summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
Licensing Program Analyst (LPA) Robin Sullivan met with Pam Carter, Regional Program Director, on 8/8/21 at 11: AM to conduct a pre-license inspection for a relocation of the facility office. The office has four private offices, a private conference room, and a six unit multi-station work space. The office has an integrated fire alarm system connected to the building system. LPA observed client files are locked in a multi-drawer cabinet in the open office space. The employee files are stored in a locked cabinet inside the Regional Program Director's office. LPA discussed the single site locations with the Program Director and Program Supervisors. Locations with minors have overnight and live-in staff. LPA discussed the relocation process with Regional Program Director. It is required that CCL receive an LIC200 application and a relocation fee along with a Board of Director's Resolution approving the relocation prior to a physical move. The relocation occurred prior to CCL receiving the required notification. The facility is cited for violation of California Code of Regulations Title 22 Operation Without a License. A copy of this report will be left with the Regional Program Director. An exit interview was conducted.

Deficiencies:
80006: Deficient Practice Statement
1
2
3
4Based on dates relocation documents and fees were received by CCL, the facility did not properly ensure all required items were submitted prior to a physical move.

title:
80006	Operation Without a License

(a)	An unlicensed facility as defined in Section 80001u.( 2), is in violation of Sections 1503.5 and/or 1508 of the Health and Safety Code unless exempted from licensure pursuant to Section 80007.   §1503.5   Unlicensed community care facility; definition; operation prohibited; procedure upon discovery.

This requirement is not met as evidenced by


state: CA

facility_name: UNITY CARE GROUP

summary: Facility Evaluation

raw_content:
Narrative:
On 9/1/21 at 10: AM, Licensing Program Analysts (LPAs) Tammy Hill and Robin Sullivan met with Deb Miller, Compliance Manager and Pam Carter, N. Cal Regional Program Director of Unity Care. The meeting was held on MS Teams to discuss a plan for the submittal of a new Program Statement (PS) and Plan of Operation (POO). Areas discussed include changes of site names which are now (1) staffed site, (2) host family, (3) Remote Site, certification from applicable county, uniformity of program, and update procedures for Program Statement. Unity Care will use a program statement review tool and the PS and POO table of contents as a guide for required content. Unity Care will provide the CCL Regional Offices in Sacramento, San Jose, and San Francisco a tabbed hard copy binder and an electronic version of the final approved PS/POO.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Deb Miller and Pam Carter


summary: Facility Evaluation

raw_content:
Narrative:
A tele inspection meeting via Microsoft Teams was held on 10/22/21 at 1: PM and in attendance were individuals representing Community Care Licensing Division and Unity Care Group. The meeting was called for by Unity Care Group to discuss the facility and agency progress since the Non Compliance Conference meeting held on August 25, 2021. Community Care Licensing representatives included Margo Castaneda, Jodean Hall and Tamara Hill from the Sacramento Regional Office and Helga Wong and Zaid Hakim from the San Jose Regional Office. Unity Care Group representatives included Andre Chapman, Pam Carter, Deb Miller, Sharae Gary, Devin Johnson, Tai Batov and Lynn Thull (consultant for Unity Care Group). The purpose of the meeting is to establish a collaborative dialogue between Unity Care Group and Community Care Licensing in areas of concern and to discuss the status of plans for improvement for the success of the program moving forward. Items discussed included Unity Care's Internal Improvement Plan, Technical Support status, Reporting Requirements, Staffing and Supervision, Neighborhood Relationship Improvements, and Program Statement review. Discussed was that the Plan of Operation and Program Statement will be submitted to the Sacramento Regional Office via FedEx on November 5, 2021. Once the Plan of Operation and Program Statement is complete and finalized by the Sacramento Regional Office, it will be shared with the other regional offices. Exit interview was conducted with Deb Miller, Compliance, and the document was provided for signature and return.

met_with: Andre Chapman, CEO


summary: Facility Evaluation

raw_content:
Narrative:
On 12/13/21 at 10: AM, Licensing Program Analysts (LPAs) Mary Shelton and Robin Sullivan made an unannounced Post-licensing inspection at the facility's administrative office. LPAs met with Devon Johnson, Supervisor. This facility provides services to minors and non-minor dependents (NMD), is licensed for 74 participants and currently has a census of 33 participants. LPAs observed the office has four private rooms; one office is for the Regional Program Director, the two supervisor's share one office, one is the therapist's office, one is a large conference room used for meetings and trainings. A multi-compartment cubicle with space for four employees is located in the middle of the main office and two additional cubicles on the back wall. The office has a bathroom and kitchen facilities. LPAs observed the client files are stored in a locked file cabinet in the main office area. The employee files are stored in a locked file cabinet inside the Regional Program Director's office. LPAs observed the facility sketch, license and emergency disaster plan are posted. LPA observed the facility has posters regarding COVID-19 practices. LPAs observed Certificates of Compliance on file for the housing units. LPAs reviewed five client files and six employee files to have all required documents. No Title 22 deficiencies were cited. An exit interview was conducted and this report was emailed to Devon Johnson.

met_with: Devon Johnson, Supervisor


summary: Facility Evaluation

raw_content:
Narrative:
On 12/13/21 at 3: PM Licensing Program Analysts (LPAs) Mary Shelton and Robin Sullivan conducted a case management inspection for the Non-compliance issues discussed on 8/11/21. The facility is complying with the following: (1)The facility will follow relocation procedures by notifying CCL in advance of a relocation. (2) The facility has submitted a Program Statement which is under review at this time. (3) The facility has conducted staff training for required incident reporting. All incidents involving law enforcement will be reported as required and authorized representatives will be notified along with CCL. (4) Facility will create a good neighbor policy. The facility has included a good neighbor policy which is included in the submitted Program Statement. Assigned LPA will continue to monitor the compliance of the above. An exit interview was conducted and a copy of this report was emailed to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On 8/2/2022 at 10: AM, Licensing Program Analyst (LPA) Mary Shelton made an unannounced Annual inspection visit at the facility's administrative office. LPA met with Devin Johnson, Program Manager. LPA did advise the agency that the inspection is being completed with the use of the CARE Tool. However, due to technical issues the CARE Tool was not implemented. There were no clients present during the inspection of the administrative office. This facility provides services to minors and non-minor dependents (NMD), is licensed for 74 participants and currently has a census of 30 participants. LPA observed the office has four private rooms; one office is for the Regional Program Director, the two supervisor's share one office, one is the therapist's office, one is a large conference room used for meetings and training's. A multi-compartment cubicle with space for four employees is located in the middle of the main office and two additional cubicles on the back wall. The office has a bathroom and kitchen facilities. LPA observed the client files are stored in a locked file cabinet in the main office area. The employee files are stored in a locked file cabinet inside the Regional Program Director's office. LPA observed the facility sketch, license and emergency disaster plan are posted. LPA Shelton inspected and/or reviewed the following: · Postings of facility license and Personal Rights Poster were appropriately posted · LPA observed a working telephone on the premises · Carbon monoxide detectors/Smoke Detectors were present and functioning · First Aid Kit was present and fully stocked as required · LPA reviewed five (5) client files. No children were present to interview · LPA reviewed five (5) staff files and one staff was interviewed. · Fire extinguishers were visible (2) around the office. There are smoke detectors and carbon monoxide detectors in the office. The tags on the extinguishers are in compliance. · LPA reviewed complaint procedures for clients. · Board Minutes were reviewed · Staff training was in compliance · Criminal record clearances were verified by LPA and in compliance · Certified Administrators certificate was valid and current · Staff job titles/qualifications were verified along with the required Hours of initial training. LPA verified that for staff that have been here longer than a year, the Hours of annual training was also present. · Trauma informed practices are implemented as needed (including specialty mental health services and extracurricular activities and social supports) per discussion with social worker. The following items were reviewed for compliance in the regional office prior to the facility inspection: Agency file, Administrator Certificate, fire clearance and Fees. LPA discussed fees and the agency is aware an amount is due. No citations were issued at the conclusion of the inspection. Exit interview was conducted and documents were provided to the facility.

met_with: Devin Johnson, Program Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 8/15/2022 at 11: AM Licensing Program Analyst (LPA) Mary Shelton conducted a case management inspection for two Incident Reports, discussed again notifying CCL in advance of a relocation and follow-up on the good neighbor policy. Assigned LPA will continue to monitor the compliance of the above. An exit interview was conducted, and a copy of this report was emailed to the facility.

