Cont. on LIC 809-C. Office/Laundry Area: There is a washer/dryer located inside a closet in the office. Laundry detergent is kept in the locked closet off of the living room. There is a staff bathroom entrance also located in the staff office and a door that leads to the back yard. Bedroom #1: Is located upstairs. The room is equipped with two twin size beds. There are adequate drawers, individual closet space, and lighting in this room. Bedroom #2: Is located upstairs. The room is equipped with two twin size beds. There are adequate drawers, closet space, and lighting in this room. Bedroom #3: Is located upstairs. The room is equipped with two twin size beds. There are adequate drawers, closet space, and lighting in this room. Bathrooms: There are two (2) bathrooms available for client use. One (1) bathroom is downstairs and has a shared entrance to the staff bathroom. The other bathroom is located upstairs in the hallway and is shared by all clients. All bathrooms were checked and were in operating conditions. The faucets that are used by the children were tested and delivered hot water at a safe temperature range. The hallway window upstairs will be used as an emergency exit with an emergency escape ladder available. Outdoor Space: LPA observed the entrance area and backyard to be free of debris and hazardous materials. The home was inspected and the following was observed: The facility is clean, safe, sanitary, and in good repair. Medications, disinfectants and cleaning solutions are inaccessible to children in care. No more than two (2) children share a bedroom. Children have comfortable mattresses, clean linens, blankets, and pillows which are all in good repair. Outdoor activity space is free of obstructions. Facility has one or more functioning carbon monoxide detectors that meet statutory requirements. There are no weapons in the facility. Sharp knives are stored in a locked cabinet inside a locked box and inaccessible to children. Staff conduct a sharps count to ensure all sharp objects are returned and locked in the lock box. There is a desk upstairs in the hallway available for staff to supervise the children when they are upstairs. Staff ensure three nutritious meals and snacks. Food supply is ample in the home. Children are accorded personal rights. Children in care are supported and encouraged to participate in extracurricular activities. Children in care can contact the licensing agency or Group Home Ombudsman person in confidence without threats or punishment for making complaints. All posting requirements were met. Children in care are not restricted in telephone use except by court order. There is a working telephone line available for clients to use. All smoke detectors and carbon monoxide are operable. The home will operate within capacity and limitations of license. LPA observed age appropriate First Aid supplies. Fire extinguishers were fully charged. There were no deficiencies cited at the time of the visit.


summary: Facility Evaluation

raw_content:
Narrative:
On January 9, 2024 at 1230pm Licensing Program Analyst (LPA) Donald Martin arrived above facility. The purpose of this visit is the continuation of the Annual/Random facility inspection. LPA was met by Program Manager, Faaputu Vaafuti (PD) and was allowed into the facility. The facility is licensed to provide care and supervision to six (6) children, ages 12-17, ambulatory only. This facility also provides services to Non-minor Dependents pursuant to W&I code 16501.1(C)(1).There are no bodies of water on the premises. There is currently 1 client at the facility. LPA will be reviewing staff and client files and interviewing staff and clients. C1 is missing Immunization form/TB test. C2 and C3 are missing TB test results. Files have been reviewed. LPA informed PD that the TB tests for the clients need to be updated. PD stated that Doctor's appointments have been made for the clients. There were no deficiencies cited at the time of the visit.

met_with: Faaputu Vaafuti-Program Manaager


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Dahl Larios conducted a case management inspection September 20, 2024, at 10:26 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, 5 out of Direct Care Staff and 4 out of 4 youth files were reviewed. 2 out of Direct Care Staff and 2 out of 4 youth were interviewed. (See the Confidential Names List, LIC 811, dated September 20, 2024). The Plan of Operation including policies and procedures 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 youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Dahl Larios 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 Program Manager Faaputu Vaafuti.


summary: Facility Evaluation

raw_content:
Narrative:
On 4/16/25, Licensing Program Analyst (LPA) Reagan Cohen made an unannounced visit to Rite of Passage (ROP) Harbor City Home for the purpose of a Case Management for Special Incident Report #1285935. During this visit, confidential interviews were conducted with staff and clients. Facility Manager stated that on 4/9/25, one (1) staff and one (1) client had been involved in an automobile accident in the facility car ( Dodge, Grand),where the facility car was hit by another car. LPA went out and observed the car which was lightly hit on the passenger side front bumper. Facility Manager stated staff and client were uninjured in the automobile accident. Facility Manager stated that neither staff nor client was in need of medical attention as a result of the automobile accident. Client and Staff interviewed also shared that they were not in need of medical attention. LPA observed and received a copy of both an up to date staff drivers license and insurance for the facility vehicle. While the car accident did happen and a staff and a client were involved, interview evidence and records review show that all staff followed the appropriate protocol and procedure during the entire incident and after. Based on the observations made during today's visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. Exit interview was conducted, and a copy of this report was given to the facility manager.

met_with: Lupe Castro Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On June 16, 2025 at 10: AM Licensing Program Analysts LPA, Kenrick Ellis made an announced visit to ROP Harbor City Home STRTP to conduct the Psychotropic Case Medication Inspection. LPA conducted a Health and safety risk assessment upon arriving at the facility. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9(a)(2). During the inspection, LPA Kenrick Ellis met with the Administrator, Faaputu Vaafuti and conducted a brief walk through of the physical plant inside and out. LPA reviewed 3 client files and conducted 1 client interview at the facility. One client declined to be interviewed. One client has been at the facility for less than one month. One client does not take psychotropic medications. One client was at school during case management inspection. LPA reviewed four staff personnel files on site at the facility. LPA interviewed two staff members. LPA reviewed the LIC500 to confirm the shift which starts in the evening and ends early morning and reviewed the staff Criminal Records Clearances. The Administrator provided a physical hard copy of the psychotropic medication training topics during the training for LPA's to review. No deficiencies were cited per Interim Licensing Standards for STRTP Version 5. An exit interview was conducted, and a copy of this report was emailed to Administrator.

