summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA) Brian Bertoli made an unannounced visit to the Administrative Office for the STRTP for the purpose of an Annual Continuation visit, and met with Human Resources Coordinator Angela Vincent, who assisted with the inspection. LPA Bertoli conducted a review of staff file records at the Administrative Office at S Orchard St in Ukiah, which completed the Annual Inspection. An exit interview was conducted and no deficiencies were cited. A copy of this report was given to Angela Vincent.

met_with: Angela Vincent


state: CA

facility_name: REDWOOD COMMUNITY SERVICES, INC.-BIRCH HOUSE

summary: Facility Evaluation

raw_content:
Narrative:
On 08/13/2025 at 9: AM, Licensing Program Analyst (LPA) Jasmine Cardeno made an unannounced visit to the facility listed above. The purpose of the visit is to conduct the required SB Psychotropic Medications inspection. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9(a)(2). During the inspection, LPA met with Therapeutic Skills Coach IV, Maria Berenice Segura Jimenez, and inspected the facility inside and out. LPA also met with STRTP Coordinator and Head of Service, Rebeca Diaz, and Program Manager, Paulita Peredia, who both facilitated the inspection. At the time of the inspection, two clients in care were present. Both clients were in and out of the facility to attend appointments and activities. The facility has one client that meets the criteria for the SB Psychotropic Medication Inspection. LPA reviewed 1 of child's records on site at the facility and 5 of staff personnel files were reviewed at the administrative office located on S Orchard Avenue, Ukiah, CA 95482. LPA reviewed 1 of child's psychotropic medications and medication records. LPA interviewed 2 of staff on site to discuss the facilities policies and procedures of operation. LPA interviewed 1 of children currently prescribed psychotropic medication. No deficiencies are being observed or cited at this time. The SB Psychotropic Medications inspection is complete. LPA conducted an exit interview and a copy of this report was given to Program Manager, Paulita Peredia, whose signature on this form confirms receipt.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Paulita Peredia


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Investigation Findings:
13On 03/04/2026 at 1: PM, Licensing Program Analysts (LPAs) Hanako Primer and Amee Li made an unannounced visit to the facility, Redwood Community Services, Inc. - Birch House. The purpose of this visit is to deliver findings for the allegation listed above. LPA Primer met with Rebecca Diaz, STRTP Coordinator, who facilitated the inspection. During the inspection, there was one client in care. During the course of the investigation, LPA Jasmine Cardeno conducted confidential interviews, records review, and walk-throughs of the facility. LPA Cardeno concluded that the allegation, "Facility staff locks or holds bedroom door closed on youth," had inconsistent support. Although the allegation may have happened or is valid, the preponderance of evidence has not been met and there is no consistent evidence to support the allegation listed above. Therefore, the allegation is Unsubstantiated. During the visit, LPA Primer conducted an exit interview and a walkthrough of the facility. A copy of this report was given to Rebecca Diaz, STRTP Coordinator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Hanako Primer LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

report_type: Complaint Investigation

met_with: Rebecca Diaz - STRTP Coordinator

complaint_status: unsubstantiated


facility_name: REFUGE SUNSET

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Angelique Hill conducted an announced Pre-licensing inspection on 2/25/2026 at 10: AM at the facility, as required for the Short-Term Residential Therapeutic Program (STRTP) license. LPA met with Jennifer Crosetti, Administrator (A1) who helped with the inspection. During the pre-licensing visit, LPA conducted a Health and Safety inspection using the CARE tool. LPA observed the facility was clean inside and outside and safe. LPA observed the facility is a one story house. LPA observed two bedrooms with bedding, three bathrooms and one office equipped with appropriate furniture. Sufficient storage space for client's personal belongings was observed in the prospective bedrooms. The STRTP is requesting to be licensed for four youths ranging in age from 12 to 17 years old. LPA Hill observed a medication Lock box in the office space which was empty, but locked, and has a lock code. The kitchen area was equipped with perishable foods in the refrigerator and non-perishable foods in the pantry. The STRTP has an attached garage space which houses one empty fridge and a facility vehicle. LPA observed a wood burner fireplace in the living room with a glass barrier. No serious concerns were observed.

visit_type: Prelicensing

met_with: Jennifer Crosetti, Administrator


facility_name: REFUGE WALNUT

summary: Facility Evaluation

raw_content:
Narrative:
On January 2, 2026 at approximately 10: AM, Licensing Program Analysts (LPA) Zaria Turner an made an announced visit with the purpose of conducting a pre-licensing inspection to the above Short Residential Therapeutic Program (STRTP). LPA met with Facility Administrator, Jennifer Crosetti, and a walk through of the interior and exterior was completed. LPA conducted a walk though of the interior and exterior of the facility. The facility was clean, safe and kept free of obstruction. LPA observed the posting of License, Personal Rights, and Emergency Disaster Plan. The facility consists of 3 bedrooms, 2 bathrooms, kitchen, dining room, living room, and a office/garage. Bedroom #1 is equipped with 2 twin size beds, bedding, 2 bedside tables, 2 dressers, and closet space for clothing and personal belongings. Bedroom #2 and #3 are equipped with 1 twin size bed, bedding, 1 bedside table, 1 dresser, and closet space for clothing and personal belongings. The 2 bathrooms in the facility are equipped with working toilets, shower/tub, and running water. Upon entry, the living room is equipped with a desk and chair, a fireplace with wood cover, 2 sofas, 3 chairs, 2 side tables, and a coffee table. The dining room is equipped with a table and 6 chairs, a side table, a cube storage organizer, and a side cart. The office/garage is equipped with 2 desks, 4 chairs, a side table, a cube storage organizer, and a stackable washer and dryer. Continue summary of inspection on 809-C Disinfectants/cleaning solutions are inaccessible to clients in care and locked in the office/garage. The refrigerator temperature is at or below 45 degrees F. There is nonperishable food for one week and fresh perishable food for three days minimum. There are containers to place leftover food. Carbon monoxide and smoke detectors are in working order. Hot water between 105-120 degrees F. Fire Extinguishers are up to date and in working order. The toilets, bathtubs, and shower fixtures are in good repair. Soap and paper towels are available to clients in care. The facility is free of vermin. The backyard contains a covered patio, side patio, grassy area, gravel area, and concrete area with a basketball hoop. There is a standalone structure in the back of the property that is not a part of the facility. There is no pool on the premises. The following adjustments need to be made: · Facility Telephone · Disaster and Mass Casualty Plan of Action on file An exit interview was conducted with Facility Administrator, Jennifer Crosetti, and a copy of this report was discussed and provided during today's inspection.

met_with: Jennifer Crosseti, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 11.4.25 1:00pm LPA Jennifer Baca met with Jason Henderson CEO and Jennifer Crosetti Program Administrator for the purpose of a Component 2. LPA disussed the Licensing process and took copies of ID's. LPA discussed the revisions that were submitted via email which included Plan of operation, Program statement, Personnel Requirements and children's records. LPA also discussed Personal Rights requirements and Discipline Policies. LPA also discussed Health related services, Manual Restraints. LPA also discussed the state of the old facility binder at the old location, and the status of the new property and if the facility has a deed or a lease as of today. CEO stated they have acquired a property and will be turning in the new binder for the new facility on Sunset blvd on 11.5.2025. LPA discussed the scheduling of COMP 3.

met_with: Jason Henderson


facility_name: REMI VISTA PORTA DEGO HOME

summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
...Continued from LIC Based on the corroborating interviews of the clients and staff members explaining acceptable disciplinary methods are used, that the staff do not put their hands on clients, and the incapability to interview the victim, the allegation, "Client received inappropriate discipline from staff," cannot be proven true. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove that alleged violation(s) did or did not occur, therefore the allegation(s) is unsubstantiated. Exit interview was completed with Chris Magera and appeal rights explained, on 3/22/22 at 1: PM. LPA provided a signed copy of LIC 9099 and appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA), Stefanie Whitlow, conducted complaint investigation for the allegation stating, "Client received inappropriate discipline from staff." LPA, Kellie McKinley, conducted initial complaint opening inspection. LPA McKinely conducted interviews with the facility program manager and one staff member. LPA, Stefanie Whitlow conducted two staff interviews and two client interviews. The victim moved placements two days after the incident and LPA was unable to interview them, after three attempts. Three out of three staff stated restriction or removal of privileges are used for discipline and that staff do not put hands on clients. Three out of three staff stated the day of the incident, food was not refused to the victim; they did not receive ice cream due to the ice cream being a reward to other clients for good behavior. Two out of two clients interviewed stated staff do not put their hands on clients and that restriction is used as discipline. Continued on LIC 9099-C... UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Daniel Allmon LICENSING EVALUATOR NAME: Stefanie Whitlow 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 25-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, COHASSET RD., Suite Chico, CA Facility Name: Remi Vista Porta Dego Homefacility Number: Visit Date: 03/22/ 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 from LIC Based on the corroborating interviews of the clients and staff members explaining acceptable disciplinary methods are used, that the staff do not put their hands on clients, and the incapability to interview the victim, the allegation, "Client received inappropriate discipline from staff," cannot be proven true. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove that alleged violation(s) did or did not occur, therefore the allegation(s) is unsubstantiated. Exit interview was completed with Chris Magera and appeal rights explained, on 3/22/22 at 1: PM. LPA provided a signed copy of LIC 9099 and appeal rights. SUPERVISORS NAME: Daniel Allmon LICENSING EVALUATOR NAME: Stefanie Whitlow 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

