summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
Staff working at the facility attempted to get S1 to return to the facility with C1 once it was observed that S1 was no longer visible by the staff. Another staff accompanied by another client walked down the driveway in the direction that it was thought that S1 and C1 had walked in and rustling was heard in the woods. C2 allegedly saw S1 and C1 on the ground together. C1 initially told staff and clients that nothing happened because C1 didn't want to get into trouble but later stated that S1 and C1 did have sex in the woods as suspected and that it was not all consensual. While Investigators with the Department and Detective from El Dorado County Sheriff's Office did attempt to make contact with S1, S1 would not agree to an interview and would not agree to a meeting to discuss the allegation. S1 informed the investigators and detective that S1 would need to contact their attorney to discuss and get back to the investigators. As of the finalization of the complaint, S1 had not come forward to schedule a meeting of any kind. Based on information obtained and interviews conducted by the Investigations Branch, the allegation that a staff sexually abused a minor while in care is SUBSTANTIATED meaning the "preponderance of the evidence" standard has been met. The facility is being cited for Personal Rights section 87072(c)(11) as the licensee shall ensure that each child is accorded the personal rights specified in Welfare and Institutions Code Section 16001.9, including the right to be free of physical, sexual, emotional, or other abuse as it pertains to S1 engaging in a sexual relationship with a client while in the facility. The facility is also being cited for Conduct Inimical as described in Health and Safety Section 1568.092(a)(2) as the department may prohibit any person from... continuing the employment of, or allowing in a licensed facility, or allowing contact with clients of a licensed facility by, any employee...who has Engaged in conduct that is inimical to the health, welfare, or safety of either an individual, in or receiving services from the facility, or the people of the State of California as this pertains to S1 engaging in sexual contact with a client in the facility. The facility was advised that this matter is being referred to our Legal Department for further review and additional legal action. In addition, this citation shall be reviewed for Enhanced Civil Penalties as applicable. Exit interview conducted with Ms. Gleason and documentation and appeal rights were provided via email.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 8/26/22 at AM and met with Anna Gleason, Chief Executive Officer to discuss the findings of the complaint allegation as stated. LPA informed Ms. Gleason that the investigation included an initial inspection by the Investigations Branch, Investigators Joseph Balarie and Melissa Bennett. During the initial inspection and throughout the investigation, staff and clients were interviewed and documents relevant to the complaint investigation were provided to the investigators. The allegation that staff sexually abused a minor while in care is related to an incident that took place at the facility on 5/12/2022 involving S1 and C1 (see LIC811 dated 8/26/22). During this incident, it was observed that C1 and S1 disappeared while together from staff and camera view for approximately 26 minutes while on a walkabout outside of the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: SUMMITVIEW CHILD AND FAMILY SERVICES - AGAPEFACILITY NUMBER: VISIT DATE: 08/26/2022

met_with: Anna Gleason, Chief Executive Officer


state: CA

facility_name: SUMMITVIEW CHILD AND FAMILY SERVICES - AGAPE

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst, Kate Mensah conducted a Case Management Inspection on July 21, 2021, at 11: AM, based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code Section 1538.7. 4 out of Direct Care Staff and 6 out of 6 youth files as identified on the LIC Confidential Names dated July 21, 2021, were reviewed. 2 out of the Direct Care Staff and 3 out of 6 youth were also interviewed. The Plan of Operation including policies and procedures were reviewed.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Alaisha Jackson


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced inspection visit to the administrative offices for Summitview Child and Family Services on 7/28/21 at 1: PM and met with Haley Randle, Director of Residential Programs to discuss an incident reports for this facility. LPA informed Ms. Randle that the visit is related to an incident report dated 5/31/21 involving C1, S1 and S2 (see LIC811 dated 7/28/21) where C1 was complaining of knee pain. When staff attempted to suggest to C1 some self help remedies for the pain, C1 rejected the suggestions and instead took the house phone and went outside to make an unauthorized phone call. C1 was supervised while outside by S2. S1 unplugged the phone from inside the facility to prevent C1 from making any calls. When the call could not be made, C1 entered the facility angry and screaming about the phone not working and S1 responded to C1 that it was because C1 did not show the staff the number dialed and because C1 was attempting to have an unauthorized call. C1 demonstrated to staff that they had dialed 911. LPA advised Ms. Randle that instead of S1 speaking to C1 in a trauma informed manner and attempting to de-escalate youth, S1 was very antagonistic and provoking toward C1. LPA reminded Ms. Randle that the facility staff need to be reminded about the obligation to approach youth in a trauma informed manner and speak to youth in a way that would de-escalate situations and not cause more trauma or escalate youth. Ms. Randle states that she was not even aware of the incident and that she would look further into this issue and provide an update regarding this incident. LPA requested that the update, counseling note or other documentation related be provided to LPA by 8/11/21. Exit interview conducted and document provided.

met_with: Haley Randle, Director of Youth Residential Programs


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Tamara Hill and Mary Shelton made an unannounced annual inspection on 10/15/21 at 11: AM and met with Eryn Dixon, STRTP Administrator, who assisted with the inspection. LPAs Hill and Shelton conducted a walk-through of the facility inside and out. There were no clients present during the inspection due to school and company barbecue happening at their school location. LPAs observed four client bedrooms, two bathrooms during the inspection. LPAs Hill and Shelton inspected and/or reviewed the following: Postings of facility license, Personal Rights Poster Disinfectants/Cleaning solutions were inaccessible Refrigerator Temperature was at or below 45 degrees F and Freezer Temperature at or below 0 degrees Nonperishable Foods for one week and fresh perishable for foods two days minimum were present Menu was present and but not posted Working telephone was present Carbon monoxide detectors and Smoke Detectors were functioning First Aid Kit was present but missing tweezers Common Room (living room) was available as was a separate room for relaxing Dining area with enough seating was present and in good condition Medication was centrally stored, locked/inaccessible LPAs did not observe a staff office area as the agency believes that the staff should be present with the clients in care and not in the office doing administrative work with clients present. All relative documentation is locked an inaccessible to clients in care. Hot Water was between 105 -120 degree F Fire Extinguisher was observed to be last inspected on 2/15/ Toilets, wash basin, bath and shower fixtures appeared to be in good repair, no leaks and delivering hot water. LPAs observed there to be soap and paper towels available in the bathrooms. Laundry Facilities were available and LPAs observed posted assigned washing days for clients. Bedrooms appeared to be clean and organized with required linen and furnishings Motor Vehicle was observed to have working seat belts, lights and adequate tires. Facility appeared to be free of vermin LPAs observed no citations during the physical plant inspection and no citations were issued for the physical plant of the facility. Exit interview conducted and documentation provided to the facility.

