raw_content:
Narrative:
The following allegations were made against the facility: Minors have access to illegal drugs while in care; minors are not being properly fed while in care; staff are not properly supervising the minors while in care; staff are not properly maintaining the facility; staff are not monitoring a minor's change in medical condition; staff are not addressing a minor's hygiene needs; facility is in disrepair, and staff interfered with CCL's visit to the facility. An unannounced inspection of the entire facility was conducted and each room was checked. Each facility room and the overall condition of the property were observed to be well maintained. The kitchen was fully stocked with food. Facility staff were following Covid-19 health and safety protocols with the use of masks, social distancing, and the facility had posters throughout the facility reminding staff and clients to follow Covid-19 safety protocols. The facility also had stock of sanitizers and personal protective equipment. Confidential statements obtained could not corroborate that clients had access to illicit drugs at the facility. The facility administrator also stated that a drug-sniffing dog used by law enforcement was also employed by the facility which did not result in discovery of illicit drugs. Confidential statements obtained also could not corroborate that clients were neglected by the facility regarding their hygiene needs, food, health and safety. There were ample supply of food and hygiene products at the facility. There were facility staff always present in each of the building that house the clients. Confidential statements obtained also could not corroborate that Community Care Licensing staff were purposely delayed in conducting their duties at the facility during unannounced inspections. Based on the information gathered, although the allegations may have happened or is valid, the preponderance of evidence to prove the allegations was not met, therefore the allegations are unsubstantiated. A copy of this report, Confidential Names Form and Appeal Rights were provided to the facility representative. There were no deficiencies cited during this inspection.

Investigation Findings:
13On August 19, 2021 at 9: AM, Licensing Program Analyst (LPA) Joshua Rarela conducted a follow-up inspection to deliver the findings of a complaint investigation concerning the allegations above. LPA Rarela discussed the findings with the facility representative named above. During the course of the investigation, LPA Rarela interview facility clients and facility staff on 2/12/21 (see Confidential Names Form dated August 19, 2021). An unannounced inspection of the facility was also conducted the same day as some of the allegations required in-person inspection to evaluate its merit. LPA also reviewed documents on 2/12/21 including placing agency records, facility repair work order documents, facility personnel and client roster and facility incident reports. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Joshua Rarela 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: TRINITY - EL MONTEFACILITY NUMBER: VISIT DATE: 08/19/2021

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

met_with: Jaime Acosta, Assistant Director


state: CA

facility_name: TRINITY - EL MONTE

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
It was reported S1 had a history of yelling at C1. S1 denied the allegation. Statements obtained from interviews conducted with staff revealed S1 speaks firmly to clients in care but does not yell. Staff denied that S1 and C1 had a history of yelling at each other. Statements obtained from confidential interview conducted provided conflicting statements regarding S1 yelling at clients. Two of the clients interviewed reported S1 does not yell at clients, one reported S1 yells at clients for minor incidents and one client reported he has not met S1. It was reported S1 told C1 he was getting sexual with her when he pressed his body against hers while he attempted to push past her. S1 denied the allegation and reported saying "This is inappropriate". Statements obtained from confidential interviews conducted and interviews with staff revealed there were no witnesses to the reported alleged comments made by S1. Based on information obtained through interviews conducted and records reviewed the allegations were Unsubstantiated. An unsubstantiated finding means that although the allegations may have occurred or are valid, the standard of the preponderance of evidence was not met. Exit interview conducted and a copy of this report was provided to the facility representative mentioned above.

Investigation Findings:
13On 9/22/21 at 1: PM, Licensing Program Analyst (LPA) Christopher Larios conducted a follow up complaint inspection and met with Administrator Jaime Acosta. The purpose of the inspection was to deliver findings for the above-mentioned complaint allegations. During the course of the investigation LPA Larios conducted a records review on 3/25/21 and obtained staff contact information, special incident reports, clients needs and services plans and staff (S1) suspension report. LPA Larios conducted interviews with one facility staff and one Administrator (AD) on 3/26/21, four facility staff on 9/21/21 and four clients on 9/21/21. LPA Larios attempted to interview one Probation Officer (PO) but, phone contacts were not returned. One client (C1) declined to provide a statement regarding the reported alleged incident. (Reference Confidential Names list LIC811 dated 9/22/21) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Deborah A Santos LICENSING EVALUATOR NAME: Christopher Larios 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: TRINITY - EL MONTEFACILITY NUMBER: VISIT DATE: 09/22/2021

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

report_type: Complaint Investigation

met_with: Jaime Acosta

complaint_status: unsubstantiated


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
It was reported S1 mishandled C1 by pushing him. S1 reported she placed her hands on C1's chest to create separation when he attempted to get past her and pushed against her with his body. S1 denied she pushed C1 because, although she used her hands to create separation, it was non-violent. Statements obtained from an interview conducted with AD indicated S1 was suspended as a result of the incident. The suspension was due to reviewing video footage of the incident and Administrators determining C1 was pushed by S1. Based on information obtained from interviews conducted and records reviewed the allegation was Substantiated. C1's personal rights were not afforded as require by the Interim Licensing Standards (ILS) Ver. 3. Sec. 87072(d)(11). The allegation is valid because the standard of the preponderance of evidence has been met. Facility cited for violation of Interim Licensing Standards (ILS) Ver. 3. Sec. 87072(d)(11): Personal Rights. Statements obtained from interviews conducted corroborated the allegation that a staff mishandled a minor in care. Exit interview conducted and a copy of this report along with a LIC9099D and LIC811 were provided to the facility representative. Appeals rights were discussed and provided.

Investigation Findings:
13On 9/22/21 at 1: PM, Licensing Program Analyst (LPA) Christopher Larios conducted a follow up complaint inspection and met with Administrator Jaime Acosta. The purpose of the inspection was to deliver findings for the above-mentioned complaint allegation. During the course of the investigation LPA Larios conducted a records review on 3/25/21 and obtained staff contact information, special incident reports, clients needs and services plans and staff (S1) suspension report. LPA Larios conducted interviews with one facility staff and one Administrator (AD) on 3/26/21, four facility staff on 9/21/21 and four clients on 9/21/21. LPA Larios attempted to interview one Probation Officer (PO) but, phone contacts were not returned. One client (C1) declined to provide a statement regarding the reported alleged incident. (Reference Confidential Names list LIC811 dated 9/22/21) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Deborah A Santos LICENSING EVALUATOR NAME: Christopher Larios 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: TRINITY - EL MONTEFACILITY NUMBER: VISIT DATE: 09/22/2021

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

complaint_status: SUBSTANTIATED


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) T. Davis and LPA Juliet Robles went to Trinity - El Monte on September 14, 2021 at 8:45am for the purposes of a joint unannounced Required Annual inspection. LPAs met with Jaime Acosta, Assistant Director (AD), and together they toured the facility both inside and outside. The facility is licensed to serve forty-three (43) male clients ages 11-17 years old. The facility is a Short Term Residential Therapeutic Program (STRTP) and is located in a residential neighborhood. It also provides services to Non-Minor Dependents (NMD) as well. The campus consists of three individual dorms (Aztecs, Trojans, and Golden Bears) for client placement. There are five clients presently at the facility and all five reside in the Aztecs dorm. Sharp knives, cleaning supplies, and medications are kept locked in areas inaccessible to clients. The bedrooms in each dorm contained twin beds, dressers, and closet space. Smoke alarms were operable throughout the facility. There is adequate seating in the common areas of each dorm. All rules and regulations were posted at the facility. LPAs observed a weight lifting area, ping pong table, basketball court, several board games, computers, reference materials and books at the facility for client use. LPAs also observed ample food supply at the facility. LPAs observed the outdoor areas to be free of debris and hazards. The last earthquake drill occurred on July 07, 2021 at 8:55am. Bulletin boards were posted in each dorm that contained personal rights information, facility license, emergency disaster plan information, ombudsman information, foster youth rights, disaster plan information, accreditation, and other important information. The last fire drill was held on August 18, 2021 at 5:41pm. The last active shooter drill (lockdown) was held on July 28, 2021 at 6:36pm. The facility has nine available vans for client transportation. LPAs obtained a current copy of the facility's staff roster (LIC500) and a client roster. LPA also obtained a copy of the minutes of the most recent Board of Director's meeting that was held on June 11, 2021. Two clients and two staff were interviewed.

