facility_name: EVOLVE TREATMENT CENTERS - ARDEN OAKS

raw_content:
Narrative:
The investigation revealed that clients are required to conduct body checks multiple times a day. During a body check, clients remove one piece of clothing at a time, gives the clothing item to staff who then feels/checks the clothing for items of self-harm or contraband. Clients remove all clothing except their undergarments. When clients are dressed down to their underwear, they are then required to do three jump squats. Clients then re-dress. Three clients stated body checks are done each time they return from an outing and every night before they go upstairs to bed. Two staff stated that body checks are conducted the day of initial admission, each time clients return from an outing, and before going to bed. Staff report that all clients are required to conduct body checks for safety. The Program policy states that based on a physician's assessment and the individual needs of a client; body checks may be conducted. One client did not receive a medical assessment nor a treatment plan because they had only been at the facility for 3 days, and the client submitted to body checks. Although all the assessments had not been completed, the facility was within the timeline for completing them, including the Needs and Services Plan. Additionally, the client's parents signed admission paperwork outlining their policy, including the body checks. There were additional conflicting statements regarding under clothing that is expected to be worn during the body checks. There was conflicting information regarding statements made in the complaint narrative and from those interviewed for the complaint. Based on the confidential interviews, observation, and record review, it has been determined that although the Allegation; Minor was not accorded dignity in their personal relationships with staff and other persons may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Investigation Findings:
13On 1/27/2022 at 11:15am, Licensing Program Analyst (LPA) Tana Kinder went to the facility to deliver findings for the allegation Minor was not accorded dignity in their personal relationships with staff and other persons. LPA Kinder met with Program Director . During the course of the investigation, confidential interviews were conducted with the following: two parents on 12/1/21 and three clients and two staff. The following documents were obtained and reviewed: four youth face sheets and current Needs and Services Plans, discharge documents for one youth, Facility Roster, and Staff Roster and schedule. 1. Minor was not accorded dignity in their personal relationships with staff and other persons. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Tana Kinder LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: EVOLVE TREATMENT CENTERS - ARDEN OAKSFACILITY NUMBER: VISIT DATE: 01/27/2022

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


state: CA

summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
and one reporting party and records reviewed were consistent that staff did not provide a safe environment by not being able to maintain line of sight at all times, other staff did not assist the residential counselors with supervision, the staff were unable to prevent children from harassing other children even when the staff had prior knowledge of these actions, children could not utilize their coping skills to mitigate their escalating mental health issues as there was not enough staff present to allow them to do such as going for a walk, going to a quiet room and the administrator was on site approximately once a month. The facility is being cited for violation of the California Code of Regulations, Title 22, Division 6, Chapter 5, Article 06, regulation 84065.5(c) Staff/Child Ratios. Based on LPA documentation reviewed, and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. An exit interview was conducted, and a copy of this report and appeal rights were provided to Ben Connolly, Operations Manager.

Investigation Findings:
13Licensing Program Analyst (LPA) Jean Stidman and Licensing Program Manager (LPM) Dara Campos conducted an unannounced complaint inspection with the above facility on 7/24/25 at 10am and met with Ben Connolly, Operations Manager. The purpose of the inspection was to deliver complaint findings for the above allegations. On 4/29/ LPA met with Angel Jandoc Facility Nurse and Operations to initiate a complaint investigation. During the course of the investigation, the following documents were gathered and reviewed Client Roster, LIC Personnel Report, Current LIC610C, Pre-Admission Assessment, Placement agreements, client Information/Face Sheet, Master Treatment Plans, Medical report, Incident Reports for three children dated 3/27/25, 4/6/25, and 4/16/25, Case Notes for six children and schedule of staff work hours for March and April 2025, weekly progress emails for one child dated 4/4/25, 4/11/25 and 4/18/25, and staff work schedules for 6/23/25-7/6/25 show approximately 22% of shifts were worked by one staff. Confidential interviews conducted between 4/29/25-7/11/25 with four children, eight staff SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jean Stidman LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: EVOLVE TREATMENT CENTERS - ARDEN OAKSFACILITY NUMBER: VISIT DATE: 07/24/2025

report_type: Complaint Investigation

met_with: Ben Connolly, Operations Manager

complaint_status: SUBSTANTIATED


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst, Robin Sullivan, met with Jennifer Samson, Administrator and Devorah Weiss, Compliance Officer, on 7/7/21 for a virtual Face-to-Face Component II Interview. The following areas were discussed: · Fire Clearance - pending fire captain Angela Hampton schedule · David Jahns is associated to the Arden Oaks location. · Electronic Medication Records system - verified records for psychotropic medications are on individual orders and separate documents. All prescribed medications are on individual orders. Evolve will emailed sample records. · Water Certification - all employees are required to be water safety certified. · Send revisions of Program Statement (PS) to all regional offices when an update occurs. Program Statement and Plan of Operation corrections were reviewed and accepted. However, PS may require updates pending complaint findings. Pre-licensing Inspection Scheduled for July 13, 2021 at 1: PM.

report_type: Facility Evaluation

met_with: Jennifer Samson, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Robin Sullivan conducted a scheduled visit on 7/13/2021 at 1: PM and met with Jennifer Samson and Devorah Weiss for the purpose conducting a Pre-licensing inspection for a Group Home license. LPA observed the following during the inspection: · Sharp items are stored in locked container inside the facility manager's locked office. Chemicals and cleaners are stored inside a locked closet and under the kitchen in a locked cabinet. · Medications will be stored in a locked cabinet inside the locked laundry room. · The facility has four bedrooms, two are double occupancy and two are single occupancy rooms. Individual beds are brand new with mattresses, mattress pads and pillows. Adequate supply of linens, and bedding were observed. Bedrooms are accommodating of all required furnishings. · Facility water was tested and is within 105 to 120 degrees Fahrenheit. · The dining room has a large table with eight chairs to accommodate all clients. · Combination smoke and carbon monoxide detectors were observed throughout the facility and in the bedrooms. The facility is equipped with an automatic sprinkler system in case of fire and fire extinguishers were observed. Appropriate forms are posted in view of clients. · A swimming pool is fully enclosed with a 5' fence that has a self-closing gate. · The yard is clean and free of hazards. There is adequate indoor and outdoor activity spaces. The following was discussed during the inspection: inform Community Care Licensing (CCL) of staff changes and update LIC 500 (personnel report) as needed. LPA discussed process for clients who leave the facility on an unauthorized absence. LPAs observed COVID-19 precaution postings, hand sanitizer, and masks. The facility will require temperatures of visitors and staff to be taken upon entrance and logged in a sign-in sheet. LPAs informed the facility that the physical plant meets Title Division Regulations at this time. Final approval of license shall be forwarded to management for review. Exit interview was conducted and documents emailed to the facility..

visit_type: Prelicensing


summary: Facility Evaluation

raw_content:
Narrative:
On 8/9/21 at 3: PM, Community Care Licensing (CCL) met with Evolve to discuss revisions to the Program Statement, Parent Handbook, Client Handbook, and Training Manual. The meeting was held virtually on MS Teams. The following were in attendance: Angela Carmack, Margo Castaneda, Helga Wong, Hedvig Marx, Madeline Freemont, Robin Sullivan of CCL and Del Sabzerou, Michelle Gross, and Devorah Weiss of Evolve. The following areas were discussed: 1. Changes for UAs will be based on the treating psychiatrist/physician's orders and based on individual assessments of each client and their medical history. 2. Body Check statement in PS, Parent and Client Handbooks, and training manual: Body checks are completed on an individualized basis as determined by a clinician based on each client's individual needs and medical history. CCL reiterated that body checks must be on an individualized basis and documented in the master treatment plan and based on client's individual needs and clinical assessments. 3. When Evolve conducts searches is a blanket statement. Further revision required. 4. Evolve will include, in the Program Statement, that a pregnancy test may be required based on a medical need of a specific client .

met_with: Devorah Weiss, Compliance Coordinator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Robin Sullivan conducted an unannounced post-licensing inspection on 12/02/2021 at 11: AM. During the inspection LPA met with Gauri Sanchez, Clinical Program Director who assisted with the inspection. LPA Sullivan conducted a walk-through of the facility both inside and out. Facility staff-client ratio at time of inspection is one staff per three clients. LPA reviewed three client files and four staff files. Two staff and three clients were interviewed. Three clients were present in the facility at the time of the inspection. LPA observed the following during the inspection: · Sharp items are stored in a locked container inside the facility manager's locked office. · Chemicals and cleaners are stored inside a locked closet. · Medications are stored in a locked cabinet inside the locked laundry room. · The facility has four bedrooms, two are double occupancy and two are single occupancy rooms. Individual twin beds have a mattress, mattress cover, top and bottom sheets, blankets and a pillow. Adequate supply of linens, and bedding were observed. Bedrooms are accommodating of all required furnishings. · Facility water was tested and is within 105 to 120 degrees Fahrenheit. · The dining room has a large table with eight chairs to accommodate all clients. · Combination smoke and carbon monoxide detectors were observed and operational throughout the facility and in the bedrooms. The facility is equipped with an automatic sprinkler system in case of fire and fire extinguishers were observed to meet regulations. Appropriate forms, including client rights are posted in view of clients. · A swimming pool is fully enclosed by a 5' fence with a self-closing gate. · The yard is clean and free of hazards. · There are adequate indoor and outdoor activity spaces. The following was discussed during the inspection: inform Community Care Licensing (CCL) of staff changes and update LIC 500 (personnel report) as needed. LPAs observed COVID-19 precaution postings, hand sanitizer, and masks. The facility will require temperatures of visitors and staff to be taken upon entrance and logged in a sign-in sheet. The facility meets Title Division Regulations at this time. An exit interview was conducted and documents left at the facility.

