summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On November 4, 2021, at 10:20AM, Licensing Program Analyst (LPA) Humberto Flores, conducted an unannounced Annual Inspection at BE Short Term Therapeutic Beloved Ones Residential Treatment (STRTP) and met with Cynthia Bertrand. LPA Flores stated the purpose of the inspection to the STRTP representative. During the inspection a copy of the Register of Facility Clients and Personnel Report was provided upon request. The following topics were inspected: EMERGENCY INTERVENTION PLAN: LPA Flores reviewed the Program Statement (PS) and identified the training that is provided for all staff. The staff does not receive Emergency Intervention Techniques training. The monthly restraint log does not contain record of restrains, the STRTP representative stated that no restrain has been conducted. DISASTER PREPAREDNESS PLAN: LPA Flores reviewed the disaster and mass casualty plan and other provisions by reviewing the program statement. cont.# The facility conducts monthly fire and emergency evacuation drills. Drills are documented and kept in the facility for at least one year. CLIENT RECORDS/INTERVIEWS: LPA Flores reviewed 2 children's files. The files contain record of client's admission agreement, medical assessment, consent forms, weight record, emergency information, centrally stored medication record, safeguards for property/valuables, personal rights form and cash resource information. The immunization record was in the file. The appraisal and needs and services plan of both children were not signed by the child and their county social worker. No tuberculosis test was observed. PERSONAL RIGHTS Clients are advised of their personal rights & house rules. The licensee ensure that gender identity, expression and orientation are respected and kept confidential. Clients received services, activities and support and are included in child and family teams regarding decisions about their plans. Clients can file a complaint or elevate concerns without retaliation. # CORE THERAPEUTIC SERVICES: During the inspection review, LPA Flores was informed that the STRTP is providing the core services and support to the individuals in placement. The facility ensures that the trauma informed, culturally relevant, age, and developmentally appropriate services are provided by other agencies. OPERATIONAL REQUIREMENTS: During the inspection review, LPA Flores observed the facility maintained an updated roster of the clients with pertinent information. The facility administrator and direct care staff are the responsible and capable staff for communicating with emergency personnel in the facility. The facility has developed, maintained and implemented written complaint procedures. ADMINISTRATIVE DUTTIES Facility License was posted in a prominent place. Administrator is onsite at least 20 hours per week. The Licensee ensure appropriate staff/client coverage/ratios for all required positions and in accordance with most recent LIC500. The Emergency/Disaster Plan is available and current. Licensee is reporting incidents appropriately to licensing and placement. The STRTP is submitting Law Enforcement contact documentation to licensing as per Assembly Bill 388. # Board of Directors meet at least quarterly. The facility representative was advised to include the review of licensing reports for each period. The Emergency and Intervention Protocols was discussed. The STRTP representative stated that the facility is in the process to obtain accreditation with the Commission of Accreditation of Rehabilitation Facilities (CARF) by March 2022. The facility does not have exemptions/waivers. The STRTP personnel is instructed to report violations of personal rights. The STRTP post child's rights. Children are not restricted in telephone use except by court order. The licensee ensures that children are accorded dignity in personal relationships with staff and others. Children live in a safe, healthy, comfortable facility and are treated with respect. STAFF RECORDS/INTERVIEWS: All facility staff have a criminal record clearance and child abuse index check. All file documentation is complete, signed and current for each staff. Evidence that Mandated Reporter training has been completed. Evidence of initial and annual training requirements were in the files reviewed. # A total of 2 employee files was reviewed. The files contain the following documentation: first aid certificate, Child Abuse Index Checks/Department of Justice (DOJ)/Federal Bureau of Investigation (FBI) criminal record clearances, education verification, personnel record, health screening, criminal record statement, employee rights and tuberculosis test. Personnel policies, job descriptions and training verification are included in the employee's files. No staff has been trained on Emergency Intervention Techniques/Restraints. A copy of this report, citation pages, LIC9102 and appeal rights was provided to the facility representative. Exit interview conducted.

Deficiencies:
87095.65(c): Deficient Practice Statement
1
2
3
4Based on the observation, record review and interview, the licensee did not comply with the section cited above in 9 out of 9 staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2021
Plan of Correction
1
2
3
4

met_with: Kahlee Kirk, Supervisor

title:
Emergency Intervention Staff Training

(c) The training must be provided by an individual who holds a valid instructor certificate from a program of managing assaultive behavior that is consistent with article 10 of these regulations.

This requirement is not met as evidenced by


state: CA

facility_name: BELOVED ONES

summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Jenny Mundo and Pamela Silva on April 26, 2022 at 8: AM. During the inspection, LPAs met with Thandi Smith, Executive Director. LPAs and the Executive Director inspected the facility inside and out. LPAs reviewed three (3) child's record on site at the facility at 9: AM. LPAs reviewed two (2) staff personnel files on site at the facility at 8: AM. LPAs reviewed three (3) child's psychotropic medications and medication records at 10: AM. LPAs interviewed one (1) staff on site at 10: AM. LPAs interviewed one (1) child on site at 9: AM. LPAs conducted exit interview with Ashley Maclearn, Administrator at 11: AM. LPAs provided the Summary Report to the facility representative upon completion. No citations are being issued at this time. One (1) Technical Assistance (LIC9102TA) and one (1) Technical Violation (LIC9102TV) were also issued.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Thandi Smith, Executive Director


summary: Facility Evaluation

raw_content:
Narrative:
On 09/27/22 at 9: AM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced Annual Inspection at the facility. LPA met with Cindy Bertrand, Administrator. The facility currently has a provisional Short Term Residential Therapeutic Program (STRTP) license. The STRTP's Mental Health Program Application is pending approval. This STRTP is licensed to serve up to six (6) ambulatory children ages 7-17 years of age. The facility also provides services to non-minor dependents pursuant to W&I Code 16501.1 (C)(1). There is one (1) ambulatory minor currently in placement. The facility is a single-story home located in a residential area. There are no bodies of water in the premises. At 9: AM, LPA conducted a walk-through of the entire facility. Physical Plant The license, facility sketch, Personal Rights, Emergency Disaster form, Complaints poster, Foster Youth Bill of Rights, Complaints/Grievance policy, emergency phone numbers and menus are posted in a prominent, publicly accessible location in the facility. Disinfectants, cleaning solutions and sharps are kept inaccessible in a locked closet in the hallway. Facility has non-perishable food for at least one week and perishable food for at least two days. Medications are centrally stored in a locked cabinet in the staff office. Smoke and carbon monoxide detectors were tested and in proper working order. Fire extinguishers are fully charged. Room temperatures are maintained at 76 degrees F. The hot water temperature was tested and measured at 115 degrees F. All sinks, showers and toilets were in working order. No more than 2 children share a bedroom. All beds are in good repair; equipped with good springs, clean mattresses and pillows. Adequate supply of beddings and linens were observed. Facility provides age-appropriate clothing items and hygiene products. Emergency exits are free from obstruction. During the tour, :LPA observed that there are no screens installed on all the windows. Operations Facility maintains a register of clients and the register is available upon request. The board of directors regularly conduct meetings to review and discuss the STRTP's operation. The facility has developed, maintained and implemented written complaint procedures. Emergency Intervention Documentation of emergency intervention training for staff is on file. The facility maintains a monthly restraint log which will be submitted bi-annually to the Department. Disaster Preparedness Plan Facility maintains a current, written disaster and mass casualty plan of action. Facility conducts disaster drill at least quarterly for each shift. Facility maintains an emergency and disaster plan, register of clients, Needs and Services Plan for each client, medication records, and contact information for each client's responsible party and physician. Core/Therapeutic Services Facility provides core services and supports to children and non-minor dependents as appropriate or necessary that are trauma informed, culturally relevant, age and developmentally appropriate and include the following: Medi-Cal specialty mental health services; transition support services; educational and physical, behavioral, and mental health supports; activities to support children and non-minor dependents and services to achieve permanency. Client Records LPA reviewed one (1) client record. Client records are available to the licensing agency to inspect, audit and copy upon demand. Client records contain required information including, but not limited to, consent forms, court orders, needs and services plan, medical assessment; safeguards for cash resources, personal property and valuables; education records; personal rights forms; removal/discipline/complaints form and medication administration records. Staff Records LPA reviewed three (3) staff records. All staff have been subjected to criminal records review and have been fingerprinted and cleared with DOJ, FBI and CACI. Documentation of the required education and experience requirements are maintained in the personnel file. Documentation of staff training are on file. LPA interviewed three (3) staff members. The client refused to be interviewed. One (1) Type B deficiency citation was issued during today's inspection, see LIC809D. An exit interview was conducted, and a signed copy of this report, LIC809D, LIC811 and appeal rights were provided to the facility administrator.

visit_type: Annual

met_with: Cindy Bertrand


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Juliet Robles and Pamela Silva on May 03, 2023 at 1: PM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Robles and Silva met with Thandi Smith, Director and Cindi Bertrand, Administrator and inspected the facility inside and out. LPAs reviewed two (2) of child's records and three (3) of staff personnel files on site at the facility. LPA s reviewed two (2) of child's psychotropic medications and medication records. LPA interviewed two (2) of staff on site to discuss the facilities policies and procedures of operation. LPAs were unable to interview children currently prescribed psychotropic medications due to clients were in school at the time of inspection. No deficiencies are being cited at this time. LPAs provided a copy of this licensing report and conducted exit interview with Cindi Bertrand, Administrator.