met_with: Chris Magera


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
...Continued from LIC Based on the corroborating interviews of the clients and staff members explaining acceptable disciplinary methods are used and that the staff do not put their hands on clients, the incident was a momentary lapse in judgement and an isolated event. The allegation, "Staff touched client in care inappropriately," is found to be substantiated, but LPA is not citing. A technical violation will be provided. The allegation, "Client received inappropriate discipline from staff," cannot be proven true. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove that alleged violation(s) did or did not occur, therefore the allegation(s) is unsubstantiated. Exit interview was completed with administrator, Chris Magera, and appeal rights explained, on 3/22/22 at 2: PM. LPA provided a signed copy of LIC 9099 and appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA), Stefanie Whitlow, conducted complaint investigation for the allegation stating, "Client received inappropriate discipline from staff," and "Staff touched client in care inappropriately." LPA, Kellie McKinley, conducted initial complaint opening inspection. LPA McKinely conducted interviews with the facility program manager and one staff member. LPA, Stefanie Whitlow conducted two staff interviews and two client interviews. The victim moved placements two days after the incident and LPA was unable to interview them, after three attempts. Four out of four staff stated restriction is used as discipline and that staff do not put hands on clients. When trying to confiscate objects, four out of four staff stated they use verbal prompts. Two out of two clients interviewed stated staff do restrain clients if they are in danger, that staff do not touch them inappropriately, and that staff use removal of privileges as discipline. Continued on LIC 9099-C... SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Daniel Allmon LICENSING EVALUATOR NAME: Stefanie Whitlow 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 25-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, COHASSET RD., Suite Chico, CA Facility Name: Remi Vista Porta Dego Homefacility Number: Visit Date: 03/22/ 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 from LIC Based on the corroborating interviews of the clients and staff members explaining acceptable disciplinary methods are used and that the staff do not put their hands on clients, the incident was a momentary lapse in judgement and an isolated event. The allegation, "Staff touched client in care inappropriately," is found to be substantiated, but LPA is not citing. A technical violation will be provided. The allegation, "Client received inappropriate discipline from staff," cannot be proven true. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove that alleged violation(s) did or did not occur, therefore the allegation(s) is unsubstantiated. Exit interview was completed with administrator, Chris Magera, and appeal rights explained, on 3/22/22 at 2: PM. LPA provided a signed copy of LIC 9099 and appeal rights. SUPERVISORS NAME: Daniel Allmon LICENSING EVALUATOR NAME: Stefanie Whitlow 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

complaint_status: SUBSTANTIATED


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Katherine Deaton emailed a copy of this report to the facility in accordance with COVID-19 precautions. The LPA met with Chris Magera, Acting Administrator, and Chad Medlin, Head of Mental Health Services, at the facility administrative office. The facility meets all Core Services, Specialty Mental Health Services, and Trauma Informed Care requirements. The facility is in the process of updating their Administrator information. Two staff members have probationary Administrator Certificates as Administrator Certification Testing is currently suspended (see PIN 20-04-CRP). Clients are advised of their personal rights & house rules. There are several posters/resources/notices posted at the facility including: Mental Health Resources, CCLD contact information, and Ombudsman contact information. Clients gender identity, expression and orientation are respected and kept confidential. Clients receive information about their own healthy sexual development. The LPA conducted an on-site file review following all COVID-19 precautions. The LPA reviewed three staff files and three client files. Staff are meeting all training requirements. The facility has scheduled outstanding PCMA training and employee evaluations. No citations were issued at the time of this inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On 5/26/ Licensing Program Analyst Kellie McKinley met with Derek Hodsdon and Rondoe Taylor Facility Manager conduct a Case Management inspection for the purpose of delivering an exclusion notice. Based on the evidence obtained during today's inspection, this LPA has verified the individual is not present, employed or residing at a resource Group home. No deficiencies observed or cited during this inspection. Copy of this report left with the agency at the conclusion of the inspection. The exclusion notice was given at the time of the inspection.

met_with: Derek Hodsdon - Program Facilitator and Rondoe Taylor- Facitly Manager


summary: Facility Evaluation

raw_content:
Narrative:
An announced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Stefanie Whitlow at STRTP Remi Vista, Porta Dego located at address above on 9/14/21 at 12: PM. During the inspection, LPA met with facility administrator, Derek Hodsdon, and inspected the facility inside and out. There were no deficiencies noted. A medication count was also conducted. LPA interviewed three staff on site during the inspection at 12: PM. LPA conducted exit interview with program manager, Chris Magera, who signed the LIC 809. Appeal rights were not explained, as no citations are being given. LPA provided the Summary Report to Chris Magera, program manager, upon completion by email.

met_with: Derek Hodsdon


summary: Facility Evaluation

raw_content:
Narrative:
An announced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Stefanie Whitlow at administrative office located at address above on 9/14/21 at 2: PM. During the inspection, LPA met with Chris Magera, program manager. There were no deficiencies noted. LPA reviewed four children's records. LPA interviewed four children currently taking psychotropic medication at 2: PM LPA reviewed three staff personnel files. LPA conducted exit interview with Chris Magera, program manager, who signed the LIC 809. Appeal rights were not explained, as no citations are being given. LPA provided the Summary Report upon completion by email.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Katherine Deaton conducted an annual required inspection at the facility in accordance with COVID-19 precautions. The LPA met with Garrett Vargas, Administrator (AD) and toured the facility; the facility is clean, safe, and sanitary. The LPA used the CARE Inspection Tool and initiated a review of the Physical Plant, Operations, Disaster Preparedness, and Emergency Interventions. The LPA conducted two staff interviews; there were no clients at the facility at this time. The LPA then traveled to the Administrative office located at Churn Creek Rd, Redding, CA and met with Chris Magera, Administrator. The LPA initiated review of Core Therapeutic Services, staff and client file reviews No citations were issued. Due to time constraints, this inspection will be completed at a later date.

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Katherine Deaton continued the annual required inspection at the Administrative office located at Churn Creek Rd, Redding, CA in accordance with COVID-19 precautions. The LPA met with Chris Magera, Administrator and completed review of the Physical Plant, Operations, Disaster Preparedness, Emergency Interventions, Core Therapeutic Services, and Staff File components of the CARE Inspection Tool. The LPA interviewed one client. The LPA then traveled to the facility location and met with Garrett Vargas, Administrator. The LPA completed review of Client Files. Advisory Note Technical Violations were issued regarding Personnel Duties, Disaster Preparedness, and Emergency Intervention Staff Training. No citations were issued throughout the course of this investigation.

met_with: Garrett Vargas


summary: Facility Evaluation

raw_content:
Narrative:
On 10/06/2023, Licensing Program Analyst (LPA) Misty Valencia arrived unannounced at the facility and met with Chris Magera, Administrator. The purpose of the visit was to conduct a Required, Two year Annual Inspection of the facility. The last Annual inspection for the facility was on 10/06/2021. LPA utilized the CARE Tool to complete the Annual inspection. LPA conducted an inspection of the physical plant, and checked for all necessary requirements. The facility was clean and organized, and maintained an acceptable room temperature. The facility is a home like setting, with three (3) client bedrooms, a large open plan kitchen/dining area, and one locked staff office. Each client had a closet and dresser in good repair. Mattresses and bedding were observed to be clean. Clients were able to decorate their rooms with their personal belongings. The backyard was free from hazards, safely fenced, with a variety of sports equipment accessible to clients. LPA observed the proper postings including: facility license, complaint hotline, client personal rights, and emergency disaster plan. The facility has three client bathrooms and one staff bathroom. All were observed to be clean and fully functioning. Smoke alarms were in working order, fire extinguishers were current, and a first aid kit was fully stocked. LPA observed the kitchen to have at least 2 days of perishable food and 7 days of non-perishable food on hand, with additional food stored in the recreational room. LPA observed client files and client medications were stored in a locked file cabinet in the locked staff office. The facility has no outstanding fees. The facility currently has five (5) clients, with a licensed maximum capacity of six (6). Staff to client ratio is two (2) to five (5). LPA reviewed five (5) staff files. Staff files had completed criminal record clearances and all required initial and annual training. All First Aid and CPR certifications were up to date for staff. LPA interviewed two (2) staff on site. continued on 809-C LPA reviewed five (5) client files. All clients had signed Admission Agreements on file. Client files had completed initial Needs and Service Treatment Plans, but not signed by clients. Clients had updated Needs and Service plans every 30 days that were signed. Needs and Service Plans detailed adequate supportive services the facility offers to the clients. Clients were current on CHDP physical exams and dental exams. four (4) of five (5) clients were taking court ordered psychotropic medications and had current JV-220's on file. LPA interviewed two (2) clients. Facility is issued a citation per childrens records 87070(c)(1) If it is determined that the facility can provide the services necessary to meet the child's needs, the following additional information shall be maintained in the child's record: (1) A copy of the child's original needs and services plan; verification, signed by the child and their authorized representative(s), that they were offered the opportunity to participate in plan development; and verification that the authorized representative(s) have approved the plan. A signed copy of this LIC-809, LIC-809C, and LIC 809D, report was provided to Administrator. An exit interview was conducted. Appeal rights were provided