report_type: Facility Evaluation

visit_type: Annual


facility_name: TRINITY - YUCAIPA

raw_content:
Narrative:
Facility staff interviewed denied witnessing inappropriate interactions amongst clients and stated that facility staff supervise the clients well. Campus Director denied being informed of inappropriate sexual interactions amongst clients. Probation officer stated that she was not informed of inappropriate sexual interactions. However, a confidential witness statement revealed that they witnessed clients engage in inappropriate sexual interaction on one occasion. For the allegation regarding cleaning supplies, it was specified that the facility did not have any cleaning supplies. Confidential witness' statements revealed that there was is always cleaning and hygiene products available to the clients. County investigators stated that they did not note a lack of hygiene or cleaning products during their investigations. Facility staff interviews revealed that there is always cleaning products for staff and clients. Campus Director stated that the facility has an abundance of cleaning and hygiene products available to clients and staff. County social worker (CSW) stated that she was never informed of a lack of cleaning and hygiene products at the facility. A confidential interview maintained that the facility did not have appropriate cleaning or hygiene products for staff. Based on confidential interviews and record reviews, the allegations that clients engaged in inappropriate sexual interactions and the facility does not have cleaning supplies available to staff and clients, may have occurred, however are not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Teresa Valles. Documents emailed to Teresa Valles. Original signature on file.

Investigation Findings:
13Licensing Program Analyst (LPA), Michael Almaraz, conducted a tele-inspection due to COVID19 and met with facility campus director, Teresa Valles, to issues the findings for the above stated allegations. The investigation was conducted by LPA Almaraz. LPA inspected the facility on December 10, 2020, at 10: AM and reviewed six client's records. During LPA inspection an interview was conducted with one facility staff. Additionally, LPA conducted interviews with four facility staff, three county social workers, probation officer, two county investigators and four of six clients. Two of six clients were unavailable for LPA interview. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Michael Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: TRINITY - YUCAIPAFACILITY NUMBER: VISIT DATE: 05/13/2021

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

met_with: Campus Director Teresa Valles


raw_content:
Narrative:
denied observing this. Confidential interviews reported that S1 had a good relationship with C1. Confidential interviews reported that S1 has been observed taking walks on campus with C1 and was reported to have been in C1's room on multiple occasions. Confidential interviews disclosed that staff had documented discussions with S1 regarding boundaries with the residents. Confidential interviews reported that C1 and S1 denied being in a relationship with one another. Confidential interviews reported that C2 was unsure how often C1 and S1 observed inappropriate behaviors. Other confidential interviews disclosed S1 had never been in an inappropriate relationship with C1. LPA received inconsistent information regarding the allegation. Based on confidential interviews during this investigation, the allegation that conduct inimical: facility staff is engaging in an inappropriate relationship with a minor in care, may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. Exit interviewed conducted. A copy of this report and appeal rights were given and explained to Jason Mayo.

Investigation Findings:
13On September 13, 2021 at 10:41am, Licensing Program Analyst (LPA), Cheraki Davis met with Jason Mayo, Short Term Residential Therapeutic Program (STRTP) Assistant Director to deliver the finding for the above complaint allegation. On 06/02/2021 at 10:30am, LPA conducted a safety inspection and no immediate safety hazards were observed. The investigation was conducted by Special Investigator Lori Wood of the Community Care Licensing (CCL) Investigations Bureau. Investigation included interviews with Inyo County Probation Officer, Campus Director, Assistant Director, Team Administrator Supervisor, Clinical Coordinator, one facility staff, Supervisor of Spartan Dorm, one former employee, and two clients (C1 & C2). San Bernardino County Sheriff's Department report was reviewed. On May 26, 2021, Community Care Licensing received an allegation which stated conduct inimical: facility staff (S1) is engaging in an inappropriate relationship with a minor (C1) in care. It was reported that a staff (S1) makes out with one of the youths (C1) that resides in one of the dorms. Confidential interviews reported that C2 observed C1 hug S1 at least once. Confidential interviews reported that S1 would "kiss" C1, but C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Cheraki Davis LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: TRINITY - YUCAIPAFACILITY NUMBER: VISIT DATE: 09/13/2021

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

met_with: Jason Mayo, Assistant Director


raw_content:
Narrative:
Community Care Licensing received information on July 20, 2021 alleging that the facility was not administering medications as prescribed. It was specified that an unknown client was given old medication from an old psychiatrist. During the investigation, confidential interviews stated not being aware of C1 and other clients being taken off a medication. Confidential interviews stated C1 and other clients refused medication at times and was encouraged to take the medication. Another confidential interview stated that they were not aware of change in medication for C1 or other clients. Other interviews did not have any information regarding the administration of medications at the facility. C1's Probation Officer stated C1 did not disclose any medication issues while placed at the facility. Based on confidential interviews, the allegation that the facility was not administering medications as prescribed, may have occurred, however, it is not supported or proven by evidence. Therefore, this allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Assistant Director Jason Mayo.

Investigation Findings:
13On March 4, 2022 at 11:50am, Licensing Program Analyst (LPA) Adaleyci Caballero met with Trinity Yucaipa Assistant Director Jason Mayo to deliver the investigative finding for the above stated allegation involving clients in the facility. On July 2021 at 10:40AM, LPA Michael Almaraz initiated the investigation at the facility and interviewed four staff and three of four clients (C1, C2, and C3). Lpa a. Caballero was unable to obtain C4 contact information and LPA was unable to locate C4 at this time. Additionally, LPA Caballero did not receive a response from C4's County Social worker. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Adaleyci Caballero LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: TRINITY - YUCAIPAFACILITY NUMBER: VISIT DATE: 03/04/2022

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

met_with: Assistant Director- Jason Mayo


raw_content:
Narrative:
OHI stated that OHI was informed that C1 and C2 engaged in a physical altercation and staff immediately intervened. CSW stated that she was informed that C1 would leave the facility and staff would try to convince C1 to stay but C1 would ignore staff. Confidential witnesses stated that anytime that clients would go out of area in an attempt to leave the facility, the facility staff follow the clients attempting to get them to stay. Confidential witnesses disclosed that staff supervise the clients appropriately. Confidential witnesses stated that C1 and C2 were involved in a physical altercation and staff immediately intervened. Other confidential witnesses stated that clients would leave area without the staff noticing and C2 was not supervised correctly allowing C2 to assault C1. LPA received inconsistent information regarding the allegations. Based on confidential interviews and record review, the allegations that due to lack of supervision facility staff did not prevent C1 from leaving the group home and C1 was physically assaulted by C2 while in care may have occurred, however, are not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Jason Mayo.