met_with: Cindi Bertrand


summary: Facility Evaluation

raw_content:
Narrative:
On 08/10/23 at 10: AM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced case management inspection at the above facility and met with the Supervising Facility Manager, Kenny Herrera. The purpose of the inspection is to follow-up on a Special Incident Report (SIR) received by the Department on 05/22/23. The SIR indicated that client C1 was taken to juvenile hall (refer to Confidential Names List LIC811 dated 08/10/23). LPA Silva conducted telephone interviews with Facility Manager (FM) Tere Paredes on 06/23/23 and with Riverside Probation Officer (PO) on 06/26/23. C1 has been running away from the facility frequently. A review of SIR indicated that C1 ran away on 05/21/23. C1 did not return to the facility and went straight to school the following day, 05/22/23. PO picked up C1 from school and was taken to juvenile hall due to running away. PO confirmed that prior to the incident, the facility has filed a 14-day removal notice for C1. Due to the 14-day notice, C1 was removed and did not return to the facility. PO did not have any concerns regarding the facility and stated that the facility did a decent job with C1 while in placement. The incident was reported to all appropriate parties. No further follow-up is needed. An exit interview was conducted. A copy of this report was provided to the facility representative

met_with: Kenny Herrera


summary: Facility Evaluation

raw_content:
Narrative:
On 09/21/2023 at 9: AM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced Annual Inspection at the facility and met with Tere Paredes, Supervising Facility Manager. This Short Term Residential Therapeutic Program (STRTP) is licensed to serve up to six (6) ambulatory children ages 7-17 years of age. The facility also provides services to non-minor dependents pursuant to W&I Code 16501.1 (C)(1). There are two (2) ambulatory minors currently in placement. The LPA requested the following: Personnel Report LIC500, Client Roster, Board of Meeting Minutes, and Clients and Staff Files. This facility is a single-story 3-bedroom home located in a residential area. There are no firearms or ammunition in the facility. At 9: AM, LPA conducted a walk-through of the entire facility. Physical Plant The license, facility sketch, Personal Rights, Emergency Disaster form, Complaints poster, Foster Youth Bill of Rights, Complaints/Grievance policy, emergency phone numbers and menus are posted in a prominent, publicly accessible location in the facility. Disinfectants, cleaning solutions and sharps are kept inaccessible in a locked closet in the hallway. Facility has non-perishable food for at least one week and perishable food for at least two days. Medications are centrally stored in a locked cabinet in the staff office. Smoke and carbon monoxide detectors were tested and in proper working order. Fire extinguishers are fully charged. Room temperatures are maintained at 76 degrees F. The hot water temperature was tested and measured at 120 degrees F. All sinks, showers and toilets were in working order. No more than 2 children share a bedroom. All beds are in good repair; equipped with good springs, clean mattresses and pillows. Adequate supply of bedding and linens were observed. Facility provides age-appropriate clothing items and hygiene products. Emergency exits are free from obstruction. Overall, facility is clean, safe, sanitary and in good repair. Operations Facility maintains a register of clients and the register is available upon request. The board of directors regularly conducts meetings to review and discuss the STRTP's operation. The facility administrator and manager are the responsible and capable staff for communicating with emergency personnel in the facility. The facility has developed, maintained and implemented written complaint procedures. Core/Therapeutic Services Facility provides core services and supports to children and non-minor dependents as appropriate or necessary that are trauma informed, culturally relevant, age and developmentally appropriate and include the following: Medi-Cal specialty mental health services; transition support services; educational and physical, behavioral, and mental health supports; activities to support children and non-minor dependents and services to achieve permanency. Disaster Preparedness Plan Facility maintains a current, written disaster and mass casualty plan of action. Facility conducts disaster drill at least quarterly for each shift. The documentation of drills are not complete with dates, signature and name of participants. Facility maintains register of clients, Needs and Services Plan for each client, medication records, and contact information for each client's responsible party and physician. Client Records LPA reviewed two (2) client records. All client records are available to the licensing agency to inspect, audit and copy upon demand. Client records contain required information including, but not limited to, consent forms, court orders, needs and services plan, safeguards for cash resources, personal property and valuables, education records, personal rights forms, and medication administration records. Signed copies of the facility's policies and procedures regarding the child's removal or transfer, discipline and complaints are not on file for both C1 and C2. Licensee has not obtained a written medical assessment for C2 within 30 calendar days following acceptance. Staff Records LPA reviewed two (2) staff records. All staff have been subjected to criminal records review and have been fingerprinted and cleared with DOJ, FBI and CACI. Documentation of the required education and experience requirements are maintained in the personnel file. Documentation of staff training are on file. LPA interviewed two (2) staff members. One (1) client was interviewed and the other client was unavailable for interview due to being at school at the time of inspection. Two (2) Type B deficiency citations and one (1) Technical Violation were issued during today's inspection, see LIC809D and LIC9102TV. An exit interview was conducted, and a signed copy of this report and appeal rights were provided to the Supervising Facility Manager.

met_with: Tere Paredes


summary: Facility Evaluation

raw_content:
Narrative:
On October 27, 2023 at 3:50 p.m., Licensing Program Analyst (LPA), Karen McGee, arrived at the facility for the purpose of conducting a Case Management. The LPA met with Facility Manager, Henry Jenkins. There was an incident in which it was revealed that when Ref. #1 was dropped off at their biological home for a family visit, that client Ref. #2 was in the car with staff. The investigation revealed that the facility was short staffed and in order to maintain Ref. #1's visit with their family, Ref. #2 had to ride along with staff. There was concern that Ref. #1's privacy may be violated. It was determined that there is no Regulation or Interim Licensing Standard that addresses this issue. It was determined to provide the facility with an Advisory Notes - Technical Assistance. Advisory Notes for Technical assistance are not tied to a violation, but provides assistance and/or best practices. (See Attached Advisory Notes- Technical Assistance.) A copy of this report was provided to the facility representative.

met_with: Henry Jenkins


summary: Facility Evaluation

raw_content:
Narrative:
On 06/25/24 at 10: AM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced case management inspection at the above facility and met with Supervising Facility Manager (SFM), Tere Paredes. The purpose of the inspection is to follow up on two (2) unusual incidents which were reported late to the Department. There were two (2) incidents that occurred on 05/11/24 that was reported late on 05/18/24, and the other one reported on 05/22/24. SFM stated during an interview that the 2 incidents were reported late due to the weekend staff's failure to submit the report the following weekday as she reports to work only on the weekends. SFM stated that the weekend staff was already trained and has been reminded on Reporting Requirements. SFM will ensure that all unusual incidents will be reported timely to the Department. A Technical Violation (TV) on Title Division Chapter Article 6, 80061(b)(1)( E) Reporting Requirements was issued , see LIC9102TV. Exit interview conducted. A copy of this report was provided to Ms. Paredes.


summary: Facility Evaluation

raw_content:
Narrative:
On 07/08/24 at 10: AM, an in-person office meeting was held at the Monterey Park Regional Office (MPRO) attended by Licensing Program Analyst (LPA) Pamela Silva, Beloved Ones' Director/Administrator Thandi Smith and Licensing Program Manager (LPM) Tira Logan-Shanks. The purpose of the meeting was to discuss the following: Administrators Mr. Smith has submitted five (5) administrator documents for their seven (7) California City facilities. Per LPA review, only one (1) candidate met STRTP administrator qualifications. Mr. Smith explained their challenges and difficulty in finding qualified administrators due to their facilities' location. Mr. Smith will submit a letter requesting for administrator exception and a documentation of the efforts the facility has taken in finding qualified administrators. Mr. Smith will also re-submit administrator documents with updated proof of education and experiences. Capacity Reduction Mr. Smith requested clarity on the need to reduce their capacity from 6 to 4, on some of their facilities. Some of their 6-bed facilities have converted the 3rd room into their mental health/staff office, leaving 2 rooms to accommodate 4 clients. Mr. Smith explained that they can easily convert the office back to another bedroom to accommodate a maximum of 6 should the need arises, as they have the beddings and furniture in storage readily available for use. Mr. Smith stated that capacity/bed reduction at this time will affect their mental health contract with the county. LPM will discuss this issue with the MPRO Regional Manager. Update to the Program Statement The facility is currently updating their Program Statement based on STRTP ILS Version 5. Mr. Smith asked if their STRTP for 1 or 2 program should be attached to the Program Statement as an addendum. LPM will consult with RM on this issue. Other matters were also discussed like Mental Health Renewal status and suggestions as to what the facility can do regarding property damages caused by clients. The meeting ended at 11: AM. A copy of this report was provided to Mr. Smith.

