summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst, (LPA) Tana Kinder conducted a pre-licensing, Component II meeting with Cheryl Karran on 2/3/2022 to review revision requests to the program design. The meeting was conducted using the video conference platform, Microsoft Teams. Section 3: Every box was checked. Do you truly see this program serving every type of need identified on the list? Have you had experience and training with every population identified? Section 4: Page 2: Other descriptions, for example, behavioral and/or medical assessments? NSP & IPPs. Page 5, Line 9: remove comma after Regional Center Staff. Page 5: includes Long Beach Aquarium as a possible activity, please remove and identify specific options in your area- what is in your community? Give names and locations of dining places, parks, gyms; etc. Page 6: Note: and parent- check with them also. Line 31 the sentence starts with "Ways." Line 32 ...not limited to (should not have colon(:). Line 33 as support (insert regulations) to the person's needs. Line 36 codes and regulations. Line 39 ensuring. Page 7: Under dating line 5 physicals written 2# 5. Page 9: Please refer to local activities. Page 10: Are these optional? Aroma and meditation. Continued... Section 5: Lists services for San Joaquin and Solano county. Also make sure the programs listed are available to Regional Center clients-use examples of vendored services if applicable. Section 6: Page 15: top- will family or legal guardian also be informed and included? Page 15, Line 3: Individual(s) *Attach a copy of the appointment history tracking form to this section. Page 16: First Aid Kit-you list some specific items. Make sure you have everything required by regulations. Page 17, 2nd paragraph, line 5: Add PMAR with MAR. 2nd paragraph, last sentence: Be specific-where are you going to store? Have a designated area assigned. Page 20: Expired Medication Disposal- Change locations to local area. Section 7: Page 21, line 1: Define vigorous background check. 2nd sentence vigorous. *If you use volunteers add information here regarding driving policy. *Address potential use of car seats or car restraint systems for younger/smaller clients. Section 8: Individual move-in agreement: Page 23, Bullet 7: What age group? Be more specific. Page 26, Initial Screening: Will you take county referrals or only Regional Center? Later it says only Regional Centers. Clarifying would provide consistency. Page 28, Line 2: "individuals (who) are..." Under admission meeting documentation: please add Personal Rights will also be reviewed and a copy will be provided (unless I missed where you cover that). Page 29: Will you be taking CSEC clients? Continued... Section 9: Page 32, Bullet 2: remove the period (.) after the word following and perhaps use a colon (:) after "the plan of operation:" since you are listing the following information. Page 36, Line 1: remove the period (.) after "Individual Behavior. Supports..." Page 36: Who is responsible for completing the IBST? Section 10: Provide a detailed policy/procedure for removal of youth. Have a copy of the discharge plan/policy that would be signed by the parent/guardian in the child's record in this section. Section 11: When are visits allowed? Are the designated times/days visits happen or times they do not happen (during groups at the facility, etc.)? Section 12: Please address: Curfews, dress codes, dating policy, completing homework (?). Gambling and betting?? Why is Personal Hygiene addressed here? There is nothing that says anything about rules in the narrative. Maybe Section 9? Section 14: Page 44: Why is that first (very long) sentence in this section? What are you trying to convey? Maybe it should be rewritten and put in Section 3? Page 44, Line 8, last word: Avoid(s), remove (s). Line 14: "When an individual is safely (restrained) no restraint. Line 16: "simultaneously are restraint" should be "are simultaneously restrained." Page 45, paragraph 5, line 3: the last word, advise(d), paragraph 6, 1st sentence does not make sense. Already involved in Criminal Justice or preventing Criminal Justice involvement or additional Criminal Justice involvement? Continued... Section 15: Incident Report Section, Bullet 1: Individua(l)'s Section 16: Do you have a grievance form for the client's to access? Will you document the process if a client initiates a grievance? Where will this be kept? Section 17: Please edit the Policy and Procedures for Handling Children's Funds to reflect a minor. For example, remove the examples that do not apply to children; tax credits, renter credit, gambling winnings, etc. Include parents in this section as it applies. Page 56, Bullet 8: remove cigarettes and perhaps some of the other examples listed on page 56 and 57 as they do not pertain to minors. Please address allowance and how that will be handled. Section 18: Page 61, 2nd paragraph, line 3: sense (of) ownership. Are there paid chores? Section 19: Page 62, 2nd paragraph, line 2: Individuals is (are). Last ling page 63: fitting (fit). Page 64, Bullet 6: similar substance is (will). 2nd Bold/underlined section: "If at any point the dishwashing machines ... staff is (are). Section 20: Bullet 1, line 3: Rapidly change(s). Last bullet, line 1: "to be spend, (spent). Continued... Section 21: What is peer partner position? If you don't have it, do you want to eliminate? Otherwise, elaborate regarding the parameters for this position, including training, background check, etc. Should this be in Section 26? Section 22: QBMP/BCBA: "Several years of writing reports," be more specific; 2-3 years? 3-4 years? Page 72, line after paragraph 3: "The success(ful) candidate must..." Section 22, 23 and LIC 500: Be consistent with job titles: Administrator/Program Administrator, RN/RN Consultant, etc. Section 24: Where will you track and keep documentation for each employee's training. Add this information. Section 25: Don't see Appendix VII, specifically LIC 309. Section 26: Should Peer Partners be included here? Where will you keep track of volunteer training? Section 27: Provide a copy of the lease. Sections 28: Please identify where the Main Shutoff Valve is located. Section 29: Please provide Board of Directors information. Continued... Appendix II: Page 1, under Policy: "Upon admissions..." Page 1, last paragraph, line 4: "and so for(th)." Or so on?? Line 5: "developed by and DDS," Page 2, Line 6: regarding a restraint not lasting longer than 10 minutes: How was that timeframe determined? If the client is still escalated, how will you end the restraint? Page 2, line 8: "child is safely restraint (restrained)." Page 2, Multiple Emergency Interventions: How do you determine adequate number of staff? In the training handbook, is there a minimum number of staff that are required? Do you need to take the size of the client and staff into consideration? Maybe defer to the protocol of the technique you are using and document that here. Page 2, last paragraph, line1: "or a compliant (complaint)." Page 3, Debriefing, Bullet 1: "Child who was restraint (restrained). Bullet 9: "Determining where (if)..." Page 4, paragraph 2, line 1: "CCH will report to the Department..." is the Department DDS, DSS or both? CCL? Appendix III: Financial Policy Page 1, paragraph 4, line 4: individual(')s file Page 2: Where is the bonding documentation kept? *This appears to have been written for an adult client population. Please review and revise for minors and their parents and/or representatives like CPS. There is policy regarding loans, paycheck stubs, etc. Is any amount of $200 going to be returned to the client's parent or representative? Page 9: The list needs to reflect minors. Same with page 11 list of disallowed expenses.

met_with: Cheryl Karran


state: CA

facility_name: YAI EAST TABOR AVE.-ENHANCED BEHAVIORAL SUPPORTS

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tana Kinder conducted an announced pre licensing inspection with the Administrator, Qualified Behavioral Modification Professional (QBMP) and Director of Residential Services on 7/28/2022 at 10:30 am at the facility. LPA conducted the walk through of the facility with the above named staff and observed 4 bedrooms, 1 garage, 2 common areas, 2 bathrooms, a kitchen, laundry room, sensory room and a locked medication room. All spaces were clean, sanitary, free of insects, and had unobstructed pathways. LPA observed 7 days' worth of non-perishable, food for 4 potential clients. The refrigerator was 39 degrees and the freezer was 0 degrees. The hot water from the kitchen sink was 106.8 degrees. The facility does not utilize protective separation rooms. All the bedrooms are furnished with a bed, dresser, nightstand, desk/chair, closet and is well-lit. The front yard and back yard are fenced in with an accessible gate to the front of the property. The grounds have a recreation area with a basketball hoop and plenty of space for activities. No cameras are in use in the facility. There is a backup located on the side of the property. The water source is county water. The water sprinkler system is located on the side of the house. There is a locked storage structure in the enclosed part of the backyard. The backyard is fenced off with extra yard on the other side that is not accessible to the clients at this time. On the other side of the locked backyard there are 2 unlocked sheds, and 2 horse stable structures that are not in use or accessible to the clients. The facility is using a monthly rental minivan to transport clients. There are 24 staff associated to the facility. There are currently no clients at the facility. Continued... LPA has observed the following that need to be brought into compliance before issuance of the license. 1. Hygiene products need to be purchased and available for 4 clients. 2. Mattress pad covers for (4) beds. 3. Laundry detergent in the laundry room. 4. Facility Sketch needs to include the whole property and all dwellings. 5. The access to the side yard will be made in accessible like the rest of the outer backyard. 6. The ditch on the outside of the fenced front yard will be filled or secured so it is inaccessible. LPA reviewed the following forms with the facility staff: An exit interview was conducted and copy for the report was provided.