met_with: Gauri Sanchez, Clinical Program Director, LMFT


summary: Facility Evaluation

raw_content:
Narrative:
On July 19, 2022, Licensing Program Analyst (LPA) Jessica Caplinger conducted an unannounced inspection to the facility for the purpose of conducting the annual inspection. LPA met with Jessica Lawrence, Facility Manager, and Gauri Sanchez, Program Director. Walk through was conducted all together. During the course of this inspection, LPA observed the facility to be clean, safe and sanitary. Seven staff and six clients were present during inspection. All required postings were observed in the entryway. The facility is equipped with 4 bedrooms for client use and 3.5 bathrooms. Two bedrooms are equipped with two beds and two bedrooms are equipped with one bed each. The facility was observed with a school room, a living room for relaxation and visits, a group therapy room and laundry room. The home has a large kitchen which opens to the main family room/group space. Kitchen was observed with a stocked fridge and freezer with adequate food supply and perishables. A smaller fridge with snack items was observed in the living room available to the clients for snacks. Menu was observed posted. Home was observed with a garage being utilized for a work out room with an extra fridge being used for extra frozen items. Three therapist rooms were observed. The backyard was observed with a fenced pool area. Over the counter medications, first aid supplies and a refrigerator for medication that may need cold storage are all locked . First aid kit is properly stocked. There are several cupboards in the bathrooms and hall with an abundance of linens, towels and hygiene supplies. Gas and water shut off valves were observed labeled. There are no firearms on the premises. All sharp objects and chemicals were observed locked to be inaccessible to clients. Fire extinguishers were observed throughout the facility and have all been inspected. Facility has a current fire inspection and carbon monoxide detectors were in working condition. Water temperature is set at 117 degrees. Faucets and showers take a long time to heat up but get to over 105 degrees after several minutes. Staff and client files are kept secure. Report continues on LIC 809-C The facility has a binder for up to date disaster plans and documented drills. A review of licensing information system was done on 7/18/22 indicating that all staff associated to the facility had DOJ, FBI and Child Abuse Index Check clearances. The facility currently has six clients, four full time clinicians, and 18 staff. LPA will return to complete the inspection tool. CARE Tool in progress. The following domains were completed: Physical Plant, Operations, Emergency Intervention, and Disaster Preparedness. No deficiencies were noted at this inspection. Exit interview was conducted with Guari Sanchez, Program Director, and a final copy of this report will be emailed to the facility.

visit_type: Annual

met_with: Gauri Sanchez; Program Director


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst-Shawndra Miles conducted an unannounced case management inspection on 07/20/2022 at 10:45 am at the above agency. LPA was met by Gauri Sanchez, Administrator, and Deborah Weiss, Compliance Manager. LPA discussed an incident reported to Community Care Licensing on July 7, 2022, concerning an exchange between staff and clients in care, on July 01, 2022. On this day, two staff and one client were interviewed. LPA received face sheets for selected clients/staff, and a copy of the LIC 500, dated 06/01/2022. LPA conducted a brief facility tour; no deficiencies were cited on today's date. Exit interview conducted and a copy of this report was emailed to the Deborah Weiss, Compliance Manager.

visit_type: Case Management

met_with: Deborah Weiss, Compliance Manager


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA), Jessica Caplinger, conducted an unannounced inspection to the facility on 7/27/22 for the purpose of continuing the annual inspection. LPA met with Program Director, Gauri Sanchez, to conduct the inspection. A walk through was conducted of the facility and personnel files were reviewed. LPA conducted six confidential interviews for the purpose of the inspection. Facility was observed with adequate food, medication and unsafe items were locked, and grounds were in good repair. Pool was observed with the appropriate self latching gate and pump system. During record review, staff files were observed lacking documentation for staff training. LPA is providing a Technical Violation regarding Interim Licensing Standard 84065 (h) Personnel Requirements and can be viewed on the attached LIC9102. Exit interview was conducted with Gauri Sanchez and a copy of this form with the appeal rights was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On 10/6/22, Licensing Program Analyst (LPA) Jessica Caplinger, conducted an unannounced inspection to the above facility for the purpose of conducting a Case Management regarding concern brought to LPA's attention during annual inspection interviews that the facility may not be allowing youth to groom properly when needed. LPA met with Gauri Sanchez, Administrator, to discuss the concern. LPA conducted a walk through to observe the facility inside and outside. Facility was observed sanitary and in good repair, the kitchen was stocked with adequate food, fire extinguisher and detectors were in compliance, and the facility does not have weapons. The facility pool was observed with an enclosed fence with a self-latching gate. LPA conducted five confidential interviews and collected documentation regarding facility grooming procedures. No deficiencies were noted during this inspection. Exit interview was conducted with Gauri Sanchez, Administrator, and a final copy of this report was left at the facility.

met_with: Gauri Sanchez, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 5/23/ Licensing Program Analyst (LPA) met with Amara Reddick, Clinical Program Director, for the purpose of a case management inspection due an incident that occurred on 4/28/23 that involved a medication error. LPA interviewed two staff. LPA inspected the facility and observed the facility is a two story home with six clients present and three staff were supervising and three additional staff were on site but not supervising the clients.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Avelina Martinez made an unannounced Annual/Random inspection on March 06, 2025, at 9: AM. During the inspection LPA met with Treahna Franco (Clinical Program Director)who assisted with the inspection. LPA Martinez conducted a walk-through of the facility inside and out with Treahna Franco (Clinical Program Director)on March 06, 2025. In addition, LPA Martinez conducted an inspection in the medication room with Treahna Franco (Clinical Program Director) on March 06, 2025. Facility staff-client ratio at time of inspection 5 children and 8 employees Number of staff interviewed Number of clients interviewed LPA observed # 4 bedrooms, # 3 bathrooms Posting of license: yes. Personal rights: yes; disinfectants/cleaning solutions inaccessible: yes; refrigerator temperature at or below 45 degrees F: Yes; freezer temperature at or below 0 degrees: yes; nonperishable foods one week and fresh perishable foods two days minimum yes; menu present and posted yes; working telephone yes; carbon monoxide detectors: in good repair; smoke detector: in good repair; first aid kit fully stocked: yes; common room available: yes; dining area (enough seating, furniture good condition): yes; medication centrally stored, locked/inaccessible: yes; office (locked and privacy); yes; hot water between 105-120 degree F- Properly labeled if over 125 degree F: yes. Fire Extinguisher: in good repair and maintained-next required inspection July 2025. toilets wash basin, bath and shower fixtures in good repair/no leaks/hot water temperature: yes water temperature measured 105 degrees; soap and -paper towels: yes; laundry facilities: in good repair and weekly laundry schedule available; Bedrooms are furnished and in good repair. Motor Vehicle properly maintained, lights, tires, registration/insurance and working seat belts: maintained and in good repair. facility free of vermin: yes; Cameras: yes- an updated copy of facility sketch was requested, and facility sketch is to reflect camera locations throughout the facility (Provider Information Notice:24-09-CRP). Facility sketch will be emailed to LPA Martinez by: March 13, 2025, by 5: PM. Continued... Disaster and mass casualty plan updated and available: yes; quarterly drills conducted and documented: yes- last documented drill was on 03/06/2025. Disaster preparedness supplies verified: yes (emergency food and water kit: yes) Four staff files were reviewed, and four criminal record clearances were verified. First Aid Certificate: yes; Certified Administrators certificate valid and current: current Job title/qualification verified: yes; Hours required training verified: yes Hours required annual training verified: yes. Number of Clients files reviewed:3; Needs and Services Plan: completed and maintained. Centrally Stored Medication and log reviewed: yes; Psychotropic Medication and log reviewed: yes. LPA Martinez reviewed two medication administration records and medication orders. Complaint Procedures posted for youth Reviewed Yes Based on today's March 06, 2025, annual/random inspection, there were no deficiencies observed. An exit interview was conducted, and a copy of this report was provided to Treahna Franco (Clinical Program Director)


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Avelina Martinez made an unannounced Annual/Random inspection on April 10, 2025, at 9: AM. During the inspection LPA met with Treahna Franco (Clinical Program Director) who assisted with the inspection. During today's inspection, LPA Martinez conducted two children file reviews. The two children files were maintained, and the required documents were obtained. There were no deficiencies cited at this annual inspection. An exit interview was conducted, and a copy of this report was provided to Treahna Franco (Clinical Program Director).


summary: Facility Evaluation

raw_content:
Narrative:
On 4/29/25 at 4:30pm Licensing Program Analyst (LPA), Jean Stidman for the purpose of initiating a case management inspection due to an incident that occurred on 4/23/25 was not reported until 4/25/25. LPA talked to Devorah Weiss, Administrator, by phone. The administrator was informed to ensure all incident reports are submitted according to regulation. No citations were issued related to the case management. A copy of this report was left with Megan Sommers Primary Therapist.

met_with: Megan Sommers Primary Therapist.