visit_type: Renewal

met_with: Thandi Smith


summary: Facility Evaluation

raw_content:
Narrative:
On October 16, 2025 at 9: AM, Licensing Program Analysts (LPAs) Pamela Silva and Juliet Robles conducted an unannounced Annual Random Inspection at the facility and met with Administrator, Tere Paredes. This Short Term Residential Therapeutic Program (STRTP) is licensed to serve up to two (2) ambulatory children ages 7-17 years of age. The facility also provides services to non-minor dependents pursuant to W&I Code 16501.1 (C)(1). There is no child currently in placement during the time of inspection. The LPAs requested the following: Personnel Report LIC500, Client Roster, Board of Meeting Minutes and Staff Files. This facility is a single-story 2-bedroom home located in a residential area. There are no firearms or ammunition in the facility. At 10: AM, LPA conducted a walk-through of the entire facility. Physical Plant The license, facility sketch, Personal Rights, Emergency Disaster form, Complaints poster, Foster Youth Bill of Rights, Complaints/Grievance policy, and emergency phone numbers are posted in a prominent, publicly accessible location in the facility. Disinfectants, cleaning solutions and sharps are kept inaccessible in a locked closet in the hallway. The facility has non-perishable food for at least one week. Medications are centrally stored in a locked cabinet in the staff office. Smoke and carbon monoxide detectors were tested and in proper working order. Fire extinguishers are fully charged. Room temperatures are maintained at 76 degrees F. The hot water temperature was tested and measured at 105 degrees F. All sinks, showers and toilets were in working order. All beds are in good repair; equipped with good springs, clean mattresses and pillows. Adequate supply of bedding and linens were observed. Emergency exits are free from obstruction. Overall, the facility is clean, safe, sanitary and in good repair. Operations Facility maintains a register of clients and the register is available upon request. The facility administrator and manager are the responsible staff for communicating with emergency personnel in the facility. The facility has developed, maintained and implemented written complaint procedures. Core/Therapeutic Services Facility provides core services and support to children and non-minor dependents as appropriate or necessary that are trauma informed, culturally relevant, and age and developmentally appropriate. Emergency Intervention Facility staff are trained in emergency intervention techniques. The facility maintains a monthly log of each use of manual restraints. Disaster Preparedness Plan Facility maintains a current, written disaster and mass casualty plan of action. Facility conducts disaster drills at least quarterly for each shift. Staff Records LPAs reviewed three (3) staff records. All staff have been subjected to criminal records review and have been fingerprinted and cleared with DOJ, FBI and CACI. Documentation of the required education and experience requirements are maintained in the personnel file. Documentation of staff training are on file. LPA Silva interviewed the Administrator. No deficiency citation is being issued during today's inspection. An exit interview was conducted, and a signed copy of this report was provided to the Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Juliet Robles and Pamela Silva on 10/16/25 at 11: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs met with Tere Paredes, Administrator and inspected the facility inside and out. LPA reviewed 0 of child's records and 3 of staff personnel files on site at the facility. LPA reviewed 0 of child's psychotropic medications and medication records. There are no children currently prescribed psychotropic medication. LPA interviewed 1 of staff on site to discuss the facilities policies and procedures of operation. LPA provided a copy of this licensing report to Tere Paredes, Administrator. No deficiencies are being cited at this time. LPA conducted exit interview with Tere Paredes, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On March 8, 2022 at 9: AM, Licensing Program Analyst (LPA) Irene Yamamoto conducted an unannounced case management inspection at the facility. LPA met with the facility representative named above. LPA Yamamoto informed the facility representative that during a review of client records by the Department, the following was observed: A client's Needs and Services Plan (NSP) and Pre-placement Appraisal had no information or signature, both documents only had the client's name. Based on the above information, a deficiency citation is issued under STRTP Interim Licensing Standards (ILS) 87068.2(a) Needs and Services Plan and 87068.1(c)(1) Intake Procedures. The following reports were provided to the facility representative: LIC 809, LIC 809-d, LIC Confidential Names and Appeal Rights forms.

met_with: Thandi Smith, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 03/09/23 at 9: AM, Licensing Program Analysts (LPAs) Pamela Silva and Ashley Ruacho conducted an unannounced case management inspection at the above facility and met with the Administrator Cindi Bertrand. The purpose of the inspection is to follow-up on a Special Incident Report (SIR) received by the Department on 12/29/22. The SIR indicated that a 16-year old client (C1) went on a supervised visit with staff S2 to the park to meet a male friend on 12/10/22. On 12/27/22, C1's biological mom notified the facility that C1 disclosed to her that she engaged in sexual intercourse with the male friend during the supervised visit at the park on 12/10/22 (refer to Confidential Names List LIC811 dated 03/09/23). LPA Silva conducted telephone interviews with the facility Administrator S1 and staff S2 on 01/09/23, C1's Probation Officer (PO) on 01/10/23, and Investigation Probation Officer (IPO) on 01/12/23. Interviews revealed that while C1 and her male friend were walking around the park, supervising staff S2 remained in the car while keeping visual of C1. At some point, S2 lost sight of C1 and this is when C1 went inside the restroom with male friend and engaged in sexual intercourse. S2 nor any facility staff was unaware of the said incident until C1's mom reported it to the facility Director after C1 disclosed the incident to mom. S2 admitted that he did not get off the car and just stayed there while maintaining visual of C1. S2 stated that he would lose sight of C1 at times, but not for more than 5 minutes. Interviews with PO and IPO indicated concerns regarding (1) facility's lack of supervision, (2) for allowing C1 to go meet a male friend and not ensuring close supervision of C1 and (3) if incident was reported to the Department. The incident occurred on 12/10/22 but was not reported to the Department until 12/29/22 due to no facility staff were aware of such incident until C1's bio mom reported it to them on 12/28/22. A meeting with PO was held immediately following the notification of the incident to discuss safety plans for C1. C1 was taken for a medical check-up to ensure C1's health and safety. Per PO, facility will monitor and supervise C1 closely and will ensure that such incident will never happen again. PO stated that C1 admitted that what happened between her and friend at the park was consensual. C1 told PO that she feels safe living in the facility. As of 01/08/23, S2 no longer works at the facility. Based on the information gathered, it is determined that the facility is in violation of Interim Licensing Standards Version 4 87065.2(b)(1) Personnel Duties: Direct care staff shall perform the following duties: (1) Supervision, protection and care of children at all times, individually and in groups. A deficiency citation is being issued, see LIC809D. Exit interview conducted. A copy of this report, LIC809D, LIC 811 and appeal rights were provided to the facility representative.


summary: Facility Evaluation

raw_content:
Narrative:
On 03/09/23 at 10: AM, Licensing Program Analysts (LPA) Pamela Silva and Ashley Ruacho conducted an unannounced case management inspection at the above facility and met with the Administrator, Cindi Bertrand. The purpose of the inspection is to follow-up on a Special Incident Report (SIR) received by the Department on 01/09/23. The SIR indicated that client C1 admitted to not have taken the medication that was administered by staff S2 the night before (refer to Confidential Names List LIC811 dated 03/09/23). The missed medication was recovered from C1 by a staff the following day. During the inspection, LPA Silva interviewed the Administrator S1. S1 stated that C1 intentionally wanted to miss her medication and cheeked the pill in because she wanted to stay awake all night and was excited for her visit. LPA reviewed S2's medication training record and the facility's protocol for medication administration. Per S1, staff S2 admitted to not have checked C1's mouth upon administering the medication due to C1's behavior. While reviewing SIRs involving C1, LPA observed that there was also an incident that occurred on 12/19/22 when C1 was found to be in pain and was taken to the hospital. The said incident on 12/19/22 was not reported via SIR until 01/10/23. Per S1, the staff making the report is new and did not know the proper procedures on reporting requirements. Based on the information gathered, it is determined that the facility is in violation of Title Division Chapter Article 6, 80061(b)(1)( D) on Reporting Requirements,.and Interim Licensing Standards (ILS) 87070(b)(12)(H). Two (2) deficiency citations are being issued, see LIC809D. Exit interview conducted. A copy of this report, LIC809D, LIC 811 and appeal rights were provided to the facility representative.


summary: Facility Evaluation

raw_content:
Narrative:
On May 12, 2023 at 1:35 pm, Licensing Program Analyst (LPA), Karen McGee, arrived at the facility for the purpose of a Case Management. The LPA met with Administrator, Cindi Bertrand. Following is the purpose of the Case Management: On May 5, 2023 the LPA arrived at the facility and met with Direct Care Staff (DCS), Emanuel Butler. The LPA was informed that the two clients in placement were present at the facility. The LPA observed that the Administrator and a Facility Manager were not present at the facility. The LPA conducted a telephone conversation with the Administrator regarding the matter at hand on that date. DCS Butler informed the LPA that Butler was covering the shift for the Facility Manager. The LPA requested a copy of the Personnel Report (LIC500) dated April 8, 2023. The LPA conducted a telephone conversation with Monitoring LPA, Pamela Silva. Based upon the information, the facility is in violation of Interim Licensing Standards (ILS): Personnel Requirements. 87097.65(g). The licensee shall designate at least one facility manager to be present at the facility at all times when one or more children are present. Due to the violation, one (1) Type B citation is being issued (see 809d). The LPA conducted an exit interview and explained the appeal rights. A copy of this report was emailed to the facility representative.


summary: Facility Evaluation

raw_content:
Narrative:
On 09/21/23 at 12: PM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced case management inspection at the above facility and met with Supevising Facility Manager, Tere Paredes. The purpose of the inspection is to follow up on multiple incident reports regarding client's (C1) refusal to attend school (refer to Confidential Names List LIC811 dated 09/21/23). LPA Silva received nine (9) Unusual Incident Reports (UIRs) of school refusal for C1 on 09/18/23. These multiple UIRs occurred from 08/23/23 to 09/15/23 but were all reported to the Department on 09/18/23. This is in violation of Title Division Chapter Article 6, 80061(b)(1)(E) on Reporting Requirements. A deficiency citation is being issued, see LIC809D. Exit interview conducted. A copy of this report, LIC809D, LIC 811 and appeal rights were provided to the facility representative.


