summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Jessica Rodriguez on May 23, 2023, at 1: P.M. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9(a)(2). During the inspection, LPA Rodriguez met with Core Program Manager, Eduardo Perez and inspected the facility inside and out. LPA reviewed 1 of 4 child's records and 2 of 2 staff personnel files on site at the facility. LPA reviewed 1 of 4 child's psychotropic medications and medication records. LPA interviewed 2 of 2 staff on site to discuss the facilities policies and procedures of operation. LPA interviewed no children currently on psychotropic medication, as the youth was not at the facility. During the inspection LPA observed deficiencies (see attached 809D), plan of corrections were discussed and appeal rights were provided. LPA provided a copy of this licensing report to Core Program Manager, Eduardo Perez


state: CA

facility_name: ARS-LINWOOD

summary: Facility Evaluation

raw_content:
Narrative:
On this date, Licensing Program Analyst's (LPAs) Reyna Martinez and Sonia Sanchez conducted a case management visit at the ARS Corporate Office, in Turlock, CA and met with Kim Franck, Administrator (AD). The purpose of the meeting was to discuss an incident report emailed to Community Care Licensing (CCL) on May 6, 2024. LPA confirmed the details of the incident that occurred on April 29, 2024. After further review and additional details gathered with AD. The Licensee did submit the incident report within the required seven day period. The Department has determined there was no late reporting found and rescinded the deficiency. No further action is needed. No deficiencies are being cited at today's visit. An exit interview was conducted, and a copy of the report were provided to the facility.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Kim Franck


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Sonia Sanchez conducted a complaint inspection and met with Kim Franck, Associate Division Director (ADD). The purpose of the inspection was to deliver the findings for the above complaint allegations. Based on interviews and record review, it was determined that administrator is not on facility premises for a sufficient amount of hours to meet the needs of the resident and staff mismanaged residents' records. Based on the LPA's observation , confidential interviews and records review which were conducted, the preponderance of evidence standard has been met, therefore, the above allegations are found to be substantiated. A deficiency is being cited for the Interim Licensing Standards (ILS) Chapter 7.5, Article 6, Section 87064(b)(1) Administrator Qualifications and Duties and 87070(h) Children's Records. A copy of this report and Appeal Rights were provided to the STRTP. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Melikian LICENSING EVALUATOR NAME: Sonia Sanchez 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 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FRESNO RO, E SHAW AVE FACILITY NAME: ARS-LINWOODFACILITY NUMBER: 500314443

report_type: Complaint Investigation

complaint_status: SUBSTANTIATED


summary: Facility Evaluation

raw_content:
Narrative:
On 04/15/2026, Licensing Program Analyst (LPA) Sonia Sanchez traveled to ARS - Linwood located in Turlock, CA and met with Francisco Villa, Direct Care Staff (DCS) to continue the investigation for a separate complaint on a different agency (24-CR-20260309180758). LPA conducted client interview on the above complaint control number. No deficiencies observed or cited during this inspection. A copy of this report was discussed and left at the facility with Frank Villa at the conclusion of the inspection.

met_with: Francisco Villa


facility_name: ARS-TUOLUMNE

summary: Facility Evaluation

raw_content:
Narrative:
On May 27, 2021, Licensing Program Analyst (LPA) Eduardo Barragan conducted an unannounced case management inspection at ARS-Tuolumne. LPA Barragan toured the facility inside and out with Sandee Dhaliwal. The purpose of this visit was to speak with three clients. No deficiency nor citations were observed, at this time. An exit interview was conducted with Sandee Dhaliwal.

met_with: Sandee Dhaliwal.


summary: Facility Evaluation

raw_content:
Narrative:
On August 25, 2021, Licensing Program Analyst (LPA) Eduardo Barragan and Licensing Program Manager (LPM) Juanita Arroyo conducted an unannounced annual required inspection at this facility. LPA and LPM were met at the facility by two Program Managers Eduardo Perez and Stefanie Goloiang. An inspection of the facility was conducted and the following was observed: No clients were residing in the home; therefore, no client nor staff files were inspected on this date. The Licensee stated that they have this facility closed at the moment. The facility was inspected indoors and outdoors. Hot water temperature measured at 106 degrees in the restrooms. LPA Barragan observed that there were no supply of perishables and non-perishables. The Licensee stated that they are not sure when this home is going to end up opening back-up. LPA observed adequate supply of linen and storage space for clients. Cleaning chemicals inaccessible to clients. There are no pets at the facility. Per the two Program Mangers, there are no weapons at the facility. There are no bodies of water at the facility. There have been two deficiencies in the prior 12 months. No deficiency were noted during this inspection. LPA left a copy at the facility. The visit was then concluded.

visit_type: Annual

met_with: Eduardo Perez and Stefanie Goloiang.


facility_name: ASHLAN HOUSE

summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Priscilla Zamudio conducted an unannounced visit to the STRTP-Ashlan House in order to deliver the findings of the above allegations and met with Patricia Bratcher, Administrator. On October 20,2021 the above allegations were referred to Community Care Licensing for investigation. The investigation included an inspection of the facility, records review, interviews with the Complainant, Staff, and Clients. During the interviews, there was conflicting information provided. Although the allegations may have happened or are valid, there is not a preponderance of evidence to provide the allegations occurred. Therefore, the above allegations are UNSUBSTANTIATED at this time. A copy of this report was discussed and provided to Patricia Bratcher along with appeal rights. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Priscilla Zamudio 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 3

met_with: Patricia Bratcher

complaint_status: unsubstantiated


raw_content:
Investigation Findings:
13Complaint Specialist C.K. Kinney(CS) traveled to Ashlan House and met with Tara Flores to deliver findings of investigation. Investigator Barragan conducted investigation that included review of documentation, and confidential interviews and due to inconsistencies in the information received could not reach a preponderance of the evidence that the allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the allegations occurred. Therefore, the above allegations are deemed UNSUBSTANTIATED at this time. Copy of this report and LIC Appeal Rights left at the facility at conclusion of inspection. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Charles Kinney 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 3

met_with: Tara Flores


summary: Complaint Investigation - Unsubstantiated - 1 deficiency

raw_content:
Investigation Findings:
13Licensing Program Analysts (LPA's) Jessica Rodriguez and Reyna Martinez conducted a complaint inspection and met with Head of Service, Vanessa Garibay. The purpose of the inspection was to deliver the findings for the above complaint allegation. During the investigation, LPA conducted interviews and reviewed supporting documents provided by the facility. Based on the information obtained during interviews and review of documentation regarding staff leaving a resident at the park, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Interim Licensing Standards are being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report and appeal rights were provided to the Facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Jessica Rodriguez 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 24-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, E SHAW AVE FACILITY NAME: ASHLAN HOUSEFACILITY NUMBER: 107206686

Deficiencies:
87065.2: (8) Any other duties that may be necessary to ensure the health and safety of children in the facility.

met_with: Vanessa Garibay

title: Personnel Duties. (b) Direct care staff shall perform the following duties


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Jessica Rodriguez conducted a complaint inspection and met with Administrator, Patricia Bratcher. The purpose of the inspection was to deliver the findings for the above complaint allegation. During the investigation, LPA conducted interviews and reviewed supporting documents provided by the facility. Based on the information obtained during interviews and review of documentation regarding facility staff not accepting minor back after a hospital stay, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Interim Licensing Standards is being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report and appeal rights were provided to the Administrator. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Jessica Rodriguez 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 24-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, E SHAW AVE FACILITY NAME: ASHLAN HOUSEFACILITY NUMBER: 107206686


