summary: Facility Evaluation

raw_content:
Narrative:
On December 19, 2023, at 10:30AM, Licensing Program Analyst (LPA) Carol Anderson conducted an unannounced inspection of the facility. The purpose of the visit is conducted an annual required inspection. LPA met with Facility Group Home Administrator Tracie Arellano. The facility is licensed for four developmentally delayed ambulatory clients. There are currently three clients residing at this facility, no clients were available to be interviewed. LPA will return to interview clients. LPA interviewed two staff. The home is a one story residence with four bedrooms, two bathrooms, staff office, kitchen, dining room, living room, garage, laundry room, backyard, and front yard. Bedroom #1 contains one twin size bed; all required linen, is present and mattresses are in good condition. Bedroom #2 contains one full size bed; all required linen is present and mattresses in good condition. Bedroom #3 contains one full size bed; all required linen is present, and mattresses are in good condition. Bedroom #4 contains one full size bed; all required linen is present, and mattresses are in good condition. The bedrooms are arranged so that no more than one client per room per bed. The facility has two bathrooms. The bathrooms are clean, sanitary and in good repair. The dining room has a dining table with four chairs and a bench. The dining room and kitchen are clean, sanitary and in good repair. LPA two day perishable supply of food in the refrigerator. The menu is posted on the refrigerator. The pantry closet is next to the dining. LPA observed a minimum seven day non-perishable in the pantry. There was a variety of snacks available for clients as well. The sharp knives are locked in a cabinet in the pantry. There is an additional freezer and refrigerator in the garage for additional food. Cleansers/chemicals are locked a cabinet in the garage. The garage is set up as a workout room with four stations, punching bag, treadmill, bike, and workout trampoline. The clients are able use the workout room under staff supervision. The garage also storage for seasonal decors, emergency disaster supplies, over follow first aid kit and over follow paper items. There is a washer and dryer for clients use with staff supervision. The overall clients' hygiene products are in a locked cabinet in the laundry area. There is a first a kit and contains all required supplies in the laundry area. The staff office has first aid supplies in the medication cabinet. Clients' medications were observed to be inaccessible and stored in a locked in a cabinet behind the staff desk in the staff office. The living room a space for art, a table for puzzles, two couches, a TV, and an indoor basketball game. There are a variety of recreational activities such as board games for clients' use. There is an additional closet with additional recreational activity items. The facility outside grounds was also inspected and it was observed to be clean, well maintained. Emergency exits were free from obstruction. The facility has ten smoke detector and two carbon monoxide detectors. The fire alarm and carbon monoxide were check and was operable. Hot water temperature reading at 107 degrees. LPA Anderson reviewed three clients' files and five staff files, and they had the necessary forms. The following required posted items were observed accessible to clients: Grievance Procedures, Personal Rights, visitation policies, emergency disaster, (LIC 610C) and license is posted. A review of Guardian on December 19, 2023, indicated that all facility staff associated to the facility had DOJ, FBI, and child abuse index check clearances. Based on observations made during the inspection, no deficiencies observed during today's visit. An exit interview was conducted, a copy of this report was given to Facility Group Home Administrator Tracie Arellano.


state: CA

facility_name: ELKHORN HOUSE

summary: Facility Evaluation

raw_content:
Narrative:
On November 13, 2025, Licensing Program Analyst (LPA) Cynthia Velasquez, began an annual inspection of the facility. The facility was toured inside with Renee Robinson, House Manager. The home is a one-story residence with 4 bedrooms, and 2 full bathrooms for staff, and clients. There are two clients placed currently. Facility was maintained and there were no blockages to walkways or entryways. The walkway from the parking location to the front door was clean and in good repair. The facility has concrete outside, including the driveway. It is situated on a street with other homes surrounding it which have higher elevations surrounding the backyard. The entrance to the facility has a current Fire Inspection Clearance certificate, Licensing Certification, Grievance Procedures, Client Rights, Emergency Disaster Plan, Child Abuse Reporting flyer, and Ombudsman poster. The kitchen area had fresh fruit options, perishable items in refrigerator and frozen items available for meals and snacks. The dining room is adjacent to the kitchen with seating for 4. The TV room is connected to kitchen area, and has two love seats, two chairs and TV with gaming console and controllers. There is a stand-up basketball hoop indoors. In the living room, there is a fireplace that has been filled with materials which allow no access. There are two locked cabinets that contain staff files and client files. Due to time constraints, this inspection will be continued at a later time. An exit interview was conducted and a copy of this report was given to Tracie Arellano, Administrator.

report_type: Facility Evaluation

visit_type: Annual

met_with: Tracie Arellano


summary: Facility Evaluation

raw_content:
Narrative:
On December 2, 2025, Licensing Program Analyst (LPA) Cynthia Velasquez, continued an annual inspection of the facility which was initiated on November 13, 2025. The facility was previously toured inside with Renee Robinson, House Manager. The home is a one-story residence with 4 bedrooms, and 2 full bathrooms for staff, and clients. There are two clients placed currently. Due to time constraints, this annual inspection is being resumed today. Staff files and client files were reviewed. All staff that work at the facility have Department of Justice and Child Abuse Clearance Index clearances, CPR/First aid and training hours in addition to education, identification, job description information, and child abuse reporting requirement forms. All client files contained Individual Service Plan (ISP) information, Individual Placement Program (IPP) information and/or addendums, placement and admission agreements, personal rights, and prescription information. The hot water in the kitchen was deemed to be at the safe temperature of 107 degrees Fahrenheit. Per facility staff, there are no firearms or weapons in the facility. Chemicals are locked the hallway closet housed in the garage. First Aid Kits are also stored in various locations within the facility. All First Aid Kits have required bandages, thermometers, tweezers, and manuals. Medications were stored in a locked box in the office area. Based on the facility inspection and file reviews this date, there are no deficiencies found at this time. Interviews were conducted with available staff, and client interviews will be conducted via telephone within 1 day. An exit interview was conducted with Tracie Arellano, Administrator and copies of report were reviewed and issued.

met_with: Tracie Arellano, Administrator


facility_name: ELLA'S HOME, INC

summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Investigation Findings:
13On 2/24/2023 at 10: AM, Licensing Program Analyst (LPA) Alyssa Ng conducted a complaint inspection at Ella's Home and spoke with Dioneil Noriega, Facility Manager. The purpose of the inspection was to deliver the findings for the above complaint allegation. During investigation, LPA Ng did a search of the active/pending Administrator certification list, and it was determined that the listed Administrator on file did not have an active certificate. Based on record review(s), the preponderance of evidence standard has been met, therefore the above allegation, Facility does not have a certified Administrator on the premises is found to be SUBSTANTIATED. Facility is being cited for violation of California Code of Regulations (CCR), Title 22, Division 6 & Chapter 1: 80066(a)(12)(B)(1) Personnel Records. Please refer to attached 9099D. At this time, one deficiency was given. An exit interview was conducted, appeal rights provided and discussed, and a copy of this report was given to Dioneil Noriega, Facility Manager. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Alyssa Ng 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 14-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, TRAEGER AVE., SUITE FACILITY NAME: ELLA'S HOME, INCFACILITY NUMBER: 075650134

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

report_type: Complaint Investigation

met_with: Dioneil Noriega

complaint_status: SUBSTANTIATED


summary: Facility Evaluation

raw_content:
Narrative:
On Wednesday 9/1/21 at 10AM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility for a required annual inspection. LPA met with Facility Manager Dioneil Noriega and informed of the purpose of the visit. Safety precautions were taken, including screening call and mask-wearing. LPA used the Inspection Tool to conduct the inspection. There are five children in care, and four children were at school. There are three staff. LPA toured the facility site and observed: -- The facility site and grounds are clean, free of debris and hazards, and is well-maintained. -- Food is properly stored, is fresh and within date, and meets the 7-day nonperishable, 2-day perishable mandate to meet the needs of residents in care. The kitchen is stocked with utensils and dishware. -- Medications, sharps, and chemicals are all locked and inaccessible to residents in care. -- The smoke detectors were tested and are functioning. -- The first aid kit is missing tweezers and scissors. LPA advises, per California Code of Regulations (CCR), Title 22, Section 80075, that the facility ensure the first aid kit is stocked with all required items. LPA inspected the facility files and observed: -- The client files are complete and contain all required documentation. Medication records are complete and indicate consistent and proper administration of medications. LPA advises, per CCR, Title 22, Section 84070, that the facility begin logging all psychotropic medications on a separate log, using the LIC 622B Psychotropic Medication Administration Record (PMAR) or variation of this form. -- The staff files are complete and contain all required documentation. All staff are cleared and associated to the facility. LPA advises, per CCR, Title 22, Section 84065, that the facility update the training records, as it does not currently reflect that the 20 hour annual requirement was met. The records do reflect that 13 hours have been completed for 2021 so far, and LPA advises that the facility ensure they meet the 20 hours by the end of the year. LPA conducted resident observation and staff interviews: -- Resident present during visit appeared happy and comfortable and was being engaged by attentive staff. -- Staff are knowledgeable about the needs of residents in care and program procedures. An exit interview was conducted, and a copy of this report was left with Facility Manager Dioneil Noriega, whose signature on this form confirms receipt.

