summary: Facility Evaluation

raw_content:
Narrative:
On 11/18/25, Licensing Program Analyst (LPA) Mariah Hawkins conducted a scheduled prelicensing inspection at the facility site. LPA met with Director Debra Camarillo, Associate Director Maria Newson, Administrator Sal Blancas, and City and County of San Francisco Department of Public Health Program Manager Ryan Fuimaono. Using the CARE Inspection Tool, LPA conducted a tour of the facility site, reviewed operating requirements with applicant representatives, and discussed the pending items to be completed prior to licensure. LPA observed the facility to be clean. The facility is a two-story house in a residential neighborhood. There are two client bathrooms and three double-occupancy client bedrooms with individual beds that each have mattress protectors. There is one staff bathroom connected to the staff office, and there are no staff bedrooms as there will be no live-in staff. There are new linens in each bedroom and extra linens stored in the linen closet. All lights were observed to be functioning. There are kitchen utensils, silverware, and dishes in the kitchen cabinets. The trashcans have tight-fitting lids. There is locked storage for medications, sharps, and confidential records in the staff office. The backyard activity space is free of hazards. There are four surveillance cameras around the exterior of the facility and none inside the facility. LPA reviewed the requirements for surveillance cameras, first aid kits, and other operating requirements with applicant representatives. LPA discussed planned activities and planned corrections or site remodel work. CONTINUED FROM LIC The following items need to be completed prior to licensure. Applicant anticipates completion by 12/15/25. 1. Post complaint/grievance procedures and send photograph to LPA once complete. 2. Post personal rights postings, including Foster Care Ombudspersons poster, and send photograph to LPA once complete. 3. Send LPA updated facility sketches. 4. Send LPA current bank statements for business accounts. 5. Send LPA photos of completed garage, including the floor and the set-up washer and dryer. 6. Send LPA photo of reversed/removed supply closet lock where the keyhole is on the inside of the closet. 7. Send LPA photo of first aid kit scissors and thermometer. 8. Send LPA photo of installed fireplace screen. 9. Complete and submit to LPA the following program statement/admission agreement revisions: A) Use of surveillance cameras per PIN 24-09-CRP. B) Additional language on the non-cash allowance policy, including the rationale behind the policy and the procedure of documenting in each client's needs and services plan the individual assessment of the client's ability to handle cash and/or the safety risks of the client handling cash. C) Statement in the cell phone policy that the program will have the authority to inspect cell phones at any time to either remove the blanket policy or clarify that such searches would only be done when a safety risk is identified and documented like other types of searches and incidents involving a safety risk. An exit interview was conducted, and a copy of this report was provided to applicant representatives.

met_with: Director Debra Camarillo, Associate Director Maria Newson, Administrator Sal Blancas, DPH Program Manager Ryan Fuimaono


state: CA

facility_name: CASA PACIFICA

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
On 10/18/2022, LPA Rosas conducted interviews with clients and facility staff that provided information on the care and supervision for the cottage. On 10/18/2022, LPA reviewed ten (10) staff records stored in Paycon digital system. LPA Rosas ensured to thoroughly review the records of the primary active staff. The facility provided evidence of staff training transcripts stored in RELIAS Training Program digital system with a schedule to complete Hours for new hires and ongoing training for various topics including Trauma Informed, and CSEC training. LPA reviewed the Personnel Report (LIC 500) and confirmed that Direct Care Staff Ratio present for clients in placement. In addition, LPA reviewed ten (10) clients records that stored in Avatar digital system that including Admission Agreement, Inventory of Personal Belongings and cash resources, Dental and Medical forms, Consent Forms, Psychotropic Medication Authorization, Psychotropic Medication logs. LPA Rosas conducted interviews with clients and facility staff that provided information on how clients in placement receive therapy sessions, provide a supportive environment for clients and facility services. Staff and clients provided statements on how the facility has on site therapist and clients are encouraged to attend therapy sessions and the staff ratio present during the day and night. LPA Rosas reviewed Child#1 (C1) discharged Progress Notes written on 10/05/2021 that provided summarized discharge summary and a copy was provided to the parent. C1 was in placement in the facility for total of five (5) days from 10/05/2021 to 10/10/2021. C1 was discharged from the facility per family request. On 02/11/2022, late addendum was written by Staff#2 (S2) regarding discharge summary and adding that discharge was not a result of any negative behaviors or presentation on C1 part. Interviews reported that C1 was in a verbal argument with another resident and C1 reported to parents before facility can submit Special Incident Report. There was not enough information to corroborate the allegation. Results from the Department's investigation, consisting of interviews with related parties, inspections, and review of records. The Department has decided that the allegations of Neglect/Lack of Supervision are unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. There were no deficiencies observed or cited at this time. Exit interview was conducted with A1 and a copy of this report was left at the facility.

Investigation Findings:
13On December 8, 2022, at 9:30am, Licensing Program Analyst (LPA) Olivia Rosas conducted an unannounced inspection to Casa Pacifica for the purpose of concluding the investigation on the above allegations and to deliver the findings. LPA Rosas, met with Staff#1 (S1) and together discussed the investigation details. During the investigation process, LPA Rosas conducted inspection and conducted interviews on January 13, 2022, and November 21, 2022. In addition, LPA Rosas interviewed witnesses and pertinent parties related to the investigation. Individuals mention in this complaint are identify on the Confidential Names List (LIC811) dated December 8, 2022. Based on the confidential interviews conducted during the investigation process, record review, statements obtained, LPA Rosas concluded the allegations of minor attacked another minor while in care, staff unlawfully removed a minor from the facility and staff behavior poses as a risk to the minors while in care. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the findings are unsubstantiated. Report continues LIC-9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Olivia Rosas LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 31-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, VENTURA BLVD., STE. WOODLAND HILLS, CA FACILITY NAME: CASA PACIFICAFACILITY NUMBER: VISIT DATE: 12/08/2022

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

report_type: Complaint Investigation

met_with: Staff#1 (S1)

complaint_status: unsubstantiated


raw_content:
Investigation Findings:
13On December 23,2024 at (;16am, Licensing Program Analyst (LPA) Christine Wilson made an unannounced inspection to the above facility for the purpose of concluding the investigation on the above allegation and deliver the findings. LPA spoke with Cheif Clinical Officer, linical Program Director, Director of Transitional Youth Services, and together, discussed the investigative findings. During the investigative process by Licensing program Analyst (LPA), Wilson, all relevant parties have been accounted for. Supporting evidence includes: interviews with group home residents, guardians and staff denying any observance of staff not supervising minors appropriately. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies are being cited at this time. Exit Interview conducted, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Christine Wilson LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Cheif Clinical Officer


raw_content:
Investigation Findings:
13On 8/28/25, at 11:21 am, Licensing Program Analyst (LPA) Nestor Gomez made an unannounced inspection to the above facility for the purpose of concluding the investigation on the above allegation(s) and deliver the findings. LPA spoke with Chief Clinical Officer (S1) Kim Bennett, and together, discussed the investigative findings. During the investigative process by Licensing program Analyst (LPA), Nestor Gomez, all relevant parties have been accounted for. The validity of the allegations could not be determined. The parties interviewed either confirmed or denied the allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies are being cited at this time. Exit Interview conducted, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Nestor Gomez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Chief Clinical Officer - Kim Bennett


raw_content:
Investigation Findings:
13On 9/25/25, at 1:00pm, Licensing Program Analyst (LPA) Nancy O'Connell made an unannounced inspection to the above facility for the purpose of concluding a follow-up investigation on the above allegations and deliver the findings. During the investigative process by Licensing program Analyst (LPA), Nancy O'Connell, all relevant parties have been accounted for. During the investigative process, LPA obtained information regarding facility discharge policies, and discharge/ treatment documentation for C1. Further, LPA O'Connell conducted a review of public advertisements for the facility and observed facility license numbers to be reflected on the facility website. Evidence obtained and statements gathered by relevant parties did not support the conduct of an improper discharge for C1 and do not reflect that the facility does not reveal licenseing infomration on advertisements. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies are being cited at this time. Exit Interview conducted, and an electronic copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Nancy O'Connell LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Tristan Martines, Cottage Supervisor (S1)