met_with: Eryn Dixon, STRTP Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Tamara Hill and Mary Shelton made an unannounced annual continuation inspection on 10/27/21 at 10: AM to the Non Public School location and met with Haley Randle, Director of Youth Residential Programs. The purpose of the visit was to continue the annual inspection started on 10/15/21 and interview clients and review client and staff documents. The facility did inform LPAs that all of their client and staff files are electronic and did work on providing LPAs access to the electronic databases. While LPAs waited for the access to review documentation, LPAs interviewed clients. LPAs spend the entire time at the agency interviewing clients and did not review staff or client documents. LPA Hill informed the agency that in order to conclude the annual inspection, it would take another inspection date on another day in order to conduct the file reviews necessary to complete the annual review for the facility. LPA reminded the agency that the visit must be unannounced. Exit interviewed conducted and document was provided. Hard copy signature was obtained via email as most the staff had already left or were leaving for the day.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Tamara Hill and Jennifer Baca made an unannounced case management visit on 12/20/21 at 9: AM and met with Haley Randle, Director of Youth Residential Programs to discuss an incident report. LPAs conducted the case management inspection at the school site located at Placerville Drive, Placerville and interviewed four youth related to an incident that took place at the facility on 11/30/21. The incident involved the four youth (C1, C2, C3 and C4 - see LIC811 dated 12/20/21) and S1. The incident involves staff and youth getting into a confrontation that lead to S1 being advised by another staff (S2) to not return inside the house and S1 subsequently left the facility while the youth were escalated and continued in an escalated state for the evening. LPA did advise the agency that additional case management is needed at this time and that LPA shall return another day to continue this case management. No citations were issued during the case management on this day.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced collateral inspection on 6/9/22 at 9: AM to the administrative office located at Placerville Drive, Placerville to discuss incident reports. LPA discussed the following incident reports while at the administrative office: 5/2/22 - C1 appeared to have been targeting a staff (unclear as to what staff) and it does not appear in the report that staff removed themselves knowing that C1 was targeting them. LPA discussed with CEO that in writing the reports, if staff are switched out then it need to be articulated. If the staff targeted in this incident did not remove themselves, the staff should be cognizant of the target and in the future remove themselves when a youth appears to be targeting them. 4/23/22 - C2 allegedly snorted a substance but the substance was never defined in the report. C2 informed staff that it was a substance that came from a previous client but there is no indication that the substance was searched for or if C2 was ever asked if there was more "substance". 4/19/22 - C2 was involved in two restraints at the facility and as written, both incidents appear to be unnecessary restraints. LPA informed Ms. Gleason that Licensing is looking at restraints and the "eminent danger" presented when restraining a youth in care. LPA informed Ms. Gleason that the reports need to articulate the danger(s) presented that warrant a restraint when they do happen. 4/15/22, C1 attempted to leave a classroom while at the school site and were stopped by staff resulting in youth being violent and aggressive towards various staff in the classroom and additional staff that came to support the incident. LPA cautioned Ms. Gleason on stopping youth when they are leaving as this may be a personal rights violation. In addition, it was discussed that there are alternatives to youth being physically stopped including assigning a staff to walk about the property with youth. 3/5/ C3 was placed in a restraint to keep youth from jumping out of a window on a second level of the facility after breaking into a locked storage cabinet in the garage and being able to obtain razors. Staff held on to C3's wrists to get items from C3. LPA again cautioned the use of restraints in an unauthorized manner. 3/5/ C4 was found in a bathtub "unconscious" and when pulled out by staff, it took C4 a minute to respond. C4 was taken to the local emergency room and subsequently returned to the facility. When discussing the incident, CEO states that she learned that youth never lost consciousness, per the doctor. LPA informed CEO that any and all additional information needs to be put in the full report. 3/2/ C3 was again placed in a restraint to keep youth from exiting the house through the bedroom window. LPA cautioned CEO about the incident in that it does not appear that there was an eminent danger to the youth that would justify the use of restraints. 3/1/ C4 was on the roof of the house and staff were "collecting couches" as described in the incident report. LPA questioned what this meant and CEO states that to the best of her knowledge, it means that staff were putting couches together to break a youth's fall/jump from the roof. LPA indicated that there was no discussion of de-escalation techniques used to get youth to come of the roof and not jump. 2/28/ C4's room was searched due to how C4 "was presenting" and due to disclosure of using substances while in their home but this is not a justification for a search. LPA advised Ms. Gleason that searches need justification and consent. There is also no indication that parent/guardian was consulted. Later on this date, C4 attempted to leave the facility but was restrained; no indication this was necessary. 9/10/ C5 did a "smiley" piercing while in the facility; there's no indication when this happened and no indication that staff asked C5 about when it happened or what was used to do the piercing. LPA asked Ms. Gleason if there was more information about how this could happen without staff being aware. In general, LPA also discussed with Ms. Gleason the need to ensure that all reports are complete. LPA also advised that some of the full reports just need additional information to indicate that the staff are being proactive in preventing additional issues; i.e. one youth making calls to get someone to pick them up at the facility but not indicating what staff are doing for additional support or assistance. LPA also discussed accompanying youth when needed to do a walk-about on the property of the school or the facility grounds. There were incidents where youth were struggling and staff would not allow them to leave and other times where youth were struggling and staff allowed them to leave unattended. In both incidents, it was a struggle for the staff and clients. LPA advised that it is necessary to be consistent with the youth in order to maintain supervision and be consistent. LPA also discussed being thorough in the reports and providing additional information it the 24 hour reports being sent. Reports should include when medical is needed or not, contacting therapists when necessary, indicating what interventions or supports are utilized when youth indicate self-harm, what youth are doing (other than just stating "engaged in self harm"), use of restraints when there is not an eminent threat or danger, staff indicating completion of Suspected Child Abuse Report when disclosures are made by the youth in care, indicating reasons for and what is found when a room search is needed/warranted. Also discussed during the inspection on this date was the licensing fees that are all confused and not appropriated correctly. LPA did advise that the agency provide details about the fee assessments via email so that discussion can be held with the Department's Accounting Unit to appropriate the fees paid appropriately. LPA did ask additional information be provided for the following incidents regarding allegations with staff: 11/30/ LPA asked for clarification on this incident involving two staff and four youth in the facility. LPA requested any/all follow up regarding S1 having to be told by S2 to "remove herself and stay outside". LPA observed that the incident report indicates that S1 yelled at C6 "Do not touch me" when C6 pushed S1 back with their body. 11/29/ LPA requested additional information regarding alleged misconduct of S1 where S1 may have provided a vape pen to C4. LPA asked if there was an internal investigation regarding the incident and, if so, LPA requested a copy of the internal investigation conducted. 5/31/ C5 alleged that a staff had provided "vape juice" to a youth in the facility (staff not identified). LPA is requesting a copy of the investigation conducted. End of incident report review and exit interview conducted with Ms. Gleason.

met_with: Anna Gleason, CEO


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
According to the interviews with staff, video cameras showed that another youth went down the hall and may have observed what C1 was doing in their room and alerted staff. At that point, youth had been alone in their room and not checked on for approximately 47 minutes. Interviews with staff, placement agency, and parent are consistent in that C1 was known to self harm with their own nails and with other objects and needed line of sight supervision or heightened supervision. C1's parent also felt that C1 was in need of heightened supervision and thought that C1 was placed in the facility to receive that level of supervision. Review of the documentation from the hospital demonstrates that the hospital staff believed that C1 had injured themselves over a period of two days as some of the injuries appeared to be infecting and older than others observed. When interviewed, staff state that C1 normally wore long sleeve clothing and did not expose much of their skin so marks of self harm were not visible until entering C1's room and C1 disclosing the injuries. Based on interviews conducted and documentation reviewed, the allegation that staff did not prevent youth from self harming is SUBSTANTIATED meaning that the "preponderance of the evidence" standard has been met. The facility was cited for Responsibility for Providing Care and Supervision 80078(a) as the licensee is required to provide care and supervision as necessary to meet the client's needs. C1's Needs and Services Plan indicates that C1 engages in self harm daily, thus requiring an additional level of supervision that C1 did not receive in the facility, including being left alone for lengthy periods of time, allowing C1 to self harm and cause significant damage to their arm. Exit interview was conducted with Ms. Gleason and documents and appeal rights were provided via email. items to the facility for C1, the parent thought that all items would have been inspected and searched and if any item(s) would have been deemed to be dangerous to C1, taken away and stored elsewhere or destroyed. The parent had no knowledge of the search policy in that they were unaware that the child's belongings, person, or room was not searched regularly to keep dangerous items away from C1. The allegation that staff did not seek medical attention for child in a timely manner is related to the severity of the injuries observed at the hospital and the suspicion by the medical staff that some of the wounds were starting to infect, indicating that the wounds happened over a period of 48 hours. During interviews conducted with staff, C1 was known to wear long sleeves which would have hidden the wounds inflicted the day prior. Until C1 was found in their room bleeding from the wounds, staff had no knowledge of existing wounds. As soon as staff saw the wounds, facility staff called 911 and C1 was transported to the hospital for evaluation and treatment. Based on investigation, interviews conducted and review of the documentation obtained, the allegation that C1 had access to a dangerous object is true but culpability by the staff to be aware and be able to remove the item is subjective and cannot be proven as youth are to be free of unreasonable searches. The allegation that staff did not seek medical attention for C1 in a timely manner cannot be proven as well since the staff, upon learning of the injury immediately called 911 and had C1 taken to the hospital. As a result, both of these allegations are UNSUBSTANTIATED at this time meaning that the allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview was conducted with Ms. Gleason and documents were provided by email.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 8/26/33 at 9: AM and met with Anna Gleason, Chief Executive Officer to discuss the finding of the allegation. LPA Hill informed Ms. Gleason that the investigation included an initial inspection conducted on 5/4/22 where staff were interviewed and a collateral visit was conducted to obtain records from the administrative offices. Hospital records for C1 (see LIC811 dated 8/26/22) were obtained on 5/9/22. C1 was not interviewed in relation to this complaint due to C1's instability in their current placement and C1's parent requested that C1 not be interviewed. LPA also conducted interviews with staff about the supervision of C1 and it was disclosed that C1 was not supervised as required by the staff in the facility, leaving C1 alone for great periods of time, longer than what the program states should have happened. Staff believe that this directly contributed to C1's ability to self harm. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: SUMMITVIEW CHILD AND FAMILY SERVICES - OAKFACILITY NUMBER: VISIT DATE: 08/26/2022