met_with: Facility Manager Dioneil Noriega


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 9/2/22 at 11: AM, Licensing Program Analyst (LPA) Alyssa Ng made an unannounced annual/required inspection to listed facility. The facility is licensed for six residents, and currently in placement are 5 clients. During this inspection, 2 clients and 1 staff were present in the home. The staff present was a direct care staff. At 12: PM, another direct care staff and client arrived at the facility. There were no facility manager or Administrator present. Safety precautions were taken, including screening call, hand hygiene, and mask-wearing. Two clients are non-verbal and one client is was verbal at the time of the inspection. LPA Ng observed the clients and staff interacting during play time. Staff were responsive to the clients needs and able to provide care and supervision to the clients in care. Clients were smiling and clapping when staff played to music. LPA conducted one client interview and two staff interviews. LPA Ng toured the facility inside and out. The home is single storied, and has two double occupancy bedroom and 1 single occupancy bedroom. There are two staff bedrooms. All client bedrooms were equipped with comfortable furnishings which included ample storage space for clients' belongings, desks and chairs, and twin sized beds. Each bedroom has a closet with sliding doors for extra storage space. Client bathroom was clean and furnished with hygiene supplies for each client. The water temperature measured 115 degrees F. The thermostat measured 71 degrees. The facility is clean, safe and sanitary. The kitchen was observed to be clean and free of hazards or chemicals. Sharps were located in a locked cabinet. The weekly menu was in the kitchen. LPA observed at least 2 days of perishable foods and 7 days of nonperishable foods. The smoke detectors are in working order. No bodies of water on the premises. All walkways were free from debris or hazards. -----------Cont. ON 809C----- At 11: AM LPA toured the backyard and observed it to be free from hazards. There is a basketball hoop and a sitting area in the backyard. The backyard is surrounded by a wooden fence with locked gates. The facility has a centralized AC unit in the side yard All client records complete with all of the required documentation. Each client has their own separate binder of all required documents. Each psychotropic medication was observed to have its own Psychotropic Medication Administration Record (PMAR), as well as individual Centrally Stored Medication Destruction Records (CSMDR). All medications were consistent with these records. Facility is in compliance, with only the following exceptions: Due to Facility Manager and Administrator not being present at the time of the inspection, staff files were not reviewed. Facility cited for California Code of Regulations 80044(a) Inspection Authority of the Licensing Agency. Please see 809D. LPA Ng will come back at a later time to review staff files/training. There was no Facility Manager and Administrator present. Facility cited for California Code of Regulation 84065(a) Personnel Requirements. Please see attached 809D. After reviewing client files, records reveal that all clients are over the age of 18. Clients ages are 23, 22, 22, 21, and 20. Facility had one age exception for a client until the age of 22. That clients' current age is 23. During the last annual dated 9/1/2021, it was discussed that the clients who were turning over 18, were going to be moved to an Adult Residential Facility. However since that visit, no application was submitted and clients are still in care. Facility cited per CCR regulation, 80010(a), Limitations on Capacity and Ambulatory Status. Please see 809D. At this time, three deficiencies were cited today. Appeal Rights were provided, an exit interview was conducted, and a copy of this report was left at listed facility.

Deficiencies:
84065(d): 84065	Personnel Requirements	 (d)The licensee shall designate at least one facility manager to be present at the facility at all times when children are present

met_with: Rosalinda Santa Maria


summary: Facility Evaluation

raw_content:
Narrative:
On 2/24/2023 at 10: AM, Licensing Program Analyst (LPA) Alyssa Ng conducted a cas management inspection at Ella's Home and spoke with Dioneil Noriega, Facility Manager. The purpose of the inspection was to discuss the conversion to Adult Residential Facility (ARF). On 9/2/2022, LPA Ng went to listed facility to conduct an Annual Inspection. During the file review, it was revealed that clients residing in the home are over the age of 18. LPA Ng cited per CCR regulation, 80010(a), Limitations on Capacity and Ambulatory Status. LPA wrote age exceptions for two clients. Currently, there are 5 clients in the home. They are ages 22, 20, 22, 24, and 22. Facility Manager Dioneil stated that their Program Design is done. The Application for the Adult Residential Facility is almost completed. The listed facility already has an ARF so they have been in contact with their LPA at Adult and Senior in the Oakland Office. Regional Center is aware of their application. Their estimated time for completion/submission is a month. LPA will contact Facility Manager Dioneil monthly for updates. At this time, no citations were given. An exit interview was conducted and copy of this report was left with Dioneil Noriega, Facility Manager.

visit_type: Case Management


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 07/19/23 at 10: AM, Licensing Program Analyst (LPA) Alyssa Ng made an unannounced annual/required inspection to listed facility. The facility is licensed for six residents, and currently in placement are 5 clients. During this inspection, 3 clients and 3 staff were present in the home. Safety precautions were taken, including screening call, hand hygiene, and mask-wearing. Three clients are non-verbal and one client is was verbal at the time of the inspection. LPA Ng observed the clients and staff interacting during play time. Staff were responsive to the clients needs and able to provide care and supervision to the clients in care. Clients were smiling and clapping when staff played to music. LPA conducted 3 client interview and 2 staff interviews. At 11: AM, LPA Ng toured the facility inside and out. The home is single storied, and has two double occupancy bedroom and 1 single occupancy bedroom. There are two staff bedrooms. All client bedrooms were equipped with comfortable furnishings which included ample storage space for clients' belongings, desks and chairs, and twin sized beds. Each bedroom has a closet with sliding doors for extra storage space. Client bathroom was clean and furnished with hygiene supplies for each client. The water temperature measured 115 degrees F. The thermostat measured 68.5 degrees. The facility is clean, safe and sanitary. The kitchen was observed to be clean and free of hazards or chemicals. Sharps and chemicals were located in the garage in a locked cabinet. The weekly menu was in the kitchen. LPA observed at least 2 days of perishable foods and 7 days of nonperishable foods. The smoke detectors are in working order. No bodies of water on the premises. All walkways were free from debris or hazards. At 11: AM LPA toured the backyard and observed it to be free from hazards. There is a basketball hoop and a sitting area in the backyard. The backyard is surrounded by a wooden fence with locked gates. The facility has a centralized AC unit in the side yard along with two storage sheds. All staff and client records complete with all of the required documentation. Each staff and client has their own separate binder of all required documents. Each psychotropic medication was observed to have its own Psychotropic Medication Administration Record (PMAR), as well as individual Centrally Stored Medication Destruction Records (CSMDR). All medications were consistent with these records. -------------cont. on 809C------------------------- Resident and staff records were observed to be complete and the facility in compliance, with only the following exceptions: During inspection, LPA requested a updated copy of the LIC Personnel Report to maintain their file current. A review of the facility's Guardian roster on July 19th, 2023 indicates that all but one staff to the facility had DOJ, FBI and child abuse index check clearances. Facility is being cited 80019(e) Criminal Background Clearance. During a review of the staff files, the listed Administrator did not have a current/active Group Home Administrator certificate. The Administrator has a current Adult Residential Facility certificate. LPA Ng stated that the Administrator would still need a Group Home Administrator certificate since the facility is still under a Children's Residential license. Complaint procedures were not posted in the facility and was not accessible for staff and clients and their authorized representatives. LPA advises per CCR regulation, 84072.2(a)(3), complaint procedures must be posted in the facility within clear view of clients and their authorized representatives. At this time, 3 deficiencies were cited. An exit interview was conducted, and a copy of this report was given to Facility Manager, Rosalinda Maria, whose signature on this form confirms receipt.