summary: Facility Evaluation

raw_content:
Narrative:
On 5/5/25 at 12:00pm Licensing Program Analysts (LPAs), Jean Stidman and Elena Gonzalez-Soto met with Devorah Moskowitz, Administrator at the Regional Office for the purpose of initiating a case management. On 4/30/ Licensing Program Analyst (LPA) Jean Stidman reviewed Guardian for staffs background clearance and association. LPA observed three staff are not associated with the Evolve - Arden Oaks facility but all three staff have a criminal record clearance. No citations given. A copy of this report was given to Devorah Moskowitz, Administrator on this date.

met_with: Devorah Moskowitz, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 7/10/ Licensing Program Analyst (LPA) Jean Stidman conducted an unannounced Case Management Inspection at the facility regarding two incidents. One incident occurred on 6/8/25 and a separate incident occurred on 7/8/25. LPA observed there were five children and seven staff on site providing client supervision. LPA interviewed two staff and two children. LPA inspected the facility inside and outside. No violations were cited. No further investigation is needed. A copy of this report was left with Ben Connolly, Operations Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 7/24/ Licensing Program Analyst (LPA) Jean Stidman and Licensing Program Manager (LPM) Dara Campos conducted a case management inspection. Upon a review of the facility's program statement dated 10/11/21 the LIC9106 dated 4/22/21 states the facility will not accept developmentally disabled children. Confidential interviews conducted between 4/29/25-7/11/25 with four children, eight staff, and records reviewed of three children's (C2, C5 and C6) Pre-admission Assessments and Master Treatment Plans show the facility admitted children with developmental disability, more specifically Autism Spectrum Disorder between 3/24/25 to 6/23/25. The Welfare and Institutions Code Section 4512(a) defines Autism as a developmental disability. LPA provided a copy of this report to Melissa Gonzalez, Clinical Program Director, on this date.


summary: Facility Evaluation

raw_content:
Narrative:
On 10/6/22, Licensing Program Analyst (LPA) Jessica Caplinger, conducted an unannounced inspection to the above facility for the purpose of conducting a Case Management regarding an incident that occurred on 7/1/22. LPA met with Gauri Sanchez, Administrator, to discuss the incident and review findings from the 7/20/ Case Management conducted regarding the incident. LPA conducted a walk through to observe the facility inside and outside. Current census is 6 youth. Youth and staff were on an outing during the inspection. Facility was observed sanitary and in good repair, the kitchen was stocked with adequate food, fire extinguisher and detectors were in compliance, and the facility does not have weapons. The facility pool was observed with an enclosed fence with a self-latching gate. Based on confidential interviews regarding the above incident, staff violated the youth's personal rights by yelling profanity at youth, making inappropriate comments regarding sexual behavior observed in movies, and touching the youth by patting down during body checks when the facility has a "no touch" policy. Personal Rights standard 84072(d)(11) is cited on the attached 809-D. Exit interview was conducted with Gauri Sanchez, Administrator, where this report, 809, 809-D and Appeal Rights were reviewed, and a final copy of all forms were left at the facility.

met_with: Gauri Sanchez; Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 10/12/ Licensing Program Analyst (LPA) Jean Stidman conducted a Case Management Inspection. On 5/23/ Licensing Program Analyst (LPA) Jean Stidman interviewed Amara Reddick Clinical Program Director who stated the procedure for reporting incident report is the facility sends the incident reports to the compliance officer within 24 hours. Based upon LPA's records reviewed, several incidents have not been reported to Community Care Licensing Division (the Department) within the required time frames. An incident occurred 4/28/23 and was reported to the Department on 5/4/23; an incident occurred on 5/17/23 and was reported on 5/19/23; and an incident occurred on 5/29/23 and was reported on 6/5/23; and an incident occurred on 7/1/23 and was reported on 7/6/23 but the department did not receive a report by Community Care Licensing Division's next business day for any of these incidents. Facility citation violation of California Code of Regulations, Title 22, Division 6, regulation 80061(b) Reporting Requirements. During an inspection on 5/23/ Licensing Program Analyst (LPA) Jean Stidman interviewed Amara Reddick Clinical Program Director who stated they have been the Administrator since December 2022 and Kelsey Shaffer, the former Administrator, is not at the facility. Amara Reddick called Devorah Weiss Compliance Officer who spoke with LPA. Devorah Weiss confirmed Kelsey Shaffer is not physically on the premises. Facility citation violation of California Code of Regulations, Title 22, Division 6, regulation 84064(c) Administrator Qualifications and Duties LPA provided a copy of this report to Amara Reddick, Clinical Program Director, on this date.

met_with: Amara Reddick Clinical Program Director


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
It was reported that the week of April 14, 2024 - April 20, 2024, C2 had been engaging in violent behaviors while at the facility. It was reported C2 hid underneath an unknown client's bed and woke them up by kicking them underneath the bed, had thrown a chair at unknown staff, made threats to harm other clients, and left the facility more than once on unapproved absence. The report also included information that C2 made comments to C1 which caused C1 emotional disturbance; however, facility staff did not report the information to C1's authorized representative. Regarding the allegation that staff did not prevent minor from engaging in inappropriate behaviors, a review of pertinent records revealed C2 had three incidents in April 2024 which involved making threats and attempting to engage in a physical altercation with clients in care. A confidential interview revealed C2 was taking medication that led to dysregulation and property damage. The confidential interview revealed C2 struggled to get along with peers, which would lead to confrontations, but did not reveal any physical incidents. A review of pertinent records and a confidential interview did not reveal any incidents in which C2 was found under a client's bed, however, there was a reported incident in which C1 left the facility on unauthorized leave after running out of the door. Regarding the allegation that facility staff did not prevent minor from making inappropriate comments towards other minors, a review of pertinent records revealed C2 made comments of wanting to harm clients in care which resulted in confrontation between clients. The review of pertinent records and a confidential interview both revealed staff engaged by intervening and deescalated the situations by creating separation between clients. A review of pertinent records and a confidential interview did not reveal any incidents in which C2 made comments to C1 which caused C1 emotional disturbance. Regarding the allegation that staff did not notify minor's parent of incidents, a review of pertinent records and a confidential interview revealed no incidents in which C2 was involved. The review of pertinent records revealed incidents that were reported regarding C1 involving other minors in care. A confidential interview revealed the facility provides notification to all necessary parties within 24 hours if involving law enforcement. Additionally, the confidential interview revealed that staff did not provide notification to authorized representatives of clients who were not involved in an incident, due to confidentiality reasons, but clients would sometimes share with others what happened in the facility, even if notification was not required. Continued... Based on interviews and review of records, the allegations that staff did not prevent minor from engaging in inappropriate behaviors, staff did not prevent minor from making inappropriate comments towards other minors, and staff did not notify minor's parent of incidents are all unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove the alleged allegations occurred. An exit interview was conducted with Tamara Fleck-Myers, Administrator. A copy of this report and appeal rights were provided and reviewed with Tamara Fleck-Myers, whose signature on this report confirms receipt of these documents.

Investigation Findings:
13On April 14, 2025 at 1: PM, Licensing Program Analyst (LPA) Abby Saeteurn accompanied by LPA Lisa Bernabe, made an unannounced visit to Evolve Treatment Center- Cole Ranch and met with Tamara Fleck-Meyers, Administrator to deliver findings to the above stated allegations. LPA Carol Anderson initiated a complaint inspection at the facility on April 25, 2024, at 12: PM and no deficiencies were observed. During the investigation, LPA Saeteurn interviewed staff (S1) and reviewed pertinent records. LPA Saeteurn also attempted to complete interviews with Clients (C1-C3), Authorized Representatives (AR1 - AR3) and Staff (S2-S4); despite multiple attempts, the parties were unable to be reached. On April 18, 2024, Community Care Licensing (CCL) received a complaint alleging staff did not prevent a minor from engaging in inappropriate behaviors, did not prevent a minor from making inappropriate comments towards other minors, and did not notify minor's parent of incidents. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Abby Saeteurn LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: EVOLVE TREATMENT CENTERS - COLE RANCH (ENCINITAS)FACILITY NUMBER: VISIT DATE: 04/14/2025