summary: Facility Evaluation

raw_content:
Narrative:
On July 23, 2021 at 2: PM, Licensing Program Analyst (LPA) Regina Martin initiated a Case Management - Incident investigation at Casa Pacifica and met with Facility Administrator, Tone Reyes. The purpose of this inspection was to inform Licensee of an investigation currently ongoing regarding self reported incident, concerning an alleged sexual assault by a "Staff Member" on Youth Resident Client #1 (C1) [see LIC811 dated 7/23/2021]. This incident has been referred to Community Care Licensing, Investigations Bureau. During this inspection, LPA Martin was informed that the subject incident was in fact alleged sexual assault by a "staff member" at the hospital where C1 was being held for observation and not an individual or "staff member" at Casa Pacifica. LPA Martin requested the following documents: Client Rosters and Personnel Schedule (LIC 500); Client #1's: Needs and Service Plan, Placement Agreement, Child and Family Team (CFT) Planning Matrix, and incident reports related to C1. Please emailed requested documents to LPA Martin at - regina.martin@dss.ca.gov Incident requires further investigation. Upon conclusion, LPA will deliver and discuss the findings. There were no deficiencies cited per California Code of Regulations, Title 22 during this inspection. A copy of this report will be emailed to Facility Administrator.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Facility Representative


summary: Facility Evaluation

raw_content:
Narrative:
On 08/04/2022 at 10:00AM, Licensing Program Analyst (LPA), Olivia Rosas made an unannounced visit to Casa Pacifica Group Home for the purpose of conducting the Required 2- Year inspection. LPA Rosas met with Staff#1(S1), Staff#2 (S2), and Staff#3 (S3) who granted access to the facility and an inspection of the facility was conducted together. Individuals mention in this report are identify on the Confidential Names List (LIC811) dated 08/04/22. Temperature and health checks are conducted at the entrance in the sign-in area in the Founders Building. LPA met with Staff#1 (S1), who granted access into the facility, and who provided a tour of the physical plant. This facility provides mental health services and has a Group Home (GH) license to provide care and supervision for forty (40) children ages 13-17 years old, Ambulatory only. There is a swimming pool on the premises which meets licensing requirements. The facility has an approved camera waiver. Staff confirmed that there are no firearms or dangerous weapons in the facility. The facility is current with their annual fees. The facility currently has an approved Council on Accreditation through October 31, 2023. LPA Rosas inspected the following: This is a one (1) story building with three (3) cottages within the Casa Pacifica Campus. Each cottage are equipped with client bathrooms, staff bathrooms, staff office, therapy offices, bedrooms, living room, dining area, kitchen, and laundry room. The facility utilizes the campus medication building, gym, basketballs courts, and pool. There are three (3) facility vehicles used by the facility. LPA Rosas was not able to inspect the Wells Fargo Cottage and Archie's Cottage due of the facility being under quarantine COVID-19. The campus has adequate indoor and outdoor activity space. The campus has non-public school, outdoor recreation area that includes a pool, gym, garden, and basketball court. Report continues on LIC 809-C Page 1 of Wells Fargo Cottage- Is currently occupied by identified "he/him/his" clients. The cottage has four (4) single beds bedrooms, and four (4) double bed bedrooms for a total of twelve (12) beds. There are also three (3) bathrooms, one (1) staff office, one (1) staff bathroom, kitchen, dining room, TV room, and laundry room. The staff office has an extra refrigerator to store any medication that may need refrigeration. The common living area was set up with tables, couches, and a shuffleboard table. There is stabilization room. Archie's Cottage - Currently occupied by identified "she/her/hers" clients. The cottage has three (3) single beds bedrooms, and five (5) double beds bedrooms for a total of thirteen (13) beds. There are also three (3) bathrooms, one (1) staff office, one (1) staff bathroom, kitchen, dining room, TV room, and laundry room. The staff office has an extra refrigerator to store any medication that may need refrigeration. The common living area was set up with tables, couches, and a shuffleboard table. There is stabilization room. Rainbow Education Cottage- Is currently unoccupied. The cottage has eight (8) double bed bedrooms. There are also four (4) bathrooms, three (3) staff office, two (2) staff bathroom, two (2) therapy offices, kitchen, dining room, TV room, and laundry room. The staff office has an extra refrigerator to store any medication that may need refrigeration. The common living area was set up with tables, couches, and storage. The facility has a capacity of forty (40) and there are currently forty-one (41) beds. The facility may be considered over-capacity because of the bed count but at this time but the census is sixteen (16). An extra bed was added due to COVID-19 quarantine and it be removed. The extra bed will be removed from the Wells Fargo Cottage. During the facility was inspected, the following was observed: LPA observed a key locked closet that stored hygiene supplies, and cleaning solutions. All windows were in good condition with screens and blinds. There were no security bars on the windows. There were multiple fire extinguishers and was fully charged and carbon monoxide detectors were working properly in the facility. The passageways are unobstructed. All posting requirements were met, (food menu, regulations, licenses, emergency disaster plan, Children's Personal Rights, and Ombudsman). The cottage has a working telephone and youths can use the telephone unless restricted by court order. The Emergency Evacuation Plan is posted. All posting requirements were met. Report continues on LIC 809-C Page 1 of LPA Rosas reviewed following during the inspection: LPA Rosas requested the following forms for review, Register of Youth, Current Census, Personnel Report Roster, Monthly Staff Roster, Health Clinic Roster, Intake Department Roster, PM Behavior Specialist Roster, approved driving list, Council on Accreditation letter, staff training records, vehicle registration and insurance. Staff Records Review: Facility files are kept digital on Paycon. LPA ensured Administrator Certificate was current. LPA reviewed the Personnel Report (LIC 500) and confirmed that Direct Care Staff Ratio present for the clients in placement. LPA confirmed that all staff have required criminal record clearance. DOJ, FBI and Child Abuse Response, which meet qualification. The Administrator provided evidence of staff training transcripts stored RELIAS Training Program with a schedule to completed hours of training for various topics including CPR, Trauma Informed and CSEC training. LPA Rosas was not able to complete staff file review and will need to return to complete. Clients Records Review: LPA Rosas was not able to complete client record review and will return to complete it. Interviews: LPA Rosas was not able to complete client interviews due to COVID-19 quarantine and will return to complete it. LPA Rosas was not able to conduct staff interviews. A review of Facility's Personnel Report Summary on 08/04/2022 indicates that all personnel have criminal record clearance has obtain the necessary clearances with DOJ, FBI, and Child Abuse Response. LPA Rosas by email send the following PINS to S PIN 20-17-CRP: New Background Check Requirements, Assembly Bill 819 (Chapter 777, Statutes of 2019), PIN 21-20-CRP: Statewide Launch of New Inspection Tools for Children's Residential Licensees, PIN 21-05-CRP: The Family Urgent Response System (FURS), Medications Guide TSP 2017-03 (version 08/23/21). There were no deficiencies observed or cited at this time.


