summary: Facility Evaluation

raw_content:
Narrative:
On 12/02/2022 at 10:30 am, Licensing Program Analyst (LPA) Sarah Lo conducted an unannounced Annual Inspection of the facility. LPA Lo was greeted by Administrator Aaron Ramsey and was allowed entry into the facility. At 10:35 am, LPA Lo toured the facility and inspected inside and out with the Administrator. The home is a two story residence with three bedrooms and two bathrooms. The Administrator stated current census is six. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. The beds and dressers in all the bedrooms are in good repair, and all window screens are attached. LPA Lo observed age-appropriate clothing in the closet of the clients. The bathrooms were clean and in good repair. The temperatures in rooms that clients occupy are maintained between 68 degrees F and 85 degrees F. The hot water temperature was tested and noted to be within the regulations of 105 degrees F to 120 degrees F in the client bathroom. All hazardous items have been properly made inaccessible to areas where clients will have access. The medications were stored and locked in a cabinet in the staff office area. Cleaning supplies and chemicals are locked and stored in a cabinet under the kitchen sink. Sharp knives are inaccessible and stored in a locked drawer in the kitchen. The First Aid Kit is located in a locked cabinet in the staff office area and contains all required items. The facility's smoke detectors located in each bedroom and common areas were checked and were operable. The carbon monoxide detector located in hallway was operable. There are no guns or weapons in the facility as stated by Administrator at this time. The following required posted items were observed accessible to clients: Grievance Procedures, Personal Rights, Ombudsman Poster, Visitation policies, and current menu. (Continue in LIC 809-c) LPA Lo observed a minimum 7-day non-perishable and a 2-day perishable supply of food. There was a variety of snacks available for clients as well. Refrigerators in the kitchen and garage are maintained in a good temperature. The facility outside grounds was also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. The facility has no pools or bodies of water on the grounds. At 12:16 pm LPA Lo reviewed a sample of client and staff files. LPA Lo reviewed files for five clients in care: C1, C2, C3, C4, and C5. All client files were found to have Cash/Property/Valuables records, Medical Consent Forms and signed Needs and Services Plans. LPA Lo also reviewed staff files for S1, S2, S3, S4, and S5. All staff files reviewed have Department of Justice (DOJ), Federal Bureau of Investigation (FBI) and Child Abuse Clearance Index (CACI) clearances, proof on file of acknowledging the child abuse reporting requirements and meet the minimum qualifications and training requirements per Community Care Licensing Regulations. LPA Lo conducted two staff interviews and two client interviews. Based on the facility inspection and file reviews on this date, there are no deficiencies found at this time. An exit interview was conducted and a copy of this report and LIC 811 was provided to Administrator, Aaron Ramsey.

met_with: Aaron Ramsey, Administrator


state: CA

facility_name: BERHE GROUP HOMES

summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Sarah Lo on 08/16/24 at 09:02 am. The case management inspection is conducted pursuant to Health and Safety Code Section 1538.9(a)(2). During the inspection, LPA met with Aaron Ramsey, Administrator and inspected the facility inside and out. LPA reviewed three children's records on site at the facility. LPA reviewed five staff personnel files on site at the facility. LPA reviewed three child's psychotropic medications and medication records. LPA interviewed three children that is currently prescribed psychotropic medication at their school. No deficiencies are being cited at this time. LPA provided a copy of this licensing reporting and conducted an exit interview with Aaron Ramsey, Administrator.

report_type: Facility Evaluation

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
On 3/27/2025 at 9:43 am, Licensing Program Analyst (LPA) Jacob Ortega conducted an unannounced Annual Inspection of the facility. LPA was greeted by Facility Manager Ms Rosemary and was allowed entry into the facility. LPA toured the facility and inspected inside and out with the Manager. The home is a two story residence with three bedrooms and two bathrooms. The Administrator stated current census is four. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. The beds and dressers in all the bedrooms are in good repair, and all window screens are attached. LPA observed age-appropriate clothing in the closet of the clients. The bathrooms were clean and in good repair. The temperatures in rooms that clients occupy are maintained between 68 degrees F and 85 degrees F. The hot water temperature was tested and noted to be within the regulations of 105 degrees F to 120 degrees F in the client bathroom. All hazardous items have been properly made inaccessible to areas where clients will have access. The medications were stored and locked in a cabinet in the staff office area. Cleaning supplies and chemicals are locked and stored in a cabinet under the kitchen sink. Sharp knives are inaccessible and stored in a locked drawer in the kitchen. The First Aid Kit is located in a locked cabinet in the staff office area and contains all required items. The facility's smoke detectors located in each bedroom and common areas were checked and were operable. The carbon monoxide detector located in hallway was operable. There are no guns or weapons in the facility as stated by Ms Rosemary at this time. The following required posted items were observed accessible to clients: Grievance Procedures, Personal Rights, Ombudsman Poster, Visitation policies, and current menu. *** LPA observed a minimum 7-day non-perishable and a 2-day perishable supply of food. There was a variety of snacks available for clients as well. Refrigerators in the kitchen and garage are maintained in a good temperature. The facility outside grounds was also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. The facility has no pools or bodies of water on the grounds. LPA reviewed the client and staff files. LPA reviewed files for four clients in care: C1, C2, C3, and C4. All client files were found to have Cash/Property/Valuables records, Medical Consent Forms and signed Needs and Services Plans. LPA also reviewed staff files for S1, S2, S3, S4, and S5. All staff files reviewed have Department of Justice (DOJ), Federal Bureau of Investigation (FBI) and Child Abuse Clearance Index (CACI) clearances, proof on file of acknowledging the child abuse reporting requirements and meet the minimum qualifications and training requirements per Community Care Licensing Regulations. LPA conducted two staff interviews and two client interviews. Based on the facility inspection and file reviews on this date, there are no deficiencies found at this time. An exit interview was conducted and a copy of this report and LIC 811 was provided to Administrator, Ms Rosemary.

visit_type: Annual

met_with: Rosemary Glaven


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Rachel Vanegas and Carissa Aviles on July 08, 2025 at 09:35AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs Vanegas and Aviles met with Aaron Ramsey, Administrator and inspected the facility inside and out. LPAs reviewed three of three child's records and five of five staff personnel files on site at the facility. LPAs reviewed three of three child's psychotropic medications and medication records. LPAs interviewed two of five staff on site to discuss the facilities policies and procedures of operation. LPAs interviewed two of three children currently prescribed psychotropic medication. LPAs provided a copy of this licensing report to Aaron Ramsey - Administrator. No deficiencies are being cited at this time. LPAs conducted an exit interview with Aaron Ramsey - Administrator.

met_with: Aaron Ramsey - Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On Tuesday October 14, 2025 at 2: PM Licensing Program Analyst (LPA) Linda Haynes arrived at Berhe Group Home to inspect kitchen for ants and Mattresses per concerns expressed by two clients. LPA was met at the door by Administrator (AD) Aaron Ramsey. AD led LPA into the kitchen where LPA checked cabinet tops, floors, inside cabinets, and pantry LPA did not observe any signs of ants. LPA was informed by AD that the home is sprayed once a month for insects. LPA requested a copy of the invoice. AD then showed LPA the mattress of the clients all beds have the same mattress and bedding set up. The beds are not card board as reported to LPA.

met_with: Aaron Ramsey


summary: Facility Evaluation

raw_content:
Narrative:
On October 28, 2025 at 03: PM Licensing Program Analyst (LPA) Linda Haynes met with Berhe Short Term Residential Treatment Program (STRTP) Lead Staff Jose Lopez to amend LIC 9099 from complaint control number 61-CR-20250512100310 dated 09/09/2025.

met_with: Jose Lopez


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
The allegation staff took personal items from minor specifically refers to FM taking C1's favorite stuffed animal and throwing it away. Confidential interviews revealed that staff members do not take away client belongings unless they are used in an inappropriate way. Further confidential interviews revealed that FM did not take C1's stuffed animal and throw it away but that C1 threw it away after C1 had ripped it up and it could not be fixed. Other confidential interviews stated the allegation is true. The allegation that staff handled a minor in a rough manner specifically refers to FM grabbing C1's hands to restrain C1. Confidential interviews revealed that FM and S1 both put C1 in an approved Crisis Prevention Institute (CPI) standing high level restraint. Other information obtained stated the allegation occurred. Based on confidential interviews and record reviews, the allegations that FM Pushed C1, FM took personal items from C1, and FM handled C1 in a rough manner, may have occurred, however, they are not supported or proven by evidence. Therefore, the above allegations are unsubstantiated. A copy of this report, LIC 811, and appeal rights were given to Lead Staff Jose Lopez.