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13Licensing Program Analysts (LPAs) Lisa Slusher and Wayne Aoki conducted a complaint inspection and met with Administrator, Patricia Bratcher. The purpose of the inspection was to deliver the findings for the above complaint allegation. During the investigation, LPA conducted interviews and reviewed other documentation. Based on confidential interviews and review of documentation, an incident occurred on 6/28/2022 where a staff person (S1, See lic 811) left a knife out on the counter. Two clients were involved in an altercation involving the knife. Neither staff present during the altercation, and in 9 of the 12 files reviewed, staff lacked Emergency intervention training. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Citations for Personnel Requirements 80065(a)(1) and Emergency Intervention staff training 87095.65 (a)(1) are issued on this date. An exit interview was conducted, and a copy of this report and appeal rights were provided to the Administrator. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lisa Slusher 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 24-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, E SHAW AVE FACILITY NAME: ASHLAN HOUSEFACILITY NUMBER: 107206686

met_with: Patricia Bratcher, Tara Flores


raw_content:
Investigation Findings:
13On November 2, Licensing Program Analyst (LPA) Wayne Aoki and Licensing Program Manager (LPM) Juanita Arroyo was met by facility Administrator, Patricia Bratcher. The purpose for the inspection is to deliver the findings for the above complaint allegations. Based on confidential interviews and information obtained during the investigation, there is a preponderance of the evidence to prove the above allegations are substantiated. The facility is cited for Interim Licensing Standards, STRTP, Article Continuing Requirements 87065.5(a)(1) Direct Care Staff/Child Ratio, 87065.1(d)(3)(M) Supervision, Evaluation and Training Requirements and California Code of Regulations, Title 22, Division 6, Section 80078(a), Responsibility for Providing Care and Supervision. A copy of this report along with Appeals Rights were left with the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Wayne Aoki 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 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SIERRA CASCADE AC/SC, E SHAW AVE FACILITY NAME: ASHLAN HOUSEFACILITY NUMBER: 107206686


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13On November 2, Licensing Program Analyst (LPA) Wayne Aoki and Licensing Program Manager (LPM) Juanita Arroyo was met by facility representative Patricia Bratcher. The purpose for the inspection is to deliver the findings for the above complaint allegation. Based on confidential interviews and information obtained during the investigation, there is a preponderance of the evidence to prove the above allegation is substantiated. The facility is cited for Interim Licensing Standards, STRTP, Article Continuing Requirements 87072(a)(1)(b) Personal Rights. A copy of this report along with Appeals Rights were left with the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Wayne Aoki 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 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SIERRA CASCADE AC/SC, E SHAW AVE FACILITY NAME: ASHLAN HOUSEFACILITY NUMBER: 107206686


raw_content:
Investigation Findings:
13On November 2, Licensing Program Analyst (LPA) Wayne Aoki and Licensing Program Manager (LPM) Juanita Arroyo was met by facility representative Tara Flores. The purpose for the inspection is to deliver the findings for the above complaint allegations. During the course of the investigation, based on confidential interviews and other documents obtained, although the allegation may have happened or is valid, there is not a preponderance of the evidence, therefore, the above allegations are unsubstantiated. There were no deficiencies cited during this inspection. A copy of this report and appeals rights were left with the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Wayne Aoki 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 3


raw_content:
Investigation Findings:
13On November 2, Licensing Program Analyst (LPA) Wayne Aoki and Licensing Program Manager (LPM) Juanita Arroyo was met by facility Administrator, Patricia Bratcher. The purpose for the inspection is to deliver the findings for the above complaint allegations. Based on confidential interviews and other information obtained, the department has made the following determination. Although the allegation may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. There was no deficiencies cited during this inspection. A copy of this report and appeals rights were left with Ms. Bratcher. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Wayne Aoki 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 3


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13On December 22, Licensing Program Analyst (LPA) Wayne Aoki was met by facility representative Patricia Bratcher. The purpose for the inspection is to deliver the findings for the above complaint allegation. Based on confidential interviews and information obtained during the investigation, there is a preponderance of the evidence to prove the above allegation is substantiated. The facility is cited for INTERIM LICENSING STANDARDS Short-Term Residential Therapeutic Program, Chapter 7.5, Version 4, Articles Through 10, 87072(c)(11) Personal Rights. A copy of this report along with Appeals Rights were left with the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Wayne Aoki 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 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SIERRA CASCADE AC/SC, E SHAW AVE FACILITY NAME: ASHLAN HOUSEFACILITY NUMBER: 107206686


raw_content:
Investigation Findings:
13On December 22, Program Analyst (LPA) Wayne Aoki was met by facility Administrator, Patricia Bratcher. The purpose for the inspection is to deliver the findings for the above complaint allegations. There currently are no placements in the facility as the facility is in the process of relinquishing their license. Based on confidential interviews and information obtained during the investigation, there is a preponderance of the evidence to prove the above allegations are substantiated. The facility is cited for Title 22, Division 6, Chapter 1, Article 06, Continuing Requirements, 80064(a)(3) Administrator-Qualifications and Duties. A copy of this report along with Appeals Rights were left with the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Wayne Aoki 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 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SIERRA CASCADE AC/SC, E SHAW AVE FACILITY NAME: ASHLAN HOUSEFACILITY NUMBER: 107206686


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPA) Priscilla Zamudio and Rachel Bruce traveled to Ashlan House to conduct an Annual Inspection. LPAs met with Tara Flores Compliance Director and Patricia Bratcher Administrator CEO. The home is one story, three bedrooms and two bathrooms. An inspection of the facility was completed and the following was observed: Hot water temperature measured within appropriate range, All smoke detectors were in proper working order, Menu was posted, First aid kit available, Medications were centrally stored and locked, Fire extinguishers properly charged, Adequate indoor and outdoor activity space and activities observed. Client appeared to have adequate clothing and storage space, Adequate supply of linens observed, Sharps locked. Facility does not have any bodies of water. Per the Administrator, there are no weapons at the facility. Client file, Staff files and training were reviewed for compliance on this date. Facility has no active waivers or exceptions. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. LPAs conducted exit interview with Patricia and provided a copy of this report.


summary: Facility Evaluation

raw_content:
Narrative:
On this date, October 13, 2022 at 9: AM, an unannounced required annual inspection was conducted by Licensing Program Analyst (LPA) Wayne Aoki. LPA was met by facility Administrator Patricia Bratcher. LPA inspected the facility, inside and out. Centrally stored medications and sharps are maintained in a locked file cabinet. The facility has a written emergency disaster plan. All facility smoke and carbon monoxide detectors were tested and appear to be in appropriate working order, fire extinguisher is properly charged. Individual beds were observed with appropriate clean linens and are in good repair. There is at least one week supply of nonperishable and a two day supply of perishable foods. The facility is maintained at 73 degrees. Hot water temperature measured 115 degrees. Facility cameras are allowed in the facility and there are no pets. There were 2 staff present during this inspection. Staff files were reviewed. The annual inspection shall be completed at a later date. There were no deficiencies cited today for the Required Annual Inspection. A copy of this report was left at the facility at the conclusion of the inspection


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On this date, LPAs (Licensing Program Analysts) Wayne Aoki and Lisa Slusher conducted a case management inspection for the purpose of completing the annual inspection begun on 10/13/22. Met at the facility by Administrator Patricia Bratcher and Compliance officer Tara Flores. During this inspection client interviews (4) were completed. Previous to this date 5 personnel files were reviewed. On this date, LPAs reviewed 6 additional personnel files and 3 client files. LPA Aoki is also issuing citations and technical advisory/Technical Violations in the following areas: Faciltiy is cited for General Licensing Requirements- General Licensing Requirement 80066(a) STRTP Interim licensing standards section 87068. Technical Violations/Advisory notes are issued for- STRTP Interim Licensing Standards Training Requirements sections 87065.1(d)(1)(B), 87065.1(d)(3), 87065.1(d)(3)(C), 87065.1(d)(5), 87065.1(e)(3)(F) for training topics not noted in the initial 8 hours, 16 hours of additional training, and training topics for annual training.