Investigation Findings:
13On March 18, 2022, Licensing Program Analyst (LPA), Michael Almaraz, arrived at the facility and met with assistant campus director, Jason Mayo, to issue the finding for the above stated allegations. On July 21, 2021, at 10: AM LPA Almaraz conducted a safety inspection at the facility. During the inspection, LPA reviewed children's records and conducted interviews with four clients (C3, C4, C5, C6) and four staff. Additionally, LPA conducted an interview with one client (C1), one county social worker (CSW), and Riverside County Out of Home Investigator (OHI). One client (C2) was unavailable for LPA interview. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Michael Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: TRINITY - YUCAIPAFACILITY NUMBER: VISIT DATE: 03/18/2022

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

met_with: Jason Mayo


raw_content:
Narrative:
Continued from LIC C On December 7, 2022, LPA Cynthia Urena, attempted to conduct an interviewed with two staff members (S1, and S3) however, LPA was unable to contact both S1 and S3. On December 8, 2022, at 11: AM, LPA Urena conducted and interview with staff 4 (S4). In regard to the allegation that staff handled minor in a rough manner, a confidential interview stated that there was an altercation between C1 and C2 that resulted in staff handling C1 in a rough manor causing C1 to have shoulder pain. Other confidential interviews denied being handled in a rough manner by staff. Confidential interviews continued stating not witnessing C1 being handled in a rough manner by staff. Other confidential interviews stated that C1 has temperament problems and other behaviors, however, the interviews denied that C1 was handled in a rough manner. Regarding the allegation that staff are discriminating against minor, a confidential interview stated S1 was picking on C1 and was blaming C1 for the issues occurring among clients resulting in C1 feeling discriminated. Confidential interview further stated liking other staff, however, felt that S1 was favoring C2. Another confidential interview stated not liking the placement and feeling unsafe due to S1 and C2 being good friends. Confidential interview further stated that S1 allows C2 to get away with things that are not allowed. Confidential interview also stated that S1 overlooks C2's behaviors and C2 is not reprimanded for picking on other clients. Another confidential interview stated not witnessing S1 or staff discriminating against other clients. Confidential interview further stated that staff favor C1 more than other clients. Confidential interviews denied that staff are discriminating against minors. Based on the confidential interviews, the allegations that staff handled C1 in a rough manner, and staff are discriminating against C1, may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Trinity Yucaipa STRTP, Campus Director, Teresa Valles.

Investigation Findings:
13On December 12, 2022, at 9: AM, Licensing Program Analyst (LPA) Cynthia Urena, met with Trinity Yucaipa Short Term Residential Therapeutic Program (STRTP) Campus Director, Teresa Valles, to deliver the investigative finding for the above stated allegations. On March 14, 2022, Community Care Licensing received a complaint alleging that staff handled minor in a rough manner, and staff are discriminating against minor. On March 18, 2022, at 2: PM, Licensing Program Analyst (LPA) Michael Almaraz, initiated the investigation at the STRTP. LPA Almaraz conducted a health and safety inspection, and no immediate deficiencies were observed. LPA Almaraz reviewed client's files and conducted interviews with one staff member staff 2 (S2) and two clients (C1, C2). On March 30, 2022, LPA Almaraz conducted an interview with client 3 (C3). Continued on LIC C page 2... UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Cynthia Urena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: TRINITY - YUCAIPAFACILITY NUMBER: VISIT DATE: 12/12/2022

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

met_with: Campus Director, Teresa Valles


raw_content:
Narrative:
Other confidential witnesses stated that S1 and C1 were involved in a verbal altercation, but they did not witness S1 slapping C1. Furthermore, a confidential interview denied that S1 was physically aggressive toward C1 and added that it was C1 who was attempting to hit S1. LPA received conflicting information throughout the investigation. Based on confidential interviews and record review, the allegation that S1 slapped C1 may have occurred, however, it is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Jason Mayo.

Investigation Findings:
13On February 16, 2023, at 10: AM Licensing Program Analyst (LPA) Michael Almaraz, arrived at the facility and met with Trinity Yucaipa Assistant Campus Director, Jason Mayo, to issue the finding for the above stated allegation. On September 22, 2022, at 9: AM, LPA Almaraz arrived at the facility to initiate the investigation and conducted a safety inspection. During the safety inspection, LPA reviewed one client's records, interviewed three facility staff, and interviewed one client (C1) listed on the confidential names list (LIC 811) dated February 16, 2023. Additionally, LPA conducted two staff interviews. On September 19, 2022, the Department received a complaint that alleged staff #1 (S1) slapped C1. During the investigation, a confidential witness disclosed that on September 15, 2022, C1 and S1 were involved in a verbal altercation and S1 slapped C1 on the face. Confidential witnesses added that S1 was upset and attacked C1, but another staff was able to intervene to prevent a physical altercation between S1 and C1. Another confidential witness stated that C1 had an injury on C1's face after the dispute with S1, but it was indicated that C1 had self injurious behaviors. (continued on page 2...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Michael Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: TRINITY - YUCAIPAFACILITY NUMBER: VISIT DATE: 02/16/2023

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


raw_content:
Narrative:
Confidential witness' interviews revealed that staff provided appropriate supervision to clients. Furthermore, it was revealed that room visiting was not allowed to prevent clients from stealing from one another. Additional confidential witnesses stated that C1 walked into C3 and C4's bedroom then C3 and C4 fought with C1. It was revealed to LPA that staff attempted to redirect C1 from entering C3 and C4's bedroom but C1 ignored staff. LPA received other information that lack of supervision led to C1 being beaten up. Regarding the allegation that C1's belongings were stolen confidential witnesses stated that C1 did not have a personal cellular phone while placed at the facility and the phone that was reported as being C1's was the facility phone. Other confidential witnesses stated that C1 had his own personal phone that was stolen at the facility. LPA received inconsistent information regarding the allegations. Based on confidential interviews and record reviews, the allegations that due to lack of supervision C1 was beaten up by two clients and C1's cellular phone was stolen at the facility may have occurred, however, they are not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Teresa Valles.

Investigation Findings:
13On May 17, 2023, at 12: PM Licensing Program Analyst (LPA), Michael Almaraz, arrived at the facility and met with Campus Director, Teresa Valles, to issue the finding for the above stated allegations. This complaint investigation was jointly conducted by LPA Cynthia Urena and Michael Almaraz. On October 5, 2022, at 9: AM, LPA Urena arrived at the facility to initiate the investigation, review staff and client files and conducted a safety inspection. Additionally, LPA Almaraz conducted six staff interviews, five client (C2, C3, C5, C6, C7) interviews see confidential names list (LIC 811) date May 17, 2023, and an additional confidential witness interview. Two clients could not participate in LPA interview due LPA Almaraz being unable to locate them. On September 26, 2022, the Department received a complaint that alleged minor was physically abused by other minors due to lack of supervision and minor's belonging was stolen. It was specifically alleged that due to lack of supervision client #1 (C1) was beaten up by two clients and C1's cellular phone was stolen at the facility. (continued on page 2...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Michael Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: TRINITY - YUCAIPAFACILITY NUMBER: VISIT DATE: 05/17/2023

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


raw_content:
Narrative:
C1 and C7 engaged in sexual activity due to lack of supervision by staff. Confidential witness' interviews revealed that they had never seen or heard S1 requesting sexual favors from clients. An additional confidential witness interview denied that S1 had requested sexual favors from clients. PO stated that she was not informed of inappropriate interactions between a staff and clients. Other confidential witness stated that S1 would offer clients vape pens and drugs in exchange for allowing S1 to touch clients in a sexual manner. Regarding the allegation that S1 offered vape pens to clients. Confidential witness denied that S1 provided clients with vape pens or any other contraband. Furthermore, additional confidential witnesses stated that they had not seen or been informed of S1 or any other staff providing clients with vape pens or contraband. PO stated that she was not informed of staff providing clients with contraband. Other confidential witnesses maintained that S1 had provided C1 and C4 with vape pens and drugs. In regard to the allegation that lack of supervision led to C1 and C7 engaging in inappropriate sexual behavior while in care. LPA was informed by confidential witnesses that they had not seen any sexual inappropriateness amongst clients occurring at the facility. Other confidential witnesses stated that they had heard that C7 engaged with clients in an inappropriate sexual manner. PO stated that she did not suspect of lack of supervision resulting inappropriate sexual behaviors. Based on confidential interviews and record reviews, the allegations that S1 would offer C1 vape pens in exchange for allowing S1 to touch C1's private areas, S1 provided vape pens to clients, and C1 and C7 engaged in sexual activity due to lack of supervision by staff may have occurred, however, they are not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Jason Mayo.