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:

report_type: Complaint Investigation

complaint_status: unsubstantiated


raw_content:
Narrative:
Confidential interviews revealed that when clients tell staff that they are missing items staff will assist in looking for the items if the item is not found or if it is presumed stolen staff will check the cameras and return the item to the minor that it belongs to. Other information obtained stated the allegation is true. The allegation that staff are not allowing minors to have phone calls specifically refers to the staff not allowing clients to make court approved phone calls. Confidential interviews revealed that staff do allow clients to make their court approved phone calls during phone hours. Other information obtained stated the allegation is true. Based on confidential interviews and record reviews, the allegations that due to lack of supervision, minors are stealing other minor's belongings and staff are not allowing minors to have phone calls, may have occurred, however, they are not supported or proven by evidence. Therefore, the above allegations are unsubstantiated. A copy of this report, LIC 811, and appeal rights were given to Facility Manager Rosemary Glavan.

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: Rosemary Glavan


raw_content:
Narrative:
Confidential interviews revealed that clients have never been threatened with losing phone calls or from attending court hearings. Other information obtained stated the allegation occurred. The allegation that staff restricted youths phone calls to personal representatives specifically refers to the staff telling C1 to end their court approved phone calls early. Confidential interviews revealed that staff do not make clients end their phone calls early if anything they give them more time. Other information obtained stated the allegation occurred. Based on confidential interviews and record reviews, the allegations that staff threaten C1 with inappropriate forms of punishment and staff restricted C1 phone call to personal representatives, may have occurred, however, they are not supported or proven by evidence. Therefore, the above allegations are unsubstantiated. A copy of this report, LIC 811, and appeal rights were given to Facility Manager Rosemary Glavan.

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:


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPA) Shanae Pharaoh on May 5, 2022 at 11: AM. During the inspection, LPA met with Administrator Aaron Ramsey and inspected the facility inside and out. LPA reviewed five of five client records C1, C2, C3, C4 and C5 on site at the facility at 11: AM. During the records review LPA did not observe needs and servics plans that were signed by C1, C2, C3, C4 and C5's authorized representatives. LPA did not observed a child signature on the need and service plan for C1. LPA did not observe JV223 for C1 and LPA did not observe a current JV223 for C5. LPA interviewed two of three staff, S1 and S2 on site at 1: PM. LPA reviewed two of two staff S1 and S2 personnel files on site at the facility at 3: PM. LPA interviewed five of five children currently taking psychotropic medication at 4: PM LPA conducted exit interview with Administrator at 4: PM. LPA issued technical violations for Interim Licensing Standards Section 87068.2(e), 87068.2(d ), Need and Service Plan and 87070(b)(11), Children Records. The facility is being cited for violation of Interim Licensing Standards Section 87068.2(e) and 87068.2(d ) Needs and Service Plan on LIC 809D. LPA provided the Summary Report to the Administrator, Aaron Ramsey upon completion.

met_with: Administrator - Aaron Ramsey


facility_name: BERHE GROUP HOME, INC.

raw_content:
Narrative:
Other confidential interviews provided the LPA with corroborating information the staff do not use any physical punishment on the clients. When the clients get in trouble, they are sent on time out, cannot play video games, have to go to bed early or have to write sentences as a consequence. It was also reported sometimes the staff physically play with the clients but no hitting is involved. C1 constantly needed to be redirected or have staff assigned to supervise him on a one on one basis because of C1's difficult acting out behaviors. The LPA did not receive any evidence from the other confidential interviews to support the allegation. However, other information received stated the allegation occurred. Based on confidential interviews, the allegation S1 hit C1 may have occurred, however is not supported or proven by evidence. Therefore, the above allegation is unsubstantiated at this time. An exit interview was conducted and a copy of this report and appeal rights were provided to Wendy Telley.

Investigation Findings:
13On 09/02/21 at 3: PM Licensing Program Analyst (LPA), Belinda Torres, made contact with Wendy Telley, Facility Manager, for the purpose of issuing the investigative finding to the allegation listed above. The LPA inspected the facility on 05/27/21 at 1: PM and no safety concerns were observed. During the course of the investigation, the LPA conducted confidential interviews with six out of six clients and three staff. On 05/19/21, Community Care Licensing (CCL) received a report staff hit client #1 (C1) for no reason. No details were provided. During the course of a confidential interview, it was reported to the LPA staff #1 (S1) accidentally yanked a chair and C1 fell off the chair. No details were provided. It was further reported the staff did not hit C1 or any of the other clients. S1 reported to the LPA he could not remember C1 falling off of a chair. S1 further stated he did not move a chair and there were no incidents in which C1 fell by S1. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Belinda Torres 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 19-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, MAIN ST., Suite Riverside, CA Facility Name: Berhe Group Home, INC.FACILITY NUMBER: VISIT DATE: 09/02/2021

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

met_with: Wendy Telley


raw_content:
Narrative:
Confidential interviews and record review revealed C1 was placed in the STRTP from 6/10/2021-7/21/2021. Confidential interviews revealed C1 ran out of C1's medication and was not given C1's medication for approximately one month; while other interviews revealed C1 was out of medication for a few days. Record review revealed C1 ran out of psychotropic medication and took C1's last dose on 7/9/2021 and did not receive his prescribed medication from 7/10/2021 through 7/21/2021. Interviews with staff revealed they were aware that C1 was low on medication however believed it would still be the Wellness Recovery Action Plan (WRAP) team's responsibility to obtain C1's refill. Other confidential interviews revealed that the STRTP staff was told C1 could be seen by an outside psychiatrist to obtain a refill however the STRTP did not schedule an appointment for C1 to be seen. Interviews and record review revealed that in a meeting held on 7/14/2021 it was determined C1's WRAP services would be terminated, however, the WRAP team was able to schedule an emergency appointment on 7/15/2021 for C1 to be seen by a psychiatrist and obtain a prescription refill on C1's medication. Interviews revealed the STRTP obtained the medication refill on 7/19/2021 however record review revealed C1 was not given C1's medication for the remainder of C1's placement in the STRTP. Based on confidential interviews and record review, the preponderance of evidence standard has been met. The department has determined the allegation that staff did not ensure C1 received medication is substantiated. The facility is being cited for violation of the Title General Regulations Division Chapter 1, Section 80075 (a) Health Related Services. Per confidential interviews and record review facility staff did not ensure C1 was provided medical services to obtain a refill on medications which resulted in C1 not receiving their psychotropic medications which poses an immediate health, safety or personal rights risk to clients in care. An exit interview was conducted and a copy of this report, LIC 811 and appeal rights was provided to Senior Facility Manager Cedric Reliford. Confidential interviews and record review revealed that on 7/20/2021, C2 and C3 believed C1 went through their belongings so C2 and C3 went into C1's bedroom, C2 threw a sandal at C1, hitting C1 in the head and C3 slapped C1 in the face, causing C1 to get a bloody nose. Other confidential interviews revealed C2 and C3 slapped and punched C1 several times. Confidential Interviews and record review revealed staff did not observe the assault on C1, however there were two staff, S1 and S2 on duty and present in the facility at the time of the incident. Confidential interviews revealed after the incident occurred, S1 offered C1 medical attention and S1 had C1 sleep in the living room for the remainder of the night. All confidential interviews revealed that there are usually two staff on shift except during overnight shift and that staff check on clients every 15 minutes. It was also reported that this incident occurred within 5-10 minutes of S1, C2 and C3 returning to the STRTP. The interview with CSW revealed there were no concerns of supervision in the STRTP. Based on confidential interviews and record review, C1 was physically assaulted by C2 and C3 while in care, however, it is not supported or proven by evidence that it occurred due to lack of supervision. Therefore, the above allegation is unsubstantiated. A copy of this report, LIC 811 and appeal rights were explained and given to Senior Facility Manager Cedric Reliford.

