raw_content:
Narrative:
During the investigation, interviews were conducted with, but not limited to, C1, S1, residents, and staff members. A review of facility records including past incident reports and client file history revealed insufficient evidence to support alleged claims. Review of an incident report involving S1 and C1 dated 12/17/2017, revealed in part that C1 was "bullying another client" while S1 was attempting to de-escalate the situation. C1 became upset and attempted to attack S1 as S1 attempted to restrain C1. At some point a physical altercation ensued between C1 and S1 resulting in both parties wrestling on the floor. Other staff were present and assisted S1 with restraining C1. S1 states that any physical contact made with C1 was non-sexual and only with the intent of restraining C1. There was no corroborating evidence to support claim. The investigation revealed that while physical contact was made during an apparent restraint between C1 and S1 on 12/17/2017, to which other staff were present and assisted, there is not enough evidence to support the allegation that S1 touched C1 inappropriately in private areas during the restraint and/or while in care. The finding has therefore been determined as Unsubstantiated meaning, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or disprove a violation occurred. There are no deficiencies cited at this time. Exit interview conducted and a copy of this report and appeal rights are emailed to Facility Administrator. C1's room and on another instance where C1 was showering. S1 reports that the instances were inadvertent, and no knocks were made prior to entering C1's door. S1 reports being in a rush at the time and accidentally walked in on C1 during both incidents. S1 denies any sexual gratification derived from these incidents and states they were accidents. S1 states that S1 left immediately after both incidents. Based on the confidential interviews conducted and documentary evidence obtained during the investigation the preponderance of evidence standard has been met that a violation occurred, therefore the above allegation is determined Substantiated. Facility is cited per the Interim Licensing Standards for STRTP V 3.1; Section 87065. Personnel Duties. S1 accidentally walked in C1's room on two separate occasions while C1 was undressing and while C1 was showering. Actions as such pose potential health and safety risks to children in care. Exit. A copy of the report and Appeal Rights will be emailed to Facility Administrator. (Continued on page LIC9099-D)

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

met_with: Facility Representative


state: CA

facility_name: HILLSIDES

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
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:

report_type: Complaint Investigation

complaint_status: unsubstantiated


summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13LPA Connie Jones-Steward interviewed Andrew Hernandez (Director of Cottage Services) and Crystal Nava (Cottage Supervisor) regarding the above allegations, Per both staff people, Client #1 is always offered healthy snacks at bedtime. However the client is not always willing to accept the healthy snack. In this incident, the client became agitated because she wanted junk food at bedtime and it was denied to her. Therefore she alleged that she did not receive her snack. Both staff people also stated that Client #1 often provokes other clients as well as being provoked herself. When staff sees disagreements starting, clients are redirected and offered alternative activities such as going for a walk. LPA attempted to interview Client #1 about the allegations on two separate occasions. Both times, she declined to be interviewed Based on the information gathered and the clients unwillingness to be interviewed, these allegations are resolved as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Connie Jones-Steward 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


facility_name: HOME OF EXCELLENCE

raw_content:
Narrative:
It was alleged that on or around 06/30/21, S1 engaged in a physical altercation with C1. Specifically, it was reported that C1 took a pen and S1 charged at C1 and tackled C1. Details state C1 sustained a "fat lip" during the attack and then C1 was placed on a 5150 hold. S1 denies charging and attacking C1 and denies injuring C1 and giving C1 a "fat lip". S1 states C1 was threatening to hurt and kill S1 and also threatening to self-harm which is why S1 took away the pencil from C1. S1 states S1 raised S1's arms to block the attack from C1, however, denies hitting, assaulting, or attacking C1 in any form. Additionally, S1 states she did not give C1 a "fat lip" either. Another witness maintains staff put hands on C1, however, witness was unsure of how S1 physically attacked or grabbed C1 as could not provide any details. All witnesses corroborate that there was a verbal altercation between C1 and S1, however, S1 states she had to raise her voice to try to de-escalate C1 as C1 was extremely escalated and yelling loudly. There were no witnesses that observed any physical interaction between S1 and C1. One witness states they heard C1 yell things such as, "Get off me! Get your hands off me!" but did not see what was happening as the room door was closed and the incident occurred in the hallway area of the house. The majority of witnesses state S1 has never put hands on any clients in the STRTP. Based on interviews conducted and information obtained, the allegation that S1 engaged in a physical altercation with C1, may have occurred, however, it is not supported or proven by evidence. The allegation is, therefore, UNSUBSTANTIATED. There are no deficiencies to be cited. An exit interview was conducted and a copy of this report, LIC 811, and appeal rights, were provided to Ms. Leticia Castaneda for original signature. Signed report will be placed in facility file.

Investigation Findings:
13On December 16, 2021 at 4: PM, Licensing Program Analyst (LPA) Carmen Escobar conducted an unannounced inspection at the Short Term Residential Therapeutic Program (STRTP) in order to issue the investigative finding for the above allegation. During the investigation, LPA requested documents from client 1 (C1's) file including placement agreement, copy of needs and service plan, and special incident reports involving C1 in regards to the allegations reported. LPA also obtained a copy of STRTP client roster, staff roster, and staff 2 (S2's) training history. LPA Escobar conducted interviews with facility manager (FM), staff 1 (S1), staff 2 (S2), C1, client 2 (C2), client 3 (C3), client 4 (C4), and client 5 (C5) as well as C1's county social worker (CSW). LPA Escobar completed the initial ten-day inspection at the facility to initiate the complaint on 07/01/21 at 4: PM. No safety concerns were observed. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Carmen Escobar 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: HOME OF EXCELLENCEFACILITY NUMBER: VISIT DATE: 12/16/2021