met_with: Deb Miller, Director & Devin Johnson, Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 5/8/2023 at 2: PM Licensing Program Analyst, (LPA) Mary Shelton conducted an unannounced case management related to an incident report that occurred on 5/1/2023. An underage client had been sneaking out of the home and meeting older women. LPA interviewed Devin Johnson regarding the incident and requested a copy of the plan in place to prevent the client from sneaking out of the home. LPA provided a copy of this report to Devin Johnson, Program Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 11/16/2023 at 1: PM, Licensing Program Analysts (LPAs) Mary Shelton and Uchenna Ajaero conducted an unannounced case management visit. The purpose of the visit was to introduce the newly assigned LPA Uchenna Ajaero to the staff and to confirm that minors are no longer being served by this Unity Care as stated by the Compliance Director, Deb Miller on September 5, 2023. During inspection LPA Shelton and Ajaero reviewed the UCG-THP Monthly Inspection Form by the THPP staff, requested copies of the Certificate of Compliance for all locations, Certificate of approval for the approving county for this THPP, client rosters for all locations, placement agencies contacts and staff schedules. LPAs requested all county letters of support and confirmation that they have notified the county agencies that they are no longer serving minors. Confirmation of the cancellation by the counties is requested within 30-days or by December 18, 2023. The facility has the capacity to serve 74 clients in Placer/Sacramento County. The staff site model location is zero, there are two remote site models and one Host family model. These are all located in Placer/Sacramento. On September 12, 2023, LPA Mary Shelton requested an updated program statement removing all reference to minors in care and requested the amended program statement by October 13, 2023 (30-days). The amended program statement was not received. On October 15. 2023, LPM Jodean Hall requested the amended program statement no later than November 22, 2023. No title 22 regulations were cited during today's inspection. An exit interview was conducted, and a copy of the report was given to the agency.


summary: Facility Evaluation

raw_content:
Narrative:
On 12/6/2023 at 12: PM, Licensing Program Analyst (LPA) Mary Shelton conducted an unannounced case management visit. The purpose of the case management inspection was to obtain additional information regarding LIC 9020 that was emailed to Community Care Licensing on 12/6/2023. Jeffrey Jefferson, Division Director, Sanders Trent, Vice President of Operations and Deb Miller, Compliance Director joined via Zoom. No title 22 regulations were cited during today's inspection. An exit interview was conducted, and a copy of the report was given to the agency.


summary: Facility Evaluation

raw_content:
Narrative:
On Monday, December 2nd, 2024, Licensing Program Analyst (LPA) Brittany Crass, conducted an unannounced, annual inspection at the Administrative Office. Administrator Devin Johnson, assisted with the inspection. LPA Crass toured the administrative office and observed the office to be clean, safe and sanitary. The office consisted of a lobby, administrative office, file room, large conference room, three private offices, kitchen, six cubicals, and a bathroom. LPA noted the license and Evacuation Plan were posted. Currently, the facility has 25 participants in placement. All apartments are located within two hours from the administrative office. The THPP has apartments in Rocklin, and Sacramento, as well as a house in Rocklin. There are three Case Manager/Social Workers. The facility is current with their annual fees. LPA reviewed five client files, the administrators file, and four other staff files. The facility is being cited two Type B citations. One for Interim Licensing Standards, Section 86268.3(d) Needs and Services Plan, and another for Health and Safety Code 1565(b). See attached LIC D page. The Facility was also given multiple Technical Violations, and Technical Advisories, which are not citations. An exit interview was conducted with Devin Johnson. A copy of this report and Appeal Rights were given.

visit_type: Annual

met_with: Devin Johnson


summary: Facility Evaluation

raw_content:
Narrative:
On Thursday, May 1st, 2025, Licensing Program Analyst (LPA) Brittany Crass arrived at the Agency Unannounced for the purpose of a Case Management inspection. There was no one at the Facility when LPA arrived, however Administrator Devin Johnson arrived at 4:20pm to allow LPA entry and to assist with the inspection. LPA was following up with a self reported incident the Department received on 4/25/25. No deficiencies are being cited. Exit interview conducted with Devin Johnson. A copy of this report was given.

announced_status: Unannounced


summary: Facility Evaluation

raw_content:
Narrative:
On Friday, August 8th, 2025, Licensing Program Analyst (LPA) Brittany Crass, conducted an Unannounced, annual inspection at the Administrative Office. Administrator Devin Johnson, assisted with the inspection. LPA Crass toured the administrative office and observed the office to be clean, safe and sanitary. The office consisted of a lobby, administrative office, file room, large conference room, three private offices, kitchen, six cubicles, and a bathroom. LPA noted the license and Evacuation Plan were posted. The Agency has done an annual training on the Emergency Disaster Plan, but has not been conducting quarterly drills of various emergency scenarios with staff. Currently, the facility has 26 participants in placement. All apartments are located within two hours from the administrative office. The THPP has apartments in Rocklin, and Sacramento, as well as a house in Rocklin. There are three Case Manager/Social Workers. The facility is current with their annual fees. LPA reviewed five client files, and three staff files. LPA observed no deficiencies in the staff files. In the client files, LPA observed that the Needs and Services Plans for 5/5 clients did not match the Transitional Independent Living Plans, were missing planned length of placement, and were also missing the required signatures. (Continued on LIC 809-C). On the attached LIC 809-D page, the facility is being cited four Type B citations for: 1) Health and Safety Code Section 1565(c), 2) Interim Licensing Standards Section 86268.3(c)(1) NEEDS AND SERVICES PLAN, 3) Interim Licensing Standards, Section 86268.3(a) NEEDS AND SERVICES PLAN, and 4) Interim Licensing Standards, Section 86268.3(d) NEEDS AND SERVICES PLAN, which also has a Civil Penalty attached for a repeat violation within 12 months. Three out of the four citations given today, were already given as Technical Violations on the Agency's prior annual inspection on 12/2/24. The Agency was also given one Technical Violation for NON MINOR DEPENDENT RECORDS, and two Technical Advisory's for PARTICIPANT MEDICAL ASSESSMENTS and REGISTER OF PARTICIPANTS, which are not citations. An exit interview was conducted with Devin Johnson. A copy of this report and Appeal Rights were given.

met_with: Administrator Devin Johnson


facility_name: UNITY CARE GROUP, INC

summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Based on the information obtained from records and interviews, the allegation that staff did not report youth's absence from the facility is SUBSTANTIATED. The facility is cited for violation of Title Transitional Housing Placement Program (THPP) Regulation Reporting Requirements.

Investigation Findings:
13On 8/8/ Licensing Program Analyst (LPA) Robin Sullivan went to the facility to deliver findings for the allegation that staff did not report youth's absence from the facility and met with Pam Carter, Regional Director. LPA conducted interviews with three staff (S2, S3, S4, see confidential names LIC811);S3 on 6/7/21, S2 on 7/15/21, S4 on 7/27/21, the county social worker on 7/13/21, and probation officer on 7/27/21. The following documents were reviewed: Transitional Independent Living Plan (TILP), admission agreement, Needs and Services Plan, client Health and Education Passport, dental appointment confirmation, an accounting of balances paid to youth, and incident reports. A foster youth's county social worker (CSW) reported not receiving notification when the youth did not return to the facility after an approved overnight. The CSW stated the reporting issue has been resolved and she is now getting reports. The probation officer (PO) stated the facility contacted him on about day six of the youth missing. Community Care Licensing (CCL) has no report indicating the youth was missing for six days. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Robin Sullivan 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 CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: UNITY CARE GROUP, INCFACILITY NUMBER: VISIT DATE: 08/09/2021

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

report_type: Complaint Investigation

met_with: Pam Carter, Regional Director

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
C1 stated he was greeted by an unidentified male saying something about heard you ordered me up and the male touched C1's waist. S2 stated he may have put his hands up, about stomach high, as a means to motion hey it's okay calm down. S1 stated S2 grabbed the client by the hips. S1 and S2 verify it was meant to be funny but the client reacted in anger. C1 stated S2 made other comments about his attractive appearance and beautiful blue eyes which made C1 feel uncomfortable. S2 confirmed he spoke to C1 about becoming a model. S3 and S4 stated they independently wrote an incident report detailing the above event. CCL did not receive an incident report detailing the interactions between S1, S2 and C1. CCL received an incident report stating S1 had boundary issues and used vulgar language. A verbal report from RD to LPA Sullivan indicated the interactions and language were in the presence of other staff members but did not involve a client. The facility was advised to send a written incident report to CCL and refer the staff's behavior to human resources. Based on the interviews conducted and incident reports reviewed the allegations that staff inappropriately touched minor, staff made sexual advances towards minor, and the facility did not notify licensing of an incident are SUBSTANTIATED. The facility is cited for violations of Interim Licensing Standards AB Nonminor Dependents, THPP Article 6, Personal Rights. A violation of Reporting Requirements is substantiated, however no citation is issued at this time. A citation was issued on 8/9/21 for this violation. An exit interview was conducted and a copy of this report and appeal rights discussed and emailed to Devin Johnson.

Investigation Findings:
13On 10/5/21 at 12: PM, Licensing Program Analyst (LPA) Robin Sullivan went to the facility and met with Devin Johnson, Supervisor, to deliver findings for the allegations that staff inappropriately touched minor, staff made sexual advances towards minor, and facility did not notify licensing of an incident. LPA interviewed one staff (S3) on 5/24/21, regional director (RD) on 6/17/21, Staff 1 (S1) on 8/12/21, S2 on 8/22/21 and C1, S3 and S4 on 10/1/21. LPA reviewed the following documents: incident report, Transitional Independent Living Plan, Needs and services plan, Transitional Housing Program (THP) rules and expectations, facility file review and program statement. The investigation revealed that two staff (S1 & S2) intended to play a joke on a non-minor dependent client (C1). C1 and S1 had a well-established staff-to-client relationship. S2 was a new employee meeting C1 for the first time. It is confirmed by S1 and S2 that S1 encouraged S2 to "punk" C1 by saying "is this what you ordered up", indicating himself, when C1 comes to the door. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Robin Sullivan 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 CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: UNITY CARE GROUP, INCFACILITY NUMBER: VISIT DATE: 10/05/2021

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

met_with: Devin Johnson, Supervisor


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Based on interviews conducted the allegation that staff threw away resident's belongings is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and a copy of this report, appeal rights and the confidential names list, LIC811, were discussed and left with Devon Johnson.