report_type: Facility Evaluation

visit_type: Prelicensing

met_with: Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 8/01/23 at approximately 12:40 p.m. Licensing Program Analysts (LPA) Jacqueline Carmona conducted an unannounced visit to the facility above for the purpose of conducting a collateral visit. LPA Carmona met with Elizabeth Steffens, the Facility Program Director and requested to interview Client #1 and 2 staff regarding an investigation. Licensing Program Analyst conducted the interviews during the visit regarding the allegations. LPA Carmona, conducted a walk through of the interior and exterior of the facility and it is in compliance, no deficiencies noted during todays walk through. Exit interview was conducted and a copy of this report will be provided to the Facility Program Director.

met_with: Elizabeth Steffens, Director


summary: Facility Evaluation

raw_content:
Narrative:
On 9/14/23, Licensing Program Analysts (LPA) Stephanie Lor made an announced required inspection to the above facility. LPA met with the Administrator who provided a tour of the exterior and interior of the facility. LPA observed and tested smoke detectors and carbon monoxide detectors. There is 1 staff office with locked files, desks, and lockers. LPA observed 4 bedrooms with appropriate bedding, furniture, and working lights. All bathrooms were tested and working. The water tested at the required temperature. All cleaning chemicals were locked and inaccessible to clients. LPA observed a locked room for medication. There were 2 fire extinguishers on site. First aid kits had all required items. LPA observed the kitchen refrigerator and pantry to be filled with perishable and non- perishable food items. LPA observed an adequate supply of utensils, dishes and a menu. A trash bin with a lid is located in the kitchen. The living room was observed to have adequate furniture and lamps. A laundry room with a washer and dryer is available to the clients. LPA observed the outdoor area to be clear of clutter and debris. LPA reviewed 5 staff and 2 youth files. LPA interviewed 2 staff and 1 client during this inspection. Technical Violation (TV) were given for the domain of operational requirement and client records. Technical Assistant (TA) were given for the domain of staffing and client records. A copy of this report was provided to the Administrator.

visit_type: Annual

met_with: ELIZABETH STEFFENS, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 12/01/23 at approximately 11:00 a.m. Licensing Program Analyst (LPA), Jacqueline Carmona made an unannounced visit to conduct a case management regarding a medication error. LPA Carmona met with Marshaila Thomas, Registered Behavioral Technician (RBT). On 11/30/23 an incident report was received by the Department regarding a client missing their medication dose(s). It was reported that on 11/22/23 a client was transported to a visit and the facility staff packed 3 bags of medication for the client. During the visit it was discovered the client only had one of the three bags of medication. It is unclear if client missed their medication. LPA conducted a walk through of the facility. LPA conducted interviews with (3) staff and (1) client. LPA obtained LIC500, MARS Log, Activity Log and Facility Staff Schedule. An exit interview was conducted and a copy of this report was provided to RBT. This case management investigation needs further investigation.

visit_type: Case Management

met_with: Marshaila Thomas, RBT


summary: Facility Evaluation

raw_content:
Narrative:
On 1/12/24 at approximate 12:34 p.m. Licensing Program Analyst (LPA) Jacqueline Carmona conducted a visit to the facility above with the purpose of closing a case management investigation . LPA Carmona met with Cerena Mixon, DSP who assisted with the inspection. LPA Carmona toured the interior and exterior of the facility. At the time of the visit there were DSP staff and no clients present. LPA Carmona was informed via a telephone call by Regional Deputy Director Elizabeth Steffens that there was no administrator available near by and LPA Carmona would have to wait approximately 1 to 1.5 hours at the facility. LPA Carmona informed Elizabeth Steffens LPA Carmona would have to return at a later time. Exit interview conducted. No report was left at the facility.

met_with: Cerena Mixon, DSP


summary: Facility Evaluation

raw_content:
Narrative:
On January 26, 2024 at 11: AM, The Department met with Licensee for the purpose of an Informal Office Meeting to discuss areas of facility compliance. Attendees were: Licensing Program Analysts (LPAs), Farhaan Sarangi, Jacqueline Carmona, Sara Luman-Gonzalez, Licensing Program Manager (LPM), Rosa Rodriguez, Regional Manager (RM), Margo Castaneda, CDSS Staff Attorney, Erik Brunkal, Licensee, Cheryl Karran, HR Manager, Emily Ramos, Attorney Jake Reinhardt, Department of Developmental Services (DDS), Leah O'Meara, Catherine Knight and Angela Craven, Regional Center of the East Bay, Brooke Guerrero, Regional Manager at Regional Center of the East Bay, Jeff Nagafuji, Resource Developer with Regional Center for the East Bay, Heather Jacobs and DDS Angela Munoz. Areas of Concern: · Increase in number of complaints between both facilities (YAI East Tabor Rd and YAI Davis Rd.) primarily due to lack of staffing. Licensee acknowledges issues with staffing. The population that the facility serves requires a lot of attention. Licensee acknowledges that the clients they serve have a 2 to 1 ratio. HR Manager reports that there are four applicants going through the hiring process. Licensee reports that the house has been challenging regarding the culture in that home and the former facility staff. Licensee terminated previous employees that created a toxic work environment. Licensee has hired Prospective Administrator, Amber Palesi. Licensee reports having staff work double shifts. Licensee reports that the contingency plan put in place is sharing staff from other homes if staffing issues continue. New staff have been very good at picking up extra shifts. HR is adamant about visiting colleges, recruitment fairs and ongoing recruitment efforts. · Department of Developmental Services (DDS), Leah O'Meara advised that 80 hours of training is required for new staff and per diem staff that are new to YAI facilities. (Page 1 of 2) · Licensee was reminded of Reporting Requirements as it relates to submitting incident reports timely. · Required records availability-Licensing needs to have access to records as per Inspection Authority. Protocol for providing documentation to Licensing agency; ensuring records are readily available and easily accessible to CCL during business hours. LPA, Carmona advised that the Internet connectivity issues being a concern. Licensee acknowledges that there have been struggles with the internet connectivity. Licensee uses two different internet providers and is currently exploring other options to remedy this issue. · Staff do not feel that they are properly trained on medication dispensing. Staff issues with dispensing medication and the changes around medication dispensing. Licensee acknowledges their multiple medication errors and has since hired a Registered Nurse to train staff on medication procedures and review the MARS for both facilities. · No authorized staff members delegated at the facility to sign licensing reports. Licensee plan is to ensure an Administrator or lead staff is always in the home should Licensing arrive to the home. · General upkeep of physical plant: General Window discussion on replacing windows in a timely manner Window Screens need to be in place and inspected regularly. Heating and AC in facilities. Licensee reports that there have been multiple windows being broken. Licensee acknowledges the property destruction and physical plant concerns. Licensee reports of putting in a brand new screens. Licensee reports that the heating has been fixed in the facility. Licensee reports that they have hired two maintenance staff for both facilities. Licensee will put in procedure for submitting work orders when maintenance issues arise upon the departments request. · Accessibility to all parts of the facility. Licensee reports that it is a lactation room. Licensee reports that the leads have all the codes. Licensee will submit a new facility sketch to address the lactation room and will ensure that lead staff have access when CCL comes for unannounced inspections. Licensee has requested the Program Director to be contacted if a room is not accessible. Support & Resources: Licensee requested a Technical Support Program Referral (TSP). Referral to CDSS Technical Support Program pending. Exit interview was conducted and a copy of this report was emailed to the Licensee for signature.

met_with: Licensee, Cheryl Karran


summary: Facility Evaluation

raw_content:
Narrative:
On January 30, 2024 at approximately 12: PM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at YAI East Tabor Ave.-Enhanced Behavioral Supports for the purpose of Amending a Complaint Investigation Inspection dated for January 25, 2024. LPA was greeted at the door by, Licensee/Regional Director, Cheryl Karran, and was granted access into the facility. During this Case Management-Other inspection, LPA amended the report due to a discrepancy in job titles on the report. LPA advised that the findings of the complaint investigation will not change. Exit interview was conducted and a copy of this report along with the Amended Report was given to the Licensee/Regional Director, Cheryl Karran.