Investigation Findings:
13On September 10, 2021 at 3:17 pm, Licensing Program Analyst (LPA), Jessica Rubio met with Berhe Group Home (STRTP), Senior Facility Manager Cedric Reliford, to discuss the investigative finding of the allegation listed above. On July 30, 2021 at 12:33 pm, LPA Jose Gonzalez conducted a safety inspection of the facility. No safety hazards were observed and no deficiencies were cited. During the investigation, LPA Jessica Rubio conducted confidential interviews with four clients (C1, C2, C3, C4), three staff (FM, S1, S2), county social worker of C1 (CSW) and Child and Family Team Facilitator for C1 (CFTF). LPA Rubio obtained and reviewed copies of the staff roster and the needs and services plan for C1. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Christina Barnes LICENSING EVALUATOR NAME: Jessica M Rubio 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 19-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, MAIN ST., Suite Riverside, CA Facility Name: Berhe Group Home, INC.FACILITY NUMBER: 366401709

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: Cedric Reliford


raw_content:
Narrative:
On August 30, 2022, Community Care Licensing received information alleging that Client #1 (C1) was being hit by other clients in care due to lack of supervision. It was specified that C1 has been physically abused by C3 when staff were not present. It was also alleged that another client, Client #3 slapped C1 across the face while they were in a back portion of the STRTP when staff was not present with no further details. A confidential interview reported not having any knowledge of the allegation. Another confidential interview stated C1 was the aggressor and was not bullied by any peers. A different confidential interview reported hitting C1 on the head because C1 was being annoying, however, staff intervened. It was added that staff did not allow clients to play video games as a form of punishment. Based on confidential interviews, the allegation that C1 was hit by other clients in care due to a lack of supervision may have occurred, however, it is not supported or proven by evidence. Therefore, the above allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Facility Manager Wendy Flowers.

Investigation Findings:
13On August 30, 2023, at 1:15PM, Licensing Program Analyst (LPA) Adaleyci Caballero met with Berhe STRTP Facility Manager Wendy Flowers to discuss the investigative finding for the above stated allegation for Client #1. Lpa B. Torres began the investigation at the facility on September 7, 2022, at 2:35PM. On July 12, 2023, LPA A. Caballero interviewed Client #3, Client #4, Client #5, Client #6, and Staff #2. Lpa a. Caballero reviewed client and staff rosters and previous incident reports. Client #1 refused to be interviewed. LPA conducted a telephone interview with Client #2. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Adaleyci Caballero LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., Suite Riverside, CA Facility Name: Berhe Group Home, INC.FACILITY NUMBER: VISIT DATE: 08/30/2023

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

met_with: Facility Manager-Wendy Flowers


raw_content:
Narrative:
For the allegations regarding staff physically assaulted youth in care, staff allowed youth in care to be physically assaulted by another adult, and staff physically restrained youth in care. It was alleged that a STRTP staff member entered C1's room punched C1 on the back of the head and threw C1's head against the wall causing C1's earring to fall out of C1's ear. Furthermore, it was indicated that a staff allowed the staff's relative to slap and beat up C1. It was also reported that the adults at the STRTP abuse C1 by pushing C1 and verbally abuse C1. Confidential interviews denied witnessing any form of physical abuse at the STRTP to any client. Confidential interviews reported that all STRTP staff treat clients well. Other confidential interviews stated C1 was the aggressor at the STRTP. A confidential interview reported witnessing C1 get restrained by staff because C1 was being destructive. A confidential interview stated some restraints had to happen for the safety of the clients in care, but everything has been documented. One interview shared that all the allegations remain truthful with no further details. Regarding the allegations that staff used inappropriate forms of discipline and staff took youth in care to staff's personal residence, it was specified that when clients get in trouble, they are sent to Staff #1's (S1's) personal residence as punishment. It was specified that C1 was taken to S1's home to mow S1's lawn. Confidential interviews stated not hearing about C1 mowing S1's lawn as punishment. Other confidential interviews denied going to S1's residence. One confidential interview shared that the allegations are true and C1 was taken to S1's home with no further details. Based on confidential interviews, the allegations that staff physically assaulted youth in care, staff allowed youth in care to be physically assaulted by another adult, staff physically restrained youth in care, staff used inappropriate forms of discipline, and staff took youth in care to staff's personal residence may have occurred, however, it is not supported or proven by evidence. Therefore, these allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Facility Manager Wendy Flowers.

Investigation Findings:
13On August 30, 2023, at 12:48PM, Licensing Program Analyst (LPA) Adaleyci Caballero met with Berhe STRTP Facility Manager Wendy Flowers to discuss the investigative findings for the above stated allegations involving a client in the facility. On July 10, 2023, Community Care Licensing received information alleging that staff physically assaulted youth in care, staff allowed youth in care to be physically assaulted by another adult, staff physically restrained youth in care, staff used inappropriate forms of discipline, and staff took youth in care to staff's personal residence. On July 10, 2023, at 12:15PM, LPA Caballero initiated the investigation at the facility and a safety inspection was conducted. There were no immediate hazards observed. During the visit, LPA interviewed two staff and four clients. During the investigation, LPA interviewed Client #1(C1). County Social Worker was not interviewed. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Adaleyci Caballero LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., Suite Riverside, CA Facility Name: Berhe Group Home, INC.FACILITY NUMBER: VISIT DATE: 08/30/2023

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


raw_content:
Narrative:
Community Care Licensing received information on October 11, 2023, alleging that staff did not provide adequate supervision, resulting in youths engaging in inappropriate sexual activities. It was specified that client #1(C1) and another client were observed in the garage with their pants down. It was specifically stated that C1 had an erected penis but refused to answer any more questions. A confidential interview reported that C1 and client #2 (C2) were observed in the garage by themselves by Staff #2(S2). The same interview indicated that S2 was preparing the kitchen table for dinner when C1 and C2 snuck out of the common area to go to the garage. A confidential interview stated the therapist staff #3(S3) was at the STRTP doing therapy sessions and at one point was sitting with the clients in the common area; however, S3 stepped out. One interview indicated that S2 assumed S3 and Staff #4(S4). were keeping an eye on the clients. Another confidential interview reported S3 was in the office doing therapy sessions with clients not in the common area. One confidential interview indicated having concerns on the care and supervision from the STRTP after this alleged incident. Other confidential interviews stated C1 and C2 were not observed naked or with an erected penis. Additional interviews reported that there were no witnesses to this alleged incident. Based on confidential interviews, the allegation that staff did not provide adequate supervision, resulting in youth engaging in inappropriate sexual activities in the premises may have occurred, however, there was not a preponderance of evidence to support or deny this allegation. Therefore, this allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Facility Manager Wendy Flowers via email.

Investigation Findings:
13On January 12, 2024, at 9:20AM, Licensing Program Analyst (LPA) Adaleyci Caballero met with Berhe Group Home Inc. Facility Manager Wendy Flowers to discuss the investigative finding for the above stated allegation involving clients in care. LPA began the investigation at the facility on October 18, 2023, at 8:40AM and interviewed one member of staff. During the investigation, LPA interviewed four out of six clients and four staff. County Social Worker was interviewed. Clients #1 and #2 refused an interview. LPA reviewed an incident report from clients' files. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Adaleyci Caballero LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., Suite Riverside, CA Facility Name: Berhe Group Home, INC.FACILITY NUMBER: VISIT DATE: 01/12/2024

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


raw_content:
Narrative:
facility, however confidential interviews were unable to confirm or dispute the inappropriate behaviors occurred between C1 and S1. Based on record review and confidential interviews the allegation alleging staff (S1) sexually abused minor (C1) in care, may or may not have occurred, however it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of the report was provided along with appeal rights Berhe Goup Home Inc., Senior Facility Manager, Wendy Flowers,