summary: Facility Evaluation

raw_content:
Narrative:
On 08/04/2022 at 10:00AM, Licensing Program Analyst (LPA), Olivia Rosas made an unannounced visit to Casa Pacifica Group Home for the purpose of conducting Case Management inspection. LPA Rosas met with Staff#1(S1), Staff#2 (S2), and Staff#3 (S3) who granted access to the facility and an inspection of the facility was conducted together. Individuals mention in this report are identify on the Confidential Names List (LIC811) dated 08/04/22. Temperature and health checks are conducted at the entrance in the sign-in area in the Founders Building. LPA met with Staff#1 (S1), who granted access into the facility, and who provided a tour of the physical plant. This facility provides mental health services and has a Group Home (GH) license to provide care and supervision for forty (40) children ages 13-17 years old, Ambulatory only. There is a swimming pool on the premises which meets licensing requirements. The facility has an approved camera waiver. Staff confirmed that there are no firearms or dangerous weapons in the facility. The facility is current with their annual fees. The facility currently has an approved Council on Accreditation through October 31, 2023. The Group Home license has with three (3) cottages the Wells Fargo Cottage, Archie's Cottage, and Rainbow Education Cottage. LPA Rosas inspected the Rainbow Education Cottage that is currently not being used and is expected to be used for Education services. The Wells Fargo and Archie's Cottage will be used for mental health services. Report continues on LIC 809-C Page 1 of LPA Rosas inspected the following: Rainbow Education Cottage- Is currently unoccupied. The cottage has eight (8) double bed bedrooms. There are also four (4) bathrooms, three (3) staff office, two (2) staff bathroom, two (2) therapy offices, kitchen, dining room, TV room, and laundry room. The staff office has an extra refrigerator to store any medication that may need refrigeration. The common living area was set up with tables, couches, and storage. During the facility was inspected, the following was observed: LPA observed a key locked closet that stored hygiene supplies, and cleaning solutions. All windows were in good condition with screens and blinds. There were no security bars on the windows. There were multiple fire extinguishers and was fully charged and carbon monoxide detectors were working properly in the facility. The passageways are unobstructed. All posting requirements were met, (food menu, regulations, licenses, emergency disaster plan, Children's Personal Rights, and Ombudsman). The cottage has a working telephone and youths can use the telephone unless restricted by court order. The Emergency Evacuation Plan is posted. All posting requirements were met. LPA Rosas inspected the Rainbow Cottage and found the cottage to met physical plan requirements. Facility is still pending approval of Plan of Operation review. Upon the approval of the Plan of Operation the Rainbow Cottage will be placement ready. There were no deficiencies observed or cited at this time. Exit interview was conducted with S1 and a copy of this report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On 10/04/2022 at 10:00AM, Licensing Program Analyst (LPA), Olivia Rosas made an unannounced visit to Casa Pacifica Group Home for the purpose of conducting the Required 2- Year inspection. LPA Rosas met with Staff#1(S1), Staff#2 (S2), who granted access to the facility and an inspection of the facility was conducted together. Individuals mention in this report are identify on the Confidential Names List (LIC811) dated 10/04/22. Temperature and health checks are conducted at the entrance in the sign-in area in the Founders Building. LPA met with Staff#1 (S1), who granted access into the facility, and who provided a tour of the physical plant. This facility provides mental health services and has a Group Home (GH) license to provide care and supervision for forty (40) children ages 13-17 years old, Ambulatory only. There is a swimming pool on the premises which meets licensing requirements. The facility has an approved camera waiver. Staff confirmed that there are no firearms or dangerous weapons in the facility. The facility is current with their annual fees. The facility currently has an approved Council on Accreditation through October 31, 2023. LPA Rosas inspected the following: This is a one (1) story building with three (3) cottages within the Casa Pacifica Campus. Each cottage are equipped with client bathrooms, staff bathrooms, staff office, therapy offices, bedrooms, living room, dining area, kitchen, and laundry room. The facility utilizes the campus medication building, gym, basketballs courts, and pool. There are three (3) facility vehicles used by the facility. LPA Rosas inspected the Wells Fargo Cottage, Archie's Cottage, Camino Education (Rainbow) cottages. The campus has adequate indoor and outdoor activity space. The campus has non-public school, outdoor recreation area that includes a pool, gym, garden, and basketball court. Report continues on LIC 809-C Page 1 of Wells Fargo Cottage- Is currently occupied by identified "he/him/his" clients. The cottage has five (5) clients in placement. The cottage has four (5) single beds bedrooms, and four (3) double bed bedrooms for a total of twelve (12) beds. There are also three (3) bathrooms, one (1) staff office, one (1) staff bathroom, kitchen, dining room, TV room, and laundry room. The staff office has an extra refrigerator to store any medication that may need refrigeration. The common living area was set up with tables, couches, and a shuffleboard table. There is stabilization room. At the time of the inspection the Central Air Conditioning System was broken. The facility placed individual fans in each bedroom and around common areas. The facility is using two portable air conditioning units in two vacant bedrooms rooms (3 and 7). At time of the inspection the cottage temperature was 75 degrees F. LPA Rosas informed S1, that licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C). Archie's Cottage - Currently occupied by identified "she/her/hers" clients. The cottage has eight (8) clients in placement. The cottage has three (3) single beds bedrooms, and five (5) double beds bedrooms for a total of thirteen (13) beds. There are also three (3) bathrooms, one (1) staff office, one (1) staff bathroom, kitchen, dining room, TV room, and laundry room. The staff office has an extra refrigerator to store any medication that may need refrigeration. The common living area was set up with tables, couches, and a shuffleboard table. There is stabilization room. Camino Education (Rainbow) Cottage- The cottage is divided into two wings and is separated by two locked mental doors. One wing is for identified "she/her/hers" clients and the second wing for identified "he/him/his" clients. They are currently five (5) clients in placement. The cottage has eight (8) double bed bedrooms. There are also four (4) bathrooms, three (3) staff office, two (2) staff bathroom, two (2) therapy offices, kitchen, dining room, TV room, and laundry room. The staff office has an extra refrigerator to store any medication that may need refrigeration. The common living area was set up with tables, couches, and storage. Report continues on LIC 809-C Page 1 of During the facility was inspected, the following was observed in each cottage: LPA observed a key locked closet that stored hygiene supplies, and cleaning solutions inside of the laundry room inside of each cottage. All windows were in good condition with screens and blinds. There were no security bars on the windows. There were multiple fire extinguishers and was fully charged and carbon monoxide detectors were working properly in the facility. The passageways are unobstructed. All posting requirements were met, (food menu, regulations, licenses, emergency disaster plan, Children's Personal Rights, and Ombudsman). The cottage has a working telephone and youths can use the telephone unless restricted by court order. The Emergency Evacuation Plan is posted. All posting requirements were met. LPA Rosas reviewed following during the inspection: LPA Rosas was given a copy current census, and Personnel Report Roster. Client and Staff Records Review: LPA Rosas was not able to complete client record review and will return to complete it. Client Interviews: LPA conducted confidential interviews with eight (8) clients according to the census willing to be interviewed. A review of Facility's Personnel Report Summary on 10/03/2022 indicates that all personnel have criminal record clearance has obtain the necessary clearances with DOJ, FBI, and Child Abuse Response. There were no deficiencies observed or cited at this time.


facility_name: CASA YOUTH SHELTER

raw_content:
Narrative:
There were no witnesses to the said incident. Regarding privacy during phone calls: It was also reported that staff was present during C1's phone calls to their mother. Confidential interviews revealed that clients can make phone calls at the dining room table and the front reception area. Confidential interviews reported inconsistencies with the doors being shut to the reception area, however, LPA observed there were individuals talking in the reception area and their words were not discernable. Confidential interviews and records reviewed did not provide a preponderance of evidence to prove or disprove the allegations that staff did not prevent C1 from being attacked by C2 and C1 was not allowed any privacy during phone calls. Therefore, the allegations are unsubstantiated. An exit interview was conducted, and appeal rights were reviewed with Christina Garcia and Jessica Hubbard. Due to printer malfunction, a copy of this report, along with the LIC 811, and appeal rights will be emailed to the Facility Administrator. A signed copy of this report will be kept in the Facility file.

Investigation Findings:
13On March 27, 2023, at 11:35 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Christina Garcia, Director of Operations and Jessica Hubbard, CEO, of Casa Youth Shelter, to discuss the investigative findings for the allegations noted above. LPA Charmaine Linley conducted an inspection of the facility on 12/05/2022 at 4:00 pm and no deficiencies were found. LPA Linley interviewed four clients (C1-2, C4-5), was unable to interview three clients (C3, C6-7), despite multiple attempts to contact them, and interviewed five staff (S1-5). LPA reviewed the following documents during the investigation: Special Incident Reports, Discharge Reports, Client Roster, and staff schedule. On 12/05/2022, Community Care Licensing received allegations that staff did not prevent youth from being attacked by another youth and youth was not allowed any privacy during phone calls. It was reported that C2 jumped on C1 while they were asleep, kicked them and put them in a headlock. Confidential interviews revealed conflicting information; C2 put C1 in a headlock and C1 or C2 put each other in a chokehold. 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 CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: CASA YOUTH SHELTERFACILITY NUMBER: VISIT DATE: 03/27/2023

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

met_with: Christina Garcia and Jessica Hubbard


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
On 04/12/2023, Community Care Licensing (CCL) received an allegation that C1 was sexually assaulted while in care. It was reported that while C1 was asleep at the facility, an unknown male came into their bedroom and sexually assaulted them. Confidential interviews did not corroborate the allegation with a preponderance of evidence. There were no witnesses to this allegation. The allegation that C1 was sexually assaulted while in care., may or may not 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 were discussed with Josue Montenegero. Due to printer malfunction, a copy of this report and appeal rights will be emailed to the Facility Administrator. A signed copy of this report will be kept in the Facility file.

Investigation Findings:
13On 07/05/2023, at 9:20 am, Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced complaint inspection at the above facility. LPA Linley met with Josue Montenegero, Program Manager. The purpose of the inspection was to deliver the finding of the complaint investigation. Investigator Deniss Douglas from the Community Care Licensing Investigative Branch initiated the investigation at the facility on 04/19/2023. The following individuals were interviewed by Investigator Douglas for the complaint investigation: two Clients (C1-2), attempted to interview one Client (C3), however, was unable to interview them despite multiple attempts to contact them, three Staff (S1-3), attempted to interview one Staff (S4), however, was unable to interview them despite multiple attempts to contact them, one Adult (A1), and one Hospital Supervisor (H1). During the investigation, the following were reviewed: Emergency Response Referral Information, DCFS Service Logs, DCFS Investigation Report, Personnel Report, and Los Alamitos Police Department Incident Report. 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 CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: CASA YOUTH SHELTERFACILITY NUMBER: VISIT DATE: 07/05/2023