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

report_type: Complaint Investigation

complaint_status: unsubstantiated


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
The allegation that staff did not prevent inappropriate sexual interaction between minors is related to an incident that took place in the facility between June 24, 2022 to June 27, 2022, where C1 and C2 (see LIC811 dated 10/6/22) shared a room together and engaged in inappropriate sexual contact. LPA Hill conducted confidential interviews with staff and clients and obtained documentation related to staff supervision during these overnight shifts in the facility. The allegation is directly related to inappropriate contact between C1 and C2 during the overnight shift(s) and the lack of supervision which lead to this. LPA obtained documentation from the facility and conducted interviews that staff which lead to the discovery that the staff on duty during the dates indicated did not conduct the required bed checks on clients per the program statement. This lack of bed checks as documented by the facility left clients unsupervised and vulnerable to inappropriate interactions. As a result of the investigation, the allegation that staff did not prevent inappropriate sexual interaction between clients is SUBSTANTIATED at this time meaning that the the "preponderance of the evidence" standard has been met. The facility was cited for 87078(b) Responsibility for Providing Care and Supervision as the licensee shall provide those services identified in each child's or nonminor dependent's needs and services plan, Transitional Independent Living Plan, and/or individualized health care plan or each child with special health care needs, as applicable, as necessary to meet the child's or nonminor dependent's needs. The licensee identified that the youths' needs include heightened supervision including bed checks every 15 minutes throughout the overnight shift. This did not happen during the date(s) indicated leading to the identified inappropriate interactions between C1 and C2. Exit interview conducted and documents were provided to Ms. Randle via email along with appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 10/6/2022 at 1: PM and met with Haley Randle, Director of Youth Residential Programs for the purposes of delivering findings for the allegation as stated. LPA informed Ms. Randle that the complaint investigation included an initial inspeciton on July 6, 2022 and a subsequent inspeciton on August 31, 2022, where files were reviewed, documents obtained, and interviews were conducted with clients and staff. LPA Hill conducted complaint interviews with staff, clients and responsible parties from July 6, 2022 through October 5, 2022. In addition, LPA Hill obtained documentation related to clients and supervision in the facility to include incident reports, needs and services plans, client information documentation and emails related to supervision of youth in the facility from June 24, 2022 through June 27, 2022. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: SUMMITVIEW CHILD AND FAMILY SERVICES - OAKFACILITY NUMBER: VISIT DATE: 10/06/2022

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

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
happened on 12/9/22 where C1 and C2 left the facility and broke into a neighbor's home and vandalized the home. Investigation showed that there were two staff present at the facility with six clients. When C1 and C2 left the facility on an unauthorized absence, one of the staff were going to follow but then another client, not related to the incident, left the facility on an unauthorized absence as well, and staff followed that third client. While away from the facility, C1 admitted to breaking a neighbor's window in an attempt to burglarize the home but the residents of that home were there, scaring C1 and C2 off, and they fled the neighbor's property. Sheriff deputies did issue felony citations to C1 for the damages and the break in but the clients were not arrested or transported to juvenile hall. During the confidential interviews conducted, it was disclosed that staff observed C1 and C2 were possibly preparing to leave the facility on an unauthorized absence as they were talking about "getting up and getting ready to go". Staff indicated that they were on high alert and had alerted the management of the need but they felt that there should have been an additional staff at that facility as C1 had been struggling during the days leading up to this incident. Staff felt that they needed the additional support but the agency didn't provide that additional staff. When LPA Hill reviewed incident reports, it was noted that the day prior to this incident, 12/8/22, C1 had left the facility on an unauthorized absence and went to a different neighbor's house claiming to have killed someone and buried their body as part of a gang initiation. In addition, there was another unauthorized absence on 12/6/22, and two incidents related to inappropriate interactions with two different clients on 12/2/22 and 12/7/22, one of which was a sexual interaction. An additional staff did respond to the facility when summoned after three clients left on an unauthorized absence and this staff person did assist in transporting clients back to the house. While the facility was within the required staff ratio requirements set by Short Term Residential Therapeutic Programs, the facility is also required to meet the needs of the clients in care which would include having additional staff at the facility to assist as needed. As a result of this, the allegation that staff did not provide adequate supervision to the minors is SUBSTANTIATED at this time meaning the "preponderance of the evidence" standard has been met. The facility was cited for violation of the California Code of Regulations (CCR), Title 22, Division 6, Section 80065(a) Personnel Requirements. The facility did not have the necessary staff at the facility to meet the needs of the clients in care in that there were only two staff with the six residents. Staff knew, or should have known, the propensity of the clients and had a sufficient number of staff present to meet that need. Exit interview conducted with Ms. Randle and documents were provided with appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPAs) Tamara Hill made an unannounced inspection on 3/22/23 at 1: PM and met with Haley Randle, Director of Youth Residential Programs to discuss the findings of the complaint allegation. LPA Hill informed Ms. Randle that the complaint investigation consisted of an initial inspection 1/10/23 and a subsequent inspection on 1/19/23 where two staff were interviewed and documents related to C1 and C2 (see LIC811 dated 3/22/23) were obtained. A collateral inspection was conducted on 3/3/23 at Summitview administrative offices and three staff and C2 were interviewed. C1's guardian was interviewed 3/6/23 via phone. C1 was interviewed 3/9/23 via video conference due to C1 being in placement out of the state of California. LPA Hill also requested a copy of the police report related to an incident that took place 12/9/22 where the Sheriff were called. The allegation that staff did not provide adequate supervision to the minors is related to an incident that SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: SUMMITVIEW CHILD AND FAMILY SERVICES - OAKFACILITY NUMBER: VISIT DATE: 03/22/2023

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

met_with: Haley Randle, Director of Youth Res Programs


facility_name: SUMMITVIEW CHILD AND FAMILY SERVICES - OAK

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Tamara Hill and Mary Shelton made an unannounced annual inspection on 10/15/21 at 1: PM and met with Eryn Dixon, STRTP Administrator, who assisted with the inspection. LPAs Hill and Shelton conducted a walk-through of the facility inside and out. There were no clients present during the inspection due to school and company barbecue happening at their school location. LPAs observed three dual occupancy client bedrooms and two bathrooms during the inspection. LPAs Hill and Shelton inspected and/or reviewed the following: Postings of facility license, Personal Rights Poster were appropriately posted Disinfectants/Cleaning solutions were inaccessible and locked as required Refrigerator Temperature was at or below 45 degrees F and Freezer Temperature at or below 0 degrees. There were multiple refrigerators and freezers on the premises. Nonperishable Foods for one week and fresh perishable for foods two days minimum were present Menu was present and posted Working telephone was present Carbon monoxide detectors and Smoke Detectors were functioning First Aid Kit was present but missing tweezers Common Room (living room) was available as was a separate room for relaxing and activities Dining area with enough seating for clients in care was present and in good condition Medication was centrally stored, locked/inaccessible LPAs did not observe a staff office area as the agency believes that the staff should be present with the clients in care and not in the office doing administrative work with clients present. All relative documentation is locked an inaccessible to clients in care. Hot Water was between 105 -120 degree F Fire Extinguisher was observed to be last inspected on 7/6/ Toilets, wash basin, bath and shower fixtures appeared to be in good repair, no leaks and delivering hot water. LPAs observed there to be hand soap and paper towels available in the bathrooms and kitchen area. Laundry Facilities were available and LPAs observed posted assigned washing days for clients. Bedrooms appeared to be clean and organized with required linen and furnishings Motor Vehicle was not observed as the staff had taken the facility vehicle to pick up clients from company activity at Golden Plaza location. Facility appeared to be free of vermin and other pests as required. LPAs did not observe there to be screens on the sliding door but on all other windows throughout the facility where they are opened for ventilation and air circulation. LPAs observed no citations during the physical plant inspection and no citations were issued. Exit interview conducted and documentation provided to the facility.