summary: Facility Evaluation

raw_content:
Narrative:
On 2/07/2025 at 10: AM Licensing Program Analyst (LPA) Sarina Buchannan made an unannounced visit with the purpose of conducting an Annual inspection to the above facility using the Compliance and Regulatory Enforcement (CARE) tool. LPA met with Lanasha Devers, Assistant Administrator, and a walk through of the interior and exterior was completed.The facility serves up to 2 ambulatory and 2 non ambulatory female and male clients between the ages of 12-17 and 18-22 years old with an exception. Physical Plant Room 1 is a staff office with client files, a printer, and an exit to the garage. Room 2 is a client bedroom that has a dresser, a full size bed, and a Television. Room 3 is a bathroom which has a toilet, storage drawers, and a trash can with a tight fitting lid. Room 4 is a medication closet that has medical binders, a mini refrigerator, a safe, and a fire extinguisher. Room 5 is a common area with a large sectional, a facility phone, and a coffee table. Room 6 is entertainment room with 2 couches, an area rug, and a television. Room 7 is a sensory room connected to room 6 and has a foosball table, an office chair, and pads to sit on. Room 9 is a kitchen with a working stove, trash with a tight fitting lid, and a combination refrigerator and freezer. Room 10 is a dining room with 2 tables, 6 chairs, and a emergency disaster plan posted. Room 11 is a closet connected to the dining room and only stores the facility routers and other technology. Room 12 is a client bedroom with a twin size mattress, 2 storage units, and a rug. Room 13 is a bathroom with a working toilet, a storage unit, and trash can with a tight fitting lid. Room 13 is a client bedroom with a full bed, 2 storage units, and a PlayStation 5. Room 14 is a client bedroom with a twin bed, table, and chairs. The 2 client bathrooms have water temperatures at 112.9 degrees Fahrenheit. The backyard is gated, has a shed, and is clear of debris. (continued on LIC 809C)(Page 1) The following required documents were posted, License and Personal Rights. Disinfectants/cleaning solutions were inaccessible to clients in care and stored in the locked garage. Refrigerator Temperature at or below 45 degrees Fahrenheit. Nonperishable foods one week and fresh perishable foods two days minimum. Menu present and posted in the kitchen area on the fridge. Working telephone are available at the facility. Carbon monoxide and smoke detectors are in working order. First Aid Kit fully stocked. Medication centrally stored, locked/inaccessible to children. Hot Water between 105-120 degrees Fahrenheit. Fire Extinguisher up to date and in working order. Toilets wash basin, bath, and shower fixtures in good repair/no leaks/hot water temperature. Soap and Paper towels are available to clients. Bedrooms required linen and furnishings are fully stocked. Facility is free of vermin. The following domains were also reviewed during today's inspection, Operations, Disaster Preparedness, Staffing, Emergency Intervention, and Client Records. A total of 5 staff files and 2 client files were reviewed. LPA also conducted 2 staff interviews. LPA was unable to conduct client interview but will follow up at a later date. A review of the Licensing Information System indicates the facility is not up to date on their facility. The facility fees which are due in the amount of 681.00 were due on 09/26/24. All the staff were fingerprint cleared and associated to the facility. Based on confidential interviews conducted no concerns for follow up were noted at this time. An exit interview was conducted with Lanasha Devers, Assistant Administrator, and a copy of this report, and the Appeal Rights were provided to the facility.

met_with: Lanasha Devers, Assistant Administer


summary: Facility Evaluation

raw_content:
Narrative:
On August 20, 2025 at approximately 10:18am Licensing Program Analyst (LPA) Tatyana Shulz made an unannounced inspection to close a case management at the above facility. LPA was greeted by Lanasha Devers, Assistant Administrator who granted LPA access. Prior to the meeting LPA Shulz conducted a tour of the inside and outside of the facility where LPA observed the following deficiency. All the kitchen cabinets do not have doors and drawers installed and are all covered by curtains affixed by Velcro. LPA conducted a walk through of the facility and observed that the deficiency noted on the August 06, 2025 inspection has not been fixed, the facility is currently looking for a cabinet supplier and states that due to the cabinets being custom the process will take an additional 5-6 weeks after the order is placed. LPA will conduct a follow up visit around that time. This case management will remain open until a follow up inspection has been conducted. An exit interview was conducted, and a copy of this report was left at the facility with Assistant Administrator, Lanasha Devers.

met_with: Lanasha Devers-Assistant Admistrator


summary: Facility Evaluation

raw_content:
Narrative:
On 9/24/2025 at 10: AM Licensing Program Analyst (LPA) Tatyana Shulz made an unannounced visit with the purpose of conducting an Annual inspection to the above facility using the Compliance and Regulatory Enforcement (CARE) tool. LPA met with Lanasha Devers, Assistant Administrator, and a walk through of the interior and exterior was completed. The facility serves up to 2 ambulatory and 2 non ambulatory female and male clients between the ages of 12-17. There were 5 staff present and 1 client during the time of the annual inspection. LPA interviewed 3 staff and attempted 1 client interview at this time. LPA observed 4 bedrooms, 2 bathrooms, 1 sensory room, 1 staff office, 1 medication room, 1 living room, 1 dining room, 1 den area and a kitchen. Physical Plant: License, Personal Rights and other required documentation were posted throughout the facility. Disinfectants/Cleaning Solutions were stored away in the garage and are made inaccessible to clients in care. Refrigerator and Freezer were observed to be in working order with nonperishable foods one week and fresh perishable foods two days minimum. Menu present and posted in the kitchen area on the fridge. Hot water was tested at 108 degrees F. Fire Extinguishers are up to date and in working order. Carbon Monoxide and Smoke Detectors were observed to be in working order. First Aid Kit is fully stocked. Adequate bed linens were observed in the facility. Fixtures are in adequate repair. Multiple common areas are available for client to utilize. The dining area was observed to have enough seating for all clients with furniture in good repair. All bathroom fixtures were observed to be in good repair with adequate soap and towels. Laundry services are available for client use. (Continued on LIC 809C) Medication is centrally stored, locked/inaccessible to clients in the medication room. The office is locked/inaccessible to client, files are stored in the office area. Working telephones are available at the facility. The exterior was observed to be in a safe condition. Operations: Fire Clearance was observed. Board Meeting minutes were reviewed with the facility. Disaster Preparedness: Disaster & Mass Casualty Plan is updated and available at the facility. Emergency Intervention: Staff training was observed. Restraint Logs were reviewed and up to date. The facility is trained on manual restraints and will utilize it when necessary. Staffing: 5 staff files were reviewed. All were currently First Aid/ CPR Certified through American Red Cross. Job title and qualifications were verified. All Criminal Record Clearances were observed. Client Records: 2 client files were reviewed. Admission agreements were signed and dated. Clients MAR and PMAR documentation is current. Cash Resources show current ledger accounting with needed signatures. Special Health Care Needs: Health Care Provider available at the facility. Individual Health Care Plans are up to date and available. The following items were reviewed for compliance: Annual Fees: No fees due. Administrator Certificate for: Kristen Fox and Lanasha Devers is current. Emergency Disaster Plan (per H&S Code 1565) Personnel Roster, Guardian Fingerprint Clearance and Facility Sketch. Based on confidential interviews there were no concerns for follow up needed. An exit interview was conducted with Lanasha Devers, Assistant Administrator and a copy of this report, and the Appeal Rights will be provided to the facility.

met_with: Lanasha Dever-Assistant Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On November 4, 2025 at approximately 11:33am Licensing Program Analyst (LPA) Tatyana Shulz made an unannounced inspection to close a case management at YAI E. Tabor. LPA was greeted by Kristen Fox, Administrator who granted LPA access to the facility. Prior to the meeting LPA Shulz conducted a tour of the inside and outside of the facility where LPA observed the following deficiency. All the kitchen cabinets do not have doors and drawers installed and are all covered by curtains affixed by Velcro. LPA conducted a walk through of the facility and observed that the deficiency noted on the August 6, 2025 inspection has been fixed, the facility is in full compliance. This case management is now closed. An exit interview was conducted, and a copy of this report was left at the facility with Kristen Fox, Administrator.

met_with: Kristen Fox- Administrator


summary: Facility Evaluation - 2 deficiencies

raw_content:
Narrative:
On August 6, 2025 at 10:13am Licensing Program Analyst (LPA), Tatyana Shulz made an unannounced visit to conduct a case management regarding DDS Semi-Annual Review that took place at the facility on June 26, 2025. LPA met with Lanasha Devers, Assistant Administrator who granted LPA access to the facility. Prior to the meeting DDS Behavior Specialist II, Justin Pineda Carlos conducted a tour of the inside and outside of the facility where the Specialist observed the following deficiencies: · A buildup of residue, cobwebs, dust bunnies, smudges/grime, and residual adhesives throughout the facility. · The side gate leading to the gated and repaved parking lot could not be open as it is obstructed by gravel or other material. · All the kitchen cabinets do not have doors and drawers installed and are all covered by curtains affixed by Velcro. LPA Shulz conducted a walk through of the facility and observed that the obstruction and the residue throughout the facility that was noted on the June 26, 2025, inspection have been corrected. The facility is currently waiting for the custom cabinet and drawers to be delivered to the facility. LPA was shown that the work order was placed on July 1, 2025. An exit interview was conducted, and a copy of this report and the Appeal Rights were provided to Lanasha Devers, Assistant Administrator. The facility has been cited for Buildings and Grounds on LIC809D. This case management will remain open until a follow up inspection has been conducted.