met_with: Josue Montenegero


summary: Facility Evaluation

raw_content:
Narrative:
The facility is set up as follows: Facility has six (06) bedrooms totaling a full capacity of twelve (12) clients. There is adequate shelf and closet space for client's belongings. There is a staff office located in front building. The client and staff records are located and locked in the staff office in file cabinets. Three (03) Bathrooms- used by all the clients. The medication and knives/sharps is stored in the locked cabinet in the staff office. The medication logs are kept updated and the dispensing records had no discrepancies. Facility has complete first aid supplies. The cleaning products are stored in the locked cabinet. The facility is clean, organized and very well maintained. The facility has a sufficient supply of sheets, bedding and linens. The facility's smoke detectors in bedrooms and hallways were checked and were operable. The carbon monoxide detector located in the hallways near kitchen/dining room area were operable. All smoke detectors/sprinklers are connected to a fire safety monitoring agency Beacon Security. Detectors are tested quarterly and semi-annually and last tested on 02/11/2022. There are no guns or weapons in the facility as stated by Ms. Hettig. The following required posted items were observed accessible to clients: Grievance Procedures, Personal Rights, Ombudsman Poster, Visitation policies, and current menu. Hot water temperature tested within regulatory requirements. LPA observed a minimum 7-day non-perishable and a 2-day perishable supply of food. There was a variety of snacks available for clients as well. No expired food was located in the supply. All toxins and cleaning agents were secured at the time of visit. Emergency exits were free from obstruction. There is no swimming pool/bodies of water located on the facility premises. ---------- A sample of client and staff files were reviewed during the inspection. Eight (08) client files and ten (10) staff files were reviewed. All the files reviewed were well organized and contained all pertinent documents required per Title 22 regulations. All staff that work at the facility have Department of Justice and Child Abuse Clearance Index clearances. A review of administrative records indicate that the facility has paid their current licensing fees. Based on the facility inspection and file reviews this date, the facility has demonstrated compliance in accordance to Title 22, Division 6 of the California Code of Regulations. There are no deficiencies found at this time. A copy of this report was reviewed and given Shelter Program Manager, Josue Montenegro along with a Confidential Names List (LIC 811). The facility was advised to list each psychotropic mediation on a separate form. LPA Smith provided facility representative with a copy of the LIC622B.

met_with: Josue Montenegro, Shelter Program Manager


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPA's) Jacqueline Garcia and Rachel Vanegas on February 3, 2025 at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA's met with Chief Operating Officer, Lupita Gutierrez. LPA's inspected the facility inside and out and did not observe any deficiencies. LPA's reviewed 0 child records and 6 staff personnel files on site at the facility. LPA's reviewed 0 of 0 child's psychotropic medications and medication records. LPA's interviewed 2 of 6 staff on site to discuss the facilities policies and procedures of operation. LPA's interviewed 0 of 0 youth currently prescribed psychotropic medication. During the inspection LPA's did not observe any violations therefore no deficiencies are being cited at this time. LPAs conducted exit interview with Chief Operating Officer, Lupita Gutierrez and a copy of this report, LIC 811 dated 02/03/25 were provided to the Chief Operating Officer, Lupita Gutierrez.

met_with: Lupita Gutierrez-Chief Operating Officer


summary: Facility Evaluation

raw_content:
Narrative:
On 04/01/2025 at 09: AM, Licensing Program Analyst (LPA) Gilbert Marquez conducted an unannounced annual inspection at the facility listed on this form. LPA met with the facility manager, Kathleen Cyr. LPA and facility manager toured the facility inside and out. Review of the facility's operations shows that the facility is licensed to serve twelve (12) clients ages 12 - 17 years of age for shelter care with stays for 21 days. The facility currently has a census of five (05) clients in care at this time. LPA noted that the facility has an exterior camera system. LPA noted that the monitors are located on the outside of the facility. The facility is set up as follows: There is a parking lot behind the building, and some street parking in the front of the building. Facility has six (06) bedrooms totaling a full capacity of twelve (12) clients. There is adequate shelf and closet space for client's belongings. There is a front lobby, and an intake office located in front of the building. The client records, their medications, and knives/sharps are located here in file cabinets. There are four (04) bathrooms, one used by staff only, and three by only the clients. There is a recreation room upstairs, and nothing else is on the second floor. Facility has complete first aid supplies. The cleaning products are stored outside in another locked cabinet. The facility is free of debris, organized and well maintained. The facility has a sufficient supply of sheets, bedding, towels, and toiletries. The facility uses one van for transportation, and no maintenance lights were on. **Continued on LIC809-C** **Continued from LIC809** Hot water temperature tested in bathroom #2 at 108 degrees Fahrenheit and that is within regulatory requirements. LPA observed a minimum 7-day non-perishable and a 2-day perishable supply of food. There was a variety of snacks available for clients as well. No expired food was located in the pantry supply area. The facility's smoke and carbon monoxide detectors in bedrooms and hallways were checked by one staff pulling the signal system, which in all alarms and lights going off. Owens Security maintains the fire system. There are no guns or weapons in the facility as stated by facility manager. The following required posted items were observed accessible to clients: License, Grievance Procedures, Personal Rights, Ombudsman Poster, and current menu. Emergency exits were free from obstruction. No client windows had locks on them, and all window screens were in good repair. A second building on the campus holds two floors, and only the therapy rooms are visited by the clients. The second floor has four offices that are used as therapy locations or for office work for the administrators. The operations manager office has the staff flies in a locked cabinet; some files are also on the digital server. On the bottom floor is the conference room, and two staff offices. A sample of client and staff files were reviewed during the inspection. Five (05) client files (C1-C5) and five (05) staff files (S1-S5) were reviewed. All the files reviewed contained all pertinent documents required per Title 22 regulations. All staff that work at the facility had criminal background clearances. Two of five clients were interviewed (C1 and C2), and two of forty-six staff (S3 and S4) were interviewed. Based on the facility inspection, files reviewed, and interviews, there are no deficiencies found at this time. An exit interview was conducted with Interim Executive Director Lupita Gutierrez. A copy of this report was reviewed and given along with a Confidential Names List (LIC 811).

met_with: Kathleen Cyr, Facility Manager


facility_name: CATHOLIC CHARITIES/ANGEL'S FLIGHT

raw_content:
Narrative:
There were no witnesses of insects or pest, including evidence of monthly Residential & Commercial pest control services and the children's and staff's records are safe guarded. Due to lack of evidence obtained during the investigation. LPA determines that the allegation of Neglect/Lack of Supervision, Physical Plant and Personal Rights are Unsubstantiated at this time meaning, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. There are no deficiencies cited at this time. An exit interview was conducted, and a copy of this report was left at the Program Administrator.

Investigation Findings:
13On September 23, 2022, at 9:40AM Licensing Program Analyst (LPA), Rosslyn Gray made an unannounced visit to conclude the investigation and to deliver the findings. Prior to entering the facility LPA-Gray conducted a Health and safety risk assessment and asked were there any positive COVID-19 cases and or Monkey Pox. During the investigatio LPA-Gray interviewed and accounted for all available relevant parties; and gathered pertinent information in reference to the allegations. The Licensee denied the allegations. Based on confidential interviews and review of documentary evidence, there is no evidence or witnesses to support that the facility does not provide a safe environment for minors in care;facility has pests; facility is not properly maintaining minors' and employees' personal records/documents. Documentary interviews were congruent that staff does provide proper supervision and ensure that the environment is safe, that also include evidence of monthly emergency evacuations. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Rosslyn Y. Gray LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: CATHOLIC CHARITIES/ANGEL'S FLIGHTFACILITY NUMBER: VISIT DATE: 09/23/2022

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

met_with: PROGRAM ADMINISTRATOR


raw_content:
Narrative:
On October 6, 2022, LPA Martin met with facility representative, informed of the investigation and obtained records. The investigation further included review of facility file records, review of records from the Los Angeles Police Department, review of facility video footage dated October 2, 2022 and confidential interviews with related parties including C1, staff members, facility resident, assigned Social Worker and other associated parties. Based on records reviewed and confidential interviews, the allegation cannot be substantiated due to a lack of corroborating evidence. Information obtained did not confirm or negate inappropriate touches. The investigation found no evidence that the alleged occurred; therefore, the allegation is found Unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. There are no deficiencies cited per California Code of Regulations, Title 22 at this time. Exit interview completed. A copy of this report and LIC811 was provided to Facility Administrator.