Deficiencies:
87068.3(a): Modifications to The Needs And Services Plan

(a) The needs and services plan specified in Section 87068.2 shall be updated at least every 30 days to determine the following


summary: Facility Evaluation

raw_content:
Narrative:
On October 18, 2022, Licensing Program Analysts (LPAs) Lisa Slusher and Wayne Aoki conducted a case management inspection at the facility above. Met at the facility by Administrator Patricia Bratcher. The purpose of the case management is to discuss policies regarding Removal and Transfer Procedures and Emergency Intervention Runaway Plan. The above policies were discussed with the administrator as well as updates to the program statement regarding two plans of correction submitted July 31, 2022 for Emergency Intervention Runaway Plan and August 29, 2022 for Removal and Transfer Procedures. Ms. Bratcher will submit further updates and amendments to this LPA on or before October 28, 2022. A copy of this report is given to Ms. Bratcher, Administrator on this date.


summary: Facility Evaluation

raw_content:
Narrative:
On November 2, Licensing Program Analyst (LPA) Wayne Aoki and Licensing Program Manager, Juanita Arroyo was met by facility Compliance Director Tara Flores. The purpose for the inspection is to clear a Plan of Correction that was cited on 10/28/22 for Section 87068.3(a). Facility has updated and completed the needs and services plans for youth. The deficiency is cleared.


summary: Facility Evaluation

raw_content:
Narrative:
On December 22, 2022, Licensing Program Analyst (LPA) Wayne Aoki traveled to Ashlan House to conduct a Case Management inspection. LPA was met by Administrator, Patricia Bratcher. LPA toured the facility. LPA observed that the facility is not in operation. LPA and Ms. Bratcher CS discussed future plans for the building. Ms. Bratcher surrendered the facility License to LPA at conclusion of the facility tour. No deficiencies observed or cited during this inspection. Copy of this report was provided to Ms. Bratcher at conclusion of inspection


summary: Facility Evaluation

raw_content:
Narrative:
Complaint Specialist C.K. Kinney(CS) traveled to Ashlan House to conduct a Case Management inspection to discuss deficiencies observed during complaint investigation. CS conducted entrance interview, reviewed the deficiencies and issued citation. This facility is being cited for violation of STRTP Interim Licensing Standards section 87061(j) Reporting Requirements. Copy of this report, deficiency citation, LIC Appeal Rights left at the facility at conclusion of inspection.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On the above date, LPAs Lisa Slusher and Reyna Martinez conducted a case management inspection. During the investigation of a previous allegation, CS (Complaint Specialist) Charles Kinney enquired about the fingerprint status of S1 (See LIC 811). S1 does not have verification of obtaining a clearance or exemption and worked in the facility without a current fingerprint clearance or exemption. On this date, a citation is issued in violation of section 80019(e) Criminal Record Clearance. A civil penalty is assessed on this date. Additionally, the facility associates all staff to a "sister" facility owned and operated by the same Licensee. A technical advisory note is given to the facility on this date advising the facility to apply for a Waiver for an Administrative Main File.

Deficiencies:
80019(e): (1)	Obtain a California clearance or a criminal record exemption as required by the Department.

title:
1
2
3
4
5
6
7Criminal Record Clearance 80019 (e)	All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility


summary: Facility Evaluation

raw_content:
Narrative:
On this date Licensing Program Analysts (LPA's) Jessica Rodriguez and Reyna Martinez met with Head of Service, Vanessa Garibay. The purpose of the meeting was to discuss an incident report as well as the facilities Program Statement; specifically, the Runaway Plan Policy & Procedures. LPA Rodriguez reviewed an incident report in which the Runaway Plan & Procedures were not followed by staff. Concerns regarding the incident were discussed with Vanessa Garibay, as well what information is to be included in a facilities Runaway Plans according to the Interim Licensing Standards. Based on LPA's observations, Interim Licensing Standards. s are being cited on the attached 809D. The plan of correction discussed with Vanessa Garibay will also include a submission of an updated Runaway Plan and Program Statement to the Department for approval. A copy of this report and appeal rights were provided to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On October 13, Licensing Program Analyst (LPA) conducted a Case Management Inspection. LPA was met by Administrator, Patricia Bratcher. LPA reviewed client's personal inventory list and determined that the inventory list was not completed when the Minor was admitted into this facility. Therefore LPA was unable to determine if the minor came to the facility with all of their belongings. The facility was cited for violation of California Code of Regulations, Title 22, Division 6, regulation 80026(h). Safeguards for Cash Resources, Personal Property, and Valuables of Residents


summary: Facility Evaluation

raw_content:
Narrative:
On this date, LPAs Lisa Slusher and Wayne Aoki conducted a case management inspection at the facility. The purpose of this inspection is to follow up on issues discovered during the investigation of the complaint. The complaint relates to an incident which occurred on 6/28/22. During this incident, there was an altercation between two youth where two staff were present at the facility. Based on a review of the file for S1 and S2, S1 did not qualify as a Direct Care Staff, and neither staff qualified as a facility manager, meaning that during the incident there was no facility manager present at the facility. The facility is cited for ILS (interim Licensing Standards) section 87065 (f) and (g) Personnel Requirements. A copy of this report is left with the facility manager on this date.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On October 21, Licensing Program Analyst (LPA) Wayne Aoki was met by Compliance Director, Tara Flores. The purpose for this Case Management is to review the facility's Incident Reporting Requirements and the facility's Biannual Emergency Intervention Plan. Based on the LPA's investigation, it was determined that the facility has failed to submit Incident Reports in a timely manner. The facility also failed to submit to Community Care Licensing their Bi-Annual Emergency Intervention Plan. The facility is cited for violation of California Code of Regulations, Title 22, Division 6, regulation 80061(b) Reporting Requirements and Short-Term Residential Therapeutic Program Interim Licensing Standards, Chapter 7. Version 4, 87095.22(h) Emergency Intervention Plan.

Deficiencies:
87095.22(h): Procedures for an internal biannual review of the use of emergency interventions must be
developed. Such procedures must include at least the following: 1
2
3
4
5
6
7
8
9
10
11
12
13
14

title:
1
2
3
4
5
6
787095.22(h) Emergency Intervention Plan


facility_name: ATLAS HOUSE

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill conducted an office visit for the applicants at the Licensing Office and met with Lance McHan, Chief Strategic Officer, and Shynelle Smith, Administrator, to discuss the application status. LPA Hill provided Ms. Smith with a copy of the STRTP Review Tool indicating items that are in need of revisions. LPA Hill informed the agency that the primary areas of concern at this time include: Population to be served - the specification of the youth to be served by the facility and compatibility with the other youth in the facility. There are references to parenting minors and LPA Hill questioned how supervision will be assessed for the parenting minors and their infant children. Agency states that they will not be admitting parenting minors and will remove this from the program. Services and how they are to be provided. LPA Hill explained that throughout the document the agency must explain the HOW in providing services to youth that they will accept into the program. Requirement to utilize the LIC9106A when writing their Program Statement and Plan of Operation as this document is very specific about the requirements necessary. LPA Hill also informed the agency that the cover sheets eluding to the county that they will be working and needs to be modified to remove this as it insinuates that this is a county run or county operated facility. All documentation related to the application needs to be about the applicant, the corporation, and not about individuals on the board. Not copying Title 22 and telling about the Department's requirements and HOW this applies to and will be implemented in this facility. Training and how staff will be trained to provide care and supervision in the facility. LPA Hill provided the agency with a copy of all noted corrections and LIC9106A. LPA Hill informed the agency that they have 30 days, until 1/20/25, to provide the corrections to LPA Hill. Corrections should be provided electronically and with highlights. End of documentation and exit interview was conducted.

met_with: Lance McHan and Shynelle Smith


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill and Systems of Care (SOC) analyst, Ansar Muhammad met with Rise Family Services representatives, Shynelle Smith, Theresa Galano, and Zach Lupton on 5/28/25 at 10: AM to discuss the application review. LPA Hill and SOC Muhammad gave the floor to Ms. Smith to ask questions about the requested changes and some of the following items were discussed and clarified for the applicant: Cover pages needed for each section with information from licensing form LIC 9106A Cell phone usage and/or restriction in the facility - this may be a violation of personal rights. It was advised that the applicant use Prudent Parent Procedures when restricting times when the cell phones are to be used or not used. Also discussed was the discussion about restriction(s) of cell phones during intake and/or during Child & Family Team Meetings when issues arise. Removal of all reference to gender in the program description so that this can be utilized for more or so that the facility can admit youth based on their gender identity versus gender at birth. Admission Agreement - ensure that any admission agreement used meets expectations set in the Interim Licensing Standards; possibly the development of an admission agreement specifically for this agency. Emergency Intervention Plan - being careful to ensure that the facility speaks to the use of the plan and what it will and will not be utilized for (i.e. property destruction) and speaking to what the facility can do. Do not include reference to what an outside agency will do or will not do when contacted for assist as this cannot be controlled by the Licensee. Analysts both discussed with Ms. Smith that the changes needed to be submitted using the strike-through method for removal of content and highlight of added content for ease of review. Other items discussed included timelines and what is to be expected. It was shared that some STRTP applications are taking longer but it all depends on how individual(s) work together and how responsive individuals are in the process. It was requested that if there are specific questions about sections, as Ms. Smith goes through to make the corrections, that they wait until the changes are completed and put all questions in one email and provide that to LPA and SOC analyst for response as there are some revisions that answer questions to other sections as the revisions are completed. It was also discussed that these applications are difficult and lengthy and SOC analyst advised that the agency give themselves grace in their review and revisions as they are doing a great job in their application. It was agreed upon that the revision is due by June 6, 2025, but Ms. Smith indicated that if there is additional time needed to finalize the review, then an email with this request will be submitted by that date. End of overall discussion about the revisions and this document was provided to Ms. Smith for signature and return to LPA Hill.