Deficiencies:
80087(a): 1
2
3
4
5
6
7
80087(c): 1
2
3
4
5
6
7

met_with: Lanasha Devers- Assistant Administrator

title:
1
2
3
4
5
6
780087 (a) Buildings and Grounds
The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by

description:
1
2
3
4
5
6
7

title:
1
2
3
4
5
6
780087 (c) Buildings and Grounds
All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.
This requirement is not met as evidenced by

description:
1
2
3
4
5
6
7


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Dawn Eunice conducted an unannounced case management inspection to the above facility for the purpose of ensuring compliance with Title 22 regulations regarding Health Related Services. The Department received an incident report regarding a child's missed medication on or about 10/26/2023. A staff person administered medication, and it was not documented in the facility's medication log. When the mistake was discovered, a full medication audit was conducted, staff training followed, Enhanced Behavioral Supports Home administrative staff conducted an internal investigation, a medical professional/registered nurse was notified. Additionally, a preventative plan was put in place which included the previously mentioned medication audit, training plan and Registered Behavior Technician (RBT) staff devised and implemented a new medication protocol. This case management inspection is closed on 11/08/2023.

met_with: Ileya Silva, Administrator


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On December 5, 2023 at approximately 08: AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at YAI East Tabor Ave.-Enhanced Behavioral Supports for the purpose of conducting a Case Management-Deficiencies Inspection. LPA was greeted at the door by Caregiver, Lanasha Devers, and was granted access into the facility. Administrator arrived 30 minutes later. Upon arrival to the facility at 08: AM, LPA observed that the staff office window had large wooden slab covering the staff office where resident binders/information is located (See LIC 809D and See LIC 812-Photos). LPA was informed by the Administrator that the window has been broken since late October 2023. During this Case Management-Deficiencies inspection, LPA observed no work order to have the staff window replaced. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Administrator.

Deficiencies:
80088(b): (b)	All window screens shall be in good repair and be free of insects, dirt and other debris.

met_with: Administrator, Ileya L. Silva Caregiver, Kristin Fox

title:
1
2
3
4
5
6
780088 Furniture, Fixtures, Equipment, and Supplies


summary: Facility Evaluation

raw_content:
Narrative:
On December 27, 2023 at approximately 12: PM, Licensing Program Analyst (LPAs), Farhaan Sarangi and Sara Lumen-Gonzalez arrived unannounced at YAI East Tabor Ave.-Enhanced Behavioral Supports for the purpose of a Case Management-Deficiencies Inspection. Also accompanying the LPAs is State of California-Department of Developmental Services (DDS), Leah O'Meara. LPAs and DDS worker were greeted at the door by Caregiver, Reina Sumili and was granted access into the facility. During the tour, LPA observed that the back door by both the children's rooms had no operating door lock. LPA observed that a vacant room had no screen and the screen in the child room was damaged (See LIC 809D). Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in additional civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the interim Administrator.

met_with: Administrator, Steven Toal Lead RBT, Reina Sumili


summary: Facility Evaluation

raw_content:
Narrative:
On 1/18/24 at approximately 11:00 a.m. Licensing Program Analyst (LPA), Jacqueline Carmona made an unannounced visit to conduct a case management regarding a medication error. LPA Carmona met with Steven Toal, Program Administrator. On 11/30/23 an incident report was received by the Department regarding a client missing their medication dose(s). It was reported that on 11/22/23 a client was transported to a visit and the facility staff packed 3 bags of medication for the client. During the client's visit it was discovered the client only had one of the three bags of medication. LPA Carmona conducted 9 confidential interviews and LPA Farhaan Sarangi conducted 1 confidential interview. LPA Carmona obtained and reviewed LIC500, MARS Log, Behavior Agent Notes, Facility Staff Schedule, Internal Investigation Report, Medication Transfer Sheet, Sections 6 and 7 of Program Statement, Staff Training Certificates, and SIR dated 11/22/23. Based on confidential interviews and documents obtained it was confirmed a client had possession of their medication during an unsupervised period of time. 4 confidential interviews confirmed facility staff did not include a Medication Transfer Sheet form with the medication prepared for the visit. In addition, Program Statement section 6 states medications will not be left unattended by staff members. Due to the facility staff allowing the client to have possession of their medication while being unsupervised and the proper protocols not being met the facility has been cited. An exit interview was conducted and a copy of this report was provided to the Administrator. This case management investigation is closed and has been cited Plan of Operation 80022 (k).

met_with: Steven Toal, Program Administrator


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On February 13, 2024 at approximately 12: PM, Licensing Program Analyst (LPAs), Farhaan Sarangi arrived unannounced at YAI East Tabor Ave.-Enhanced Behavioral Supports for the purpose of conducting a Case Management-Deficiencies Inspection. LPA met with Lead RBT, Kristen Fox, and was granted access into the facility. During the Case Management-Deficiencies Inspection LPA received an incident report on February 9, 2024 reporting that a client was not given prescribed medication on February 7, 2024. Clients physician was contacted and instructions were given to staff (See LIC 809D). LPAs requested the following documents: -Medication Administration Record (MAR) for said date Deficiencies cited from the California Code of Regulations. Appeal Rights were given. Failure to correct the deficiency and/or repeated deficiencies within a 12-month period may result in additional Civil Penalties. Exit interview was conducted, and a copy of this report was signed and given to the Lead RBT, Kristen Fox.

Deficiencies:
80075(b): (b)	Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. 1
2
3
4
5
6
7Plan of Correction: Shall include Licensee filling out an LIC 9098. In addition, Licensee shall conduct staff training to ensure that clients are getting proper medication administered. Furthermore, Licensee shall fill out a statement on how future compliance will be met.
8
9
10
11
12
13
14

met_with: Lead RBT, Kristen Fox

title:
1
2
3
4
5
6
780075(b) Health Related Services


summary: Facility Evaluation

raw_content:
Narrative:
On January 23, 2026 at 12:30pm Licensing Program Analyst (LPA), Tatyana Shulz made an unannounced visit to conduct a case management regarding DDS Semi-Annual Review that took place at the facility on January 15, 2026. LPA met with Kristen Fox, Administrator, who granted LPA access to the facility. Prior to the meeting DDS Behavior Specialist II, Justin Pineda Carlos conducted a tour of the inside and outside of the facility where the Specialist observed the following deficiencies: A ceiling pipe was leaking resulting in water damage of the ceiling above one bathroom. The leaking pipe has been repaired, however there is still a visible opening/hole where the puncture occurred. A buildup of residue/grime on the BBQ grill. LPA Shulz conducted a walk through of the facility and observed that the deficiencies that were noted on the January 15, 2026, inspection is still being corrected. LPA was shown and received the work order that was placed on January 5, 2026 for the ceiling repairs and the grill has been cleaned. An exit interview was conducted, and a copy of this report will be provided to Kristen Fox, Administrator. The facility has been given a LIC9102 (TV) for Buildings and Grounds. This case management will remain open until a follow up inspection has been conducted.


summary: Facility Evaluation

raw_content:
Narrative:
On April 7, 2026 at approximately 10:45am Licensing Program Analyst (LPA) Tatyana Shulz made an unannounced inspection to close a case management at the above Enhanced Behavioral Support Home. LPA was greeted by Lanasha Devers, Assistant Administrator who granted LPA access to the facility. Prior to the meeting LPA Shulz conducted a tour of the inside and outside of the facility where LPA observed the following deficiencies. A ceiling pipe was leaking resulting in water damage of the ceiling above one bathroom causing a visible opening/hole where the puncture occurred. A buildup of residue/grime on the BBQ grill. LPA conducted a walk through of the facility and observed that the deficiency noted on the January 15, 2026 inspection has been fixed, the facility is in full compliance. This case management is now closed. An exit interview was conducted with Lanasha Devers, Assistant Administrator and a copy of this report will be sent to the licensee.

met_with: Lanasha Devers-Assistant Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On April 7, 2026 at approximately 10:45am Licensing Program Analyst (LPA) Tatyana Shulz made an unannounced case management inspection at the above Enhanced Behavioral Support Home and met with Lanasha Devers, Assistant Administrator who assisted LPA Shulz with the inspection. The purpose of the inspection is to follow up on an Incident Report that was received by the Department on April 3, 2026, involving lack of supervision. LPA conducted 1 staff interview and attempted 1 client interview during this inspection and obtained the following documents: Staff schedule for April 2026, staff training's and the most up to date staff contact list. This case management will remain open. Further investigation is need. Exit interview conducted and a copy of this report will be sent to the licensee.