summary: Facility Evaluation

raw_content:
Narrative:
On 11/28/23 at 12: PM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced case management inspection at the above facility and met with Supervising Facility Manager, Tere Paredes. The purpose of the inspection is to follow up on LPA Karen McGee's observation regarding multiple unreported incidents of medication refusal for client C1 (refer to Confidential Names List LIC811 dated 11/28/23). Based on LPA McGee's review of C1's Psychotropic Medication Administration Records (PMARs) for the period of March to May 2023, there were nineteen (19) incidents of medication refusal for C1. However, only one (1) incident of C1's medication refusal was reported to the Department during that period. This is in violation of Title Division Chapter Article 6, 80061(b)(1)(E) on Reporting Requirements. A deficiency citation is being issued, see LIC809D. A previous violation of California Code of Regulations 80061(b)(1)(E ) was cited on 09/21/23. Based upon repeating the same violation within a 12-month period, it is determined that an immediate civil penalty of $250 be assessed (see LIC421FC). Exit interview conducted. A copy of this report, LIC809D, LIC 811 and appeal rights were provided to the facility representative.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Juliet Robles and Pamela Silva on 08/15/24 at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs met with Administrator, Tere Paredes and inspected the facility inside and out. LPAs reviewed one (1) of child's records and three (3) of staff personnel files on site at the facility. LPAs reviewed one (1) of child's psychotropic medications and medication records. LPAs interviewed two (2) of staff on site to discuss the facility's policies and procedures of operation. LPAs interviewed (0) of child currently prescribed psychotropic medications. Child was unavailable and LPAs will conduct interview at a later date. During the inspection, LPAs observed deficiency (see attached 809-D). Plan of correction was discussed, and appeal rights were provided. LPAs provided a copy of this licensing report to Tere Paredes, Administrator.


facility_name: BELOVED ONES 10

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Shikya Belfield conducted an announced meeting regarding the application for Beloved ones 10. Present during this meeting were Licensing Program Managers (LPM) Carolyn Flynn, LPM Marjana Jackson, LPA Kristin Pierotti, LPA Cynthia Galindo, and Licensee Thandi Smith. The purpose of this meeting is to discuss any concerns, ask questions, and give or provide any needed clarification. During this meeting the following was discussed, program statement updates, submitted revisions, outstanding forms, and questions regarding timelines of completion. LPA Belfield discussed missing information regarding LIC308 administrator designation form, LIC610C emergency disaster preparedness form, and county letter of support. LPA explained that there are other missing forms and that program statement was in the final review process. LPM Flynn asked for clarification regarding the program statement that CCL currently has, will be used for all of the Licensees other programs. Licensee confirmed that it would be. No other concerns were raised. LPA's thanked Licensee for the updated revisions and expressed appreciation for the new formatting and added information to the program statement. LPA agreed to submit the request for outstanding items in an email separate from the request for the revisions of the program statement. Licensee asked if there was time line in which the review would be complete. LPA explained that no specific time and date could be provide for completion of the review however, they would do their best to provide the response as quickly as possible. This meeting was concluded.


summary: Facility Evaluation

raw_content:
Narrative:
On 8/6/2025 at 10: AM, Licensing Program Analysts (LPA) Shikya Belfield and LPA Omar Sawyer met with the above facility via Teams to conduct components II and III of the Licensing Orientation process. Representatives present during the orientation was Licensee Thandi Smith. The following items were discussed: Component II · Client Assessments - Depending the clients and the type of assessment needed, this process will be completed by the Head of Service, Program Psychiatrist, Mental Health Program Director, or referred to the appropriate licensed professional. · Mental Health Program Approval and Head of Service - It was discussed who is assigned as Head of Service for the program and who they report to. · Organization (chain of command, roles and responsibilities) - It was discussed who each person in the program would report to. From Direct Care Staff to Program Director. · Administrator Assigned - Gina Smith on the 308 and Salih Robinson as assigned Administrator. · Any missing forms or clarifications - Licensee submitted forms LIC 610C with the added second location per required by revision request and LIC308 with new designee. The Component Three presentation was conducted and STRTP specific information and regulations were reviewed. An exit interview was conducted, and a copy of this report will be sent to Licensee Thandi Smith.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Celeste Aparicio and Kaitlyn Wong conducted a Pre-licensing inspection and met with Facility Director, Thandi Smith. The entire home was toured, inside and out. The applicant is interested in providing care for a capacity of six children, ages seven - seventeen years, ambulatory only. The home is set up as follows: This is a two- story home with three bedrooms, three bathrooms, a living room, a dining-room, and kitchen. Bedroom # 1 - occupied by minor (two twin beds, two dressers and shared closet space, single standing lamp). Bedroom # 2 - occupied by minor ( two twin beds, two dressers and shared closet space, single standing lamp) Bedroom # 3 - occupied by staff used as a staff office/ therapy room. There were appropriate furnishings in the home. There was a fireplace in the living room that was fenced properly. Three full bathrooms and one full bathroom with be utilized specifically for staff. The faucets that will be used by the children were tested and delivered hot water at a temperature of 127.5 degrees. The facility was made aware of this issue and is advised to put up warning signs advising clients of hot water temperatures. The facility is aware of having two day perishable and 7 day non - perishable food supply. Technical Advisories were issued for Sections 80088(e)(2) and 87072.2(a)(3) as a reminder for water temperature and location of complaint procedures. The trash cans to be used by clients and in the kitchen were covered to stop the transmission of communicable diseases or odors. The smoke detectors and carbon monoxide alarms were tested and are operable. LPA reminded the facility that emergency telephone numbers, Personal Rights, food menu needed to be posted in a prominent location. The home will have a locked container and cabinet where medications and or contraceptives will be stored. Disinfectants and cleaning solutions were stored in a location that will be inaccessible to children. The storage area for poisons was locked and accessible only to employees. The first aid kit was checked and found to be complete. The front and backyard were inspected and found cleared of hazards. There were no pools and/or bodies of water on the premises. The applicant stated that there are no firearms in the home. LPAs requested an updated copy of the LIC500 and conducted [1] interview with staff to discuss intake procedures and trauma informed care of the program. An exit interview was conducted, and a copy of this report was provided to Facility Director, Thandi Smith.

visit_type: Prelicensing

met_with: Director, THANDI SMITH


facility_name: BELOVED ONES 11

summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
between S1 and C1. During investigation, confidential interviews reported that prior to their arrival, S1 was asked by other facility staff not to respond. Confidential interviews reported that S1 ignored this request and responded regardless. Confidential interviews reported that upon arrival to the facility, S1 was asked by other staff to not take the lead in de-escalating C1, as it was suspected S1 and C1 had animosity against each other. Confidential interviews reported that S1 again dismissed any such request. Other confidential interviews reported that upon arrival to the facility, S1 did not attempt to de-escalate C1, but instead instigated C1 by reminding C1 that C1 had threatened physical violence upon S1 at a previous occasion and S1 encouraged C1 to follow through on this threat. Confidential interviews continued reporting that S1 and C1 immediately became physically entangled and that S3 and S4 attempted to separate S1 and C1. Confidential interviews indicated that prior to being separated, S1 punched C1 with a closed fist on at least one occasion and made contact with C1's head and/or body area. Confidential interviews disclosed that after a review of the facility's video surveillance footage of this incident, it was observed that S1 punched C1. Based on the confidential interviews, a review of pertinent documentation and a review of video footage, the preponderance of evidence standard has been met, and the allegation that facility staff punched a minor in care is substantiated. The facility is being cited for violation of ILS 87072(c)(1) Personal Rights (See attached 9099D). An exit interview was conducted. A copy of this report, LIC 809D and appeal rights were explained and given to Supervising Facility Manager Tiana Bolden.

Investigation Findings:
13On 04/17/2025, at 09: AM, Licensing Program Analysts (LPAs) Joon Choi and Claudia Aguilera conducted an unannounced visit at Beloved Ones Short Term Residential Treatment Program (STRTP) and met with Supervising Facility Manager Tiana Bolden to deliver the investigative finding for the allegation listed above. On 02/26/2025, Community Care Licensing received an allegation that facility staff punched a minor in care. On 03/06/2025, LPA Joon Choi arrived at the facility, conducted a health and safety inspection, and obtained pertinent documents. No immediate health and safety hazards were observed. In addition, LPA interviewed clients 1 and 2 (C1, C2) and staff 1, 2, and 3 (S1-S3). Staff 4 (S4) who is no longer employed at the facility, did not return any of LPA's requests for communication. In regard to the allegation that facility staff (S1) punched a minor in care (C1); it was reported that S1, S3 and S4 arrived at the facility because assistance was requested. It was further reported that upon arrival, S1 engaged in a verbal altercation with C1, and that this incident escalated into a physical altercation. CONTINUED ON THE NEXT PAGE SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Joon R Choi LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 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 FACILITY NAME: BELOVED ONES 11FACILITY NUMBER: VISIT DATE: 04/17/2025

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

report_type: Complaint Investigation

met_with: Supervising Facility Manager, Tiana Bolden

complaint_status: SUBSTANTIATED


summary: Facility Evaluation

raw_content:
Narrative:
On August 20. 2024, Licensing Program Analyst (LPA) Babatunde Aborchie and Licensing Program Manager (LPM) Abdoulaye Traore met with applicant Thandi Smith for component II. LPA and LPM went over revisions needed for the application prior to licensure. Applicant is applying for STRTP license. LPA and LPM gave a copy of the LIC 184, Notice of Incomplete Application, and additional correspondence to assist with the revisions needed to the application. Copy of this report was provided to applicant.