visit_type: Annual


summary: Facility Evaluation

narrative: Licensing Program Analysts (LPAs) Tamara Hill and Mary Shelton made an unannounced annual continuation inspection on 10/27/21 at 10: AM to the Non Public School location and met with Haley Randle, Director of Youth Residential Programs. The purpose of the visit was to continue the annual inspection started on 10/15/21 and interview clients and review client and staff documents. The facility did inform LPAs that all of their client and staff files are electronic and did work on providing LPAs access to the electronic databases. While LPAs waited for the access to review documentation, LPAs interviewed clients. LPAs spend the entire time at the agency interviewing clients and did not review staff or client documents. LPA Hill informed the agency that in order to conclude the annual inspection, it would take another inspection date on another day in order to conduct the file reviews necessary to complete the annual review for the facility. LPA reminded the agency that the visit must be unannounced. Exit interviewed conducted and document was provided. Hard copy signature was obtained via email as most the staff had already left or were leaving for the day.


summary: Facility Evaluation

raw_content:
Narrative:
On 1/19/2023, at 9:30 a.m., LPAs Monica Roberts (LPA1) and Tammy Hall (LPA2) conducted an unannounced visit to Summitview Child and Family Services in regards to an incident that occurred on 12/18/2022. LPAs introduced themselves and explained the reason for the visit. Met with C1 (see LIC811 dated 1/19/2023) to discuss incident from 12/18/2022. Further investigation is needed at this time. Exit interview was conducted.

met_with: Haley Randle, Director of Youth Residential Prgms


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPAs) Tamara Hill and Monica Roberts made an unannounced inspection on 1/19/23 at 9: AM and met with Haley Randle, Director of Youth Residential Programs to discuss an incident report. LPA discussed a cross report received in December 2022 related to C1 (see LIC811 dated 1/19/23). LPA spoke to youth about the cross report and asked youth information about the report. LPA then spoke with youth's therapist about the conversation and asked that therapist check in with youth when possible to ensure that youth is in a good place. LPA also discussed another incident dated 12/3/22 in which C2 got upset over not being allowed a cell phone charger to charge their phone. There is no mention in the report that youth was given the opportunity to have the phone charged by staff and then returned to the youth. While staff may have offered this to youth, this information was not articulated in the report. LPA reminded staff about being trauma informed and documenting interventions as appropriate. LPA discussed with facility staff other information that is necessary to be in the incident reports (particularly the 24 hour reports) when submitting reports to Licensing. LPA discussed that it has been observed that there is an up-tick in medication related incident indicting that they are either not administered or incorrectly administered doses. LPA advised that the agency needs to do something to ensure that youth are given their medications as prescribed and missing medications for youth is not acceptable. LPA discussed 24 hour reports with the agency as well. LPA pointed out that there are incidents in which there is little to no information about the incidents and why or how things happen. LPA advised that this is vital to provide this on the reports. LPA provided examples of 24 hour incident reports that need additional information on them so that staff are aware of the missing or incomplete reports. No citations were issued as a result of the inspection and exit interview was conducted.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 4/13/23 at 9:30 am and met with Haley Randle, Director of Youth Residential Programs to discuss incident reports and lack of full reports being received. LPA Hill informed Ms. Randle on 4/6/23 via email that Licensing had not received any of the required full reports for the month of March for the 24 hour reports that were provided. Administrator Danielle Bingle provided those reports for the Month of March on that same date via email. LPA Hill did inform Ms. Bingle and Ms. Randle that the Department still has to cite for not providing the full written report within the required timeline of seven days as prescribed in 80061(b) "a written report containing the information specified... shall be submitted to the licensing agency within seven days following the occurrence of such event." LPA Hill also discussed an incident report dated 3/13/23 for C1 in which C1 allegedly felt uncomfortable sleeping in the same room as their roommate. LPA Hill questioned Ms. Randle about this report as there is no indication of why C1 was uncomfortable, how it was addressed the following day (was C1 referred to their therapist to discuss, were room changes conducted, etc.) After discussing the incident report, Ms. Randle stated that C1 was uncomfortable due to an incident involving two other youth from the same house. LPA Hill asked Ms. Randle to update information on the report to give reasoning, what the facility did, and how the issue was resolved and resubmit the report to Licensing. LPA Hill discussed medication incident reports received since January 1, 2023, detailing medication errors due to medications not being picked up, staff forgetting to administer at time(s) prescribed by doctors or other staff/facility errors. LPA Hill informed Ms. Randle that the Department is not concerned for medication errors due to pharmacy not having medications but errors that are within the control of Summitview and staff, are of concern. LPA Hill asked Ms. Randle how the facility has addressed or is planning to address this issue to ensure that there are no medication errors due to staffing and/or Summitview not having the prescribed medications on site? Ms. Randle states that medication training was conducted with all residential staff and the agency has begun to track for medication patterns and staff responsible for any medication errors moving forward will be retrained immediately and/or corrective actions conducted with said staff. In addition, Summitview's Health Services has met with transporters to ensure that refills and notifications are sent to transporters a minimum of seven to ten days prior to medications running out and refill requests are completed. Controlled medications are counted daily and other medications are counted twice weekly. When these counts happen, staff are to notify Health Services for refill of medications a minimum of ten days prior to the medications running out in an effort to prevent the facility from running out of medications. LPA Hill requested a written policy that would indicate how all of these things will be defined and/or put into place shall be provided to Licensing by 5/1/23. Lastly, LPA Hill discussed the closure of this location with Ms. Randle in that the agency has decided to relocate all of the youth from this location by 4/14/23. With the house vacant, the agency has decided to sell the property but will be relocating this facility to another one of their properties currently under renovation. Ms. Randle states that they will be submitting something to Licensing as soon as their board has approved of the plan and provides the board resolution for the relocation. Exit interview was conducted with Ms. Randle and documentation provided with appeal rights.


raw_content:
Narrative:
LPA interviewed both therapists involved in C1 and C2's care on 9/22/21. Based on the therapists' knowledge of C1 and C2 and their interviews conducted immediately following the disclosure, they did not believe that the incident took place. As a result of the investigation, interviews conducted and documentation reviewed, the allegation that foster children engaged in inappropriate activities while in care is UNSUBSTANTIATED at this time meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted with Ms. Gleason and documentation was provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 9/23/21 at 1: PM to the administrative office for the agency to deliver findings for the allegation as stated. LPA met with Haley Randle, Director of Children's Residential Programs to discuss the allegation and findings. LPA informed Ms. Gleason that the investigation included initial virtual inspection at the facility on 4/16/21, interviews with C1 (see LIC811 dated 9/23/21), C2 and staff between 8/6/21 and 9/22/21. LPA obtained documentation related to C1 and C2 and staff contacts information related to the staff that were present during the alleged incident. On 3/25/21, C2 disclosed that an incident occurred between C2 and C1 involving inappropriate touching while both youth were in a shared room, unsupervised. When the incident allegedly occurred, C1 denied any inappropriate contact and continued to deny the contact when interviewed at another facility on 9/21/21. Staff interviewed state that nothing was witnessed and youth were in the room together for three minutes or less. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: SUMMITVIEW CHILD AND FAMILY SERVICES - PIONEERFACILITY NUMBER: VISIT DATE: 09/23/2021

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


raw_content:
Narrative:
During interviews with the clients, C2 continued to say that the inappropriate sexual interaction happened while C1 denied that any inappropriate interaction or touching ever happened between them. During interviews with staff, it was discussed that no staff ever saw any indication that C1 or C2 felt uncomfortable around the other client or that there was one of the clients seeking the other. Staff further indicated that they never saw any inappropriate interactions of any kind between C1 and C2. As a result of the investigation conducted, documentation obtained and interviews conducted, the allegation that minors engaged in inappropriate sexual interactions is UNSUBSTANTIATED at this time meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Ms. Randle and documents were provided with appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 3/22/23 at 11: AM and met with Haley Randle, Director of Youth Res Programs to discuss the complaint findings for the allegation as stated. LPA Hill informed Ms. Randle that the complaint investigation included an initial inspection on 1/19/23 where documents were obtained related to C1 and C2 (see LIC811 dated 3/22/23). Collateral interviews were conducted on 3/3/23 with two staff and C2 at the Summitview Administrative offices. A tele interview was conducted with C1 on 3/9/23. LPA Hill informed Ms. Randle that the allegation that minors engaged in inappropriate sexual interactions is related to an incident reported by the facility following a disclosure made by C2 who was involved in the reported incident. C2 made the disclosure after C1 had been discharged from the agency. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: SUMMITVIEW CHILD AND FAMILY SERVICES - PIONEERFACILITY NUMBER: VISIT DATE: 03/22/2023