met_with: Faaputu Vaafuti, Administrator


facility_name: ROP LIVINGSTON HOUSE

raw_content:
Narrative:
On April 05, 2021, Community Care Licensing received an allegation that foster children are not treated with respect by S3, and staff (S2 and S3) ignore C1, S2 and S3 made inappropriate comments towards C1, and S2 and S3 encouraged other foster children to ignore C1. Confidential interviews revealed staff always treat foster children in care with respect. However, confidential interviews revealed staff can get agitated at foster children and they don't treat them respectfully. LPA received inconsistent information regarding the allegation. Confidential interviews revealed staff do not ignore foster children, however there may be times where a foster child is argumentative and verbal redirection does not work. Staff will then listen to the foster child but will not engage in further dialogue to avoid further conflict. Confidential interviews revealed staff did not make inappropriate comments towards C1, however confidential interviews revealed that a staff member did make an inappropriate comment towards C1. LPA received inconsistent information regarding the allegation. Confidential interviews revealed that staff at times do tell other foster children to ignore C1 when C1 is argumentative with staff. Confidential interviews revealed that C1 tends to try to create a hostile environment by bringing in other foster children into C1 arguments with staff. In order to deescalate an argument, staff discourage other foster children from partaking in C1's arguments with staff. Based on confidential interviews and record review, the allegations that foster children are not treated with respect by S3, and staff (S2 and S3) ignore C1, S2 and S3 made inappropriate comments towards C1, and staff (S2 and S3) encouraged other foster children to ignore C1 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 Dana Centanni.

Investigation Findings:
13On August 20, 2021, at 11: AM, Licensing Program Analyst (LPA) Jesus Cervantes made an unannounced visit at the facility. LPA met with Dana Centanni, to issue the investigative findings of the allegations listed above. On April 14, 2021, Licensing Program Analyst (LPA), Jesus Cervantes, conducted an unannounced tele-inspection of the facility, and no deficiencies were noted. LPA Cervantes conducted interviews with three of three (S1, S2, and S3) staff members, two of six (C2, and C3) foster children, and Orange County Senior Social Worker (SSW). Four of six (C1, C4, C5, and C6) foster children declined to be interviewed. During the investigation, LPA reviewed facility records and obtained copies of the following documents: Needs and Service plan for C1 and Case Notes. 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: ROP LIVINGSTON HOUSEFACILITY NUMBER: VISIT DATE: 08/20/2021

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

met_with: Dana Centanni


raw_content:
Narrative:
Confidential interviews reported that C1 might have been drinking alcohol the night before. Confidential interviews reported that C1 was taken to the hospital from school. Confidential interviews reported that C1's toxicology screening showed an alcohol level of 0.001. Confidential interviews reported that C1 has a history of running away from their facility. Confidential interviews reported that sometimes it was suspected that C1 was under the influence of alcohol upon return from AWOL. Confidential interviews reported that C1 did not obtain alcohol at the facility, nor was their alcohol available at the facility or provided by staff. Confidential interviews reported that C1 may have received alcohol while AWOL from the facility but could not prove it. Confidential interviews reported that alcoholic beverages or alcoholic containers were not found in C1's room or the facility premises. Community Care Licensing also received an allegation that medication is accessible to a minor (C1). Confidential interviews reported that a minor in care (C1) admitted to taking Percocet before attending school on 04/19/2022. Confidential interviews reported that C1 was not prescribed Percocet while at the facility. Confidential interviews reported that facility staff locked and secured all psychotropic medication within the facility. During the health and safety inspection, LPA observed that the psychotropic medication was locked and inaccessible to clients. Confidential interviews reported that it was unknown where C1 obtained the Percocet. Confidential interviews reported that C1 may have received Percocet while C1 was absent without permission from the facility. Confidential interviews reported that facility staff did not find any Percocet in C1's or any other client's bedroom. Based on inconsistent confidential interviews, the allegations that the minor (C1) has access to alcohol and medication accessible to minor (C1), may have occurred, however, is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted. A copy of this report and appeal rights were explained and provided to Senior Coach Counselor Angelica Littlefield.

Investigation Findings:
13On 01/24/2023, at 01:40PM, Licensing Program Analyst (LPA) Joon Choi conducted an unannounced visit to Rite of Passage (ROP) Livingston Short Term Residential Treatment Facility (STRTP) to deliver the investigative findings for the allegations listed above. On 04/28/2022, LPA Leslie Covarrubias conducted an initial health and safety inspection at the facility, and no immediate health and safety hazards were observed. On 12/30/2022, LPA Choi conducted a follow-up health and safety inspection of the facility, and no immediate health and safety hazards were observed. The investigation included interviews with clients (C1, C2, and C3) and staff (S1, S2, and S3). LPA obtained pertinent documentation during this investigation, such as the Special Incident Report relating to this complaint and the Orange County Child Protective Services Cross Report Documents. On 04/20/2022, Community Care Licensing received an allegation that a minor (C1) in care, has access to alcohol. Confidential interviews reported that C1 was observed to be sleeping at school on 04/19/2022. CONTINUED ON THE NEXT PAGE UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Joon R Choi 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: ROP LIVINGSTON HOUSEFACILITY NUMBER: VISIT DATE: 01/24/2023

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

met_with: Angelica Littlefield, Senior Coach Counselor


raw_content:
Narrative:
reviewed indicated C1 was not given medication #1 on November 29, 2023, medication #2 was not given to C1 from December 23-27, 30-31 in 2023, medication #3 was not given to C1 on December 23-26, 28-31 in 2023, and medication #4 was not given to C1 on December 23-24 (in the evening) and December 27 (in the morning) in 2023. Based on confidential interviews and record review the allegation that C1's medication log is incomplete is substantiated. The preponderance of evidence standard has been met. The facility is cited for violation of the California Code of Regulations, Title Division Six, regulation 80075(b) Health Related Services. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Kayla Dembek. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights will be emailed to the Administrator. A copy of this report will be placed in the facility file. Confidential interviews revealed conflicting statements. Due to not being able to interview all individuals, although multiple attempted contacts were made, confidential interviews did not corroborate the allegations with a preponderance of evidence. Based on confidential interviews and records reviewed the allegations that S9 yells at C1 in care, S4 engaged in a verbal altercation with C1, and S5 speaks inappropriately about minors in care, 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 were reviewed with Kayla Dembek Due to printer malfunction, a copy of this report and the LIC 811 will be emailed to the Facility Administrator. A signed copy of this report will be kept in the Facility file.