summary: Facility Evaluation

raw_content:
Narrative:
On September 20. 2024, Licensing Program Analyst (LPA) Babatunde Aborchie and Licensing Program Manager (LPM) Abdoulaye Traore reviewed corrections made by applicant Thandi Smith during the component II. LPA and LPM went over revisions of the corrections made prior to licensure. Applicant is applying for STRTP license. Copy of this report was provided to applicant.


summary: Facility Evaluation

raw_content:
Narrative:
On October 3, 2024, Licensing Program Analyst (LPA) Babatunde Aborchie and Licensing Program Manager Abdoulaye Traore began a pre-licensing inspection for a Short Term Residential Therapeutic Program (STRTP) license. LPA and LPM met with director Thandi Smith, administrator, Philip Cook and operations manager, Salih Robinson who led a tour of the home. The facility was toured both inside and out with the applicants. Currently there is no child placed in the home. The applicant is applying to serve six minor and nonminor dependents children (NMD). The residence is a four-bedroom two story-house with three bathrooms. The downstairs area consists of a living room, a kitchen, dining area, laundry room, storage down the stairs, a bathroom, the garage, and the backyard. There was one bedroom and it consists of two twin-size beds; it will sleep two clients. Upstairs consists of 3 bedrooms and two bathrooms. The 2 bedrooms will be utilized for clients, they consist of two twin-size beds in each room, and they will sleep two clients per room. In addition to the upstairs bedrooms, the master bedroom was utilized as a locked office and it consists of office desks, furniture, a bathroom, and a room to store medications and files. Bedrooms were arranged so that no more than two clients share a room, and there was one child per bed. No room commonly used for other purposes was used as a bedroom, and no bedroom serves as a passageway to another room. There were adequate drawers and closet space for children's belongings. Towels and linens were stored in a cabinet by the clients' bedrooms. The smoke detectors and carbon monoxides were checked and were working properly. The fireplace was in the living room area, and it was properly screened. Telephone service and appliances were in a working order. All hazardous items have been properly made inaccessible to areas where clients would have access. The medications and sharp objects/knives will be locked and stored in a storage box in the office closet. Cleansers/chemicals were locked and stored in the laundry room. The first aid kit was in a cabinet in the kitchen area by the kitchen sink, accessible and contained all required items. There were no guns or weapons as stated by applicant at this time. The hot water temperature was tested and noted to be 111 degrees. There was adequate food storage supply of two days of perishable foods and a week of non-perishable food. Proper storage of all food was discussed. Trash cans for storage of solid waste have tight fitting lids. The Facility Sketch, Emergency Disaster Plan, visitation policy and Personal Rights were posted. There were no pool or other body of water and the backyard where clients will have access to play was completely fenced and free of hazards. Currently, the facility is appropriate for a capacity of six ambulatory clients, ages seven to seventeen and non-minor dependents. All requirements were met at this time. Licensing Program Manager will complete a final review prior to issuing a provisional license. Exit interview was conducted and a copy of this report was provided the director, Thandi Smith.


summary: Facility Evaluation

raw_content:
Narrative:
On April 3, 2025, Licensing Program Analysts (LPAs) Babatunde Aborchie and Claudia Aguilera began a post-licensing inspection for Beloved Ones Short Term Residential Therapeutic Program (STRTP). LPAs met with Salih Robinson, Operations Manager, who led a tour of the home. The facility was toured both inside and out with the manager. Currently there is one child in placement in the home. The residence is a four-bedroom two story-house with three bathrooms. The downstairs area consists of a living room, a kitchen, dining area, laundry room, storage down the stairs, a bathroom, the garage, and the backyard. There was one bedroom, and it consists of one twin-size bed; it was vacant. Upstairs consists of 3 bedrooms and two bathrooms. Bedroom #2 the master bedroom was utilized as a locked office and it consists of office desks, furniture, a bathroom, and a room to store medications and files. Bedroom #3 consists of one twin bed, it was vacant. Bedroom #4 consist of one twin bed; it sleeps one client. Bedrooms were arranged so that no more than two clients share a room, and there was one child per bed. No room commonly used for other purposes was used as a bedroom, and no bedroom serves as a passageway to another room. There were adequate drawers and closet space for children's belongings. Towels and linens were stored in a cabinet by the clients' bedrooms. The smoke detectors and carbon monoxides were checked and were working properly. The fireplace was in the living room area, and it was properly screened. Telephone service and appliances were in a working order. All hazardous items have been properly made inaccessible to areas where clients would have access. The medications and sharp objects/knives were locked and stored in a storage box in the office closet. Cleansers/chemicals were locked and stored in the storage under the staircase. The first aid kit was in a cabinet in the kitchen area by the kitchen sink, accessible and contained all required items. There were no guns or weapons as stated by the manager at this time. The hot water temperature was tested and noted to be 109 degrees. There was adequate food storage supply of two days of perishable foods and a week of non-perishable food. Proper storage of all food was discussed. Trash cans for storage of solid waste have tight fitting lids. The Facility Sketch, Emergency Disaster Plan, visitation policy and Personal Rights were posted. There were no pool or other body of water and the backyard where clients will have access to play was completely fenced and free of hazards. LPA interviewed one of one client and two staff. Based on this post-licensing inspection of the home, no deficiencies were found during this inspection. An exit interview was conducted, a copy of this report was provided to the operation manager Salih Robinson.

met_with: Salih Robinson


summary: Facility Evaluation

raw_content:
Narrative:
On October 13, 2025, Licensing Program Analyst (LPA) Babatunde Aborchie began an annual/required inspection for Beloved Ones Short Term Residential Therapeutic Program (STRTP). LPA met with Supervising Facility Manager (SFM), Tiana Bolden who led a tour of the home. The facility was toured both inside and out with the SFM. Currently there is no child placed in the home; the last placement was moved after turning 18-year-old. The residence is a four-bedroom two story-house with three bathrooms. The downstairs area consists of a living room, a kitchen, dining area, laundry room, storage down the stairs, a bathroom, the garage, and the backyard. There was one bedroom, and it consists of one twin-size bed; it would sleep on client, it was vacant. Upstairs consist of 3 bedrooms and two bathrooms. The 2 bedrooms will be utilized for clients, they consist of one twin-size bed in each room, and they will sleep one client per room. In addition to the upstairs bedrooms, the master bedroom was utilized as a locked office and it consists of office desks, furniture, a bathroom, and a room to store medications and files. Bedrooms were arranged so that no more than two clients share a room, and there was one child per bed. No room commonly used for other purposes was used as a bedroom, and no bedroom serves as a passageway to another room. There were adequate drawers and closet space for children's belongings. Towels and linens were stored in a cabinet by the clients' bedrooms. The smoke detectors and carbon monoxides were checked and were working properly. The fireplace was in the living room area, and it was properly screened. Telephone service and appliances were in working order. All hazardous items have been properly made inaccessible to areas where clients would have access. The medications and sharp objects/knives were locked and stored in a storage box in the office closet. Cleansers/chemicals were locked and stored in the storage downstairs. The first aid kit was in a cabinet in the kitchen area by the kitchen sink, accessible and contained all required items. There were no guns or weapons as stated by the SFM at this time. The hot water temperature was tested and noted to be 113 degrees. There was adequate food storage supply of two days of perishable foods and a week of non-perishable food. Proper storage of all food was discussed. Trash cans for storage of solid waste have tight fitting lids. The Facility Sketch, Emergency Disaster Plan, visitation policy and Personal Rights were posted. Five staff files were reviewed, and met requirements. There was no pool or other body of water and the backyard where clients have access to play was completely fenced and free of hazards. All requirements were met at this time. Based on this annual/required inspection of the home, no deficiencies were found during this inspection. An exit interview was conducted, and a copy of this report was provided to the Supervising Facility Manager, Tiana Bolden.


summary: Facility Evaluation

raw_content:
Narrative:
On December 3, 2025, Licensing Program Analyst (LPA) Babatunde Aborchie met with Beloved Ones Short Term Residential Therapeutic Program (STRTP), Facility Administrator Philip Cook to conduct a case management visit following the incident report dated November 20, 2025. LPA interviewed Client 1 (C1) two Supervising facility managers (FM1 and FM2), Administrator. LPA will review documentation and interviews for final determination of findings.

met_with: Philip Cook


facility_name: BELOVED ONES 12

raw_content:
Narrative:
This is an amended LIC9099C to the original issued on 05/23/2025. Confidential interviews confirmed that S4 violated facility policy which states that staff should be "hands off". Staff are not permitted to use physical force toward clients. If a restraint is required, it is only used as a last resort after attempting de-escalation techniques, and two staff members are to be present to perform the restraint. Confidential interviews reported that S4 was the only staff present at the facility when the incident occurred, and corroborating statements supported by evidence, showing that S4's self-defense claims were disproved. It was reported that S4 did not attempt to evade, separate from C1, or de-escalate the situation. Video footage corroborated that S4 was "antagonizing" C1. In addition, S4 initiated the confrontation and aggressively walked towards C1 multiple times. Furthermore, the evidence shows S4 physically assaulting C1 by wrestling and throwing C1 to the ground resulted in C1's broken arm. The aggressive behavior shown by S4 toward C1 indicated that S4 did not provide trauma-informed care or show a regard for C1's well-being, showing S4 acted in a way to violate licensing regulations that state minors are to be treated respectfully. Moreover, based on the evidence, S4 was arrested for PC 243(D)- Battery with serious bodily injury and PC 273a(a)- child abuse with possible great bodily injury. Based on confidential interviews and supportive evidence, the allegation that a Minor (C1) sustained broken arm while in care and facility staff (S4) do not treat minor (C1) with dignity and respect is substantiated. The preponderance of evidence standard has been met. The Short Term Residential Therapeutic Program is cited for violation of Interim Licensing Standards (ILS) Personal Rights (c)(16), which states (c) The licensee shall ensure that each child, regardless of whether the child is in foster care, is accorded the personal rights... (16) To be free of physical, sexual, emotional, or other abuse, and from corporal or unusual punishment, exploitation, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature ... An Enhanced Civil Penalty (ECP) determination is pending. If an ECP is assessed a CCL representative will return to the facility to deliver the penalty assessment. The Program Administrator approved the assessment of this Enhanced Civil Penalty. Therefore, an ECP was issued to this facility in the amount of $2,500 on the {LIC809 and LIC421}. A copy of this report, LIC 811, and appeal rights were provided to Facility Manager Shaun Dwyer.