Deficiencies:
80019(e): Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility

met_with: Rosalinda Maria


summary: Facility Evaluation

raw_content:
Narrative:
On 09/11/2024 at 11:00 a.m., Licensing Program Analyst (LPA) Brenda Rodriguez and Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced Annual Inspection and met with Dioneil Noriega, Administrator. LPA Rodriguez disclosed the purpose of the inspection and was granted entry into the facility. LPA Rodriguez and LPA Medina used the CARE Inspection Tool. There were three (3) staff members, and four (4) clients were present at the time of inspection. One client present was verbal, and the rest of the clients present were non-verbal. The facility currently has a census of five clients. All clients are non-minor dependents ages twenty-one and up. LPA Rodriguez and LPA Medina reviewed four (4) staff files and five (5) client files. LPA Rodriguez and LPA Medina also reviewed the personnel binder and the emergency disaster plan. LPA Medina conducted two confidential staff interviews and one confidential client interview. During the physical plant inspection, no deficiencies were found. The facility was clean, sanitary, free of obstructions, and an adequate amount of food for all clients in care was present. Client bedrooms were clean and had space for belongings and client necessities. LPA Rodriguez and LPA Medina observed the locked cabinet where all facility files and medication is stored and kept. Administrator informed LPA's that the Group Home is currently in the process of turning into an Adult Residential Facility. The required Annual Inspection is complete. No deficiencies were cited. An exit interview was conducted at 3:20 p.m., and a copy of this report was emailed to Administrator Dioneil Noriega, whose signature on this form confirms receipt.

met_with: Dioneil Noriega, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 08/05/2025 at 10:00 a.m., Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced annual inspection and met with Dioneil Noriega, Administrator. LPA Medina disclosed the purpose of the inspection and was granted entry into the facility. The CARE Inspection Tool was used to guide the inspection. At the time of the visit, there were three staff members and two clients present. One of the clients is verbal and the others are non-verbal. Administrator Noriega stated that the Group Home is currently in the process of converting to an Adult Residential Facility. Due to personal family matters, there have been delays in submitting the required documentation for the conversion process. At approximately 10:30 a.m., LPA Medina reviewed five client files under the client records section of the CARE tool. All clients were confirmed to be non-minors. Clients are enrolled in day programs and regularly participate in weekend outings. An area of improvement was noted in this section: several clients' Needs and Services Plans were overdue for updates. Per regulation, Needs and Services Plans must be reviewed and updated at least every six months. Please refer to LIC9102 for more information. At 12:00 p.m., LPA Medina reviewed four staff files belonging to staff who actively work in the day-to-day operation of the facility. Each file contained current CPR certifications, health screenings, criminal record statements, personnel records, and documentation of completed training. No deficiencies were observed in the staff records section. Continues on LIC809-C At 1:15 p.m., LPA Medina began the physical plant inspection. The facility was observed to be clean, sanitary, and free of hazards or obstructions. Client bedrooms were well-maintained, with appropriate furnishings, clean linens, and adequate storage space. Medications and facility records were stored in a locked cabinet. All bedrooms are double-occupancy. Food observed on-site was of good quality, properly stored, within expiration dates, and sufficient to meet regulatory requirements. The water temperature measured 108°F, and the thermostat reading was 69°F-both within regulatory limits. No deficiencies were observed in the physical plant section. At 2:00 p.m., LPA Medina reviewed the operational requirements section of the CARE tool. Upon review of the facility's license, it was determined that the home is operating outside the conditions authorized by its license. The facility is licensed to serve clients ages 6 to 17; however, all current clients are over the age of 18. Please refer to LIC809-D for details regarding this deficiency. At 2:15 p.m., LPA Medina reviewed the disaster preparedness section. The most recent emergency drill was conducted on July 21, 2024. As required by regulation, emergency drills must be conducted quarterly. However, the facility maintains an up-to-date client roster, medication log, and current Needs and Services Plans for all clients to ensure preparedness in the event of an emergency. Please refer to LIC809-D for additional information on the deficiency. At 2:30 p.m., LPA Medina reviewed the emergency intervention plan. The Administrator reported that staff are trained in Pro-Act, and the home operates as a hands-off facility. No restraints are used. No deficiencies were observed in this section. During the inspection, LPA Medina conducted two confidential staff interviews and one confidential client interview. The required annual inspection has been completed. Two deficiencies were cited during today's visit: one under California Code of Regulations, Title 22, Section 80010(a), and one under Health and Safety Code, Section 1565(c). An exit interview was conducted with Administrator Dioneil Noriega at 3:30 p.m. During the meeting, the findings, including appeal rights, were reviewed and a copy of the report was provided via email. Administrator's signature on this form acknowledges receipt of the report and understanding of the information discussed.


summary: Facility Evaluation

raw_content:
Narrative:
On 08/20/2025 at 12:30p.m., Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced inspection at the facility and met with Dioneil Noriega, Administrator, to follow up on outstanding Plans of Correction (POCs). LPA Medina disclosed the purpose of the visit and was granted entry. At the time of the inspection, there were two staff members and three clients present. On 08/05/2025, LPA Medina conducted the facility's annual inspection. As a result of that inspection, the facility was cited for two deficiencies: California Code of Regulations, Title 22, Section 80010(a) - Operating beyond the limitations of the license. Health and Safety Code, Section 1565(c) - Failure to conduct required emergency drills. During today's visit, LPA Medina reviewed the POCs with the Administrator. It was determined that both deficiencies were not corrected by the agreed due date. Consequently, the facility was assessed two civil penalties totaling $200 for failure to correct, and will continue to accrue $100 per day until the deficiencies are cleared. Additionally LPA conducted a quick walk through of the home and observed the home was clean and in good repair. An exit interview was conducted, and the report along with appeal rights was reviewed with and provided to Dioneil Noriega, Administrator.

met_with: Dioneil Noriega - Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 12/12/2025 at 10:00am, Licensing Program Manager (LPM) Kristin Pierotti and Licensing Program Analyst (LPA) Amee Li met with Applicant, Emani House Inc., for the scheduled Component II face-to-face meeting. Representing the applicant was Executive Director and Administrator, Ella Bell. Joining the meeting remotely was Associate Governmental Program Analyst (AGPA) Zoe Wilson. During the meeting, the following topics were discussed. • Application Process Overview • Goal/Purpose of the Facility • Basic Services and Planned Activities • Needs and Services Plans • Care and Supervision Policies • Emergency Intervention Policies • Emergency Disaster Procedures • Reporting Requirements • Background Clearance/Guardian Process At the conclusion of the meeting, LPM discussed that the Pre-licensing inspection will be scheduled upon receipt of the administrator certificate and revisions to the Emergency Intervention Plan. LPA thanked the Applicant representative for attending the meeting. A copy of this report was provided to the Applicant representative, whose signature confirms receipt.

met_with: Ella Bell, Executive Director & Adminstrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Simran Nayyar conducted a Pre-licensing inspection and met with Executive Director, Ella Bell. The entire home was toured, inside and out. The applicant is interested in providing care for a capacity of six children, ages six - seventeen years, ambulatory only. The home is set up as follows: This is a two-story home with four bedrooms, three bathrooms, a living room, a dining-room, and kitchen. Bedroom # 1 - occupied by minor (two twin beds, two dressers, and shared closet space). Bedroom # 2 - occupied by minor (one single twin bed, one dresser, and closet) Bedroom # 3 - occupied by minor (one single twin bed, one dresser, and closet) Bedroom # 4 - occupied by minor (one single twin bed, one dresser, and closet) There were appropriate furnishings in the home. There was a fireplace in the living room that was fenced properly. There are two full bathrooms and one full bathroom will be utilized specifically for staff. The faucets that will be used by the children were tested and delivered hot water at a temperature of 129.5 degrees. The facility was made aware of this issue and is advised to put up warning signs advising clients of hot water temperatures. The facility is aware of having two day perishable and 7 day nonperishable food supply. 3 out of 4 client bedrooms were clean and in good repair, 1 out of 4 client bedrooms had a dresser with a broken drawer. LPA advised Executive Director to get that repaired before a client is placed in that room. Technical Advisories were issued for Sections 80088(e)(1) and 84088(c)(4)(A) as a reminder for water temperature and client furniture being in good repair. The trash cans to be used by clients and in the kitchen were covered to stop the transmission of communicable diseases or odors. The smoke detectors and carbon monoxide alarms were tested and are operable. LPA reminded the facility that emergency telephone numbers, Personal Rights, complaint procedures, food menu needed to be posted in a prominent location. The home has a locked container and cabinet where medications and or contraceptives will be stored. Disinfectants and cleaning solutions were stored in a location that will be inaccessible to children. The first aid kit was checked and found to be complete. The front and backyard were inspected and found cleared of hazards. There were no pools and/or bodies of water on the premises. The applicant stated that there are no firearms in the home. Technical Advisory was issued for 84072.2(a)(3) as a reminder of the location for complaint procedures. LPA conducted [1] interview with staff to discuss intake procedures and trauma informed care of the program. An exit interview was conducted, and a copy of this report was provided to Executive Director, Ella Bell.