Investigation Findings:
13On 11/18/21 at 2: PM, Licensing Program Analyst (LPA) Robin Sullivan made an unannounced complaint inspection for the purpose of delivering findings for the allegation that staff threw away resident's belongings. LPA met with Devon Johnson, Supervisor. During the investigation, LPA interviewed seven clients, three staff, one probation officer, and one social worker, between 4/27/21 and 11/1/21 and obtained the following documents: financial payment and deduction information for eleven clients, copies of payment stubs, Needs and Services Plans, THP Orientation booklet, and Transitional Independent Living Plans. The investigation revealed that a client left some belongings at a residential site after moving into an apartment. The client would not confirm that personal belongings where disposed of prior to the allowed period of time after exit date. The client indicated that his caseworker took care of getting the personal items and if anything was thrown out it occurred after the client left the residence. The facility has a policy that client's may retrieve their personal belonging within 30 days of moving out. After 30 days any remaining items will be removed from the premise. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Robin Sullivan 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 CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: UNITY CARE GROUP, INCFACILITY NUMBER: VISIT DATE: 11/18/2021

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

complaint_status: unsubstantiated


raw_content:
Narrative:
LPA obtained information that staff are trained to write incident reports when they are present during an incident or they obtain information that requires a written report. After the report is written, staff submits to their supervisor or regional manager for review. Management reviews the reports for thoroughness of content and accuracy and then enters the report into a computer system. It is alleged that the living units are not clean. LPA obtained photographs of one house with a sink full of dirty dishes and the kitchen trash can overflowing. During an unannounced inspection, LPA observed the same house to be clean and clutter free. The kitchen sink was clean, the floors were clean, the trash was half full, and the main living area was clean and tidy. LPA observed a client washing dishes at a second location upon entering the house. The client stated that chores rotate and this was his day to wash the dishes. Client stated that sometimes he lets the pots and pans stacked up and then washes them all at once. Client stated that everyone in the house rotates chore duties. It is alleged that client information is not being kept confidential. One staff reported that cabinets used for client files are not locked properly. One staff reported that one drawer of a file cabinet was broken but no client files were stored in the broken drawer. LPA has observed all client files to be locked and secure in the regional office. It is alleged that clients are not receiving necessary services. Clients have access to weekly individual counseling, group counseling, and case management sessions. Two clients confirm they go to individual counseling. One client stated not needing anything. Two clients declined to talk about using services or if services are offered. One case manager had concerns for two clients that present with mental health issues but may not be getting additional services. One of the two clients verified he attends therapy sessions and the probation officer confirmed the client's attendance. The other client stated there is no need for additional services. Based on interviews and observations the allegations that staff are falsifying incident reports, living units are not clean, clients are not receiving necessary services, and client information is not being kept confidential are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted and a copy of this report, appeal rights and the LIC811 were discussed and left with Devon Johnson.

Investigation Findings:
13On 11/18/21 at 4: PM, Licensing Program Analyst (LPA) Robin Sullivan went to the facility for the purpose of delivering findings for the allegations that staff are falsifying incident reports, living units are not clean, clients are not receiving necessary services, and clients information is not being kept confidential. During the investigation six clients, four staff, one probation officer, and one social worker were interviewed between 4/14/21 and 10/26/21. LPA obtained and reviewed the following documents Needs and Services Plans, Transitional Independent Living Plans, physician reports, medical and dental reports, budget plans, and photographs. It is alleged that staff are falsifying incident reports. LPA obtained information from two staff that when they wrote incident reports they were submitting the reports directly into an electronic reporting system. Both staff indicated that procedures changed and they now submit their written reports to their supervisor and/or the regional manager. The staff were concerned that some reports may get modified or not reported to the proper authorities because they can no longer track reports in the system. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Uchenna Ajaero 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 CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: UNITY CARE GROUP, INCFACILITY NUMBER: VISIT DATE: 11/18/2021

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


facility_name: UNITY CARE GROUP, INC. THPP/THP+FC

raw_content:
Narrative:
The clients that resided at the home are no longer participants with this agency. LPA Raissi could not make further contact with the witness. Based on interviews and a inspection at the residence (THPP staff site) there is no further information that could be obtained. Therefore, the complaint findings are Unsubstantiated. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation(s) are Unsubstantiated. No deficiencies were cited. Exit interview conducted, appeal rights discussed, and a copy of the report was left at the agency with Administrator, Kenya Kennedy.

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

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

met_with: Kenya Kennedy


raw_content:
Narrative:
On 09/23/2021, LPA Raissi interviewed W1, who stated that these allegations were not true, and that police had responded to an incident at the facility site for an incident in which the victim named in the complaint was the one who had pushed staff, and not staff pushing a resident as it is stated in allegation #1. This information is corroborated by an incident report dated 09/13/2021 which was submitted to this department. LPA Fremont attempted to contact several other witnesses over the course of this investigation, but was ultimately unsuccessful in recording other witness statements. LPA also attempted to contact the police department in jurisdiction of this facility site, but was unable to obtain a police report to corroborate or disprove these allegations. This agency has investigated the allegations (1) "Facility staff pushed a resident," and (2) "Resident is not accorded dignity in relationship to staff," and has determined that although the allegations may be true or are valid, the preponderance of evidence standard has not been met, therefore the allegations are found to be unsubstantiated, based on records review and witness interviews. At this time, no deficiencies were observed or cited. An exit interview was conducted, Appeal Rights provided, and a copy of this report was emailed to Compliance Officer Deepa Bhat, whose signature on this form confirms receipt.

Investigation Findings:
13On 09/13/2022 at 1:45PM, Licensing Program Analyst (LPA) Madi Fremont traveled to the facility above to conduct an unannounced complaint investigation inspection. The purpose of this inspection was to deliver findings for the allegations listed above. LPA met with Compliance Officer Deepa Bhat, who helped faciliate this inspection. On 09/14/2021, the San Jose Children's Residential Program Regional Office received a complaint for the facility above with two allegations: (1) "Facility staff pushed a resident," and (2) "Resident is not accorded dignity in relationship to staff." This complaint was investigated by LPAs Sam Raissi and Madi Fremont. (CONTINUED ON LIC9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Madeleine Fremont 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 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. San Jose, CA Facility Name: Unity Care Group, INC. THPP/THP+FCFACILITY NUMBER: VISIT DATE: 09/13/2022

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

met_with: Compliance Officer Deepa Bhat


raw_content:
Investigation Findings:
13On 2/24/25 at 3: PM, Licensing Program Analyst (LPA) Vaishali Singh-Sood conducted an unannounced inspection to the above facility. The purpose of the inspection was to inform the facility representative of the findings for the above listed allegation. LPA Singh-Sood met with Diane Braz, , who assisted with the inspection. During the investigation of the aforementioned allegations, confidential interviews were conducted, as well as a review of supportive documentation. However, the program statement clearly indicated that stipends are only provided to clients who successfully discharge from the program. Addtionally, the program statement also indicated that they recommend no one to store any expensive items at the facility due to the property being unable to be fully safeguarded. Although the allegation above may have happened, there is not enough of the evidence to support that they are true. Therefore, this allegation is Unsubstantiated. At 4; PM, an exit interview was conducted, and copy of this report was provided to Ms. Braz. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Vaishali Singh-Sood LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Diane Braz


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Sam Raissi conducted a case management tele-inspection on May 13, 2021 at 11: AM via Tele-visit (due to COVID 19 precautions). LPA Raissi met with Administrator (admin), Kenya Kennedy, via Facetime. The purpose of the case management was regarding an incident reported by the agency listed above this report to Community Care Licensing (CCL) involving resident(s) at the TRANSITIONAL HOUSING PLACEMENT PROGRAM (THPP). Refer to ( Confidential Names list, dated May 13, 2021). The following was discussed; On May 12, 2021, LPA Sam Raissi received a call from Unity Care THPP Administrator (admin), Kenya Kennedy. Admin told LPA Raissi that a youth tested positive for TB at a THPP remote site (apartment). Per admin, the Doctor advised that other's in the apartment, that may have had contact with Client 1 (C1) should quarantine. Action was taken by agency; a hotel has been provided for C1's roommate until further testing is done to determine if C1 has TB and if C1 is contagious. Per admin C1 has went for x-rays and further blood work. Results are expected by today. The THPP staff and admin will monitor the situation and update CCL and LPA Raissi promptly if there are any issues regarding this matter. No citation was given for this visit. A copy of this report was emailed to Kenya Kennedy for review and signature.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Sam Raissi conducted a case management tele-inspection on May 13, 2021 at 11: AM via Tele-visit (due to COVID 19 precautions). LPA Raissi met with Administrator (admin), Kenya Kennedy, via Facetime. The purpose of the case management was regarding an incident reported by the agency listed above this report to Community Care Licensing (CCL) involving resident(s) at the TRANSITIONAL HOUSING PLACEMENT PROGRAM (THPP). Refer to ( Confidential Names list, dated May 13, 2021). The following was discussed; On April 10, 2021, approximately at 9: AM, Client 1 (C1) texted Case Manager (CM), stating Client 2 (C2)'s "girlfriend has to go". C1 reported to CM that C2's Girlfriend (GF) tried to fight him. Given the information presented to CM, C2 was told that GF needed to leave the property. On April 14, 2021, C1 disclosed to CM that C2 and GF had an domestic dispute. C1 tried to intervene. C2 threatened to fight C1 and to bring friends to jump C1. (Update) On May 3, 2021, it was reported to CM by another youth that when the incident took place on April 10, 2021, C2 told C1 that C1 had a blade (possible knife) but didn't threat him with it. Action was taken by agency, CM asked C2 if he wanted to move, C2 declined. Per admin, there was not fight between C1 and C2, and that they resolved their differences. C1 denied the allegation of having a blade or knife. The THPP staff and admin will monitor the situation and update CCL and LPA Raissi promptly if there are any issues regarding this matter. No citation was given for this visit. A copy of this report was emailed to Kenya Kennedy for review and signature.