Investigation Findings:
13On July 18, 2024, at 10:05 am, Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced complaint inspection at the above facility. LPA Linley met with Kayla Dembek, Facility Administrator. The purpose of the inspection was to deliver the findings of the complaint investigation. LPA Linley conducted an inspection of the facility on May 6, 2024, and no deficiencies were observed. LPA interviewed two clients (C1-2), one County Social Worker (CSW), eight staff (S1-8), and LPA was unable to interview one staff (S9) despite multiple attempts to contact them. During the investigation, the following documents were reviewed: Staff Schedule, C Medication Administration Records, C1's Standing Order for medication, C1's Child-Family-Team Meeting Notes, C1's Needs and Services Plan, C1's Behavior Contract, and the facility's visitor log. On April 30, 2024, Community Care Licensing (CCL) received an allegation that C1's medication log is incomplete. Confidential interviews indicated staff forgot to give C1 their prescribed medication. Records 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 ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: ROP LIVINGSTON HOUSEFACILITY NUMBER: VISIT DATE: 07/18/2024

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: Kayla Dembek


summary: Facility Evaluation

raw_content:
Narrative:
On September 20, 2021, at 1: PM 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 August 24, 2018. LPA was met at the facility by Senior Coach, Kammy Delp. There are currently six residents in placement. LPA toured the facility inside and out at 1: PM. The facility consists of a common area, kitchen, pantry, laundry room, three client bedrooms, one client bathroom, one staff bathroom, and one staff office. 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. A client's mattress and box spring in bedroom #2 did not have good springs and was in disrepair. The bathroom was clean and in good repair. The hot water was tested in client bathroom #1 at 3: PM and registered at 109.4 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 laundry room. Sharp knives were observed to be inaccessible and stored in a locked closet. Medications are stored in a locked filing cabinet inside the entry closet. 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 Senior Coach, Kammy Delp. LPA observed facility posted items in the living room that included: Disaster Plan, Personal Rights, Grievance Procedures, and Foster Care Ombudsman poster. LPA observed a minimum 7-day non-perishable and a 2-day perishable supply of food. There is one camera at the facility located on the wall in the hallway. 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. LPA interviewed two clients in care. Due to the need to complete staff/client interviews, staff/client file reviews, and complete the inspection, this annual will continue on a later date. A copy of this report was provided to House Parent Lisa Ramirez.

met_with: Kammy Delp


summary: Facility Evaluation

raw_content:
Narrative:
On September 21, 2021, at 9: AM, Licensing Program Analysts (LPA), Jesus Cervantes continued the unannounced annual inspection, which was started on September 20, 2021. LPA met with Senior Coach, Kamy Delp. Licensee obtained their Mental Health (MH) Certification on March 14, 2021 and it expires on March 24, 2022. Licensee obtained National Accreditation through CARF and the accreditation is valid through August 31, 2022. Licensee has received a Medi-Cal approval through March 24, 2022. Licensing fee payments are current. LPA discussed the following with Senior Coach, Kamy Delp: operational requirements, disaster preparedness, and core/therapeutic services. All the client files are stored and locked in the file cabinet in the staff office. At 10: AM, LPA began to review a sample of six clients files during the time of inspection. Due to the need to conduct client/staff interviews, and continue client/staff 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 Senior Coach, Kamy Delp.


summary: Facility Evaluation

raw_content:
Narrative:
On September 22, 2021, at 9: AM, Licensing Program Analysts (LPA), Jesus Cervantes continued the unannounced annual inspection, which was started on September 20, 2021. LPA met with Senior Coach, Kamy Delp. At 9: AM, LPA began to review a sample of six clients files during the time of inspection. All files contained the required documentation per Title Regulations. Three facility staff were interviewed during the inspection. Personnel files are located at ROP Corporate Office located at N. Tustin Ave. Suit #120. Santa Ana, CA 92705. At 2: PM, LPA met with Director, Dana Centanni. LPA reviewed sample of ten of ten 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. Due to the need to conduct additional client/staff interviews, and continue staff training 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 Director, Dana Centanni.


summary: Facility Evaluation

raw_content:
Narrative:
On September 23, 2021, at 9: AM, Licensing Program Analysts (LPA), Jesus Cervantes continued the unannounced annual inspection, which was started on September 20, 2021. LPA met with Compliance Manager, Crystal Maxwell. Personnel and training files are located at ROP Corporate Office located at N. Tustin Ave. Suit #120. Santa Ana, CA 92705. At 9: PM, LPA reviewed sample of ten of ten staff training files. All files contained the required documentation and training per Title Regulations. At 2: PM, LPA returned to the facility and met with Child Care Worker, Yesennia Villa. LPA completed three staff interviews. Four clients refused to be interviewed. Based on the facility inspection completed and files reviewed, the facility is not in compliance. The facility is cited for Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS), Chapter 7.5, Version 3.1, Section 87088(c)(1), Furniture, Fixtures, Equipment, Supplies. (c) The licensee shall provide and make readily available to each child the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene: (1) An individual bed maintained in good repair; equipped with good springs and a clean mattress; and supplied with pillow(s) which are clean and in good repair. Based on the observation, the licensee did not comply with the section cited above in one out of six beds which posed a potential health, safety or personal rights risk to persons in care. An exit interview was conducted, and a copy of this report, LIC 811, and LIC 809D was provided to Senior Coach, Leo Trammell

met_with: Crystal Maxwell


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Veronica Whitaker conducted a case management inspection May 24, 2022, at 11: AM, based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During the inspection, 9 out of Direct Care Staff and 6 out of 6 youth files were reviewed. 4 out of Direct Care Staff and 2 out of 6 youth were interviewed. (See the Confidential Names List, LIC 811, dated May 24, 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 youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Veronica Whitaker 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 Sylvia Arballo,Compliance Manager, Dana Centanni, Program Director, Rabah Mahmoud..