visit_type: Prelicensing


summary: Facility Evaluation

raw_content:
Narrative:
On 03/18/2026 at 11: AM, Licensing Program Analysts (LPAs) Amee Li and Simran Nayyar conducted an unannounced post-licensing inspection at the above listed facility. LPAs met with Administrator Ella Bell and explained the purpose of the inspection. At the time of the inspection, there are three clients in care and one client present. LPAs conducted a physical plant inspection of the two-story home with four client bedrooms, three bathrooms, a living room, dining-room, kitchen, and backyard. LPAs observed facility license, fire clearance, facility sketch, emergency disaster plan, foster youth bill of rights, and complaint procedures posted on the walls of the facility. The fireplace in the living room was fenced properly. Facility thermostat read at 72 degrees F, which is within range. LPAs observed bedrooms and found clean linens and appropriate storage space. The closet door of one client bedroom was broken and had a crack in the bottom left of the door's inset mirror. Facility was aware of broken closet door and had plans to replace it with a wooden door. LPAs advised facility to maintain record of work orders for facility repairs. The faucet in the client bathroom delivered water at a temperature of 115 degrees F, which is within range. LPAs observed two days of perishables and seven days of nonperishable food supply in the refrigerator and pantry. Refrigerator and freezer temperatures were in compliance. Menu was posted on kitchen fridge. Sharps are locked and trash cans are covered. Smoke and carbon monoxide detectors are operable and located on the walls of facility.. Medications are stored in a locked closet where inaccessible to clients. First aid kit contained all the required components. Cleaning solutions containing chemicals are stored where inaccessible to clients. The facility has no pools, bodies of water, or firearms. LPAs observed one broken window at the front of the house with sharp exposed edges. LPAs also inspected facility backyard and found one window with sharp exposed edges. Facility immediately covered both broken windows with cardboard and tape. One technical violation is being issued under California Code of Regulations (CCR) 80087(a). See LIC 9102. LPAs inspected four staff files and three client files. Client files contained all the necessary forms and were up to date. LPAs advised facility to maintain a record of client meetings with their psychiatrist. See LIC9102. LPAs also advised facility to obtain one out of three client signatures for their personal rights and needs and services plan. See LIC 9102. Administrator stated that client had not yet signed due to client's age. LPAs found staff criminal record clearances to be in compliance. LPAs were unable to observe staff trainings for initial and emergency intervention. One Technical Violation was issued under CCR 84065(i). See LIC 9102. LPAs found that two out of four staff members did not have updated driver's licenses on file. One Technical Violation is being issued under CCR 80066(a)(2). See LIC 9102. LPAs found that two out of four staff members did not have current CPR training on file. One Type B Violation is being issued under CCR 84065(i)(6). See LIC 809D. LPAs found that two out of four staff members did not have TB test results on file. LPAs issued another Type B Violation under CCR 80066(a)(11). See LIC 809D. LPAs observed record of facility emergency drill trainings on kitchen fridge. LPAs advised facility to additionally maintain records of type of drill conducted and list of staff who attended emergency drill trainings. See LIC 9102. LPAs also advised facility to maintain binder of emergency procedures. Administrator immediately compiled emergency binder containing clients' contacts, needs and services, and medications. LPAs conducted one staff interview and no client interviews. Client was asleep during the inspection. The post-licensing inspection is complete. At this time, two Type B citations and three Technical Violations were issued under Title 22 regulations. An exit interview was conducted, appeal rights discussed, and a copy of this report was provided to Ella Bell, Administrator, whose signature below confirms receipt.

met_with: Ella Bell, Executive Director


facility_name: EMBARK AT SAN MARTIN

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility to inform them that a new complaint had been filed with Licensing and that LPA Simien was opening an investigation for the above listed allegations. LPA discussed this with Dawn Halliburton-Rudy, Administrator (ADM) at 10: AM on 7/1/22. Based on confidential interviews conducted on 7/1/22. There was evidence of above allegations occurring. The complaint allegations, facility did not provide supervision resulting inappropriate interaction between clients, is valid because the preponderance of the evidence standard has been met, therefore the allegation is substantiated. As a result of this visit, there is one title Regulation and General Licensing Standards Responsibility for Providing Care and Supervision (a) violation observed. The facility will be cited (see LIC 9099-D for details). Appeal rights were discussed and provided. Exit interview was conducted and a copy of this report was provided to Jael Debora, Residential Dirctor whose signature on this form confirm receipt of these documents SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: EMBARK AT SAN MARTINFACILITY NUMBER: 435390032

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

met_with: Dawn Halliburton-Rudy, Administrator


summary: Complaint Investigation - Substantiated - 1 deficiency - 1 allegation

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility to inform them of the findings for the above listed allegation. LPA met with Daniel Padron Garcia, Site superviser (SS) at 1: PM on 6/7/23. LPA conducted confidential interviews and reviewed documents during this investigation. During interviews with individuals invovled it was determined that the facility at times was operating out of ratio due to a staff shortage. There were times where there was only one staff member watching six clients. This lead to some of the individuals' needs not being met.Things individuals could do were limited due to not having enough staff to provide supervision for everyone. Based on interviews and documents review, the preponderance of evidence standard has been met, therefore the above listed allegations are found to be SUBSTANTIATED. As a result of this visit, there is one General Licensing Standards Personnel Requirements violation (80065(a)) an one General Licensing Standards Plan of Operation (80022(k)).The facility will be cited. Appeal rights were discussed and provided to ED. Exit interview was conducted and a copy of this report was provided to Daniel Padron Garcia, SS whose signature on this form confirm receipt of these documents (POC will be made on a different day due to Admin being ill). SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: EMBARK AT SAN MARTINFACILITY NUMBER: 435390032

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

Deficiencies:
80065: Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

title: Personnel Requirements (a)


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with Maira Sanchez, Residential Program Director (RPD), at 1: PM on 11/29/23. Based on confidential interviews conducted it was determined that the allegations listed above are Unsubstantiated. Witnesses interviewed stated the facility conducted AWOL protocols within regulations. The facility had an Administrator in place at the start of this investigation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was emailed to Maira Sanchez, RPD. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN JOSE RO, N. First Street, Ste. This is an official report of an unannounced visit/investigation of a complaint received in our office on 04/04/2023 and conducted by Evaluator Paul Simien PUBLICCOMPLAINT CONTROL NUMBER: 26-CR- FACILITY NAME:EMBARK AT SAN MARTINFACILITY NUMBER: ADMINISTRATOR:DAWN HALIBURTON-RUDYFACILITY TYPE: ADDRESS: EAST MIDDLE AVENUETELEPHONE: (408) 838- CITY:SAN MARTINSTATE: CAZIP CODE: CAPACITY:6CENSUS: 3DATE: 11/29/ UNANNOUNCEDTIME BEGAN: 01: PM MET WITH:Maira Sanchez, Residential Program DirectorTIME COMPLETED:03: PM 9Staff did not notify minors parent that minor wasn't eating Minor loss an excessive amount of weight INVESTIGATION FINDINGS: 13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with Maira Sanchez, Residential Program Director, at 1: PM on 11/29/23. Based on confidential interviews conducted and documents reviewed it was determined that the allegations listed above are Substantiated. The facility was aware of minor restricting food intake and skipping weigh-ins and failed to inform minor's parent. This was despite the minor's parent expressing concerns with minor's poor eating habits and issues with having eating disorders at previous treatment facilities at the time of admission. Documents provided showed that minor had a huge fluctuation of weight between 3/2/23 and 3/27/23. From 3/9 to 3/27 the minor lost aproximitly12 pounds. The preponderance of evidence standard has been met, therefore the above allegations, are found to be SUBSTANTIATED. As a result of this visit, there is one Interim Licensing Standards Personal Rights violation (84072(d)(3)) and one General Licensing Requirement violation Responsibility for Providing Care and Supervision (80078(a)). The facility will be cited (see 809-D for details). Appeal rights were discussed and provided. Exit interview was conducted and a copy of this report was emailed to RPD. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 2 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN JOSE RO, N. First Street, Ste. FACILITY NAME: EMBARK AT SAN MARTINFACILITY NUMBER: 435390032

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

complaint_status: unsubstantiated


summary: Complaint Investigation - Substantiated - 3 allegations

raw_content:
Narrative:
Based on a review of facility training records, staff did not receive training in the required training topics as outlined in the regulations and were not trained to handle or in preparations for situations in the facility. Therefore, these allegations are Substantiated. Facility cited for violations of the California Code of Regulations, Title 22, Division Six, Section 80022(k) Plan of Operation, 80022(k) Plan of Operation, 84065(i) Personnel Requirements, and an advisory is being issued for section 80087(a) Buildings and Grounds as described on the following page LIC 9099D. An exit interview was conducted a copy of this report along with appeal rights was left with Alyssa Avila.