Investigation Findings:
13THIS IS AN AMENDED VERSION OF THE ORIGINAL REPORT ISSUED ON 3/17/2023. On March 17, 2023 at 11: AM, Licensing Program Analyst (LPA), Regina Martin conducted a follow-up complaint inspection to deliver findings concerning the above-mentioned allegation. LPA met with Patricia Chaidez, Program Director to discuss the outcome. The investigation was referred and conducted by Community Care Licensing Investigations Bureau, Investigator Lorraine Patterson. On October 3, 2022, the El Segundo Children's Residential Program Regional Office received claims of sexual abuse by Staff member #1 (S1) on youth resident/Client #1 (C1) as C1 was reportedly touched inappropriately by S1 [see Confidential Names form, LIC 811, dated 3/17/2023]. (Continued on LIC9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Regina Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: CATHOLIC CHARITIES/ANGEL'S FLIGHTFACILITY NUMBER: VISIT DATE: 03/17/2023

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

met_with: Patricia Chaidez


raw_content:
Narrative:
The following documents were reviewed: the Client Inventory Form, House Rules, Visitation Rules, Handbook, and Food Menu. After completing the interviews and reviewing the documentation, it was determined that there was insufficient evidence or testimony to substantiate the allegations. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. The Department has decided that the allegation(s) are Unsubstantiated, but if any additional information is received, this complaint can be amended and the finding can be changed. There were no deficiencies cited. An exit interview was completed, and a copy of this report was provided to the facility.

Investigation Findings:
13On July 25, 2025, at 12:15PM, Licensing Program Analyst, (LPA), Justine Armstrong conducted an unannounced visit to CATHOLIC CHARITIES/ANGEL'S FLIGHT facility for the purpose of delivering findings for a complaint investigation alleging, (1) Staff did not seek timely medical and mental attention for a minor (2) Staff do not provide adequate food service to a minor (3) Staff demonstrated inappropriate form of punishment (4) Staff mistreat a minor while in care (5) Staff do not prevent a minor from being bullied while in care (6) Staff interfere with a minor's visitations (7) Staff are retaliating against a minor This complaint was received by the Department on February 27, 2024. Upon arrival, LPA was granted access to the facility by Christie Rubalcava the Residence Attendant LPA J. Armstrong conducted confidential interviews and gathered relevant information regarding the allegations. Staff members denied the accusations, and the client's statements did not provide sufficient details to support the allegations. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Enrique M Hernandez LICENSING EVALUATOR NAME: Justine Armstrong LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: CATHOLIC CHARITIES/ANGEL'S FLIGHTFACILITY NUMBER: VISIT DATE: 07/25/2025

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

met_with: Christie Rubalcava


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward arrived at the facility at 10: AM to conduct the Year Inspection. LPA met with administrator Patricia Chaidez who stated that the facility is on "Outbreak Status" according to the Dept. of Health. Currently there is one staff member that tested positive for COVID 19 on 04/19/22. All clients were tested on 04/19, 04/21 and 04/26 and were found to be negative for COVID 19 although one client did test positive for the flu. LPA Jones-Steward informed Ms. Chaidez that the inspection would be completed on a later date once the facility is cleared by the Dept. of Health.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward met with administrator Patricia Chaidez to complete the inspection which began on 04/28/22. The following was observed: The facility received COVID outbreak clearance from the County of Los Angeles Public Health on 05/05/22. Ms. Chaidez will submit a copy of the clearance letter via email to this LPA. The COVID positive staff has returned to work as of 05/06/22. No clients tested positive during this outbreak. The facility is licensed for a Group Home with a capacity of 16. The census today is 5. The facility is an emergency shelter for children ages 10 through 17 with an average stay of 30 days per client.. Clients are placed in the shelter on a voluntary basis and usually no other placement agencies are involved however Catholic Charities/Angel's Flight does occasionally accept DCFS placements and unaccompanied minors. Facility is a two story building. All residents sleep on second floor. There is no signal system in place. Program Director Patricia Chaidez states that there is always at least one full time staff located on the second floor during the night or when children are in their bedrooms. Due to COVID, children are usually in their bedrooms when they are home. Social distancing is maintained when clients are in the day room or using any common area There are a total of 10 bedrooms and 16 beds. The kitchen area, bedrooms and bathrooms were all clean and well maintained. Hot water temperature was within the required range. There is food available to meet the requirements of Title 22. There are no bodies of water on the premises. There are no security bars on windows Hazardous items are stored in locked cabinets as required. Fire alarm panel is working and fire drills are conducted on a monthly basis. The last fire drill was conducted 04/14/22 and is conducted monthly LPA reviewed 5 client files and interviewed 2 clients. Review of staff files and staff interviews will be conducted at a later date. There were no deficiencies cited as a result of this inspection.

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward met with administrator Patricia Chaidez to review staff file. and conduct staff interviews. A total of five staff files were reviewed and two staff were interviewed, There were no deficiencies cited as a result of the staff file review,


summary: Facility Evaluation

raw_content:
Narrative:
On March 24, 2923 at 2: PM, Licensing Program Analyst (LPA) Regina Martin conducted a Case Management inspection at CATHOLIC CHARITIES/ANGEL'S FLIGHT for the purpose of obtaining signature and delivering amended Complaint Investigation Report. LPA met with Facility Administrator Patricia Chaidez. There are no deficiencies cited per California Code of Regulations, Title 22, during this inspection. Exit


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward met with Program Director Patricia Chaidez to commence the annual/random inspection. The facility is licensed for a Group Home with a capacity of 16. The census today is 7. The facility is an emergency shelter for children ages 10 through 17 with an average stay of 30 days per client.. Clients are placed in the shelter on a voluntary basis and usually no other placement agencies are involved however Catholic Charities/Angel's Flight does occasionally accept DCFS placements and unaccompanied minors. Facility is a two story building. All residents sleep on second floor. There is no signal system in place. Director Patricia Chaidez states that there is always at least one full time staff located on the second floor during the night or when children are in their bedrooms. During the day, clients are usually in the common area. There are a total of 10 bedrooms and 16 beds. All bedrooms have one or two twin beds with the required linens. Each bedroom has the required closet space. The kitchen area, bedrooms and bathrooms were all clean and well maintained. There is food available to meet the requirements of Title 22. There are no bodies of water on the premises. There are no security bars on windows of bedrooms. There is a complete first aid kit. Disaster drills are conducted on a monthly basis. The last drill was conducted on 04/24/2024. There is a working fire alarm panel and several fire extinguishers throughout the facility and on both floors. There are carbon monoxide detectors throughout the facility. A review of client records was conducted. Licensee was cited under sections 80069(a), 84070(c)(3), 84070(b)(12) and 84070(b)(13)(H). Staff files will be reviewed at a future date.

met_with: Patricia Chaidez, Program Director


summary: Facility Evaluation

raw_content:
Narrative:
On 05/05/26, Licensing Program Analyst (LPA) Andrea Aceves arrived at the above facility for the purpose of conducting an Annual/Random Inspection. LPA met with Program Director Tracy Alvarez who granted access to the facility. The facility is licensed to serve children ages 10-17, ambulatory only. Currently the census is (7). There is no pool on the premises. Facility overview: The facility is a two-story building. All clients reside on the second floor. The facility has ten (10) Bedrooms, seven (7) Bathrooms, Kitchen/Dining Hall, Laundry Rooms, Staff Offices, Visitation Room, Recreational Room and Outdoor recreation area. During the inspection LPA observed the following: Bedrooms: bedrooms two (2) twin beds; all rooms are equipped with closet space, adequate lighting, dressers, a window, and clean linen. Bathrooms: three (3) bathrooms upstairs are for the clients and contain toilet stalls, showers with individual shower doors, and sinks; two (2) bathrooms downstairs near kitchen area are for the clients. The water temperature was tested and found to be between 105 - 120 (F). Kitchen: is equipped with two (2) refrigerator/freezers, a large stove all burners were operational at the time of inspection, microwave, dishwasher, toaster, ample plates, cups, and eating utensils. The kitchen cabinets are labeled, and sharp items are stored in a locked drawer near the sink. LPA observed the weekly sample menu posted on the refrigerator.Report continued on LIC 809C (Page 1 of 3) LPA observed the facility to have ample perishable food items in the refrigerator and the pantry is fully stocked with non-perishable food items. Dining Hall: is equipped with a large table and multiple chairs. Laundry Room: the laundry room located in the basement and is equipped with two washer s and two dryers; Laundry room is locked and clients must enter with staff to use laundry room. It also has emergency supply of food and water. Phone Room: It is equipped with chairs, a coffee table, and a phone for clients to make confidential calls. Staff Offices: Each office has a desk, chair, and a computer. Medication is stored in the first floor staff office in the recreation room. Medication is locked in a cabinet. Clients are able to make phone calls in the office. All staff offices are kept locked and made inaccessible to clients in care. Visitation Room: is located on the first floor. It is used for visitation for clients. The room is equipped with couches, a coffee table, and chairs. Recreation Room: the room is located on the first floor and is equipped with lounge chairs, a television, books, board games, computers and a pool table. Storage Room: located on the second floor, hygiene supplies, clothes, and linens. The room is kept locked and inaccessible to clients. Miscellaneous: Smoke and Carbon Monoxide combination detectors were tested and found to be in working order by the fire department. Fire extinguishers, located throughout the facility, were observed and fully charged. The facility has a separate fire alarm system. The following posting requirements were observed and posted in a public area: Grievance Procedures, Personal Rights, the facility license, the food menu, the daily activity schedule. Report continued on LIC 809C (Page 2 of 3) Miscellaneous: Smoke and Carbon Monoxide combination detectors were tested and found to be in working order by the fire department. Fire extinguishers, located throughout the facility, were observed and fully charged. The facility has a separate fire alarm system. The following posting requirements were observed and posted in a public area: Grievance Procedures, Personal Rights, the facility license, the food menu, the daily activity schedule. Transportation: The facility has a total of 2 vehicles to transport clients. LPA inspected the vehicles and found seat belts and horn in working order, current registration, and insurance. Vehicles are insured by Arthur J. Gallagher and Co. and it expires 10/24/2026. Overall LPA observed the facility to be clean, safe, and in good repair. The facility operates within license conditions and limitations including capacity limitations. LPA reviewed 2 clients files and 3 staff files. Files did not meet licensing regulations; therefore a deficiency will be issued. Exit interview was completed and a copy of this report was provided to the Program Director Tracy Alvarez.