summary: Facility Evaluation

raw_content:
Narrative:
On April 7, 2026 at 10:45am Licensing Program Analyst (LPA) Tatyana Shulz arrived at the above Enhanced Behavioral Support Home for the purposes of conducting a case management. LPA was greeted by Lanasha Devers, Assistant Administrator who granted LPA access. LPA conducted a tour of the inside and outside of the facility where LPA observed the following deficiency. The handrail leading towards the front door is loose and is being held in place by a single screw and wire. A work order has been placed during today's visit. LPA requested and obtained work order documentation. The facility is being issued a Technical Violation for Buildings and Ground. (See LIC9102 for further details) Exit interview conducted and a copy of this report will be sent to the licensee.


summary: Complaint Investigation - Substantiated - 1 deficiency

raw_content:
Narrative:
Based on evidence obtained and confidential interviews conducted during the investigation process the allegation above has been substantiated. 4 out of 6 confidential interviews stated that they witnessed a staff member sleeping while on shift the morning of January 2, 2026, and that the client also attempted to obtain the staff members' attention with no response. Administration was informed of the sleeping staff and instructed the lead to remove them from the floor. LPA was informed later that the staff member has since been terminated as of February 4, 2026. Based on LPA observations and interviews which were conducted and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Title 22 regulations are being cited on the attached LIC 9099D. Exit interview conducted, copy of this report and the Appeal Rights were discussed and will be provided to the licensee.

Investigation Findings:
13On April 2, 2026, at 11:15am Licensing Program Analyst (LPA) Tatyana Shulz made an unannounced visit to deliver findings to the above Enhanced Behavioral Support Home (GH) and met with Kristen Fox, Administrator. Prior to the meeting LPA Shulz conducted the 10-day inspection of the facility on 1/12/2026. No deficiencies were cited during that inspection. LPA Shulz requested the Staff and Client Roster, Staff Schedule, Staff Contact Information, Client Face Sheet and Individual Behavioral Support Plans for all clients in care. LPA Shulz conducted 8 interviews between 1/12/2026-3/25/2026. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Connie Goldie LICENSING EVALUATOR NAME: Tatyana Shulz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: YAI EAST TABOR AVE.-ENHANCED BEHAVIORAL SUPPORTSFACILITY NUMBER: VISIT DATE: 04/02/2026

Deficiencies:
84065.2: Supervision, protection and care of children individually and in groups at all times.

report_type: Complaint Investigation

met_with: Kristen Fox-Administrator

complaint_status: SUBSTANTIATED

title:
(b)(1) Personnel Duties
Child care staff shall perform the following duties


summary: Facility Evaluation

raw_content:
Narrative:
On April 23, 2026 at approximately 11:30am Licensing Program Analyst (LPA) Tatyana Shulz made an unannounced case management inspection at the above Enhanced Behavioral Support Home and met with Lanasha Devers, Assistant Administrator, who assisted LPA Shulz with the inspection. The purpose of the inspection is to follow up on an Incident Report that was received by the Department on April 9, 2026, involving lack of supervision and inappropriate contact. LPA conducted 1 staff interview and attempted 1 client interview during this inspection and obtained the following documents: Staff schedule for April 2026, staff training's and the most up to date staff contact list. This case management will remain open. Further investigation is need. Exit interview conducted and a copy of this report will be sent to the licensee.


facility_name: YAI MORRO RD. EBSH

summary: Complaint Investigation - Unsubstantiated - 3 allegations

raw_content:
Narrative:
Confidential interviews did not believe the interactions was due to lack of supervision, however, other confidential interviews did not provide consistent statement of the alleged events. LPA received a conflicting information. Based on confidential interviews, the allegation that due to lack of supervision, inappropriate sexual interactions between C1 and C2 occurred, may have occurred, however, there was not a preponderance of evidence to support or deny the allegation. Therefore, the above allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this signed report was provided to Portia Tresvant, Administrator.

Investigation Findings:
13On March 20, 2024, at 9: AM, Licensing Program Analyst (LPA) Lucero Jauregui conducted an unannounced complaint inspection and met with Portia Tresvant, Administrator. The purpose of the inspection is to deliver the finding for the above allegation. LPA conducted an inspection of the facility on December 6, 2023, and one deficiency was noted. During the investigation, LPA conducted five staff interviews (S1, S3-S6), two client interviews (C1 and C2) and obtained incident narratives. On December 6, 2023, Community Care Licensing (CCL) received the allegation that due to lack of supervision, inappropriate sexual interactions between minors occurred. Confidential interviews indicated staff intervened with Ukeru pads when staff witnessed inappropriate interaction between C1 and C2. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Yai Morro Rd. EBSHFACILITY NUMBER: VISIT DATE: 03/20/2024

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0

met_with: Portia Tresvant, Administrator

complaint_status: unsubstantiated


raw_content:
Narrative:
Confidential interviews did not produce information to corroborate the allegation, and the investigation did not reveal any there were no other witnesses to the alleged event. Based on confidential interviews, the allegation that S2 and S3 handled C1 in a rough manner, may have occurred or is valid, however, the allegation is not supported, or proven by evidence. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this signed report and appeal rights were provided to Portia Tresvant, Administrator.

Investigation Findings:
13On July 24, 2024, at 1: PM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Portia Tresvant, Administrator to discuss the investigative finding for the allegation noted above. LPA Jauregui conducted an inspection of the facility on January 26, 2024 and no deficiencies were noted. During the investigation, LPA Jauregui interviewed nine staff (S1-S11), one client (C2), and LPA attempted to interview Client 1 (C1), however, C1 is non-verbal. LPA obtained C1's Individual Behavior Support Plan, and staff schedule. On January 24, 2024, Community Care Licensing (CCL) received an allegation that staff (S2 and S3) handled minor in a rough manner. It was reported that C1 became physically aggressive towards S1, and S2 and S3 stepped in to assist, and S2 and S3 grabbed C1 by their wrists and ankles.Confidential interviews yielded that staff have not observed S2 or S3 be aggressive towards C1. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Yai Morro Rd. EBSHFACILITY NUMBER: VISIT DATE: 07/24/2024

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0


summary: Complaint Investigation - Substantiated - 3 allegations

raw_content:
Narrative:
Confidential interviews and record reviewed also indicated that the facility is out of ratio when there are three staff present for two clients, as 1:1 supervision is not safe due to the behaviors of clients in care. Confidential interviews indicated the facility struggles with meeting staffing ratio, and staff are called in for coverage when needed. Record reviewed reflected that during the week of January 15 through January 19, 2024, the facility was out of ratio during the hours of 2: PM to 10: PM. Additionally, the facility was out of ration on January 15, 2024 and January 19, 2024 during the hours of 10: PM to 6: PM. Based on confidential interviews and record review, the allegation that facility was out of ratio is SUBSTANTIATED because the preponderance of evidence has been met. This posed a potential Health, Safety, or Personal Rights risk to children in care. The facility will be cited for violating Title 22, Division 6, Chapter 1, Article 06. Continuing Requirements, Responsibility for Providing Care and Supervision 80078(a), [See LIC 9099D]. An exit interview was conducted, and a plan of correction was developed with Portia Tresvant, Administrator. A copy of this report and appeal rights were provided to Portia Tresvant, Administrator.

Investigation Findings:
13On July 24, 2024, at 12: PM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Portia Tresvant, Administrator to discuss the investigative findings for the allegation noted above. LPA Jauregui conducted an inspection of the facility on January 26, 2024 and no deficiencies were noted. During the investigation, LPA Jauregui interviewed seven staff (S1-S6, S10), one client (C1), and LPA attempted to interview C2, however, C2 is non-verbal. LPA obtained C1's Individual Behavior Support Plan, level of supervision chart, staff schedule and Client Activity notes dated January 2024. On January 22, 2024, the Department received an allegation that the facility was out of ratio. It was reported that the facility was out of ratio during the week of January 15 through January 19, 2024. Confidential interviews and record reviewed indicated the required ratio was is 2:1 for each client (C1 and C2). SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Yai Morro Rd. EBSHFACILITY NUMBER: VISIT DATE: 07/24/2024

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


raw_content:
Narrative:
Confidential interviews conducted during the investigation did not yield evidence to corroborate the allegation. The investigation did not yield any other evidence that indicated that the alleged event occurred. Based on a lack of evidence, the allegation that facility staff sedated a minor while in care, may have occurred, however, it is not supported, or proven by evidence. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this signed report was provided to Portia Tresvant, Administrator.