met_with: Chris Magera,Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Misty Valencia arrived unannounced at the facility and met with Chris Magera, Administrator of Remi Vista facilities. The purpose of the contact was to initiate a Case Management Inspection following up on three (3) Special Incident Reports (SIR) LPA received from the facility between 9/20/2023, 9/25/2023 and 10/08/2023 relating to client in care medication errors. LPA requested the following documents from the facility: · Procedures on medication administration and description of training · Retraining on Medication procedures. On 09/21/2023- Client 1 (C1) C1's medication Clonidine 0.1mg was prescribed to give two (2) tabs by mouth at bedtime and was not provided on 09/19/2023. On 09/25/2023-Client 2 (C2) C2's medication Divalproex SOD DR 500mg was prescribed to give one (1) tab by mouth daily with dinner and two (2) tabs every night at bedtime. C2 was given two (2) tablets at dinner instead of one (1). Staff contacted the pharmacy, who ordered staff to give C2 only one (1) tablet at bedtime instead of two (2) and continue as normal the next day. On 10/08/2023-Client 3 (C3) C3s medication Ziprasidone 40 mg was proscribed to give one (1) tab at bedtime. Due to the pharmacy not delivering the medication it was not being available and the pharmacy was closed on the weekend. In the future there will more diligence in attempting to obtain medications last minute on the weekend. A copy of this report has been provided to the facility. No citations issued at this time Administrator already conducted medication retraining to the staff and provided LPA with the copy.

met_with: Chris Magera, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Misty Valencia on 11/17/2023 at 11:00AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Valencia met with Chris Madera, Administrator and inspected the facility inside and out. LPA reviewed two of Four (2 of 4) child's records and three of seven (3 of 7) staff personnel files on site at the facility. LPA reviewed two of Four (2 of 4) of child's psychotropic medications and medication records. LPA interviewed three of seven (3 of 7) staff on site to discuss the facilities policies and procedures of operation. LPA interviewed two of Four (2 of 4) of children currently prescribed psychotropic medication. LPA provided a copy of this licensing report to Chris Madera, Administrator. No deficiencies are being cited at this time. LPA conducted exit interview with Chris Madera, Administrator

met_with: Chris Madera, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 10/16/2025, Licensing Program Analysts (LPA) Misty Valencia arrived unannounced at the facility and met with Chris Magera, Administrator. The purpose of the visit was to conduct a Required Annual Inspection of the facility. The last Annual inspection for the facility was on 10/06/2023. LPA utilized the CARE Tool to complete the Annual inspection. The facility is licensed to provide treatment services for ambulatory children ages 13-18years. The facility currently has # clients, all Regional Center placements. One client was present during the inspection. The facility is licensed for a maximum capacity of 6. Staff to client ratio is two to four. LPA conducted an inspection of the physical plant, and checked for all necessary requirements. The facility was clean and organized, and maintained an acceptable room temperature. The facility is a home like setting, with three (3) client bedrooms, a large open plan kitchen/dining area, and one locked staff office. Each client had a closet and dresser in good repair. Mattresses and bedding were observed to be clean. Clients were able to decorate their rooms with their personal belongings. The backyard was free from hazards, safely fenced, with a variety of sports equipment accessible to clients. LPA observed the proper postings including: facility license, complaint hotline, client personal rights, and emergency disaster plan. continued on 809-C The facility has three client bathrooms and one staff bathroom. All were observed to be clean and fully functioning. Smoke alarms were in working order, fire extinguishers were current, and a first aid kit was fully stocked. LPA observed the kitchen to have at least 2 days of perishable food and 7 days of non-perishable food on hand, with additional food stored in the recreational room. LPA observed client files and client medications were stored in a locked file cabinet in the locked staff office. The facility has no outstanding fees. LPAs reviewed 3 client files. 3 clients were taking psychotropic medications and had current parental consent on file. Psychotropic medication logs for clients were written on separate Psychotropic Medication Administration Records. Clients were current on CHDP physical exams and dental exams. The client's Needs and Services Plan/Individual Program Plan, were complete and up to date. LPAs reviewed 5 staff files. Staff files had completed criminal record clearances and all required initial and annual training. First Aid and CPR certifications were up to date for all staff. Administrators Certificate was valid. LPA interviewed 2 staff on site. LPA interviewed 0 clients. No citations were given on this date. A signed copy of this LIC-809 and LIC-809C, report was provided to Administrator An exit interview was conducted.


raw_content:
Narrative:
During the course of the investigation, interviews and records reviewed were inconsistent in that Staff did not provide adequate supervision to the minors in care. Interviews with 3 minors corroborated that there had been inappropriate interactions between the minors, but it was without the staff's knowledge. Two out of 3 minors interviewed admitted that the interactions were consensual, usually in their bedrooms, and always done when the staff were not around. During the interviews all three minors reported that they felt safe. Staff interviewed reported that once they became aware of the situation the minors were placed in separate rooms, extra supervision was put in place so that no minors were left alone in each other's room, and a staff member is always in the hall supervising the minors at nighttime. Based on LPA's observations, interviews which were conducted, and records reviewed, although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove the violation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED. A signed copy of this LIC-9099 report, the LIC-9099C, and appeal rights were provided to the facility. An exit interview was conducted.

Investigation Findings:
13Licensing Program Analyst (LPA) Misty Valencia arrived unannounced at the facility on this date for the purpose of delivering findings for the complaint investigation. LPA met with Chris Magera, Administrator . LPAs Valencia and Lyta Vue conducted the complaint investigation. LPA Valencia initiated the investigation with the facility on 10/16/2025 and met with Chris Magera, Administrator and conducted a Health and Safety Inspection. During the course of the investigation, LPAs interviewed three minors and four facility staff. LPA reviewed records including: Needs and Services plans (NSP): Placement Roster, Serious Incident Reports (IR): and prior complaint history. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Hillary Hall LICENSING EVALUATOR NAME: Misty Valencia 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 25-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CHICO - RESIDENTIAL, COHASSET RD., STE. FACILITY NAME: REMI VISTA PORTA DEGO HOMEFACILITY NUMBER: VISIT DATE: 12/18/2025


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPA) Misty Valencia and Hillary Hall on 12/8/22 at 10AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs met with Chris Magera, Administrator, and inspected the facility inside and out. The facility currently has 2 clients prescribed psychotropic medication. LPAs reviewed 2 client's files and 3 staff personnel files at the Administrative main office at Churn Creek Rd., Redding, 96002. LPAs reviewed 2 client's psychotropic medications and medication records at the facility. LPAs interviewed 3 staff to discuss the facilities policies and procedures of operation. LPAs interviewed 2 clients currently prescribed psychotropic medication at the facility. During the inspection, LPAs observed the facility did not have a proper authorization for the administration of psychotropic medication (JV-220/223) for one client on file (see attached 809D). The Administrator called the placing agency and the JV-223 was emailed immediately. The JV-223 which was emailed, was one month out of date. Per the placing agency worker's verbal report to LPA's, the court date to renew the JV-223 was continued until January 2023. The plan of correction was met with the JV-223 being produced. However, the citation is still issued as the court order was not on file and not been requested prior to the inspection. Citation issued per Interim Licensing Standards Section 87070(b)(!2) Childrens Records: (b) The following information regarding the child shall be obtained and maintained in the child's record: (12) A copy of the current court order, or written authorization of the child's parent or guardian, for each psychotropic medication.. LPAs provided a copy of this LIC-809 and the LIC-809D report to the Administrator. Appeal rights provided and exit interview was conducted.