met_with: Program Director Tracy Alvarez


facility_name: CENTER FOR DISCOVERY-WHITTIER

raw_content:
Narrative:
Additional interviews reveal that clients are checked every 15 minutes; doors are required to be open and staff supervising clients in groups always have a line of sight. Due to high risk behaviors of some clients in placement, staff are on standby within the vicinity of restrooms if clients need to use the restroom. Clients are monitored when going inside and when coming out of restrooms. No statements were obtained from the alleged involved clients; parents did not grant consent for interviews. One client and parent requested one agency case to be closed and signed a complaint refusal form. Information obtained from additional records reviewed showed no evidence of any sexual acts between clients. Based on information obtained, there is insufficient evidence found to support the allegation, so the allegation is unsubstantiated. Although the allegation may have happened or is valid, the preponderance of evidence to prove the allegation was not met. An exit interview was conducted. A copy of this signed report, the Confidential Names Form and Appeal Rights forms were provided via electronic mail. There was no deficiency citation issued.

Investigation Findings:
13On September 2, 2021, Licensing Program Analyst (LPA) Irene Yamamoto delivered the finding of the allegation at the facility. LPA discussed the finding with the facility representative named above. The allegation was investigated by the Department's Investigations Branch (IB), assigned to Investigator Laura Garcia. Investigator Garcia conducted confidential interviews with staff, clients and other related parties (refer to Confidential Names Form LIC 811 dated September 2, 2021). Investigator Garcia also reviewed pertinent documents obtained from the client file, the facility complaint history, supervision check logs and other agency reports. It was alleged that there was lack of supervision resulting in clients engaging in inappropriate sexual activities. Confidential interviews reveal that a client engaged in inappropriate sexual behavior inside a bathroom due to peer pressure. No other client was present, and client did not engage in any sexual acts with other clients. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Irene Yamamoto LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: CENTER FOR DISCOVERY-WHITTIERFACILITY NUMBER: VISIT DATE: 09/02/2021

met_with: Sam Edman, Administrator


raw_content:
Narrative:
Confidential interviews revealed there was an incident. Client stated the incident occurred but provided inconsistent statements during interviews. Additional interviews revealed clients are checked every 15 minutes; doors are required to be open and staff supervising clients in groups always have a line of sight. Due to high risk behaviors of some clients in placement. No statements were obtained from the alleged perpetrator. Witness stated the clients did not disclose anything inappropriate at the time of incident. Based on information obtained, there is insufficient evidence found to support the allegation, so the allegation is unsubstantiated. Although the allegation may have happened or is valid, the preponderance of evidence to prove the allegation was not met. An exit interview was conducted. A copy of this signed report, the Confidential Names Form and Appeal Rights forms were provided via electronic mail. There was no deficiency citation issued.

Investigation Findings:
13On June 8, 2022 at 1:30PM, Licensing Program Analyst (LPA) Pedro Ramos conducted a follow-up complaint inspection to CENTER FOR DISCOVERY-WHITTIER and met with staff above. The purpose of the inspection was to deliver findings for the above complaint allegation. During the course of the investigation, LPA Ramos received pertinent documents. Confidential interviews were conducted with client and other relevant parties (see Confidential Names Form dated: 6/8/22). It was alleged inappropriate interactions between minors in care. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Pedro Ramos LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: CENTER FOR DISCOVERY-WHITTIERFACILITY NUMBER: VISIT DATE: 06/08/2022

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

met_with: Kelly Gonderman, Program Director


summary: Facility Evaluation

raw_content:
Narrative:
On July 20, 2021, at 11:05 am, Licensing Program Analyst (LPA), Belinda Gilmer conducted an unannounced Case Management Inspection to the above agency and spoke with Kelly Gonderman Assistant Program Director. The purpose of the inspection was to discuss and investigate a special incident reports Community Care Licensing (CCL) received on 07/14/21. The incident occurred on 07/03/21 but wasn't reported until 07/14/21. When the group home was made aware of the incident. The C2 and C3 weren't interviewed today as they were both discharged on 07/14/21. LPA spoke with C1 about the incident and C1 confirmed the incident took place between the time the staff conducted their 15 minutes rounds. LPA Gilmer also discussed a special incident report that Community Care Licensing received on 07/16/21. Involving C4 and C5 engaging in a sexual act. Both C4 and C5 were discharged after completing their program. An exit interview was held and copies of the facility evaluation form, confidential names list, and the technical assistant were emailed to Kelly Gonderman.

met_with: Kelly Gonderman


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by Licensing Program Analysts (LPAs) Carrie Palmer and Johanna Lofton on October 5, 2022 at 9:00am. During this visit, LPAs met with Facility Manager Samuel Edman and Kelly Gonderman Assistant Program Director. LPAs and staff toured the facility inside and out. The facility is licensed for a capacity of 25 clients. Current census is 19. The facility consists of two (2) buildings with addresses 119111 and 11913. Unit 11911 is the administrative building and therapy services for the clients. This building has a reception area, six (6) therapy rooms, a processing room, reception area, kitchen and restrooms. Building 11913 is the residential building which consists of fifteen (15) bedrooms, recreational rooms, nursing stations, bathrooms, laundry area, staff offices, outdoor activity space, dining room and kitchen. LPAs were able to see food supply and verified there was enough perishables and non-perishables items. The facility was observed to be clean, safe, sanitary, in good repair and passageways were unobstructed. There were no bodies of water on the premises. Cleaning solutions, poisons and sharp objects were locked and inaccessible to clients. Medication was observed to be double locked in a cart in the nurse's office. Smoke and carbon monoxide detectors were not tested today because it mainlines are wired directly to the fire department. Staff reported having a fire drill the day before (10/04/22). During the inspection LPAs observed the children's Personal Rights, Ombudsman flyer,emergency disaster plan, facility sketch and foster youth bill of rights were posted. LPAs received a copy of the LIC500 and the Client Roster. An exit interview was conducted and a copy of this report was provided to staff. This annual requires a continuation.

met_with: Samuel Edman- Administrator


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by Licensing Program Analysts (LPAs) Carrie Palmer and Johanna Lofton on October 27, 2022 at 10:30am. During this visit, LPAs met with Facility Manager Samuel Edman and Kelly Gonderman Assistant Program Director. LPAs reviewed staff training plans, training logs, records of restraints/logs in their electronic tracking system; as well as Quarterly Board Meeting Minutes. Current census is 21. During the inspection, LPAs completed the following domains: Emergency Intervention Plan and Operational Requirements. Both domains were in compliance. Exit interview was conducted and a copy of this report was emailed to administrators. .