Investigation Findings:
13On May 23, 2025, at 2: PM, Licensing Program Analyst (LPA) Jessica Peete made an unannounced visit to Beloved Ones Short Term Residential Therapeutic Program (STRTP) and met with Facility Manager Shaun Dwyer to deliver the investigative findings for the allegations mentioned above. The investigation was conducted by Special Investigator (Inv) Jesus Gonzalez of the Community Care Licensing (CCL) Investigations Bureau. The investigation included interviews with the facility staff (S1-S3), clients in care (C1-C3), and the County Social Worker (CSW). Inv Gonzlez attempted to interview S4, but S4 declined to provide a statement. On February 26, 2025, Community Care Licensing (CCL) received allegations that a minor (C1) sustained a broken arm while in care and facility staff (S4) do not treat minor (C1) with dignity and respect. It was alleged that S4 and C1 got into a physical altercation which resulted in in C1 sustaining a dislocated left elbow and a fractured radius bone. Inv Gonzalez obtained sufficient evidence to support the allegations. (Continued on LIC 9099C) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Jessica M Peete 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 PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: BELOVED ONES 12FACILITY NUMBER: VISIT DATE: 05/23/2025

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

met_with: Shaun Dwyer Facility Manager


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
In regard to the allegation, it was specifically alleged that staff went to wake C1 up for school in the morning and found an unknown female minor in bed with C1. During the investigation, a confidential interview stated there was an unknown female minor in C1's bed. The confidential interview did not know how the unknown female minor got in the room. Another confidential interview was conducting a room check during morning shift change and found the unknown female minor. The confidential interview indicated that C1 snicked the unknown minor in by distracting the staff. A confidential witness observed on facility camera that C1 brought in the unknown female minor and staff was unaware. Based on confidential interviews, a review of pertinent documentation and a review of the facility's video surveillance footage, the preponderance of evidence standard has been met, and the allegation that staff are not adequately supervising minors is substantiated. The facility is being cited for violation of Title 22, Division 6, Chapter 1, Article 06. Continuing Requirements Responsibility for Providing Care and Supervision, (a) The licensee shall provide care and supervision as necessary to meet the client's needs (see LIC 9099D). An exit interview was conducted. A copy of this report (LIC 9099), (LIC 9099D) and appeal rights were explained and given to facility representative.

Investigation Findings:
13On October 22, 2025, Licensing Program Analyst (LPA) Babatunde Aborchie arrived at Beloved Ones 12, Short Term Residential Therapeutic Program (STRTP) and met with Jonathan Bethel to deliver the investigative finding involving STRTP and clients as listed on the Confidential Name List (LIC 811). On May 14, 2025, a complaint report was referred to Community Care Licensing (CCL) alleging that staff are not adequately supervising minors. On May 27, 2025, (LPA) B. Aborchie arrived at STRTP to initiate the investigation and interviewed, a client and the facility manager (FM). Additionally, LPA interviewed staff 1 (S1), staff 2 (S2). LPA was unable to interview County Social Worker (CSW). SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Babatunde Aborchie 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 FACILITY NAME: BELOVED ONES 12FACILITY NUMBER: VISIT DATE: 10/22/2025

met_with: Jonathan Bethel


summary: Facility Evaluation

narrative: On August 20. 2024, Licensing Program Analyst (LPA) Babatunde Aborchie and Licensing Program Manager (LPM) Abdoulaye Traore met with applicant Thandi Smith for component II. LPA and LPM went over revisions needed for the application prior to licensure. Applicant is applying for STRTP license. LPA and LPM gave a copy of the LIC 184, Notice of Incomplete Application, and additional correspondence to assist with the revisions needed to the application. Copy of this report was provided to applicant.


summary: Facility Evaluation

narrative: On September 20. 2024, Licensing Program Analyst (LPA) Babatunde Aborchie and Licensing Program Manager (LPM) Abdoulaye Traore reviewed corrections made by applicant Thandi Smith during the component II. LPA and LPM went over revisions of the corrections made prior to licensure. Applicant is applying for STRTP license. Copy of this report was provided to applicant.


summary: Facility Evaluation

raw_content:
Narrative:
On October 3, 2024, Licensing Program Analyst (LPA) Babatunde Aborchie and Licensing Program Manager Abdoulaye Traore began a pre-licensing inspection for a Short Term Residential Therapeutic (STRTP) license. LPA and LPM met with applicant Thandi Smith, Philip Cook and Salih Robinson who led a tour of the home. The facility was toured both inside and out with the director, Thandi Smith. The applicant is applying to serve six ambulatory clients and non-minor dependents children (NMD). The residence is a five-bedroom two story-house with three bathrooms. The downstairs area consists of a living room, a kitchen, dining area, laundry room, a storage down the stairs, a bathroom, the garage, and the backyard. One room was observed to be the Therapy room. Upstairs consists of 4 bedrooms and two bathrooms. The 3 bedrooms will be utilized for clients, they consist of two twin-size beds in each room, and they will sleep two clients per room. In addition to the upstairs bedrooms, the master bedroom will be utilized for staff office to store clients' file, cleaning supplies and sharp objects. Outside the bedrooms, there was a large loft with a furniture, a television and two computer desks. Bedrooms were arranged so that no more than two clients share a room, and there was one child per bed. No room commonly used for other purposes was used as a bedroom, and no bedroom serves as a passageway to another room. There were adequate drawers and closet space for children's belongings. There were towels and linens stored in downstairs' cabinet. The smoke detectors and carbon monoxides were checked and were working properly. Telephone service and appliances were in a working order. All hazardous items have been properly made inaccessible to areas where clients would have access. The medications and sharp objects/knives will be locked and stored in a storage box in the storage room. Cleansers/chemicals were locked and stored in the laundry room. The first aid kit was in the kitchen cabinet in area by the pantry, accessible and contained all required items. There were no guns or weapons as stated by applicant at this time. The hot water temperature was not tested due to the gas line being shutoff. There was adequate food storage supply of two days of perishable foods and a week of non-perishable food. Proper storage of all food was discussed. Trash cans for storage of solid waste have tight fitting lids. The Facility Sketch, Emergency Disaster Plan, visitation policy and Personal Rights were posted. There were no pool or other body of water and the backyard where clients will have access to play was completely fenced and free of hazards. Based on this inspection of the home, the facility will need the following correction: • The water temperature needs to measure between 105-120 degrees. After the correction is completed, the applicant will notify LPA so that another inspection can be completed. Exit interview was conducted and a copy of this report was provided the administrator Thandi Smith.


summary: Facility Evaluation

raw_content:
Narrative:
On October 7, 2024, Licensing Program Analyst (LPA) Babatunde Aborchie began the continuation of a pre-licensing inspection for a Short Term Residential Therapeutic Program (STRTP) license. LPA met with the operations manager Salih Robinson. LPA conducted a test of the water temperature, and the temperature was measured to be 111 degrees. Currently, the facility is appropriate for a capacity of six ambulatory clients, ages seven to seventeen and non-minor dependents. All requirements were met at this time. Licensing Program Manager will complete a final review prior to issuing a provisional license. Exit interview was conducted and a copy of this report was provided the administrator Salih Robinson.


summary: Facility Evaluation

raw_content:
Narrative:
On March 27, 2025, Licensing Program Analyst (LPA) Babatunde Aborchie began a post-licensing inspection for Beloved Ones Short Term Residential Therapeutic (STRTP). LPA met with, Philip Cook, Salih Robinson and Jonathan Bethel who led a tour of the home. The facility was toured initially with Phillip Cook, Salih Robinson and Jonathan Bethel took over when Phillip Cook's attention was needed by a client in care. The tour was conducted both inside and out. The facility currently has 3 clients in care. The facility was licensed to serve six ambulatory clients and non-minor dependents children (NMD). The residence is a five bedroom two story house with three bathrooms. The downstairs area consists of a living room, a kitchen, dining area, laundry room, a storage down the stairs, a bathroom, the garage, and the backyard. One room was observed to be used as an office. Upstairs consists of 4 bedrooms and two bathrooms. The 3 bedrooms used for clients, they consist of one twin bed in room 2, two twin-size beds in room 4 and 5, they sleep one client per room currently. In addition to the upstairs bedrooms, the master bedroom was used for staff office to store clients' file, and sharp objects. Outside the bedrooms, there was a large loft with furniture, a television and two computer desks for clients. Bedrooms were arranged so that no more than two clients share a room, and there was one child per bed. No room commonly used for other purposes was used as a bedroom, and no bedroom serves as a passageway to another room. There were adequate drawers and closet space for children's belongings. There were towels and linens stored in downstairs' cabinet. The smoke detectors and carbon monoxides were checked and were working properly. Telephone service and appliances were in a working order. All hazardous items have been properly made inaccessible to areas where clients would have access. The medications and sharp objects/knives were locked and stored in a storage box in the storage room. Cleansers/chemicals were locked and stored in the laundry room. The first aid kit was in the kitchen cabinet in area by the pantry, accessible and contained all required items. There were no guns or weapons as stated by the facility manager at this time. The hot water temperature was tested to be 109 degrees. There was adequate food storage supply of two days of perishable foods and a week of non-perishable food. Proper storage of all food was discussed. Trash cans for storage of solid waste have tight fitting lids. The Facility Sketch, Emergency Disaster Plan, visitation policy and Personal Rights were posted. There were no pool or other body of water and the backyard where clients will have access to play was completely fenced and free of hazards. LPA interviewed three of two clients present and two staff. Based on this post-licensing inspection of the home, no deficiencies were found during this inspection. An exit interview was conducted, a copy of this report was provided to facility manager, Phillip Cook.