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

met_with: Facility manager-Leticia Castaneda


raw_content:
Investigation Findings:
13On January 26, 2021 at 11:15am, Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera conducted an unannounced inspection to the facility to deliver the findings of the above allegations. LPA met with Ebony Jones. LPA Lisi Leon conducted an inspection of the facility on February 10, 2022 at 11:00 am and no immediate deficiencies were observed. Four of four children (C1, C2, C3, C4), three staff and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that staff (unknown name) is aggressive towards C1, C1 was sexually assaulted by C2 and staff did not report it. Confidential staff interviews reported that staff treats all of the clients including C1 with respect and appropriate discipline is used. Confidential staff interviews reported that C1 did not disclose any sexual abuse to any staff. Confidential interviews reported that when staff did become aware of this alleged incident, staff took appropriate actions to ensure that C1 was separated from C2. The interviews that were provided to the LPA were not consistent regarding staff being aggressive towards C1, C1 was sexually assaulted by C2 and staff did not report it. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Ebony Jones. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Darlene Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Ebony Jones


raw_content:
Investigation Findings:
13On January 26, 2021 at 11:41am, Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera conducted an unannounced inspection to the facility to deliver the findings of the above allegation. LPA met with Ebony Jones. LPA Carmen Escobar conducted an inspection of the facility on March 30, 2022 at 02:45 pm and no immediate deficiencies were observed. Three of three children (C1, C2, C3), three staff and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that C1 sustained multiple injuries due to self-harming. Confidential staff interviews reported that C1 does have a history of self-injurious behaviors. Confidential staff interviews reported that C1 is always being supervised and staff ensures that C1 has no sharp objects. Additional confidential interviews reported that C1 did self-harm several times while being placed at the facility. However, C1 self-harms while in the shower, even though staff is sitting outside the restroom door. Confidential interviews reported that C1 will find any sharp while at school and hide it on the body and use it while in the shower. There are no other witnesses to C1 during C1's injurious behaviors while in the shower. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Ebony Jones. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Darlene Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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


raw_content:
Narrative:
During the investigation, confidential interviews reported that C1 left the facility on a continuous basis despite staff efforts to keep C1 from leaving the facility while in care. Confidential interviews further reported that C1's placement was terminated due to safety concerns for staff and other clients in care. Confidential interviews maintained that staff followed the programs protocols when C1 left the facility or attempted to leave the facility. Another confidential interview reported that C1 was placed at the facility with an agreement that C1 was going to have one on one care due to C1's history however, that care was not provided to C1 at the facility due to staff shortage. Another confidential interview stated that C1 left the facility when C1 felt like leaving the facility and there were times when staff attempted to redirect C1 and other times where staff did not do anything about C1 leaving the facility. Another confidential interview stated not witnessing Absent Without Leave (AWOLs) at the facility and further stated feeling safe at current placement and reported no concerns about staff supervision. Based on the confidential interviews, and record review the allegation that staff did not prevent C1 from wandering from the facility, 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 Home of Excellence, House Manager, Leticia Castaneda.

Investigation Findings:
13On March 24, 2023, at 12: PM , Licensing Program Analyst (LPA) Cynthia Urena met with Home of Excellence Short Term Residential Therapeutic Program (STRTP) House Manager, Leticia Castaneda to deliver the investigative finding for the above stated allegation. On July 8, 2022, Community Care Licensing received a complaint alleging that staff did not prevent minor from wandering from the facility. On July 15, 2022, Licensing Program Analyst (LPA) Carmen Escobar initiated an investigation at the STRTP. LPA Escobar conducted a Health and Safety Inspection, and no immediate deficiencies were observed. LPA Escobar obtained copies of pertinent documents from the Short-Term Residential Therapeutic Program staff and client files. Additionally, LPA Escobar conducted interviews with Facility Manager (FM) and one staff member (S1). LPA Urena conducted interviews with Administrator, (ADM), three staff members (S2, S3, S4), two clients (C1, C2) and a County Social Worker (CSW). 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: HOME OF EXCELLENCEFACILITY NUMBER: VISIT DATE: 03/24/2023

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

met_with: House Manager, Leticia Castaneda


raw_content:
Narrative:
Confidential interviews reported that C1 is always supervised while at the facility. Other confidential interviews stated that C1 does contact these individuals to meet them while awol from the facility through cell phones that C1 would get while awol. The interviews that were provided to the LPA were not consistent regarding the allegations that staff are not properly supervising C1 and did not provide any further specific details regarding staff supervision. Based on interviews and record reviews the allegations that staff did not prevent C1 from awoling from the facility and staff did no prevent C1 from engaging in inappropriate internet usage, may have occurred, however is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Tiffany Merritt.

Investigation Findings:
13On April 12, 2023 at 11:10am, Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera conducted an unannounced inspection to the facility to deliver the findings of the above allegations. LPA met with facility administrator, Tiffany Merritt. Carmen Escobar conducted an inspection of the facility on April 13, 2022, at 2:15 pm and no immediate deficiencies were observed. Four of four children (C1, C2, C3, C4), four staff and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that staff did not prevent C1 from awoling (absent without leave) from the facility and staff did no prevent C1 from engaging in inappropriate internet usage. Confidential staff interviews reported that C1 will leave the facility without permission and staff will verbally give C1 directives but C1 refuses to follow verbal directives of staff. Confidential staff interviews reported that C1 had a cell phone that was initially approved by C1's authorized representative. Confidential interviews reported that then there was a court order that C1 could not have a cell phone due to C1 engaging in inappropriate internet usage. Confidential interviews reported staff then took C1's cell phone away. Additional interviews reported that C1 continued to leave the facility without permission and come back to the facility with a different cell phone. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Darlene Almaraz 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: HOME OF EXCELLENCEFACILITY NUMBER: VISIT DATE: 04/12/2023

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

met_with: Tiffany Merritt


raw_content:
Narrative:
A confidential witness reported C1 was physically assaulted by S6 by putting their hands on C1's throat and hit C1's left hand, however the date the incident took place was not known. Additional confidential witnesses reported the alleged incident happened in January 2023. LPA requested but did not receive a copy of the incident report to confirm the validity of the statements provided. A confidential witness reported the incident was a result of C1 not letting go of a pair of pants. It was reported C1 would not loosen their grip on the pants, fell back onto the couch, and then fell to the floor. S6 denied all allegations of physical abuse. Community Care Licensing also received an allegation that staff spoke inappropriately to minor in care. It was alleged that staff called C1 names. A confidential witness reported that staff did not call any of the clients names or speak inappropriately to clients in care. It was further reported, that C1 would get upset when clients made blunt remarks about C1. A Confidential witness also reported that C1 was yelled at by staff, no longer employed at the facility,and S2. However, they did not reveal what was said to C1. It was further stated that staff will use a firm tone when redirecting clients, but they do not yell at the clients. Based on inconsistent confidential interviews and lack of documentation, the allegations staff hit minor and staff spoke inappropriately to minor in care in care, may have occurred. However, the allegations are not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights were provided to Home of Excellence, Facility Manager, Leticia Castaneda.