met_with: Shynelle Smith, CEO


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill conducted a Component III Orientation with the facility on 7/11/25 at 11: AM and in attendance was Shynelle Smith, Administrator. This meeting was conducted via MS Teams. LPA Hill and Administrator Smith discussed all aspects of operation covered with the Component III Orientation slides and questions were answered. LPA Hill and Administrator Smith also discussed some of the requested revisions of the application at the conclusion of the Orientation deck. LPA Hill reiterated that the due date for the latest corrections is 7/25/25. Fingerprint associations have been completed for Ms. Smith. Accreditation was discussed and Ms. Smith states the agency has begun their application process. LPA Hill reiterated that during the 12 months following licensure, the agency must also seek approval of the Mental Health Program Plan from the Department of Health Services and Medi-Cal Approval in addition to securing Accreditation. LPA Hill and Administrator Smith also discussed the Pre-Licensing Inspection to be conducted by fellow LPAs Brittany Crass and Michelle Silva and how best the facility can be ready for the inspection. There were no further questions and documentation was provided via email for Administrator Smith to sign and return to LPA Hill.

met_with: Shynelle Smith, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On Friday, July 25th, 2025, Licensing Program Analysts (LPA) Brittany Crass and Michelle Silvas arrived Announced at the Facility to conduct a pre-licensing inspection. LPA's were greeted by Administrator, Shynelle Smith who assisted with the inspection. LPA's observed the facility to be clean, safe, sanitary and in good repair. LPA observed the Personal Rights posted, and grievance form. There was a Mass Casualty Plan. LPA observed working smoke and carbon monoxide detectors. Fire extinguishers were accessible and charged. LPA observed locked cabinets housing sharps, and cleaning supplies separately. LPA observed adequate furnishings which were in good repair and free from hazards. LPA was unable to test the water temperature due to LPA's thermometer being unavailable. Water was manually tested and was found to be warm to the touch, but not scalding. Exterior of the facility was observed to be well maintained and free of hazards. LPA advised that facility maintain a thermometer and test water on a regular basis to assure it is within 105 to 120 degrees Fahrenheit. Administrator will email LPA photos of 1. thermometers, 2. a fixed screen in the living room, 3. the removal of the refrigerator, washer and dryer being stored in the garage. 4. items from upstairs room removed. This license will be processed for approval once LPA receives these documents. Exit interview was conducted with Administrator, Shynelle Smith and a copy of this report was given.

visit_type: Prelicensing

announced_status: Announced

met_with: Shynelle


summary: Facility Evaluation

raw_content:
Narrative:
On 04/20/2026 at 11: AM Licensing Program Analyst (LPA), Elena Gonzalez-Soto, arrived at the facility unannounced to conduct a post licensing inspection. LPA met with Shynelle Smith, Administrator who assisted with the inspection. LPA provided Technical Assistance on Incident Reporting and Fixtures, Furniture, Equipment, and Supplies requirements. LPA provided Administrator with the Reporting Requirements Resource Guide. Physical Plant: LPA observed the facility is a two-story home with three bedrooms, a front yard and a backyard. LPA observed posting of personal rights, working carbon monoxide and smoke detectors, first aid kit, fire extinguisher, inaccessible cleaning solutions, food menu, hot water temperature of 116F, Fridge Temperature of 37F, and freezer temperature of 0F, and two out three working toilets. Operations: LPA observed posting of personal rights, register of clients, complaint procedures, board of directors meeting agenda, observed the area for cash storage. Client Records: LPA reviewed three client files which contained three out three admission agreements, three out of three weight records, three out of three signed personal rights, two out of two applicable Needs and Services Plans, two out of three TB test results. Cont. on LIC809-C The facility is being issued a citation for a violation of California Code Regulations, Title 22, Section 80069(c)(1) Client Medical Assessments, one technical violation for California Code Regulations, Title 22, Section 80088(e)(3) Fixtures, Furniture, Equipment and Supplies and one technical violation for Interim Licensing Standards STRTP, Article Continuing Requirements, Section 87070(b)(1) Children's Records. An exit interview was conducted and a copy of this report, citation and technical violation was issued to Shynelle Smith.


facility_name: BARSTOW HOUSE

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Daiquiri Boyd conducted a follow-up complaint inspection with the Short Term Residential Theraputic Program (STRTP) and met with Virginia Hernandez . The purpose of the inspection was to deliver the findings for the above complaint allegations. During the course of the investigation, LPA Boyd conducted interviews with client's parole officer, client's biological mother, clients, and staff. The interviews revealed that there is no consistent consensus as to whether the allegation listed above happened or didn't happen. Although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove the above allegation; therefore, the allegation is unsubstantiated. LPA provided a copy of the report to the STRTP. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Daiquiri Boyd 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 2

met_with: Virginia Hernandez


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Daiquiri Boyd conducted a follow-up complaint inspection to the Short Term Residential Theraputic Program (STRTP) and met with OOO. The purpose of the inspection was to deliver the finding for the above complaint allegation regarding staff handling minor in a rough manner. During the course of the investigation, LPA spoke with staff and residents in care, reviewed files and requested the police report. Staff stated that the minor was not following rules, being persistent, and hit the staff and staff admitted to using force to get the minor out of the money/medication closet and further out of the office area. Based on the information obtained during the investigation, including the admission of the staff, there is a preponderance of the evidence to prove the staff handled minor in a rough manner; therefore, the allegation is substantiated. A deficiency was cited and a copy of the report and appeal rights were provided to the STRTP. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Daiquiri Boyd 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 24-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, E SHAW AVE FACILITY NAME: BARSTOW HOUSEFACILITY NUMBER: 107202349


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Jessica Rodriguez conducted a complaint inspection at the facility and spoke with Administrator, Virginia Hernandez. The purpose of the inspection was to deliver the findings for the above complaint allegation. Records were obtained from the STRTP and Social Worker which included: email exchanges, an incident report, and the clients JV-220. LPA also conducted interviews with the client, Social Worker, and Administrator. During the investigation, LPA confirmed the client had been administered a new medication, without the Courts approval of a new JV-220. Email communications from Head of Service express the agencies oversight in not providing an updated JV-220 and moving forward with administering the medication. Based on the above, the preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated. Interim Licensing Standards are being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report was provided to the Administrator. Appeal rights were also provided to the Administrator. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Jessica Rodriguez 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 24-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, E SHAW AVE FACILITY NAME: BARSTOW HOUSEFACILITY NUMBER: 107202349