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

met_with: Tamara Fleck-Myers, Administrator

complaint_status: unsubstantiated


facility_name: EVOLVE TREATMENT CENTERS - COLE RANCH (ENCINITAS)

summary: Facility Evaluation

raw_content:
Narrative:
On February 3, 2022 at 10: AM, Licensing Program Analyst (LPA) Carol Anderson conducted an announced pre-licensing inspection. LPA met with Compliance Officer Devorah Weiss, Clinical Program Director Tamara Fleck-Myers and Milieu Manager Kelsey Palassou. The facility is a five bedroom, five bathroom single family, two story home. The applicant is applying for a group home with the capacity of six ambulatory clients' ages 12-17 years old. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. Living room, dining room, art room, school room and group therapy room for clients' to utilized. Telephones are installed on the walls throughout the facility for clients. There is adequate indoor and outdoor activity space. Medication will be locked in the locked cabinet in the laundry room. The facility smoke detectors and carbon monoxide detectors tested and were observed to be in working order; fire extinguisher is properly charged and serviced. The facility has a fully equipped first aid kit and first aid manual. The facility has cameras in the common areas. The applicants stated there were no weapons in the facility. Disinfectants and cleaning solutions were stored locked in closet in the laundry room. Sharp knives were made inaccessible and stored in a locked cabinet in staff's office. The staff and client files will be maintained electronically stored. LPA advised Compliance Officer Devorah Weiss that staff and client files to be accessible to Community Care Licensing (CCL) at any time. The following required forms were posted in the facility: Personal Rights form, and California "See Something Say Something Poster" and Disaster plans were posted throughout the facility. The bedrooms (downstairs) are set up as follows: Bedroom 1: designated for two clients, two twin beds, two dresser drawers, two night stands, closet space and one bathroom. Bedroom 2: designated for two clients, two twin beds, two dresser drawer, two night stands, closet space and one bathroom. Bedroom 3: designated for two clients, two twin beds, two dresser drawers, two night stands and closet space Each room has adequate clean linens, pillows, blankets, comforters, mattress pads, and mattresses. The upstairs are set up as follows: One facility manager's office. One clinical program director's office. Clients will be allowed to make and receive confidential phone calls upstairs in the staff offices. The Backyard is set up as follows: Facility has a pool which is appropriately fenced and secured with a mesh fence. The enclosure was measured to five-foot-high feet, self-closing access gate that opened away from the pool, with a self-latching device. The backyard is fully fenced and there is a covered patio with patio furniture. Therapy's office is located in the back yard. Storage shed located in the backyard. The applicant has been informed that the address to this facility is available to the public. All special incident reports (SIR's) will be sent via e-mail to: cclpaccr@dss.ca.gov. The reporting requirements were reviewed with the applicant on this date. The applicant was provided with an updated Facility Personnel Report Summary at the time of this visit and understands that once the license is approved, all employees and volunteers shall have an approved criminal record clearance for CCL and be associated to this facility. The fire clearance has been approved. Based on the facility pre-licensing inspection and facility records' review,no deficiencies were noted at time of the inspection Upon managers final review, the license will be provided. An exit interview was conducted, due to printer failure. LPA emailed the Compliance Officer Devorah Weiss the LIC 9099s.

met_with: Devorah Weiss


summary: Facility Evaluation

raw_content:
Narrative:
On February 27, 2023, at 10: AM, Licensing Program Analyst (LPA) Carol Anderson conducted an unannounced annual/post-licensing inspection. LPA met with Clinical Program Director/Facility Group Home Admin. Tamara Fleck-Myers. LPA interviewed two clients and two staff. LPA reviewed six clients and five staff files. All the required staff and client's documentation was in the file. The facility is a five bedroom single-family, two story home group home currently six ambulatory clients. All the bedrooms had appropriate fixture, furnish and equipment. LPA observed adequate non-perishable and perishable foods in the kitchen area. LPA observed the personal chef preparing the food for today. At 10:44AM, LPA toured the interior and exterior of the physical plant which included the following checks: Facility grounds are clean and free of debris. Living room, dining room, art room, school room and group therapy room for clients. Medication was locked in the locked cabinet in the laundry room in the nursing's office. The facility smoke detectors and carbon monoxide detectors tested and were observed to be in working order; fire extinguisher is properly charged and serviced. The facility has a fully equipped first aid kit and first aid manual. The facility has cameras in the common areas. Disinfectants and cleaning solutions were stored locked in closet in the laundry room. Sharp knives were made inaccessible and stored in a locked cabinet in staff's office. LPA measured the hot water in the bathroom using a thermometer and observed the water temperature at 110 degrees. LPA reviewed staff and clients records via team with Compliance Officer Devorah Weiss and Clinical Program Director Tamara Fleck-Myers. LPA observed posted forms in the facility: Personal Rights forms, and California "See Something Say Something Poster" and Disaster plans were posted throughout the facility. LPA observed in the pool area appropriately fenced and secured with a mesh fence. The enclosure was measured to five-foot-high feet, self-closing access gate that opened away from the pool, with a self-latching device. Also, the backyard is fully fenced and there is a covered patio with patio furniture. Therapy's office is in the back yard and storage shed located in the backyard. Based on interviews and observations made during the inspection, no deficiencies were observed during today's visit. An exit interview was conducted, a copy of this report was given to Clinical Program Director/Facility Group Home Admin. Tamara Fleck-Myers.

met_with: Tamara Fleck-Myers


summary: Facility Evaluation

raw_content:
Narrative:
On December 12, 2025, at 10: AM, Licensing Program Analyst (LPA) Jacob Salem conducted an unannounced visit to the above facility for the purpose of conducting an annual inspection and met with Tamara Fleck-Meyers, Administrator. LPA conducted two client and two staff interviews. LPA initiated an inspection of the facility's physical plant. LPA reviewed one client file (C1). Due to time constraints, the annual is being extended to complete file reviews and the physical plant inspection. An exit interview was conducted and a signed copy of this report was provided to Tamara Fleck-Myers, Administrator .


raw_content:
Narrative:
evidence. Based on confidential interviews and records reviewed that facility staff did not adequately supervise C1 and C2 resulting in C1 and C2 overdosing at the facility which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Tamara Fleck-Meyers. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights will be emailed to the Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On 10/16/2023, at 11:35 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Tamara Fleck-Meyers, Clinical Director, to discuss the investigative finding for the allegation noted above. LPA Anderson conducted an inspection of the facility on 11/10/2022 and no deficiencies were observed. LPA's Linley and Anderson interviewed three clients (C1-3), one Guardian (BM), and two staff (S1, S3), and were unable to interview three staff (S2, S4, S5), despite multiple attempts to contact them. LPA reviewed the following documents during the investigation: C1 and C2's Admissions Agreements, C1 and C2's Treatment Plan, Shift Notes, Room Checks Log, and Special Incident Reports. On 11/04/2022, Community Care Licensing (CCL) received an allegation that facility staff did not adequately supervise C1 and C2 resulting in C1 and C2 overdosing at the facility. Confidential interviews revealed conflicting statements. Confidential interviews did not corroborate the allegation with a preponderance of UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: EVOLVE TREATMENT CENTERS - DOVE SONG (ENCINITAS)FACILITY NUMBER: VISIT DATE: 10/16/2023

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

met_with: Tamara Fleck-Meyers


facility_name: EVOLVE TREATMENT CENTERS - DOVE SONG (ENCINITAS)

raw_content:
Narrative:
...CONTINUED Confidential interviews revealed S7 stated she would adopt C1, and S8 transported C1 to a runaway youth shelter without contacting Child Protective Services. Confidential interviews revealed conflicting statements to whether the comments were made or not, and who transported C1 to the runaway shelter. Based on confidential interviews and records reviewed, the allegations that S7 made inappropriate comments towards C1, S8 engaged in inappropriate interactions with C1, and the facility failed to meet reporting requirements, may or may not have occurred, however, it is not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted with Tamara Fleck-Myers and a signed copy of the report and appeal rights were provided.

Investigation Findings:
13On December 8, 2023 at 9:40AM, Licensing Program Analyst (LPA) Jacob Salem conducted an unannounced complaint inspection at the above facility. LPA Salem met with Tamara Fleck-Myers, Administrator of Evolve Treatment Centers - Dove Song group home (Evolve). The purpose of the inspection was to deliver the findings of the complaint investigation. LPA Salem conducted an inspection of the facility on 10/28/23 and no deficiencies were observed. LPA Salem interviewed one former client (C1), six staff (S1-S6), and three witnesses. LPA Salem was unable to interview staff #7 (S7) and staff #8 (S8), even after multiple attempts. During the investigation, LPA Salem reviewed C1's Master Treatment Plan signed 4/11/23, as well as an email sent from S5 to all Evolve staff on 6/20/23. On 6/29/23, Community Care Licensing (CCL) received allegations that staff made inappropriate comments towards a minor, staff engaged in inappropriate interactions with a minor, and the facility failed to meet reporting requirements. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Evolve Treatment Centers - Dove Song (Encinitas)facility Number: Visit Date: 12/08/ Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32...CONTINUED Confidential interviews revealed S7 stated she would adopt C1, and S8 transported C1 to a runaway youth shelter without contacting Child Protective Services. Confidential interviews revealed conflicting statements to whether the comments were made or not, and who transported C1 to the runaway shelter. Based on confidential interviews and records reviewed, the allegations that S7 made inappropriate comments towards C1, S8 engaged in inappropriate interactions with C1, and the facility failed to meet reporting requirements, may or may not have occurred, however, it is not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted with Tamara Fleck-Myers and a signed copy of the report and appeal rights were provided. SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 2 of 2

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


raw_content:
Narrative:
It was reported that the facility had clients in care that would leave unauthorized, and there were clients who required one on one supervision, and it was unclear if staff were present at the facility to provide supervision. During the investigation confidential interviews revealed the facility had staff present daily that would provide clients with care and supervision. Confidential interview revealed there were two clients who left the facility unauthorized during the reported time, and a review of pertinent facility records confirmed their unauthorized leave. The review of records revealed that on both occasions, staff were unable to utilize prior de-escalation techniques due to attending to other clients, however, confidential interviews did not yield evidence to confirm lack of supervision was a reason for the clients' unauthorized leave. Based on interviews and record review, the allegation staff are not providing the minors adequate supervision is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to provide the alleged violation occurred. An exit interview was conducted with Rachel Henry. A copy if this report and appeal rights were provided and reviewed with Rachel Henry, Operations Manager, whose signatures on this report confirms receipt of these documents.