Investigation Findings:
13On 3/19/2024 at 9: AM, Licensing Program Analyst (LPA) Shikya Belfield and LPA Mona Lam, conducted an unannounced inspection to the above facility. The purpose of this visit was to inform the facility representative of the findings for the allegations above. LPA met with Alyssa Avila who assisted with the inspection. Based on confidential interviews conducted and supportive documentation to include but not limit repair receipts. The facility grounds has a septic tank that became backed up and the plumbing in the facility was not able to be used. Clients needed to use the restrooms in the main office next door. Facility also has a broken dryer and the dryer used to dry clients clothing is in the office next door. Facility maintenance person responded and the septic tank was worked on for at least two days. Technical advisory issued. Based on confidential interviews and a review of supportive documentation to include but not limit staff schedule and program plan of operation, the facility was operating outside of the required operating ratio according to plan of operation. Based on confidential interviews administrator and supervisors did not respond to crisis situations when called on for support as outlined in the plan of operation emergency intervention plan. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Shikya Belfield LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: EMBARK AT SAN MARTINFACILITY NUMBER: VISIT DATE: 03/19/2024

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Estimated Days of Completion: 90

met_with: Alyssa Avila


raw_content:
Narrative:
Therefore, these allegations are Substantiated. Facility cited for violations of the California Code of Regulations, Title 22, Division Six, Section 84072(d)(14)(a)(1) Personal Rights, 80022(k) Plan of Operation, and 84065(i) Personnel Requirements as described on the following page LIC D.

Investigation Findings:
13On 3/19/2024 at 9: AM, Licensing Program Analyst (LPA) Shikya Belfield and LPA Mona Lam, conducted an unannounced inspection to the above facility. The purpose of this visit was to inform the facility representative of the findings for the allegations above. LPA met with Alyssa Avila who assisted with the inspection. Based on confidential interviews conducted and a review of supportive documentation to include but not limit, incident reports and video surveillance. Facility did not prevent client from assaulting other staff and client in care. It was also confirmed that the client who committed the assaults was in placement outside of the compliance of the facility's plan of operation as C1 (see lic811 dated 3/19/2024) was 18 years old. No exception was requested before their birthday to allow them to remain in the facility. Based on confidential interviews and observations of video surveillance, the placement of C1 in the facility was not compatible with other clients who were placed in the facility. Based on a review of facility training records, staff did not receive training in the required training topics as outlined in the regulations and were not trained to handle or in preparations for situations in the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Shikya Belfield LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: EMBARK AT SAN MARTINFACILITY NUMBER: VISIT DATE: 03/19/2024

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Estimated Days of Completion: 90


summary: Complaint Investigation - Unsubstantiated - 5 allegations

raw_content:
Narrative:
Facility has also been cited for reporting requirements and currently have a plan of correction in place Facility is cited for violations of the California Code of Regulations, Title 22, Division Six, Section 84075(e) Health Related services. Facility is issued a Technical Violation Advisory for section 84070(b)(16) - (B)(C)(D)(G) medication. An exit interview was conducted a copy of this report along with appeal rights was left with Facility Manager Arianna Mandoza.

Investigation Findings:
13On 8/27/2024 at 1: PM, Licensing Program Analyst (LPA) Shikya Belfield and LPA Kristin Pierotti, conducted an unannounced inspection to the above facility. The purpose of this inspection is to inform the facility representative of the findings for the complaint investigation regarding the allegations above. Facility Manager Arianna Mendoza assisted with the inspection. Based on confidential interviews, obtained documentation to include but no limit, staff communication, a review of program statement, client files and staff schedules. It was observed that clients did not receive medications as required. Based on confidential interviews and a review of client files, it was confirmed that clients did not receive training or information regarding sexual reproductive health as outlined in the regulations. Based on a review of staff schedules it was observed that facility did not have sufficient staff in the facility to meet the required ratio outlined in the plan of operation. Based on a review of law enforcement logs and incident reports, it was observed that their were incidents that occurred and the department was not notified. Facility is currently addressing issues of ratio and currently have a plan of correction in place. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Shikya Belfield LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. This is an official report of an unannounced visit/investigation of a complaint received in our office on 05/08/2024 and conducted by Evaluator Shikya Belfield COMPLAINT CONTROL NUMBER: 26-CR- FACILITY NAME:EMBARK AT SAN MARTINFACILITY NUMBER: ADMINISTRATOR:AMIR RAFIEIFACILITY TYPE: ADDRESS: EAST MIDDLE AVENUETELEPHONE: (408) 838- CITY:SAN MARTINSTATE: CAZIP CODE: CAPACITY:6CENSUS: 4DATE: 08/27/ UNANNOUNCEDTIME BEGAN: 01: PM MET WITH:Arianna MendozaTIME COMPLETED:02: PM 9clients do not receive educational support. INVESTIGATION FINDINGS: 13On 8/27/2024 at 1: PM, Licensing Program Analyst (LPA) Shikya Belfield and LPA Kristin Pierotti, conducted an unannounced inspection to the above facility. The purpose of this inspection is to inform the facility representative of the findings for the complaint investigation regarding the allegations above. Facility Manager Arianna Mendoza assisted with the inspection. Based on confidential interviews and observations in the facility, although the above allegation may have happened or is valid, there is not enough of the evidence to support that the violation occurred. The preponderance of the evidence has not been met and this allegation is Unsubstantiated. An exit interview was conducted and a copy of this report was left with facility manager Arianna Mendoza. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Shikya Belfield LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 2 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: EMBARK AT SAN MARTINFACILITY NUMBER: 435390032

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 90

met_with: Arianna Mendoza


raw_content:
Investigation Findings:
13On 8/27/2024 at 1: PM, Licensing Program Analyst (LPA) Shikya Belfield and LPA Kristin Pierotti, conducted an unannounced inspection to the above facility. The purpose of this inspection is to inform the facility representative of the findings for the complaint investigation regarding the allegations above. Facility Manager Arianna Mendoza assisted with the inspection. On 8/27/2024 at 10: AM, Licensing Program Analyst (LPA) Shikya Belfield and LPA Kristin Pierotti, conducted an unannounced inspection to the above facility. The purpose of this inspection is to inform the facility representative of the findings for the complaint investigation regarding the allegations above. Facility manager Arianna Mendoza assisted with the inspection. Based on confidential interviews, obtained documentation to include but do not limit, staff communication, medication records, and staff schedules. There were at least four occasions where staff were operating out of ratio according to the plan of operation. Based on a review a of medication administration records, the medication logs were missing information or incomplete and medication logs did not list reasons for missed medication. Based on a review of client files it was observed that client documents were incomplete and missing information. The preponderance of the evidence has been met. Therefore, these allegations are Substantiated. Facility is issued a Technical Violation Advisory for California Code of Regulations, Title 22, Division Six, Section 84070(b)(16) Children's Records. Facility is cited for California Code of Regulations, Title 22, Division Six, Sections 80022(k) Plan of Operation as described on the following page LIC9099D. An exit interview was conducted on 8/27/2024,due to technical issues with equipment, LPA sent a copy of this report along with Appeal rights to Facility Manager Arianna Mendoza on 8/29/2024. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Shikya Belfield LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: EMBARK AT SAN MARTINFACILITY NUMBER: 435390032