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


raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA), Lidia Tinoco traveled to the Barstow House and met with Administrator, Virginia Hernandez. The purpose of the inspection was to deliver the findings for the above complaint allegation. The department has investigated the complaint alleging residents needs are not being met. LPA Galindo interviewed resident and staff, as well as obtained relevant documents. There were inconsistencies in the interviews, and the documents obtained demonstrate that the youth got his allowance and had enough clothing. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations is unsubstantiated. An exit interview was conducted, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lidia Tinoco 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 3


raw_content:
Investigation Findings:
13Licensing Program Analysts (LPA's) Reyna Martinez and Lidia Tinoco conducted a complaint inspection and met with Virginia Hernandez, Program Director. The purpose of the inspection was to deliver the findings for the above complaint allegations. During the investigation, LPA conducted interviews and reviewed supporting documents provided by the agency. Based on the information obtained during the investigation a preponderance of the evidence that the allegation occurred as reported could not be found. Although the allegations may or may not have happened, or is valid, there is not a preponderance of the evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report and appeal rights were provided to the Program Director. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Reyna Martinez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Virginia Hernandez, Program Director


summary: Facility Evaluation

raw_content:
Narrative:
LPA Boyd requested Virginia Hernandez to come into the office to sign documents.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by Licensing Program Analyst (LPA) Jessica Rodriguez at Barstow House in Fresno, CA. LPA met with Administrator, Virginia Hernandez and inspected the facility, inside and out. A physical plant inspection was completed. Outdoor facility grounds are clean and free of debris. LPA observed maintenance needed in the following areas inside the home: front door repairs, kitchen table repairs, kitchen tile repairs, room 2 door handle, room 3 wall scrapings, living room floor replacement, and kitchen cabinets/locks. LPA was provided with a maintenance order request for all the above-mentioned items put in by the facility dated October 14, 2021. Adequate indoor and outdoor activity space and materials observed. The facility is maintained at 75 degrees. All facility smoke detectors and carbon monoxide detectors are in appropriate working order, fire extinguisher is properly charged and serviced. Facility maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. All required forms are posted. Medications are locked and centrally stored. Individual beds were observed with appropriate clean linens and are in good repair. No firearms or weapons are allowed in the facility. Facility appears to be meeting the terms and conditions of their license. LPA reviewed client files and conducted three staff interviews and two client interviews. A technical violation was issued for the client's dressers/nightstands not being in good repair/working order. A copy of this report was left with Administrator, Virginia Hernandez. An annual continuation will be completed at the facility main office.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Jessica Rodriguez conducted an unannounced annual inspection of staff records and training for the above facility. The inspection was conducted at the corporate offices of KYJO. LPA was met with Executive Director, Kevin Jordan. An inspection of staff records and training was conducted. A review of staff records on 10/20/2021 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. An exit interview was conducted, and a copy of this report given to the Executive Director. The annual inspection will be completed at a later date.

met_with: Kevin Jordan


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Jessica Rodriguez conducted an unannounced annual inspection of staff records and training for the above facility. The inspection was conducted at the corporate offices of KYJO. LPA was met by Administrator, Virginia Hernandez LPA continued inspection of staff records and training. A review of staff records on 10/20/2021 and 10/22/2021 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. It is requested that the licensee submit the following updated forms to CCL: LIC 308, 309, 500 and emergency disaster plan. In addition, the most recent minutes for the Board of Directors meeting. There are no deficiencies to be cited on this date. An exit interview was conducted, and a copy of this report given to the Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Corina Carrillo conducted a case management inspection May 11, 2022 based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 7 out of Direct Care Staff and 4 out of 4 youth files were reviewed. 2 out of Direct Care Staff and 1 out of 4 youth were interviewed. (See the Confidential Names List, LIC 811, dated May 11, 2022). The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, youth case plans, quarterly assessments, and crisis intervention plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Carrillo observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Virginia Hernandez.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by LPA's (Licensing Program Analyst's) Reyna Martinez and Lidia Tinoco. LPA's met with Shayla Taylor, Residential Director and inspected the facility, inside and out. Centrally stored medications are maintained in a locked closet in a locked cabinet. Sharps and Toxic chemicals are kept locked. The facility has a written emergency disaster plan. All facility smoke detectors were tested and appear to be in appropriate working order, fire extinguisher is properly charged and was last serviced January 2022. Individual beds were observed with appropriate clean linens. There is at least one-week supply of nonperishable and a two-day supply of perishable foods. The facility is maintained at 73 degrees. Hot water temperature measures 112 degrees. Facility has cameras in common areas of the facility. No firearms or weapons are allowed in the facility. Appropriate staff/client ratios were verified during this inspection. The facility employs 1 facility manager and 8 direct care staff and 2 behavior specialist's. Personnel Files are maintained at the main office. 5 staff files were reviewed. 1 staff was available to be interviewed. 5 records of clients were reviewed and 4 clients were available to be interviewed. A review of Licensing Information System on December 23, 2022, indicates that all facility staff associated to the STRTP have DOJ, FBI, and child abuse index clearances. Facility was cited for two Type B Violations and one Technical Violation. A copy of this report and appeal rights were discussed and left with the STRTP.

met_with: Shayla Taylor


summary: Facility Evaluation

raw_content:
Narrative:
On this date, Licensing Program Analyst (LPA) Reyna Martinez conducted a Case Management inspection at Barstow House and met with Administrator, Dekeydra Mothershed. The purpose of the inspection was to discuss concerns in regards to incident reports received by CCL, for incidents that occurred on 04/11/2023 and 05/02/2023. LPA discussed the staffing concerns for incident that occurred on 05/02/2023 involving Staff member (S1) and Clients C1 and C2. Licensee stated that the S1 was terminated as 05/8/2023 due to violating safety concerns with C1 and C2. Licensee stated that they spoke with all staff and reminded them of appropriate supervision and safety concerns. LPA discussed the incident that occurred on 04/11/2023 with Client C3. After further discussion and file review it was determined that biological mother still has parental rights and was in agreement with the assigned social worker to scheduled calls with biological mother. Licensee stated they will continue to monitor the home, staff and clients. The facility will be closing and have submitted a closure plan to CCL. The Licensee reports they will have all clients placed in new placement's by June 30, 2023 and the facility will be closed after there are no more clients in the home. No deficiencies are being issued at this time. A technical violation was given to the Licensee on the attached LIC 9102. LPA left a copy of this report at the FFA.

met_with: Dekeydra Mothershed


summary: Facility Evaluation

raw_content:
Narrative:
On this date, Licensing Program Analyst (LPA) Reyna Martinez conducted a Case Management inspection at Barstow House and met with Lupita Munoz. The purpose of the inspection was to conduct a tour of the facility. LPA inspected the home and ensured there are not children in the home. Licensee is surrendering their license effective June 14, 2023.

met_with: Lupita Munoz


summary: Facility Evaluation

raw_content:
Narrative:
On July 5, 2022, Licensing Program Analyst's (LPA's) Reyna Martinez and Jessica Rodriguez conducted an unannounced Case Management Inspection at the Short Term Residential Therapeutic Program (STRTP). The purpose of the case management was to discuss late incident reports received by the facility and information contained in an incident report from 06/21/2022. LPA's reviewed six incident reports sent in by the STRTP that were not reported within the 7-days to Community Care Licensing as required by the regulations. Two incident reports dated 04/22/22 were not received by the Department until 05/04/2022. Another report dated 04/24/2022 was not received until 05/04/2022. Report dated 06/12/2022 was not received until 06/21/2022. One report dated 06/19/2022 was not received until 06/29/2022. Another report dated 06/20/2022 was not received until 06/29/2022. LPA's discussed the importance of reporting incidents to the Department in a timely manner. Additionally, LPA's discussed information during an incident that occurred on 06/21/2022. The incident report indicates that a client requested staff contact Mental Health head of service on site, stating if staff did not then someone would get hurt. The report does not indicate if Mental Health was called or arrived at the facility; however, the client continued to escalate. Further, the client ran out of the facility and was not followed by staff, due to "safety concerns." The client became so escalated that Fresno Police Department was contacted and he was placed on a 51/50 hold. LPA's and manager discussed the incident in depth and the importance of ensuring Mental Health Services are being utilized to attempt to de-escalate clients instead of contacting law enforcing. Additionally, AWOL procedures were discussed. . Based on the above, there is a preponderance of evidence to substantiate a violation of based on California Code of Regulation which is being cited on the attached LIC 809D. A copy of the report and Appeal Rights was provided to the facility.

met_with: Luis Santiago, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Tamara Melikian and Jessica Rodriguez on January 25, 2023 at 9:00AM. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPAs met with Virginia Hernandez, Administrator and inspected the facility inside and out. LPAs reviewed 4 child's records and 2 staff personnel files on site at the facility. LPAs reviewed 4 child's psychotropic medications and medication records. LPAs interviewed 2 staff on site to discuss the facilities policies and procedures of operation. During the inspection the LPAs observed deficiencies (see attached 809D), plan of corrections were discussed and appeal rights were provided. LPAs provided a copy of the licensing report to Virginia Hernandez, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On this date, Licensing Program Analyst (LPA) Reyna Martinez conducted a Case Management inspection at Barstow House and met with Facility Manager, Doris Anderson. The purpose of the inspection was to discuss concerns in regards to incident reports received by CCL, for incidents that occurred on 01/16/2023 and 01/25/2023. LPA reviewed one incident report sent in by the STRTP that was not reported within the 7-days to Community Care Licensing as required by the regulations. One incident report dated 01/16/2023 was not received by the Department until 01/25/2023. LPA discussed the importance of reporting incidents to the Department in a timely manner. Additionally, LPA discussed information during an incident that occurred on 01/25/2023. LPA and facility manager discussed the incident in depth, gathered additional information. If further action is needed LPA will address the matter with facility manager at a later date. LPA discussed the importance of ensuring Client #1 (C1) has extra supervision due to his behaviors. Based on the above, there is a preponderance of evidence to substantiate a violation of based on California Code of Regulation which is being cited on the attached LIC 809D. A copy of the report and Appeal Rights was provided to the facility.