Investigation Findings:
13On March 25, 2025 at 1: PM, Licensing Program Analyst (LPA) Abby Saeteurn, made an unannounced visit to Evolve Treatment Center - Dove Song and met with Rachel Henry, Operations Manager to deliver findings to the above stated allegation. LPA Carol Anderson initiated a complaint inspection at the facility on April 9, 2024, at 10: AM and no deficiencies were observed. During the investigation, LPA Saeteurn interviewed staff (S1), client (C1), Authorized Representatives (AR1-AR2), reviewed pertinent facility records and attempted to complete an interview with client (C2). On April 05, 2024, Community Care Licensing (CCL) received a complaint alleging staff are not providing the minors adequate supervision. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Abby Saeteurn LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: EVOLVE TREATMENT CENTERS - DOVE SONG (ENCINITAS)FACILITY NUMBER: VISIT DATE: 03/25/2025

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

met_with: Rachel Henry, Operational Manager


summary: Facility Evaluation

raw_content:
Narrative:
On March 16, 2021 at 11:00AM, Licensing Program Analyst (LPA) Carol Anderson conducted an announced pre-licensing inspection. LPA met with Compliance Officer Devorah Weiss. The facility is a six bedroom, five bathroom single family, two story home. The applicant is applying for a group home with the capacity of six ambulatory clients' ages 12-17 years old. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. Living room, dining room, art room, school room and group therapy room for clients' to utilized. Clients will use a cordless telephone to make and receive confidential telephone calls. The hot water temperature reading at 112 degrees. There is adequate indoor and outdoor activity space. Medication will be locked in the locked cabinet in the laundry room. The facility smoke detectors and carbon monoxide detectors tested and were observed to be in working order; fire extinguisher is properly charged and serviced. The facility has a fully equipped first aid kit and first aid manual. The facility has cameras in the common areas. The applicants stated there were no weapons in the facility. Disinfectants and cleaning solutions will be stored locked in cabinet in the laundry room. Sharp knives will be stored in a locked cabinet in staff's office. The staff and client files will be maintained on the computer database via Microsoft Cloud. LPA advised Compliance Officer Devorah Weiss that staff and client files to be accessible to Community Care Licensing (CCL) at any time. The following required forms were posted in the facility: Personal Rights form, and California "See Something Say Something Poster" and Disaster plans were posted throughout the facility. The downstairs area is set up as follows: Living room, dining room, kitchen area, art room school room, therapy room, laundry room and garage with exercise equipment. One clinical program director's office with a bathroom. The upstairs are set up as follows: One staff's office with bathroom. Bedroom 1: designated for two clients, two twin beds, two dresser drawers, two night stands, closet space and one bathroom. Bedroom 2: designated for one client, one twin bed, one dresser drawer, one night stand, closet space. Bedroom 3: designated for one client, one twin bed, one dresser drawer, one night stand and closet space with one bathroom. Bedroom 4: designated for two clients, two twin beds, two dresser drawers, two night stands, closet space Each room has adequate clean linens, pillows, blankets, comforters, mattress pads, and mattresses. The Backyard is set up as follows: Facility has a pool which is appropriately fenced and secured with an iron wrought fence. The enclosure was measured to five-foot-high feet, no self-closing access gate that opened away from the pool, with a self-latching device. Compliance Officer Devorah Weiss stated that the self-latching device will be installed on the pool gate by March 30.2022. Also, Compliance Officer Devorah Weiss stated the facility not be accepting any clients until April, 2022. The backyard is fully fenced and there is a covered patio with patio furniture. The applicant has been informed that the address to this facility is available to the public. All special incident reports (SIR's) will be sent via e-mail to: cclpaccr@dss.ca.gov. The reporting requirements were reviewed with the applicant on this date. The applicant was provided with an updated Facility Personnel Report Summary at the time of this visit and understands that once the license is approved, all employees and volunteers shall have an approved criminal record clearance for CCL and be associated to this facility. The fire clearance has been approved. Based on the facility pre-licensing inspection, the facility is ready for licensure.


summary: Facility Evaluation

raw_content:
Narrative:
On March 28, 2023, at 10:35AM, Licensing Program Analyst (LPA) Carol Anderson conducted an unannounced annual required inspection. LPA met with Clinical Program Director Antoinette Mastronardi. Currently in placement six clients. At 10:45AM, LPA inspected the interior and exterior of the facility: living room, dining room, art room, school room and group therapy room. Bedrooms are furnished and have adequate shelf and closet space for client's personal belongings. Clients' individual beds were observed with appropriate clean linens, pillows, comforters and mattresses are in good repair. The hot water temperature reading at 115 degrees. There is adequate indoor and outdoor activity space. Medications were locked in the locked cabinet in the laundry room. Disinfectants and cleaning solutions locked in the hall closet. The facility smoke detectors and carbon monoxide detectors were tested and properly working, fire extinguisher is properly charged. The facility has a fully equipped first aid kit and first aid manual. The facility has cameras in the common areas. Sharp knives were stored in a locked cabinet in staff's office, facility license, emergency disaster plan, facility sketch, and personal rights were posted. Clients are allowed to make and receive confidential calls from family and friends. There were no weapons in the facility, LPA reviewed staff and client files via Zoom with Compliance Officer Devorah Weiss. A review of Guardian fingerprinted System on March 28, 2023 indicates that staff associated to above facility had DOJ, FBI and child abuse index check clearances. Facility has a pool which is appropriately fenced and secured with an iron wrought fence. The enclosure was measured to five-foot-high feet, with padlock on the pool gate. The backyard is fully fenced, covered patio with patio furniture. Based on the facility inspection and file reviews conducted, there are no deficiencies found at this time. A exit interview was conducted. A copy of this report was reviewed and given to Clinical Program Director Antoinette Mastronardi

met_with: Antoinette Mastronardi


summary: Facility Evaluation

raw_content:
Narrative:
On November 14,2023, at 2:14PM, Licensing Program Analyst (LPA) Carol Anderson conducted a Case Management Inspection to the above facility to interview staff that work at Evolve Treatment Centers-Cole Ranch regarding a complaint investigation at Evolve Treatment Centers-Cole Ranch. LPA met with Brandon Spencer, Mileu Trainer. LPA conducted three confidential interviews with staff.

met_with: Brandon Spencer


summary: Facility Evaluation

raw_content:
Narrative:
On March 12, 2024, at 10:15AM, Licensing Program Analyst (LPA) Carol Anderson conducted an unannounced annual/required inspection. LPA met with to Interim Associate Clinical Director Ellen Urtecho. LPA interviewed two staff. Clients were unavailable to be interviewed. . LPA inspected the interior and exterior of the facility: living room, dining room, art room, school room and group therapy room. Bedrooms are furnished and have adequate shelf and closet space for client's personal belongings. Clients' individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses are in good repair. The hot water temperature reading at 117 degrees. There is adequate indoor and outdoor activity space. Medications were locked in the locked cabinet in the laundry room. Disinfectants and cleaning solutions locked in the hall closet. The facility smoke detectors and carbon monoxide detectors were tested and properly working, fire extinguisher is properly charged. The facility has a fully equipped first aid kit and first aid manual. The facility has cameras in the common areas. Sharp knives were stored in a locked cabinet in staff's office, facility license, emergency disaster plan, facility sketch, and personal rights were posted. There are no weapons in the facility. LPA reviewed staff and client files via Zoom with Peoples Operation Generalist, HR. Dina Letitchevski. All the necessary forms were in file. A review of Guardian fingerprinted System on March 12, 2024, indicates that staff associated to above facility had DOJ, FBI, and child abuse index check clearances. Per Devorah Weiss, Compliance Officer annual fees to be paid today (3/12/24) Facility has a pool which is appropriately fenced and secured with an iron wrought fence. The enclosure was measured to five-foot-high feet, with padlock on the pool gate. The backyard is fully fenced, covered patio with patio furniture. Based on the facility inspection and file reviews conducted, there are no deficiencies found at this time. An exit interview was conducted. A copy of this report was reviewed and given to Interim Associate Clinical Director Ellen Urtecho

met_with: Ellen Urtecho


summary: Facility Evaluation

raw_content:
Narrative:
On April 10, 2026, at 10: AM, Licensing Program Analyst (LPA) Jacob Salem conducted an unannounced visit to the above facility for the purpose of conducting an annual inspection and met with Rachel Henry, Operations Manager. LPA initiated an inspection of the facility's physical plant. LPA reviewed the facility's operations and disaster preparedness plan. LPA conducted two client and two staff interviews. Due to time constraints, the annual is being extended to complete file reviews and the physical plant inspection. An exit interview was conducted and a signed copy of this report was provided to Rachel Henry, Operations Manager.