summary: Facility Evaluation

raw_content:
Narrative:
On June 10, 2021, at 11: AM, Licensing Program Analyst (LPA) Sam Raissi was met by Administrator, Kenya Kennedy at the agency listed above this report (announced visit due to COVID-19 precautions). The purpose of the case management was regarding an incident involving a resident at the Transitional Housing Placement Program (THPP) residential apartment. Refer to ( Confidential Names list, dated June 10, 2021). On May 17, 2021, Eddie Brown, property manager texted (911) at 9: PM to Samara Lacapa, case manager. Samara called Eddie and informed her that Client 3 (C3) called him stating that his roommate, Client 2 (C2), raped his girlfriend, Client 1 (C1). All clients are residents of the THPP. Eddie was advised to call San Jose Police Department (SJPD). Samara and Kenya went to the residential apartment (UP1) to wait for SJPD to arrive on the scene. SJPD arrived and took statements from staff C1, and C3. C2 was not at his apartment when the report was made and when the SJPD came to the apartment. C1 reported to SJPD that C2 raped her on Saturday, May 15, 2021. SJPD transported C1 to the hospital for observation. A restraining order was put on C2. SJPD communicated C2 was able to return to the house. Due to the circumstances Unity Care THPP representatives moved C2 to another THPP residential site, were there is increased staff supervision. On June 9, 2021, C2 moved back to residential apartment (UP1). The above agency is monitoring the situation and will keep this LPA informed of any developments. No citation was given for this visit. A copy of this report was given to Kenya Kennedy for review and signature.


summary: Facility Evaluation

raw_content:
Narrative:
On July 29, 2021, at 11: AM, Licensing Program Analyst (LPA) Sam Raissi was met by Administrator (Admin), Kenya Kennedy at the agency listed above this report. The purpose of the case management was regarding an incident involving a resident at the Transitional Housing Placement Program (THPP) residential apartment. Refer to ( Confidential Names list, dated July 28, 2021). On Saturday, July 24, Client 1 (C1) and his girlfriend were arguing/yelling for a lengthy period. Per Admin, PM called the police. PM arrived at the property; the police cars were lined across the block. PM was told by the police officers that C1 said his girlfriend stabbed him with a knife. When police arrived C1 told the police officers that he did not want to press charges. C1 told the police officers that his girlfriend had a seizure. The police officers requested to speak with the girlfriend. C1 ran into his room, locked the door, and barricaded themselves. After several verbal requests, C1 opened the door and pulled out the girlfriend. C1 proceeded to charge towards the police officers. The police eventually took C1 into custody, on a gurney (handcuffed). C1 was taken to the hospital. The girlfriend was also taken to the hospital. Per Admin, C1 was released from custody and discharged from the THPP program. Admin said she does not have any more information and wants to see the police report before she describes what accurately happened. Admin notified C1's Alameda County Social Worker. The girlfriend is not placed with Unity Care THPP. Admin sent an Incident Report (IR) describing what had taken place. An updated IR will be submitted following the police report. Admin will update LPA regarding this matter. No citation was given for this visit. A copy of this report was given to Kenya Kennedy.


summary: Facility Evaluation

raw_content:
Narrative:
On today's date, this Licensing Program Analyst (LPA) was met by Property Manager, Eddie Brown, at the facility listed above. The purpose for this case management inspection was regarding an incident involving a client at the Transitional Housing Placement Program (THPP) residential apartment. Refer to ( Confidential Names list, (dated 5/23/22). On May 18, 2022, facility staff called and submitted a death report to the Department reporting the death of an 18 year-old male client, possible suicide. Facility case manager went to client's apartment on May 18, 2022 for their visit. When the client did not answer the door, the property manager provided entry to the case manager and they found him deceased. There is no additional information provided regarding the cause of death or when this happened. Unity Care Group Chief Executive Officer notified the death to the San Jose Police Department and Santa Clara County Coroner's Office and will investigate the cause of death. On May 19, 2022, this matter was referred to Department of Social Services, Investigative Branch (IB) Investigator McIntosh,, and accepted as an assignment. No citation was given for this inspection. A copy of this report was emailed to Mr. Trent Saunders, and the inspection was concluded at 12: PM

met_with: Eddie Brown


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Vaishali Singh-Sood made an unannounced case management inspection to the above facility on March 28, 2023, at 10: AM. LPA Singh-Sood met with Apartment Manager, Eddie Brown, who assisted with the inspection. The purpose of this inspection was to discuss the detailed information regarding an incident report which was received by Community Care Licensing (CCL) on March 28, 2023. The report indicated one participant (refer to confidential names list on LIC 811 dated 3/28/2023) had a gun that was found in a shoe box in her room. It was noted that the participant, as well as the participant's roommate both had young children who also reside in the apartment. Due to the severity of the incident, San Jose Police Department was contacted, and the gun was confiscated by Police. LPA Singh-Sood interviewed Mr. Brown regarding the incident. The interview has been attached on an LIC 812 form dated 3/28/2023. Due to the facility following all protocols, no citation was given for this inspection. An exit interview was conducted at 12: PM, and copy of this report were emailed to Mr. Saunders.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Vaishali Singh-Sood made an unannounced case management inspection to the above facility on October 4, 2023, at 1: PM. LPA Singh-Sood met with Apartment Manager, Eddie Brown, who assisted with the inspection. The purpose of this inspection was to discuss the detailed information regarding an incident report which was received by Community Care Licensing (CCL) on October 3, 2023. The report indicated one client (refer to LIC 812 dated 10/3/2023) had stabbed another client. Due to the severity of the incident, San Jose Police Department was contacted, and arrived on scene. Subsequently, one client was arrested, and taken into custody. LPA Singh-Sood interviewed Mr. Brown regarding the incident. The interview has been attached on an LIC 812 form dated 10/3/2023. Due to the facility following all protocols, no citation was given for this inspection. An exit interview was conducted at 4: PM, and copy of this report were emailed to Ms. Miller


summary: Facility Evaluation

raw_content:
Narrative:
On December 13, 2023, at 11: AM Licensing Program Analyst (LPA) Vaishali Singh-Sood conducted an unannounced inspection to the facility for the purpose of conducting an Annual/Random inspection. LPA Singh-Sood met with VP of Operations, Trent Saunders, and both toured the office space. The facility is a single story office building that includes a front security desk, offices, and cubicles. There are locked filing cabinets throughout the office in various areas. There are no exceptions on file, and there have not been any deficiencies cited in the past year. The THPP program currently has two locations, both which are apartment complexes in San Jose. Currently, there are nineteen participants between the apartments at the two sites. A review of Licensing Information System (LIS)/ Guardian December 13, 2023 indicates that all facility staff are associated to the facility had DOJ, FBI, and child abuse index check clearances. LPA used a physical copy of the CARE tool to document client file information. LPA will relay the information onto the digital CARE tool after the visit. There were no deficiencies cited during this inspection. LPA conducted an exit interview with Mr. Trent at 3: PM, whose signature confirms the receipt of this document.

met_with: Trent Saunders


facility_name: UNITY TRANSITIONAL HOUSING INC.

summary: Facility Evaluation

raw_content:
Narrative:
On December 18, 2023, a virtual Component II Orientation was conducted by LPA (Licensing Program Analyst) Vanessa Galvan with Program Director, Mary Beth Irons and Board Member/Administrator, Rose Churchill. The following was addressed and discussed: The program expectation/review. An overview of the first revision letter. Requirements for the physical plant and pre-licensing inspection will provide tool to applicants. Informed the applicants of corrections needing to be made to the application. Revisions to the Plan of Operation (POO)/Program Statement (PS) to meet regulatory standards. Unity Transitional Housing transferring and associating employees and board members in Guardian. Unity Transitional Housing foster care rates has submitted application, LPA will submit Program Statement to Rate consultant. Letter of Documentation for correction and missing paperwork. Tentatively corrections will be submitted the week of 01/18/2022. The location of the Pre-licensing inspection will be conducted at W. Cambridge Ave, Visalia, CA, 93277, and is scheduled for 01/08/2023 at 12: PM

met_with: Mary Beth Iron & Rose Churchill


summary: Facility Evaluation

raw_content:
Narrative:
On February 6, 2024, Licensing Program Analyst (LPA) Vanessa Galvan traveled to the Unity Transitional Housing office located in Visalia CA. LPA was met by Administrator, Rose Churchill, Program Director, Mary Beth Irons, and ILP Specialist Noe Lara for the purpose of a scheduled pre-licensing inspection. A general overview of their program and a tour of the facility was provided. This facility has a reception area, waiting area, and office space for staff. Observed fixtures and furniture, equipment and supplies necessary for this operation. Also observed locked cabinets for client and staff files in order to ensure confidentiality. Discussed daily ongoing functions including incident reports. There is ample confidential space for meeting with clients on an as needed basis. The above licensee meets the requirements to be licensed as a THPP serving clients age 18-21 within a two hour driving radius pending approval of updates requested during the component II orientation. Once licensed the applicant will submit updated version of the program statement to Rates. On a quarterly basis, facility is to submit a roster of THPP clients that includes client names, dates of birth, county worker and current address of placement.