Investigation Findings:
13On April 12, 2023, at 08: AM, Licensing Program Analyst (LPA) Jessica Peete conducted an unannounced visit to Home of Excellence Short Term Residential Therapeutic Program ( STRTP) to deliver the investigative findings for the allegations listed above. On 02/28/2023, LPA Peete inspected the physical plant, and no immediate health or safety hazards were observed. During the investigation, LPA obtained documents pertinent to the investigation. LPA conducted interviews with clients (C1, C2, C3, ) Staff (S1, S2, S3, S4, S5,S6 ) and County Social Workers (CSW) . Client 4 ( C4) was not available for interviews. On 02/27/2023, Community Care Licensing received an allegation that staff hit minor in care and staff spoke inappropriately to minor in care. It was alleged that C1 was being hit by facility staff and this had happened on 2/24/2023. C1 denied being hit by staff on 02/24/2023. Confidential witness reported working on 02/24/2023 and did not witness C1 being hit by staff. Another confidential witness reported not remembering anything happing to C1 on 02/24/2023. Other confidential witnesses reported that staff did not hit C1 or any other clients in care. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Jessica M Peete 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: HOME OF EXCELLENCEFACILITY NUMBER: VISIT DATE: 04/12/2023

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

met_with: Facility Manager Leticia Castaneda


raw_content:
Narrative:
trafficked" and "opening" their legs. Additional follow up confidential interviews denied that staff was mean, yelled, or cussed in the home. LPA attempted to contact C1's case worker multiple times, but the attempts were unsuccessful. Other information obtained from confidential interviews stated that staff had called C2 a "whore." LPA was not provided specific details regarding which staff made the comment. One confidential interview stated that they had never overheard staff calling clients names or cussing directed at them. In this interview, it was disclosed that staff yelled and used inappropriate language in the facility, but this was not directed towards the clients. LPA Hood conducted an unannounced visit to the home on 4/19/2023 to request facility documentation. Based on interview, C1 was verbally aggressive towards staff and had difficulty being redirected. In this interview, interviewee said that they had not witnessed or heard of staff calling clients names, cussing, or saying inappropriate comments to the clients. Based on confidential interviews and record review, the allegation that staff was mean to minor, may have occurred; however, it has not met the preponderance of doubt. Therefore, the above allegations are unsubstantiated at this time. No deficiencies were cited during this visit. LPA Hood conducted an exit interview with Lisa Brooks, Youth Counselor, and a copy of this report including appeal rights was provided.

Investigation Findings:
13On 4/21/2023 at 10:05AM, Licensing Program Analyst (LPA) Selena Hood conducted a visit to the Home of Excellence and met with Lisa Brooks, Youth Counselor. The purpose of this visit was to deliver the findings for the above allegations. During the investigation, LPA Hood and LPA Carmen Escobar conducted six confidential interviews with five interviewees (C1, C2, C3, ADM, and FM). Of the five interviewed, three denied that staff had called clients names or made inappropriate comments. In addition, facility and county records were reviewed. It was reported to Community Care Licensing (CCL) that staff were "mean" to minor. On 4/13/2022, LPA Escobar conducted an unannounced visit to the facility to inform the of the allegations. On 4/13/2022, LPA Escobar conducted an interview with Client (C1) and Facility Manager (FM). According to confidential interviews it was disclosed that C1 did not like being told what to do and acted out when given direction. Based on a confidential interview it was disclosed that staff had made comments about youth being "sex UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Christina Barnes LICENSING EVALUATOR NAME: Selena Hood 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: HOME OF EXCELLENCEFACILITY NUMBER: VISIT DATE: 04/21/2023

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

met_with: Lisa Brooks


raw_content:
Narrative:
Based on the confidential interviews, staff had called law enforcement when C1 had eloped from the facility. Four of the seven interviewed stated that staff reported elopements to CCL, the clients' county social workers, and law enforcement. Based on interviews and record review, C1 had received a CSEC advocate, but counseling was unsuccessful in redirecting. According to one interview, the facility had been working with the Rialto Police Department to catch the adult men that C1 had engaged with. Based on one confidential interview, the facility did not report elopements with adult men to law enforcement. LPA Hood conducted an interview with C1's current case worker (CW). CW shared that they were not the case worker at the time of the allegations, the case worker at the time of the allegations was no longer with the county. LPA Hood reviewed the CPS Screener Narratives, two were submitted for this incident with C1. On 5/13/2022, the CPS narrative states that the facility had not yet submitted a referral, but they had alerted the county case worker. Another referral was opened on 5/19/2023 due to other concerns with C1 engaging in CSEC activity. The CPS investigations are not complete, LPA Hood made unsuccessful attempts to contact the investigating case worker. LPA Hood reviewed twelve incident reports between 5/10/2022 and 2/1/2023. Based on a review of the incident reports, the facility did report elopements to CCL, law enforcement, and the social worker. Based on confidential interviews and record review, the allegation that client engaged in CSEC activity due to a lack of supervision may or may not be true; however, the allegation has not met the preponderance of doubt. Therefore, the above allegation is unsubstantiated at this time. No deficiencies were cited during this visit. LPA Hood conducted an exit interview with Lisa Brooks, Youth Counselor, and a copy of this report including appeal rights was provided.

Investigation Findings:
13On 4/21/2023 at 10:05AM, Licensing Program Analyst (LPA) Selena Hood conducted a visit to Home of Excellence and met with Lisa Brooks, Youth Counselor. The purpose of this visit was to deliver the findings for the above allegation. During the investigation, LPA Hood and LPA Carmen Escobar conducted eight confidential interviews with seven interviewees (C1, C3, S1, S2, S3, FA, and CW). In addition, facility and county records were reviewed. LPA Hood attempted to contact C1's case worker and the reporting party, but the attempts were unsuccessful. It was reported to Community Care Licensing (CCL) that minor is engaging in CSEC (Commercial Sexual Exploitation of Children) activity. On 5/24/2022, LPA Escobar conducted a visit to facility to inform of the allegations. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Christina Barnes LICENSING EVALUATOR NAME: Selena Hood 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: HOME OF EXCELLENCEFACILITY NUMBER: VISIT DATE: 04/21/2023

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


facility_name: HOPE REFUGE, INC

summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Before S4 left the hospital, S4 informed the nurses not to let C1 go with A1, because A1 is not C1's legal guardian. A1 stated that when she arrived at the hospital A1 did not see any staff member with C1, S3 confirmed that S4 had already left by the time S3 arrived at the hospital. In Addition, SW said that C1 should not be left alone with A1,because the in-person visits of A1 with C1 must be supervised. SW is concern that the facility staff left C1 be alone in the hospital. Based on LPA interviews and record reviews, the preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. A deficiency was cited to the facility for Neglect Lack of supervision. Due to repeat deficiency 80078(a) within 12 months, a civil penalty will be issue of $250 and $100 a day until the violation is corrected. Exit interview was conducted with the Administrator, Appeal Rights and a copy of this report will be send via e-mail to the licensee for signature.