met_with: Sylvia Arballo, Compliance Manager, Dana Centanni, Director, Rabah Mahmoud, Administrator


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On April 06, 2023, at 1: PM Licensing Program Analyst's (LPA's) Eduardo Barragan and Adrian Mendez conducted an unannounced annual inspection. The facility converted from a Group Home to a STRTP (Short Term Therapeutic Program) on August 24, 2018. LPA's was met at the facility by Angelica Littlefield, Senior Coach. There are currently four 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, one client bathroom, one staff bathroom, and one staff office. 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. A client's mattress and box spring in bedroom #1 and bedroom #2 did not have good springs. You could feel the springs when you apply pressure on the mattress. The bathroom was clean and in good repair. The hot water was tested in client bathroom and registered at 111 degrees. Cleaning solutions and hazardous items were observed to be stored in a locked cabinet in the laundry room. Sharp knives were observed to be inaccessible and stored in a locked closet. Medications are stored in a locked filing cabinet inside the entry closet. The facility's smoke and carbon monoxide detectors observed to be operable. The fire extinguishers are properly charged and serviced. There are no guns or weapons in the facility as stated by Angelica Littlefield, Senior Coach. LPA's observed facility posted items in the living room that included: Disaster Plan, Personal Rights, Grievance Procedures, and Foster Care Ombudsman poster. LPA's observed a minimum 7-day non-perishable and a 2-day perishable supply of food. There is one camera at the facility located on the wall in the hallway and one camera on the exterior of the home. 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. LPA's interviewed two clients in care and interviewed two staff. Due to the need to complete staff/client file reviews, and complete the inspection, this annual will continue on a later date. A copy of this report was provided to Angelica Littlefield, Senior Coach.

Deficiencies:
80087(b): Buildings and Grounds

(b) All clients shall be protected against hazards within the facility through provision of the following

met_with: Angelica Littlefield, Senior Coach


summary: Facility Evaluation

raw_content:
Narrative:
This is a continuation of the annual initiated on 04/06/2023. The continuation was completed on 04/07/2023. This form will serve as an attachment to the form that was administer to Angelica Littlefield, Senior Coach, on 04/06/23. On 04/07/23, at 9: AM, Licensing Program Analyst (LPA) Eduardo Barragan arrived to the facility listed above in order to complete the client file reviews. All client's files contained all required documentation per Title Regulations. LPA Barragan had to travel to the facilities corporate office in order to review staff files due to the staff files not being kept in the STRTP. The location was N Tustin Ave, Santa Ana, Suite 120. Prior to inspection LPA reviewed personnel files to ensure they contained all required documentation per Title Regulations. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Staff training were reviewed as well. Concluding the two day inspection there is one citation being administered and one technical Violation. (Please refer to the LIC 809D.) A copy of this report and appeal rights was discussed and provided to Sylvia Arballo, Compliance Manager.


summary: Facility Evaluation

raw_content:
Narrative:
On this date at 10:30 am, Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced case management inspection to this facility. LPA Linley met with Reyna Salas, Facility Administrator. LPA conducted a walk through of the facility and no deficiencies were observed. A case management has been opened regarding personal rights. LPA requested the following items be emailed to LPA by 5:00 pm: Facility sketch, C1's IEP, Placement Agreement, Emergency Identification Information, Court Report, Needs and Services plan, client roster, and house rules. LPA Informed facility that the investigation will be conducted by Community Care Licensing Special Investigations Branch Investigator, Angelica Medina. An exit interview was conducted with Reyna Salas. Due to printer malfunction, a copy of this report was sent to Reyna Salas. A copy of the signed report will be placed in the facility file.

met_with: Reyna Salas


summary: Facility Evaluation

raw_content:
Narrative:
On June 15, 2023, at 11:00 am, Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced case management inspection of the facility. LPA Linley met with Reyna Salas, Facility Administrator. LPA conducted a walk through of the facility, and no deficiencies were observed. The purpose of the inspection was to follow up on a case management visit on 05/11/2023. The investigation was conducted by Community Care Licensing Special Investigations Branch Investigator, Angelica Medina. IB Investigator interviewed two staff (S1-2) and one client (C1). Investigator Medina found that there were no personal rights violated. Thus, no deficiencies were noted, and the facility is in compliance. An exit interview was conducted with Reyna Salas. Due to a printer malfunction, a copy of this report was sent to Reyna Salas. A copy of the signed report will be placed in the facility file.


summary: Facility Evaluation

raw_content:
Narrative:
On November 18, 2024, at 12:00 pm, Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced annual inspection. LPs was met at the facility by Latasha Wilson, Child Care Worker, and Facility Administrator, Kayla Dembek. There are currently five residents in placement. LPA toured the facility with Latasha Wilson. LPA toured the facility inside and out. The facility consists of a common area, kitchen, pantry, laundry room, three client bedrooms, one client bathroom, one staff bathroom, and one staff office. 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 bathroom was clean and in good repair. The hot water was tested in the client bathroom at 3:09 pm and registered at 105 degrees, which is within the regulatory requirements of 105-125 degrees. Cleaning solutions and hazardous items were observed to be stored in a locked cabinet in the garage and laundry room. Sharp knives were observed to be inaccessible and stored in a locked closet. Medications are stored in a locked filing cabinet inside the entry closet. The facility's smoke and carbon monoxide detectors were observed to be operable. The fire extinguishers are properly charged and serviced. There are no guns or weapons in the facility as stated by Kayla Dembek. LPA observed facility posted items in the living room that included: Disaster Plan, Personal Rights, Grievance Procedures, and Foster Care Ombudsman poster. LPA observed a minimum 7-day non-perishable and a 2-day perishable supply of food. 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. LPA tested the water temperature in the kitchen at 12:15 pm and it registered at 109 degrees, which is within the regulatory requirements of 105-125 degrees. *** Client's medications were observed to be inaccessible and stored inside a locked cabinet in the locked closet in the entryway. Medication records were reviewed and observed to be completed with dates and staff initials on dispensing records. All client files are stored and locked in the file cabinet in the locked entryway closet. LPA reviewed five client files (C1-5) to ensure clients had all required documents per Title 22. LPA interviewed two clients. LPA interviewed two staff. Due to time constraints, LPA was unable to review the staff files and will return at a later date. The licensing fee payments are current. Based on the facility inspection on this date, there are no deficiencies found at this time. An exit interview was conducted, and a copy of this report was provided to Kayla Dembek. A copy of this report will be placed in the facility file.