visit_type: Prelicensing

met_with: Mary Beth Irons, Rose Churchill, Noe Lara


summary: Facility Evaluation

raw_content:
Narrative:
On May 29, 2024, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Unity Transitional Housing located in Visalia, CA, and met with Administrator/Social Worker Supervisor, Rose Churchill and Program Director, Mary Beth Irons. The purpose of the inspection is to conduct a post-licensing inspection. LPA Galvan conducted a physical plant inspection and included the following observation and checks: client and staff files are kept in locked filing cabinets. The agency has adequate confidential meeting space, space for Social Worker and Case Manager to complete job duties. The facility has a current copy of the license, Facility Sketch, Client Personal Rights, LIC 610C, posted in a common area. The agency has a client register roster LIC 9120, with all required information. The agency's office is located within two hours of travel time of the THPP participants living units. The agency employs (1) Administrator/Social Worker Supervisor, (1) Program Director, and (1) Case Manager. LPA Galvan reviewed three staff files. A review of the staff files on this date indicates that all facility staff has received child abuse index and fingerprint clearances. Agency staff meets the requirements of respective job descriptions. Staff files meet regulatory standards. The agency currently has (6) THPP NMD participants. LPA Galvan reviewed (5) THPP NMD Participant files on this date. Client files meet regulatory standards. LPA reviewed an updated LIC 500, roster of clients, board meeting minutes, and certified THPP units certificated. LPA discussed the client's medical assessments and domains in the client's Needs and Services Plan. LPA provide LIC 625, LIC 9108, and LIC 621 forms to the agency's Administrator and Program Director. No deficiencies were issued on this date. An exit interview was conducted, and a copy of this report was provided to Rose Churchill at the conclusion of the inspection.

met_with: Mary Beth Iron and Rose Churhill


summary: Facility Evaluation

raw_content:
Narrative:
On June 4, 2024, Licensing Program Analysts (LPAs) Vanessa Galvan and Angelica Borja traveled to Unity Transition Housing located in Visalia, California and conducted an unannounced visit. The purpose of the visit was to complete the inspection that was started on 5/29/2024. LPAs met with Program Director, Mary Beth Irons and Administrator, Rose Churchill. LPAs conducted interview (3) staff interviews. No deficiencies were issued or observed at this time. A copy of this report was provided to Rose Churchill at the conclusion of this inspection.

met_with: Mary Beth Irons and Rose Churchill


summary: Facility Evaluation

raw_content:
Narrative:
On June 20, 2024, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Unity Transitional Housing located in Visalia, CA, and met with Program Director, Mary Beth Irons (PD). The purpose of the inspection is to provide PD with the LIC 200 for updated capacity. PD added the capacity on the LIC 200 for a capacity increase. No deficiencies observed or cited during today's inspection. A copy of this report was provided to the Mary Beth Irons at the conclusion of the inspection.

met_with: Mary Beth Irons


summary: Facility Evaluation

raw_content:
Narrative:
On March 4, 2025, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Unity Transitional Housing located in Visalia, CA, and met with Administrator/Social Worker Supervisor Rose Churchill, Program Director Mary Beth Irons, and Case Manager Noe Lara. The purpose of the inspection is to conduct an Annual/Required inspection. LPA conducted a physical plant inspection and included the following observation and checks: clients and staff files are kept in locked filing cabinets. The agency has adequate confidential meeting space, space for Social Worker and Case Manager to complete job duties. The facility has a current copy of the license, Facility Sketch, Client Personal Rights, LIC 610C, fire clearance, and "Let Us No" reporting hotline poster posted in a common area, . The agency has a client register roster LIC 9120, with all required information. The agency's office is located within two hours of travel time of the THPP participants living units. The agency employs (1) Administrator/Social Worker Supervisor, (1) Program Director, and (1) Case Manager. LPA reviewed three staff files. A review of the staff files on this date indicates that all facility staff has received child abuse index, DOJ, and FBI clearances. Agency staff meets the requirements of respective job descriptions. Staff files meet regulatory standards. The agency currently has (15) THPP Non-Minor Dependent (NMD) participants. LPA reviewed (6) THPP NMD Participant files on this date. Client files meet regulatory standards. LPA reviewed an updated LIC 500, roster of clients, certified THPP units certificated, and Disaster Preparedness Plan. No deficiencies were issued on this date. An exit interview was conducted, and a copy of this report was provided to Rose Churchill at the conclusion of the inspection.

met_with: Rose Churchill, Mary Beth Irons, Noe Lara


summary: Facility Evaluation

raw_content:
Narrative:
On February 5, 2026, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Unity Transitional Housing located in Visalia, CA, and met with Administrator Mary Beth Irons. The purpose of the inspection is to conduct an Annual/Required inspection. LPA conducted a physical plant inspection and included the following observation and checks: clients and staff files are kept in locked filing cabinets. The agency has adequate confidential meeting space, space for Social Worker and Case Manager to complete job duties. The facility has a current copy of the license, Facility Sketch, Client Personal Rights, LIC 610C, fire clearance, and "Let Us No" reporting hotline poster posted in a common area. The agency has a client register roster LIC 9120, with all required information. The agency's office is located within two hours of travel time of the THPP participants living units. The agency employs (1) Administrator (1) Program Director, and (2) Social Workers. LPA reviewed four staff files. A review of the staff files on this date indicates that all facility staff have received child abuse index, DOJ, and FBI clearances. Agency staff meets the requirements of respective job descriptions. Staff files meet regulatory standards. The agency currently has (12) THPP Non-Minor Dependent (NMD) participants. LPA reviewed (5) THPP NMD Participant files on this date. Client files meet regulatory standards. LPA reviewed an updated LIC 500, roster of clients, certified THPP units certificated, and Disaster Preparedness Plan. On 02/05/2026, LPA reviewed Guardian Roster and confirmed all staff have a background clearance. No deficiencies were issued on this date. An exit interview was conducted, and a copy of this report was provided to Mary Beth Irons at the conclusion of the inspection.


raw_content:
Narrative:
Valor staff denied the alleged allegations further indicating that C1 was fully supported and various accommodation were made to support C1. Staff indicated that due to C1's frequent medical visits and in the best interest of C1, a seven-day notice was given due to Valor program not being able to meet C1's mental health needs; however were willing to work out a plan if provided with more services by Kern Behavioral Health & Recovery Services (KBHRS). Information obtain from CSW corroborated the above information further disclosing that the initial seven-day notice was issued on 5/7/21, however it was retracted due to KBHRS providing further mental health services. Therefore, based on the information received, the above allegations are determined to be unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the allegations are found to be unsubstantiated. There are no deficiencies to be cited at this time. A copy of the report along with the (LIC 811) was sent by courier to the address on file, Due to the above facility permanently closing.

Investigation Findings:
13On September 1, 2021 at 10: A.M., Licensing Program Analyst (LPA) Winston Moroney, conducted a teleconference inspection to the above Agency and met with Agency Administrator Randy Martin. The purpose of the teleconference was to deliver the findings for the above complaint allegations. On May 10, 2021, the California Department of Social Services Community Care Licensing Division received a complaint from Centralized Complaint and Information Bureau (CCIB) with the above allegations. The investigation to the above allegations was conducted by this LPA and it consisted of, but not limited to a review of records, including the clients' needs and service plan, medical records and interviews with Valor Administrator on 5/13/2021, C1 on 5/13/2021 and Kern County Social Worker (CSW) on 5/14/2021. (Reference Confidential Names Form LIC 811, dated September 1, 2021). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Deborah A Santos LICENSING EVALUATOR NAME: Winston Moroney LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: VALOR RESIDENTIAL & EDUCATIONAL SERVICESFACILITY NUMBER: VISIT DATE: 08/31/2021

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

met_with: Randy Martin - Administrator


raw_content:
Narrative:
On 03/23/2021, the Department received a complaint alleging that, there are individuals working at the facility without background clearance. Reporting Party alleged that on 03/19/21 there were two uncleared adults (A1) and (A2) reviewing clients files which contain personal information. Administrator denied the allegation stating that (A1) was hired as a bookkeeper consultant for the facility. That there were no clients present at the facility while (A1) was conducting bookkeeping duties. Administrator provided the Board of Director's Unanimous Written Consent dated 03/10/2021 to prove that (A1) was authorized to be present in the facility as a bookkeeper consultant. Administrator denies having any other unauthorized person present in the facility reviewing any type of documentation. After conducting confidential interview with Staff 1 (S1) it was determined that (S1) was laid-off before 03/19/21. Also, (S1) & (S2) confirmed that (A1) was present in the facility but did not witness any unauthorized person reviewing client's files and there were no client's present at the time. The facility is permanently closing effective July 15, 2021. All of the clients were sent to different facilities. Therefore, based on the information received, the above allegations are determined to be unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. There are no deficiencies to be cited at this time. An exit interview was conducted and a copy of the report along with the (LIC 811) was sent via email and by courier to the address on file.