Investigation Findings:
13On May 26, 2021 at 11:50am Licensing Program Analyst (LPA) Enrique Hernandez made an unannounced Telephone call inspection to Hope Refuge Short Term Residential Therapeutic Program (STRTP), the purpose of the call is to conclude the investigation on the above allegation and to deliver the finding. LPA spoke with Facility Administrator Sharon Stevens and together discussed the investigation details. During the course of the complaint investigation, all relevant parties were interviewed. The interviews produced corroborating evidence for the above allegation. Based on the interviews with C1, S1, S2, S3, S4, S6, A1 and SW It was confirmed that C1 had to go to the hospital and the staff did not follow the ambulance, because S4 lost the keys to the vehicle. C1 was upset that no one was in the hospital with her. S4 and S3 stated that they tried to contact S1 and S2 several times to find out what to do, and who was going to the hospital. After a couple of hours of C1 been in the hospital alone, S4 arrived at the hospital. S2 authorized S4 at 12:14 am to go home, because S3 was heading to the hospital to relieve S4. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: HOPE REFUGE, INCFACILITY NUMBER: 425802135

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

met_with: Sharon Stevens

complaint_status: SUBSTANTIATED


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Investigation Findings:
13On 8/06/2021 at 8:45am Licensing Program Analyst (LPA) Enrique Hernandez made an unannounced inspection to the above facility, for the purpose of concluding the investigation on the above allegation and to deliver the findings. LPA spoke with the facility Program Manager Taylor Abernethy and the licensee Sally Cook, and together discussed the investigation details. During the course of the complaint investigation, all relevant parties were interviewed. Staff and clients confirmed, that the doors to both medicine cabinets where were left open. S6 confirmed that S6 left the two doors open of the medicine cabinet because, was attending the emergency of another client. S6 said it was a mistake to leave both doors open.C1 indicated taken medicine out of the cabinet as soon as C1 saw that it was left open. The facility staff responded by calling Immediately emergency services for C1. Based on LPA interviews and record reviews, the preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. A deficiency was cited to the facility for Health-Related Services. (See 9099-D) Exit interview was conducted and a copy of this report was left at the home with the Licensee whose signature on this form confirm receipt of this document. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: HOPE REFUGE, INCFACILITY NUMBER: 425802135

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

met_with: Licensee


summary: Complaint Investigation - Substantiated

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Narrative:
continued from page 1 (LIC 9099) Medications are being mismanaged. In staff and client interviews it was confirmed that medications were given at the wrong time or missed because there wasn't a staff to administer them. It was also reported during an emergency, a staff left the med closet open and a client was able to access her meds to attempt an overdose. In other reports it was disclosed by staff and clients, and facility documentation, that a client was able to self-harm by putting bleach and other chemicals in her mouth, as well as reports of clients self-harming by cutting themselves. Based on LPA interviews and record reviews, the preponderance of evidence standard has been met, therefore the allegations are found to be SUBSTANTIATED. A deficiency was cited to the facility for Personnel Requirements and Health-Related Services (See 9099-D). Exit interview was conducted, signature from Facility Representative was received, and a copy of this report was left at the facility.

Investigation Findings:
13On August 15, 2021 at 12: PM, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard made an unannounced inspection to the above facility for the purpose of concluding the investigation and to deliver findings. Upon arrival, AGPA Woodard was greeted by Jackie George, Facility Manager. During today's visit, investigation details were discussed. During the course of the investigation, relevant parties were interviewed, staff files and other facility records were reviewed. Staff and clients confirmed activities are minimal. Weekly they will have a volunteer come and do art therapy. On occasion they can use the pool, or they will go to the beach after church on Sunday. However, if they choose not to go to church, they can't go to the beach. There are no planned activities, and other activities that require to be purchased are denied and staff will try to get activities donated. continue on page 2 (LIC C) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: HOPE REFUGE, INCFACILITY NUMBER: VISIT DATE: 08/15/2021

met_with: Jackie George, Facility Manager


summary: Complaint Investigation - Substantiated - 1 deficiency

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Narrative:
continued from page 1 (LIC 9099) other machine smells like a dead animal; (Photo of two dryers with do not use were taken on June 5, 2021). Also observed by AGPA trash bins outside of cottages were overflowing, trash dumpsters by front gate were overflowing, and trash cans in Stone House were full; (Photo taken of trash bin on June 5, 2021 and trash dumpster on 08/14/2021). Staff and clients both state that the facility is hazardous due to the location poses a hazard if there was a fire, and broken glass and screws are often found on the ground. On 08/06/2021, during a case management inspection, LPA observed a chainsaw on the ground located near stone house along the path. Although the staff to client ratio is 1:4, there is not enough staffing to meet the needs of the girls. There are incidents where clients are self-harming, clients will request to go to the doctor/hospital and will have to wait because of not enough staff, and a client was left at the hospital without a staff. Based on AGPA interviews and record reviews, the preponderance of evidence standard has been met, therefore the allegations are found to be SUBSTANTIATED. Deficiencies were cited to the facility for Plan of Operation, Personal Services, Building and Grounds, Transportation, Health and Safety Code, and Furniture, Fixtures, Equipment, and Supplies (See 9099-D). Exit interview was conducted, signature from Facility Representative was received, and a copy of this report was left at the facility.