Investigation Findings:
13On May 3, 2024 at 1:31pm Licensing Program Analyst (LPA), Nicole Strickland met with Berhe Group Home Inc., Senior Facility Manager, Wendy Flowers, to deliver the finding(s) for the above stated allegation. The investigation was conducted by Special Investigator (SI) Oliva Spindola and LPAs C. Urena and N. Strickland and included interviews with Staff #1 (S1), Child #1 (C1), and County Social Worker (CSW). In addition, county records and facility records were reviewed. On December 18, 2023, Community Care Licensing (CCL) received an allegation alleging staff (S1) sexually abused minor (C1) in care. Specifically, it was reported that on an unknown date S1 touched C1 all over C1's body. Confidential interviews and record review could not confirm when the alleged assault occurred. In addition, confidential interviews revealed conflicting statements. Confidential interviews and record review were able to confirm C1 had sexualized behaviors and at times would be inappropriate with others at the UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Nicole Strickland 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 19-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 Orange, CA Facility Name: Berhe Group Home, INC.FACILITY NUMBER: VISIT DATE: 05/03/2024

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

met_with: Facility Manager, Wendy Flowers


summary: Facility Evaluation

raw_content:
Narrative:
On December 15, 2022, Licensing Program Analysts (LPAs) Michael Almaraz and Jose Gonzalez conducted an unannounced Annual Inspection of the facility. At 9: AM, the facility was inspected inside and out with Wendy Flowers, Facility Manager. The home is a one-story residence with three bedrooms and two bathrooms. Three clients were present at time of inspection. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. The bathrooms were clean and in good repair. The temperatures in rooms that clients occupy are maintained between 68 and 85 degrees (F). The hot water temperature was tested and noted to be 115 degrees. All hazardous items have been properly made inaccessible to areas where clients will have access. Cleansers/chemicals are locked and stored and locked in a cabinet. Sharp knives are inaccessible and stored in a locked cabinet in the kitchen. The First Aid Kit is located in the locked upper kitchen cabinet and contains all required items. The facility's smoke detectors located in each bedroom and common areas were checked and were operable. The carbon monoxide detector located in hallway was operable. There are no guns or weapons in the facility as stated by licensee at this time. The following required posted items were observed accessible to clients: Grievance Procedures, Personal Rights, Ombudsman Poster, Visitation policies, and current menu. Clients medications were observed to be inaccessible and stored in a lock box and locked in the kitchen cabinet. LPA observed a minimum 7-day non-perishable and a 2-day perishable supply of food. There was a variety of snacks available for clients as well. The facility outside grounds was also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. Facility has no pool/bodies of water on premises. Administrator, Judy Berhe, is present at the facility a minimum of 20 hours a week, as verified by staff schedules. Staff/client ratios were verified during this inspection, and they were in accordance with the regulations. Licensee had obtained their Mental Health (MH) Certification on May 10, 2022. Facility obtained National Accreditation through CARF. Six clients (C1, C2, C3, C4, C5) and five staff records (S1, S2, S3, S4, S5) were reviewed on this date to ensure they contained all required documentation per Interim Licensing Standards. Three out of the six clients were unavailable at the time of the inspection. Facility appears to be meeting the terms and conditions of their license. Based on the facility inspection and file reviews on this date, there are no deficiencies found at this time. LPAs provided a copy of these reports, along with appeal rights, to Wendy Flowers.

met_with: Wendy Flowers


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Leslie Covarrubias on February 2, 2023 at 8: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Covarrubias met with Wendy Flowers, Facility Manager and inspected the facility inside and out. LPA reviewed five of child's records and three of staff personnel files on site at the facility. LPA reviewed five of child's psychotropic medications and medication records. LPA interviewed three of staff on site to discuss the facilities policies and procedures of operation. LPA will interview two of children currently prescribed psychotropic medication at their schools. LPA Covarrubias issued a technical violation and provided a copy of this licensing report to Wendy Flowers.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Sarah Lo on 10/24/24 at 09:00 am. The case management inspection is conducted pursuant to Health and Safety Code Section 1538.9(a)(2). During the inspection, LPA met with Aaron Ramsey, Administrator and inspected the facility inside and out. LPA reviewed two children's records on site at the facility. LPA reviewed three staff personnel files on site at the facility. LPA reviewed two child's psychotropic medications and medication records. LPA interviewed two children that is currently prescribed psychotropic medication at their school. No deficiencies are being cited at this time. LPA provided a copy of this licensing reporting and conducted an exit interview with Aaron Ramsey, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On March 6, 2025 at 9:30 am, Licensing Program Analysts (LPA's) Sarah Lo, Emina Preciado, and Raina Perez-Diaz arrived unannounced at Berhe Group Home, Inc. Short Term Residential Therapeutic Program (STRTP). The purpose of the visit was to conduct a Random Annual. LPA's were granted access to the facility and met with, Wendy Flowers, Facility Manager and Rueben Arrieta, Facility Administrator. While at the facility, LPA's reviewed client and facility records, conducted staff interviews, and conducted a physical plant inspection. The home is a one-story residence with three bedrooms and two bathrooms. The facility bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The bathrooms were clean and in good repair. The temperatures in rooms that clients occupy are maintained between 68 and 85 degrees (F). All hazardous items have been properly made inaccessible to areas where clients will have access. There is adequate indoor and outdoor activity space. Licensee maintains an adequate supply of perishable and non-perishable foods and the menus were posted. LPA's observed a minimum 7-day non-perishable and a 2-day perishable supply of food. There was a variety of snacks available for clients as well. Cleansers/chemicals are locked and stored in a locked cabinet. Sharp knives are inaccessible and stored in a locked cabinet in the kitchen. The First Aid Kit is located in the locked upper kitchen cabinet and contains all required items. The facility's smoke and carbon monoxide detectors located in each bedroom and common areas were checked and were operable. Fire extinguishers were properly charged and serviced. There are no guns or weapons in the facility as stated by licensee at this time. Clients medications were observed to be inaccessible and stored in a lock box and locked in a kitchen cabinet. * LIC 809-C* The facility outside grounds was also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. Facility has no pool/bodies of water on premises. The following required posted items were observed accessible to clients: Grievance Procedures, Personal Rights, Ombudsman Poster, Visitation policies, and current menu. The facility fees are not current with a balance of $908.00 due by 04/29/2025. The facility has an approved Mental Health Program Approval that is due to renewal on May 19th, 2025. The facility has a National Accreditation through CARF until April 30th, 2025. During the inspection LPA's reviewed five staff files, four client files, and two staff interviews. There were no clients present at the facility at the time of the inspection. Five out of five staff files contained all required documentation as required per Interim Licensing Standards. Four out of four client files reviewed contained all required documentation as required per Interim Licensing Standards. Based on observation and record review, there were no deficiencies observed at this time. Exit interview conducted and a copy of this report was provided to Facility Administrator, Rueben Arrieta.

met_with: Rueben Arrieta


facility_name: BERKELEY COTTAGE

summary: Complaint Investigation - Unsubstantiated

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

met_with: Angelica Espinoza


summary: Complaint Investigation - Substantiated - 1 deficiency - 3 allegations

raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Lidia Tinoco conducted a complaint inspection, the purpose of the inspection was to deliver the findings for the above complaint allegations and met with Angelica Espinoza. During the course of the investigation, Community Care Licensing (CCL) conducted interviews, conducted a review of records, and inspected the facility. The interviews conducted along with documents reviewed showed evidence of staff not providing adequate supervision. Type A: This poses an immediate health and safety risk to clients in care. Based on the LPA's observations, interviews and records review, the preponderance of evidence standard has been met, therefore, the above allegations are found to be substantiated. A copy of the report and Appeal Rights was provided to the agency. Facility was cited for The Interim Licensing Standard (ILS) Chapter 7. Version Articles 1 through 10. The Agency is being cited for violations of Section 87065.2(b) Personel Duties. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lidia Tinoco LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 24-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, E SHAW AVE FACILITY NAME: BERKELEY COTTAGEFACILITY NUMBER: 500305469

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Estimated Days of Completion: 0

Deficiencies:
87065.2(b): (1) Supervision, protection, and care of children at all times, individually and in groups.
(2) Assistance to each child in working with a group and in handling individual problems.
(3) Administration of discipline and setting of limits for behavior that are consistent with trauma-informed care standards.
(4) Notation of the child's progress; identification of the possible need for additional professional services; and communication of such findings to professional staff...