facility_name: RICHMOND

raw_content:
Narrative:
It was specifically reported to CCL that S1, who is not assigned a role over client care and supervision at the facility is providing clients with drug paraphernalia in care. During the investigation there was no corroborating evidence to support the allegation. Although the department received information that S1 was providing drugs to clients in care the information received is inconsistent. Confidential interviews reported that clients obtain drugs from school and deny that S1 provides drugs to clients in care. Other confidential interviews stated that clients have been observed under the influence of substances and in possession of nicotine, and marijuana, however it is not known where clients obtain the drugs. A confidential interview revealed an incident in which smoke was observed as S1 was exiting an area of the facility where clients were congregating. It was further revealed that S1(non-childcare staff) was socializing with clients in care when S1 was directed not to socialize with clients. There were no other known witnesses to the allegation or to the incident involving S1 and clients in care. Based on confidential interviews, the allegation that staff provides drugs to youths while in care, may have happened or is valid but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Administrator, Stacey Rougely

Investigation Findings:
13On March 14, 2024, at 11: AM, Licensing Program Analyst (LPA), Cynthia Urena met with Richmond Short Term Residential Therapeutic Program (STRTP) Administrator, Stacey Rougely to deliver the investigative finding for the above stated allegation. On November 8, 2023, at 2: PM, LPA Cynthia Urena initiated the investigation at the STRTP and collected pertinent documents from the STRTP staff and client files. A health and safety inspection was conducted with a Residential Manager, and no immediate deficiencies were observed. LPA advised the Residential Manager that Charlotte Jackson with the Community Care Licensing Division (CCLD) Investigations Branch (IB) would be leading the investigation. Interviews were completed with four staff members (S1, S2, S3, S4,), four clients (C1, C2, C3, C4), a Probation Officer and a witness. On November 8, 2023, Community Care Licensing (CCL) received a complaint alleging that staff provides drugs to youths while in care. (**Continued on LIC C**) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Cynthia Urena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: RICHMONDFACILITY NUMBER: VISIT DATE: 03/14/2024

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

met_with: Administrator, Stacey Rougely


raw_content:
Narrative:
Confidential interviews revealed that S1 never made any inappropriate comments to C1 or any clients. Confidential interviews revealed that C1 dislikes S1 and C1 would make false allegation towards to S1 in hopes to get S1 fired. Confidential interview revealed that there are no concerns with S1 violating C1's personal rights. Based on confidential interviews, the allegation that S1 made inappropriate comments to C1 in care may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this report along with appeal rights was provided to Olive Crest - Richmond Short Term Residential Therapeutic Program (STRTP), Mwape Nchima Chongwe, Residential Coordinator.

Investigation Findings:
13On 05/09/24 at 09: AM, Licensing Program Analyst (LPA) Sarah Lo met with Mwape Nchima Chongwe, Residential Coordinator, to deliver the finding for the above complaint allegation at Olive Crest - Richmond Short Term Residential Therapeutic Program (STRTP). On 08/11/23, LPA Emina Preciado inspected the facility's physical plant, and no immediate health and safety hazards were observed. The investigation included interviews with one staff (S1), Residential Manager (RM), and two clients (C1 and C3). Clients' Needs and Services Plans and case notes were reviewed. On August 01, 2023, Community Care Licensing received an allegation that staff (S1) made inappropriate comments to a client (C1) in care. Specifically, it was reported that S1 made an inappropriate comment to C1 on an outing. The investigation resulted in conflicting statements: Confidential interview revealed that S1 made a sexual innuendo regarding a toy to C1. (Continued on LIC 9099c) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Sarah Lo LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: RICHMONDFACILITY NUMBER: VISIT DATE: 05/09/2024

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


raw_content:
Narrative:
Confidential interviews reported that C1 received pictures of C2 on their (C1) personal cell phone and showed the pictures to staff and clients. Confidential interviews reported that the STRTP does not monitor personal cell phones due to personal rights. Confidential interviews reported that C1 showed pictures of C2 to staff and that they (C1) were directed to delete the photos immediately. Confidential interviews reported that C1 was not told to delete the photos immediately but two or three days after staff was made aware. LPA received inconsistent information on the timeline from when staff was made aware of the photos and when staff directed C1 to delete the photos. Based on inconsistent confidential interviews, the allegation that due to a lack of supervision, the minor (C1) engaged in inappropriate interactions is unsubstantiated. The allegation may have happened or are valid, but there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted. A copy of this report and appeal rights were explained and given to Stacy Rougely, Adminstrator.

Investigation Findings:
13On October 15, 2024, at 9: AM, Licensing Program Analyst (LPA) Cynthia Robinson conducted an unannounced visit to Richmond- Olive Crest STRTP to deliver the investigative findings for the allegation listed above. On 06/24/2024, LPA Robinson conducted a health and safety inspection at the STRTP. LPA obtained documents pertinent to the investigation. LPA interviewed Clients (C1, C4, and C5), and Staff (S1, S3, S4, and S5). LPA attempted to interview C2 but was unsuccessful because C2 was apprehended. LPA attempted to interview C3 and C6 but was unsuccessful because both clients refused to be interviewed. LPA made several attempts to interview S2 and the Probation Officer (PO) but was unsuccessful. On 06/19/2024, Community Care Licensing received an allegation that, due to a lack of supervision, a minor (C1) engaged in inappropriate interactions. It was alleged that C1 was sharing inappropriate pictures of C2. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Cynthia Robinson LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: RICHMONDFACILITY NUMBER: VISIT DATE: 10/15/2024

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

met_with: Stacy Rougely, Administrator


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
Confidential interviews revealed that the staff position of House Supervisor oversees notifying the mental health team of the prescription refills, but S1 did not notify the mental health team in a timely manner. Additional confidential interviews reported that the House Supervisor does not oversee medication and that the staff position, the Residential Coordinator, oversees medication refills. LPA obtained pertinent documentation of job descriptions and confirmed that the Residential Coordinator job description states this position is responsible for ensuring there is a sufficient supply of prescribed and over-the-counter medication on hand. As a result of the STRTP staff blaming each other, the STRTP did not meet the needs of C1, causing C1 not to receive their (C1) medication according to the physician's order. In addition, LPA observed that C1 was missing medication, and there was no more medication for C1 to take due to a missed refill in a timely manner. Based on consistent confidential interviews and pertinent documentation, the allegation that staff did not refill minors (C1) prescriptions is substantiated.The facility is cited with a violation of the Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS), Section 87075(c) Health Related Services (c) Psychotropic medications shall be used only in accordance with the written directions of the physician prescribing the medication.... The STRTP did not meet the needs of C1, causing C1 not to receive their (C1) medication according to the physician's order. LPA observed the missing medication, and confidential interviews revealed that C1 did not receive their medication due to a missed refill. This posed an immediate risk to the Health, Safety, and Personal Rights of children in care. An exit interview was conducted. A copy of this report and appeal rights were explained and given to Stacey Rougely, Administrator.

Investigation Findings:
13On January 7, 2025, at 10AM, Licensing Program Analyst (LPA) Cynthia Robinson conducted an unannounced visit to Richmond- Olive Crest Short-Term Residential Therapeutic Program (STRTP) to deliver the investigative findings for the allegation listed above. On 10/24/2024, LPA Robinson conducted a health and safety inspection at the STRTP, and no immediate health and safety hazards were observed. LPA obtained documents pertinent to the investigation. LPA interviewed Clients (C1 and C2), and Staff (S1, S2, S3, and S4). LPA attempted to interview Clients (C3, C4, C5, and C6) but was unsuccessful because clients refused to be interviewed. On 10/23/2024, Community Care Licensing received an allegation that staff did not refill minors (C1) prescriptions. It was alleged that C1 did not get a refill promptly, resulting in missed medication for C1. Confidential interviews revealed that C1 did not receive their medication due to not having a filled prescription. (Continued on LIC 9099C...) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Cynthia Robinson LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: RICHMONDFACILITY NUMBER: VISIT DATE: 01/07/2025

met_with: Stacey Rougely, Administrator


raw_content:
Narrative:
Confidential interviews reported that S1 hit C1 with a closed-hand fist to the back of the head three times because C1 had stopped S1 from trying to touch them (C1). Other confidential interviews denied hitting C1 in the back of C1's head. Additional confidential interviews reported that S1 had pointed to C1's new nose ring and this caused C1 to think S1 was trying to take it out and raised their (C1) hands to "block" S1's hand. Confidential interviews reported that S1 then raised their (S1) hands to "block C1's hands" with an open palm. Confidential interviews reported that C1 was under the influence during the incident causing C1 to become defensive. Confidential interviews denied hitting C1 with closed fists or any physical abuse toward C1. Regarding the allegation that staff (S1) inappropriately spoke to youth (C1) in care, confidential interviews reported that S1 called C1 inappropriate words after the alleged incident between C1 and S1. In addition, confidential interviews reported that S1 did not say any inappropriate words toward C1. LPA was unable to determine if the allegations occurred or did not occur. Based on inconsistent confidential interviews, the allegations that staff (S1) hit youth (C1) in care and staff (S1) inappropriately spoke to youth (C1) in care are unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted. A copy of this report and appeal rights were explained and given to Stacy Rougely, Administrator.