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


facility_name: SUMMITVIEW CHILD AND FAMILY SERVICES - PIONEER

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced inspection visit to the administrative offices for Summitview Child and Family Services on 7/28/21 at 1: PM and met with Haley Randle, Director of Residential Programs to discuss an incident report. LPA informed Ms. Randle that the visit is related to an incident report dated 6/16/21 whereby S1 (see LIC811 dated 7/28/21) was working at the facility and was working their first shift and S1's supervisor exited the facility to see where S1 had gone and found S1 to be smoking a prohibited substance outside the facility, on the facility grounds. While S1 was smoking in the back seat of their own personal vehicle, the vehicle was still located on the facility grounds. S1 was immediately dismissed from the facility and formally terminated 6/17/21. No youth witnessed S1 smoking or the interaction between S1 and S1's supervisor. During the inspection today, LPA did request a copy of the policy regarding smoking any substance while at the facility or around the facility or some policy that would speak to staff not smoking during the time that they are on the clock or during their work shift; i.e. while on a break, gone to lunch or in their car and away from the facility. LPA did ask if the agency does random drug tests for the staff and Ms. Randle states that they do not currently do random drug testing for the staff. Exit interview was conducted and document was provided.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Tamara Hill and Mary Shelton made an unannounced annual inspection on 10/15/21 at 2: PM and met with Jose Navarette, STRTP Administrator, who assisted with the inspection. LPAs Hill and Shelton conducted a walk-through of the facility inside and out. There were no clients present during the inspection due to school and company barbecue happening at their school location. LPAs observed three dual occupancy client bedrooms and two bathrooms during the inspection. LPAs Hill and Shelton inspected and/or reviewed the following: Postings of facility license, Personal Rights Poster were appropriately posted Disinfectants/Cleaning solutions were inaccessible and locked as required Refrigerator Temperature was at or below 45 degrees F and Freezer Temperature at or below 0 degrees. There were multiple refrigerators and freezers on the premises that were well stocked. Nonperishable Foods for one week and fresh perishable for foods two days minimum were present Menu was present and posted Working telephone was present Carbon monoxide detectors and Smoke Detectors were functioning First Aid Kit was present but missing tweezers Common Room (living room) was available as was a separate room for relaxing and activities Dining area with enough seating for clients in care was present and in good condition Medication was centrally stored, locked/inaccessible LPAs did not observe a staff office as the agency believes that the staff should be present with the clients and not in the office doing administrative work when clients are present. All relative documentation is locked and inaccessible. Staff utilize a laptop to conduct daily record updates. Hot Water was between 105 -120 degree F Fire Extinguisher was observed to be last inspected on 6/2/ Toilets, wash basin, bath and shower fixtures appeared to be in good repair, no leaks and delivering hot water. LPAs observed there to be hand soap and paper towels available in the bathrooms and kitchen area. Laundry Facilities were available and LPAs observed posted assigned washing days for clients. Bedrooms appeared to be clean and organized with required linen and furnishings Motor Vehicle was not observed as the staff had taken the facility vehicle to pick up clients from company activity at Golden Plaza location. Facility appeared to be free of vermin and other pests as required. LPAs observed no citations during the physical plant inspection and no citations were issued. Exit interview conducted and documentation provided to the facility.

met_with: Jose Navarette, STRTP Administrator


summary: Facility Evaluation


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPAs) Tamara Hill and Monica Roberts made an unannounced inspection on 1/19/23 at 9: AM and met with Haley Randle, Director of Youth Residential Programs to discuss an incident report. LPA discussed the incident report dated 1/6/23 in which C1 (see LIC811 dated 1/19/23) made an accusation about staff. LPA spoke with Ms. Randle about the situation and did speak to the therapist during the inspection today. Further investigation is needed at this time. LPA discussed with staff at the facility other information that is necessary to be in the incident reports (particularly the 24 hour reports) when submitting the reports to Licensing. LPA also discussed with the staff that it has been observed that there is an up-tick in medication incident reports where medications are either not administered or incorrectly administered for doses or medications. LPA advised that the agency needs to do something to ensure that youth are given their medications as prescribed and that missing medications for youth is not acceptable. LPA discussed 24 hour reports with the agency as well. LPA pointed out that there are incidents in which there is little to no information about why a youth is restrained or information is missing that is vital to know on these reports. LPA provided examples of the 24 hour incident reports that need additional information on them so that staff are aware of the missing or incomplete reports. No citations were issued as a result of the inspection and exit interview was conducted.


raw_content:
Narrative:
Investigator Barajas and El Dorado County Sheriff also conducted additional interviews with two additional clients of the facility (C2 and C3) who disclosed that they exchanged nude photos with S1 and that S1 made sexually explicit statements to them, including wanting to meet up with the youth and have sexual relations with the youth. At the time, both of these youth were under the age of 18. As a result of the investigation, the allegation that staff had an inappropriate sexual relationship with an client under the age of 18 in care and that staff engaged in an improper sexual relationship with clients in care is SUBSTANTIATED at this time meaning the "preponderance of the evidence" standard has been met. The facility is being cited for Personal Rights section 87072(c)(11) as the licensee shall ensure that each child is accorded the personal rights specified in Welfare and Institutions Code Section 16001.9, including the right to be free of physical, sexual, emotional, or other abuse as it pertains to S1 engaging in a sexual relationship with a client while in the facility. The facility is also being cited for Conduct Inimical as described in Health and Safety Section 1568.092(a)(2) as the department may prohibit any person from... continuing the employment of, or allowing in a licensed facility, or allowing contact with clients of a licensed facility by, any employee...who has Engaged in conduct that is inimical to the health, welfare, or safety of either an individual, in or receiving services from the facility, or the people of the State of California as this pertains to S1 engaging in the exchange of nude photos and making sexually explicit statements to client in the facility. The facility was advised that the matter is being referred to our Legal Department for further review and additional legal action. Exit interview was conducted with Ms. Randle and documentation and appeal rights were provided.

Investigation Findings:
13Licensing Program Analyst (LPA) made an unannounced complaint inspection on 7/15/22 at 11: AM and met with Haley Randle, Director of Youth Residential Programs to discuss the allegations of this complaint. LPA informed Ms. Randle that the investigation was completed by the Investigations Branch of Community Care Licensing (Investigations), specifically Investigator Barajas. The investigation included an initial complaint inspection on 11/12/2021 by LPA Hill where documents were obtained for Investigations. Investigator Barajas conducted the investigation in conjunction with El Dorado County Sheriff Department. Investigation with the Department showed that S1 (see LIC811 dated 7/15/22) and C1 engaged in a sexual relationship, including oral sex and sexual intercourse, while C1 was residing in the facility and continued after C1 left the program. The sexual relationship began while C1 was under the age of 18. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: SUMMITVIEW CHILD AND FAMILY SERVICES - SHADOW RUNFACILITY NUMBER: VISIT DATE: 07/15/2022

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


facility_name: SUMMITVIEW CHILD AND FAMILY SERVICES - SHADOW RUN

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced inspection visit to the administrative offices for Summitview Child and Family Services on 7/28/21 at 1: PM and met with Haley Randle, Director of Residential Programs to discuss an incident report. LPA informed Ms. Randle that the visit is related to an incident report dated 5/23/21 involving C1 and S1 (see LIC811 dated 7/28/21). The report is related to a disclosure made by C1 about inappropriate comments made by S1 regarding C1's undergarments. LPA learned from Ms. Randle that C1 had just moved to this location and that this allegation actually happened in the house that C1 had just moved from. Ms. Randle states that C1 had not disclosed the inappropriate comment(s) until relocating to this facility. S1 was terminated following the investigation related to this allegation and another allegation from the other facility involving another youth. LPA did request that the agency provide a copy of the internal investigation and employment file for S1. This documentation should include all hiring, training, and other disciplinary documentation. Ms. Randle states that since these two disclosures, there have been no other disclosures from any other youth related to S1. Exit interview was conducted and document provided to Ms. Randle.