Investigation Findings:
13On June 21, 2023, at 11: AM Licensing Program Analyst (LPA) Michael Almaraz arrived at the facility and met with Assistant Campus Director, Jason Mayo, to issue the finding for the above stated allegations. This complaint investigation was conducted by LPA Michael Almaraz. On March 1, 2023, 10: AM, LPA arrived at the facility to initiate the investigation, review one staff's files, review one client's files, and conducted a safety inspection. Additionally, LPA Almaraz conducted four staff interviews, eleven clients (C1, C2, C3, C4, C5, C6, C7, C C9, C10, and C11) interviews as listed on confidential names list (LIC 811) date June 21, 2023. LPA also interviewed a probation officer (PO). On February 21, 2023, the Department received a complaint that staff requested sexual favors from minors in care, staff offered vape pens to minors in care and due to lack of supervision, minors engaged in a sexual activity while in care. It was specifically alleged that staff #1 (S1) would offer C1 vape pens in exchange for allowing S1 to touch C1's private areas, S1 provided vape pens to clients, and...(continued on page 2...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Michael Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: TRINITY - YUCAIPAFACILITY NUMBER: VISIT DATE: 06/21/2023

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


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
preponderance of evidence of C1 being sexually abused by S1 by S1 bribing C1 to participate in sexual activities. Based on record review and confidential interviews the allegations alleging Staff (S1) sexually abused a minor (C1) in care and staff (S1) bribed minor are substantiated. The complaint allegations are valid because the preponderance of evidence standard has been met. Facility is cited for two violations of Interim Licensing Standards (ILS) v.4 standard PERSONAL RIGHTS (c)(11) To be free of physical, sexual, emotional, or other abuse, and from corporal or unusual punishment, exploitation, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature including, but not limited to, interference with the daily living functions of eating, sleeping, or toileting, or withholding of shelter, clothing, or aids to physical functioning which posed an immediate Health, Safety or Personal Rights risk to children in care. The facilities violation of ILS v.4 standard PERSONAL RIGHTS (c)(11) which resulted in C1 being sexually abused by S1 requires the facility to be assessed an immediate civil penalty per Health and Safety Code 1548(c)(1). An Enhanced Civil Penalty (ECP) determination is pending. If an ECP is assessed a Community Care Licensing (CCL) representative will return to the facility to deliver the penalty assessment. A copy of the report was discussed and provided along with Civil Penalty assessment and appeal rights to Trinity-Yucaipa Teresa Valles, Administrator.

Investigation Findings:
13On October 20, 2023 pm Licensing Program Analyst (LPA), Nicole Strickland met with Trinity-Yucaipa Administrator Tersesa Valles, to deliver the findings for the above stated allegations. The investigation was conducted by Special Investigator (SI) Dennis Seng and LPA N. Strickland and included interviews with Assistant Campus Director, five residents (Child #1 [C1], Child #2 [C2], Child #3 [C3], Child #4 [C4], and Child #5 [C5]), and four staff (Staff #1 [S1], Staff #2 [S2], Staff #3 [S3] and Staff #4 [S4]). In addition, county records and facility records were reviewed. On June 16, 2023, Community Care Licensing (CCL) received two allegations alleging Staff (S1) sexually abused a minor (C1) in care and staff (S1) bribed minor (C1). Specifically, it was reported when C1 resided at the facility, S1 propositioned C1 for sexual activities in exchange for items including drugs, candy, and things unavailable at the facility. Consistent confidential interviews and record review provided a SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Nicole Strickland LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: TRINITY - YUCAIPAFACILITY NUMBER: VISIT DATE: 10/20/2023

met_with: Teresa Valles, Administrator


raw_content:
Narrative:
changes needed to be made to ensure C1 stayed in compliance. DPO informed LPA that initially when placed there was confusion regarding C1's terms of probation which DPO clarified but due to facility staffing issues changes took longer than expected. DPO did not have suspicions of lack of supervision or neglect. LPA received conflicting information regarding this allegation. Based on confidential interviews, the allegation that facility staff did not ensure that C1's probation requirements were being followed may have occurred, however, they are not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Teresa Baraga.

Investigation Findings:
13On March 5, 2025, at 1: PM Licensing Program Analyst (LPA) Michael Almaraz met with Trinity Yucaipa Administrator, Teresa Baraga, to issue the finding for the above allegation involving client 1 (C1) listed on the confidential names list (LIC 811) dated March 5, 2025. On July 16, 2024, at 12: PM LPA inspected the facility, and no deficiencies were noted. During LPA's investigation LPA reviewed one client's file (C1) and reviewed the facility file. Furthermore, LPA Almaraz conducted interviews with one staff, four clients (C1, C2, C3, C4), County Social Worker (CSW), and a Probation Officer (DPO). On July 12, 2024, the Department received a complaint alleging staff do not ensure probation requirements are being followed for youth in care. It was specifically reported that facility staff did not ensure that C1's probation requirements were being followed. Confidential witnesses stated that facility staff ensured C1's terms of probation were followed. Other confidential witnesses stated that C1 was provided appropriate supervision at the facility. CSW stated that CSW informed the facility that C1's probation requirements were not being followed and ...(continued on page 2...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Michael Almaraz 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 61-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE N CRP RO, MAIN ST., SUITE FACILITY NAME: TRINITY - YUCAIPAFACILITY NUMBER: VISIT DATE: 03/05/2025

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

met_with: Teresa Baraga


summary: Facility Evaluation

raw_content:
Narrative:
On May 27, 2021, Licensing Program Analyst (LPA) Cindy Hamilton and Licensing Program Manager (LPM) Abdoulaye Traore conducted SB Psychotropic Medication tele-Inspection via FaceTime. The tele-meeting was held with the Assistant Director Jason Mayo. LPA and LPM conducted a virtual health and safety inspection with the Assistant Director. During the inspection, LPA guided and observed a medication count and interviewed staff and the clients . LPM and LPA conducted file reviews prior to inspection. LPM and LPA reviewed eight clients record and reviewed three staff records. At 9: AM, LPA began three staff interviews including the manager via FaceTime LPA interviewed following clients (C6 and C7) LPM interviewed the following clients ( C1, C2, and C3) Client #4, 5 and 8 refused to interview, client #9 went on home pass and client #10 was discharged prior to inspection. LPM issued a technical assistance regarding the Psychotropic Medication Administration Record (PMAR) to the facility. There were no deficiencies cited at this time. LPA conducted an exit interview with Assistant Director Jason Mayo. LPA scanned and emailed this LIC 809 to Jason with a request for signature. Signed copies will be placed in the facility file.

visit_type: Case Management

met_with: Jason Mayo- Assistant Director


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On September 9, 2021 at 8: PM Licensing Program Analysts (LPA), Michael Almaraz and Adaleyci Caballero conducted an Annual Required Inspection and met with Campus Director, Teresa Valles and Assistant Director, Jason Mayo. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Campus Director and Assistant Director. The facility converted from a Group Home to STRTP (Short Term Therapeutic Program) on September 14, 2017. At 10: AM a physical plant inspection was completed and included the following checks: The facility consists of four dorms with six bedrooms and a bathroom in each bedroom. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. The bathrooms were clean and in good repair. Each dorm has a living room area for clients use. Each dorm has an office space for staff. Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment/books/games were observed for client's recreation time. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster. Medications are locked and centrally stored in Team Administrator's office. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The hot water in the client's bathroom was measured to be 113 degrees Fahrenheit. Facility has a pool which is appropriately fenced and secured with a rod iron/chain link fence. The enclosure was measured to be 6 feet high, with a self-latching gate that swings outward. LPAs observed the pool gate to be locked as was confirmed by the Campus Director stating there was a double lock. Per facility staff, no firearms or weapons are allowed in the facility. (...) Facility appears to be meeting the terms and conditions of their license. Facility has cameras in common areas of the facility. The facility has an exception on file to use the cameras and are meeting the terms and conditions. Based on observation and file review, the facility is being cited on the following area client records. The facility was also issued a technical violation due to LPAs observing that the facility did not provide locked containers for client's contraceptives. An exit interview conducted and a copy of the LIC 809, LIC 809C, LIC 809D and LIC 9102 were provided and explained to Teresa Valles.