complaint_status: SUBSTANTIATED

title: Personnel Duties. Direct care staff shall perform the following duties


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

met_with: Dawn Lee


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


summary: Facility Evaluation

raw_content:
Narrative:
On this date, Licensing Program Analyst (LPA) Lidia Tinoco traveled to the Creative Alternatives Main Office in Merced and conducted an unannounced Case Management for the Berkeley Cottage and met with Director Brandi Boehme. The purpose of the inspection is to discuss multiple incident reports regarding medication errors by Staff. LPA Tinoco reviewed incident reports from the Berkeley Cottage facility. It was discovered that there have been 1 medication errors due to staff for this facility (See LIC812 for details) in 2021. This Facility is currently not operating. LPA Tinoco discussed with Director Brandi the concerns with the amount of incident reports regarding medication errors being received, LPA also addressed what the licensee has been done at the agency level to prevent this from happening, and what the ongoing plans are moving forward to minimize these incidents. Director Brandi stated that a company wide training on administration of medication. An exit interview was conducted, and a copy of the report and appeal rights were provided to the facility.

met_with: Brandi Boehme


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by LPA (Licensing Program Analyst) Lidia Tinoco on at Berkeley Cottage. LPA met with Brandi Boehme and inspected the facility, inside and out. Currently the facility is inactive and has been inactive since March 2021. All facility smoke detectors were tested and appear to be in appropriate working order, fire extinguisher is properly charged. The facility currently keeps their food supply at an off site warehouse where they store non-perishables, fresh foods, and dairy that would be ready to be transported to the home would they choose to become active again. Individual beds were observed with appropriate clean linens and are in good repair. The facility is maintained at 72 degrees. No bodies of water were observed. No firearms or weapons are allowed in the facility. Licensee has obtained Mental Health Certification Including the following: Mental Health Program Approval valid through 9/24/21, Medi-Cal site certification issued on January 1, 2019 and a county contract through June 30, 2022. Licensee has obtained National Accreditation through CARF. The Accreditation is valid through September 30, 2023. Due to the facility being inactive no records of personnel/ staff members were reviewed and no records of clients were reviewed. There were no deficiencies to be cited on this date. A copy of this report was left with Brandi Boehme


summary: Facility Evaluation

raw_content:
Narrative:
On this date, Licensing Program Analyst (LPA) Lidia Tinoco traveled to the Creative Alternatives Main Office in Merced and conducted a Case Management for the Berkeley Cottage and met with Director Brandi Boheme and Administrators Monica Alexander, Aaron Holloway and Dawn Lee. The purpose of the inspection is to discuss multiple incident reports regarding medication errors by Staff for 2022. LPA Tinoco reviewed incident reports from the Berkeley Cottage facility. It was discovered that there have been 4 medication errors due to staff for this facility (See LIC812 for details) in 2022. LPA Tinoco discussed with Director Brandi the concerns with the amount of incident reports regarding medication errors being received, LPA also addressed what the licensee has been done at the agency level to prevent this from happening, and what the ongoing plans are moving forward to minimize these incidents. Director Boehme also noted that starting April 1, 2022 the Facility Administrators are in charge of Medication Reconciliation which will help with supervision of medications. A plan to provide a Medication training to the facility is ongoing. No Deficiencies were cited. An exit interview was conducted, and a copy of the report and appeal rights were provided to the facility.

met_with: Brandi Boehme, Monica Alexander, Aaron Holloway, Dawn Lee


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA) Lidia Tinoco traveled to the Berkeley Cottage STRTP in Turlock, California for the purpose of conducting an unannounced Annual Inspection. LPA met with Administrator Dawn Lee and inspected the facility, inside and out. A physical plant inspection was completed and included the following checks. Facility grounds are clean and free of debris. Adequate indoor and outdoor activity space and materials observed. The facility is maintained at 68 degrees. All facility smoke detectors and carbon monoxide detectors are in appropriate working order. While conducting an audit of the food, LPA found expired perishable and non-perishable food. Facility keeps a two day supply of perishable foods and a two week supply of non-perishable foods. The facility has enough adequate food to meet the needs of the children. All required forms are posted. Facility has the ability to keep medications locked and centrally stored. Individual beds were observed with appropriate clean linens and are in good repair. Licensee has obtained Mental Health Certification Including the following: The Facility is currently holds a mental health program approval valid through September 24, 2022. Licensee has obtained National Accreditation through CARF valid through September 30, 2023. The facility has a county contract valid through June 30, 2022. No firearms or weapons are allowed in the facility. One type A and One type B deficiency were cited.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA) Lidia Tinoco traveled to the Berkeley Cottage STRTP in Turlock, California for the purpose of conducting an unannounced Annual Inspection, LPA met with Angelica Espinoza. LPA reviewed Client files and conducted a walk through of the facility. LPA provided Angelica with letters clearing the POC for the deficiencies issued on 5/13/22. No Deficiencies were observed or cited on today's visit. A copy of this report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco traveled to the Creative Alternatives Main office in Turlock and met with Dawn Lee and Program Director Brandi Boehme for the purpose of conducting an annual inspection. LPA reviewed 10 staff files. No deficiencies were cited on todays visit. A copy of this report was left at the conclusion of the inspection.

met_with: Dawn Lee, Brandi Boehme


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Tamara Melikian and Briana Placencia on June 18, 2024 at 9:30AM. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPAs met with Monica Alexander, Administrator and inspected the facility inside and out. Administrator Dawn Lee was on vacation and unavailable at this time. LPA reviewed 4 child's records and 2 staff personnel files on site at the facility. LPA reviewed 4 child's psychotropic medications and medication records. LPA interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPA interviewed no children currently psychotropic medication as they all refused at this time. LPAs will re-attempt interview with children at a later time. LPA provided a copy of the licensing report to Administrator, Monica Alexander. No deficiencies are being cited at this time. LPA conducted exit interview with Monica Alexander, Administrator.

met_with: Monica Alexander


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco arrived at the Creative Alternatives main office in Turlock for the purpose of Starting the Annual inspection for Berkeley Cottage STRTP. LPA Tinoco met with Administrator, Dawn Lee. LPA reviewed 5 staff files (see LIC Confidential Names List). Administrator, Dawn Lee is present at the facility a minimum of 20 hours a week. Appropriate staff/client ratios were verified during this inspection. The facility employs Social Worker, 2 facility Supervisors and 13 direct care staff. Licensee has obtained Mental Health Certification Including the following: Mental Health Program Approval valid through September 24, 2024. Licensee has obtained National Accreditation through CARF. The Accreditation is valid through September 30, 2026. Interviews will be conducted at a later time. An Annual continuation will be required to complete this annual inspection. A follow-up visit will be conducted at a later time. No deficiencies were observed or cited on this date. This report was discussed and a copy was provided at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco arrived at the Berkeley Cottage STRTP for the purpose of continuing the Annual inspection. LPA met with Administrator, Dawn Lee and inspected the facility, inside and out. Centrally stored medications are maintained in a locked cabinet. Sharps and Toxic chemicals are kept locked. The facility has a written emergency disaster plan and provided a copy to LPA. All facility smoke detectors were tested and appear to be in appropriate working order, fire extinguisher is properly charged. A fire department inspection was conducted on 1/26/24 and marked as passed as verified by documentation reviewed. Individual beds were observed with appropriate clean linens and are in good repair. There is at least one-week supply of nonperishable and a two-day supply of perishable foods. No firearms or weapons are allowed in the facility. 2 records of clients were reviewed (See LIC Confidential Names List). One Technical Violation was discussed on today's date for Buildings and Grounds. LPA Tinoco was informed that one of the bathrooms is currently receiving maintenance. Another bathroom is available for use within the home and meets regulatory requirements. Client interviews will be conducted at a later time. A copy of this report along with appeal rights was provided at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA) Lidia Tinoco traveled to the Berkeley Cottage STRTP in Turlock, California for the purpose of conducting an unannounced Annual Inspection. LPA met with Administrator, Dawn Lee and inspected the facility, inside and out. A physical plant inspection was completed and included the following checks. Facility grounds are clean and free of debris. Adequate indoor and outdoor activity space and materials observed. The facility is maintained at 75 degrees. All facility smoke detectors and carbon monoxide detectors are in appropriate working order. Facility keeps some canned foods and non-perishables in the home, there is no perishable food in the house at this time but has access to a full pantry located at Berkeley Lodge where they can stock the facility should they chose to open the house again. All required forms are posted. Facility has the ability to keep medications locked and centrally stored. Individual beds were observed with appropriate clean linens and are in good repair. Licensee has obtained Mental Health Certification Including the following: The Facility has the Mental Health Certification valid through September 25, 2025. Licensee has obtained National Accreditation through CARF valid through September 30, 2026. No firearms or weapons are allowed in the facility. Facility appears to be meeting the terms and conditions of their license. Currently the facility is inactive, and has been inactive since October 2024, therefore no children or staff are in placement, one staff file was reviewed for the Administrator. No Deficiencies were cited on today's visit. A copy of this report was left with Dawn Lee.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analysts (LPA's), Lidia Tinoco and Briana Placencia traveled to Creative Alternatives in Turlock for the purpose of conducting an unannounced Case Management and met with Administrator Dawn Lee. LPA's informed Administrator that during interviews on 6/28/ LPA's were informed of inappropriate comments made by a staff person towards the youth in the home. LPA's also discussed staff Cell Phone usage. Administrator informed LPA that the comments reported are not like the staff and will communicate with the facility supervisor and follow-up on the incident. Facility is being cited from the Interim Licensing Standards Version Chapter 7. Section 87072(a)(11) Personal Rights. A copy of this report was left at the facility at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analysts (LPAs), Lidia Tinoco and Reyna Martinez traveled to the Creative Alternatives Main office in Turlock for the purpose of conducting a Case Management and met with Mental Health Director, Joni Green. On September 21, LPA Tinoco was informed that a grievance was submitted to the mental health department of Creative Alternatives by a client at the Berkeley Cottage Facility against a staff member. Joni Green conducted an internal investigation which found the steps taken during the incident to be appropriate forms of intervention by the staff based on the Mental Health portion of the intervention. However, based on the information provided, LPA's determined that although the proper steps were taken, the hold performed by staff was inappropriate. Therefore the facility is being cited on the Interim Licensing Standards section 87095.01(b) Emergency Interventions Prohibition. A copy of this report was provided at the end of the inspection.