met_with: Phillip Cook


summary: Facility Evaluation

raw_content:
Narrative:
On August 5, 2025, at 2: PM, Licensing Program Analyst (LPA) Jessica Peete met with Beloved Ones Short Term Residential Therapeutic Program (STRTP), Facility Manager Shaun Dwyer to assess an Enhanced Civil Penalty (ECP). On May 23, 2025, LPA Peete delivered a Complaint Investigation Report to the STRTP. The allegations that a Minor (FC1) sustained a broken arm while in care and facility staff (S1) do not treat a minor (FC1) with dignity and respect were substantiated. The investigation provided sufficient evidence that S1 physically assaulted FC1, resulting in FC1 sustaining a broken arm. The STRTP was cited from the Interim Licensing Standards(ILS) Personal Rights (c)(16), which states (c) The licensee shall ensure that each child, regardless of whether the child is in foster care, is accorded the personal rights... (16) To be free of physical, sexual, emotional, or other abuse, and from corporal or unusual punishment, exploitation, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature ... Based on an analysis of confidential interviews and documentation, the Department has determined that an ECP is warranted for the facility not ensuring FC1's personal rights were protected, as a result, FC1 was subjected to physical abuse by S1, which resulted in serious bodily injury. Penal Code section 243 defines serious bodily injury as a serious impairment of physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture... Therefore, pursuant to the Enhanced Civil Penalty Law, Health, and Safety Code 1548(f)(1)(C), the Department will be issuing an immediate Civil Penalty of $2,500.00. (Continued on LIC 809C) An exit interview was completed, and appeal rights were discussed. A copy of this report, the Confidential Names List LIC 811, and the Civil Penalty Assessment-Serious Bodily Injury/Sexual Abuse (Form 421-D) were provided to the Facility Manager Shaun Dwyer. The signed copy will be retained in the facility file.

met_with: Facility Manager Shaun Dwyer


summary: Facility Evaluation

raw_content:
Narrative:
On October 2, 2025, Licensing Program Analyst (LPA) Babatunde Aborchie began an annual/required inspection at Beloved Ones Short Term Residential Therapeutic (STRTP). LPA met with Philip Cook, and Jonathan Bethel who led a tour of the home. The facility was toured with Phillip Cook, and Jonathan Bethel. The tour was conducted both inside and out. There were two gentlemen working on the property, painting and fixing the property. The facility currently has 2 clients in care. The facility was licensed to serve six ambulatory clients and non-minor dependents children (NMD). The residence is a five-bedroom two-story house with three bathrooms. The downstairs area consists of a living room, a kitchen, dining area, laundry room, storage down the stairs, a bathroom, the garage, and the backyard. One room was observed to be used as an office. Upstairs consist of 4 bedrooms and two bathrooms. The 3 bedrooms used for clients consist of two twin beds in room 2, one twin-size bed in room 3 and two twin size bed in room 4, they sleep one client per room currently. In addition to the upstairs bedrooms, the master bedroom was used for staff office to store clients' files, and sharp objects. Outside the bedrooms, there was a large loft with furniture, a television and one computer desk for clients. Bedrooms were arranged so that no more than two clients share a room, and there was one child per bed. No room commonly used for other purposes was used as a bedroom, and no bedroom serves as a passageway to another room. There were adequate drawers and closet space for children's belongings. There were towels and linens stored downstairs' cabinet. The smoke detectors and carbon monoxides were checked and were working properly. Telephone service and appliances were in working order. All hazardous items have been properly made inaccessible to areas where clients would have access. The medications and sharp objects/knives were locked and stored in a storage box in the office. Cleansers/chemicals were locked and stored in the office. The first aid kit was in the kitchen cabinet in an area by the pantry, accessible and contained all required items. There were no guns or weapons as stated by the facility manager at this time. The hot water temperature was tested to be 112 degrees. There was an adequate food storage supply of two days of perishable foods and a week of non-perishable food. Proper storage of all food was discussed. Trash cans for storage of solid waste have tight fitting lids. The Facility Sketch, Emergency Disaster Plan, visitation policy and Personal Rights were posted. There was no pool or other body of water and the backyard where clients will have access to play was completely fenced and free of hazards. LPA was unable to interview two clients and two staff who were not in the facility during the inspection. Based on this annual/required inspection of the home, no deficiencies were found during this inspection. An exit interview was conducted, and a copy of this report was provided to the facility manager, Phillip Cook.


facility_name: BELOVED ONES 14

summary: Facility Evaluation

raw_content:
Narrative:
On December 15, 2025, Licensing Program Analyst (LPA) Babatunde Aborchie began a pre-licensing inspection for a Short Term Residential Therapeutic Program (STRTP) license. LPA met with administrator, Philip Cook and operations manager, Salih Robinson who led a tour of the home. The facility was toured both inside and out with the applicants. Currently there is no child placed in the home. The applicant is applying to serve two minor and nonminor dependents children (NMD). The residence is a four-bedroom single-story-house with two bathrooms. The area consists of a living room, a kitchen, dining area, storage, two bathrooms, the garage, laundry area and the backyard. There were four bedrooms in total. Bedroom #1 consists of one twin-size bed; it will sleep one client. Vacant. Bedroom #2 will be utilized for one client; it consists of one twin-size bed; it will sleep one client. Bedroom #3 consists of office furniture; it will be used as an office, to store medications and files. Bedroom #4 was vacant; it will be used as a study room. Bedrooms were arranged so that no more than two clients share a room, and there was one child per bed. No room commonly used for other purposes was used as a bedroom, and no bedroom serves as a passageway to another room. There were adequate drawers and closet space for children's belongings. Towels and linens were stored in a cabinet by the clients' bedrooms. The smoke detectors and carbon monoxides were checked and were working properly. The fireplace was in the living room area, and it was properly screened. All appliances were in working order. All hazardous items have been properly made inaccessible to areas where clients would have access. The medications and sharp objects/knives will be locked and stored in a storage box in the office closet. Cleansers/chemicals were locked and stored in the hallway closet. The first aid kit was in a cabinet in the office, accessible and contained all required items. There were no guns or weapons as stated by applicant at this time. The hot water temperature was tested and noted to be 113 degrees. There was adequate food storage supply of two days of perishable foods and a week of non-perishable food. Proper storage of all food was discussed. Trash cans for storage of solid waste have tight fitting lids. The Facility Sketch, Emergency Disaster Plan, visitation policy and Personal Rights were posted. There was no pool or other body of water and the backyard where clients will have access to play was completely fenced and free of hazards. Currently, the facility is appropriate for a capacity of two ambulatory clients, ages seven to seventeen and non-minor dependents. All requirements were met at this time. Licensing Program Manager will complete a final review prior to issuing a provisional license. Exit interview was conducted and a copy of this report was provided to the administrator, Philip Cook and operations manager, Salih Robinson.

met_with: Administrator


facility_name: BELOVED ONES 2

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Continued from pg. LIC It was alleged that the facility staff allowed a foster youth to AWOL, staff did not prevent a foster youth from engaging in inappropriate behaviors and a facility window is in disrepair. Statements obtained from the confidential interviews did not provide sufficient information to corroborate the allegations. The staff that were interviewed stated that the facility is not a lock-down facility. Therefore staff is not allowed to physically prevent residents from leaving. Facility staff stated that residents are verbally encouraged not to go AWOL. The staff stated that law enforcement was called once the foster youth began engaging in inappropriate behaviors in order to de-escalate the situation. The staff stated that the foster youth broke a window and the window was immediately boarded up on the same day. Facility staff called in a work order to have the window repaired the next day. The county social worker stated that the foster youth was in need of a higher level of care and the facility staff did their best. LPA Mundo was unable to get a statement from the foster youth. There was no corroborating information obtained through the interviews and review of records to confirm the allegation. Based on the interviews and records reviewed, the allegations are found Unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the allegations. The following reports were provided to the facility representative: LIC 9099, LIC 9099C, LIC 811, and Appeal Rights. There were no deficiencies cited.