summary: Facility Evaluation

raw_content:
Narrative:
On December 4, 2024, at 12:00 pm, Licensing Program Analyst (LPA), Charmaine Linley continued the unannounced annual inspection, which was started on November 18, 2024. LPA met with Gavin Hager, Human Resources Generalist. Personnel and training files are located at ROP Corporate Office located at N. Tustin Ave. Suite #120. Santa Ana, CA 92705. LPA reviewed five staff files (S1-5). All staff met the minimum qualifications and training requirements. A review of records shows that all staff have FBI, DOJ, and Child Abuse Index Check clearances. All staff have proof in file of acknowledging the child abuse reporting requirements. Based on the file reviews on this date, there are no deficiencies found at this time. An exit interview was conducted with Gavin Hager. Due to printer difficulties, a copy of this report was emailed to the Facility Administrator.

met_with: Gavin Hager


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Cheraki Davis on 08/17/2021 at 3: PM. During the inspection, LPA met with Lisa Ramirez, House Parent and Leo Trammell, Senior Coach and inspected the facility. LPA reviewed four children's psychotropic records on site at the facility at 4: PM. During the review of children's records, LPA Davis observed four children Needs and Services Plan were not signed by C1, C2, C3, and C4 and were not signed by the child's Social Worker. LPA reviewed three staff personnel files at 5: PM. LPA began three staff interviews at 4: PM. LPA interviewed three children currently taking psychotropic medication at 3: PM. One child was out in the community. LPA conducted exit interview with Leo Trammell, Senior Coach at 6: PM. LPA provided the Summary Report, LIC 809D, Appeal Rights, to Leo Trammell, Senior Coach upon completion. One deficiency was observed (refer to LIC 809D) and cited from the Interim Licensing Standards during the inspection.

Deficiencies:
87068.2(e): 08/27/2021
8
9
10
11
12
13
14

met_with: Leo Trammell

title:
1
2
3
4
5
6
787068.2(e) Needs and Services Plan. (e) The licensee shall obtain written approval from the child, if age and developmentally appropriate, and the child's authorized representative prior to implementing the child's needs and services plan.

1
2
3
4
5
6
7Refresher training on documentation to ensure written approval from the child, if age and developmentally appropriate, and the child's authorized representative prior to implementing the child's needs and services plan. POC due date

description:
08/27/2021
8
9
10
11
12
13
14


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On July 18, 2024 at 11:00 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Kayla Dembek, Facility Administrator, to discuss the records reviewed. During a record review of C1's records, LPA observed that on 01/01/2024 and 01/02/2024, C1 was given a second dose of their medication that was prescribed to take once daily. Based on record review, the facility is being cited for California Code of Regulations, Title Division Six, regulation 80075(b) Health Related Services. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Kayla Dembek. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights will be emailed to the Administrator. A copy of this report will be placed in the facility file.

Deficiencies:
80075(b): Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

title:
1
2
3
4
5
6
7Health Related Services


summary: Facility Evaluation

raw_content:
Narrative:
On April 23, 2026 at 9: AM, Licensing Program Analyst (LPA) Gilbert Marquez conducted an unannounced annual inspection. LPA was met at the facility by Child Care Worker Yahir Olguin-Rodriguez, and Facility Administrator Kayla Dembek. The Facility is licensed to serve six ambulatory children ages 11 to 17 years old, and non-minor dependents. The facility is current with licensing fees. The facility is a single story dwelling located on a residential street in a suburb. A physical plant inspection was completed with Yahir and included the following checks: common area, dining room, kitchen, pantry, laundry room, garage, three client bedrooms, one client bathroom, one staff bathroom, therapy room, and two staff offices. 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. All the required linens were on every bed. The one client bathroom and three bedrooms are arranged the following way: Bedroom #1 sleeps two clients, and has two single beds, closet, and two dressers Bedroom #2 sleeps one client, and has two single beds, closet, and two dressers Bedroom #3 sleeps one client, and has two single beds, closet, and one dresser Bathroom #1 is located in the hallway and has a sink, shower, and toilet **Continued on LIC809C** **Continued from LIC809** The water temperature was tested in the client bathroom which measured 108.5 degrees Fahrenheit, and the kitchen sink hot water measured at 111.2 degrees Fahrenheit, which is within the regulatory range of 105 degrees to 120 degrees Fahrenheit. The first aid kit was accessible to all staff and had all required supplies. All required forms are posted including Grievance Procedures, Visitation Policies, Personal Rights, and the Emergency Disaster Plan. Clients' medications were observed to be inaccessible and stored in medication room. Medications are stored in a locked filing cabinet inside the entry closet. Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. Emergency exits were free from obstruction. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguisher is properly charged and serviced. Cleaning solutions and hazardous items were observed to be stored in a locked cabinet in the garage and laundry room. Sharp knives were observed to be inaccessible and stored in a locked closet. 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. There are no guns or weapons in the facility as stated by Administrator Kayla Dembek. All client files are stored and locked in the file cabinet in the locked entryway closet. LPA reviewed four client files (C1 - C5, see Confidential Names List LIC811) to ensure clients had all required documents per Title 22. Client files had education records, physical examinations, Needs and Services plans, and mental health notes. LPA also reviewed five client medication records. All staff files are stored at the Corporate office. Due to time constraints, LPA Marquez will review staff files at another date. LPA conducted three staff interviews (S1, S2, S7) and two client interviews (C1, C2). No deficiencies were observed during today's inspection. An exit interview was conducted, this report was discussed, and a copy of this report and the Confidential Names List LIC811 was provided to Facility Administrator, Kayla Dembek. A copy of this report will be placed in the facility file.