met_with: Joni Green


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Melikian on April 28, 2023 at 9:00AM. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPA met with Dawn Lee, Administrator and inspected the facility inside and out. LPA reviewed 3 child's records and 2 staff personnel files on site at the facility. LPA reviewed 3 child's psychotropic medications and medication records. LPA interviewed 1 staff on site to discuss the facilities policies and procedures of operation. The other staff was unable to be interviewed at this time. LPA interviewed one child on site currently taking psychotropic medication. The other children were at school and will be interviewed at a later time. LPA provided a copy of the licensing report to Administrator, Dawn Lee. During the inspection, LPA observed deficiencies (see LIC809D), plan of corrections were discussed and appeal rights were provided.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco traveled to the Berkeley Cottage Facility for the purpose of conducting a Case Management regarding an incident reported on 5/1/23. LPA Tinoco met with Angelica Espinoza, Facility Supervisor and Dawn Lee, Administrator. On 5/1/23 an incident was reported to the department regarding a staff violating a youths personal rights. Supporting documentation was received on 5/4/23 regarding the incident which proved the youths personal rights were violated. The staff in question was provided with a retraining and proof of training was provided to LPA Tinoco on 5/8/23. A type A deficiency was issued on today's visit and cleared on the same date. A copy of this report was provided at the conclusion of the inspection.

met_with: Angelica Espinoza, Dawn Lee


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco traveled to Berkeley Cottage for the purpose of conducting a Case Management regarding an incident that occurred 5/28/23. The incident consisted of a staff witnessing another staff speak inappropriately to the youth in care. Per an internal investigation the allegations were substantiated. Staff was removed from the schedule on 5/30/23 and received a suspension effective 5/31/23. The results of the findings were delivered to the staff 6/2/23 and staff received a counseling form. A Personal rights training was scheduled for 6/5/23. Facility was cited for the Interim Licensing Standards (ILS) 87072(c)(11) Personal Rights. A copy of this report was provided at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco met with Administrator, Dawn Lee for the purpose of conducting a Case Management inspection. LPA Tinoco discussed with Dawn an incident that occurred and was reported on 2/16/24. LPA was provided with records of training and the internal investigation. Agency is being Cited for Personal Rights. A copy of this report was provided along with appeal rights.


summary: Facility Evaluation

raw_content:
Narrative:
On March 13, 2024, Licensing Program Analyst (LPA) Lidia Tinoco met with Administrator, Dawn Lee and Program Director, Brandi Boehme for the purpose of conducting a Case Management. The purpose of the inspection is to discuss incidents dated 2/21/24, 2/24/24 and 2/25/24 that indicated medication errors made by staff. LPA Tinoco reviewed incident reports from the Berkeley Cottage Facility (See LIC812 for details). LPA Tinoco discussed with Administrator the incidents. LPA highlighted the importance of keeping track of the medications. Administrator stated that the plan moving forward is that there will be one person assigned as the lead staff to administer medications, and there will be a secondary staff that will do medication checks once medications have been distributed. Administrator also conducts random medication checks. This new process was started on Monday, March 26, 2024. The agency will bring on a nurse that will begin conducting audits and meeting with small groups of staff for a period of time to potentially reduce the errors. As a result of the incidents mentioned above, The Agency is being cited for the Interim Licensing Standards Section 87075(c) Health Related Services. An exit interview was conducted, and a copy of the report and appeal rights were provided to the facility.


facility_name: BERKELEY LODGE

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Lidia Tinoco conducted an unannounced visit to the Creative Alternatives main office in Merced in order to deliver the findings of the above allegations regarding the Berkeley Lodge and met with Director Brandi Boehme. During the course of the investigation, Community Care Licensing (CCL) conducted interviews with facility staff and foster youth as well as conducted a review of records. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation occurred. Therefore, the allegation that the group home staff did not provide appropriate supervision resulting in inappropriate interactions is UNSUBSTANTIATED at this time. LPA Tinoco conducted exit interview with Brandi Boehme. A copy of this report was provided to the Facility Representative. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lidia Tinoco LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2


raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA), Lidia Tinoco conducted a complaint inspection, the purpose of the inspection was to deliver the findings for the above complaint allegations. LPA met with Program Director Brandi Boehme. The above allegations were referred to Community Care Licensing for investigation. The investigation included an inspection of the facility, interviews and a review of facility and foster children's records. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation occurred. Therefore, the allegations are UNSUBSTANTIATED at this time. A copy of this report was discussed and provided along with appeal rights. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lidia Tinoco LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, E SHAW AVE This is an official report of an unannounced visit/investigation of a complaint received in our office on 09/29/2022 and conducted by Evaluator Lidia Tinoco PUBLICCOMPLAINT CONTROL NUMBER: 24-CR- FACILITY NAME:BERKELEY LODGEFACILITY NUMBER: ADMINISTRATOR:ALEXANDER, MONICAFACILITY TYPE: ADDRESS: N. BERKELEY AVENUETELEPHONE: (209) 667- CITY:TURLOCKSTATE: CAZIP CODE: CAPACITY:8CENSUS: 8DATE: 12/22/ UNANNOUNCEDTIME BEGAN: 02: PM MET WITH:Brandi BoehmeTIME COMPLETED:02: PM 9Staff Inappropriately Restrain the Children Facility is in Disrepair INVESTIGATION FINDINGS: 13On the above date, Licensing Program Analyst (LPA), Lidia Tinoco conducted a complaint inspection, the purpose of the inspection was to deliver the findings for the above complaint allegations. LPA met with Program Director Brandi Boehme. During the course of the investigation, Community Care Licensing (CCL) conducted interviews, as well as conducted a review of records and a facility inspection. The information obtained during the investigation showed a prepoderance of evidence to prove the allegations occured. This poses an immediate health and safety risk to clients in care. Facility was cited for the California Code of Regulations (CCR) 80087(a) Buildings and Grounds and Intermim Licensing Standards (ILS) 87095.65(f) Emergency Intervention Staff Training. A copy of the report and Appeal Rights was provided to the agency. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lidia Tinoco LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 2 of Control Number 24-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, E SHAW AVE FACILITY NAME: BERKELEY LODGEFACILITY NUMBER: 500308363