summary: Facility Evaluation

raw_content:
Narrative:
On 8/11/22 at AM, Licensing Program Analyst (LPA) Tamara Hill made an unannounced collateral case management inspection to the administrative offices for Summitview Child and Family Services and met with Anna Gleason, Chief Executive Officer to assess an Enhanced Civil Penalty for a violation of Personal Rights Section 87072, the licensee shall ensure that each child is accorded personal rights specified in Welfare and Institutions Code Section 16001.9, including the right to be free of physical, sexual, emotional, or other abuse and Conduct Inimical, Health & Safety Code Section 1568.092(a)(2), a staff member of the licensed Short Term Residential Therapeutic Program (STRTP) owned and operated by Summitview Child and Family Services engaged in inappropriate sexual acts with a foster child in care. On July 15, 2022, LPA Tamara Hill delivered findings for a complaint investigation at the facility. The complaint investigation revealed that "staff had an inappropriate sexual relationship with an underage client in care" and "staff engaged in an improper sexual relationship with minors in care". Based on information gathered during confidential interviews it was determined the allegation of sexual abuse was substantiated. A staff member sexually abused a minor in care. This abuse is conduct inimical to the health, morals, welfare, or safety of clients in the home. The Department has determined that the enhanced civil penalty is warranted for the physical abuse of C1 while under the care and supervision of the STRTP. The violation does meet the definition of Physical Abuse per H&S 1548(e)(2) Physical Abuse to include Sexual Abuse as defined in Penal Code section 11165.1, which defines sexual abuse means sexual assault, AND Penal Codes section 11165.l(b)(l)-(2) describes sexual assault as including penetration, oral copulation, intrusion by one into the genitals of another, and intentional touching for purpose of sexual arousal or gratification. Pursuant to the Enhanced Civil Penalty Law, Health & Safety Code section 1548(f)(1)(C) the Department will be issuing an immediate civil penalty of $2500.00. An exit interview was conducted, and appeal rights were provided.


facility_name: SUMMITVIEW CHILD AND FAMILY SERVICES - VISTA

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced inspection visit to the administrative offices for Summitview Child and Family Services on 7/28/21 at 1: PM and met with Haley Randle, Director of Youth Residential Programs to discuss two incident reports. LPA informed Ms. Randle that the visit is related to an incident report involving C1 (see LIC811 dated 7/28/21). The 24 hour notification for the incident clearly states that youth had just returned from a psychiatric hold and had glass in their pocket which they refused to turn in to facility staff as part of the agreed upon safety plan prior to discharge from the psychiatric facility. This subsequently lead to youth being restrained for their own safety. In reading the full report received from the facility, the information is not consistent between the 24 hour report and the full report. The full report does not detail any information about glass but instead details a struggle over a "plastic spoon" which they were not allowed to have as part of the safety plan agreed upon when discharged from the psychiatric hospital. Youth attempted to leave the facility and became aggressive towards staff and was subsequently placed in a restraint. LPA informed Ms. Randle about the inconsistencies and did ask that the report be updated and resubmitted to ensure the accuracy between the 24 hour report(s) and the full reports. LPA also asked that the facility clearly define in the report the efforts that were made by the staff to de-escalate youth prior to engaging in the physical restraint as it is not evident in the way that the report is written. LPA also discussed another incident report involving C2 whereby C2 disclosed an incident that took place while on a home pass visiting family. The incident was reported to law enforcement in C2's home county and El Dorado County as C2 is currently living at the facility in this county. Agency reports that an attempt was made to report the incident to Child Protective Services as well but were informed that they could not take reports with "unknown perpetrators" and were informed that it was a law enforcement issue. Agency did inform placement agency of the disclosure. Exit interview conducted and document provided.

met_with: Haley Randle, Director of Residential Programs


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Tamara Hill and Mary Shelton made an unannounced annual inspection on 10/15/21 at 1: PM and met with Abigail Nelson, STRTP Administrator, who assisted with the inspection. LPAs Hill and Shelton conducted a walk-through of the facility inside and out. There were no clients present during the inspection due to school and company barbecue happening at their school location. LPAs observed three dual occupancy client bedrooms and two bathrooms during the inspection. LPAs Hill and Shelton inspected and/or reviewed the following: Postings of facility license, Personal Rights Poster were appropriately posted Disinfectants/Cleaning solutions were inaccessible and locked as required Refrigerator Temperature was at or below 45 degrees F and Freezer Temperature at or below 0 degrees. There were multiple refrigerators and freezers on the premises. Nonperishable Foods for one week and fresh perishable for foods two days minimum were present Menu was present and posted Working telephone was present Carbon monoxide detectors and Smoke Detectors were functioning First Aid Kit was present but missing tweezers Common Room (living room) was available as was a separate room for relaxing and activities Dining area with enough seating for clients in care was present and in good condition Medication was centrally stored, locked and inaccessible LPAs did not observe a staff office area as the agency believes that the staff should be present with the clients in care and not in the office doing administrative work with clients present. All relative documentation is locked an inaccessible to clients in care. Staff utilize portable computers to perform any updates required during shifts. Hot Water was between 105 -120 degree F Fire Extinguisher was observed to be last inspected on 7/6/ Toilets, wash basin, bath and shower fixtures appeared to be in good repair, no leaks and delivering hot water. LPAs observed there to be hand soap and paper towels available in the bathrooms and kitchen area. Laundry Facilities were available and LPAs observed posted assigned washing days for clients. Bedrooms appeared to be clean and organized with required linen and furnishings Motor Vehicle was not observed as the staff had taken the facility vehicle to pick up clients from company activity at Golden Plaza location. Facility appeared to be free of vermin and other pests as required. LPAs did not observe there to be screens on the sliding door but on all other windows throughout the facility where they are opened for ventilation and air circulation. LPAs observed no citations during the physical plant inspection and no citations were issued. Exit interview conducted and documentation provided to the facility.

met_with: Abigail Nelson, STRTP Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Tamara Hill and Mary Shelton made an unannounced annual continuation inspection on 10/27/21 at 10: AM to the Non Public School location and met with Haley Randle, Director of Youth Residential Programs. The purpose of the visit was to continue the annual inspection started on 10/15/21 and interview clients and review client and staff documents. The facility did inform LPAs that all of their client and staff files are electronic and did work on providing LPAs access to the electronic databases. While LPAs waited for the access to review documentation, LPAs interviewed clients. LPAs spend the entire time at the agency interviewing clients and did not review staff or client documents. LPA Hill informed the agency that in order to conclude the annual inspection, it would take another inspection date on another day in order to conduct the file reviews necessary to complete the annual review for the facility. LPA reminded the agency that the visit must be unannounced. Exit interviewed conducted and document was provided. Hard copy signature was obtained via email as most the staff had already left or were leaving for the day.


raw_content:
Narrative:
Regarding the allegation that the facility has physical plants deficiencies that impacts the health and safety of the clients (e.g mold problem), this is related to a leak that was observed prior to July 2022 and continued through November 2022 and December 2022, per the photos received during the investigation. Documentation received indicates that the facility was aware of the leak and possible contamination in July 2022, per the notation from ServPro that was provided on 3/20/23 by the facility. The notation clearly states that a moisture check was requested by Summitview (or a representative of the agency) as a result of a leak identified and that ServPro clearly found that the "upstairs has drywall affected common wall to backside of shower", vinyl flooring in the bathroom read moisture, and that the scope of the work indicated removal of the affected ceiling downstairs, removal of the vinyl and particle board flooring in the bathroom, removal of the baseboard and drill holes to dry the backside of the shower if no mold growth was found. Note states that the [customer] only wanted the moisture check and they would follow up for an estimate and services. Photos received indicate that the facility knew or should have known in November 2022 the leak issue was not resolved adequately as the photos show additional dark ceiling stains were present with new stains appearing daily and/or weekly. Photos received show spots on ceilings on the first floor as well as walls and floors on the second level of the facility and were taken from November 6, 2022 through February 10, 2023. Interviews with staff also indicate staff knew about the leak and thought that the agency was addressing the issue by shutting the facility down and making the necessary repairs in February 2023. As a result of the information obtained, documentation provided, and interviews conducted, the allegation that the facility has physical plant deficiencies that impact the health and safety of the clients is SUBSTANTIATED at this time meaning that the "preponderance of the evidence" standard has been met. The facility was cited for Title 22, Division 6, General Licensing Requirements Section 80087(a) Buildings and Grounds as the facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of the clients, employees and visitors. The facility knew about a leak and possible mold issues in the facility prior to July 2022 but did not address the issues appropriately until February 2023. Exit interview was conducted with Ms. Randle and documentation was provided along with appeal rights. indicating that overtime was mandatory but that the mandatory overtime didn't actually happen. The facility did indicate that they were having some staffing shortages but not to the point that they couldn't meet the Title 22 ratio requirements of three clients to one staff. When speaking with Haley Randle, Director of Youth Residential Programs, and Anna Gleason, Chief Executive Officer, it was discussed that the program statement reflects the ideal staffing levels for their short term residential therapeutic program at one staff to two clients but since the pandemic, finding qualified individuals to work has not been easy and they have not been able to maintain their desired staffing levels and have had to work with the one staff to three clients staffing ratio set by Title Regulations. As a result of the investigation and interview conducted, the allegation that the facility is understaffed is UNSUBSTANTIATED at this time meaning that while the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Ms. Randle and documentation along with appeal rights was provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 3/22/23 at 12: PM and met with Haley Randle, Director of Youth Res Programs to discuss the findings of the complaint allegation. LPA Hill informed Ms. Randle that the complaint investigation included an initial inspection at the facility on 2/3/23 where photos were taken of the ceiling in the staff area. LPA Hill was also informed during this inspection that the bedroom and bathroom where the alleged leak is from was closed 2/17/23, and no clients were using the bathroom or staying in the bedroom prior to the closure due to the ongoing leak repairs needed. LPA Hill also conducted interviews with complainant and Environmental Consultant on 2/3/23. Four collateral staff interviews were conducted on 3/8/23 at Summitview Administrative Office. LPA Hill received documentation from Haley Randle, Director of Youth Residential Programs on 3/20/23 that came from ServPro and RegasGroup Environmental Consultants related to the identified water damage and removal and the mold clearance air sampling conducted at the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: SUMMITVIEW CHILD & FAMILY SERVICES-STEPPING STONESFACILITY NUMBER: VISIT DATE: 03/22/2023