Investigation Findings:
13On February 7, 2025, at 10: AM, Licensing Program Analyst (LPA) Cynthia Robinson conducted an unannounced visit to Richmond- Olive Crest STRTP to deliver the investigative findings for the above-stated allegations. On 12/17/2024, LPA Robinson conducted a health and safety inspection at the STRTP. LPA obtained documents pertinent to the investigation. LPA interviewed Client (C1), and Staff (S1, S2, S3, S4, and S5). LPA attempted to interview clients (C2, C3, C4, C5, and C6) but was unsuccessful because clients refused to be interviewed. On 12/16/2024, Community Care Licensing received allegations that staff (S1) hit youth (C1) in care and staff (S1) inappropriately spoke to youth (C1) in care. Confidential interviews reported that S1 had reached their hand out to point out C1's new nose ring and tried to reach out to pull it out. Confidential interviews reported that C1 raised their hands to stop S1 from touching them (C1). (Continued on LIC 9099C...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Cynthia Robinson LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: RICHMONDFACILITY NUMBER: VISIT DATE: 02/07/2025

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


summary: Facility Evaluation

raw_content:
Narrative:
On October 26, 2021, at 9: AM Licensing Program Analysts (LPAs) Leslie Covarrubias and Carmen Escobar arrived at Richmond, Short Term Residential Program (STRTP). LPAs met with Residential Manager, Tyresha Calhoun. The purpose of the visit is to conduct an annual inspection of the facility. At 9: AM, Residential Manager, Tyresha Calhoun, led the physical inspection of the facility. The home is set up as follows: Bedroom #1- Was furnished with one twin bed and sleeps one client. Bedroom #2- Was furnished with one twin bed and sleeps one client. Bedroom #3- Was furnished with one twin bed and sleeps one client. Bedroom #4- Was furnished with one twin bed and sleeps one client. Bedroom #5- Was furnished with one twin bed and sleeps one client. Bedroom #6- Was furnished with one twin bed and sleeps one client. Bedrooms are arranged so that only one child is placed per room. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. There is adequate drawer and closet space for children's belongings. Bedroom #2 was observed to be missing a screen on the window, and therefore is being given a technical violation of Section: Physical Plant 80088(b). A physical plant inspection was completed and included the facility's kitchen area, four refrigerators/freezers, food storage areas, client rooms, two bathroom/showers, and community gathering area and dining area. Facility grounds are clean and free of debris and observable hazards. Sports equipment/toys/books/games/musical instruments were observed for client's recreation time. There is adequate indoor and outdoor activity space. Facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods and the menus were posted. At the time of inspection the facility license was observed to be posted by the front door. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsperson poster. Medications are locked and centrally stored inside staff office. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The hot water in the client's bathrooms was measured to be 107.6 degrees Fahrenheit for bathroom #1 and bathroom #2 was 106.8 degrees Fahrenheit. Per the Residential Manager, no firearms or weapons are allowed in the facility. LPAs inspected the facility vehicle to be in good repair. LPAs conducted a client record review of six of six client files. Client #1 did not have a TB test on file and therefore is being cited for violation of Section: Client Medical Assessment 80069(c)(1). Licensee has Mental Health Program Approval that is valid through 12/13/2021. Licensee has obtained National Accreditation that is valid through 10/31/2021. Licensing fee payments have been paid and there is currently a balance of $0. An exit interview was conducted and a copy of this report, LIC 809D, LIC9102, LIC 811 and appeal rights were provided to Residential Manager, Tyresha Calhoun.

met_with: Tyresha Calhoun


summary: Facility Evaluation

raw_content:
Narrative:
On November 10, 2021, at 8:35am, Licensing Program Analyst (LPAs) Ronnesha Fountain and Leslie Corvurriabias conducted an announced inspection. The purpose of the inspection was to complete the continuation inspection for STRTP annual inspection that was initiated on October 05, 2021. LPA's already completed the physical plant inspection, client records and three client interviews of the facility. During this annual inspection continuation LPAs interviewed three of the six clients to ensure the STRTP are meeting the Title Regulations and Interim Licensing Standards (ILS), see LIC 811 dated 11/10/21. The client interviews are located under the LIC 809 dated 10/05/21. Based on the interview with clients, there was some confusion over the "point system" used that determines the amount of cash a client can keep on them physically, but the amount that is deposited into their savings does not change. The STRTP appears to be meeting Core Services/Supports requirements. Based on the need to conduct staff interviews and a review staff records, this inspection will be continued at a later date. No deficiencies were found during this inspection. An exit interview was conducted and a copy of this report was provided to the residential manager Anne Lacy.

met_with: Anne Lacy


summary: Facility Evaluation

raw_content:
Narrative:
On Friday, November 19, 2021, at 9:30 am, Licensing Program Analyst (LPA) Ronnesha Fountain conducted an announced inspection. The purpose of the inspection was to complete the continuation inspection for the Richmond STRTP annual inspection initiated on October 26, 2021. LPA Fountain has already completed the physical plant inspection, client records, client and staff interviews. During the time of the inspection, there were no clients on site. During this annual inspection, LPA Fountain interviewed one staff, reviewed staff records and Operational Requirements, Disaster Preparedness, Emergency Intervention Plan, and Core/Therapeutic Services to ensure the STRTP meets the Title Regulations and Interim Licensing Standards (ILS), see LIC 811 dated 11/10/21. The client interviews are located under the LIC 809 dated 10/26/21 and 11/19/21. Based on the interview with the staff, the STRTP appears to be meeting Core Services/Supports requirements. With the facility's inspection, interviews with clients and staff, and a review of their records, CCL does not recognize any violation of regulations and/or ILS. This will conclude the annual inspection for the Richmond STRTP's last visit. No deficiencies were found during this inspection. An exit interview was conducted, and a copy of this report was provided to the residential manager Anne Lacy.


summary: Facility Evaluation

raw_content:
Narrative:
On November 8, 2023 at 8:30 am, Licensing Program Analysts (LPA's), Emina Preciado and Darlene Almaraz Oseguera, conducted an unannounced visit at Richmond, Short Term Residential Therapeutic Program (STRTP) for the purpose of a required annual. LPA's met with Residential Manager, Erika Oliva. While at the facility, LPA's reviewed client and facility records, conducted staff interviews, and conducted a physical plant inspection. LPA's conducted a physical plant inspection of the facility at 10:30 am that included the facility's kitchen area, four refrigerators/freezers, food storage areas, client rooms, two bathroom/showers, and community gathering area and dining area. Facility grounds are clean and free of debris and observable hazards. There are six bedrooms at the facility and each client at the facility has their own room. Bedrooms #1-4 are currently occupied by a client and are set up as follows: Bedroom #1, 3, 4, and 6 are furnished with one twin bed and sleep one client. Bedroom #2 and 5 are open beds and do not have clients but are furnished with one twin bed and sleeps one client. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. Water temperature was observed to be at 113 degrees Fahrenheit. Per the Residential Manager, no firearms or weapons are allowed in the facility. There is adequate indoor and outdoor activity space. Facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods and the menus were posted. At the time of inspection, all required forms are posted and the facility license was observed to be posted by the front door. Medications are locked and centrally stored inside the staff office. *, LIC 809-C* Due to time constraints, LPA's were unable to review staff records and conduct client interviews. LPA's will be returning at a later date. LPA's conducted a records review of four of four client files. Client #2 did not have a medical assessment on file please refer to the LIC 811 (confidential names list) dated November 8, 2023. Based on observation and record review, the facility is cited for Continuum of Care Reform (CCR) section 80069(a) Client Medical Assessments. This poses a potential health, safety or personal rights risk to clients in care. An exit interview was conducted, appeal rights were discussed and a copy of this report along with LIC 809-D, LIC 809-C, and LIC 811 were provided to Residential Manager, Erika Oliva.