Investigation Findings:
13On 8/27/2021 at 2:25 pm, Licensing Program Analyst (LPA) Jenny Mundo conducted a follow-up complaint inspection with the Short Term Residential Therapeutic Program (STRTP) for the purpose of providing findings for the above complaint allegations. LPA Mundo met with the facility Administrator Crystal Downey. During the course of the investigation, LPA Mundo conducted interviews with 2 facility staff on 5/21/2021 via telephone and a county social worker on 8/26/2021 via telephone (see Confidential Names form LIC 811 dated 8/27/2021). LPA Mundo also reviewed documents on 6/2/2021 and 8/27/2021 including but not limited to the facility's LIC 500 and staff trainings for 2021, Special Incident Reports (SIRs) involving one foster youth for the period of 4/11/2021-5/11/2021, the following documents for one foster youth: current Needs and Service Plan (NSP), current Child and Family Team Meeting (CFTM) minutes, Treatment plan from College Hospital and case notes for 4/11/2021-5/11/2021. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Jenny Mundo 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 32-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, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BELOVED ONES 2FACILITY NUMBER: VISIT DATE: 08/27/2021

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

met_with: Crystal Downey, Administrator

complaint_status: unsubstantiated


raw_content:
Narrative:
Statements from other interviews revealed that C1 reached out their hand and tapped C2's breast when C2 was passing, and it happened only once. Staff did not see the incident as it occurred very quickly. Statements obtained from the confidential interviews did not provide sufficient information to corroborate the allegation. Based on the information gathered, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that alleged violation occurred, therefore the allegation is unsubstantiated. There were no deficiencies cited during this inspection. An exit interview was conducted. Appeal rights explained and a copy of this report, and Appeal Rights were provided to the facility representative.

Investigation Findings:
13On July 27, 2023, at 11: AM, Licensing Program Analyst (LPA) Karen Suh conducted a follow-up complaint inspection to deliver the finding of an investigation concerning to the allegation above. The LPA met with the representative named above and discussed the finding. The investigation included confidential interviews that consisted of but were not limited to: one client and three staff and C1's therapist on April 6, 2023. The LPA was unable to interview C2 as C2 has been terminated from the facility and where about is unknown. The LPA was unable to contact the County Social Worker (CSW) after several attempts. The LPA reviewed Needs and Services Plans, Treatment Plans, Child and Family Team (CFT) Meetings and Special Incident Report. It was alleged that minors engaged in inappropriate interactions due to lack of supervision: one client touched another client's breast. Staff denied the allegation. On the day of the incident, staff were in the kitchen area sitting at the table and one client (C1) was on the computer and the other client (C2) was in a room. Staff did not see any alleged incident; staff did not see C1 touching C2's breast. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Yan Yeung LICENSING EVALUATOR NAME: Karen Suh 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 32-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, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BELOVED ONES 2FACILITY NUMBER: VISIT DATE: 07/27/2023

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

met_with: Danielle Council, Supervising Facility Manager


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
In addition to the interviews conducted, it is important to note the efforts to engage with the reporting party (RP) and neighbors for their statement. On 10/31/23, LPA Martinez emailed the RP seeking a statement regarding the incident under investigation. Despite efforts by LPA Martinez, the reporting party's statement was absent from the investigation. On 10/19/23, LPA Martinez approached the neighbors to discuss the complaint investigation. Despite this attempt, the neighbors declined to provide a statement. On 09/11/23, the department received a complaint alleging that staff did not provide adequate supervision to youth in care. Confidential interviews consistently revealed that staff are always available for supervision. All interviewed staff members (S1, S2, S3), along with C1, reported that staff is available to provide supervision. Additionally, staff members receive ongoing training in handling crises, ensuring they are prepared to handle challenging situations. Daily logs help maintain effective communication among staff. The staff members consistently stated that the youth placed in the facility are always under supervision. The staff interviewed denied the allegation that the facility failed to provide adequate supervision to the youth in their care. Based on the confidential interviews and records reviewed, the allegation against license 157807000 is unsubstantiated. An unsubstantiated determination means the allegation lacks a preponderance of the evidence to prove that the violation occurred. There are no deficiencies to be cited at this time. An exit interview was conducted, and a copy of the signed LIC9099 was provided to the administrator.

Investigation Findings:
13On 01/11/24, Licensing Program Analyst (LPA) Joe Martinez met with Danielle Council, Administrator, to deliver findings for the above complaint. During an investigation into the complaint received by the department, LPA Martinez interviewed three (3) staff members and one (1) youth on 09/13/23. At the time of the inspection the facility only had one youth placed in the home. On 11/06/23, LPA Martinez reviewed records relevant to the investigation. Records included the Needs and Services Plan, Special Incident Reports (SIR), Team Meeting Records, and Daily Program Notes. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Yan Yeung LICENSING EVALUATOR NAME: Joe Martinez 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 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BELOVED ONES 2FACILITY NUMBER: VISIT DATE: 01/11/2024

met_with: Danielle Council


raw_content:
Narrative:
S1 and S2 denied the allegations, asserting that they are both certified in Professional Assault Crisis Training (Pro-Act) and will utilize this training only as a last resort to prevent self-harm among clients or to protect others from harm. S2 additionally noted that all staff members are trained in trauma-informed care and will employ effective communication strategies to de-escalate potential conflicts. S1 and S2 mentioned that physical interventions may include blocking by proximity or guiding clients to a safer location. They also reported an incident that took place on July 12, 2024, involving C1, who, after receiving a phone call informing them of a family member's passing, became emotionally distressed and threw an object at a wall shelf, resulting in its collapse. S1, who was seated in the office adjacent to C1's room, heard the disturbance and went to assess the situation. Upon opening the door, S1 was met with C1's demand to "get the fuck out of her room." S1 observed C1 with their head down on the bed and the shelf on the floor and refusing to engage in conversation. Shortly thereafter, C1 requested a hammer to reattach her bookshelf to the wall. When S1 offered assistance, C1 declined, and since C1 was at baseline, S1 provided the hammer. S1 then positioned themselves at the doorway of C1's room and watched as C1 attempted to rehang the shelf before returning to the office. While at their desk, S1 noticed C1 exit her room and head towards the back door. S1 followed C1, who then threatened to strike S1 with the hammer if not left alone. C1 subsequently used the hammer to damage the outside cameras and continued into the facility to break the cameras located inside. S1 reported that upon entering the facility, she contacted S2, who arrived shortly thereafter to provide assistance. S2 noted that upon their arrival, they observed C1 wielding a hammer and refusing to relinquish it to S1, while also making threats to strike S1 with the hammer. Given the emergency situation and the risk of physical harm, S1 swiftly attempted to secure the hammer from C1, resulting in C1 dropping it on the floor. Subsequently, S2 secured the cooperation of C1 and instructed S1 to retrieve the hammer and place it in the staff office. S2 explained that C1 was held back solely to prevent C1 from accessing the hammer or inflicting harm on another (S1). Upon S1's return from the office, C1 exhibited signs of distress and attempted to reach out to S1; however, C1 lost their balance and fell to the ground, requiring a brief support on C1's arm and shoulder that lasted no longer than forty seconds. S2 then advised S1 to return to the office, while C1 attempted to jump out of the living room window. S2 intervened by grasping C1's hand and pulling C1 back, cautioning C1 about the dangers of attempting to leave the facility without proper attire, as they were only wearing a t-shirt and undergarments. C1 subsequently hurried to their room, expressing a need to smoke, and took a cell phone along with marijuana vape pens, attempting to smoke in the presence of S2. S2 intervened, confiscating the contraband and informing C1 that, due to a court order, possession of a cell phone was prohibited. Subsequently, S2 initiated a dialogue with C1, who disclosed that their behavior was influenced by the recent passing of a family member. At this point, S2 offered assistance, which C1 opted to refuse. Based on information obtained during interviews describing the incident in question, the circumstances involved did not result in the usage of restraints or meet the restraint criteria. Additionally, findings from the investigation indicated that the personnel had received training in Pro-Act and employed the correct techniques when applying restraints. The facility's staff documented the application of restraints and promptly submitted Serious Incident Reports (SIRs) to the relevant agencies. Therefore, based on the information received, the above allegation(s) is determined to be unsubstantiated. Although the allegation(s) may have happened are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the allegations are found to be unsubstantiated. Appeal Rights were provided and discussed with the Foster Family Agency. There are no deficiencies to be cited at this time. An exit interview was conducted and a copy of the report along with the (LIC 811) was left with the STRTP Facility Manager.

Investigation Findings:
13On September 27, 2024, at 12: PM, Licensing Program Analyst (LPA) Winston Moroney conducted a complaint inspection at the above Short-Term Residential Therapeutic Program (STRTP) and met with the Supervising Facility Manager Serina Lindsay. The inspection aimed to deliver the finding(s) regarding the complaint allegation(s). On July 22, 2024, the Community Care Licensing Division of the California Department of Social Services received a complaint from the Centralized Complaint and Information Bureau (CCIB) with the following allegation(s): Staff improperly restrained a minor in care. This LPA conducted the investigation of the above allegation(s) and it consisted of but was not limited to a review of records, including the client's needs and services plans, medical records, and interviews with the two staff members (S1) on 7/31/24, and S2 on 8/6/24. (C1), and (C2) declined to be interviewed, so no statement was obtained from them. (Reference Confidential Names Form LIC 811, dated September 26, 2024). **This is an amended findings report delivered on February 14, 2025*** The Following Allegation(s) were reported: The staff improperly restrained a minor in care. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Yan Yeung LICENSING EVALUATOR NAME: Winston Moroney 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 32-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, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BELOVED ONES 2FACILITY NUMBER: VISIT DATE: 09/27/2024

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

met_with: Serina Lindsay - Supervising Facility Manager