Deficiencies:
87068.3(a): Modifications to The Needs And Services Plan

(a) The needs and services plan specified in Section 87068.2 shall be updated at least every 30 days to determine the following


summary: Facility Evaluation

raw_content:
Narrative:
On December 21, 2022, at 9: AM Licensing Program Analyst (LPA), Michael Almaraz, arrived at Trinity Yucaipa Short Term Residential Therapeutic Program (STRTP) and met with assistant campus director (ACD), Jason Mayo, to conduct a case management visit for the purpose of decreasing the capacity for clients' placement as requested by the licensee. The STRTP was licensed to provide care for 48 ambulatory clients. The licensee requested a capacity decrease to a total capacity 16 clients. The STRTP had 8 clients placed on the date of inspection. At 10: AM LPA began the inspection of the facility with ACD. LPA toured the facility inside and out. LPA observed that there was a total of seven buildings. Building one was the administration office, dining hall, and game room. Building two was the team administrator's office, student store and the independent living house. The independent living house is seven bedrooms, laundry room, seven and a half restrooms, a kitchen, living room and family room. The independent house will not be used for the STRTP program. Building three was conference rooms, mental health offices, and the STRTP laundry area. Building four and five acted as dorms for the clients. Each had six restrooms, a staff office and dayroom. Building five did not have clients at the time of inspection. Building six and seven used to be used as dorms for the STRTP but with the decrease in capacity they will not be utilized for the STRTP as dorms. Dorm one in building four Bedroom #1: consisted of two single beds and slept two clients age 16 and 17. Bedroom #2: consisted of two single beds and slept one client age 17. Bedroom #3: consisted of two single beds and slept one client age 14. Bedroom #4: consisted of two single beds and slept two clients age 16 and 16. Bedroom# 5: consisted of two single beds and slept one client age 17. Bedroom#6: consisted of two single beds and slept one client age 17. (...) Dorm two in building five Bedroom #1: consisted of two single beds and did not have any clients. Bedroom #2: consisted of two single beds and did not have any clients. Bedroom #3: consisted of two single beds and did not have any clients. Bedroom #4: consisted of two single beds and did not have any clients. Bedroom# 5: consisted of two single beds and did not have any clients. Bedroom#6: consisted of two single beds and did not have any clients. Bedrooms were arranged so that no more than two clients share a room, and there was one client per bed. There was adequate shelf and closet space for client's belongings. The bathrooms were clean and in good repair. The hot water in the client bathroom was measured to be 116 degrees Fahrenheit. All hazardous items have been properly made inaccessible to areas where clients will have access. Cleansers/chemicals were locked and stored in a locked cabinet located in the staff offices in dorm four and a locked closet located in the team administrator office. Sharp knives were inaccessible and stored in a locked cabinet locked in a office located in the cafeteria. The First Aid Kit is located in the team administrator office and contained all required supplies. The facility's smoke/carbon monoxide detectors located in client's bedrooms and in the dorm dayrooms were checked and were operable. A Fire extinguisher was observed and properly charged. There are no guns or weapons in the facility as stated by ACD. Client's medications were observed to be inaccessible and stored in the team administrator office in a locked cabinet located in a locked medication storage room. LPA observed a minimum 7-day non-perishable and a 2-day perishable supply of food. There was a variety of snacks available for clients as well. Proper storage of all food was discussed. Trash cans for storage of solid waste have tight fitting lids. The facility outside grounds was also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. The Facility Sketch, Emergency Disaster Plan, visitation policy and Personal Rights were posted. Facility will complete a fire safety inspection for the approved decreased capacity of 16 clients and a copy of the approved fire safety clearance will be sent to the Department. (...) There are no deficiencies to be cited at this time. The request for the license capacity change will be forwarded to Licensing Program Manager for final approval. An exit interview was conducted, and a copy of this report was provided to Jason Mayo.


summary: Facility Evaluation

raw_content:
Narrative:
On October 11, 2023, at 10: AM Licensing Program Analyst (LPA), Michael Almaraz conducted an Annual Required Inspection and met with Campus Director, Teresa Valles and Assistant Director, Jason Mayo. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Campus Director and Assistant Director. The facility converted from a Group Home to STRTP (Short Term Therapeutic Program) on September 14, 2017. At 12: PM a physical plant inspection was completed and included the following checks: The facility consists of four dorms with six bedrooms and a bathroom in each bedroom. Only one dorm is currently being used. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. The bathrooms were clean and in good repair. Each dorm has a living room area for clients use. Each dorm has an office space for staff. Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment/books/games were observed for client's recreation time. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster. Medications are locked and centrally stored in Team Administrator's office. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The hot water in the client's bathroom was measured to be 111 degrees Fahrenheit. Facility has a pool which is appropriately fenced and secured with a rod iron/chain link fence. The enclosure was measured to be 6 feet high, with a self-latching gate that swings outward. LPA observed the pool gate to be locked as was confirmed by the Campus Director stating there was a double lock. (continued on page 2) Per facility staff, no firearms or weapons are allowed in the facility. Facility has cameras in common areas of the facility. The facility has an exception on file to use the cameras and are meeting the terms and conditions. Based on the facility inspection and file reviews on this date, no deficiencies were cited. Facility appears to be meeting the terms and conditions of their license. An exit interview conducted and a copy of the LIC 809 was provided and explained to Teresa Valles.

met_with: Teresa Valles


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Leslie Covarrubias on November 2, 2023 at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Covarrubias met with Assistant Director, Jason Mayo and inspected the facility inside and out. LPA reviewed one of child's records and five of staff personnel files on site at the facility. LPA reviewed one of child's psychotropic medications and medication records. LPA interviewed three of staff on site to discuss the facilities policies and procedures of operation. LPA interviewed one of children currently prescribed psychotropic medication. LPA provided a copy of this licensing report to Assistant Director, Jason Mayo. No deficiencies are being cited at this time. LPA conducted exit interview with Assistant Director, Jason Mayo.

met_with: Assistant Director, Jason Mayo


summary: Facility Evaluation

raw_content:
Narrative:
On November 8, 2023 at 3: PM, Associate Governmental Program Analyst (AGPA) Kim Robinson met with the short term residential treatment program (STRTP) administrator, Teresa Valles, and Gil Quinbar, Director via telephone in order to assess an Enhanced Civil Penalty (ECP). On October 20, 2023, the Department concluded a complaint investigation alleging that staff #1 (S1) engaged in sexual acts with 15-year-old client #1 (C1). The allegation was determined substantiated, and the STRTP was cited for the violation of the Title 22, California Code of Regulations Section 87072(c)(11), Personal Rights. An immediate civil penalty of $500.00 was assessed. See the Confidential Names List, LIC 811, dated October 20, 2023. Based on the analysis of the interviews and record reviews, the Department has determined that an ECP is warranted for S1 engaging in obscene sexual conduct with a child in care. The Penal Code Section 11165.1 defines sexual conduct with a minor as physical abuse. This section describes a number of more or less direct and (always) willful acts that constitute physical abuse. Pursuant to the Enhanced Civil Penalty law, Health & Safety Code section 1548 (f)(1)(C), the Department will be issuing an immediate civil penalty of $2,000.00. An exit interview was completed, and appeal rights discussed. A copy of this report, the Confidential Names List, and a Civil Penalty Assessment - Serious Bodily Injury/Physical Abuse (Form 421-D) were provided to the administrator. The signed copy will be retained in the facility file.

met_with: Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA), Michael Almaraz, conducted an unannounced case management inspection on June 14, 2024, at 10: AM. During the inspection, LPA met with office manager, Lourdes Perez. The purpose of the inspection was to address information obtained during a review of an incident that occurred on or around June 6, 2024. LPA reviewed staff files and interviewed one staff on June 14, 2024, at 10: AM. An exit interview was conducted, a copy of this report was provided to Lourdes Perez.