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Estimated Days of Completion: 90


raw_content:
Investigation Findings:
13On September 18, 2025 at 2: PM Licensing Program Analyst (LPA) Mona Lam made an unannounced inspection to the above listed facility. The purpose of this inspection is to deliver the finding for the above allegation. Micki Hankes assisted LPA with the inspection. Based on confidential interviews, statements indicated that staff responded accordingly to youth's actions when youth took items from the pantry from another facility. Multiple interviews stated youth was not touched when a blocking occurred. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation occurred. Therefore, the allegation is UNSUBSTANTIATED. A copy of this report was given to Micki Hankes prior to exiting the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Mona Lam LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Micki Hankes


facility_name: EMBARK AT SAN MARTIN-NEW AVENUE CAMPUS

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility to inform them of the findings for the above listed allegation. LPA met with Daniel Padron Garcia, Site superviser (SS) at 1: PM on 6/7/23. LPA conducted confidential interviews and reviewed documents during this investigation. During interviews with individuals invovled it was determined that the facility at times was operating out of ratio due to a staff shortage. There were times where there was only one staff member watching six clients. This lead to some of the individuals' needs not being met.Things individuals could do were limited due to not having enough staff to provide supervision for everyone. Based on interviews and documents review, the preponderance of evidence standard has been met, therefore the above listed allegations are found to be SUBSTANTIATED. As a result of this visit, there is one General Licensing Standards Personnel Requirements violation (80065(a)) an one General Licensing Standards Plan of Operation (80022(k)).The facility will be cited. Appeal rights were discussed and provided to ED. Exit interview was conducted and a copy of this report was provided to Daniel Padron Garcia, SS whose signature on this form confirm receipt of these documents (POC will be made on a different day due to Admin being ill). SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: EMBARK AT SAN MARTIN-NEW AVENUE CAMPUSFACILITY NUMBER: 435390042

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

Deficiencies:
80065: Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

title: Personnel Requirements (a)


raw_content:
Investigation Findings:
13On 10/27/2023 at 9: AM, Licensing Program Analyst's (LPA) Shikya Belfield and LPA Celest Aparicio, conducted an unannounced complaint inspection to the above facility. The purpose of this inspection is to deliver the findings for the above allegations. LPA's met with administrator Princess Garcia who assisted with the inspection. Based on LPA's observations, conducted confidential interviews, and supportive documentation to include but not limit, incident reports. There were more than 10 incident reports and a minimum of five that were law enforcement contact, that were not reported to the department. It was also determined that during the evening hours of operation there is not facility manager on site while clients are in care. Facility is cited for violation of the California Code of Regulations, Title 22, Division Six, Section 84061(i) Reporting Requirements and 84065.2(a)(1)(A)(3) Personnel Duties as outlined on the following D. An exit interview was conducted a copy of this report along with appeal rights will be sent to Administrator Princess Garcia. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Shikya Belfield LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: EMBARK AT SAN MARTIN-NEW AVENUE CAMPUSFACILITY NUMBER: 435390042

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Estimated Days of Completion: 90

met_with: Princess Garcia


raw_content:
Narrative:
These allegations are Substantiated. Facility cited for violation of the California Code of Regulations, Title 22, Division Six, Section, 84072(d)(10) Personal Rights, 84061(i) Reporting Requirements, and 84072.1(c) Discipline Policies and Procedures, as described on the following page 9099D. Section is 84061(i) is a repeat violation within twelve months and a civil penalty is being assessed. Advisory issued Welfare & Institutions Code Section 16001.9 (a)(1) Personal Rights. Advisory Issued. An exit interview was conducted and a copy of this report along with appeal rights, will be sent to House Manager Alyssa Avila, Administrator Amir Rafiei, and Maira Sanchez.

Investigation Findings:
13On 2/15/2024 at 9: AM, Licensing Program Analyst (LPA) Shikya Belfield and LPA Celest Aparicio, conducted an unannounced inspection to the above facility. The purpose of this visit was to inform the facility representative of the findings for the allegations above. House Manager Alyssa Avila assisted with the inspection. Based on confidential interviews conducted, it was confirmed that staff spoke rudely to clients in care and made them feel uncomfortable. Based on observations by LPA's and review of supporting information including but not limited to, Incident Reports and video surveillance, clients were placed on psychiatrics holds prematurely. Based on observations of video surveillance and confidential interviews, incidents occurred at the facility and they were not reported to the department. Based on confidential interviews conducted, clients felt unsafe in their living environment where they were surrounded by all males and they were the only female. When expressed to staff, client was ignored, spoken to rudely, and no changes were made. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Shikya Belfield LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: EMBARK AT SAN MARTIN-NEW AVENUE CAMPUSFACILITY NUMBER: VISIT DATE: 02/15/2024

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


raw_content:
Investigation Findings:
13On 3/19/2024 at 12: PM, Licensing Program Analyst (LPA) Shikya Belfield and LPA Mona Lam, conducted an unannounced inspection to the above facility. The purpose of this visit was to inform the facility representative of the findings for the allegations above. LPA met with Alyssa Avila who assisted with the inspection. Based on observations of video surveillance, confidential interviews, and supportive documentation to include but not limit incident reports. Incidents occurred at the facility and they were not reported to the department. Based on confidential interviews conducted and a review of supportive documentation to include but not limit, incident reports and video surveillance. The facility staff are not trained to for the program design / description of the program. Based on confidential interviews conducted and a review of supportive documentation to include but not limit, incident reports and video surveillance. Clients were affected by sexual incidents taking place in the facility and one client was not able to sleep in their room. Therefore, these allegations are Substantiated. Facility cited for violation of the California Code of Regulations, Title 22, Division Six, Section, 84072(d)(11) Personal Rights and 84061(i) Reporting Requirements. Section is 84061(i) is a second repeat violation within twelve months and a civil penalty is being assessed. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Shikya Belfield LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: EMBARK AT SAN MARTIN-NEW AVENUE CAMPUSFACILITY NUMBER: 435390042

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Estimated Days of Completion: 90


raw_content:
Investigation Findings:
13On 3/19/2024 at 12: PM, Licensing Program Analyst (LPA) Shikya Belfield and LPA Mona Lam, conducted an unannounced inspection to the above facility. The purpose of this visit was to inform the facility representative of the findings for the allegations above. LPA met with Alyssa Avila who assisted with the inspection. Based on confidential interviews conducted and observations of video surveillance, and supportive documentation to include but not limit, incident reports. Staff were instructed not to contact emergency services and during one incident the client's lips turned blue and they were rushed to the hospital. Staff were also not trained on the medical emergency response. Therefore, this allegation is Substantiated. Facility cited for violation of the California Code of Regulations, Title 22, Division Six, Section 80075(a) Health Related Services as described on the following page LIC D. An exit interview was conducted and a copy of this report along with appeal rights were left with Alyssa Avila. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Shikya Belfield LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: EMBARK AT SAN MARTIN-NEW AVENUE CAMPUSFACILITY NUMBER: 435390042

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Estimated Days of Completion: 90


raw_content:
Narrative:
The preponderance of the evidence has been met. Therefore, these allegations are Substantiated. Facility is issued a Technical Violation Advisory for California Code of Regulations, Title 22, Division Six, Section 84070(b)(16) Childrens Records. Facility is cited for California Code of Regulations, Title 22, Division Six, Section 80022(k) Plan of Operation, 80070(a) Client Records, 84061(i) Reporting Requirements. An exit interview was conducted and a copy of this report along with appeal rights was left with Executive Director Amy Bravo.