Investigation Findings:
13On August 15, 2021 at 12: PM, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard made an unannounced inspection to the above facility for the purpose of concluding the investigation and to deliver findings. Upon arrival, AGPA Woodard was greeted by Jackie George. During today's visit, investigation details were discussed. During the course of the investigation, relevant parties were interviewed, staff files and other facility records were reviewed. Staff and clients confirmed, that the majority of staff hired have no previous experience and are not properly trained on procedures. The majority of staff and all clients interviewed do not know the evacuation plan. If there is an evacuation plan in place, they are not aware of it, and emergency drills are not being performed. Facility Vehicles are dirty inside and out and require maintenance; oil light was on for weeks and it was reported that the facility vehicles have run out of gas. On June 5th, AGPA observed two out of three dryers that were out of order. Both staff and clients say one of the dryers has flames and the continue on page 2 (LIC 9099C) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: HOPE REFUGE, INCFACILITY NUMBER: VISIT DATE: 08/15/2021

Deficiencies:
87022(f): Be appropriate to meed the needs of staff and population(s) being served.

title: The facility shall operate in accordance with the terms specified in the plan of operation and may be cited for not doing so. A plan for the supervision, evaluation, and training of staff. The training plan shall


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Investigation Findings:
13On August 21, 2021 at 1PM Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted an unannounce complaint inspection at the above facility for the purpose of delivering findings. Upon arrival, AGPA Woodard was greeted by Stephanie Reteria-Perez, Facility Manager. During the course of the investigation, relevant parties were interviewed, and an inspection was conducted. Staff and clients did not confirm that toiletries were not provided. Statements varied. Shampoo, conditioner, body wash, etc. are being provided, however on occasion they run low in stock on personal hygiene items such as tampons. Items that run low in the cottages are able to be refilled from the storage area near the stone cottage where overstock is kept, such as toilet paper, paper towels, cleaning supplies, etc. Durning inspection of the facility, AGPA observed personal hygiene items/toiletries in an office located in the dining hall as well as the storage room near the Stone House. Based on AGPA interviews and observance of toiletries, the preponderance of evidence standard was not met, therefore the allegation is found to be unsubstantiated. A finding that the complaint is unsubstantiated means that the allegation may have occurred, however not supported or proven by evidence. A copy of this report was left at the facility and emailed to Sally Cook. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard 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: Sally Cook


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Narrative:
Additionally, clients and staff confirmed that if a client's starts vandalizing the facility, staff are always there to intervene and to make sure no one gets injured. Clients confirmed that they receive group and individual therapy at the facility, which was confirmed by facility staff. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. The Department has decided that the above allegations are unsubstantiated but if any additional information is received this complaint can be amended and findings can be changed. Per California Code Regulation, Title 22, Division 6, Chapters 1, General Licensing Regulations, and Short Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS), there are no deficiencies to be cited at this time. Exit interview was conducted and a copy of the report will be email to the licensee due to technical difficulties with LPA computer at the time of the inspection.

Investigation Findings:
13On August 25, 2021, at 11:00 am, Licensing Program Analyst (LPA) Enrique Hernandez made an unannounced visit to the above facility for the purpose of concluding the investigation on the above allegations and to deliver the findings. LPA met with the licensee, and due to computer issues LPA was not able to discuss the findings with the licensee until August 26, 2021 via telephone. Based on the confidential interviews with all the pertinent parties and file review, the allegations cannot be substantiated, although interviews with C4 and C5 confirmed that they smoked a small marijuana cigarette at the facility, staff tried to intervene to prevent clients from continuing to smoke the cigarette. C4 stated that as punishment C4 had to go to the room but does not remember for how long. C5 denied being in the room as a form of punishment for smoking. The facility staff confirmed that they do not send clients to their rooms as a form of punishment. Facility staff confirmed that there is a level system in place and clients lose points if they do something bad like smoking marijuana or if they AWOL from the facility. During LPA's inspection on 6/9/2020 at the facility, LPA did not observe locks on the client's room doors. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: HOPE REFUGE, INCFACILITY NUMBER: VISIT DATE: 08/25/2021

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


summary: Complaint Investigation - Substantiated - 1 deficiency - 1 allegation

raw_content:
Investigation Findings:
On September 4, 2021 at 12:45PM, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted an unannounced complaint inspection at the above facility for the purpose of delivering findings. AGPA met with Stephanie Renteria-Perez, Facility Manager. During the course of the investigation, AGPA Woodard conducted confidential interviews with staff, clients and other relative parties. Staff state they will use their own money for facility related projects, gasoline, oil changes, food, etc. and it takes about 1-3 weeks to get reimbursed. 95% of the food at the facility is purchased from the food bank. When interviewing the CEO he stated there were no outstanding reimbursements, but in other interviews reimbursements are up to $70,000 pending. CEO signs off on his and the Executive Director's reimbursements, however Balance Financial Services states that "Executive team members do not approve their own expenses. Reimbursements are approved by another manager." Based on interviews and documentation received through the course of this investigation, the preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. A deficiency was cited to the facility for Finances (See 9099-D). Exit interview was conducted, signature from Facility Representative was received, and a copy of this report was left at the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: HOPE REFUGE, INCFACILITY NUMBER: 425802135

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

Deficiencies:
80062: (1) Development and maintenance of a financial plan which ensures resources necessary meet operating costs for care and supervision of clients.

met_with: Stephanie Renteria-Perez

title: (a)The licensee shall  meet the following financial requirements


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
The investigation revealed during a facility outing on May 8, 2021, S1 provided alcohol to clients C1 and C2. Confidential interviews revealed S1 gave C1 a mixed alcoholic drink which S1 provided to clients in a pink colored plastic bottle. C1 indicated that C1 "got a buzz" from the alcohol as a result. Witness statements remained consistent throughout the investigation process. S1 denied providing alcohol to the minors. Upon discovery of the incident, facility filed an incident report notifying required parties and conducted an internal investigation into the matter. It was also revealed during the same outing, S1 took out an unlit marijuana cigarette and put in S1's mouth "jokingly". Upon facility's discovery of S1's actions, S1 was place on suspension and later terminated from facility's program. According to witness statements and documentary evidence, S1 allowed C1 and C3, to use S1's cell phone to message through outside communications and/or post selfie. Evidence of C3's photo and/or messages was observed posted in social media. The investigation revealed that S1 knew C1, C2 and C3 were victims of Child Sex Trafficking; however, S1 allowed minors to use S1's cell phone to post messages and potentially communicate with sex traffickers. Based on confidential interviews and documentary evidence, the Department has determined the allegations that S1 provided alcohol to minors to consume and exposed minors to CSEC activity is Substantiated. Staff's actions poses an immediate health, safety and personal rights risk of harm to children placed in care. The licensee is therefore issued a citation in accordance with the Short-Term Residential Therapeutic Program Interim Licensing Standards, Chapter 7.5, Version 3.1: 87065. Personnel Duties. See page LIC9099-D for citation. An exit interview was completed and appeal rights discussed. A copy of this report was emailed to Program Manager.