met_with: Lourdes Perez


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Sarah Lo and Rachel Vanegas on November 08, 2024 at 09: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Lo and LPA Vanegas met with Jason Mayo, Assistant Director and Maysel Grimarez, Medical Serivce Clerk and inspected the facility inside and out. No immediate health or safety risks were observed. LPAs reviewed three child's records and three staff personnel files on site at the facility. LPAs reviewed three child's psychotropic medications and medication records. LPAs interviewed two staff on site to discuss the facilities policies and procedures of operation. LPAs interviewed three of children currently prescribed psychotropic medication at their school. No deficiencies are being cited at this time. A Technical Violation was provided. LPAs conducted exit interview with Assistant Director, Jason Mayo. LPAs provided a copy of this licensing report, LIC 811 dated 11/08/24 and Violation to Assistant Director, Jason Mayo.


summary: Facility Evaluation

raw_content:
Narrative:
On June 5, 2025, at 9:05 am Licensing Program Analyst (LPA), Jacob Ortega conducted an Annual random Inspection and met with Jason Mayo Assistant Director. At the entrance of the STRTP, there is a two-story administrative building located across from the client dormitories. Separating the dorms and the administrative building is a parking lot, next to which are basketball courts designated for client use. Adjacent to the administrative building is a fenced-off structure that belongs to the STRTP but is used by a separate program. The Administrator clarified that clients do not have access to this building or its surrounding area. The second floor of the administrative building is utilized by staff and consists of a long hallway with multiple offices. At the end of the hallway is the Administrator's office, and near the center is a reception area that serves as a central hub for staff coordination. The first floor includes restrooms and a spacious lounge/playroom for clients. This lounge is used during therapy sessions or for recreational downtime and is equipped with pool tables, an arcade machine, a television, and couches. Adjacent to the lounge is a large cafeteria furnished with multiple tables and chairs. The Administrator explained that clients walk through a cafeteria line to receive their meals. Located at the back of the cafeteria is a commercial kitchen containing several stoves and serving trays used to prepare and distribute food. The facility itself consists of four dormitory buildings, two of which (the ones furthest from the entrance) are currently unused. Each dorm has six bedrooms, with each bedroom containing its own bathroom. Rooms are arranged so that no more than two clients share a bedroom, and each client has their own bed. Adequate shelf and closet space was observed for storing personal belongings. Bathrooms were clean and in good repair, and all individual beds had clean linens, pillows, comforters, and mattresses in good condition. Each dorm also includes a dedicated living room area for client use and a staff office for supervision and administrative needs. Continued on C Page** The facility grounds were observed to be clean and free of debris or safety hazards. There is sufficient indoor and outdoor activity space, with sports equipment, books, and games readily available for client recreation. Fire extinguishers were properly charged and serviced. The licensee maintains an adequate supply of both perishable and non-perishable food, and the posted menu appears to be followed. All required forms, including the Grievance Procedures, Visitation Policies, and Personal Rights form, were properly posted. Medications are securely locked and centrally stored in the Team Administrator's office, which is located separately from the client dorms. The Team Administrator's office area consists of a small courtyard surrounded by multiple rooms. Two of these rooms function as open office spaces with cubicles for staff and mental health specialists. A connected conference room is available for meetings with clients' parents, social workers, and other authorized representatives. Across from the administrative offices are therapy rooms used for client sessions. Adjacent to these therapy rooms is a laundry facility, equipped with washers, dryers, folding tables, and storage for clothing and cleaning supplies that are locked behind the laundry room door. The facility includes a swimming pool that is properly fenced with a six-foot-high wrought iron and chain-link enclosure. The pool gate is self-latching and swings outward. LPA confirmed the gate was locked at the time of inspection, and the Campus Director explained that the pool area is secured with a double-locking system. The Assistant Administrator stated that the pool is cleaned twice a week. LPA continued the inspection past the pool area to a large open field surrounded by a running track. The Administrator stated that this area is used by clients for organized sports and outdoor activities. Beyond the field and down a gentle slope is a dedicated baseball field for client recreation. Further beyond the baseball field are additional fenced-off open areas that are not currently in use by clients. Due to time constraint LPA will continue annual at a later date. A copy of this report was was given Jason Mayo Assistant Director.

met_with: Jason Mayo Assistant Director


summary: Facility Evaluation

raw_content:
Narrative:
***This is an amended report of the original report delivered on June 10, 2025.*** On June 10, 2025, at 1:20 am Licensing Program Analysts (LPAs), Jacob Ortega and Raina Perez conducted a continuation of a Annual random Inspection and met with Teresa Valles Campus Director. During inspection LPA reviewed five client files (C1-C5). three of five files contained the required documentation, including signed placement agreements, client demographic information, consent for medical treatment authorization forms, needs and services plans, medical assessment clearances, and signed personal rights documents. During inspection LPAs observed that C4 and C5 did not have TB test results, this is a type B violation. LPA reviewed five staff files for Staff (S1-S5). LPAs also observed that the facility did not have a register for the clients that included the required information such as contact information for authorized representatives, ambulatory status, and attending physician. This is a type B violation. Each file contained the required documents including verification of criminal background check clearance, Child Abuse Index Check clearances, signed acknowledgment of mandated child abuse. All staff files had the appropriate education requirements. LPA interviewed three staff. During the time of inspection deficiencies were noted and a copy of this report and LIC 811 was provided to Teresa Valles Campus Director.

met_with: Teresa Valles Campus Director


summary: Facility Evaluation

raw_content:
Narrative:
On June 11, 2025, at 1:15 am Licensing Program Analyst (LPA), Jacob Ortega conducted a continuation of an Annual random Inspection and met with Vance Carr Team Administrator. During inspection LPA interviewed three clients. At the time of inspection LPA did not observed any deficiencies and a copy of this report and LIC 811 was provided to Vance Carr Team Administrator.

met_with: Vance Carr Team Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On this date, June 18, Licensing Program Analyst (LPA) Jacob Ortega conducted an unannounced visit to Trinity Yucaipa for the purpose of delivering an amended report initially delivered on June 10, 2025 and met with Nestor Mcfarlane Team Supervisor. A copy of this report was provided to Nestor Mcfarlane Team Supervisor.

met_with: Nestor Mcfarlane Team Supervisor


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPA's) Jacqueline Garcia, Rachel Vanegas, and Emina Preciado on November 03, 2025 at 09: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA's met with Assistant Director, Jason Mayo and inspected the facility inside and out. LPA's reviewed 5 child records and 5 staff personnel files on site at the facility. LPA's reviewed 5 child's psychotropic medications and medication records. LPA's interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPA's interviewed 2 of 5 youth currently prescribed psychotropic medication. During the inspection, LPA's observed deficiencies (see attached 809D), plan of corrections were discussed. LPA's conducted exit interview with Assistant Director, Jason Mayo and provided a copy of this report, along with LIC 811 and appeal rights.

met_with: Jason Mayo-Assistant Director


facility_name: TRINITY HOUSE 2

summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Reported information received alleged that S1's inappropriate conduct towards a minor, not associated with the facility, poses a risk to minors in care. Based on gathered information, including inconsistent statements and a lack of corroborating evidence, the allegation is deemed unsubstantiated. Although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove S1's conduct poses a risk to minors in care. The finding is Unsubstantiated. There are no deficiencies cited at this time. Facility is no longer operating; no children in placement. On March 30, 2022, Licensing Program Analyst (LPA) Regina Martin mailed certified a copy of this report and confidential name form LIC811, to Facility Representative, CEO for signature.