met_with: Rachel Henry, Operations Manager


summary: Facility Evaluation

raw_content:
Narrative:
On April 17, 2026 at 9: AM, Licensing Program Analyst (LPA) Jacob Salem arrived to the facility and met with Tamara Fleck-Myers, Administrator. The purpose of this Case Management inspection is to conduct an annual continuation from 4/10/2026. LPA reviewed five client files (C1-C5), which are on a secure electronic system. The client files reviewed contain required information and records, including needs and services plans, personal rights and facility policy acknowledgements, and medication logs. During the review, LPA observed that written parental consent for two psychotropic medications was missing for two clients (C1 and C3) and attempts had not been made by the facility to obtain written parental consent. It was also observed that clients (C1-C5) in care did not have a TB test prior to or within a month of admission or documented client refusals. LPA inspected the facility's physical plant, including personal rights postings, health-related services, buildings and grounds, food services, telephones, indoor and outdoor activity space, and furniture, fixtures, equipment and supplies. The home is clean, in good repair, and free from observable risks to clients' health, safety, and personal rights. The home is a two story building with four client bedrooms and four client bathrooms which are set up as follows: Bedroom #1 has two twin beds and sleeps two clients, bedroom #2 has two twin beds and sleeps two clients, bedroom #3 has one twin bed and sleeps one client, and bedroom #4 has one twin bed and sleeps one client. Continued... ...CONTINUED All client bedrooms except for one have attached bathrooms and showers. There is a kitchen and living room, multiple vitiation room areas, staff office and storage closets, and backyard/patio with pool and recreation equipment in the garage. LPA reviewed five staff files (S1-S5), which contained the required information, including the background information and health screenings, criminal record clearances, staff qualifications, and training requirements. Based on observations during inspection, the facility is being issued a citation (see LIC 809D) for violating California Code of Regulations, Title 22, section 84070(b)(15) Client Records and 80069(c)(1) Client Medical Assessments. An exit interview was conducted with Tamara Fleck-Myers, Administrator and a signed copy of this report, LIC 811, and appeal rights was provided.


facility_name: EVOLVE TREATMENT CENTERS - LA MESA

summary: Facility Evaluation

raw_content:
Narrative:
On June 10, 2024, at 11: AM, Licensing Program Analyst (LPA) Carol Anderson conducted an announced pre-licensing inspection with Compliance Officer Devorah Weiss and Program Director Margaret Gutgsell.The facility is a seven bedrooms, four-five-bathrooms single-family, two story home. The applicant is applying for a group home with the capacity of six ambulatory clients ages 12-17 years old. The facility downstairs is set up as follows: A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. Kitchen, school room, nurse's office, program office, milieu room. Telephones are installed on the walls throughout the facility for clients. There is adequate indoor and outdoor activity space. Medication will be locked in the locked cabinet nurse's office. The facility smoke detectors and carbon monoxide detectors tested and were observed to be in working order; fire extinguisher is properly charged and serviced. Disinfectants and cleaning solutions will be stored locked in closet in the hallway. Sharp knives will be stored in locked cabinet in staff's office. The facility has a fully equipped first aid kit and first aid manual. The hot water temperature was measured at 113. There are cameras in the common areas. Per Compliance Officer Devorah Weiss stated that there were no weapons in the facility. The staff and client files will be kept electronically with Human Resources and which in Los Angeles. LPA advised Compliance Officer Devorah Weiss that staff and client files to be accessible to Community Care Licensing (CCL) at any time. The Backyard is set up as follows: The facility has a pool which is appropriately fenced and secured with a mesh fence. The enclosure was measured to five-foot-high feet, self-closing access gate that opened away from the pool, with a self-latching device. Two therapy office and one staff office are in the back yard. Storage shed located in the backyard. The applicant has been informed that the address to this facility is available to the public. All special incident reports (SIR's) will be sent via e-mail to: cclpaccr@dss.ca.gov. The reporting requirements were reviewed with the applicant on this date. The applicant was provided with an updated Facility Personnel Report Summary at the time of this visit and understands that once the license is approved, all employees and volunteers shall have an approved criminal record clearance for CCL and be associated to this facility. The fire clearance has been approved. Based on the facility pre-licensing inspection and facility records' review, no deficiencies were noted at time of the inspection. Upon managers final review, the license will be provided. An exit interview was conducted, and a copy of this report was left with Compliance Officer Devorah Weiss


summary: Facility Evaluation

raw_content:
Narrative:
On April 18, 2025 at 9: PM, Licensing Program Analysts (LPAs) Jacob Salem and Lisa Bernabe conducted an unannounced visit to the above facility for the purpose of conducting a post-licensing inspection and met with Dajah Lockett, Manager. LPAs conducted staff and client interviews. LPAs reviewed two client files (C1 and C2). Due to time constraints, the annual is being extended to conduct an additional files reviews and physical inspection. An exit interview was conducted and a signed copy of this report was provided to Dajah Lockett, Manager.

met_with: Dajah Lockett, Manager


facility_name: EVOLVE TREATMENT CENTERS, CALABASAS

summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
It was noted in the facility's program statement that staff are to ensure that the clients keep the bathroom door ajar when using the restroom. Minors are not allowed hygiene items Confidential interviews revealed conflicting statements regarding whether clients are not allowed hygiene items. Interview information revealed that clients are given hygiene boxes that contain toothbrush, toothpaste, soap, shampoo, conditioner, deodorant, lotion, and other products which are available when the clients request them. Confidential interviews stated that clients are provided razors to shave but under the supervision of staff. It was noted in the facility's program statement that staff can withhold hygiene items from clients and provide them upon the request of the client depending on the client's level. Staff open minors' personal mail Confidential interviews indicated that the therapist keep all mail, unopened until the clients' next one-on-one therapy sessions. It was also disclosed that clients are required to open their letters in front of staff to make sure there is no contraband and confirmed that staff do not open clients' mails. Other confidential witnesses were unaware of the mail process and could not speak to this allegation. Some confidential witnesses stated that the clients open their personal mail in front of staff, and others stated the clients' primary therapists open their mail for them to screen letters and packages for contraband or triggering content. Minors not receiving an allowance Confidential interviews revealed that none of the minors received allowance during their residency at this Group Home. Per Facility Representative(s), the purpose of not providing clients allowance was to reduce the ability of incoming contraband. Facility Representative(s) also indicated that clients did not have a need for allowance as the Program provide the necessities for clients. Confidential interviews revealed that although allowance is not given, the facility provide for clients' needs which includes items while on outings. Minors are denied access to personal property Confidential interviews revealed that clients are denied personal property based on scheduled activities and for their safety. Some personal items are stored locked in a cabinet and made available to clients upon request. Per Facility Representative(s) some items such as razors require direct supervision, while other personal items (such as books, clothing and etc.) are not allowed to be possessed by clients because the item could trigger client's behaviors or jeopardize their safety while in treatment Based on the confidential interviews, observation, and record review, it has been determined that although the allegations that minors are not treated with dignity; minors are not allowed hygiene items; staff open minors' personal mail, minors not receiving an allowance, and minors being denied access to personal belongings may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. The program statement has been updated to ensure that the clients' needs will be met based on their individual assessments per Title Group Home Regulations. An exit interview was conducted, appeal rights discussed, and a copy of this report was provided to Devorah Weiss.

Investigation Findings:
13On 12/02/2021 at 10: AM, Licensing Program Analyst (LPA) Miguel Gomez arrived at the facility to deliver the findings of a complaint investigation. LPA Gomez met with Administrator, Devorah Weiss and discussed the investigative findings. On June 7, 2021, the Department received a complaint alleging minors are not treated with dignity; minors are not allowed hygiene items; staff open minors' personal mail; minors are not receiving an allowance; minors are being denied access to personal property. Confidential interviews were conducted with 3 staff and 5 of 6 clients. Facility's Program Statement, Plan of Operation, Parent Handbook and Training Manual were reviewed. The following information was obtained during the course of the investigation: Minors are not treated with dignity Confidential interviews revealed conflicting statements that clients must leave the bathroom door ajar while using the restroom. Some confidential interviews reported that the clients did not have to leave the door open while using the restroom and other interviews stated that clients must leave the bathroom door ajar while using the restroom. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Miguel A Gomez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: EVOLVE TREATMENT CENTERS, CALABASASFACILITY NUMBER: VISIT DATE: 12/02/2021


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Olivia Rosas made an announced inspection to the Evolve Treatment, Calabasas on 12/16/21 at 9:00am for the purpose of conducting Annual Inspection. The Evolve Treatment, Calabasas is a therapeutic treatment program that's designed to accept "Private Placement's" for a length of 30 - 45 days and is licensed to provide care supervision for six (6) youths, ages 12-17 years; ambulatory only. Individuals mention in this report are identify on the Confidential Names List (LIC811) dated 12/16/21. On August, 5, 2021 the Department received a Unusual Incident/Injury Report (LIC624) reporting that several employees tasted positive for COVID and due to various unvaccinated employees needing to quarantine per Cal-OSHA guidelines, this facility did not have enough staff to continue serving clients. The clients that were in placement one (1) was discharged and two (2) clients were transferred to Evolve Agoura with the full permission and acquiescence of their caregivers for continuing of care. Due to the lack of staff and not having a administrator the Evolve Treatment, Calabasas will be closed till further notice. Upon the facility obtaining new staff, and administrator the facility will notify the Department. LPA Rosas was not able to complete Annual inspection due to facility not being in operation. LPA Rosas discussed with and advised when the facility reopens, if any changes or modifications to the program or facility physical plant need to be submitted to the Department for review and approval before implementing the new changes or reopening. There were no deficiencies observed or cited at this time. Exit interview was conducted with S1 and a copy of this report was left at the facility.