met_with: Doris Anderson


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On this date, Licensing Program Analyst (LPA) Reyna Martinez conducted a Case Management inspection at Barstow House and met with Facility Manager, Doris Anderson. The purpose of the inspection was to discuss concerns in regards to incident reports received by CCL. LPA reviewed 02/16/2023 incident report sent in by the STRTP. The incident in question is regarding the Care and Supervision, as staff was not able to provide appropriate supervision due to being short staff which has resulted in not ensuring clients medical needs were met. LPA discussed with Licensee that there has been several incidents with supervision and being short staffed which has resulted with clients escalating behaviors during the night shift and multiple AWOL's. LPA confirmed with Licensee that due to staff being singled staff during the nocturnal shift these incidents have increased. LPA discussed the importance of increasing staff to provide appropriate supervision and meet clients needs. Additionally, LPA discussed information during several incident's that occurred on 02/09/2023 and 02/11/2023. LPA and facility manager discussed the incident in depth, gathered additional information. LPA discussed the importance of ensuring Client #1 (C1) and Client #2 (C2) has extra supervision due to their escalating behaviors. Based on the above, there is a preponderance of evidence to substantiate a violation based on Interim Licensing Standards which is being cited on the attached LIC809D. A copy of the report and Appeal Rights was provided to the facility.

Deficiencies:
87065.2: (1) Supervision, protection, and care of children at all times, individually and in groups.

title:
Personnel Duties.
(b) Direct care staff shall perform the following duties


summary: Facility Evaluation

raw_content:
Narrative:
On March 8, 2023, Licensing Program Analyst (LPA) Reyna Martinez conducted a case management visit at the corporate office. Met by Interim Human Resources/Finance Coordinator, Adela Dominguez-Jordan. The purpose of the case management is to review staff files and issue a deficiency for the facility not having mental health program approval effective February 17, 2023. Deficiency on the attached page. A copy of this report is given to Interim Human Resources/Finance Coordinator, Adela Dominguez-Jordan.

met_with: Adela Dominguez-Jordan


facility_name: BEAR CREEK

raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA), Lidia Tinoco conducted an unannounced visit to the Bear Creek STRTP in order to deliver the findings of the above allegations and met with Administrator, Dawn Lee. On July 9, 2025, the above allegations were referred to Community Care Licensing for investigation. The investigation included an inspection of the Facility, confidential interviews, and review of records. Based on the investigation conducted, the department found that C1 was injured when S1 attempted to remove an item from C1's hand. Although an injury did occur, based on the confidential interviews conducted and review of records, the department concluded that the injury was accidental. Therefore, the allegations are Unsubstantiated at this time. A copy of this report was provided at the conclusion of the inspection along with appeal rights. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lidia Tinoco LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Dawn Lee, Administrator


raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Lidia Tinoco conducted an unannounced visit to the Bear Creek STRTP in order to deliver the findings of the above allegations and met with Head of Service, Veronica Ramirez. LPA Tinoco spoke with Administrator, Dawn Lee over the phone. On 08/21/25, The above allegations were referred to Community Care Licensing for investigation. The investigation included an inspection of the Facility, Interviews and a review of facility and children's records. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the allegations that Staff physically abused youth while in care resulting in bruises occurred. Therefore, the allegations are UNSUBSTANTIATED at this time. A copy of this report was discussed and provided at the conclusion of the inspection along with appeal rights. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lidia Tinoco LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Veronica Ramirez


summary: Facility Evaluation

raw_content:
Narrative:
On this date, Licensing Program Analyst (LPA) Lidia Tinoco traveled to the Creative Alternatives Main Office in Merced and conducted an unannounced Case Management for the Bear Creek and met with Director Brandi Boheme. The purpose of the inspection is to discuss multiple incident reports regarding medication errors by Staff. LPA Tinoco reviewed incident reports from the Bear Creek facility. It was discovered that there have been 3 medication errors due to staff for this facility (See LIC812 for details) in 2021. LPA Tinoco discussed with Director Brandi the concerns with the amount of incident reports regarding medication errors being received, LPA also addressed what the licensee has been done at the agency level to prevent this from happening, and what the ongoing plans are moving forward to minimize these incidents. Director Brandi stated that a company wide training on administration of medication. An exit interview was conducted, and a copy of the report and appeal rights were provided to the facility.

met_with: Brandi Boehme


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Eduardo Barragan on 11/10/2021 at 9 am. During the inspection, LPA Barragan met with Moraima Stewart, Facility Supervisor. LPA inspected the facility inside and out. LPA interviewed 1 staff on site at 10:24 am. LPA will be going to the corporate office in order to review the staff's files after the client interviews at the schools. LPA reviewed 3 of child's records on site at the facility. LPA reviewed 3 of child's psychotropic medications and medication records. LPA will be interviewing the children currently taking psychotropic medications at their schools after this inspection. LPA conducted exit interview with Moraima Stewart, Facility Supervisor at 11 am. LPA provided the Summary Report to Moraima, Facility Supervisor, upon completion. LPA Barragan is traveling to the main office in order to complete this inspection. No deficiencies were noted at this moment.

met_with: Moraima Stewart


summary: Facility Evaluation

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Narrative:
On the above date, Licensing Program Analyst (LPA) Lidia Tinoco traveled to the Bear Creek STRTP in Merced, CA for the purpose of conducting an unannounced annual inspection. LPA met with Administrator, Moraima Stewart and inspected the facility, inside and out. A physical plant inspection was completed and included the following checks. Facility grounds are clean and free of debris. Adequate indoor and outdoor activity space and materials observed. The facility is maintained at 75 degrees. All facility smoke detectors and carbon monoxide detectors are in appropriate working order. Facility maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. All required forms are posted. Five out of Six Clients are currently taking psychotropic medications, facility has the ability to keep Medications locked and centrally stored. Individual beds were observed with appropriate clean linens and are in good repair. Licensee has obtained Mental Health Certification Including the following: Mental Health Program Approval valid through September 24, 2021, a review was conducted on August 16-23, 2021 and have not been issued. Licensee has obtained National Accreditation through CARF valid through September 30, 2023. The facility has a county contract valid through June 30, 2022. Medical Certification valid From March 29, 2019 through March 28, 2022. No firearms or weapons are allowed in the facility. Facility appears to be meeting the terms and conditions of their license. No Deficiencies were cited on today's visit. A copy of this report was left with Jeanne Johnson.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA) Lidia Tinoco traveled to the Bear Creek STRTP in Merced, CA for the purpose of conducting an unannounced annual inspection. LPA met with Administrator, Moraima Stewart and Program Director Brandi Boehme. LPA Tinoco interviewed five out of six clients, one client refused to be interviewed. Seven Client files were reviewed. LPA Tinoco interviewed three staff and reviewed ten staff files. LPA Tinoco spoke with Administrator and discussed needs and services plans, and telephone policies of the facility including that any supervised calls need to be included in the needs and services plans with reasons why a decision was made to supervise the calls. One deficiency was cited on todays visit. Facility was cited for the Interim Licensing Standards (ILS) 87072(d) Personal Rights. A copy of this report was left at the facility at the end of inspection.

met_with: Moraima Stewart, Brandi Boehme


summary: Facility Evaluation

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Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Melikian on April 19, 2023 at 9:00AM. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPA met with Dawn Lee, Administrator and inspected the facility inside and out. LPA reviewed 0 child's records and 1 staff personnel file on site at the facility. LPA reviewed 0 child's psychotropic medications and medication records as no children are currently placed in the facility. LPA interviewed 1 staff on site to discuss the facilities policies and procedures of operation. LPA interviewed no children as no children are currently placed in the facility. LPA provided a copy of the licensing report to Dawn Lee, Administrator. No deficiencies are being cited at this time. LPA conducted exit interview with Dawn Lee, Administrator.