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection/file review was conducted by Licensing Program Analysts (LPAs) Carrie Palmer and Noubar Yerkatyan on December 21, 2022 at 9:15am. During this visit, LPAs met with Facility Manager Samuel Edman and Kelly Gonderman Program Director. The purpose of today's visit was to review 5 client files with Facility Manager and Program Director. During the clients file review LPAs were able to review the program statement, policies and procedures specific to cash allowances, children's phase sheets, menus and glucose logs. At the time of the inspection, one technical violation was observed and discussed with staff (CCR 84087(e) Building and Grounds). An exit interview was conducted and a copy of this report along with the LIC 811 was provided to staff via email.


summary: Facility Evaluation

raw_content:
Narrative:
On 01/06/23 at 1:50pm, Licensing Program Analysts (LPA) Carrie Palmer conducted an unannounced inspection at Center for Discovery - Whittier to complete a 2-Year Required inspection initiated on 10/05/22. LPA met with the Sam Edman, Facilities Manager, and stated the purpose of the inspection. LPA stated that the purpose of today's inspection was a continuation from the previous visit (12/21/22) and the focus would be staff and client interviews. LPA requested a copy of the Personnel Report and the and the phase sheet for all residents in care. LPA Palmer conducted 3 staff interviews and 3 client interviews. A copy of the LIC 809 and LIC 811 were discussed and provided to the facility representative. An exit interview was conducted.


summary: Facility Evaluation

raw_content:
Narrative:
On June 19, 2023, Licensed Program Analyst (LPA), Carrie Palmer conducted a Case Management visit. Upon arrival, LPA explained the nature of the visit. The facility has a current census of 23 clients. During the visit, LPA Palmer was able to interview one staff and one client. Documents were reviewed such as: shift notes from May 17, 2023 and one child's electronic file. LPA requested a printed file for the client. The Program Director made the request to the facilities Human Resources team. The Program Director was unable to provide documents during the visit. The documents will be emailed to the LPA on or before June 20, 2023. LPA also took photographs of the areas of where each incident took place. LPA requested copies of the staffing schedule for the weeks of May 8th and May 15th of 2023 and a copy of the discharge summary. Program Director unable to provide the staffing schedule during the visit. LPA was provided with the discharge summary. LPA requests that the schedule be sent via email to LPA on or before June 20, 2023. Additional time is needed to conduct this Case Management. A copy of this report has been provided to the Program Director. And a Form 811 and two 811c's were completed.


facility_name: CENTER FOR DISCOVERY - BRENTWOOD

summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13On 7/1/22, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the residential treatment group home facility to deliver findings of an investigation of the above allegation, which was conducted by the Licensing Agency's Investigations Branch (IB). LPA met with Mental Health Technician Latiesha O'Neal and informed of the purpose of the visit. Based on confidential interviews, an overnight staff member would kiss a client on the forehead when helping the client to bed and took another client out of their bedroom on their 18th birthday, kissed the client, and touched the client's buttocks, vagina, and breasts. The preponderance of evidence standard has been met, and therefore the above allegation is found to be Substantiated. LPA is issuing a citation of California Code of Regulations, Title 22, Division 6, Chapter 5, Article 6, Section Personal Rights. An exit interview was conducted, appeal rights provided, and a copy of this report left with Mental Health Technician Latiesha O'Neal, whose signature on this form confirms receipt. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Mendoza LICENSING EVALUATOR NAME: Mariah Hawkins LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, TRAEGER AVE., SUITE FACILITY NAME: CENTER FOR DISCOVERY - BRENTWOODFACILITY NUMBER: 075650136

complaint_status: SUBSTANTIATED


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
The preponderance of evidence standard has been met, and therefore the above allegation is found to be Substantiated. LPA is issuing a citation of California Code of Regulations, Title 22, Division 6, Chapter 5, Article 6, Section Personal Rights. An exit interview was conducted, appeal rights provided, and a copy of this form was left with Administrator Sara Stokes, whose signature on this form confirms receipt.

Investigation Findings:
SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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

met_with: Administrator Sara Stokes; Interim Administrator Virginia Parish


summary: Facility Evaluation

raw_content:
Narrative:
On Wednesday 5/18/22 at 9:51AM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility for a required 2-year inspection. LPA met with Interim Administrator Virginia Parish and informed of the purpose of the visit. Safety precautions were taken, including mask-wearing and pre-visit screening call. The CARE Inspection Tool was used to conduct this inspection. The facility is a house in a residential neighborhood. The yard and facility grounds are well maintained. There is a pool in the backyard secured by a fence and locked gate. There are three double-occupancy bedrooms. All residents have their own beds, and beds have clean linens. The kitchen is stocked with quality food that is stored safely and in a quantity to meet the needs of residents in care. Special diets are being followed. First aid kit was observed to be complete. Files were observed to be complete and contained required documentation. The following deficiencies were found (See LIC 809-D and LIC 9102s): 1) Seven (7) staff (S1, S2, S3, S4, S5, S6, and S7 -- See LIC Confidential Names) do not have a clearance associated to the facility and are therefore not cleared to work at the facility. LPA is issuing a citation of California Code of Regulations (CCR), Title 22, Section 80019(e) as well as an immediate civil penalty, per Section 80019(g), of $100 per day, for a maximum of 5 days, per individual in violation, for a total of $3,500. 2) One youth (R1 - See LIC 811) did not have a medical assessment on file and was admitted just over 30 days ago. LPA is issuing an advisory of CCR, Title 22, Section 80069(a). 3) There is one designated facility manager for this facility and nearby sister facility. LPA advises that there should be a facility manager present at all times children are present when the administrator is absent, and the facility may designate more than one facility manager. LPA is issuing an advisory of CCR, Title 22, Section 84065(d). 4) Hot water measured very slightly above the upper limit of the hot water range, at 120. F. LPA is issuing an advisory, in case of fluctuations in hot water that may result in hotter temperatures, of CCR, Title 22,... ...Section 80088(e)(1). 5) There is a pool on the premises, but staff do not have valid water safety certificates on file. LPA is issuing an advisory of CCR, Title 22, Section 80065(e)(2). 6) There was no bedroom sharing agreement documentation. LPA is issuing an advisory of CCR, Title 22, Section 84087(e). An exit interview was conducted, appeal rights provided, and a copy of this report was left with Program Director Virginia Parish, whose signature on this form confirms receipt.

met_with: Interim Administrator Virginia Parish


summary: Facility Evaluation

raw_content:
Narrative:
On 9/21/22, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit at the facility. LPA met with Interim Administrator Virginia Parish and informed of the purpose of the visit. On 7/1/22, the facility was issued a citation of California Code of Regulations, Title 22, Section 84072(d)(11) Personal Rights, and on 9/16/22, the facility was issued another citation of Section 84072(d)(11). LPA is issuing a civil penalty for repeat violation of $250. See LIC 421FC, dated 9/21/22. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Interim Administrator Virginia Parish, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On January 11, 2023 at 2:30PM, Licensing Program Analyst (LPA) Mariah Hawkins, Licensing Program Manager (LPM) Isabel Mendoza, and Regional Manager (RM) Nelson Martinez conducted a scheduled Office Meeting in order to assess an Enhanced Civil Penalty (ECP) for a violation found during an investigation at the facility. LPA, LPM, and RM met with Division President Amy Brown, Chief Operating Officer James Bailey, Regional Director Monica Powers, Program Director Virginia Parish, and Administrator Sara Stokes. On 09/16/2022, the Department of Social Services, Community Care Licensing Division concluded an investigation into the allegation that the facility failed to provide care and supervision resulting in resident R1 being sexually assaulted by their roommate, resident R2 (See LIC Confidential Names List, dated 01/11/23). The assault included digital penetration of the vagina. Based on confidential interviews conducted during the investigation, the staff member on shift did not conduct bedroom checks per the facility procedures in the facility's plan of operation and did not check the room for a period of almost 2 hours, during which the assault occurred. Additionally, the facility was aware that R2 had a history of sexualized behavior toward other residents. On 09/16/2022, the Department issued substantiated findings and a citation of California Code of Regulations, Title 22, Division 6, Chapter 5, Article 6, Section 84072(d)(11). The Department has concluded an analysis of applicable laws and regulations and has determined that an Enhanced Civil Penalty is warranted for a violation resulting in physical abuse. Therefore, on this date (01/11/23), pursuant to Health and Safety Code section 1548(f)(1)(C), the Department has issued a civil penalty of $2,500. See LIC 421, dated 01/11/23. The above information and appeal rights were discussed during the meeting, and a copy of this LIC 809 report, the referenced LIC 811 and LIC 421, and the appeal rights were provided to Division President Amy Brown, Chief Operating Officer James Bailey, Regional Director Monica Powers, Program Director Virginia Parish, and Administrator Sara Stokes, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 4/19/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit at the facility and met with Administrator Sara Stokes. LPA informed Administrator that the purpose of the visit was to meet the requirement set during the noncompliance conference (NCC) for quarterly inspections to review staff training and knowledge of supervision and reporting requirements. The additional terms of the NCC were: (2) to ensure staff were fully trained, per applicable regulations, at hire and additionally on no less than a quarterly basis; (3) to designate two overnight staff each night with at least one being a facility manager, meeting this requirement by March 13, 2023; (4) to designate an administrator to oversee only one facility, meeting this requirement by March 13, 2023; (5) to revise the plan of operation / program statement (POO/PS) and/or develop an addendum to include discussion of the use and purpose of motion sensors in the facility, meeting this requirement by March 13, 2023; (6) to provide notification of desire to utilize technical support program (TSP) services by January 25, 2023; and (7), if desired, submitting a central administrative facility waiver by January 25, 2023. See the notes by the corresponding number below. (2) During the visit, LPA reviewed staff training and interviewed staff. Interviews and training records reflect that trainings are conducted at monthly staff meetings and include topics such as supervision, de-escalation, reporting requirements, and cultural competency. Staff interviewed were knowledgeable of facility procedures. The facility also has verbal de-escalation tips posted in the facility. (3) LPA obtained a current LIC 500. The facility has designated two staff for each night. There is at least one facility manager on each night shift. The facility is conducting 15-minute bed check rounds from 10PM to 6AM, and staff log and sign off on each check for each resident. The logs were available for LPA's review, and LPA observed checks each night for each resident. [] (4) The facility had a candidate for the administrator role who ended up leaving the organization. Another candidate has been hired but still needs to complete administrator training. (5) LPA has not received a POO/PS addendum or revision. LPA is granting one extension. The revision/addendum to meet the requirement as stated above and in the NCC report provided to the licensee is requested to be submitted no later than May 1, 2023. (6) The licensee was referred for TSP services. (7) The licensee has decided to not request a central administrative facility waiver at this time. An exit interview was conducted, appeal rights discussed, and a copy of this report was left with Administrator Sara Stokes, whose signature on this form confirms receipt.