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


facility_name: SUMMITVIEW CHILD & FAMILY SERVICES-STEPPING STONES

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an announced inspection on 9/23/21 at 11: AM and met with Haley Randle, Director of Children's Residential Programs to tour the facility. The inspection on this date is for the purposes of relocation of one of the other facilities by the same licensee to this location. As such, all of the furnishings or other items were not present in the facility as would be expected for new licenses. LPA did observe some non perishable food items, chemicals used for cleaning and other furniture items in the facility but not all. During the inspection today, the following items were noted: This is a three story house with a large amount of storage space for clients and the facility staff. LPA observed a fire extinguisher near the kitchen area with an inspection tag dated 7/7/21. LPA discussed that this location will be doing schooling for youth as well as group therapies for clients admitted to the facility. LPA observed that there was adequate space for these services and more based on the size and make up of the home. LPA observed that there are two dual occupancy client bedrooms and two single occupancy client rooms in the facility that were all well stocked with dresser space, beds and night stands as required. There are no lamps but LPA did observe that each of these rooms had central lighting in the rooms. LPA observed that the screens for the windows in the client rooms were present. LPA observed two client bathrooms: the front bathroom was equipped with two sinks, toilet and tub and shower combination. There are a total of three full bathrooms and one half bathroom in the facility. Hot water was not available to be tested as there was a company installing a new HVAC system today which meant that they needed to disconnect the hot water lines. LPA observed that water delivery locations are receiving water and functioning and toilets were flushing. LPA was informed that shower doors were being replaced prior to accepting clients. The facility was observed to have viable exits from each level of the facility. LPA did advise that the facility ensure that the banister is safe and/or inspected as it was secure but seemed a bit loose near the stairs on the side of the house. LPA observed that the laundry facilities are in the garage as well as additional storage space facility supplies as needed. LPA observed an that the medication cabinet is located in the kitchen, near the refrigerator. The main entrance for visitors, staff and clients will near the driveway and garage area. LPA observed the cameras throughout the facility are still be installed. LPA did observe that the cameras are in the common areas only and on the exterior of the facility. The use of cameras shall not violate the personal rights of youth in care as they do not capture audio and are not used in client bedrooms or bathrooms. Fire clearance has not been received yet as facility needs to clear the exterior of the facility for defensible space as defined by fire marshal. LPA did observe that the exterior of the home did appear to have had a lot of the work done recently as some trees were cut down and stacked with ground cover ready to move. LPA was also informed that there is a great number of things pending at this time that the agency would like to do to the house prior to accepting clients, including painting of the interior of the home. The only obstacle that LPA observed at this time is the fire clearance. LPA did inform the agency that once the fire clearance is received then the license can be issued. LPA shall update the license information as this is not an accurate name for this facility at this time. LPA shall correct the document so that upon licensure, it is accurately reflected in the documents produced. Exit interview was conducted with Ms. Randle and document was provided via email.

visit_type: Prelicensing


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced post licensing inspection at the facility on 3/25/22 at 11: AM and met with Abigail Nelson, administrator within the agency. There are no current clients in care in this facility. The agency anticipates beginning to accept clients beginning next week some time but that there is maintenance that needs to be done on the property prior to accepting any clients. LPA facility outside and observed that there are many fallen branches that could be dangerous to clients. LPA advised that they all be removed prior to having clients in the facility. LPA also observed that some of the boards on top of the patio cover are lose and could be seen from one of the client bedrooms with large nails indicating that they are not nailed in place. LPA advised the facility to ensure that that is taken care of prior to accepting clients. LPA toured the inside of the facility was in substantial compliance during the inspection. LPA observed that the house was equipped with three dual occupancy client bedrooms and multiple bathrooms accessible to clients in care. All bedrooms were fully equipped with appropriate furnishings as required. There was no bedding on the beds as the facility does not have clients at this time. The bathrooms were properly clean and had toilet paper but otherwise had no supplies due to being vacant at this time. LPA observed that the smoke detectors were functioning as required and that there are numerous fire extinguishers on all levels of the home. There was no food in the facility at this time as there are no clients in care. LPA observed that there are some nonperishable but not a great number. There are no client files to review at this time. LPA reviewed only administrator's file as there are no clients or staff that work at this location at this time. No citations were issued. Exit interview conducted and document was provided to the agency.

met_with: Abigail Nelson, Administrator


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection at the facility administrative office on 3/25/22 at 12: PM and met with Anna Gleason, Chief Executive Officer. The purpose of the inspection on 3/25/22 was to discuss the following incident reports: 1/31/ AM incident - this report indicates that C1 was on a "stop-run" and subsequently restrained in the classroom, after leaving the relaxation room, and upon getting outside the building. LPA asked about the "stop-run"as leaving is part of youth's personal rights. The agency states that this is for the youth that are most at risk due to recent suicide attempts and other self harm behaviors and that these orders are evaluated frequently. LPA asked that the agency provide something in writing about the policy of these orders including how they are derived, how long they last, how frequently they are evaluated, and what input the youth have in making these decisions as they are to have a say in their needs and services and voices in their child and family team meetings. 1/31/ PM incident - this report indicates that C1 was set to leave the non-public school site at the end of the day and was asked to sit in the back of the vehicle due to previously exhibited behaviors but C1 refused. The reports indicates that there were four staff surrounding C1 as they stood by the van. C1 dropped their belongings and attempted to leave, running towards a busy roadway where they were subsequently restrained. LPA explained to the agency about how intimidating it appears on paper and that this must have felt pretty intimidating to C1, standing there surrounded by four staff. LPA further explained that the report does not indicate any verbal de-escalation techniques as they were all standing there or even some of the staff removing themselves from the immediate physical proximity to allow youth to build rapport or speak to youth about what was happening - all protocol for de-escalation. LPA did not issue citations on this date but did discuss additional training needs for staff regarding restraints, de-escalation techniques, and incident report writing. LPA is aware that the agency is undergoing some major changes including a change in facility type. Exit interview conducted with Ms. Gleason.