Investigation Findings:
13On July 24, 2024, at 1: PM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Portia Tresvant, Administrator to discuss the investigative finding for the allegation noted above. LPA Jauregui conducted an inspection of the facility on February 12, 2024, and no deficiencies were noted. During the investigation, LPA Jauregui interviewed five staff (S1-S5) and one client (C2). LPA attempted to interview Client 1 (C1), however, C1 is non-verbal. On February 7, 2024, Community Care Licensing (CCL) received an allegation that facility staff sedated a minor while in care.It was reported that S1 sedated C1. It was alleged that, in response to behaviors exhibited by C1, S1 gave C1 a medication and 10-15 minutes later C1 began to appear drowsy and went to their bedroom to lie down. It was also reported that C1's 2:1 staff (S3 and S4) were inside the bedroom with C1 when S1 went into the bedroom, reached over to check C1's pulse, and informed S3 and S4 that S1 sedated C1. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Yai Morro Rd. EBSHFACILITY NUMBER: VISIT DATE: 07/24/2024

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Confidential interviews further indicated that while both staff were away from the facility, the facility would be out of ratio, as there would be one staff for each client instead of two staff for each client, as required. Based on confidential interviews and record review, the allegation that facility operated out of ratio is SUBSTANTIATED because the preponderance of evidence has been met. This posed a potential Health, Safety, or Personal Rights risk to children in care. The facility will be cited for violating Title 22, Division 6, Chapter 1, Article 06. Continuing Requirements, Responsibility for Providing Care and Supervision 80078(a), [See LIC 9099D]. The facility is being issued a civil penalty for the repeat violation of the above noted standards. An exit interview was conducted, and a plan of correction was developed with Portia Tresvant, Administrator. A copy of this report, LIC9099D, LIC421 and appeal rights were provided to Portia Tresvant, Administrator. The investigation did not yield evidence to corroborate the allegation that staff engaged in inappropriate behavior in the presence of a minor. Based on confidential interviews, the allegation may have occurred, however, it is not supported, or proven by evidence. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this signed report was provided to Portia Tresvant, Administrator

Investigation Findings:
13On July 24, 2024, at 2: PM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Portia Tresvant, Administrator to discuss the investigative findings for the allegation noted above. LPA Jauregui conducted an inspection of the facility on February 7, 2024, and no deficiencies were noted. During the investigation, LPA Jauregui interviewed eight staff (S1-S8) and one client (C2). LPA attempted to interview Client 1 (C1), however, C1 is non-verbal. On January 30, 2024, Community Care Licensing (CCL) received an allegation that the facility was operating out of ratio. It was reported that while S1 and S2 worked on the same shifts, S1 and S2 would run errands during the shift, leaving the facility out of the required staffing ratio. A review of client records indicated that, during the day, C1 and C2 required a minimum of two to one staffing each. Confidential interviews yielded that, on multiple occasions while S1 and S2 worked on the same shifts, S1 would take S2 to accompany S1 while running errands to the pharmacy and grocery store. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Yai Morro Rd. EBSHFACILITY NUMBER: VISIT DATE: 07/24/2024

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


raw_content:
Narrative:
Confidential interviews indicated C1 and C2 were running around attempting to go out through the facility's gates. Confidential interviews indicated C1 was approved to go on a walk; however, due to C2's dangerous behavior, C2 was not allowed to go out at that time. Confidential interviews yielded C1 began hitting and spitting at S2 and, according to a staff interview, staff observed S2 closing the door on C1 leaving black marks on C1's arms. Other confidential interviews yielded there were no injuries on C1, and the black marks were caused by dirt that was on the fence and it was easily wiped off. It was stated in one confidential interview that C1 was shoved with a ukeru pad. However, there was no corroborating evidence. The allegations were denied, LPA received conflicting statements, and there were no other witnesses to corroborate the event. Based on confidential interviews, the allegation that staff inappropriately handled a youth in a rough manner while in care and staff hit a youth while in care may have occurred, however, the allegations are not supported or proven by evidence. Therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this signed report and appeal rights were was provided to Portia Tresvant, Administrator.

Investigation Findings:
13On August 8, 2024, at 11: AM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Portia Tresvant, Administrator to discuss the investigative findings for the allegations noted above. LPA Jauregui conducted an inspection of the facility on March 6, 2024, and no deficiencies were noted. During the investigation, LPA Jauregui interviewed five staff (S1-S5) and one client (C1). LPA attempted to interview C2; however, C2 is nonverbal. On March 1, 2024, it was reported to Community Care Licensing (CCL) that staff inappropriately handled a youth in a rough manner while in care and staff hit a youth while in care. It was reported that S2 was allowing C1 to take a walk if they wanted to, C1 became aggressive towards S2, and S2 closed the door on C1. Confidential information received also indicated that C1 was hit by S2, and C1 was observed to have a scrape and black marks on C1's arms. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Yai Morro Rd. EBSHFACILITY NUMBER: VISIT DATE: 08/08/2024

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


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
C1 was transported from the facility to a local hospital, at which time C1 was admitted into the hospital on a 5150 hold. It was reported that on 2/22/24, C1 met with the hospital psychiatrist, and the 5150 hold was discontinued, as it was determined that C1 did not need to go to a psychiatric hospital. It was reported that on 2/22/24, S2 was informed that C1 was ready for discharge, and S2 refused to pick up C1 from the hospital. Confidential interviews indicated the facility was not comfortable to pick C1 up from the hospital due to C1's dangerous behavior. Confidential interviews indicated that facility staff were waiting for a referral for C1 to be transferred to the hospital or for C1 to be reassessed. However, C1 was unable to be transported to the hospital due to the termination of C1's 5150 hold. Record review indicates C1's 5150 hold was discontinued by medical personnel on 2/22/24. Although confidential interviews revealed that facility staff were present with C1 at the hospital, confidential interviews and record review indicate that C1 was not picked up from the hospital by facility staff and returned to the facility until 2/24/24. Based on confidential interviews and record review, the allegation that staff refused to pick up minor from the hospital is SUBSTANTIATED because the preponderance of evidence has been met. This posed a potential Health, Safety, or Personal Rights risk to children in care. The facility will be cited for violating Title 22, Division 6, Chapter 1, Article 03. Application Procedures, Plan of Operation 80022 (b) The plan and related materials shall contain the following: (10) Transportation arrangements for clients who do not have independent arrangements. An exit interview was conducted, and a plan of correction was developed with Portia Tresvant, Administrator. A copy of this report, LIC9099D, and appeal rights were provided to Portia Tresvant, Administrator.

Investigation Findings:
13On August 8, 2024, at 11: AM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Portia Tresvant, Administrator to discuss the investigative findings for the allegation noted above. LPA Jauregui conducted an inspection of the facility on March 6, 2024, and no deficiencies were noted. During the investigation, LPA Jauregui interviewed five staff (S1-S5) and one Protective Service Worker (PSW1). LPA attempted to interview Client 1 (C1), however, C1 is non-verbal. LPA obtained C1's hospital discharge paperwork and Special Incident Reports. On February 28, 2024, Community Care Licensing (CCL) received an allegation that staff refused to pick up minor from the hospital. It was reported that on 2/21/ C1 was admitted to the hospital for a 5150 hold because C1 was running into the streets, assaulting staff, and hitting themselves. Law enforcement was called to the facility in response to C1's dangerous behaviors. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Yai Morro Rd. EBSHFACILITY NUMBER: VISIT DATE: 08/08/2024

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


raw_content:
Narrative:
It was reported that the client, aggressively attacked two women who'd come from the direction of the facility and a scuffle ensued, during which the client and women fell to the ground. Confidential interviews indicated C1 eloped to the neighbor's property and began to bang their head on a parked vehicle on the property. Confidential interviews indicated facility staff used ukeru pads to intervene, and C1 would push the pads out of the way. Confidential interviews indicated C1 was hanging on the side view mirrors of the vehicle. Confidential interviews indicated C1 attempted to open the house door of the property. Confidential interviews indicated staff attempted to place C1 on two holds, however, staff were unsuccessful due to C1 dropping their body to the floor. Confidential interviews indicated staff used ukeru safe turn approaches to redirect C1. Confidential interviews indicated C2 remained at the facility and wanted to follow C1. Confidential interviews indicated C2 walked to the property with staff and C2 wanted to get close to C1. Confidential interviews indicated C1 spit and hit C2, and C2 responded by grabbing C1 by the hair, which resulted in C1 and C2 falling to the ground. Confidential interviews indicated there was a physical altercation; however, interviews yielded that the altercation was between C1 and C2. The investigation did not yield no evidence to corroborate the allegation that staff engaged in a physical altercation with a client. Based on confidential interviews, the allegation that staff engaged in a physical altercation with a minor in care may have occurred, however, the allegation is not supported or proven by evidence. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this signed report and appeal rights were provided to Portia Tresvant, Administrator.