Investigation Findings:
13On 8/27/2024 at 10: AM, Licensing Program Analyst (LPA) Shikya Belfield and LPA Kristin Pierotti, conducted an unannounced inspection to the above facility. The purpose of this inspection is to inform the facility representative of the findings for the complaint investigation regarding the allegations above. Executive Director Amy Bravo assisted with the inspection. Based on confidential interviews, obtained documentation to include but no limit, staff communication, medication records, and staff schedules. There were at least four occasions where staff were operating out of ratio according to the plan of operation. Based on confidential interviews, there was at least one occasion where parents were trying to contact their child and there was no answer and there was no answer by staff when contacting the facility. Due to this an appointment was missed. Based on a review a of medication administration records, the medication logs were missing information or incomplete and medication logs did not list reasons for missed medication. Based on a review of client files it was observed that client documents were incomplete. Based on observations of law enforcement call logs, staff communication, and incident report, there were incidents involving law enforcement that were not reported to the department. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Shikya Belfield LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: EMBARK AT SAN MARTIN-NEW AVENUE CAMPUSFACILITY NUMBER: VISIT DATE: 08/27/2024

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Estimated Days of Completion: 90

met_with: Amy Bravo


summary: Complaint Investigation - Unsubstantiated - 3 allegations

raw_content:
Investigation Findings:
13On 8/27/2024 at 10: AM, Licensing Program Analyst (LPA) Shikya Belfield and LPA Kristin Pierotti, conducted an unannounced inspection to the above facility. The purpose of this inspection is to inform the facility representative of the findings for the complaint investigation regarding the allegations above. Executive Director Amy Bravo assisted with the inspection. Based on confidential interviews, Although the above violation may have happened or is valid, there is not enough of the evidence to prove that the above allegations occured. The preponderance of the evidence has not been met and these allegations are Unsubstantiated. An exit interview was conducted and a copy of this report was left with Amy Bravo. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Shikya Belfield LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 90


raw_content:
Narrative:
Facility cited for violation of California Code of Regulations, Title 22, Division Six, Section 80022(k) Plan of Operation, 84064(c) Administrator qualifications and duties, and 80065(f) Personnel requirements as described on the following page LIC9099D. An exit interview was conducted a copy of this report was left with Executive Director Amy Bravo.

Investigation Findings:
13On 8/27/2024 at 10: AM, Licensing Program Analyst (LPA) Shikya Belfield and LPA Kristin Pierotti, conducted an unannounced inspection to the above facility. The purpose of this inspection is to inform the facility representative of the findings for the complaint investigation regarding the allegations above. Executive Director Amy Bravo assisted with the inspection. Based on confidential interviews, obtained documentation to include but no limit, staff communication, a review of prgram statement, staff training records, and staff schedules. It was observed that staff do not receive sufficient training hours or topics to perform their roles in the facility. Based on confidential interviews, it was confirmed that the administrator is not present in the facility and has not been for at least 60 days. Based on a review of facility program statement and plan of operation, facility has failed to follow the current plan of operation regarding, changes to staff schedules, changes to administrative staff, and accepting clients outside of the listed reuirements in the plan of operation. Based on observations of staff schedules and plan of operation, it was confirmed that facility staffing was not in ratio on at least four occassions. Therefore these allegations are Substantiated. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Shikya Belfield LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: EMBARK AT SAN MARTIN-NEW AVENUE CAMPUSFACILITY NUMBER: VISIT DATE: 08/27/2024

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Estimated Days of Completion: 90


summary: Facility Evaluation

raw_content:
Narrative:
On June 1, 2022, at 8:30am, Licensing Program Analyst (LPA) Monica Pavia conducted a pre-licensing inspection. Embark at San Martin - New Avenue Campus has submitted an application for a Group Home license, for a capacity of 6 ambulatory children, ages 12-17. This inspection was conducted with Noel Beaulieu and included observation of the following: The facility is a one story home. The home includes three client bedrooms; three and a half client bathrooms; kitchen and living room; area set up for school; mindfulness nook; a private space to meet with clients; a staff office; an admissions office; and, an isolation room/extra office, with a Murphy bed, which will only be used for COVID positive clients or additional staff space. The facility and grounds are in good repair, and free of obstructions; chemicals are stored and locked in the closet; locked and centrally stored medication room/cabinet observed; observed medication logs and discussed procedures for psychotropic medications; first aid kit complete; individual beds are in good repair; food storage space observed; emergency foods observed; perishable foods and nonperishable foods will be bought as soon as licensed and have a placement; dining room equipped with tables and chairs accommodating all clients; all smoke detectors were tested by a fire inspector and appear to be in proper working order; carbon monoxide detector observed; fire extinguishers are properly charged; appropriate forms are posted in view of facility clients; and, no firearms or weapons are allowed in the facility or on premises. The backyard includes a swimming pool/hot tub with fencing (facility meets the regulation requirements for inaccessibility for their population); outdoor BBQ area; solar paneling in the far rear of the property; garden area; dog kennel (will not be utilized unless for storage); and, grapevines on the extended property. All staff and client files are electronic and available to Community Care Licensing (CCL). (There will also be hard copy files for clients.) Embark at San Martin - New Avenue Campus is ready for licensure today, 6/1/22. Your license will be mailed.

met_with: Noel Beaulieu


summary: Facility Evaluation

raw_content:
Narrative:
On 05/07/2026 at 11:35 a.m., Licensing Program Analyst (LPA) Brenda Rodriguez met with Luis Martinez, Assistant Program Director to conduct a Case Management on their Runaway Plan. LPA Rodriguez disclosed the purpose of the inspection and was granted entry into the facility. LPA Rodriguez discussed how their runaway policy on their current Program Statement states, "Report the incident to the sheriff department IF the client cannot be visually located and is outside the facility without permission." The facility called an hour later when victim disappeared from site. LPA Rodriguez issued a Technical Violation (TV) for Plan of Operation. LPA Rodriguez also issued a Technical Assistance (TA) regarding an update with their runaway policy to their Program Statement, regarding supervisor approval based on confidential interviews, and needing clarity when or when not to call law enforcement. An exit interview was conducted, and a copy of this report was given to Assistant Program Director Luis Martinez, whose signature on this form confirms receipt.


facility_name: EMBARK AT SAN MARTIN - SAN MARTIN AVE

raw_content:
Investigation Findings:
13On September 30, 2025 at 10: AM Licensing Program Analyst (LPA) Mona Lam made an unannounced inspection to the above listed facility. The purpose of this inspection is to deliver the findings for the above allegation. Micki Hankes, Administrator assisted LPA with the inspection. Based on confidential interviews, it was confirmed that staff spoke sarcastically to clients in care regarding their treatment progress in front of multiple clients. Multiple statements were made regarding a staff's conversation towards a youth was deemed sarcastic in addition to statements aligned in the delivery of the tone and words used in the conversation. This is a potential Health, Safety, and/or Personal Rights risk to clients in care. LPA issued a Type B deficiency under 84072(d)(18) Personal Rights. The preponderance of the evidence standard has been met; therefore, the allegation is SUBSTANTIATED. A copy of this report and appeals rights were given to Micki Hankes, Administrator prior to exiting the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Mona Lam LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN JOSE RO, N. First Street, Ste. FACILITY NAME: EMBARK AT SAN MARTIN - SAN MARTIN AVEFACILITY NUMBER: 435390063

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

met_with: Micki Hankes, Administrator


raw_content:
Narrative:
The preponderance of the evidence standard has been met; therefore, the allegation is SUBSTANTIATED. A copy of this report and appeals rights were given to Micki Hankes prior to exiting the facility.

Investigation Findings:
13On September 30, 2025 at 10: AM Licensing Program Analyst (LPA) Mona Lam made an unannounced inspection to the above listed facility. The purpose of this inspection is to deliver the findings for the above allegation. Christine Ziemba assisted LPA with the inspection. Based on confidential interviews, it was stated that clients were moved to another facility temporarily due property damaged caused by a youth on 09/09/25. Multiple interviews stated upon clients' return to the property, there was some remaining glass on the exterior. Multiple interviews and an incident report on 09/16/25 confirmed one client was injured due to removing glass from broken windows. Based on LPA's observations on 09/18/25 and 09/30/25, multiple windows on the property were broken on the exterior panels. This was observed on the day that clients were on the property. This poses an immediate Health, Safety, and/or Personal Rights risk to clients in care. LPA issued a Type A deficiency under 80087(a) Buildings and Grounds. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Mona Lam LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN JOSE RO, N. First Street, Ste. FACILITY NAME: EMBARK AT SAN MARTIN - SAN MARTIN AVEFACILITY NUMBER: 435390063

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


raw_content:
Narrative:
LPA reviewed files and found that the department did not receive an incident report of the incident. This poses potential Health, Safety, and/or Personal Rights risk to clients in care. LPA issued a Type B deficiency under 80061(E) Reporting Requirements. The preponderance of the evidence standard has been met; therefore, the allegation is SUBSTANTIATED. A copy of this report and appeals rights were given to Micki Hankes prior to exiting the facility.