met_with: Residential Manager, Erika Oliva


summary: Facility Evaluation

raw_content:
Narrative:
On November 21, 2023 at 12:02 pm Licensing Program Analyst (LPA), Emina Preciado, conducted an unannounced visit at Olive Crest- Richmond, Short Term Residential Therapeutic Program (STRTP). The purpose of the visit was to continue a required annual inspection that was initiated on November 8, 2023 by LPA's Emina Preciado and Darlene Almaraz Oseguera. LPA Preciado met with Residential Manager, Erika Oliva. While at the facility, LPA Preciado completed two client interviews. Based on staff/client interviews, the facility appears to be meeting Core Therapeutic Services, and Supports, and Emergency Intervention Plan requirements. On November 13, 2023, LPA Emina Preciado met with Human Resources Administrative Manager to conduct the Staff Records review portion of the inspection at Olive Crest (336425183) located at: Technology Court Suite Riverside, CA 92507. LPA reviewed five personnel records to ensure they contained required documentation per Title Regulations and Interim Licensing Standards (ILS). Five out of five personnel records reviewed were associated to the facility and had completed background clearances: Department of Justice (DOJ), Federal Bureau of Investigation (FBI), and Child Abuse Central Index (CACI) on file. Five out of five personnel records reviewed had a health screening and tuberculosis (TB) test on file. Five out of five personnel records reviewed had required annual trainings, current cardiopulmonary resuscitation (CPR), and first aid certification on file. Based on observation and record review, there are no deficiencies noted at this time during the inspection. Exit interview conducted and a copy of this report was provided to Residential Manager, Erika Oliva.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Leslie Covarrubias on March 1, 2024 at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Covarrubias met with Regional Director, Kelly Duguay and inspected the facility inside and out. LPA reviewed zero of child's records and three of staff personnel files on site at the facility. LPA reviewed zero of child's psychotropic medications and medication records. No clients were eligible for inspection review. LPA interviewed two of staff on site to discuss the facilities policies and procedures of operation. LPA interviewed zero of children currently prescribed psychotropic medication. No clients were eligible for inspection review. LPA provided a copy of this licensing report to Regional DIrector, Kelly Duguay. No deficiencies are being cited at this time. LPA conducted exit interview with Regional Director, Kelly Duguay.

met_with: Regional DIrector, Kelly Duguay


summary: Facility Evaluation

raw_content:
Narrative:
On August 14, 2025, at 10:20 am, Licensing Program Analyst (LPA), Julian Lucas, arrived unannounced at Richmond Short Term Residential Therapeutic Program (STRTP) located at 20025A Vista Del Lago, Perris, CA 92570. The purpose of the visit was to conduct a required annual inspection of the facility. LPA met with Administrator, Stacy Rougely. During the inspection, LPA reviewed 3 client files, facility records, three staff files, and conducted two staff interviews. Based on the annual required inspection on this date, there were no deficiencies found. An exit interview was conducted with the Administrator, Stacy Roughley and a copy of this report was given to the administrator.

met_with: Stacy Roughley, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On August 27, 2025, at 9:39 am, Licensing Program Analyst (LPA), Julian Lucas, arrived unannounced at Richmond Short Term Residential Therapeutic Program (STRTP) located at 20025A Vista Del Lago, Perris, CA 92570. The purpose of the visit was to conduct client interviews. LPA met with Randy Davis, Youth Partner. LPA conducted a walk through of the facility and conducted two client interviews. Based on the continued annual required inspection on this date, there were no deficiencies found. An exit interview was conducted with the Youth Partner, Randy Davis and a copy of this report was given to the Randy Davis, Youth Partner.

met_with: Randy, Davis, Youth Partner


raw_content:
Narrative:
Confidential interviews stated that S1 was supervising C1-C4 when they (S1) encouraged them (C1-C4) to physically assault C5 so that C5 would be moved to other houses and they (C1-C4) would not have to "deal" with C5 any longer. Additional confidential interviews stated that S1 stated things such as, "I won't tell anyone" and "Now is a good time to do it", thus encouraging the clients (C1-C4) to assault C5 physically. Other confidential interviews denied S1, encouraging the minors (C1-C4) to fight C5. Additionally, a witness stated that S1 appeared anxious and flustered shortly after the fighting incident. Based on consistent confidential interviews and pertinent documentation, the allegation that staff (S1) encourage minors (C1-C4) to fight at the facility is substantiated. The facility is cited for a violation of the Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS), Section Personal Rights (c)(16) To be free of physical, ..., emotional, or other abuse, and from ...unusual punishment, ...humiliation, intimidation, ridicule, coercion, threat, ...or other actions of a punitive nature...The facility staff did not ensure that C5 was free from physical and emotional abuse, humiliation, intimidation, coercion, and threat. An exit interview was conducted, and a copy of this report, LIC 9099D, and the appeal rights were discussed and provided to Stacy Rougely, Administrator. Confidential interviews reported that S1 drove the youth to smoke shops and purchased items for the youth when another staff member was not present. Confidential interviews denied S1 providing any illegal substances to the minors in care. LPA was unable to determine how often S1 was purchasing illegal substances (marijuana pens, nicotine patches, and alcohol) for the minors in care. LPA was unable to determine on where and how S1 would provide unlawful substances to minors in care. LPA was unable to determine a precise timeline of S1 allegedly providing any illegal substances to minors in care. Based on inconsistent confidential interviews, the allegations that staff (S1) provided minors (C1-C4) with marijuana pens while in care, that staff (S1) provided minors (C1-C4) with nicotine patches while in care, and that staff (S1) provided alcohol to minors (C1-C4) in care are unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted. A copy of this report and appeal rights were explained and given to Stacy Rougely, Administrator.

Investigation Findings:
13On November 24, 2025, at 10: AM, Licensing Program Analyst (LPA) Cynthia Robinson conducted an unannounced visit to Olive Crest - Richmond, Short Term Residential Therapeutic Program (STRTP), to deliver the investigative findings for the allegation listed above. LPA Robinson conducted a health and safety inspection at the STRTP, and no immediate health and safety hazards were observed. LPA obtained documents pertinent to the investigation. LPA interviewed clients (C1, C2, C3, C4, and C5), and staff (S1, S2, and S3). LPA attempted to interview the County Social Worker (CSW) but was unsuccessful after multiple attempts. On 07/03/2025, Community Care Licensing (CCL) received an allegation that staff (S1) encouraged minors (C1, C2, C3, and C4) to fight at the facility. Collected documentation provided that C5 was physically assaulted by C1-C4, resulting in C5's injury. Confidential interviews revealed that C1-C4 were upset with C5 because C5 would not leave the facility for an outing. (Continued on LIC 9099C...) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Cynthia Robinson LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: RICHMONDFACILITY NUMBER: VISIT DATE: 11/24/2025

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


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Leslie Covarrubias on February 21, 2023 at 9: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Covarrubias met with Courtney Brandon, Administrator and inspected the facility inside and out. LPA reviewed 2 of child's records and 2 of staff personnel files on site at the facility. LPA reviewed 2 of child's psychotropic medications and medication records. LPA interviewed 2 of staff on site to discuss the facilities policies and procedures of operation. LPA interviewed 1 of children currently prescribed psychotropic medication. During the inspection the LPA observed deficiencies (see attached 809D), plan of corrections were discussed and appeal rights were provided. LPA provided a copy of this licensing report to Courtney Brandon, Administrator.

Deficiencies:
80075: 1
2
3
4
5
6
7(k)(7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following

met_with: Administrator, Courtney Brandon


summary: Facility Evaluation

raw_content:
Narrative:
On July 28th, 2023, at 11:37 am Licensing Program Analyst (LPA), Emina Preciado, met with Patricia Mendoza, Youth Specialist to deliver a case management deficiencies report. According to information obtained by Community Care Licensing (CCL) Child #1 (C1)'s personal rights were violated when Staff #1 (S1) (see confidential names list LIC811, dated 07/31/23) encouraged a fight between C1 and Client #2 (C2). On 07/11/2023, C1 and C2 engaged in a verbal and physical altercation that resulted in bruising on C1's arms and torso. S1 supervised the altercation and did not attempt to immediately de-escalate the situation between the clients. Information received disclosed S1 and C2 began shoving each other while exchanging inappropriate comments. S1 did not report the incident to any other facility staff and did not offer medical help to C1. Furthermore, S1 failed to act in a manner that was trauma informed which posed an immediate health, safety, and personal rights risk to clients in care. The facility suspended and terminated S1 from employment at the facility. Based on information obtained, the facility is being cited for violation of Interim Licensing Standards (ILS) Personal Rights section 87072(c)(11). Exit interview conducted, appeal rights provided, and discussed; A copy of the report along with LIC811 and LIC809D page was provided to Patricia Mendoza, Youth Specialist.