met_with: Staff#1 (S1)


summary: Facility Evaluation

raw_content:
Narrative:
On 09/08/2022 at 11: AM, Licensing Program Analysts (LPA), Olivia Rosas made an unannounced visit to Evolve Treatment Centers, Calabasas for the purpose of conducting a Case Management Inspection to gather additional information regarding the Unusual Incident/Injury Report (SIR) dated 08/25/2022. LPA Rosas and Staff#1 (S1) discussed the details SIR (See confidential name list LIC811 dated 09/08/22). Temperature and health checks are conducted at the entrance in the sign-in area. On 08/24/22 at approximately 3:30pm Client#1 (C1) was taken to Emergency Room due not eating for three (3) days and refusing to eat anything. C1 reported, not waiting to eat, and was taken to be assessed. C1 was medically assessed and medically clear to return to treatment. On 08/30/022, C1 faint during beach outing. C1 was taken to Urgent Care and completed lab work and vital signs. C1 was assessed by Urgent Care and prescribed medication. Based on the interviews conducted and documentation gather no further information is needed. LPA Rosas interviewed C1 and obtained discharge summaries of Urgent Care and Emergency Room visits. CCLD has determined that there has been no violation in the SIR. LPA observed adequate perishable/nonperishable food supplies. Facility has Administrative Facility Waiver on file. A review of Facility's Personnel Report Summary on 09/08/2022 indicates that all personnel have criminal record clearance has obtain the necessary clearances with DOJ, FBI, and Child Abuse Response. There were no deficiencies observed or cited at this time. Exit interview was conducted with S1 and a copy of this report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On 09/08/2022 at 11: AM, Licensing Program Analysts (LPA), Olivia Rosas made an unannounced visit to Evolve Treatment Centers, Calabasas for the purpose of conducting a Case Management Inspection to gather additional information regarding Unusual Incident/Injury Report (SIR) dated 08/05/2021. LPA Rosas and Staff#1 (S1) discussed the details SIR (See confidential name list LIC811 dated 09/08/22). On 08/05/2021 the Department received an Unusual Incident/Injury Report (LIC624) reporting that several employees tested positive for COVID and due to various unvaccinated employees needing to quarantine per Cal-OSHA guidelines, this facility did not have enough staff to continue serving clients. On 07/21/22, LPA Rosas received email by Devorah Weiss, Compliance Officer informing the Department that Evolve Treatment Centers, Calabasas will reopen. LPA Rosas received a copy of LIC500. On 09/08/2022, received copy of LIC500 dated 07/13/2022 which showed facility's staffing ratio in compliance. LPA observed adequate perishable/nonperishable food supplies. Based on the interviews conducted and documentation gather no further information is needed. CCLD has determined that there has been no violation in the SIR. Facility has Administrative Facility Waiver on file. A review of Facility's Personnel Report Summary on 09/08/2022 indicates that all personnel have criminal record clearance has obtain the necessary clearances with DOJ, FBI, and Child Abuse Response. There were no deficiencies observed or cited at this time. Exit interview was conducted with S1 and a copy of this report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On December 12, 2023 at 9:37am, Licensing Program Analyst (LPA) Christine Wilson made an announced inspection to the Evolve Treatment, Calabasas for the purpose of conducting a 2-Year Annual Inspection. The Evolve Treatment, Calabasas is a therapeutic treatment program that's designed to accept "Private Placement's" for a length of 30 - 45 days and is licensed to provide care supervision for six (6) youths, ages 12-17 years; ambulatory only. There is a swimming pool which meets licensing regulations. There is a camera and Naloxone waiver on file. This is a two-story facility located at Woodbluff Road in Monte Nido California. LPA Wilson was greeted by staff (S1) who allowed entrance into the facility. At 9:59am, LPA Wilson was greeted by the Operations Manager (OM) who provided LPA with a tour of the facility. Individuals mentioned in this report are identified on the Confidential Names List [see LIC811 dated 12/12/2023.] LPA Wilson observed the second story: There are 7 smoke detectors 2 carbon monoxide detectors. Thermostat 63 degrees. Water temperature averaged between 100-105 degrees. Staff Office 1: This large area has three (3) desks for Operations Manager, Nurse and staff use. There is a full bathroom with large tub, sink and toilet. The sharps log is kept here and filled out by chef staff. In the storage area, there are client files over 5 years additional hygiene supplies and emergency supplies, bottled water, emergency and first aid kits, fire extinguishers and smoke alarm. All fire extinguishers were inspected in November of 2023. Postings observed by LPA were, Facility license, staff contact information. program schedule, hot line emergency numbers Covid information, waiver on file, facility sketch, evacuation plan, LIC610C, and weekly drills posted on calendar. Accreditation is current (CARF) Bedroom Is unoccupied. There is a smoke alarm, twin bed, closet and two (2) cabinets. Bedroom 2 is occupied by (C3). There is a smoke alarm, two (2) twin beds, closet and two (2) cabinets. (continued on 809C page 2) Page Hallway closet with clean bed linens Bedroom 3 is occupied by (C1). There is a smoke alarm, two (2) twin beds, closet and two (2) cabinets. There are cabinets with clean bathroom towels. Bedroom 4: is occupied by (C2)There is a smoke alarm, two (2) twin beds, closet and two (2) cabinets. There are locked hygeine products for each client in client boxes, telephone and books LPA Wilson observed the first story: 10:03am Education Area: Has three (3) desks and round table and six (6) chairs Group Room Area: For group theraputic services Office 2: Clinical Directors Office has a smoke alarm Office 3: Therapist Office has one (1) on suite bathroom and smoke alarm Supply Closet: contains cleaning supplies and is locked. Client Bathroom: There is a client restroom with sink and toilet. 11:00am Garage: has gym equipment table for crafts , closet with water heater and fire extinguisher telephone Outdoor Area: Clean and free of debris and hazards. Therapists Office: has one desk, couch and smoke detector and separate heating/cooling HVAC Facility Vehicle: Toyota Sienna Current vehicle registration and insurance with Ace Company and Property and Casualty dated to expire on 12/20/2023. There is a 5ft perimeter fence. There are outdoor couches (3) for 8 persons and table with 6 chairs, pool equipment in storage box grill pool key in lock box 11:12am Laundry Room: medications stored here PRN kept in a locked cabinet individual packets controlled medications are double locked. There is a medication dispensary room with nursing, school and art supplies, fire extinguisher and personal cubbies. Living room: This is a large space with furniture for six (6) persons, TV Fireplace unused and decorated for Christmas (continued on 809C page 3) Page Kitchen: Table with six (6) chairs Cooking island, telephone, covered trashcans. Refrigerator is set at 40 degrees.Pantry has 2 weeks non perishable food and first aid kit. There is a sink, stove with six (6) burners and grill, Instapot, toaster, two (2) microwave ovens and dishwasher all in good repair. Client refrigerator with snacks available and fresh fruit on top. LPA Wilson reviewed following during the inspection: LPA Wilson requested the following forms for review, Register of Youth (LIC 9020), which was created during the time of the inspection, Personnel Report (LIC 500), Emergency Disaster Plan (LIC610C), Emergency Intervention Plan, vehicles registration and auto insurance. In addition, written menus, staff weekly schedule. Current Census is (3) residents, Staff Records Review: LPA ensured Administrator Certificate was current. LPA reviewed the Personnel Report (LIC 500) and confirmed that Direct Care Staff Ratio present for the three (3) clients in placement. LPA confirmed that all staff have required criminal record clearance. DOJ, FBI and Child Abuse Response, which meet qualification. LPA Wilson was able to complete three (3) staff file reviews (S1, S5, FA), one (1) client file review (C2), one (1) staff interview (OM) and one (1) client interview (C2) A review of Facility's Personnel Report Summary on 12/11/2023 indicates that all personnel have criminal record clearance and have obtained the necessary clearances with DOJ, FBI, and Child Abuse Response. There were no deficiencies observed or cited at this time. Exit interview was conducted with staff (OM) and a copy of this report was emailed to the facility.

met_with: Operations Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 09/19/2024 at 09:59 am, Licensing Program Analyst (LPA) Christine Wilson made and unannounced visit to the above listed facility in order to conduct a case management incident inspection, regarding SIR dated 09/01/24. During the course of the incident investigation, it was revealed that on 9/1/24 the youth (C1) was encouraged to use an Ice-Dive TIPP skill to help regulate their behaviors. LPA Wilson interviewed clients (C1, C2, C3 and C4) as well as the Operations Manger (OM) Client did do an ice dive. The client had no safety or personal rights concerns. LPA Wilson inspected (2) bathrooms with Maintenance Technician (MT) regarding client concerns over mold, which no mold was observed by LPA. There are no deficiencies at this time. An exit interview was conducted and a copy of this report and appeals rights were discussed and left with licensee Operations Manger (OM) whose signature on this form confirm receipt of these documents.


summary: Facility Evaluation

raw_content:
Narrative:
On November 18, 2024 at 9:27 am, Licensing Program Analyst (LPA) Christine Wilson made an unannounced visit to the above listed facility, in order to conduct a case management incident inspection, regarding SIR dated 11/06/24. During the course of the incident investigation, it was revealed that on 11/06/24; due to the Malibu fires, SoCal power pre-emptively turned off all power in this region. The decision was made to move all clients; six (6) from the Calabasas facility and six (6) from the Agoura facility to the Evolve Aura location in Tarzana, which had three (3) clients in care. The number of clients (12) total; did not return to their homes until 11/08/24 which resulted in the licensee not operating in accordance with the Emergency Disaster Plan terms specified in the Plan of Operation. Further, due to the number of clients (15) total; there was not sufficient accommodations, furnishings and equipment to meet clients needs. A (2) deficiency Type A has been determined at this time. The following deficiencies have been cited. (See LIC 809D) An exit interview was conducted and Plans of Correction was developed and reviewed with the licensee. A copy of this report and appeals rights were discussed and left with licensee. (S1) whose signature on this report confirms receipt.