met_with: Facility Administrator Kayla Dembek


facility_name: ROP PARAGON HOUSE

raw_content:
Narrative:
Confidential interviews revealed that whenever the staff are made aware that a client may be in possession of drugs or under the influence of drugs the staff performs a room search, and the incident is reported to Community Care Licensing (CCL). Confidential interviews revealed that there was a wax pen given to staff that was reported to belong to C1. Staff completed a search of C1's room and did not find any other drug paraphernalia. Additional confidential interviews stated that C2 advised C1 how to sneak drug paraphernalia into the facility. It is unclear how the drug paraphernalia was brought to the facility. Based on confidential interviews and record review, the allegation that Minor in possession of drug paraphernalia may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. A copy of this report and Appeals Rights were provided and explained to Sylvia Arballo, Compliance Manager.

Investigation Findings:
13On March 23, 2022 at 10:05 a.m., Licensing Program Analyst (LPA) Sarah Smith met with ROP Paragon House Short Term Residential Therapeutic Program (STRTP) Compliance Manager, Sylvia Arballo to deliver the findings of the complaint investigation for the above allegation. LPA Cervantes conducted a health and safety inspection of the facility on 10/12/2021 at 3:15 p.m. and no immediate deficiencies were observed. During the course of investigating the allegation, LPA Smith conducted confidential interviews with three staff, three clients, and the County Social Workers (CSW1 and CSW2). LPA reviewed reports and records for the facility and clients (C1, C2, and C3). On October 06, 2021, a complaint was received that Minor in possession of drug paraphernalia. During confidential interviews it was revealed that C1 would return to the facility with drug paraphernalia and offer it to the other clients in care. Information obtained from confidential interviews disclosed that staff became aware of C1 being in possession of the drug paraphernalia and performed a search of C1's possessions. -----Continued on the next page----- 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: ROP PARAGON HOUSEFACILITY NUMBER: VISIT DATE: 03/23/2022

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

met_with: Sylvia Arballo, Compliance Manager


raw_content:
Narrative:
denied the allegations that there was a lack of supervision. Confidential information received revealed that the facility was in ratio and had no staffing issues at the time of the allegation. According to confidential interviews, once staff became aware of the allegation, the staff put a plan in place to monitor and inspect food deliveries. Other confidential information received by Licensing Office stated that these allegations had occurred, and that C1 had engaged in inappropriate relationship and had access to contraband due to a lack of staff supervision. LPA received inconsistent information regarding staff providing a lack of supervision at the facility. Based on confidential information obtained during the course of this investigation, the allegations that staff failed to prevent minor from engaging in inappropriate behavior with an adult, as well as did not prevent minor from obtaining illegal paraphernalia, more specifically that Child # 1 (C1) had been communicating with and had sent nude pictures to an adult male via telephone, and that this adult male had also placed contraband such as "wax pens" inside food delivery, may have occurred, however is not supported or proven by evidence. Therefore, the above allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report was provided.

Investigation Findings:
13Licensing Program Analyst (LPA), Daniel Mena met with Senior Coach, Shanice Green to discuss the investigative findings for the above stated allegations. Licensing Program Analysts (LPAs), Jesus Cervantes and Daniel Mena conducted an inspection to the Short Term Residential Therapeutic Program (STRTP) on September 02, 2021 at 3:15pm and on May 12, 2022 at 1:58pm. No immediate hazards observed. LPAs Cervantes and Mena interviewed three staff (S1, S2 & S3), three foster children (C1, C2 & C3), as well as reviewed client and facility records. Community Care Licensing received information on September 01, 2021 alleging that staff did not prevent minor from engaging in inappropriate behavior with an adult, as well as did not prevent minor from obtaining illegal paraphernalia, more specifically that Child # 1 (C1) had been communicating with and had sent nude pictures to an adult male via telephone, and that this adult male had also placed contraband such as "wax pens" inside McDonald's food delivery. Information obtained in confidential interviews did not corroborate the allegations with a preponderance of evidence. Information obtained from confidential interviews disclosed that the allegations occurred while other confidential UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Daniel Mena 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: ROP PARAGON HOUSEFACILITY NUMBER: VISIT DATE: 05/27/2022

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

met_with: Shanice Green


raw_content:
Narrative:
interviews also stated that staff took immediate action and reported incident to all required agencies once they had been made aware of these allegations. According to confidential interviews, staff provide proper supervision and will conduct random checks to all bedrooms throughout the day and night every 15 to 30 minutes. While other confidential information received by Licensing Office stated that these allegations had occurred. There were no other known witnesses to this allegation. Based on confidential information obtained during the course of this investigation, the allegation of a lack of supervision resulting in minors engaging in inappropriate sexual behavior, may have occurred, however is not supported or proven by evidence. Therefore, the above allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report was provided

Investigation Findings:
13Licensing Program Analyst (LPA), Daniel Mena met with Program Manager, Rabah Mahmoud to discuss the investigative findings for the above stated allegation. Licensing Program Analyst, Nicole Strickland conducted an inspection to the facility on January 21, 2022 at 9:16am. Special Investigator (SI), Nikki Vo interviewed four staff (S1, S2, S3, S4 & S5), three foster children (C1, C2 & C3), County Social Worker (CSW), as well as reviewed client and facility records. Community Care Licensing received information on January 13, 2022 alleging a lack of supervision resulting in minors engaging in inappropriate sexual behavior. Information obtained in confidential interviews did not corroborate the allegation with a preponderance of evidence. Confidential interviews denied that Child # 1 (C1) had ever been sexually inappropriate or had touched Child # 2 (C2) on or near their private parts. Confidential interviews also denied that either C1 and C2 had taken sexually explicit photos of one another, as well as masturbated together in their bedroom. Confidential UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Daniel Mena 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: ROP PARAGON HOUSEFACILITY NUMBER: VISIT DATE: 07/08/2022