met_with: Dawn Lee


summary: Facility Evaluation

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Narrative:
On the above date, Licensing Program Analyst (LPA) Lidia Tinoco traveled to the Bear Creek STRTP in Merced, California for the purpose of conducting an unannounced Annual Inspection. LPA met with Assistant Executive Director Lisa Jacobs and inspected the facility, inside and out. A physical plant inspection was completed and included the following checks. Facility grounds are clean and free of debris. Adequate indoor and outdoor activity space and materials observed. The facility is maintained at 75 degrees. All facility smoke detectors and carbon monoxide detectors are in appropriate working order. Facility keeps some canned foods and non-perishables in the home, there is no perishable food in the house at this time but has access to a full pantry located at Merced Ranch where they can stock the facility should they chose to open the house again. All required forms are posted. Facility has the ability to keep medications locked and centrally stored. Individual beds were observed with appropriate clean linens and are in good repair. Licensee has obtained Mental Health Certification Including the following: The Facility has the Mental Health Certification valid through September 24, 2023. Licensee has obtained National Accreditation through CARF valid through September 30, 2023. The facility has a county contract valid through June 30, 2025. No firearms or weapons are allowed in the facility. Facility appears to be meeting the terms and conditions of their license. Currently the facility is inactive, therefore no children or staff are in placement therefore no files were reviewed. No Deficiencies were cited on today's visit. A Technical Assistance was discussed. A copy of this report was left with Lisa Jacobs.

met_with: Lisa Jacobs


summary: Facility Evaluation

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Narrative:
On the May 23, 2023, Licensing Program Analyst (LPA), Lidia Tinoco traveled to Merced and met with the head of service Veronica Ramirez. The purpose of this visit was to Amend language from the Annual Inspection conducted on 5/19/23. A copy of this report was provided at the conclusion of the inspection, including a copy of the Amended Annual Inspection documents. No deficiencies were observed or cited.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Melikian on May 3, 2024 at 9:00AM. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPA met with Dawn Lee, Administrator and inspected the facility inside and out. LPA reviewed 0 childrens records and 2 staff personnel files on site at the facility. The only child in placement had been placed at the facility for less than 30 days. LPA reviewed 1 childrens psychotropic medications and medication records. LPA interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPA interviewed 0 children currently prescribed psychotropic medication. LPA provided a copy of the licensing report to Dawn Lee, Administrator. No deficiencies are being cited at this time. LPA conducted exit interview with Dawn Lee, Administrator.


summary: Facility Evaluation

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Narrative:
An unannounced annual inspection was conducted by LPA (Licensing Program Analyst) Lidia Tinoco on September 12, 2024 at Bear Creek STRTP. LPA met with Administrator, Dawn Lee and inspected the facility, inside and out. Centrally stored medications are maintained in a locked cabinet. Sharps and Toxic chemicals are kept locked. The facility has a written emergency disaster plan and provided a copy to LPA. All facility smoke detectors were tested and appear to be in appropriate working order, fire extinguisher is properly charged. Individual beds were observed with appropriate clean linens and are in good repair. There is at least one-week supply of nonperishable and a two-day supply of perishable foods. The facility is maintained at 71 degrees. No firearms or weapons are allowed in the facility. Administrator, Dawn Lee is present at the facility a minimum of 20 hours a week. Appropriate staff/client ratios were verified during this inspection. The facility employs Social Worker, 2 facility Supervisors and 9 direct care staff as well as a head of service. Licensee has obtained Mental Health Certification Including the following: Mental Health Program Approval valid through September 24, 2024. Licensee has obtained National Accreditation through CARF. The Accreditation is valid through September 30, 2026. 3 records of clients were reviewed (See LIC Confidential Names List). One type B deficiency was cited on today's date for the California Code of Regulations 80088(e)(3). A staff file review and interviews will be completed at a later date. A copy of this report along with appeal rights was provided at the conclusion of the inspection.


summary: Facility Evaluation

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Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco arrived at the Creative Alternatives main office in Turlock for the purpose of continuing the Annual inspection for Bear Creek STRTP. LPA Tinoco met with Administrator, Dawn Lee. LPA reviewed 5 staff files (see LIC Confidential Names List). Interviews will be conducted at a later time. No deficiencies were observed or cited on this date. This report was discussed and a copy was provided at the conclusion of the inspection.


summary: Facility Evaluation

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Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco arrived at the Creative Alternatives main office in Turlock for the purpose of continuing the Annual inspection for Bear Creek STRTP. LPA Tinoco met with Administrator, Dawn Lee. LPA conducted 3 client interviews and 2 staff interviews (See confidential names list LIC811). LPA verified that the corrections have been made to the deficiencies cited on 9/12/24. The POC was cleared and a clearance letter was provided on todays date. No deficiencies were cited. A copy of this report was provided at the conclusion of the inspection.


summary: Facility Evaluation

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Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco arrived at the Bear Creek STRTP for the purpose of conducting a Case Management regarding incident reports received by the department and met with Program Director, Brandi Boehme. LPA Tinoco addressed an incident regarding a staff medication error that occurred 1/31/25 involving C1 (See LIC Confidential Names List). LPA Tinoco addressed an incident that occurred on 2/15/24 involving C2. LPA addressed regulation Personal Services and Personal Rights. Ongoing follow-up is being conducted regarding the needs of C2 with the treatment team. LPA will be provided a copy of the updated and signed needs and services plan with the changes once approved. No deficiencies were cited on today's date. A copy of this report along with appeal rights were provided at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Briana Placencia on April 3, 2025 at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPA met with Dawn Lee, Administrator and inspected the facility inside and out. LPA reviewed 1 child record and 2 staff personnel files on site at the facility. LPA reviewed 1 child psychotropic medications and medication records. LPA interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPA was unable to conduct any interviews as the child currently on psychotropic medication is currently at the hospital. LPA provided a copy of this licensing report to Dawn Lee, Administrator. No deficiencies are being cited at this time. LPA conducted exit interview with Dawn Lee, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco arrived at Bear Creek for the purpose of conducting an unannounced Case Management inspection and met with Facility Manager, Moraima Stewart. The purpose of the inspection was to discuss incident report dated 4/21/25 regarding C1 (See LIC Confidential names list). LPA Tinoco discussed the importance of providing medications when children go on a home visit. Per Facility manager, this will be addressed at the next staff meeting on May 13, 2025. No deficiencies were cited. An exit interview was conducted, and a copy of this report was provided at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco arrived at Bear Creek STRTP for the purpose of returning the Program Statement/Plan of Operation. The agency is working on updates for the most current regulations and will resubmit once the updates are complete. No deficiencies were cited on this date. A copy of this report was provided at the conclusion of the inspection.


summary: Facility Evaluation

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Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco arrived at the Bear Creek STRTP for the purpose of conducting a Case Management and met with Administrator, Dawn Lee. LPA Tinoco amended the complaint report from 04/23/25. A copy of this report and the amended report were provided at the conclusion of the inspection.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco arrived at the Bear Creek Short Term Residential Therapeutic Program (STRTP), for the purpose of conducting an unannounced Annual Required 2-year inspection. LPA met with Administrator, Dawn Lee and inspected the facility, inside and out. Centrally stored medications are maintained in a locked cabinet. Licensee has provisions for contraceptives to be held in individually locked containers by clients. Sharps and Toxic chemicals are kept locked. The facility has a written emergency disaster plan. All facility smoke detectors were tested and appear to be in appropriate working order, fire extinguisher is properly charged. Individual beds were observed with appropriate clean linens and are in good repair. There is at least one-week supply of nonperishable and a two-day supply of perishable foods. The facility is maintained at 72 degrees. No firearms or weapons are allowed in the facility. Administrator, Dawn Lee is present at the facility a minimum of 20 hours a week, as verified by staff schedule and interviews. Appropriate staff/client ratios were verified during this inspection. The facility employs Social Worker, 1 facility supervisor and 9 direct care staff. Licensee has obtained Mental Health Certification Including the following: Mental Health Program Approval valid from September 24, 2024 through September 24, 2025. Licensee has obtained National Accreditation through CARF (Commission on Accreditation of Rehabilitation Facilities), valid through September 30, 2026. 3 records of clients were reviewed, 2 youth and 2 staff confidential interviews were conducted.One type B deficiency was cited for Interim Licensing Standards (ILS), 87095.61(g) Documentation and Reporting Requirements. This annual inspection will be completed on a later date pending staff file reviews. A copy of this report was provided along with appeal rights.