met_with: Patricia Mendoza, Youth Specialist


summary: Facility Evaluation

raw_content:
Narrative:
On December 23, 2024, at 9:30 am, Licensing Program Analyst (LPA) Cynthia Robinson met with Olive Crest- Richmond Administrator Stacy Rougely to deliver a case management deficiencies report. On 12/17/2024, during the health and safety inspection, LPA Cynthia Robinson observed at the facility in bedroom #2 a hole in the wall approximately 1 foot in length and 1 foot in width, exposing the wall that is shared with bedroom #1. Based on LPA's observations from 12/17/2024, the facility is being cited for violation of Title 22, Division 6, Chapter 1, Article Physical Environment, Buildings and Grounds (a) The facility shall be clean, safe, sanitary, and in good repair at all times for the safety and well-being of clients, employees, and visitors. A type B citation is being issued. The STRTP facility did not ensure the health, safety, and well-being of Client 1 and Client 2, which poses an immediate Health, Safety, or Personal Rights risk to children in care. A copy of the report, along with LIC 809-D, appeal rights, and LIC 811, was discussed and provided to Richmond Administrator Stacy Rougely.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Jose Gonzalez on February 12,2026 at approximately 9: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Gonzalez met Administrator, Stacey Rougely and Facility Manager Felicia Ware, and conducted a tour of the facility. During the visit there were three staff present at the facility. LPA reviewed one client record and two of staff personnel files on site at the facility. LPA reviewed one client psychotropic medications and medication records. LPA interviewed two staff on site to discuss the facilities policies and procedures of operation. During the inspection the LPA observed no deficiencies. LPA provided a copy of this licensing report to Administrator Stacey Rougely.

met_with: Administrator Stacey Rougely


raw_content:
Narrative:
Confidential interviews reported that S2 and S3 made threats to call Immigration and Customs Enforcement (ICE) on C1 as a form of reprimand. Other confidential interviews reported that the staff did not use ICE or any other threatening words as a form of discipline. LPA was unable to determine whether staff (S1, S2, and S3) threatened a minor (C1) in care. Based on inconsistent confidential interviews and collected documentation, the allegation is that staff (S1, S2, and S3) threatened a minor (C1) in care. The allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted. A copy of this report and appeal rights were explained and given to Stacy Rougely, Administrator.

Investigation Findings:
13On April 6, 2026, at 11: AM, Licensing Program Analyst (LPA) Cynthia Robinson conducted an unannounced visit to Richmond, Short Term Residential Treatment Facility (STRTP) to deliver the investigative findings for the allegation listed above. On 12/30/2025, LPA initiated the complaint at the STRTP, obtained documents pertinent to the investigation, and conducted a health and safety inspection. No immediate health and safety hazards were observed. LPA interviewed Clients (C1, C2, C4, and C6) and staff (S1, S2, and S4). LPA attempted to interview Client 3 (C3) but was unsuccessful due to refusal. LPA attempted to interview Client 5 (C5) but was unsuccessful due to client's whereabouts are unknown. LPA attempted to interview Probation Officer (PO) but was unsuccessful after multiple attempts were made. On 12/24/2025, Community Care Licensing (CCL) received an allegation that staff (S1 and S2) threatened a minor (C1) in care. (Continued on page LIC 9099C...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Cynthia Robinson LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: RICHMONDFACILITY NUMBER: VISIT DATE: 04/06/2026

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

met_with: Administrator, Stacy Rougely


facility_name: ROP ATCS BAKER HOUSE

raw_content:
Narrative:
Confidential interviews revealed conflicting statements. Some interviews indicated that it was requested for staff to stay with C1 while at the Hospital while other interviews indicated the Hospital contacted the facility and told the facility they did not need to stay at the Hospital with C1. Therefore, confidential interviews did not corroborate the allegation with a preponderance of evidence. Based on confidential interviews and records reviewed the allegation that staff left C1 unaccompanied while receiving medical attention, 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, and appeal rights explained. A copy of this report and appeal rights were provided to Erika Merales. A copy of this report will be placed in the facility file.

Investigation Findings:
13On March 6, 2025, at 1:20 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Erika Merales, Senior Coach, and Facility Administrator, Brittnie Peluso, was on the telephone, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on December 16, 2024, at 10:25 am and no deficiencies were observed. LPA Linley interviewed one of five Clients (C1), and five Staff (S1-5), LPA was unable to interview one Adult (A1) and one County Social Worker (CSW), despite multiple attempts to contact them. LPA reviewed facility documents during the investigation. On December 20, 2024, Community Care Licensing (CCL) received an allegation that staff left a minor unaccompanied while receiving medical attention. It was reported that C1 was transported to the Hospital via ambulance and staff did not accompany C1 to the Hospital, which resulted in A1 responding to the Hospital to stay with C1. It was reported that the Hospital attempted to contact the facility and could not reach anyone. 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 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: ROP ATCS BAKER HOUSEFACILITY NUMBER: VISIT DATE: 03/06/2025

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

met_with: Erika Merales


raw_content:
Narrative:
staff bathroom located inside of the staff office. Confidential interviews further revealed that there were no staff nor clients that have witnessed staff smoking in any facility bathrooms however no specific bathroom was identified in the complaint. Confidential interviews also indicated there were no witnesses to support that staff are transporting minors while under the influence in addition staff files were reviewed and had all required documents for staff providing transportation protocols. Therefore, the allegations could not be confirmed. Based on confidential interviews, that staff are smoking inside of the facility and that staff are transporting minors while under the influence, may have occurred, however, it is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained. A copy of this report, LIC 811, and appeal rights was provided to the Administrator.

Investigation Findings:
13On March 10, 2025, at 2: PM, Licensing Program Analyst (LPA) Guadalupe Munoz arrived unannounced at the STRTP facility and met Senior Coach, Erka Merales and on the phone with Administrator, Brittnie Peluso, to discuss the investigative finding for the allegations noted above. LPA conducted an inspection of the facility on 05/23/24 at 1: PM and no deficiencies were observed at this time. LPA Interviewed four Staff (S1-4), LPA interviewed four out of six Clients (C1-4), LPA attempted to interview two Clients (C5-6), however clients declined. During the investigation, the following documents were reviewed: staff schedule, special incident reports, staff file review. On 05/16/2024, Community Care Licensing (CCL) received an allegation that staff are smoking inside of the facility and that staff are transporting minors while under the influence. Specifically, it was reported that staff "smokes inside of the bathroom" and that "staff member transported minors while under the influence". Confidential interviews revealed that there are two bathrooms in the facility. A shared client bathroom and a UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz 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 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: ROP ATCS BAKER HOUSEFACILITY NUMBER: VISIT DATE: 03/10/2025

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

met_with: Brittnie Peluso on phone and Erika Merales


raw_content:
Narrative:
Interviews revealed conflicting statements regarding the reason C1 wanted to change rooms and conflicting statements on whether or not C2 was hitting C1 in the bedroom. Confidential interviews further revealed that the staff counseled both clients on conflict resolution however they did not move either client at that time. Furthermore, interviews confirmed that clients are redirected if observed having any type of negative interactions with each other. In addition, there are no witnesses that observed clients hitting each other, therefore, the allegations could not be confirmed. Based on confidential interviews the allegation that due to lack of supervision, minor is hitting another minor in care, may have occurred, however, it is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained. A copy of this report, LIC 811, and appeal rights was provided to Senior Coach, Ashley Wilson.

Investigation Findings:
13On March 28, 2025, at 11: AM, Licensing Program Analyst (LPA) Guadalupe Munoz arrived unannounced at the STRTP facility and met with Ashely Wilson, Senior Coach,to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 10/09/24 at 10: AM and no deficiencies were observed at this time. LPA Interviewed two staff (S1-2), LPA interviewed three out of six clients (C1-3), LPA attempted to interview two clients (C4-6), however clients declined. During the investigation, the following documents were reviewed: Staff Schedule, Special Incident Reports, and Clients' Needs and Services Plans. On 10/04/2024, Community Care Licensing (CCL) received an allegation that due to lack of supervision, minor is hitting another minor in care. Specifically, it was reported that clients "hit each other". Confidential interviews revealed that C1 and C2 were roommates and that C1 had requested to change rooms. ***Continued on 9099C*** UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz 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 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: ROP ATCS BAKER HOUSEFACILITY NUMBER: VISIT DATE: 03/28/2025