Investigation Findings:
13On October 17, 2025 at 10: AM Licensing Program Analyst (LPA) Mona Lam made an unannounced inspection to the above listed facility. The purpose of this inspection is to deliver the findings for the above allegation. Micki Hankes assisted LPA with the inspection. The alleged incident that occurred is that youth met a staff member's partner during an outing, which resulted in the partner throwing gang signs at the youth. Based on staff training, it was indicated that under no circumstances are the driver and the use of personal vehicles permitted to transport clients whether on shift or not on shift. Based on interviews, there is a discrepancy if an altercation occurred, however, it was confirmed during an outing with a client, a staff member met up with their partner with the client present. This poses immediate Health, Safety, and/or Personal Rights risk to clients in care. LPA issued a Type A deficiency under 84072(d)(19) Personal Rights. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Mona Lam LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN JOSE RO, N. First Street, Ste. FACILITY NAME: EMBARK AT SAN MARTIN - SAN MARTIN AVEFACILITY NUMBER: VISIT DATE: 10/17/2025

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


summary: Facility Evaluation

raw_content:
Narrative:
On December 20, 2024, at 10: AM, Licensing Program Analyst (LPA) Vaishali Singh-Sood conducted a pre-licensing inspection. Embark at San Martin - San Martin Ave has submitted an application for a Group Home license, for a capacity of 6 ambulatory children, ages 12-17. This inspection was conducted with Amy Bravo and included observation of the following: The facility is a two story home. The home includes 3 client bedrooms; 2 client bathrooms; kitchen and parlor room; dining room, butler's pantry area set up for school; mindfulness nook; two private spaces to meet with clients; a staff office; an admissions office; and, an isolation room/extra office, with a Murphy bed, which will only be used for COVID positive clients or additional staff space. The facility and grounds are in good repair, and free of obstructions; chemicals are stored and locked in the closet; locked and centrally stored medication room/cabinet observed; observed medication logs and discussed procedures for psychotropic medications; first aid kit complete; individual beds are in good repair; food storage space observed; emergency foods observed; perishable foods and nonperishable foods will be bought as soon as licensed and have a placement; dining room equipped with tables and chairs accommodating all clients; all smoke detectors were tested by a fire inspector and appear to be in proper working order; carbon monoxide detector observed; fire extinguishers are properly charged; appropriate forms are posted in view of facility clients; and, no firearms or weapons are allowed in the facility or on premises. The backyard includes three patio areas, and two separate lawns; two seating areas, fireplace area, an outdoor BBQ area; and a garden area. All staff and client files are electronic and available to Community Care Licensing (CCL). Embark at San Martin - San Martin Ave will ready for licensing upon completion of the approved Program Statement which is currently in review.


summary: Facility Evaluation

raw_content:
Narrative:
On August 27, 2025 at 11: AM Licensing Program Analyst (LPA) Mona Lam made an unannounced inspection to the above listed facility. The purpose of this inspection is inspect the physical plant. At the time of the inspection, there were two clients in care. LPA met with Micki Hankes, Administrator. LPA inspected refrigerator and observed perishables within refrigerator. LPA advised for facility to maintaining fresh perishable foods for a minimum of two days on the premises. LPA observed a posted menu of the previous week and not an updated menu of the current week. LPA issued a technical violation under 84076(b) Food Service. LPA observed telephone to be located in a public area near the entrance. LPA advised phone to be located in an area for youth to conduct confidential calls. LPA asked administrator where grievance forms can be submitted to the facility. Administrator indicated it is next to the locked box for youth to submit near to the entrance of the facility. LPA did not observe any indication of the purpose of the locked box. LPA advised posting a sign next to the locked box for complaint purposes. LPA inspected exterior of the property. LPA observed grill with an open drawer of a connected gas tank. LPA advised administrator to close drawer to prevent youth from accessing potential hazardous items. No deficiencies were cited at this time. An exit interview was conducted with Micki Hankes, Administrator and a copy of this report was printed and left with Micki Hankes, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On November 10, at 10: AM, Licensing Program Analysts (LPA) Mona Lam and Amee Li conducted a post-licensing inspection. At the time of the inspection, there are three clients at the facility and three staff members. Micki Hankes, Administrator, assisted LPAs with the inspection. The facility is a two story home. The home includes 3 client bedrooms, 2 client bathrooms, kitchen, dining room, a staff office, and nurse's office. Two of the client bedrooms have holes in the walls, including broken doors. However, the facility shows signs of repair. Facility provided rugs, but were slightly non-slip. LPAs advised in taping rugs down if non-slip were not provided and issued a technical assistance under 80087(b)(1) Buildings and Grounds. The facility is free of obstructions. The facility have enclosed fireplace areas. Rights were posted on board, however it showed one page of the rights and did not include all the rights. LPAs advised in ensuring all rights were visibly posted and issued a technical assistance under 84072(a) Personal Rights. Chemicals are stored and locked in the closet; hygiene products and clean linens were located, locked and centrally stored medication room/cabinet observed; observed medication logs; first aid kit complete; individual beds are in good repair; food storage space observed; emergency foods observed; perishable foods and nonperishable foods were identified. (Continued on LIC 809-C). Carbon monoxide detectors were located at different wall outlets. The backyard includes three patio areas, and two separate lawns; two seating areas, fireplace area, an outdoor BBQ area; and a garden area. LPAs inspected emergency disaster plan. Material of storage of medications, including refrigeration, were not identified in emergency disaster plan. LPAs issued a technical violation under Health and Safety Code 1565(a)(7)(E). Needs and services plan were not identified in emergency binder. LPAs issued a technical violation under Health and Safety Code 1565(e)(2). LPAs inspected manual restraint log. Description of the interventions prior to holds were written, however it does not contain description of the interventions used. LPAs issued a technical violation under 84361(f)(5) Documentation and Reporting Requirements. Dates were mentioned, however the time of day that the intervention was used was not identified. LPAs issued a technical assistance under 84361(f)(2) Documentation and Reporting Requirements. LPAs inspected three client records. Bedroom compatibility assessment was identified, however there was a lack of content regarding why youth were compatible with one another. LPAs issued a technical assistance under 84087(e) Building and Grounds. At this time, LPAs have not finished the post-licensing inspection and will return to finish reviewing client files, staff files, etc. No deficiencies were cited at this time. An exit interview was conducted with Micki Hankes, Administrator and a copy of this report was printed and left with Micki Hankes, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On November 14, at 10: AM, Licensing Program Analysts (LPA) Mona Lam and Amee Li conducted a continuation of the post-licensing inspection. At the time of the inspection, there are three clients at the facility and two staff members. Micki Hankes, Administrator, assisted LPAs with the inspection. LPAs conducted three client interviews and two staff interviews. LPAs inspected the remaining three client files. LPAs were not able to identify one of the three client's immunization records. LPAs inspected five staff files. The following items were missing from staff files: facility manager training, one staff file is missing on mandated reporting/incident reporting. LPAs issued technical violations under 84070(c)(3) Children Records, 84065(d)(3) Personnel Requirements, and 84065(i)(3)(C) Personnel Requirements. No deficiencies were cited at this time. An exit interview was conducted with Micki Hankes, Administrator and a copy of this report was printed and left with Micki Hankes, Administrator.


raw_content:
Investigation Findings:
13On November 5, 2025 at 10: AM Licensing Program Analyst (LPA) Mona Lam made an unannounced inspection to the above listed facility. The purpose of this inspection is to deliver the findings for the above allegation. Chad Oldenburg assisted LPA with the inspection. Based on confidential interviews, interviews stated there are incidents on C1 and C2 would cross boundaries or have fights, however none of the incidents indicated client would touch another client inappropriately. Based on residential shift notes, incident report, and interviews, there are multiple occasions staff would intervene between C1 and C2 if youth were crossing boundaries or fighting. Staff used verbal or physical interventions. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation occurred. Therefore, the allegation is UNSUBSTANTIATED. No deficiencies were cited at this time. A copy of this report was given to Chad Oldenburg prior to leaving the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Mona Lam LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Chad Oldenburg, Assistant Program Director


summary: Facility Evaluation

raw_content:
Narrative:
IRFU: 2957-FN On May 5th, 2026 at 11:30AM, Licensing Program Analyst (LPA) Hanako Primer conducted a Case Management - Incident inspection at the abovementioned facility to follow up on a incident report received on April 28th, 2026. At the time of the inspection, there were six clients at the facility. LPA conducted three interviews with clients and staff on the incident regarding an allegation of a staff member having inappropriate physical contact with a client. As of April 24th, 2026 the staff member is no longer employed at the facility. LPA requested one staff training on boundaries and documentation of staff termination. A physical plant inspection was conducted. No citations were issued at this time. An exit interview was conducted, and a copy of this report was left with William Han, Program Director, whose signature on this form confirms receipt.

met_with: William Han - Program DIrector