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

met_with: Rabah Mahmoud


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
out the UIR and the report was not sent to the Probation Officer and CCL within the allotted time frame. On all the above dates, the facility failed to make the required notices within the allotted time frame. Based on confidential interviews and record review, the preponderance of evidence standard has been met regarding the allegation that the Facility did not report Unusual Incident Reports, therefore the allegation is substantiated. This poses an immediate Health, Safety or Personal Rights risk to the children in care. The facility will be cited for violating California Code of Regulations, Title 22, 80061(b)(E) Reporting Requirements. An exit interview and appeal rights were reviewed with Reyna Salas. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights will be emailed to the Facility Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On April 18, 2023, at 2:30 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Reyna Salas of ROP/Paragon to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 01/23/2023 at 10:45 am. No deficiencies were observed. LPA interviewed one out of one staff (S1). LPA reviewed the following documents: Special Incident Reports, Placentia Police Department Incident Reports/CAD calls, and Special Incident Reports sent to C1's Probation Officer. On 01/20/2023, Community Care Licensing (CCL) received an allegation that the Facility did not report Unusual Incident Reports (URI). Confidential interviews and record review indicated that the facility did not report reportable incidents on 01/05/2023, 01/10/2023, and 01/11/2023 involving C1. Regarding the incident on 01/05/2023, confidential interviews revealed there was a miscommunication regarding who was to send 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: ROP PARAGON HOUSEFACILITY NUMBER: VISIT DATE: 04/18/2023

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

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
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 Cedric Jones. A copy of this report, LIC 811, and appeal rights were provided to the Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On November 14, 2023, at 11: AM, Licensing Program Analyst (LPA) Guadalupe Munoz arrived unannounced at the facility and met with ROP/Paragon Administrator to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 8/22/2023 at 1:00 pm. No deficiencies were observed at that time. LPA interviewed four staff (S1-S4) and three clients (C1-C3). LPA reviewed the following documents: Special Incident Reports and Needs and Services Plan for C1 and C2. On 08/15/2023, Community Care Licensing (CCL) received an allegation that the staff at the facility did not intervene in minor on minor assault. Confidential interviews did not corroborate the allegation with a preponderance of evidence. Based on confidential interviews and records reviewed regarding the allegation that, staff did not intervene in minor on minor assault. it may have occurred, however, it is not supported or proven by the evidence. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz 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: ROP PARAGON HOUSEFACILITY NUMBER: VISIT DATE: 11/14/2023

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

met_with: Cedric Jones


raw_content:
Narrative:
the clients and called C1 weird. Confidential interviews indicated that S2 asked C5 to go to their bedroom so they could check their backpack for inappropriate items and C5 did not listen, so S2 told C5, "I don't give a fuck, you are going to stay in your bedroom." Confidential interviews indicated that S2 lost their temper and later apologized to the clients. It was also reported that S2 called C1 weird. Confidential interviews and an audio recording confirmed that S2 told C1, "your mama is weird...you are a square...you a sucker." Based on confidential interviews and audio recording, the allegations that staff spoke inappropriately to minors in care and that staff's behavior poses a risk to minors in care is substantiated. The preponderance of evidence standard has been met. The facility is cited for violation of the California Code of Regulations, Title Division Six, regulation 87072(c)(15) Personal Rights. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Sylvia Arballo. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights will be emailed to the Administrator. A copy of this report will be placed in the facility file. facility. Confidential interviews revealed conflicting statements. Some interviews indicated that staff contacted Law Enforcement after C1 ran away from the facility. While other interviews indicated that staff did not contact Law Enforcement to report C1 ran away, however, an exact date could not be provided. Thus, 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 follow proper reporting requirements, 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 Sylvia Arballo. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights will be emailed to the Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On January 5, 2024, at 2:55 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility and met with Julia West, Senior Coach Counselor, while Sylvia Arballo, Compliance Manager, was on the phone to discuss the investigative finding for the allegations noted above. LPA conducted an inspection of the facility on 09/11/2023 at 2:00 pm and no deficiencies were observed. LPA interviewed two staff (S1, S2), and one County Social Worker (CSW), LPA interviewed three clients (C1, C2, C4), and LPA was unable to interview one client (C3), despite multiple attempts to contact them. LPA reviewed the following documents: Client Roster, Personnel Record, Overnight room check forms, staff schedule, staff communication log, C1's Needs and Services Plan, C1's Special Incident Reports, and a cell phone audio recording of C1 and S2. On 09/01/2023, Community Care Licensing (CCL) received allegations that staff spoke inappropriately to minors in care and that staff's behavior poses a risk to minors in care. It was reported that staff yelled at 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 ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: ROP PARAGON HOUSEFACILITY NUMBER: VISIT DATE: 01/05/2024

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: Julia West


raw_content:
Narrative:
interviews indicated C1 refused to complete their chores and S1 yelled at them and called them "lazy." Other interviews denied S1 yelled at C1 and denied S1 called C1 "lazy." While other interviews, denied staff yelled at the clients. Confidential interviews indicated S1 was joking around with another staff and made a gesture to choke them. Some interviews denied S1 made any comments that they were going to choke C1. Other interviews indicated S1 and C1 were laughing and made a joke about being choked. Due to being unable to interview all individuals, confidential interviews did not corroborate the allegations with a preponderance of evidence. Based on confidential interviews and records reviewed the allegations that staff speak inappropriately to minors in care and staff yell at minors, 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 Kayla Dembek. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights were emailed to the Facility Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On April 8, 2024, at 10:20 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Kayla Dembek, Facility Administrator, to discuss the investigative finding for the allegations noted above. LPA conducted an inspection of the facility on January 18, 2024, at 9:45 am and no deficiencies were observed. LPA Linley interviewed three clients (C1, C2, C3), one client declined to interview (C4), five staff (S1-5), and was unable to interview one staff (S6), despite multiple attempts to contact them. LPA reviewed the following documents during the investigation: C Needs and Services Plan, Client Roster, Staff Schedule, Special Incident Reports, Police Department Incident Report. On January 8, 2024, Community Care Licensing (CCL) received allegations that staff speak inappropriately to minors in care and staff yell at minors. It was reported that S1 yelled at C1, other staff yell at the clients, and S1 said they were going to choke C1. Confidential interviews revealed conflicting statements. Some 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: ROP PARAGON HOUSEFACILITY NUMBER: VISIT DATE: 04/08/2024