met_with: Program Director/Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On November 19 2025, at 8: AM. Licensing Program Analyst (LPA), Wendely Moodie-Naranjo and Licensing Program Manager (LPM) Kevin Sauk made an unannounced visit to the above-mentioned facility for the purpose of conducting an annual/random required Inspection visit. Licensing team met with (Valeria Gabrielli, Residential Counselor), who granted access to the facility and together a tour of the facility was conducted. This facility is designed to accept privately placed children and will be licensed to provide care/supervision for six (6) ambulatory only clients, ages 12-17 years. There is a camera waiver on file. This is a two-story house located in a residential area. There are four (4) bedrooms, five (5) bathrooms, a living room, school room, group room, two (2) staff offices, kitchen/dining area, medication/laundry room,and attached converted garage and backyard with a pool. The home is set up as follows: Bedroom #1: Is located upstairs and is occupied by Client # C6. The room is equipped with a twin size bed. There are adequate drawers, closet space, and lighting in the room. Bedroom #2: Is located upstairs and is occupied by Client #C5. The room is equipped with one(1) twin size bed. There are adequate drawers, closet space, and lighting in the room. There is also a bathroom connecting Bedroom #2 and Bedroom #3 however clients can only access the bathroom through one side which is through Bedroom #3. Bedroom #3: Is located upstairs and is occupied by Client #C3 and C4. The room is equipped with two(2) twin size beds. There are adequate drawers, closet space, and lighting in the room. There is also a bathroom connecting Bedroom #3 to Bedroom #2 however clients can only access the bathroom through one side. (Report cont... LIC 809-C pg 2) Bedroom #4: Is located upstairs and is occupied by Client #C1 and C2. The room is equipped with two twin size beds. There are adequate drawers, closet space, and lighting in the room. Bathrooms: There are two (2) bathrooms downstairs and three (3) bathrooms upstairs. All bathrooms were kept locked and required a key for entry. All bathrooms were checked and were in good operating condition.School Room: Is an open area with three desk and three computers used for clients to complete schoolwork. There is also a round table with five (5) chairs in the center. Group Room: There is a private room with eight (8) chairs where clients and therapist meet as a group.Living Room: There are two sofas, small center table, and TV. Furniture seems to be in good conditions. There are also two sofa chairs located to the left once they enter the facility. Staff Offices: Staff Office #1: Is located downstairs to the right once entering the home. There is a desk with desk chair, a sofa, two individual sofa chairs, small center table, a bookshelves, and drawers/cabinets. Staff Office #2: Is located upstairs. There are three desks with a computer, a sofa with two sofa chairs, mini fridge, center table and two lamp tables. There is also a covered fireplace. Therapy Rooms: Is located downstairs and next to the medication/laundry area. There is a desk with desk chair, a sofa, and two individual sofa chairs. Therapy room #2: Is located downstairs but can only be accessed through the outside of the home. There is a desk with desk chair, a sofa, a large sofa chair, and a little table to the side. Kitchen: There is a table with six (6) chairs where clients can sit to eat their meals. There is a stove/oven with six (6) burners and center grill all working at this time. There is a microwave and refrigerator/freezer. The food service in the home is adequate with perishable/nonperishable food supplies. The trash can have a tight lid on it. Medication/laundry room: There is a washer and dryer. Detergents are stored inside the locked cabinets. The medication is kept locked at all times and only staff administering medications have access to the medications. Medication/laundry room is kept locked at all times. Medication Administration Area: Area adjacent to Medication/laundryroom were medication is administer and medication documentation is performed. Garage: The garage can be accessed through the inside of the house and has been converted into a gym/art room. There are several pieces of gym equipment available for client use, and several storage cabinets. There is also a refrigerator/freezer used to store extra food. Backyard: There is an outdoor seating area as well as a table with six (6) chairs. LPA also observed enclosed/fenced pool and the jacuzzi. Report...cont LIC 809-C pg Backyard: There is an outdoor seating area as well as a table with six (6) chairs. LPA also observed enclosed/fenced pool and the jacuzzi. The home has a first aid kit stored inside a cabinet in the kitchen, another one inside the pantry and one in the staff office upstairs. The facility has a total of five(5) fire extinguishers which are all full. Facility is clean, safe, sanitary and in good repair. Passageways, stairways, inclines, ramps and open porches are unobstructed. Swimming pools, hot tubs, spas, or similar bodies of water in facilities serving children are made inaccessible to clients. Disinfectants/cleaning solutions and poisons inaccessible to clients. Temperatures in rooms that clients occupy are maintained between 68 and 85 degrees (F). Hot water temperatures is maintained between 105 and 120 degrees (F). All knives and sharp objects are made inaccessible to the clients in care locked in a security box that is stored inside staff office #2 upstairs. Chef logs out the knives when they are used. All smoke detectors and carbon monoxide are operable. Children in care are always supervised & protected. Facility has non-perishable foods for one week and perishable foods for two days. Medications are locked and accessible only to employees supervising stored medications. Children are not restricted in telephone use except by court order. Children accorded dignity in personal relationships with others in the home. Children live in a safe, healthy, comfortable facility and are treated with respect. Children can contact the licensing agency or foster Care Ombudsperson in confidence without threats or punishments for making complaints. All smoke detectors and carbon monoxide are operable. There is a working telephone line available for clients to use in the kitchen. Per California Code of Regulations, Title Regulations, Division 6, Chapters 1 & 5, the following deficiencies were observed and cited at the time of inspection. (See LIC809-D) Exit interview was conducted and a copy of this report will be emailed to the facility administrator.

met_with: Valeria Gabrielli-Residential Counselor


facility_name: EVOLVE TREATMENT CENTER, DANVILLE

raw_content:
Narrative:
2. Minors are not allowed hygiene items Confidential interviews revealed conflicting statements regarding whether clients are not allowed hygiene items. Interview information revealed that clients are given hygiene boxes that contain toothbrush, toothpaste, soap, shampoo, conditioner, deodorant, lotion, and other products which are available when the clients request them. Confidential interviews stated that clients are provided razors to shave but under the supervision of staff. It was noted in the facility's program statement that staff can withhold hygiene items from clients and provide them upon the request of the client depending on the client's level. 3. Staff open minors' personal mail Confidential interviews indicated that the therapist keep all mail, unopened until the clients' next one-on-one therapy sessions. It was also disclosed that clients are required to open their letters in front of staff to make sure there is no contraband and confirmed that staff do not open clients' mails. Other confidential witnesses were unaware of the mail process and could not speak to this allegation. Some confidential witnesses stated that the clients open their personal mail in front of staff, and others stated the clients' primary therapists open their mail for them to screen letters and packages for contraband or triggering content. 4. Minors not receiving an allowance Confidential interviews revealed that none of the minors received allowance during their residency at this Group Home. Per Facility Representative(s), the purpose of not providing clients allowance was to reduce the ability of incoming contraband. Facility Representative(s) also indicated that clients did not have a need for allowance as the Program provide the necessities for clients. Confidential interviews revealed that although allowance is not given, the facility provide for clients' needs which includes items while on outings. 5. Minors are denied access to personal property Confidential interviews revealed that clients are denied personal property based on scheduled activities and for their safety. Some personal items are stored locked in a cabinet and made available to clients upon request. Per Facility Representative(s) some items such as razors require direct supervision, while other personal items (such as books, clothing and etc.) are not allowed to be possessed by clients because the item could trigger client's behaviors or jeopardize their safety while in treatment Based on the confidential interviews, observation, and record review, it has been determined that although the allegations that minors are not treated with dignity; minors are not allowed hygiene items; staff open minors' personal mail, minors not receiving an allowance, and minors being denied access to personal belongings 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. The program statement has been updated to ensure that the clients' needs will be met based on their individual assessments per Title Group Home Regulations. An exit interview was conducted, appeal rights discussed, and a copy of this report was provided to Evolve Compliance Officer Devorah Weiss and Facility Manager Stacy Guerrero, whose signature on this form confirms receipt.

Investigation Findings:
13On 11/29/2021 at 9:59AM, Licensing Program Analyst (LPA) Madeleine Fremont arrived at the facility to deliver the findings of a complaint investigation. LPA Fremont met with Facility Manager Stacy Guerrero and discussed the investigative findings. On June 7, 2021, the Department received a complaint alleging minors are not treated with dignity; minors are not allowed hygiene items; staff open minors' personal mail; minors are not receiving an allowance; minors are being denied access to personal property. Confidential interviews were conducted with 4 staff and 7 clients. Facility's Program Statement, Plan of Operation, Parent Handbook and Training Manual were reviewed. The following information was obtained during the course of the investigation: 1. Minors are not treated with dignity: Confidential interviews revealed conflicting statements that clients must leave the bathroom door ajar while using the restroom. Some confidential interviews reported that the clients did not have to leave the door open while using the restroom and other interviews stated that clients must leave the bathroom door ajar while using the restroom. It was noted in the facility's program statement that staff are to ensure that the clients keep the bathroom door ajar when using the restroom. (CONTINUED ON LIC9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Madeleine Fremont LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 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, FACILITY NAME: EVOLVE TREATMENT CENTER, DANVILLEFACILITY NUMBER: VISIT DATE: 11/29/2021

met_with: Facility Manager Stacy Guerrero