Investigation Findings:
13On August 15, 2024, at 10: AM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Portia Tresvant, Administrator to discuss the investigative finding for the allegation noted above. LPA Jauregui conducted an inspection of the facility on April 26, 2024, and no deficiencies were noted. During the investigation, LPA Jauregui interviewed five staff (S1-S5). LPA was unable to interview C1 due to C1 being non-verbal. On April 18, 2024, it was reported to Community Care Licensing (CCL) that staff engaged in a physical altercation with a minor in care. It was reported that a client was sitting on the steps of a nearby residential property and a couple of women were with the client. It was reported that the women were trying to place ukeru pads between the client and a car that was parked on the property. It was reported that more people came over, from the direction of the facility, with ukeru pads and tried to intervene by placing the ukeru pads between the client and a the parked car. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Yai Morro Rd. EBSHFACILITY NUMBER: VISIT DATE: 08/15/2024

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0


raw_content:
Narrative:
Confidential interviews indicated S1 and C1's interactions were good. Confidential interviews indicated if S1 and C1 hugged it would be a side hug. Confidential interviews denied seeing S1 hold C1 like a baby. Although there was no corroborating evidence of inappropriate physical contact, confidential interviews indicated S1 called C1 "turd." Confidential interviews corroborated S1 addressed C1 with "turd" and C1 would call S1 "turd" also. Based on confidential interviews, the allegation that staff engaged in inappropriate behavior with minor in care is SUBSTANTIATED because the preponderance of evidence has been met. This posed a potential Personal Rights risk to children in care. The facility will be cited for violating Title 22, Division 6, Chapter 5, Article 06. Continuing Requirements, Personal Rights 84072(d)(18), [See LIC 9099D]. An exit interview was conducted and Plan of Corrections was developed with Portia Tresvant, Adminsitrator. A copy of this signed report, LIC 9099D and appeal rights were provided to Portia Tresvant, Adminsitrator. Confidential interviews indicated S7 and S8 were assigned to C1's supervision and S1 remained in the staff office in meetings. Confidential interviews indicated S7 would step away from C1 due to C1 being inappropriate. Confidential interviews indicated that C1 was triggered C1 and began throwing items at their relative. According to confidential interviews, S8 intervened with a ukeru pad and the items did not make contact with the relative. Confidential interviews indicated music was playing on the television in the living room, staff mistakenly left the remote on the couch arm rest, and C1 snatched it and raised the television volume as loud as it could go. Confidential interviews indicated C1 has music restrictions where they do not listen to music with explicit language and songs with lyrics only on the screen, and interviews did not corroborate that C1 was allowed to listen to inappropriate music. Based on confidential interviews the allegations that staff did not prevent minor from engaging in sexual behavior and staff allow minors to listen to inappropriate music may have occurred, however, the allegations are not supported or proven by evidence. Therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this signed report and appeal rights were provided to Portia Tresvant, Adminsitrator.

Investigation Findings:
13On October 3,2024 09: AM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Kelsea Wochaski, QBMP to discuss the investigative finding for the allegation noted above. LPA Jauregui conducted an inspection of the facility on June 19, 2024, and no deficiencies were noted. During the investigation, LPA Jauregui interviewed seven staff (S2-S8), one witness (W1), and reviewed staff schedule, C1's needs and services plan and YAI's internal investigation. LPA attempted to interview one staff (S1), however after various attempts LPA was unsuccessful. On June 13, 2024, it was reported to Community Care Licensing (CCL) that staff engaged in inappropriate behavior with minor in care. It was reported that a staff member, S1, was observed to be inappropriate with C1. It was reported that S1 was observed cradling C1 like a baby with C1's arms around S1's neck, and it was reported that S1 had several nicknames for S1 that are inappropriate. It was reported that S1 was observed to be cuddling with C1 under the blankets on the couch. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Yai Morro Rd. EBSHFACILITY NUMBER: VISIT DATE: 09/19/2024

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

met_with: Kelsea Wochaski, QBMP


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Narrative:
It was reported that on 5/20/24, C1 was taken to the hospital for abdominal pain and minor surgery was performed. It was reported that on 5/24/24, C1 was discharged from a psychiatric hold, and on 5/28/24, C1 ingested a silica packet. Confidential interviews indicated that on 5/14/24, C1 swallowed a paperclip at school that was found in the bathroom after a school aid did not conduct a sweep prior to C1 going in. Record review indicated on 5/19/ C1 exhibited highly escalated behaviors breaking the phone box open and ripping a piece of phone chord off that C1 swallowed. Confidential interviews indicated on 5/20/ C1 was taken to the hospital to address stomach pain. Confidential interviews indicated C1 engaged in a behavior where C1 was attempting to take masks to swallow the metal nose piece found in the face mask. Record review indicated C1 was admitted to the hospital and was discharged on 5/24/24. Confidential interviews indicated on 5/28/ C1 was at an outing with three staff at the movie theater. Confidential interviews indicated C1 was eating beef jerky and C1 ingested gel silica packet from the beef jerky pack. Confidential interviews indicated staff contacted Poison Control and were advised it was harmless and to have C1 rinse off their mouth. Confidential interviews indicated staff were advised by facility administration (regional deputy director) to still take C1 to the Emergency Room. Confidential interviews indicated during the van ride, C1 was not feeling well, unbuckled their seat belt, and went to the trunk of the vehicle. Confidential interviews indicated C1 grabbed the pin from the fire extinguisher in the trunk and swallowed it. Confidential interviews indicated the vehicle was in motion and staff could not engage in a hold. Although there were plans in place to address C1's behavior of ingesting items, confidential interview indicated there was an increase in C1's ingestion due to the anniversary of C1's relative passing in May and C1's deceased relative's birthday in April. Based on confidential interviews the allegations that staff are not addressing the needs of minor and staff are not providing adequate supervision for minor may have occurred, however, the allegations is are not supported or proven by evidence. Therefore, the allegations are unsubstantiated. An exit interview was conducted. A copy of this report along with appeal rights was provided to Portia Tresvant, Adminsitrator

Investigation Findings:
13On September 19, 2024, at 9: AM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Portia Tresvant, Adminsitrator to discuss the investigative findings for the allegation noted above. LPA Jauregui conducted an inspection of the facility on June 4, 2024, and no deficiencies were noted. During the investigation, LPA Jauregui interviewed three staff (S1,S2,S6) and obtained C1's Individual Behavior Supports Plan, Hospital Discharge Paperwork and Special Incident Reports (SIR's). LPA attempted to interview one staff (S3), however after various attempts LPA was unsuccessful. On May 30, 2024, it was reported to Community Care Licensing (CCL) that staff are not addressing the needs of minor and staff are not providing adequate supervision for minor. It was reported that on 5/14/ C1 was taken to the hospital for throat discomfort due to swallowing a paperclip. It was reported that on 5/19/ C1 was taken to the hospital for abdominal pain, an x-ray was conducted, and a foreign object was found. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Yai Morro Rd. EBSHFACILITY NUMBER: VISIT DATE: 09/19/2024

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

met_with: Portia Tresvant, Adminsitrator


raw_content:
Narrative:
Confidential interviews indicated C1 is aggressive towards staff and engages in self-injurious behavior. Confidential interviews indicated C1 elopes frequently, and for C1's safety, C1 is placed in CPI (crisis prevention intervention) holds. Confidential interviews indicated when C1 is placed in CPI holds, at times, C1 drops down to the floor with their knees and thighs together and legs outward. Confidential interviews indicated on March 6, 2024, when C1 was being dropped off at school, C1 was running to and from the van repeatedly. Confidential interview indicated, after several minutes of the back and forth, C1 ran past the staff and outside the gate going into oncoming traffic. Confidential interviews indicated S1 and S2 attempted to place C1 in a hold, however, C1 dropped to the floor, so staff let go of C1. Confidential interview indicated staff did not observe C1 drop down on their knee. Confidential interviews indicated school aids walked over to provide support and escorted C1 into the school. Based on confidential interviews, the allegation that staff inappropriately restrained a minor resulting in a fracture may have occurred, however, the allegation is not supported or proven by evidence. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this signed report and appeal rights were provided to Kelsea Wochaski, QBMP.