Investigation Findings:
13On September 23, 2021 at 2: PM, Licensing Program Analyst (LPA) Regina Martin conducted a subsequent complaint inspection at the above facility for the purpose of delivering findings. LPA met with Taylor Abernethy Program Manager and together the findings are discussed. On May 17, 2021, Community Care Licensing received a complaint alleging Staff Member #1 (S1) provided alcohol to minors and S1 exposed minor to CSEC (Commercial Sexually Exploited Children) activity. The complaint was referred and assigned to Investigations Bureau, Investigator, Olivia Spindola. [see Confidential Names form, LIC811, dated 9/23/2021]. During the investigation confidential interviews were conducted with facility residents, Client #1 (C1) and Client #2 (C2), staff members, assigned Probation Officer for C1 and S1. (Continued on page LIC9099-C) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Regina Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: HOPE REFUGE, INCFACILITY NUMBER: VISIT DATE: 09/23/2021

met_with: Taylor Abernethy Program Manager


facility_name: HOUSE OF BETHESDA, THE

summary: Facility Evaluation

raw_content:
Narrative:
On December 17, 2021 at 9:00am, Licensing Program Analyst (LPA), Daphne Edison made an announced visit to The House of Bethesda for the purpose of conducting a Case Management (Post Licensing) inspection visit. This was a follow-up visit which took place on November 12, 2021 at the above location in which no one was at the home. LPA Edison met with Robert Smith, Licensing Executive Director who granted access to the facility and a tour was conducted. The home is licensed to provide care and supervision to six (6) children, ages 13 -17 years old, ambulatory only. There is a provisional license with an expiration date of May 4, 2022. There is no swimming pool or bodies of water on the premises. The census today is zero (0). The home is set up as follows: This is a one story house with three (3) bedrooms, two (2) bathrooms, living room, two (2) staff offices, dining area, kitchen/laundry area, and outdoor space. Living Room: There is adequate furniture which appears to be in good condition. There is a sofa and desk with an operable computer. Staff Office #1: Located off of the living room. There is a desk with an operable computer, fax machine, and closet space. All medications kept will be double locked in the staff office inside of a locked box. Staff Office #2: Located to the right of Staff Office #1. There is a desk with an operable computer, fax machine, and closet space. Dining Area: There is one table with six (6) chairs. Report Cont. on LIC 809-C. Kitchen/Laundry Area: There is a working stove/oven with four (4) gas burners, and two refrigerators/freezers. There is a fully charged fire extinguisher located to the right once entering the kitchen. The kitchen trash can have a tight lid on it. All cleaning supplies will be kept locked in cabinets above the washer and dryer. The knives will be kept locked in the kitchen cabinet and will only be accessible to employees. Hot water is delivered at a safe temperature range. Bedroom #1: Is vacant and furnished with two (2) twin size beds. There are adequate drawers, closet space, and lighting in this room. The beds have comfortable mattresses, clean linens, blankets, and pillows which are all in good repair. The windows have security bars with a working emergency release handle. Bedroom #2: Is vacant and furnished with two (2) twin size beds. There are adequate drawers, closet space, and lighting in this room. The beds have comfortable mattresses, clean linens, blankets, and pillows which are all in good repair. Bedroom #3: Is vacant and furnished with two (2) twin size beds. There are adequate drawers, closet space, and lighting in this room. The beds have comfortable mattresses, clean linens, blankets, and pillows which are all in good repair. The windows have security bars with a working emergency release handle. Bathroom #1: (Located in Staff office #2) Clean and operable at the time of visit. Hot water is delivered at a safe temperature range. Bathroom #2: (Located next to Bedroom #3). Clean and operable at the time of visit. Hot water is delivered at a safe temperature range. Outdoor Space: LPA Edison observed the entrance area and backyard to be free of debris and hazardous materials. Garage: The detached garage is kept locked and is only used for storage space. Report Cont. on LIC 809-C. The facility is clean, safe, sanitary, and in good repair. There are storage cabinets in the hallway where extra linens will be kept. Medicines, disinfectants, and cleaning solutions will be inaccessible to children in care. No more than two (2) children will share one bedroom. There are no weapons in the facility. Sharp knives will be stored in a locked cabinet and inaccessible to children. Staff will ensure all sharp objects are returned and locked in the lock sharps box. Adequate supervision will be provided for children in care. Children will be accorded personal rights. Children in care will be supported and encouraged to participate in extracurricular activities. Children in care will be able to contact the licensing agency or Ombudsperson in confidence without threats or punishment for making complaints. All posting requirements are met. Children in care will not be restricted in telephone use except by court order. There is a working telephone line available for clients to use. All smoke detectors and carbon monoxide are operable and meet statutory requirements. All fire extinguishers are fully charged. LPA Edison observed age appropriate First Aid supplies which also contains tweezers and a thermometer. The home is expected to operate within the capacity and limitations of the license. Currently, there are no clients or staff at the facility. Facility is still waiting to receive CARF accreditation and mental health certification and does not expect to have staff or clients return until July 2022. There were no deficiencies observed or cited at the site visit Exit interview was conducted and a copy of this report will be emailed to the facility.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Robert Smith - Licensing Executive Director