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

met_with: Ashely Wilson


summary: Facility Evaluation

raw_content:
Narrative:
On December 20, 2023 at 9: AM, Licensing Program Analysts (LPAs) Guadalupe Munoz and Jacqueline Garcia conducted an announced pre-licensing inspection and completed Component III. LPAs met with Facility Administrator, Dana Butler. The facility is a three client bedroom one client bathroom single-family, single-story home. The applicant is applying for a Short Term Residential Treatment Program (STRTP) with the capacity of six ambulatory clients aged between 9-17 years old. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. Clients will use a cordless telephone to make and receive confidential telephone calls. The water temperature in bathroom #1 located in the hallway measured to be Degrees Fahrenheit. The facility smoke detectors and carbon monoxide detectors tested and were observed to be in working order; the fire extinguishers are properly charged and serviced. The facility has a fully equipped first aid kit and first aid manual. The applicants stated there were no weapons in the facility. Disinfectants and cleaning solutions will be stored and locked. Sharp knives will be stored in a locked kitchen cabinet. Medication will be locked in the locked cabinet in the attached garage used as a staff office. The staff and client files will be maintained on a digital database. LPA's advised Facility Administrator, 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, Foster Care Ombudsmen Poster and Disaster plans were posted. The facility is set up as follows There is adequate indoor and outdoor activity space.The entry hallway has an attached garage that is designated as a staff office. It has locked cabinets for facility logs, client files and medications. The hallway leads to an open living room that flows into the dining area and attached kitchen. There are three client bedrooms with two clients per room with twin sized beds dresser and closet space for each client. Bedroom #1 is designated for two clients, two twin beds, one dresser with four drawers, and closet space. . Bedroom #2 is: designated for two clients, two twin beds, one dresser with four drawers, and closet space. Bedroom #3 is designated for two clients, two twin beds, one dresser with four drawers and closet space. Each room has adequate clean linens, pillows, blankets, comforters, mattress pads, and mattresses. Next to the client bedrooms is a room that is used as a clinical office and for therapy sessions. The Backyard is set up as follows: The facility dining room has a sliding glass door that leads into the backyard. The backyard has seating area for visits and large yard that is free of debris. ****** Facility Vehicles: The facility has two vehicles for client needs, a facility van and a sedan. LPA Garcia observed vehicle logs that were not updated. Vehicles had current with valid registration and proof of insurance. Vehicles contained emergency backpack with required items. 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/CEO on this date. LPA explained that once the license is approved, all employees shall have an approved criminal record clearance for CCL and be associated to this facility. LPAs observed the following areas that need to be corrected: Vehicle logs for monthly inspections. Blinds are missing slider stick to open the blinds Disaster Logs that need to be updated monthly. Monthly Manual Restraint log is needed. Based on the facility pre-licensing inspection, the facility will make the corrections and once completed submit proof of correction to LPA

met_with: Dana Butler


summary: Facility Evaluation

raw_content:
Narrative:
On 03/11/24 at 1: PM, Licensing Program Analyst (LPA) Guadalupe Munoz met with Brittnie Peluso, ffor the purpose of conducting a post licensing inspection of the facility. A physical plant inspection was completed and included the facility's building and grounds, kitchen area, refrigerator/freezers, food storage areas, client bedrooms, bathroom/showers and facility vehicles used to transport clients. The facility grounds were clean and free of debris and observable hazards. Sports equipment, toys, books, games, computers were observed for children's schooling and recreation time. There is adequate indoor and outdoor activity space. Facility smoke detectors and carbon monoxide detectors are in appropriate working order. Licensee maintains an adequate supply of perishable and non-perishable foods and the menu was posted. All other required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights, Emergency Disaster Plan and Foster Care Ombudsperson poster. Medications are locked and centrally stored inside staff's office. The facility ensures that there is one client per bed with appropriate linens, pillows, comforters, and mattresses in good repair. All bedrooms have individual beds and drawer space for each client. The hot water in the client's bathrooms was measured to be between 103 and 116 degrees. Per designee, no firearms or weapons are allowed in the facility. Chemicals and/or poisons are locked in the hallway closet. The LPA reviewed LIC 610C Emergency Disaster Plan, completed disaster training for staff and clients and completed emergency drills. LPA interviewed 2 clients and 2 staff during visit. Staff files are located at corporate office and therefore inspection will need to be continued at a later date. An exit interview and a copy of this report was provided to Brittnie Peluso, facility representative.

met_with: Brittnie Peluso


summary: Facility Evaluation

raw_content:
Narrative:
On 3/15/ LPA Munoz arrived at ROP ATCS Corporate office to complete post license inspection. LPA completed 5 staff file reviews and 5 client file reviews. An exit interview and a copy of this report was provided to Dana Centanni, facility representative.

met_with: Dana Centanni


summary: Facility Evaluation

raw_content:
Narrative:
On 7/10/2024, at approximately 11:11 am, LPA Joon Choi arrived unannounced to the facility and met with Therapist Diana Guzman. LPA explained the reason for the visit was to interview a Client (C1) regarding a complaint (#19-CR-20240614124712) from a different facility (#33090238). During the visit, LPA interviewed C1 and provided a copy of this report.

met_with: Diana Guzman, Therapist


summary: Facility Evaluation

raw_content:
Narrative:
On January 23, 2025 at 10: AM, Licensing Program Analysts (LPAs) Sarah Lo and Gilbert Marquez conducted an unannounced Annual Inspection at ROP ATCS Baker House Short Term Residential Therapeutic Program (STRTP). LPAs were greeted by the Senior Coach Counselor, Erika Merales and was allowed entry into the facility; and later was joined by Facility Manager, Brittnie Peluso. At 10: AM, LPAs toured the facility and inspected inside and out with the Senior Coach Counselor, Erika Merales. The facility is a one-story home with (3) bedrooms, (1) client bathroom, living room and kitchen. There is a mental health office and a garage used as the staff office and one staff restroom. The Administrator stated current census is five. The facility is licensed to serve six ambulatory children ages between 12-17 years old and non-minor dependents. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. The beds and dressers in all the bedrooms are in good repair, and all window screens are attached. LPAs observed age-appropriate clothing in the closet of the clients. The bathroom is clean and in good repair. The temperature in rooms that clients occupy are registered at 70 degrees F. The hot water temperature was tested and noted to be 113.2 degrees F in the client bathroom. All hazardous items have been properly made inaccessible to areas where clients will have access. The medications were stored and locked in a cabinet in the staff office area. Cleaning supplies and chemicals are locked and stored in a locked cabinet in the staff office area. Sharp knives are inaccessible and stored in a locked cabinet in the kitchen. The First Aid Kit is located in a locked cabinet in the staff office and a locked kitchen cabinet and contains all required items. The facility's smoke detectors located in each bedroom and common areas were checked and were operable. The carbon monoxide detector located in the hallway was operable. There are no guns or weapons in the facility as stated by Administrator at this time. The following required posted items were observed accessible to clients: Grievance Procedures, Personal Rights, Ombudsman Poster, Visitation policies, and current menu. (continued on LIC 809c) LPAs observed a minimum 7-day non-perishable and a 2-day perishable supply of food. There was a variety of snacks available for clients as well. Refrigerators in the kitchen and garage are maintained in a good temperature. The facility outside grounds was also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. Facility has obtained Mental Health Certification which expires on March 23, 2025, and has been accredited by CARF which is valid through February 28, 2025. The facility annual licensing fees are paid to current. LPA Lo discussed the following with the Administrator: Core Services, Specialty Mental Health Service, Trauma Informed Care, Client Personal Rights, and Administrative Duties. LPA Marquez conducted two staff interviews and attempted to conduct interviews with the two clients that were present during the inspection and the two clients refused to be interviewed. Based on the facility inspection and file reviews on this date, there are no deficiencies found at this time. An exit interview was conducted and a copy of this report and LIC 811 was provided to the Administrator, Brittnie Peluso.

met_with: Brittnie Peluso, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On January 27, 2025, at 10: AM Licensing Program Analyst (LPA) Guadalupe Munoz and LPA Gilbert Marquez conducted an unannounced annual continuation visit from inspection that began on January 23, 2025.. LPAs met with Sylvia Arballo, Compliance Manager. The purpose of the visit is to complete client and staff file reviews in order to complete the annual inspection that started on 01/23/25. LPAs conducted five staff file reviews. LPAs conducted five client file reviews. . No deficiencies were noted during time of inspection. An exit interview was conducted and a copy of this report and LIC 811 dated 01/27/25 was provided to Sylvia Arballo, Compliance Manager.

met_with: Sylvia Arballo, Compliance Manager.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPA) Jacqueline Garcia on 09/15/25 at 10: AM. This Case Management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the visit, LPA Garcia met with Program Manager David Owens and Compliance Coordinator, Sylvia Arballo. This visit was a follow up visit to the Case Management inspection conducted on 09/11/25. LPA attempted 3 client interviews who are currently prescribed psychotropic medication. LPA completed 5 staff file review and interviewed 2 staff on site to discuss the facilities policies and procedures of operation. No deficiencies are being cited at this time, the facility was provided with a Technical Assistance (TA) note. LPA conducted exit interview with Program Manager, David Owens and Compliance Coordinator, Sylvia Arballo and provided a copy of this report, along with LIC 811 and the TA.

met_with: David Owens-Program Manager