Investigation Findings:
On 09/16/2021 at 11:00AM, Licensing Program Analyst (LPA) Janeth Chavez conducted a follow up inspection for the purpose of providing findings for the above complaint allegation. LPA spoke with Randy Martin, Administrator. During the investigation, LPA conducted telephone interviews with Administrator (04/01/21), Agency Social Worker and Supervising Social Worker on. During the inspection LPA requested documents for review and obtained copy of LIC 500,Client's Roster, and Board of Director's Written Consent dated 03/10/21. Report Continues on Next Page UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Yan Yeung LICENSING EVALUATOR NAME: Janeth 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 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: VALOR RESIDENTIAL & EDUCATIONAL SERVICESFACILITY NUMBER: VISIT DATE: 09/16/2021

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

met_with: Randy Covenant


facility_name: VALOR RESIDENTIAL & EDUCATIONAL SERVICES

raw_content:
Investigation Findings:
13On 10/08/2021 at 1: AM, Licensing Program Analyst (LPA) Noubar Yerkatyan conducted a follow-up complaint inspection to the above facility and met with above staff. The purpose of the visit was to discuss and deliver findings for the above compliant allegations. While investigating the allegations, LPA Dawn Mahecha and LPA Yerkatyan conducted interviews with facility staff and county social workers (see Confidential Names LIC 811 dated October 08, 2021). Certain files were reviewed such as staff and client records. The facility has been closed and currently has no placements. LPA attempted to interview C1, however C1 refused. Due to inconsistency of information obtained during the investigation, it cannot be determined whether the above allegation occurred. Based upon the interviews, the complaint findings are unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the allegation occurred. No deficiencies were cited. An exit interview was conducted, and a signed copy of this report was left with above staff. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Noubar Yerkatyan LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Randy Martin, FFA Administrator


facility_name: VARSITY TEAM INC THP

summary: Facility Evaluation

raw_content:
Narrative:
On January 23, 2024, Licensing Program Analyst (LPA) Carol Anderson conducted an announced pre-licensing inspection to the above facility. LPA Anderson met with CEO Lance Hickman, CFO Drew Dahlstedt and THP Administrator Desmond Bryan. LPA Anderson toured the administrative office for the Transitional Housing Placement Plus Foster Care (THP+FC). The participants' apartment units will be within a two hour radius from the Administration office. LPA Anderson inspected the office. The following areas were observed: The Administrative Office is in executive office building. Within the administrative office, waiting area, four administrative offices, and break room. The participant records and personnel records will be locked in cabinet in one of the administrative offices. All documents have been received and the physical plant meets the minimum requirements of Title 22 regulations. The applicant has been informed that the address to this facility is available to the public. All special incident reports (SIR's) will be sent via e-mail to: cclpaccr@dss.ca.gov. Based on the facility pre-licensing inspection and facility records' review, no deficiencies were noted at time of the inspection Upon managers final review, the license will be provided. An exit interview was conducted, a copy of this report was discussed and left with the CEO Lance Hickman and CFO Drew Dahlstedt.

met_with: Lance Hickman


summary: Facility Evaluation

raw_content:
Narrative:
On February 28, 2025 at 9: AM, Licensing Program Analyst (LPA) Lucero Jauregui conducted an unannounced inspection at the above facility. LPA Jauregui met with Desmond Bryan, Adminsitrator and Lance Hickman, CEO. The purpose of the inspection is to conduct a annual inspection. The facility is licensed to provide transitional housing placement plus foster care for non-minor dependents for 36 participants ages eighteen (18) through twenty-one (21) years old. There are currently 5 participants in the program. The Administrative Office is located at Murphy Canyon Rd Suite 227, San Diego CA 92123. The administrative office is in a executive office building. LPA Jauregui inspected the administrative office. The office has a waiting area, four offices, and a break room. The participants' files are stored and locked in a cabinet located in administrators office. Five participants' files were reviewed. Staff files are stored and locked in CEO's office. Three staff files were reviewed. LPA Jauregui conducted one staff interview due to one staff being present. Based on todays inspection and review, there are no deficiencies cited at this time. An exit interview was conducted and a copy of this report was provided to Lance Hickman, CEO.

met_with: Desmond Bryan, Adminsitrator & Lance Hickman, CEO


summary: Facility Evaluation

raw_content:
Narrative:
On April 16, 2026, at 10: AM, Licensing Program Analyst (LPA) Cynthia Velasquez conducted an unannounced inspection at the above facility. LPA met with Desmond Bryan, Administrator. LPA was invited into the administrative office located in an executive office building. There were no blockages leading to the front entrance and the office was free from debris and well kept. The facility is licensed for 36 transitional housing placements and for providing foster care to non-minor dependents ranging from ages 18 through 21. There are currently 6 participants in the program. The office has four separate offices, a waiting area, and a break room. Postings of license and necessary documents were available. The participants' files are stored and locked in a cabinet located in administrators office, and six participants' files were reviewed. All client files contained identification, health screenings, needs and service plans, independent living plans, and placement documentation. Staff files are stored and locked in CEO's office, and all staff files were reviewed. All files had necessary documentation, identification, health screenings, and trainings. Based on today's inspection and file reviews, there were no deficiencies cited at this time. An exit interview was conducted, and a copy of this report was provided to Desmond Bryan, Administrator.

met_with: Desmond Bryan, Program Manager


facility_name: VICTORY FAMILY SERVICES

raw_content:
Narrative:
There is not enough evidence to prove the allegations; as the information provided during the investigation is conflicting. Based on information obtained by LPA Palmer, there is not a preponderance of evidence to support the allegation therefore, the allegation is unsubstantiated. No deficiency cited. Copies of the following reports were provided at the conclusion of the inspection: LIC 9099 and LIC 9099-C..

Investigation Findings:
13On May 28, 2025 at 1:20pm, Licensing Program Analyst (LPA), Carrie Palmer conducted a follow-up complaint inspection with the above named facility and spoke to the Director of Operations. The purpose of the visit is to deliver the findings for the above complaint allegation. During the course of the investigation, LPA Palmer reviewed facility records and conducted investigative interviews with S1 on 11/12/24 and C1 on 11/14/24 and S2 on 5/28/25. (See Form 811 - Confidential Names List Dated 5/28/25). During the investigation, confidential interviews revealed conflicting information. There was concern regarding the need to make repairs by the above named facility, and that the repairs were not completed by the facility and the repairs needed to be completed with the clients money. However, the facility was able to provide documentation regarding repairs completed on 10/05/24, 11/27/24, 1/24/2025, 4/07/25, 4/28/25, 4/30/25, via the maintenance log. Additional confidential interviews reveals that the facility does not clearly explain the rules resulting in a non compliance. However, the facilty provided a detailed intake package which consist of all of the rules of the facilty as well as a THPP Placement handbook, which they review with the client and have the client sign upon admission into the program. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Carrie Palmer LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: VICTORY FAMILY SERVICESFACILITY NUMBER: VISIT DATE: 05/28/2025

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

met_with: Petra Gil-Vigie, Director of Operations


summary: Facility Evaluation

raw_content:
Narrative:
On December 4, 2020 at 4: PM, Licensing Program Analyst (LPA) Jean Herring conducted a tele-conference with the applicant via Microsoft Teams for the purpose of completing Component II of the Transitional Housing Placement Program (THPP). Remote "tele-inspections" of facilities is a part of Community Care Licensing Division's emergency response to the spread of Coronavirus Disease 2019 (COVID-19). LPA spoke with Tina Madan, Russell Johnson and Petra Gil-Vigie. The licensee has submitted the missing Licensing Forms (Section A) and Supportive Documents (Section B) outlined in the Notification of Incomplete Application (NOI-LIC 184) sent to the applicant on 10/15/20. A POO (Plan of Operation) review tool was also sent to the applicant on 10/15/20. The POO is still in the review process. A Pre-Licensing Tele-Inspection will be scheduled once the POO review has been completed. A copy of this document was emailed to the applicant for signature.


summary: Facility Evaluation

raw_content:
Narrative:
On January 20, 2021 at 1: PM, Licensing Program Analyst (LPA) Jean Herring conducted a Pre-licensing tele-inspection of the facility via Microsoft Teams Meeting. Remote "tele-inspection" of facilities is a part of Community Care Licensing Division's emergency response to the spread of Coronavirus Disease 2019 (COVID-19). LPA spoke with Russel Johnson, CEO and Petra Gil-Vigie, FFA Administrator. This Transitional Housing Placement Program (THPP) will share the same suite with Victory Family Services -Foster Family Agency (FFA). Currently, the THPP office is staffed by one (1) Administrator and one (1) Social Work Staff. LPA completed a virtual tour of the THPP's administrative office. The office is conveniently located for the public. LPA observed individual offices for the administrator and the social worker, cubicles for Life Coaches, conference room, and copy room. The THPP participant records will be filed in a locked filing cabinet in the Administrator's office and the THPP employee records will be filed in a locked cabinet in the CEO's office. The THPP will have available computers and printers for participants' use. This THPP will use Host Family and Remote Site models to place non-minor dependent (NMD) participants. Currently, the program has a contract with an apartment landlord for eight (8) apartment units. Each unit has two (2) bedrooms and one (1) bath. LPA requested a copy of the lease agreement and a sample floor plan. The THPP will complete and sign a Certificate of Compliance for each THPP participant living unit, as defined in Section 86001(c)(2), that verifies that the participant living unit meets the requirements of the Health and Safety Code Section 1501(b)(5). (Ref. California Code of Regulations, Title 22, Division 6, Chapter 7, Article 3, Section 86030.5.) The THPP has not identified any host families at this time. The applicant will notify the Department once host families are identified. LPA concluded the tele-inspection at 1: PM. A signed copy of this report was provided to the applicant.