Investigation Findings:
On June 22, 2021, an allegation regarding conduct inimical by Staff Member #1 (S1), was investigated by Community Care Licensing Division (CCLD) Investigations Bureau, Investigator Lorraine Patterson (see LIC811, dated 3/17/2022). On June 29, 2021, LPA Martin conducted the initial complaint inspection, spoke with Facility Administrator and obtained staff schedules. The investigation further included interviews with pertinent parties, including but, not limited to, complainant, alleged victim, alleged victim's parent, two residents, two staff members, S1 and review of related reports from the Oxnard Police Department revealed a lack of evidence to support alleged conduct inimical by S1. (Continued on page LIC9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Regina Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: TRINITY HOUSE 2FACILITY NUMBER: VISIT DATE: 03/17/2022

met_with: Facility Representative, CEO


raw_content:
Investigation Findings:
13On May 10, 2022, Licensing Program Analyst (LPA) Enrique Hernandez sent by certified mail the findings of the complaint to the P.O Box on file due to facility closure. On November 20, 2020, the Department received a complaint alleging: Staff are sleeping during the evening shifts, Staff failed to properly supervise minors while in care and Staff inappropriately transports minors while in care. During the investigation process, LPA Hernandez conducted confidential interviews and gather information about the allegations. S2 confirmed falling asleep while working with the clients, which was corroborated by the clients and S3. Also, C2 confirmed to have thrown water on S4's face, due to S4 sleeping during the night shift. Although S4 denied falling asleep, this was confirmed during confidential interviews. In addition, S2 confirmed transporting the clients in his personal vehicle, which was confirmed by S3 and the clients. Based on LPA interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegations of Neglect/Lack of supervision are found to be SUBSTANTIATED. Deficiencies were cited to the facility for Neglect/Lack of supervision A copy of this report was sent by certified mail to the P.O. Box on file for the licensee's signature. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: TRINITY HOUSE 2FACILITY NUMBER: 565801787

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

met_with: Sent to Cleo Anderson


raw_content:
Narrative:
Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. The Department has decided that the allegations are unsubstantiated but if any additional information is received this complaint can be amended and finding can be changed. A copy of this report was sent by certified mail to the P.O. Box on file for the licensee's signature.

Investigation Findings:
13On May 10, 2022, Licensing Program Analyst (LPA) Enrique Hernandez sent by certified mail the findings of the complaint to the P.O Box on file due to facility closure. On November 20, 2020, the Department received a complaint alleging: Facility has inadequate record keeping and Facility is lacking the necessary resources to operate. During the investigation process there were contradictory statements from the parties involved. S3 stated that none of the notes have been change regarding incidents with the clients. Other statements also corroborated that they do not change any of the notes, although one statement says otherwise, there is not enough evidence of the facility changing the notes of incidents that happened with the clients.Confidential interviews revealed that the facility has the funds to operate and the reason the card was declined once was because the card has protection that when you go over a certain amount the card is declined. C1 stated that they told RP not to go over the $500 budget and RP still did. Continue on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: TRINITY HOUSE 2FACILITY NUMBER: VISIT DATE: 05/10/2022

met_with: Cleo Anderson


summary: Facility Evaluation

raw_content:
Narrative:
On 10/27/2021 at 9:30AM Licensing Program Analyst (LPA) Olivia made an unannounced to Trinity House 2 for the purpose to conduct the Annual/Required licensing Inspection. LPA Rosas met with Staff#1(S1) who granted access to the facility and an inspection of the facility was conducted together. Individuals mention in this report are identify on the Confidential Names List (LIC811) dated 10/28/21. Temperature and health checks are conducted at the entrance in the sign-in area. LPA met with Staff#1 (S1), who granted access into the home, and who provided a tour of the entire physical plant. This facility has a provisional licensed to provide care and supervision for six (6) children ages 12-17 years old, Ambulatory only. The facility also provides services to non-minor dependents. The facility is in the process of obtaining Accreditation with Joint-Commission. They are in the process obtaining Mental Health Approval. There are no bodies on water on the premises. Staff confirmed that there are no firearms or dangerous weapons in the facility. The facility is current with their annual fees. LPA Rosas inspected the following: This is a one (1) story (STRP) Short Term Residential Therapeutic Program, located in a residential neighborhood. There are three (3) bedrooms, two (2) bathrooms, a living room, dining room, kitchen, staff office, backyard, and an attached garage for storage. There is one (1) facility vehicle parked outside inspected to be in good operating condition. Outdoor Area: There was no swimming pool or bodies of water on the premises. The activity space is free of hazard materials and debris. LPA observed a staff displayed the utility shut-off valves. The facility is surrounded by wooden fence and is observed to be good condition. Report continues on LIC 809-C Page 1 of Garage: The attached garage is used as storage and is kept locked. Laundry Room: The laundry room is located inside of the garage. The laundry is equipped with a washer and dryer unit that was observed to be in good condition. The laundry detergent is made inaccessible to the children and is disputed according the load of the laundry. Disinfectants and chemicals are locked in cabinets made inaccessible. Living Room: There is adequate furniture which appears to be in good condition. There is a television and fireplace that is non-operable. Staff Office: It is equipped office furniture (i.e desk, computers, printers). The medication is triple locked inside of the staff office. All the children prescribed medications are locked in the staff office and children files are kept in a lock cabinet. Staff office is located inside the main facility. The First Aid kit has the required items inside (age-appropriate, and scissors, tweezers, thermometer, and gauzes, antiseptic and First Aid Manual Guide. Dining Area: One table with six chairs is next to the Kitchen: There is a gas stove/oven with four (4) burners, all operating. There is a microwave, refrigerator/freezer and a toaster oven. LPA's observed adequate perishable/nonperishable food supplies. Sharp knives, disinfectants/cleaning solutions made inaccessible to the children locked in cabinets. Water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. Bedroom # 1: Occupied by two (2) clients, the bedroom is equipped two (2) twin sized beds, comfortable mattresses, linen, blankets and pillows; adequate drawer and one (1) wall closet. There is adequate lighting and the windows have horizontal slide locked with curtains observed to be in good condition. This bedroom was a bathroom. Bedroom # 2: Currently occupied by two (2) clients, has two (2) twin sized beds and comfortable mattresses, linen, blankets and pillows; adequate drawer and one (1) walk in closet. There is adequate lighting and the windows have horizontal slide locked with curtains observed to be in good condition. Bedroom # 3: Currently occupied by two (2) clients. The bedroom has two (2) twin sized beds and comfortable mattresses, linen, blankets and pillows; adequate drawer and one (1) walk in closet. Report continues on LIC 809-C Page 2 of Bathrooms: There are two (2) bathrooms. Bathroom #1 is the common bathroom for the clients. It is a full-sized bathroom with a toilet, sink, and tub/showers. Bathroom #2 is located inside of Bedroom#1 is full-sized bathroom with a toilet, sink, and shower. Water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. LPA observed a key locked closet that stored hygiene supplies, and cleaning solutions. All windows were in good condition with screens and blinds. There were no security bars on the windows. LPA observed ample towels and linen closet. The passageways and porches are unobstructed. All posting requirements were met, (food menu, regulations, licenses, emergency disaster plan, Children's Personal Rights, and Ombudsman). The facility has a working telephone and youths can use the telephone unless restricted by court order. The Emergency Evacuation Plan is posted on the walls throughout the facility. The Facility operates within license conditions and limitations including capacity limitations. Facility has a current, written plan of operation. Facility personnel are instructed to report violations of personal rights. Licensee will report changes in the plan of operation affecting service to youths. Licensee will report youth injuries requiring medical treatment. A review of Facility's Personnel Report Summary on 10/28/2021 indicates that all personnel have criminal record clearance has obtain the necessary clearances with DOJ, FBI, and Child Abuse Response. LPA Rosas was not able to review youth or staff files during this visit and will return to continue with the annual inspection. Youth were in school during the inspection. LPA Rosas by email the following PINS to S PIN 20-17-CRP: New Background Check Requirements, Assembly Bill 819 (Chapter 777, Statutes of 2019), PIN 21-20-CRP: Statewide Launch of New Inspection Tools for Children's Residential Licensees, PIN 21-05-CRP: The Family Urgent Response System (FURS), Medications Guide TSP 2017-03 (version 08/23/21). There were no deficiencies observed or cited at this time. Exit interview was conducted with S1 and a copy of this report was email to S1 for signature.

met_with: Staff#1 (S1)


summary: Facility Evaluation

raw_content:
Narrative:
On 01/13/2022 at 10:00AM Licensing Program Analyst (LPA) Olivia made an unannounced to Trinity House 2 for the purpose to verify facility closure. LPA Rosas, knocked the door and waited for response. LPA Rosas, waited and walked around the outdoor perimeter of the home (facility). LPA did not see or hear anyone at the facility. LPA Rosas, contacted CEO via phone and call went to voice mail. LPA, left a voice mail to return phone call to LPA Rosas. LPA Rosas will mail copy of report to the facility mailing address for signature.