Investigation Findings:
13On October 3, 2024, at 9: AM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Kelsea Wochaski, QBMP to discuss the investigative finding for the allegation noted above. On March 20, 2024, Licensing Program Analyst (LPA) Lucero Jauregui conducted an initial complaint investigation visit. The investigation was conducted by Special Investigator (SI) Ge Sun. SI Sun interviewed one client (C1), four staff (S1-S4), one witness and one San Diego County Social Worker. Pertinent records were obtained and reviewed. On March 15, 2024, Community Care Licensing (CCL) received an allegation that staff inappropriately restrained a minor resulting in a fracture. It was reported that on March 7, 2024, C1 informed facility staff about their knee hurting in the morning while getting ready for school. It was reported that C1 was taken to the doctor and staff were informed that C1 had a fracture in their knee. Additionally, it was reported that an unauthorized hold was done on C1 on the same day on which C1 complained of knee pain. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Yai Morro Rd. EBSHFACILITY NUMBER: VISIT DATE: 10/03/2024

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0

met_with: Kelsey Wochaski, QBMP


raw_content:
Narrative:
On 11/05/2024, Community Care Licensing (CCL) received an allegation that a staff left a minor unsupervised. It was specifically reported that S1 was asleep while on duty and left C1 unsupervised. During the investigation, multiple confidential interviews disclosed that S1 fell asleep while S1 was supposed to be watching C1 during an overnight shift. In addition, a confidential interview disclosed that S1 was not asleep at any point during S1's shift. In addition, multiple confidential interviews disclosed that there were three staff on shift the night S1 allegedly fell asleep and that two of the three staff witnessed S1 asleep while in C1's bedroom. Based on interviews and record review, the preponderance of evidence standard has been met, and the Department has determined that staff left a minor unsupervised. Therefore, the allegation is substantiated. The facility is being cited for the violation of the Title 22, Division Chapter Article 06. Continuing Requirements Responsibility for Providing Care and Supervision (See LIC 9099D) An exit interview was conducted. A copy of this report and appeal rights were explained and given to Devante Fields, Assistant Program Administrator.

Investigation Findings:
13On 06/30/2025, at 10:15AM, Licensing Program Analyst (LPA) Maya Chavez conducted an unannounced visit to YAI Morro Rd. Enhanced Behavioral Supports Home (EBSH) and met with Devante Fields, Assistant Program Administrator to deliver the investigative findings for the allegation listed above involving the EBSH staff and client 1(C1). On 11/12/2024, LPA L. Jauregui conducted a health and safety inspection at the EBSH, and no immediate health and safety hazards were observed. In addition, on 05/14/2025, LPA M. Chavez conducted an additional visit at the EBSH. LPAs conducted interviews with staff (S1, S2, S3, & S4) and County Social Workers. LPAs were unable to interview clients #1 and #2 (C1 & C2) due to C1 being placed on a 72-hour hold at the hospital and C2 being non-verbal. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Maya Chavez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Yai Morro Rd. EBSHFACILITY NUMBER: VISIT DATE: 06/30/2025

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


raw_content:
Narrative:
On 01/16/2025, Community Care Licensing (CCL) received an allegation that staff did not ensure the minor attended their scheduled medical appointments. It was specifically reported that staff have not taken C1 for medical care in the past and as of today (01/16/2025). During the investigation, multiple confidential interviews disclosed that the staff ensures clients are taken to medical appointments and when the clients do not attend medical appointments, CSWs are notified, and missed appointments are documented and rescheduled. In addition, a confidential interview disclosed that on 10/09/ C1 missed an appointment and it was rescheduled for 10/15/2024 and C1 attended their (C1) appointment. Community Care Licensing also received an allegation that staff did not provide records to minor's health care provider. It was specially reported that there have been several occasions when the facility's staff did not bring C1's medical documentation binder to an appointment with the caregiver. During the investigation, multiple confidential interviews disclosed that staff do not withhold clients' medical documentation from caregivers. In addition, multiple confidential interviews disclosed that staff do a great job communicating with CSWs regarding client's medical needs. In addition, a confidential interview disclosed that not to their knowledge at any point were C1's medical records requested from the clinic C1 attended. Based on confidential interviews, the allegations that staff did not ensure the minor attended their scheduled medical appointments and staff did not provide records to minor's health care provider are unsubstantiated. The allegations may have happened or be valid, but there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Devante Fields, Assistant Program Administrator.

Investigation Findings:
13On 06/30/2025, at 10:15AM, Licensing Program Analyst (LPA) Maya Chavez conducted an unannounced visit to YAI Morro Rd. Enhanced Behavioral Supports Home (EBSH) and met with Devante Fields, Assistant Program Administrator to deliver the investigative findings for the allegations listed above involving the EBSH staff and client 1(C1). On 01/21/2025, LPA L. Jauregui conducted a health and safety inspection at the EBSH, and no immediate health and safety hazards were observed. In addition, on 05/14/2025, LPA M. Chavez conducted an additional visit at the EBSH. LPAs conducted interviews with staff (S1 & S2) and County Social Workers (CSWs). LPAs were unable to interview clients #1 and #2 (C1 & C2) due to C1 being placed on a 72-hour hold at the hospital and C2 being non-verbal. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Maya Chavez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Yai Morro Rd. EBSHFACILITY NUMBER: VISIT DATE: 06/30/2025

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


raw_content:
Narrative:
On 01/16/2025, Community Care Licensing (CCL) received an allegation that staff touched a client in an inappropriate manner. It was specifically reported that there were concerns about sexual abuse and that S1 showered C1. During the investigation, a confidential interview disclosed that on one occasion, there wasn't the same gender staff available, S1 assisted C1 with showering only using verbal prompts with the bathroom door cracked open outside the bathroom. A confidential interview stated that S1 was not in the bathroom while C1 was showering and did not touch C1 at all. In addition, a confidential interview disclosed that S1 have not seen C1 naked and C1 can shower without assistance from staff and get dressed by themselves. A confidential interview disclosed that the facility staff always reports when they are short-staffed and has even adjusted the schedule so that there is always the same gender staff working with C1. Another confidential interview disclosed staff are present when C1 showers but C1 needs minimal prompting and if only the opposite gender staff are available, they will wait outside the door and assist with having C1's required equipment and clothes ready. Multiple confidential interviews disclosed that there are no concerns for staff at the facility. LPA was unable to gather additional information. In regard to the allegation that staff showed the client inappropriate violent video content, it was specifically reported that S1 has shown C2 violent and aggressive videos called "Two-year-old gets beaten down to death by babysitter and boyfriend." During the investigation, a confidential interview disclosed that while staff were at the hospital with C2, staff let C2 watch a documentary on the facility's work phone and that two staff took turns holding the phone. In addition, a confidential interview disclosed that S1 held the phone for C2 after C2 had already watched the first half of the documentary. Furthermore, a confidential interview disclosed that the documentary was called "' Monster' Babysitter and Boyfriend Savagely Beat 2-Year-Old Girl to Death" and was educational but uneasy. In addition, a confidential interview disclosed that C2 watches a lot of movies such as scary movies, cop shows, and people being arrested and C2 also tries to watch cartel videos, animals being dissected, and other inappropriate videos. LPA was unable to receive additional information. Regarding the allegation that staff applied improper forms of restraint on a client, it was specifically reported that S1 had put C2 in improper restraints. During the investigation, a confidential interview disclosed that C1 has had to be put in a restraint, but exact date and reason could not be recalled. Multiple confidential interviews disclosed that some restraints have been unsuccessful but there haven't been any improper restraints reported. Lastly, a confidential interview disclosed that the facility typically does hold restraints that are not appropriate, and restraints are not used very often. In addition, the confidential interview disclosed that the facility has done a lot of work to come up with solutions on how to work with C1 and adjust to C1's needs for example, getting padded shields to de-escalate C1 from running away and avoid having the restrain. Based on confidential interviews, the allegations that staff touched client in an inappropriate C1, staff showed C2 inappropriate violent video content, and staff applied improper forms of restraint on C2 may have happened or be valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore these allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Devante Fields, Assistant Program Administrator.

Investigation Findings:
13On 06/30/2025, at 10:15AM, Licensing Program Analyst (LPA) Maya Chavez conducted an unannounced visit to YAI Morro Rd. Enhanced Behavioral Supports Home (EBSH) and met with Devante Fields, Assistant Program Administrator to deliver the investigative findings for the allegations listed above. On 01/21/2025, LPA L. Jauregui conducted a health and safety inspection at the EBSH, and no immediate health and safety hazards were observed. In addition, LPA M. Chavez conducted an additional visit at the EBSH. LPAs conducted interviews with staff (S1 & S2). LPAs were unable to interview clients (C1 & C2) due to C1 being placed on a 72-hour hold at the hospital and C2 being non-verbal. LPAs also attempted to interview County Social Workers (CSWs). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Maya Chavez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Yai Morro Rd. EBSHFACILITY NUMBER: VISIT DATE: 06/30/2025

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