summary: Facility Evaluation

raw_content:
Narrative:
On February 8, 2021, Licensing Program Analyst (LPA) Jean Herring conducted a Transitional Housing Placement Program (THPP) Component III Category-Specific Orientation via Microsoft Teams Meeting app. Remote "tele-inspection" of facilities is a part of Community Care Licensing Division's emergency response to the spread of Coronavirus Disease 2019 (COVID-19). The Component III orientation was attended by Tina Madan, Russell Johnson and Petra Gil-Vigie. LPA Herring provided training on technical aspects associated with the operation of a THPP. Emphasis during the session was placed upon California Code of Regulations, Title 22, Article 6, "Continuing Requirements"such as Reporting Requirements (Law Enforcement Contact Reports and Special Incident Reports); Social Worker Ratios; Needs and Services and Transitional Independent Living Plan (TILP); and other Continuing Requirements. The applicant was also provided with a list of forms/documents that will be required to complete and maintain at the facility for all clients/residents and personnel. A signed copy of this report was provided to the applicant.


summary: Facility Evaluation

raw_content:
Narrative:
On December 03, 2021 at 12: PM, Licensing Program Analyst (LPA) Jean Herring conducted an unannounced Post-Licensing inspection at the above named Transitional Housing Placement Program (THPP) for non-minor dependents (NMDs). LPA met with Petra Gil-Vigie, Administrator. Currently, the THPP office is staffed by two(2) Social Work Personnel, one(1) Social Work Supervisor, two(2) Peer Life Skills, one (1) Office Manager and an Administrator. BUILDINGS AND GROUNDS A tour of the THPP administrative office was conducted with the administrator. The THPP administrative office shares the same suite with Victory Family Services- Foster Family Agency and Adoption Agency. The office is conveniently located for the public and less than two hours' travel by automobile from the THPP participant units as required. The office has a reception area, file room, copy area, conference room, break room, cubicles and individual offices. THPP participant records and personnel records are kept locked at all times in file cabinets. The administrative office has telephone service at all times. The program has 11 remote sites and 20 participants in placement. Per Administrator, the program has no non-ambulatory participants in placement. OPERATIONS The THPP maintains on file a current, written, definitive Plan of Operation. The THPP's governing body is active and functioning in order to ensure accountability. The THPP maintains a listing of all participants and living units. DISASTER PREPAREDNESS The THPP has a current Emergency and Disaster Preparedness Plan which includes emergency information, instructions and phone numbers including a 24-hour emergency number for the licensee and the participant's responsible party. The facility provides training on the plan to each staff member. (cont...) STAFFING During this inspection, LPA reviewed two(2) Social Worker Personnel files, one(1) Social Work Supervisor's file and Administrator's file. All personnel have obtained criminal record clearances and child abuse index checks. All personnel are associated to the THPP's facility number. During this inspection, the THPP was cited for violation of: Title 22, Division 6, Chapter 7, THPP regulation, Section 86030.5(e) - Record review reveals THPP does not maintain a Certificate of Compliance for each THPP living unit. Title 22, Division 6, Chapter 7, THPP regulation, Section 86071(a)(1)(A) - Record review reveals current participant roster does not contain information on the following: participant's ambulatory status; name, address and phone number of attending physician; authorized representative information. Title 22, Division 6, Chapter 7, THPP regulation, Section 86071(a)(1)(B) - Record review reveals current participant roster does not contain information on the following: participant's ambulatory status; name, address and phone number of attending physician; authorized representative information. Title 22, Division 6, Chapter 7, THPP regulation, Section 86071(a)(1)(C) -THPP's register of participants does not contain authorized representative information as specified in Section 86170(b)(7). A Case Management - Post-licensing Continuation inspection is required to complete the inspection. A signed copy of this report was provided to the THPP representative along with LIC 809C, LIC 809Ds, LIC 9102TV (Advisory Notes-Technical Violation), LIC 811 (Confidential Names list) and Appeal Rights.

met_with: Petra Gil-Vigie, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On December 9, Licensing Program Analysts (LPA) Jean Herring conducted an unannounced inspection of the facility at 4: PM. LPA met with Petra Gil-Vigie, Administrator. The purpose of the inspection was to verify proof of correction to the deficiency cited on December 3. 2021. During today's inspection, the following documents were observed: - Register of Participants which contains information specified in Section 86071 (a)(1)(A) thru (C) - Certificate of Compliance for each THPP living unit as specified in Section 86030.5(e) The deficiencies are cleared. Plan of Correction (POC) Clearance letters were provided to the facility representative along with this report.


summary: Facility Evaluation

raw_content:
Narrative:
On May 9, 2022 at 12: PM, Licensing Program Analyst (LPA) Jean Herring conducted an unannounced Case Management - Post-Licensing Continuation inspection at the above named Transitional Housing Placement Program (THPP) for non-minor dependents (NMDs). LPA met with Gregorio Aguinaldo, During this inspection, LPA reviewed four(4) participant records, including but not limited to: Admission Agreement; ID and Emergency Information; Health and Education Passports including mental health information and immunization record; education and/or work documents; Needs and Services Plan (NSP) and Transitional Independent Living Plan (TILP); modifications to NSP; Removal/Discharge Policy; and medical assessment. There are no deficiencies cited during this inspection. LPA provided one(1) Advisory Note - Technical Violation regarding medical assessment. No additional Post-licensing continuation inspection is required. An exit interview was conducted and a signed copy of this report was provided to the facility representative along with LIC TV (Advisory Notes) and LIC 811 (Confidential Name/s list).


summary: Facility Evaluation

raw_content:
Narrative:
On May 9, 2022 at 4: PM, Licensing Program Analyst (LPA) Jean Herring conducted an unannounced Case Management at the above named Transitional Housing Placement Program (THPP) for non-minor dependents (NMDs). LPA met with Gregorio Aguinaldo, Social Work Supervisor. The purpose of the inspection was to follow up on an incident report received by the Department on 2/9/22 involving NMD1 and NMD2. During today's inspection, LPA reviewed participant records and obtained copies of pertinent documents. Additional time is needed to resolve this case. A signed copy of this report was provided to the THPP representative along with LIC 811 (Confidential Names list).

met_with: Petra Gil-Vigie, Administrator and Gregorio Aguinaldo, Social Work Supervisor


summary: Facility Evaluation

raw_content:
Narrative:
On December 16, 2022 at 10:45 a.m., Licensing Program Analyst (LPA) Demetris Teal conducted an unannounced case management at the above named Transitional Housing Placement Program (THPP) for non-minor dependents (NMD's). LPA met with Raymond Martinez, FFA Social Worker Supervisor. Supervisor said he has knowledge for both the FFA and THPP. Purpose of the visit was to follow up on an incident report received by Community Care Licensing on 11/09/22 involving NMD1 and NMD2. During todays inspection, LPA reviewed participant records, staff record and obtained copies of pertinent documents. Interviews will be conducted as necessary Additional time is needed to resolve this case. A signed copy of this report was provided to the THPP representative along with LIC 811 (Confidential Names)

met_with: Raymond Martinez-FFA Social Worker Supervisor


summary: Facility Evaluation

raw_content:
Narrative:
On 12/30/22 at 11: A.M. Licensing Program Analyst (LPA) Demetris Teal conducted an unannounced case management inspection at the THPP administrative office. LPA met with Petra Gil-Vigie- Administrator, to deliver the Conclusion of the Case Management from an in-person case management inspection performed on 12/16/22, by the LPA Demetris Teal. Interviews were conducted with Staff associated with Victory Family Services, Ronald (Ron) Hernandez, Petra Gil-Vigie, Jasmeet Aujla and Dept.of Social Services with Kern County, Social Worker Somphou Siripane. Interviews were conducted with NMD 1 and an attempt to interview NMD 2 was made, without success. Based on review of files, interviews conducted and all available information, LPA did not find any personal rights or Interim Licensing Standards violated regarding Victory Family Services, where it involves a weapon produced by NMD 2 with intent to use said weapon against NMD 1. No injuries were reported by NMD 1. NMD 1 did feel threatened and called the police. Incident appears to have been isolated between two participants who lived together. NMD 2 is no longer a part of the THPP program. No further follow up is needed at this time. Exit Interview. A signed copy of this report was provided to the THPP representative along with LIC 811 (Confidential Names list).