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Investigation Findings:
13On the above date, Licensing Program Analyst (LPA), Lidia Tinoco conducted an unannounced visit to the Berkeley Lodge STRTP in order to deliver the findings of the above allegations and met with Administrator, Monica Alexander. On 04/29/2024, the above allegations were referred to Community Care Licensing for investigation. The investigation included an inspection of the Facility, confidential interviews, and review of records. Based on the investigation conducted the department found that there was conflicting information regarding these issues. Although the allegations may have happened of are valid, there is not a preponderance of evidence to prove the allegations occurred. Therefore, the allegations are Unsubstantiated at this time. A copy of this report was provided at the conclusion of the inspection along with appeal rights. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lidia Tinoco LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


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Investigation Findings:
13On the above date, Licensing Program Analyst (LPA), Lidia Tinoco conducted an unannounced visit to the Berkeley Lodge STRTP in order to deliver the findings of the above allegations and met with Administrator, Monica Alexander. On 05/17/2024, the above allegations were referred to Community Care Licensing for investigation. The investigation included an inspection of the Facility, confidential interviews, and review of records. Based on the investigation conducted the department found that there was conflicting information regarding these issues. Although the allegations may have happened of are valid, there is not a preponderance of evidence to prove the allegations occurred. Therefore, the allegations are Unsubstantiated at this time. A copy of this report was provided at the conclusion of the inspection along with appeal rights. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lidia Tinoco LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


summary: Complaint Investigation - Substantiated

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Investigation Findings:
13On the above date, Licensing Program Analyst (LPA), Lidia Tinoco conducted an unannounced visit to the Berkeley Lodge STRTP in order to deliver the findings of the above allegations and met with Administrator, Monica Alexander. On 6/27/24, the above allegations were referred to Community Care Licensing for investigation. The investigation included an inspection of the Facility, confidential interviews, and review of records. Based on the information obtained, there is a preponderance of the evidence to prove the above allegations occurred therefore these allegations are Substantiated. The Facility was cited for ILS, Version 5, Section 87095.00(c). See LIC9099D. Plans of Corrections were reviewed and developed with Monica Alexander. A copy of this report and appeal rights were provided at the conclusion of the inspection. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lidia Tinoco LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FRESNO RO, E SHAW AVE FACILITY NAME: BERKELEY LODGEFACILITY NUMBER: 500308363


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Investigation Findings:
13On the above date, Licensing Program Analyst (LPA), Lidia Tinoco arrived at the Berkeley Lodge STRTP and met with Administrator, Monica Alexander for the purpose of delivering the findings of the investigation. On 08/01/2024, the above allegations were referred to Community Care Licensing for investigation. The investigation included an inspection of the Facility, confidential interviews, and review of records. Based on the investigation conducted the department found that there was conflicting information regarding these issues. Although the allegations may have happened of are valid, there is not a preponderance of evidence to prove the allegations occurred. Therefore, the allegations are Unsubstantiated at this time. A copy of this report was provided at the conclusion of the inspection along with appeal rights. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lidia Tinoco LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


summary: Complaint Investigation - Substantiated

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Investigation Findings:
13On the above date, Licensing Program Analyst (LPA), Lidia Tinoco conducted an unannounced visit to the Berkeley Lodge in order to deliver the findings of the above allegations and met with Administrator, Monica Alexander. On December 09, 2024, the above allegations were referred to Community Care Licensing for investigation. The investigation included an inspection of the Facility, confidential interviews, and review of records. Based on the information obtained, there is a preponderance of the evidence to prove the above allegations occurred therefore these allegations are Substantiated. The Facility was cited for ILS, Version 5, Section 87095. Emergency Interventions Prohibition. See LIC9099D. Plans of Corrections were reviewed and developed with Monica Alexander. Proof of correction documents were provided to LPA Tinoco on this date and the deficiencies were cleared. A copy of this report and appeal rights were provided at the conclusion of the inspection. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lidia Tinoco LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FRESNO RO, E SHAW AVE FACILITY NAME: BERKELEY LODGEFACILITY NUMBER: 500308363


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Investigation Findings:
13On the above date, Licensing Program Analyst (LPA), Lidia Tinoco conducted an unannounced visit to the Berkeley Lodge STRTP in order to deliver the findings of the above allegations and met with Administrator, Monica Alexander. The above allegations were referred to Community Care Licensing for investigation. The investigation included an inspection of the Facility, confidential interviews, and review of records. Based on the investigation conducted the department found that there was conflicting information regarding these issues. Although the allegations may have happened of are valid, there is not a preponderance of evidence to prove the allegations occurred. Therefore, the allegations are Unsubstantiated at this time. A copy of this report was provided at the conclusion of the inspection along with appeal rights. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lidia Tinoco LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


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Investigation Findings:
13Licensing Program Analyst (LPA) Lidia Tinoco conducted an unannounced visit and met with Program Director Brandi Boehme in order to deliver the findings of the above allegations regarding the Berkeley Lodge. During the course of the investigation, Community Care Licensing (CCL) conducted interviews as well as conducted a review of children's records. Based on the interviews, inspection and documents reviewed, there is not sufficient evidence to prove the allegations occurred. These allegations are deemed Unsubstantiated at this time. LPA Tinoco conducted exit interview with Brandi Boehme. A copy of this report was provided to the Facility Representative. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lidia Tinoco LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 2 of 4


summary: Complaint Investigation - Substantiated - 1 allegation

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Investigation Findings:
13Licensing Program Analyst (LPA) Lidia Tinoco conducted an unannounced visit and met with Program Director Brandi Boehme in order to deliver the findings of the above allegations regarding the Berkeley Lodge. On July 9, 2021 the above allegations were referred to Community Care Licensing for investigation. The investigation included an inspection of the Home, interviews and review of Children's records. The complaint alleged that facility staff interacted inappropriately with a minor in care. Based on the interviews conducted it was determined that Staff provided personal contact information, such as cellphone numbers, social media handles and emails to the minor upon his exit of the facility and had telephone contact with the minor after the minor's exit from the program. Based on the information obtained, there is a preponderance of the evidence to prove the above allegations ocurred therefore these allegations are substantiated. Type A: This poses an immediate health and safety risk to clients in care. Facility was cited for The Interim Licensing Standard (ILS) Chapter 8. Version Article 9. The Agency is being cited for violations of Section 87072.1(d)(10) Personal Rights. A copy of the report and Appeal Rights was provided to the FFA. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lidia Tinoco LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 3 of Control Number 24-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, E SHAW AVE FACILITY NAME: BERKELEY LODGEFACILITY NUMBER: 500308363

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


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Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Lidia Tinoco conducted an unannounced visit to the Berkeley Lodge STRTP in order to deliver the findings of the above allegations and met with Monica Alexander. On December 1, 2022 the above allegations were referred to Community Care Licensing for investigation. LPA Tinoco and Investigator Mariana Lomeli conducted the investigation which included interviews, review of facility and foster children's records. Based on the interviews, inspection and documents reviewed, there is not sufficient evidence to prove the allegation occurred. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation occurred. Therefore, the allegations are UNSUBSTANTIATED at this time. A copy of this report was discussed and provided to Monica Alexander along with appeal rights. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lidia Tinoco LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 2 of 2


summary: Facility Evaluation

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Narrative:
On 04/14/2021, an unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Eduardo Barragan at 1: PM. During the inspection, LPA met with Melissa, Facility Supervisor and inspected the facility inside and out. Due to restrictions of COVID-19, this inspection was conducted via FaceTime. LPA reviewed 3 client's records LPA reviewed 2 staff personal file's LPA interviewed 0 clients taking psychotropic medications LPA interviewed 2 staff on-site No deficiencies to be cited at this time. LPA conducted exit interview with , Facility Supervisor at PM. A copy of this report was provided upon completion by email with a request for signature and a scan back to this LPA on this date.