summary: Facility Evaluation

raw_content:
Narrative:
On May 3, 2022 at 8:53am, Licensing Program Analyst (LPA), Daphne Edison made an announced visit to The House of Bethesda for the purpose of conducting an Annual Required Inspection visit. LPA Edison met with Robert Smith, Director who granted access to the facility and a tour was conducted. The home is licensed to provide care and supervision to six (6) children, ages 13 -17 years old, ambulatory only. There is a provisional license with an expiration date of May 4, 2022. There is no swimming pool or bodies of water on the premises. On the date of this visit, the census is zero (0). The home is set up as follows: This is a one-story house with three (3) bedrooms, two (2) bathrooms, living room, two (2) staff offices, dining area, kitchen, laundry area, and outdoor space. Living Room: Equipped with a sofa, desk, TV, First Aid Kit, and a computer. Staff Office #1: Located off the living room. Equipped with a desk, computer, fax machine, and closet space. Staff Office/Therapy Room #2: Located to the right of Staff Office #1. Equipped with a desk, computer, fax machine, and closet space. Dining Area: Equipped with a table and six (6) chairs. Kitchen: Equipped with a working stove/oven with four (4) gas burners, refrigerator/freezer, and a kitchen trash can with a tight-fitting lid. Laundry Area: Equipped with a washer, dryer, and refrigerator for extra food storage. Bedroom #1: Vacant. Equipped with two (2) twin size beds and a TV. There are adequate drawers, closet space, and lighting in this room. The beds have comfortable mattresses, clean linens, blankets, and pillows which are all in good repair. The window has a security bar with a working emergency release handle. Continued on LIC 809-C Bedroom #2: Vacant. Equipped with two (2) twin size beds and a TV. There are adequate drawers, closet space, and lighting in this room. The beds have comfortable mattresses, clean linens, blankets, and pillows which are all in good repair. Bedroom #3: Vacant. Equipped with two (2) twin size beds and a TV. There are adequate drawers, closet space, and lighting in this room. The beds have comfortable mattresses, clean linens, blankets, and pillows which are all in good repair. The window has a security bar with a working emergency release handle. Bathroom #1: (Located in Staff Office #2) Equipped with a toilet, bathtub/shower combination. Safe and sanitary operating condition. Bathroom #2: Equipped with a toilet, bathtub/shower combination. Safe and sanitary operating condition. Outdoor Space: Entrance area is free of debris and hazardous materials. Backyard: Free of debris and hazardous materials. Garage: The detached garage is kept locked and is only used for storage space. The facility is clean, safe, sanitary, and in good repair. There are storage cabinets in the hallway where extra linens will be kept. Disinfectants, and cleaning solutions will be kept in the laundry area in locked cabinets inaccessible to children in care. There are no weapons in the facility. All medications kept will be double locked in the staff office inside of a locked box. Sharp knives will be stored in a locked cabinet/drawer in the kitchen and inaccessible to children. LPA unable to review client records and conduct client interviews due to no children in care. Children in care must be supervised and protected at all times. Children must be accorded dignity in personal relationships with staff and others. Children must be able to contact the licensing agency or Foster Care Ombudsperson in confidence without threats or punishment for making complaints. It was reported that children will attend school, extracurricular, cultural, and personal enrichment activities. Continued on LIC 809-C LPA unable to review staff records and conduct staff interviews due to no staff currently. Caregiver(s)/adults working/residing in the facility must have DOJ/FBI criminal record clearances and Child Abuse Index Checks. Emergency Mass Disaster Casualty Plan was available for review. LPA reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. The facility must operate within the capacity and limitations of the license. Smoke detectors and carbon monoxide detectors tested audible and were in appropriate working order. The facility has two (2) regulation fire extinguishers fully charged. LPA Edison observed age appropriate First Aid supplies which also contain scissors, tweezers, and a thermometer. Hot water was tested within a safe range. Currently, there is no staff at the facility. Facility is still waiting to receive CARF accreditation and Mental Health Approval. · LPA observed cameras in home but was informed by Director cameras will not be utilized · Perishable food will be supplied prior to resident move-in · Landline telephone service must be set up prior to resident move-in Based on the observations made during today's inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. Exit interview was conducted and a copy of this report will be emailed to the Director.

visit_type: Annual

met_with: Robert Smith-Director


facility_name: INSPIRING PATHWAYS

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Cynthia Galindo conducted a complaint inspection at Inspiring Pathways and met with Shannon Blanchard. The purpose of the inspection was to deliver the findings for the above complaint allegations. The Department has investigated the complaint alleging staff do not ensure that minors in care participate in school and facility is not meeting minor's mental health needs. LPA interviewed staff and social workers as well as obtained documents. Clients were not interviewed because one client (C1) refused to speak with LPA and the other client (C2) is on AWOL status. According to interviews and records, minors refused to attend school on several occasions. It is unclear if the enrollment process was delayed by the STRTP or the county but ultimately, clients were enrolled in school. As far as mental health needs, the STRTP was recently approved for in-home mental heatlh services but is contracted with the county to provide mental health services. C1 was attending therapy sessions regularly although is it unclear if there was a delay in the services. Although the allegations may have happened or are valid, there is not a preponderance of evidence to provide the alleged violation did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was emailed to the facility for signature. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Cynthia M Galindo 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: Shannon Blanchard


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Cynthia Galindo conducted a complaint inspection at Inspiring Pathways and met with Shannon Blanchard. The purpose of the inspection was to deliver the findings for the above complaint allegation. The Department has investigated the complaint alleging facility staff do not prevent minors from awoling. LPA interviewed staff and clients as well as reviewed staff's training records and incident reports. Based on the interviews and incident reports, staff attempt to prevent minors from running away, but the minors ignore staff's directives and leave the home anyway. Although the allegation may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was emailed to the facility for signature. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Cynthia M Galindo 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


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Investigation Findings:
13Licensing Program Analyst (LPA) Daiquiri Boyd conducted a follow-up complaint inspection to the STRTP and met with Shannon Blanchard. The purpose of the inspection was to deliver the findings for the above complaint allegation regarding inappropriate sexual activity between monos while in care. During the course of the investigation, Investigations Bureau conducted interviews. The information obtained during the interviews, indicated that the clients in care had inappropriate sexual activity in the home, none of the staff indicated that they were aware of these activities. Type A: This poses an immediate health and safety risk to clients in care.Based on the LPA's observations, interviews and records review which were conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be substantiated. A copy of the report and Appeal Rights was provided to the FFA. 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 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, E SHAW AVE This is an official report of an unannounced visit/investigation of a complaint received in our office on 03/18/2021 and conducted by Evaluator Daiquiri Boyd PUBLICCOMPLAINT CONTROL NUMBER: 24-CR- FACILITY NAME:INSPIRING PATHWAYSFACILITY NUMBER: ADMINISTRATOR:BLANCHARD, SHANNONFACILITY TYPE: ADDRESS: W. Bryman St.TELEPHONE: (559) 585- CITY:HANFORDSTATE: CAZIP CODE: CAPACITY:6CENSUS: 6DATE: 06/28/ UNANNOUNCEDTIME BEGAN: 04: PM MET WITH:Shannon BlanchardTIME COMPLETED:06: PM 9Facility Staff are using marijuana with the minors in the home Staff allows minors to smoke while in care Minors have access to illegal drugs while in care INVESTIGATION FINDINGS: 13Licensing Program Analyst (LPA) Daiquiri Boyd and Priscilla Zamudio conducted a follow-up complaint inspection to the STRTP and met with Shannon Blanchard. The purpose of the inspection was to deliver the findings for the above complaint allegations. Investigations Bureau conduted this investigation and found, through interviews, that there was no stories that could be cooberated. 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: 3 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: INSPIRING PATHWAYSFACILITY NUMBER: 167206801