Deficiencies:
87095.61(g): Documentation and Reporting Requirements

(g) The licensee must maintain a monthly log of each use of manual restraints. The log must include


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco met with Administrator, Aaron Holloway, for the purpose of continuing the Bear Creek Annual Required 2-year inspection. LPA Tinoco reviewed 5 staff files. LPA Tinoco conducted a review of Guardian on 9/15/2025 to verify that all staff on the LIC500 were cleared and associated. No deficiencies were cited on today's date. A copy of this report was provided at the conclusion of the inspection.

met_with: Aaron Holloway


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco arrived at the Bear Creek Short Term Residential Therapeutic Program (STRTP), for the purpose of conducting an unannounced Case Management inspection and met with Administrator, Dawn Lee. The purpose of the inspection was to discuss an incident that occurred on August 24, 2025. The incident included a youth in care being able to get access to a kitchen knife and using it to self harm. Per the Administrator, an email reminder went out on August 28, 2025 to all staff regarding sharp objects and supervision. Additionally, the facility has implemented a procedure for tracking the knives. This incident will be further addressed at the all staff meeting on September 16, 2025. The Department determined this to be an immediate risk to health and safety of the children in care at this time, therefore Title 22, California Code of Regulations, Section 80078(a) Responsibility for Providing Care and Supervision is being cited on the attached LIC809D. An exit interview was conducted, and a copy of the report and appeal rights were provided at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco conducted an unannounced over the phone Case Management Inspection with Dawn Lee, Assistant Program Director for the Bear Creek Facility. The reason for this case management was regarding an incident report of a restraint conducted on 4/29/21 at the Bear Creek Facility. Dawn Lee explained to LPA that when this particular youth is given space and goes to his bedroom, he leaves the facility through his bedroom window, so usually staff have to supervise him by the door. After failing to place the youth in a Team Control Position, the youth became more combative. The youth fell on a bed in the bedroom and staff decided to do a prone restraint on the bed. Based on a review of the facility's program statement and the conversation with Dawn Lee, a prone restraint is only to be done as a last result, first the staff is to reassess the situation. This is a violation of the Interim Licensing Standards (ILS), 87095.01(a)(1) Emergency Interventions Prohibitions. Dawn Lee stated that she discussed the incident with her staff and counseled them on how the situation should have been handled and how these situations need to be handled moving forward. The Department determined this to be an immediate risk to health and safety of the children in care at this time, therefore the Interim Licensing Standards are being cited on the attached LIC809D.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco arrived at the Bear Creek STRTP for the purpose of conducting a Case Management inspection. LPA Tinoco met with Administrator, Dawn Lee. LPA Tinoco received an incident report dated August 5, 2024 reporting a medication error. The incident report indicated that C1 (See LIC Confidential Names List) received a double dose of one of their medications and did not receive one dose of a different medication. Administrator met with Staff on August 8, 2024 and provided a retraining to the staff involved on August 9, 2024. As a result of the incident mentioned above, The Agency is being cited for the Interim Licensing Standards Section 87075(c) Health Related Services. Deficiencies were cleared on today's date due to the Plan of Corrections being met. A copy of this report was provided at the conclusion of the inspection along with appeal rights.

met_with: Administrator, Dawn Lee


facility_name: BEAZER

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
CCL received another allegation that staff threatened minor. Confidential interviews revealed RC1 can be confrontational at times and it has been observed RC1 and S1 have had challenges with one another, however, de-escalation tactics, including re-direction have been used to correct RC1's behavior. Other confidential interviews revealed S1 was asked to move to another sister facility until management could determine how to proceed and create space between RC1 and S1. S1 has resigned and no longer works at any facility. Based on confidential interviews and record review, the allegation that S1 engaged in an altercation with RC1 and S1 and threatened minor may have occurred, however, it is not supported or proven by evidence. Therefore, these allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report and appeal rights were provided to Residential Manager.

Investigation Findings:
13On July 14, 2022 at 03: PM, Licensing Program Analyst (LPA), Lisi Leon, met with OliveCrest - Beazer, Residential Manager, Franco Jakic to deliver the finding for the above stated allegations regarding the Short Term Residential Therapeutic Program (STRTP). LPA Leon conducted safety and health inspection on March 03, 2022 and no immediate health & safety concerns were observed. LPA Leon conducted interviews with Residential Manager (RM), three staff (S1, S2, S3), and three residential clients (RC1, RC2, RC3). LPA Leon obtained copies of the facility and client roster including schedules. Client record files were obtained for client involved in this allegation. On February 23, 2022, Community Care Licensing (CCL) received an allegation that staff engaged in an altercation with minor. Confidential interviews revealed client and staff were at dinner table and RC1 got upset and walked in S1 personal space. Confidential interviews shared S1 was eating dinner and had knife in hand in a downward motion and did not grab RC1 or any other client by the hands. Other confidential interviews revealed staff walked away from RC1 to create space. (Continued on 9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Lisi Leon LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: BEAZERFACILITY NUMBER: VISIT DATE: 07/14/2022

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

met_with: Residential Manager Franco Jakic


raw_content:
Narrative:
On November 1, 2023, Community Care Licensing (CCL) received a complaint alleging that minor was sexually abused while in care. During investigation, a confidential interview denied that C1 was sexually abused while in care and added that C1 was in care for a short period of time. Confidential interview could not recall a report made by C1 about a sexual abuse incident involving C1 and the facility. Other confidential interviews stated that C1 left the facility on a continuous basis but there was no indication that C1 was sexually abused while in care due to C1 not disclosing sexual abuse allegations to facility staff. Other confidential interview denied that C1 was sexually abused while in care or knowing that a sexual abuse incident involving C1 occurred at the facility. Another confidential interview stated feeling safe in care, liking the placement, and denied witnessing sexual abuse while in care. C2, and C3 could not be reached for comment regarding the allegation that C1 was sexually abused while in care. C2, and C3 were reported being in care at time of the complaint and may or may have not been witnesses to the allegation previously mentioned. LPA could not determine whether C1 was sexually abused while in care due to receiving inconsistent information. Based on confidential interviews, the allegation that C1 was sexually abused while in care, may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Youth Specialist, Leilani Brown

Investigation Findings:
13On September 13, 2023, 12: PM, Licensing Program Analyst (LPA), Cynthia Urena met with Beazer Short Term Residential Therapeutic Program (STRTP) Youth Specialist, Lelanie Brown to deliver the investigative finding for the above stated allegation. On November 1, 2023, at 11: AM, LPA Daniel Mena initiated the investigation at the STRTP and collected pertinent documents from the STRTP program staff and client files. LPA Mena informed the STRTP that Special Investigator (SI) Georgina Tallagua would be leading the investigation. SI Tallagua interviews client #1 (C1). Additional interviews were conducted with an Administrator, five staff members (S1, S2, S3, S4, S5) and one client (C4). Two clients C2, C3 could not be reached after multiple attempts made by LPA Urena for interviews. LPA Urena reached C2's last known placement and was informed that C2 was no longer in care. C2's whereabouts are currently unknown, and C3 was reunified. For those reasons no further comments could be obtained by C2 or C3 about the allegation mentioned above. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Cynthia Urena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: BEAZERFACILITY NUMBER: VISIT DATE: 09/13/2023

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

met_with: Youth Specialist, Leilani Brown


raw_content:
Narrative:
Confidential interviews revealed that while C1 did AWOL from the home the Staff tried to get them to stay however C AWOLed anyway. Based on confidential interviews and record reviews, the allegation that lack of supervision resulting in C AWOLing, may have occurred, however, it is not supported or proven by evidence. Therefore the above allegation is unsubstantiated. A copy of this report, LIC 811, and appeal rights were given to Administrator Stacy Rougely.

Investigation Findings:
UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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

met_with: Stacy Rougely