met_with: Petra Gil-Vigie-Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On March 26, 2024 at 11: A.M, Licensing Program Analysts (LPA) Demetris Teal and Ashley Ruacho conducted an unannounced Annual Inspection at the above named Transitional Housing Placement Program (THPP) for non-minor dependents (NMDs). LPA's met with Petra Gil-Vigie, Administrator. Currently, the THPP office is staffed by three (3) Social Work Personnel, one (1) Acting Administrator, three (3) Peer Life Coach's, one (1) Support Staff Manager, three (3) Support Service Aide's, one (1) Office Manager and an Administrator. PHYSICAL PLANT A tour of the THPP administrative office was conducted with the administrator. The THPP administrative office shares the same suite with Victory Family Services- Foster Family Agency and Adoption Agency. The office is conveniently located for the public and less than two hours travel by automobile from the THPP participant units as required. The office has a reception area, file room, copy area, conference room, break room, cubicles and individual offices. THPP participant records and personnel records are kept locked at all times in file cabinets. The administrative office has telephone service at all times. The program has 26 remote sites and 32 participants in placement. Per Administrator, the program has no non-ambulatory participants in placement. OPERATIONS The THPP maintains on file a current, written, definitive Plan of Operation. The THPP's governing body is active and functioning in order to ensure accountability. The THPP maintains a listing of all participants and living units. Continued.... ......Continued DISASTER PREPAREDNESS The THPP has a current Emergency and Disaster Preparedness Plan which includes emergency information, instructions and phone numbers including a 24-hour emergency number for the licensee and the participant's responsible party. The facility provides training on the plan to each staff member. STAFF RECORDS Staff records are available upon request. LPA reviewed two (5) personnel records (refer to Confidential Names form LIC 811 dated March 26, 2024 and interviewed five (5) staff. All individuals who work, or have contact with clients, have a current criminal record clearance or exemption and Child Abuse Index Check clearance/Live-Scan fingerprints and/or request for association have been submitted for that purpose. The Administrator meets required education and experience. Social workers have the required education and experience. Personnel records contain documentation of staff training. CLIENT RECORDS LPA reviewed five (5) client records. Client records are maintained onsite in the administrative THPP office. Client record are in a locked cabinet. Administrative office is locked. Client record contained the name, address, telephone numbers of physicians, pertinent client information including ambulatory/non-ambulatory status. Client records were made accessible when requested. A deficiency citation was issued at the time of the inspection. An exit interviewed was conducted and a copy of the LIC 809, LIC 809C, LIC 809D and appeal rights were provided to Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Dina Camara conducted a case management inspection on 04/18/24 at 9: AM based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 6 out of Direct Care Staff and 5 out of 29 youth files were reviewed. 3 out of Direct Care Staff and 2 out of 29 youth were interviewed. (See the Confidential Names List, LIC 811, 04/18/24). The Plan of Operation including policies and procedures were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, and youth case plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Camara observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Administrator Petra Gil-Vigie.


summary: Facility Evaluation

raw_content:
Narrative:
On January 27, 2025, at 1:15PM, Humberto Flores, Licensing Program Analyst (LPA), conducted an unannounced Case Management inspection, Transitional Housing Placement Program (THPP) and met Administrator Petra Gil-Vigie. The purpose of the inspection was to initiate an investigation regarding the below incident reported via Special Incident Report (SIR). On Thursday January 23, 2025, the THPP reported to the Licensing agency that Child Ref #1 (C1) (see Confidential Names List LIC811 dated 01/27/2025) was found death on Sunday January 19, 2025, in the Alleyway of F Street and A Street, Bakersfield, with an overdose. LPA Flores interviewed Petra Gil-Vigie. Copies from C1's file were provided upon request. Further inspection is needed to deliver the findings of this case management. A copy of this report and LIC811 was provided to the facility representative. Exit interview conducted.


summary: Facility Evaluation

raw_content:
Narrative:
On February 19, 2025, at 11:40AM, Licensing Program Analyst (LPA) Humberto Flores, Licensing Program Analyst (LPA), conducted an unannounced Case Management inspection at Victory Family Services Transitional Housing Placement Program (THPP) and met with Administrator Petra Gil-Vigie and Agency Social Worker (ASW) Zohie Earnshaw. The purpose of the inspection was to initiate investigation regarding the below incident reported via Special Incident Report (SIR). On 02/12/2025, the THPP reported to Community Care Licensing Division (CCLD) that on 02/11/2025 around 5:07PM, Participant Ref #1 (P1) (see Confidential Names List LIC811 dated 02/19/2025) called Peer Life Skills Coach (PLSC) Irais Maldonado and reported to her that P1's neighbor's caregiver broke into P1's apartment. LPA Flores investigated the incident and interviewed Administrator Petra Gil-Vigie and ASW Earnshaw. A review of the documentation submitted to CCLD was conducted. The information revealed that on 02/11/2025, an unknown woman (UW), who apparently is the caregiver of P1's neighbor, broke into P1's apartment for an unknown reason. P1 called Bakersfield Police Department (BPD) and reported the ongoing incident, right after P1 called PLSC Maldonado and informed her about the incident. P1 was advised not to engage with UW and avoid her when possible and called BPD immediately. PLSC Maldonado took immediate action and reported the ongoing break-in to BPD, and she was informed that officers were on their way, which PLSC Maldonado informed to P1 right after the call. cont.# P1 informed PLSC Maldonado that BPD informed her that P1 can file charges against UW. P1 stated that she will file a restraining order against UW. Administrator Gil-Vigie and ASW Earnshaw disclosed that P1 refused to relocate from the building and stated to both that she feels safe and neither she nor her son are in danger. ASW Earnshaw disclosed to LPA Flores that she has a package ready for P1 with the steps on how to file a restraining order with Kern County Sheriff Department but has not been able to deliver it because P1 is not answering her phone calls and P1's phone does not have a set up voicemail. LPA Flores suggested to ASW Earnshaw to send the package via electronic mail and go over the paperwork with P1 when she would make herself available. No further inspection is needed. No citation was issued. A copy of this report and LIC811 was provided to the facility representative. Exit interview conducted.

met_with: Administrator, Petra Gil-Vigie


summary: Facility Evaluation

raw_content:
Narrative:
On April 25, 2025, at 3:30PM, Licensing Program Analyst (LPA) Humberto Flores, conducted an unannounced Case Management inspection, at Victory Family Services Transitional Housing Placement Program (THPP) and met with Administrator, Petra Gil-Vigie. The purpose of the inspection was to deliver the findings about the below incident reported via Special Incident Report (SIR). The THPP reported that on 1/20/25. agency received a phone call from a THPP participant being concerned they had not seen Participant #1 (P1) since Saturday night 1/18/2025. On 1/20/ THPP Social Worker (SW) Lina Frost made phone calls to P1 at 10: 51AM, but unsuccessful because it went straight to phone mailbox that has not been set up yet. THPP SW Frost attempted additional phone calls at 2:10PM and 8:22PM, with the same outcome as the prior ones. On 1/20/25 at 3:20PM THPP SW Frost travelled to P1 apartment to confirm if she was home. As there was no answer THPP SW Frost used agency master key and prior to entering announced self and proceeded to enter the apartment which was found undisturbed and P1 was not present. On 1/22/ THPP SW Frost Lina contacted P1's school to verify last days of attendance of P1. On 1/22/ THPP SW Frost contacted Bakersfield Police Department to file a missing person's report which THPP SW Frost was directed to call all hospitals, morgue and conduct inmate search to search for P1. cont.# On 1/23/2025, Bakersfield Police Department (BPD) provided the following information, that on 1/19/2025, the missing person, P1, had been death, in the Alleyway of F Street and A Street, with an overdose. LPA Flores investigated the report and interviewed Petra Gil-Vigie. On February 19, 2025, LPA Flores submitted a request for Coroner, Autopsy and Toxicology report. On April 22, 2025, the Coroner Office of Bakersfield, Kern County, replied to LPA Flores that it could take from 150 to 180 days to finalize these reports. No further action is needed currently. No citation was issued. A copy of this report and LIC811 was issued to the THPP representative. Exit interview conducted.

met_with: Administrator, PetraGil-Vigie


summary: Facility Evaluation

raw_content:
Narrative:
On Tuesday July 29, 2025, at 1:15PM, Licensing Program Analyst (LPA), Humberto Flores conducted an unannounced Case Management Inspection, at Victory Family Services Transitional Housing Placement Program (THPP) and met with Petra Gil-Vigie. The purpose of the inspection was to gather information about the incident below reported via Special Incident Report (SIR). On 7/25/2205 at 3:57PM, THPP Admin Petra Gil-Vigie received a phone call from THPP Social Worker (SW) Zohie Earnshaw stating that she received a message from THPP staff that two young children, ages 2 and 1 year old, were trying to open the front door from inside the Apartment #1 (A1), the children are the sons of Nonminor Dependent (NMD). According to the SIR, THPP staff made several attempts to knock on the apartment door, but no one answered. The Local Police Department (LPD) was contacted immediately. When THPP SW Frost and Peer Life Coach Vanessa Vega arrived at the apartment complex they met with NMD. The THPP staff was informed by an officer that NMD was sleeping inside her unit. NMD was counselled by the THPP staff regarding children safety and how she needs to always be vigilant of her own children. A full report is still pending by the THPP to be submitted to the Licensing agency. A copy of this report and LIC811 were provided to the facility representative. Exit interview conducted.