met_with: CEO


facility_name: TRINITY HOUSE I

raw_content:
Narrative:
Staff video recorded resident without permission Confidential interviews revealed that no one has seen any member of staff recording clients. Although during the interviews someone said that staff was recording a client, no name of the staff was provided. Staff do not treat resident with respect Confidential interviews indicated that clients are treated with respect, and no one is disrespectful to the clients at the facility. This was corroborated by the social worker. Facility has mold Confidential interviews indicated that they are always cleaning the facility due to COVID. This was corroborated by the social worker. Staff did not ensure facility is free from insects Confidential interviews indicated that in the past there were ants in the facility, but not anymore and pest control comes every month to spray for any kind of bugs. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. The Department has decided that the allegations are unsubstantiated but if any additional information is received this complaint can be amended and finding can be changed. PER California Code Regulation, TITLE 22, DIVISION 6, CHAPTERS 1, General Licensing Regulations, and Short Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS), Chapter 7. Version 4.0, there are no deficiencies to be cited at this time. A copy of this report will be mailed to the mailing address we have on file for the licensee's signature

Investigation Findings:
13On March 9, 2022, Licensing Program Analyst (LPA) Enrique Hernandez sent by certified mail the findings of the complaint due to facility closure. On October 14, 2020, the Department received a complaint alleging Staff hit resident, Staff video recorded resident without permission, Staff do not treat resident with respect, Facility has mold and Staff did not ensure facility is free from insects. Confidential interviews were conducted, and the following information was obtained during the course of the investigation: Confidential interviews revealed conflicting statements about staff hitting a client. Information from the interview revealed that although a confidential interview claims to have been hit by staff, no one saw, and during the interview the name of the staff was not provided. Other interviews revealed that they have not seen marks or bruises on the client's body. This was corroborated by the social worker. Continue On LIC9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: TRINITY HOUSE IFACILITY NUMBER: VISIT DATE: 03/09/2022

met_with: Licensee


raw_content:
Narrative:
The Department has decided that the allegations are unsubstantiated but if any additional information is received this complaint can be amended and finding can be changed. A copy of this report was sent by certified mail to the P.O. Box that we have on file for the licensee's signature.

Investigation Findings:
13On April 14, 2022, Licensing Program Analyst (LPA) Enrique Hernandez sent by certified mail the findings of the complaint due to facility closure. On November 30, 2021, the Department received a complaint alleging Minor was sexually abused by another minor in care and Staff did not prevent abuse of minor. The following information was obtained during the course of the investigation: During the investigation process there were contradictory statements from the parties involved. It was reported that C1 was often bother by other clients in the facility. C1 does not recall telling staff about being bother by the other clients. Other statements said that staff are always supervising them, and did not hear or see anyone bother or touching C1 inappropriately. Regarding the sexual abuse, C1 stated that it was mutual and occurred after the staff checked the rooms every 15 to 30 minutes. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: TRINITY HOUSE IFACILITY NUMBER: VISIT DATE: 04/14/2022

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


raw_content:
Narrative:
The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the findings are unsubstantiated. LPA Rosas and AGPA Barnes-Woodard conducted interviews with clients and facility staff that provided information on staff schedules and care and supervision. On 05/12/2021, reviewed a copy of LIC Personnel Report and found facility's staffing ratio in compliance. Site inspections on 05/22/2021, and 10/28/2021 had sufficient staffing ratio the clients in placement. Confidential interviews had consistent statements that clients were never left unsupervised, and staff was always present. Interviews did state during the COVID-19 pandemic staff had have longer shifts and staff had to wait long period of times for shift change. On 04/17/22, the Department received Special Incident Report (SIR) stating that office door was damage by a client running and jump kicking the office door. Staff#2 (S2) reported the door was repaired and confidential information was kept locked. On 05/12/2022, LPA Rosas received repair pictures of the office door. On 10/28/2022, LPA Rosas conducted Annual Required visit to the facility and inspected the facility office door. The facility door was able to open and close. Inside of the facility office the confidential files were kept in locked metal file cabinet and only authorized staff had access to them. LPA Rosas also observed medication to be centrally stored, locked and inaccessible to clients and unauthorized staff members. Interviews stated that clients did not have access to the facility office. Results from the Department's investigation, consisting of interviews with related parties, inspections, and review of records. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. The Department has decided that the allegations of Personal Rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There were no deficiencies observed or cited at this time. A copy of the report was sent to S1 for signature to the facility P.O Box on file, due to facility closure on December 31, 2021.

Investigation Findings:
13On October 6, 2022, at 09:00am, Licensing Program Analyst (LPA) Olivia Rosas concluded the investigation on the above allegations for Trinity House 1 and sent complaint findings to Staff#1 (S1). LPA Rosas sent by certified mail the delivery of findings of the completed complaint to the facility P.O Box on file, due to facility closure on December 31, 2021. On 05/12/2021, contacted the facility to begin the investigation process and conduct interviews. During the investigation process, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted inspection and conducted interviews on 05/22/2021. In addition, LPA Rosas interviewed witnesses and pertinent parties related to the investigation. Individuals mention in this complaint are identify on the Confidential Names List (LIC811) dated October 6, 2022. Based on the confidential interviews conducted during the investigation process, record review, statements obtained, LPA Rosas concluded the Personal Rights allegations that facility is operating out of ratio and facility is not safeguarding minors' confidential information. Report continues LIC-9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Olivia Rosas LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: TRINITY HOUSE IFACILITY NUMBER: VISIT DATE: 10/06/2022

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


raw_content:
Narrative:
The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the findings are unsubstantiated. LPA Rosas and AGPA Barnes-Woodard conducted interviews with clients and facility staff that provided information on staff schedules, allowance and care and supervision for clients. Facility denied the allegations of Personal Rights and Neglect/Lack of Supervisor. Staff#2(S2) and Staff#3(S3) reported that on August 8, 2022, Client#1 (C1) was taken to Arroyo Verde Park in Ventura. C1 and S3, preceded to hike at the park. A couple minutes into the hike C1 walked off the trail and did not want to finish the hike. S3 lost visual of C1 and S3 walked to the end of the trail to wait for C3. S3 observed C1 walking towards the facility vehicle, and both returned to the facility. S3 denied intimidating clients or handling clients in a rough manner. S3 reported, the facility was trained to use verbal prompts to redirect clients during crisis. S3 reported that on August 12, 2021, Client#2 (C2) became escalated when requesting a snack and S3 attempted to calm him down verbally. C2 was unreceptive and attempted to breach the office by jumping over the half open door. S3 reported, using his body to block the door and preventing C2 from breaching the office. Results from the Department's investigation, consisting of interviews with related parties, inspections, and review of records. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. The Department has decided that the allegations of Personal Rights and Neglect/Lack of Supervision are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There were no deficiencies observed or cited at this time. A copy of the report was sent to S1 for signature to the facility P.O Box on file, due to facility closure on December 31, 2021.

Investigation Findings:
13On October 12, 2022, at 09:00am, Licensing Program Analyst (LPA) Olivia Rosas concluded the investigation on the above allegations for Trinity House 1. The delivery of findings of the completed complaint investigation was sent by certified mail to Staff#1 (S1) due to facility closure on December 31, 2021. During the investigation process, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted inspection and conducted interviews on September 25, 2021. In addition, LPA Rosas interviewed witnesses and pertinent parties related to the investigation. Individuals mention in this complaint are identify on the Confidential Names List (LIC811) dated October 12, 2022. Based on the confidential interviews conducted during the investigation process, record review, statements obtained, LPA Rosas concluded the Personal Rights and Neglect/Lack of Supervision allegations that facility staff left youth unsupervised, staff intimidates youth, and staff handle youth in a rough manner. Report continues LIC-9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Olivia Rosas LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: TRINITY HOUSE IFACILITY NUMBER: VISIT DATE: 10/12/2022

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