met_with: Administrator Sara Stokes


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 4/19/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a required annual inspection. LPA met with Administrator Sara Stokes and informed of the purpose of the visit. The CARE inspection tool was used to complete this inspection. LPA conducted a tour of the facility and grounds, interviewed 2 staff and 2 residents, and reviewed 5 staff files. A continuation visit is required to complete the resident file reviews. Staff interviewed are aware of facility procedures and personal rights. Staff files reflect valid CPI and first aid. Residents appeared content and dressed in well-fitting, comfortable, and clean clothing. Residents interviewed reported finding the facility a safe and supportive environment. The facility was observed to be clean and tidy and kitchen and bathrooms sanitary. No hazards were observed outside or inside. The backyard pool has a tall fence around it with a locked gate, the key to which only staff have access to. Bedrooms are double-occupancy, and beds have clean linens. Staff and residents report linens are changed regularly. Knives and medications are locked away and inaccessible to residents. Food supply is plentiful with a selection of healthy, fresh, and within date foods. The following deficiencies were observed during today's visit. -- Two staff present during today's visit do not have a background clearance associated to this facility and have been working since 4/17/23 (3 days). LPA is issuing a citation of California Code of Regulations, Title 22, Section 80019 and assessing a civil penalty of $100 per day per individual for a total of $600. -- Hot water at the bathroom sinks measured above the permitted range, at F and 125. F. LPA is issuing a citation of Title 22, Section 80088. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator, whose signature on this form confirms receipt.

Deficiencies:
80019(e): Criminal Record Clearance

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


summary: Facility Evaluation

raw_content:
Narrative:
On 7/28/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit as a follow-up to the January 2023 noncompliance conference (NCC), per the first NCC term. LPA met with Administrator Sara Stokes and informed of the purpose of the visit. Per the NCC terms and previous inspection(s), the following was required and reviewed: (2) Ensure staff were fully trained, per applicable regulations, at hire and additionally on no less than a quarterly basis. | The annual inspection was completed on 7/28/23, and based on review of personnel files were complete, and training records reflect complete training. (3) Designate two overnight staff each night with at least one being a facility manager. | The facility has staff hired to have two overnight staff but is currently waiting for the third staff to receive a background clearance. The facility continues to conduct 15 minute rounds during the overnight shift and document them on paper and electronically. (4) Designate an administrator to oversee only one facility. | The licensee had two candidates who did not remain in the role. The licensee has a third candidate who has been enrolled in the administrator training. (5) Revise the plan of operation / program statement (POO/PS) and/or develop an addendum to include discussion of the use and purpose of motion sensors in the facility. | An extension was granted. Administrator confirmed it was in progress, and the draft document was shown to LPA during visit. LPA is requesting submission no later than 8/31/23, allowing time for internal approvals. An exit interview was conducted and a copy of this report was left with Administrator Sara Stokes, whose signature on this form confirms receipt.


facility_name: DISCOVERY-ORANGE

summary: Facility Evaluation

raw_content:
Narrative:
On the date listed above, Licensing Program Analyst (LPA) Charmaine Linley conducted Component III Group Home via Microsoft TEAMS with Administrator, Kendra Meija. A copy of the handout was emailed prior to Component III and the Pre-Licensing Inspection is waiting to be scheduled after a review of the Plan of Operations and Program Statement that LPA received on 11/03/2025. A copy of this report was emailed to the Administrator for a signature and a copy of the signed report will be placed in the facility file.

met_with: Kendra Mejia


summary: Facility Evaluation

raw_content:
Narrative:
*****This is an amendment to the original document dated 11/06/205***** The facility consists of a single level building with four wings. The first (100 unit) wing is currently not being used and will not be included in the license. On November 6, 2025, Licensing Program Manager (LPM) Ann Valenzuela and Licensing Program Analyst (LPA) Charmaine Linley arrived at the facility for an announced Pre-Licensing inspection. The facility was inspected inside and out with Operations Manager, Kendra Mejia, Jeff Marshall, Jenny Morey, and Hannah Dunn. The facility is located on a cul-de-sac behind a large multi-story medical building. The facility consists of a single level building with three wings. The building includes two school rooms, two group session rooms, therapy offices, kitchen prep area, kitchen, two laundry rooms, seven offices, tech room, pump rooms, staff break room, intake room and a total of 37 bedrooms. The facility will be operating with the capacity of 60. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. There is outdoor space that includes outdoor activities, including a putting ground, planting garden, cornhole game, and large Jenga game. The *** Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. The bathrooms were clean and in good repair. The facility has an industrial kitchen with one industrial sized refrigerator, one industrial sized freezer, one industrial sized oven and stove top. There is a storage room for dry goods and additional food. There is an industrial sized dishwasher and sink system. The dining hall is adjacent to the kitchen and has ample sitting space arranged with five large tables and chairs. There are a total of four fire extinguishers located in all three wing hallways and one in the kitchen. They were observed to be properly charged and inspected by the fire department. Client files will be maintained using the KIPU system which is a portal to store client files and keep all information confidential. Administrator stated licensing will have access to such portal when client files need to be reviewed for any purpose. Employee files are stored electronically and Facility was reminded that licensing will need access to the electronic files when they need to be reviewed for any purpose. The following required posted items were observed accessible to clients: Fire Clearance, Grievance Procedures, Personal Rights, Visitation policies, Emergency Disaster Plan and current menu. The fire clearance has been approved. Based on the facility pre-licensing inspection review, no deficiencies were noted at the time of inspection. Upon all employees being cleared to work at the facility and Plan of Operations and Program Statement revisions completed and approve and the Licensing Program Manager's final review, the license will be provided. An exit interview was conducted with Kendra Mejia. A copy of this report was provided to the facility. A copy of this report will be placed in the facility file. facility has inside activities, such as karaoke, piano, dominoes, and televisions that have streaming services to Netflix and Disney. The facility will provide additional games upon request. Medication and the first aid kit will be kept locked behind a locked door in the Nurse's office. Medication room has a locking door and a locking medication cabinet. The facility also has a refrigerator that locks to store medications that require refrigeration. The facility's smoke detectors are inter-connected with the carbon monoxide detectors and are hardwired. The smoke/carbon monoxide detectors were tested and observed to be in working order. There are no guns or weapons in the facility as stated by Kendra Mejia. Disinfectants and cleaning solutions were stored locked in each individual wing in a locked storage closet. Sharp knives were made inaccessible and stored in a locked toolbox in the kitchen. The following required posted items were observed accessible to clients: Grievance Procedures, Personal Rights, Visitation policies, Emergency Disaster Plan and current menu Wings has thirteen bedrooms and seven bedrooms have two twin beds in each bedroom, all required linen, and mattresses in good condition and six bedrooms have one single twin sized bed, all required linen, and mattresses in good condition. Each bedroom is equipped with drawer space and adequate closet space. There are bathrooms in each bedroom that includes one sink, one toilet, and one bath/shower stall. The hot water in one of the client bathrooms was measured at 105 degrees at 10:15 am, which is within regulatory requirements. Wings has fourteen bedrooms have two twin beds in each bedroom, all required linen, and mattresses in good condition and six bedrooms have one single twin sized bed, all required linen, and mattresses in good condition. Each bedroom is equipped with drawer space and adequate closet space. There are bathrooms in each bedroom that includes one sink, one toilet, and one bath/shower stall. The hot water in one of the client bathrooms was measured at 106 degrees at 10:35 am, which is within regulatory requirements. Wing has ten bedrooms with two twin beds in each bedroom, all required linen, and mattresses in good condition. Each bedroom is equipped with drawer space and adequate closet space. There are a total of six bathrooms on this wing that includes one sink, one toilet, and one bath/shower stall. The hot water in one of the client bathrooms was measured at 106 degrees at 10:51 am, which is within regulatory requirements. ***

visit_type: Prelicensing