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Narrative:
Services where they spent approximately two hours on the phone with both individuals. When interviewed, the therapist reported to the Investigator that staff could be heard in the background telling C1 to "hurry up" and when attempting to ascertain C1's location, staff were "not being forthcoming with information" and "not wanting to give C1 the phone back" to continue to the conversation. The agency's Chief Executive Officer (CEO) stated that they spoke with the parties on the phone and requested that the conversation be paused long enough to get C1 and the other youth back to their assigned house. CEO states that they were informed that the call could not be paused for convenience so the other youth were sent to their assigned house without C1. When CEO was asked if they heard any of the staff pushing C1 to hurry with their call, CEO states that they did not recall this but did say that they heard the other youth yelling these things as they were growing restless and hungry and wanting to return to their house. CEO states that law enforcement were summoned by the callers on the phone to the nonpublic school and did respond to the location to conduct a well check for C1. CEO states that law enforcement decided to transport C1 to the hospital for a mental health assessment. CEO states that C1 was returned to the facility the same day without further incident. As a result of the investigation conducted, the allegation that staff attempted to prevent C1 from making a complaint is UNSUBSTANTIATED at this time meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Ms. Randle and documents were provided, including appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 1/21/22 at 12: PM and met with Haley Randle, Director of Youth Residential Programs to discuss the allegations. LPA informed Ms. Randle that the investigation included an initial inspection on 11/12/21. Interview was conducted with C1 (see LIC811 dated 1/21/22) by Investigator Melissa Burgoon of the Department's Investigations Branch on 11/18/21 and 11/24/21. Investigator also conducted interviews with C1's therapist on 11/16/21 and C1's Social Worker on 11/19/21. Investigator also obtained a copy of a police report for 11/2/21. LPA Hill conducted interviews with staff present and involved during the incident on 11/2/21. The allegation that staff attempted to prevent C1 from making a complaint is related to an incident on 11/2/21 where C1 was restrained at the nonpublic school. After the restraint at the school, C1 requested to use the phone to make a call. Staff provided C1 with a phone and privacy to make the call. C1 made several calls to various individuals including C1's therapist and the Ombudsperson with the Department of Social UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: SUMMITVIEW CHILD AND FAMILY SERVICES - LOTUSFACILITY NUMBER: VISIT DATE: 01/21/2022

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


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Narrative:
While C2 did pursue C1 in the facility in an effort to get C1 to respond to C2, C1 did barricade themselves in the bathroom and C2 continued to bang on the door to gain access to C1. During another incident in the same month, C1 was on a phone call and had to enter the laundry room to get away from C2 that was again pursuing C1. Staff at the facility reported that while C1 was on their phone call, C2 almost broke the door by banging and kicking the laundry room door attempting to get at C1. During an interview with C2, they admitted to pursuing C1 stating that they were annoyed that C1 would not respond to C2 and would not talk to them. C2 denied banging on the door, bathroom or laundry room, even though this was reported by staff. The allegation that a minor physically abuses another minor is related to the same incident(s) where C1 was allegedly pursued by C2 and C2 physically assaulting C1. When LPA asked C2 about C2 allegedly hitting C1 with the phone one time, C2 states that it wasn't a big hit but more of a tap on the shoulder while C1 and C2 were passing one another in the facility hallway. C2 states that they believe that C1 did call law enforcement about that incident and they did respond but that nothing happened. C2 denied hitting C1 on any other occasion that they could recall. LPA did not interview C1 about this complaint as LPA was advised by C1's social worker that they did not want C1 interviewed due to C1's current placement being unstable at this time. As a result of the investigation conducted and information obtained and the inability to interview C1, the allegations that staff do not properly supervise minors, facility did not keep youth safe, and a minor physically abuses another minor is UNSUBSTANTIATED at this time meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Ms. Randle and documents, including appeal rights, were provided. Staff went on to disclose that as a result of not having consent forms allowing the facility to discuss C1 with this individual, the communication(s) were not returned nor was the communication forwarded to another individual within the agency that could speak to the individual. Staff also informed LPA that they did not have access or passwords to check the voice messages at the house at the time of the communications but have since obtained access to the voice messages but did not appropriately address the voices messages. As a result of the investigation and information obtained, the allegation that the facility did not return communications made to the facility is SUBSTANTIATED at this time meaning that the the "preponderance of the evidence" standard has been met. The facility was cited for STRTP Interim Licensing Standards 87072(c)(4) Personal Rights. In addition to Welfare and Institutions Code Section 16001.9, the facility shall ensure that each child is accorded personal rights including to have communications to the facility from relatives and/or authorized representative(s) answered promptly and completely. The facility did not return communications to an individual that they knew regularly spoke with C1 while in the facility nor did the facility engage anyone at the agency level return said communications as required by this regulation. Exit interview was conducted with Ms. Randle and documents, including appeal rights, were provided to the facility.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 12/7/22 at 9:30 am and met with Haley Randle, Director of Youth Residential Programs to deliver findings for the allegation stated. LPA informed Ms. Randle that the investigation included an initial inspection on 8/11/22 where documents were obtained. Subsequent inspections were conducted 8/31/22 and 10/13/22 where interviews were conducted with staff and C2 (see LIC811 dated 12/7/22). LPA spoke with C1's social worker on 10/15/22 who advised this LPA that they did not want C1 interviewed while in their current placement due to the instability of the placement. LPA informed Ms. Randle that staff disclosed that they did receive communication and/or voicemails from an individual inquiring about C1 but that they were unable to disclose information about C1 due to privacy laws. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE This is an official report of an unannounced visit/investigation of a complaint received in our office on 08/01/2022 and conducted by Evaluator Tamara Jensen-Hill PUBLICCOMPLAINT CONTROL NUMBER: 23-CR- FACILITY NAME:SUMMITVIEW CHILD AND FAMILY SERVICES - LOTUSFACILITY NUMBER: ADMINISTRATOR:ABIGAIL NELSONFACILITY TYPE: ADDRESS: MAGPIE COURTTELEPHONE: (530) 644- CITY:PLACERVILLESTATE: CAZIP CODE: CAPACITY:6CENSUS: 6DATE: 12/07/ UNANNOUNCEDTIME BEGAN: 09: AM MET WITH:Haley Randle, Director of Youth Residential ProgramsTIME COMPLETED:11: AM 9Staff do not properly supervise minors Facility not keeping youth safe Minor physically abuses another minor INVESTIGATION FINDINGS: 13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 12/7/22 at 9:30 am and met with Haley Randle, Director of Youth Residential Programs to deliver findings for the allegation stated. LPA informed Ms. Randle that the investigation included an initial inspection on 8/11/22 where documents were obtained. Subsequent inspections were conducted 8/31/22 and 10/13/22 where interviews were conducted with staff and C2 (see LIC811 dated 12/7/22). LPA spoke with C1's social worker on 10/15/22 who advised this LPA that they did not want C1 interviewed while in their current placement due to the instability of the placement. LPA informed Ms. Randle that the allegation that staff do not properly supervise minors or that the facility did not keep a youth safe are related to an incident that took place in July 2022 between C1 and C2 (see LIC811 dated 12/7/22) in which C1 was being pursued in the facility by another youth. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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: 4 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: SUMMITVIEW CHILD AND FAMILY SERVICES - LOTUSFACILITY NUMBER: VISIT DATE: 12/07/2022

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


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Narrative:
LPA Hill informed Ms. Randle that the investigation of this incident included interviews with staff and C1, C2, along with other youth in the facility at the time of the alleged incident. Investigation shows that C2 was inconsistent in their statements during interviews and follow up interviews conducted by the investigator. Despite C2 naming several staff and clients as witnesses, investigation failed to show any witnesses that could corroborate the alleged incident(s). In addition, S1 was specifically named as the awake night staff during the alleged incident(s) and when interviewed, S1 denied any knowledge or unreported incident(s) where youth were awake during the overnight shifts as reported. A review of the facility's documentation of the overnight shift did indicate that bed checks are required every 15 minutes but the documentation indicated inconsistent bed checks being conducted. Per the agency's policy, the bed checks are required to be conducted every 10 to 15 minutes. This not being conducted as indicated in the policy which would have left youth unsupervised for periods of time to include 30 to 45 minutes. When interviewed, S1 stated that while they did not document all room check(s) conducted, S1 was adamant that the room checks were completed per the agency policy and that camera review would indicate such but cameras were not available for review and/or reviewed. As a result of the investigation of the allegation that a lack of supervision resulted in a minor inappropriately touching another minor in care is UNSUBSTANTIATED at this time meaning the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Ms. Randle, and documentation was provided along with appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 4/16/24 at 2: PM and met with Haley Randle, Director of Youth Resdiential Programs to discuss the findings of this complaint investigation. LPA Hill informed Ms. Randle that the complaint investigation included an initial inspection to the facility on 8/11/23 and a collateral inspection to the agency's administrative offices was conducted the same on the same date to obtain documentation to assist the Department's Investigation Branch in the investigation. The allegation that a lack of supervision resulted in a minor inappropriately touching another minor is related to an incident reported to the Department by the facility on 8/1/23, where C1 allegedly touched C2 inappropriately (see LIC811 dated 4/16/24). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: SUMMITVIEW CHILD AND FAMILY SERVICES - LOTUSFACILITY NUMBER: VISIT DATE: 04/16/2024

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