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


raw_content:
Narrative:
Based on confidential interviews and records reviewed the allegation that staff did not provide adequate supervision resulting in minor engaging in inappropriate behavior with another minor in care, 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 Kayla Dembek. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights were emailed to the Facility Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On April 8, 2024, at 10:00 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Kayla Dembek, Facility Administrator, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on February 1, 2024, at 4:15 pm and no deficiencies were observed. LPA Linley interviewed two clients (C1-2) and two staff (S1-2) and one client declined to interview (C3). LPA reviewed the following documents during the investigation: C1 and C Needs and Services Plan, Client Roster, Staff Schedule, and Special Incident Reports. On January 29, 2024, Community Care Licensing (CCL) received an allegation that staff did not provide adequate supervision resulting in minor engaging in inappropriate behavior with another minor in care. It was reported that C1 pulled down their pants and exposed themselves to C3. Disclosures during the interviews were inconsistent with the allegation and due to being unable to interview all individuals, 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: ROP PARAGON HOUSEFACILITY NUMBER: VISIT DATE: 04/08/2024

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


raw_content:
Narrative:
they told anyone what happened. There were no witnesses to this allegation. Confidential interviews revealed conflicting statements. Thus, confidential interviews did not corroborate the allegation with a preponderance of evidence. Based on confidential interviews and records reviewed the allegation that S1 sexually abused C1, 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 and provided to Kayla Dembek. A copy of this report will be placed in the facility file.

Investigation Findings:
13On December 16, 2024, at 12:05 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Kayla Dembek, Facility Administrator, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on August 27, 2024, at 11:47 am and no deficiencies were observed. The investigation was conducted by the Department's Investigations Branch (IB), assigned to Investigator John Rante. Investigator Rante interviewed three of five clients (C2-4), five staff (S2-6), one County Social Worker (CSW), and one Hospital Social Worker (HSW). During the investigation, Investigator Rante conducted a comprehensive review of facility records and Law Enforcement Reports. On August 22, 2024, Community Care Licensing (CCL) received an allegation that staff sexually abused a minor. It was reported that S1 had sexual intercourse with C1 on three separate occasions while working at the facility. It was reported that C1 told S1 to stop and S1 did not stop and threatened to harm C1 if 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: ROP PARAGON HOUSEFACILITY NUMBER: VISIT DATE: 12/16/2024

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


raw_content:
Narrative:
indicated that S1 yelled at C5 for getting a piece of chicken off the cutting board. Conflicting interviews indicated that C5 tried to eat raw chicken off the cutting board and S1 raised their voice to stop C5 from eating the raw chicken. Confidential interviews revealed conflicting statements. Thus, confidential interviews did not corroborate the allegations with a preponderance of evidence. Based on confidential interviews and records reviewed the allegations that staff provides minors with nicotine pens and staff yelled at minors, which may have occurred, however, they are 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 and provided to Kayla Dembek. A copy of this report will be placed in the facility file.

Investigation Findings:
13On December 16, 2024, at 12:30 pm, Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced complaint inspection at the above facility. LPA Linley met with Kayla Dembek, Facility Administrator. The purpose of the inspection was to deliver the findings of the complaint investigation. LPA Linley conducted an inspection of the facility on October 1, 2024, at 10:05 am and no deficiencies were found. LPA Linley interviewed five out of six clients (C1-5) and three staff (S1-3). During the investigation facility records were reviewed. On September 24, 2024, Community Care Licensing (CCL) received allegations that staff provides minors with nicotine pens and staff yelled at minors. It was reported that S1 provided nicotine vape pens to C1, C2, C3 and S1 yells at the clients for walking away from the stove or getting a piece of meat off the cutting board. Some interviews indicated that S1 vaped in the agency vehicle with the clients present, while other interviews denied seeing S1 vape at any time. As for the allegation that S1 yelled at minors, some interviews 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: ROP PARAGON HOUSEFACILITY NUMBER: VISIT DATE: 12/16/2024

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


raw_content:
Narrative:
interactions, some interviews denied clients took showers when S1 was working at the facility. There were no witnesses to these allegations. Thus, confidential interviews did not corroborate the allegations with a preponderance of evidence. Based on confidential interviews and records reviewed the allegations that staff engages in inappropriate interaction with minors and staff makes inappropriate comments towards minors, which may have occurred, however, they are not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted and appeal rights reviewed. Due to printer difficulties, a copy of this report, LIC 811, and appeal rights were emailed to Kayla Dembek. A copy of this report will be placed in the facility file.

Investigation Findings:
13On June 23, 2025, at 2:10 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Jennifer Sanabria, Senior Coach Counselor, to discuss the investigative finding for the allegations noted above. LPA conducted an inspection of the facility on April 21, 2025 at 3:45 pm and no deficiencies were observed. LPA interviewed four of five Clients (C1-4) and five Staff (S1-5). LPA reviewed the facility documents during the investigation. On April 14, 2025, Community Care Licensing (CCL) received allegations that staff engage in inappropriate interaction with minors and staff makes inappropriate comments towards minors. It was reported that S1 made a comment towards C2 about wanting to touch them and S1 made a comment that they feel aroused when C2 is around them. It was also reported that S1 looks at the clients while they are showering. Confidential interviews revealed conflicting statements. Some interviews denied S1 made any comments towards C2 about touching them or being aroused around C2. As far as the allegation of inappropriate 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: ROP PARAGON HOUSEFACILITY NUMBER: VISIT DATE: 06/23/2025

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

met_with: Jennifer Sanabria