met_with: Melissa Mazuelos


summary: Facility Evaluation

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Narrative:
On this date, Licensing Program Analyst (LPA) Lidia Tinoco traveled to the Creative Alternatives Main Office in Merced and conducted an unannounced Case Management for the Berkeley Lodge and met with Director Brandi Boheme. The purpose of the inspection is to discuss multiple incident reports regarding medication errors by Staff. LPA Tinoco reviewed incident reports from the Berkeley Lodge facility. It was discovered that there have been 3 medication errors due to staff for this facility (See LIC812 for details) in 2021. LPA Tinoco discussed with Director Brandi the concerns with the amount of incident reports regarding medication errors being received, LPA also addressed what the licensee has been done at the agency level to prevent this from happening, and what the ongoing plans are moving forward to minimize these incidents. Director Brandi stated that a company wide training on administration of medication. An exit interview was conducted, and a copy of the report and appeal rights were provided to the facility.


summary: Facility Evaluation

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Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco traveled to the Creative Alternatives Main office and met with Dawn Lee. The purpose of the visit was to discuss an incident reported on 9/3/2021 to the department full report received on 9/8/2021. Details of the conversation and incident are documented on an LIC812. The county investigation is pending. The agency will provide LPA with updates as they become available. A copy of this report was left with Dawn Lee.


summary: Facility Evaluation

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Narrative:
On the above date, Licensing Program Analyst (LPA), Cynthia Galindo traveled to the Creative Alternatives main office in order to initiate the annual inspection for Berkeley Lodge STRTP. LPA met with Program Director, Brandi Boehme. Licensee has obtained Mental Health Certification Including the following: Mental Health Program Approval valid through September 24, 2021, a review was conducted on August 16-23, 2021 and have not been issued. Licensee has obtained National Accreditation through CARF valid through September 30, 2023. The facility has a county contract valid through June 30, 2022. Medical Certification valid through April 26, 2022. LPA conducted 10 staff file reviews. No deficiencies were cited. A copy of this report was left with Brandi Boehme at the conclusion of inspection.


summary: Facility Evaluation

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Narrative:
An unannounced annual inspection was conducted by Licensing Program Analyst (LPA) Cynthia Galindo traveled to the Berkeley Lodge House STRTP in Turlock, California. LPA met with Administrator Milo Gandarilla-Esparza and inspected the facility, inside and out. The home is licensed to serve eight clients. Currently in placement are six clients. A physical plant inspection was completed and included the following checks. Facility grounds are clean and free of debris. Adequate indoor and outdoor activity space and materials observed. The facility is maintained at 68 degrees. All facility smoke detectors and carbon monoxide detectors are in appropriate working order. Facility maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. All required forms are posted. Medications properly stored and secured. Individual beds were observed with appropriate clean linens and are in good repair. There is adequate client furnishings. There is a body of water at the facility with a self latching gate in accordance with the interim licensing standards. No firearms or weapons are allowed in the facility. Facility appears to be meeting the terms and conditions of their license. LPA reviewed six client files; conducted two staff and six client interviews. No deficiencies were cited on today's visit. A copy of this report was left with staff.

met_with: Milo Gandarilla-Esparza


summary: Facility Evaluation

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Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco traveled to the Creative Alternatives main office in Turlock and met with Monica Alexander. LPA Tinoco and Monica Alexander discussed the COVID protocols for the facility and scheduled a Tele-Visit. The initial report was sent to CCL on 1/23/ The Official Incident report was sent to CCL on 1/24/ Results came back for the facility on 1/26/22; Staff tested positive and Child. The facility was placed on quarantine and Isolation has begun for the positive child. The positive staff have been sent home to quarantine.


summary: Facility Evaluation

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Narrative:
On the above date, Licensing Program Analysts (LPA's), Lidia Tinoco and Briana Placencia met with Administrator Monica Alexander for the purpose of conducting a Case Management regarding an incident report received by the department. On June 27, 2022 the department received an incident report regarding manual restraints. LPA's addressed with Monica the concerns related to the report. Administrator, Monica stated that on June 27, 2022 she had a conversation with staff on the new established protocols set by the facility to prevent the use of manual restraints, including but not limited to de-escalation techniques. LPA will be presented with a copy of a memo of records for the conversation with staff. A copy of this report was left with Monica Alexander.


summary: Facility Evaluation

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Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco conducted a Case Management regarding an incident report received 04/24/23 and met with Brandi Boehme. On April 22, 2023 an incident involving a restraint of a client occurred. LPA addressed the incident with Program Director Brandi. No Deficiencies were cited on today's visit. A copy of this report was provided.


summary: Facility Evaluation

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Narrative:
Complaint Specialist C.K. Kinney(CS) traveled to Berkeley Lodge and met with Dottie Sherman, Counselor 2 and Administrator Monica Alexander to conduct annual inspection. CS toured the facility and observed the facility to be in good condition, pleasant temperature, odor free, and all appropriate furnishings were observed to be in good working order. CS reviewed 7 client files, and reviewed documentation related to emergency disaster plan, Emergency Intervention logs, and Cash Resources. Administrator shall provide updated copies of LIC Personnel Report, CARF renewal certificate, copy of Board Meeting Minutes, to CS or LPA Lidia Tinoco by 12/15/2023. Copy of this report and appeal rights left at the facility at conclusion of inspection. This Annual Inspection will be concluded at a later date.

met_with: Dottie Sherman and Monica Alexander


summary: Facility Evaluation

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Narrative:
On 12/13/2023, Licensing Program Analyst (LPA) Tamara Melikian conducted an unannounced case management inspection to continue the annual inspection to inspect the staff files and conduct interviews. Met by Administrator Monica Alexander. At 10:30AM, staff files and training were inspected. At 11:30AM, staff interviews were conducted. At 12:15PM, client interviews were conducted. One other client was at school and the interview will be conducted at a later time. There are no deficiencies to be cited on this date. A copy of this report is left with Administrator Monica Alexander on this date.


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Reyna Martinez on May 16, 2024 at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPA met with Monica Alexander, Administrator and inspected the facility inside and out. LPA reviewed 4 child's records and 2 staff personnel files on site at the facility. LPA reviewed 4 child's psychotropic medications and medication records. LPA interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPA interviewed 3 children currently on psychotropic medication on site and was unable to interview 1 child as they were in school at this time. LPA will attempt interview with 1 child at a later time. LPA provided a copy of the licensing report to Administrator, Monica Alexander. No deficiencies are being cited at this time. LPA conducted exit interview with Monica Alexander, Administrator.


summary: Facility Evaluation

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Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco met with Program Director, Brandi Boehme and Administrator, Dawn Lee for the purpose of conducting an Annual Inspection. Administrator, Monica Alexander is present at the facility a minimum of 20 hours a week. The facility employs Social Worker, 1 facility managers and 10 direct care staff. Licensee has obtained Mental Health Certification Including the following: Mental Health Program Approval valid through September 24,2024. Agency had a Mental Health Program Approval inspection the week of September 16-20, 2024 and are pending results. Licensee has obtained National Accreditation through CARF. The Accreditation is valid through September 30, 2026. 5 records of staff were reviewed. (See LIC811 confidential names list). This annual will be completed at a later date. No deficiencies were observed or cited on today's date. A copy of this report was provided at the conclusion of the inspection.

met_with: Brandi Boehme, Dawn Lee


summary: Facility Evaluation

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Narrative:
On the above date, Licensing Program Analysts (LPAs), Lidia Tinoco and Olivia Medrano arrived at the Berkeley Lodge STRTP for the purpose of continuing the Annual inspection. LPA met with Administrator, Monica Alexander and inspected the facility, inside and out. Centrally stored medications are maintained in a locked cabinet. Sharps and Toxic chemicals are kept locked. The facility has a written emergency disaster plan and provided a copy to LPA. Individual beds were observed with appropriate clean linens and are in good repair. There is at least one-week supply of nonperishable and a two-day supply of perishable foods. No firearms or weapons are allowed in the facility. 4 records of clients were reviewed (See LIC Confidential Names List). One Technical Violation and One type B Deficiency was discussed on today's date. Client and Staff interviews will be conducted at a later time. A copy of this report along with appeal rights was provided at the conclusion of the inspection.


summary: Facility Evaluation

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Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco arrived at the Berkeley Lodge STRTP and met with Administrator, Monica Alexander. LPA Tinoco observed that the door to the pool gate was repaired and the door self closes and is self latching. LPA Tinoco also attempted confidential interviews. At this time there are no deficiencies observed or cited. The Annual has been completed for this facility. A copy of this report was provided at the conclusion of the inspection.