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


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Investigation Findings:
13On October 7, 2021, Licensing Program Analyst (LPA) Cynthia Galindo conducted a follow-up complaint inspection at Inspiring Pathways on behalf of LPA Priscilla Zamudio and spoke with Shannon Blanchard. The purpose of the inspection was to deliver the findings for the above complaint allegations. LPA Zamudio interviewed staff, clients and reviewed pertinent documents. Based on interviews conducted and information gathered, there were some discrepencies found. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. A copy of this report and appeal rights were left with Shannon. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Cynthia M Galindo 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


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Investigation Findings:
13On October 7, 2021, Licensing Program Analyst (LPA) Cynthia Galindo conducted a follow-up complaint inspection at Inspiring Pathways on behalf of LPA Priscilla Zamudio and spoke with Shannon Blanchard. The purpose of the inspection was to deliver the findings for the above complaint allegations. LPA Zamudio interviewed staff, clients and reviewed pertinent documents. Based on interviews conducted and information gathered, there were some discrepancies found. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. A copy of this report and appeal rights were left with Shannon. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Cynthia M Galindo 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


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Narrative:
2. Staff driving foster children with suspended license: A staff member admitted that her license had been suspended. She stated that she had notified the Administrator that she was not allowed to drive but stated she could not provide dates of when the suspension was in effect. Staff member has since provided valid license and plan of correction will be cleared at today's visit. This is a TYPE A violation 3. Facility staff did not safeguard a foster child's funds. In this particular case while the client's regular allowance and clothing allowance were accounted for, her personal funds that had been stored in the locked box came up short. Staff stated that tracking the client's personal funds has been an issue in the past. The Administrator replaced the missing funds. This is a TYPE B violation. TYPE A violations pose an immediate risk to the health and safety of the clients in care while TYPE B violations pose a potential risk to the health and safety of the clients in care. Based on the LPA's observations, 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 copy of the report and Appeal Rights was provided to Zelisa Gayton

Investigation Findings:
13On December 13, 2021, Licensing Program Analyst (LPA) Rachel Bruce conducted a follow-up complaint inspection to Inspiring Pathways, STRTP. The purpose of the inspection was to deliver the findings for the above complaint allegations. On September 13, 2021, the above allegatsion were referred to Communciaty Care Licensing for investigation. During the course of the investigation, Community Care Licensing (CCL) conducted interviews with clients, staff, county social worker as well as reviewed documentation on clients and staff. The information obtained during the interviews, indicated the following: 1. Administrator allowed a foster child to be at an unknown residentail home unsupervised. Interviews revealed that a foster child was taken out of the county and transported to Fresno County to get her hair braided. Prior approval was not obtained by her County Social Worker who indicated she would not have allowed the outing had she been notified. This is a TYPE A violation. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Rachel A Bruce 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: INSPIRING PATHWAYSFACILITY NUMBER: VISIT DATE: 12/13/2021

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

met_with: Zelisa Gayton, Childcare Worker


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Investigation Findings:
13Licensing Program Analyst (LPA) Cynthia Galindo conducted a complaint inspection at Inspiring Pathways and met with Zelisa Gayton. The purpose of the inspection was to deliver the findings for the above complaint allegations. The Department has investigated the complaint alleging facity did not provide a safe environment for minor and minor has access to sharp objects. LPA interviewed residents, staff and social worker as well as obtained documents. Due to the inconsistencies in the interviews, the allegations are unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to provide the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Cynthia M Galindo 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: Zelisa Gayton


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Investigation Findings:
13Licensing Program Analyst (LPA) Cynthia Galindo conducted a complaint inspection at Inspiring Pathways and met with Natalia Yado. The purpose of the inspection was to deliver the findings for the above complaint allegations. The Department has investigated the complaint alleging staff bully residents. LPA interviewed residents, staff and social worker as well as obtained documents. Due to the inconsistencies in the interviews, the allegations are unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to provide the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Cynthia M Galindo 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: Natalia Yado


facility_name: JAMES PENNY HOUSE INC.

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Narrative:
Clients became hostile and threatened first responders. One client attempted to vandalize first responders' vehicles. One of the staff went to the hospital only after the situation at the facility calmed down. No other staff reported for duty to assist. In addition, the facility plan of operation show that staff is to either accompany a client or follow the ambulance when a client has to be transported to an emergency facility. Based on information obtained, the preponderance of evidence standard was met, therefore, the above allegation is substantiated. This poses an immediate Health, Safety, or Personal Rights risk to clients in care. Deficiencies are being cited under STRTP General Regulations Responsibility for Providing Care and Supervision and STRTP Interim Licensing Standards (ILS) 87065.5 (g) Direct Care Staff/Child Ratios. It was revealed that alcohol and drugs are not allowed at the facility and these are confiscated if found by staff. Based on information obtained, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there was no preponderance of evidence found to support it. A copy of this signed report, the LIC 811 (Confidential Names dated 7/23/21) and appeal rights were provided to the facility representative at the conclusion of the inspection.

Investigation Findings:
13On July 27, 2021, Licensing Program Analyst (LPA) Irene Yamamoto conducted a complaint inspection at the facility to deliver the findings of the allegation. LPA met with the facility representative named above. The allegation was investigated by Community Care Licensing (CCL), Investigations Branch (IB) Investigator Maria Barragan. The Department received a complaint alleging multiple allegations on 4/12/21. IB Investigator Barragan investigated the allegation by conducting interviews and reviewing records such as, but not limited to, Register of Clients, Personnel Report, Placement Agency and Short Term Residential Therapeutic Program (STRTP) Agreements, hospital, police and ambulance records. LPA Yamamoto reviewed the facility plan of operation. It was alleged that staff did not accompany client who was transported to the hospital. Confidential interviews reveal that only one staff was present during the night shift, when the incident happened. Another staff reported to work but both staff remained with clients at the facility who became upset when an intoxicated client became uncooperative with first responders and had to be restrained for client's safety. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Irene Yamamoto LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200a Monterey Park, CA Facility Name: James Penny House INC.FACILITY NUMBER: VISIT DATE: 07/27/2021

met_with: Danyelle Jones, Unit Coordinator


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Narrative:
It was alleged that at least one staff member (S1; See LIC Confidential Names Form) at the facility failed to meet the needs of one client (C1) in care. More specifically, it was alleged that the staff member failed to take C1's comments seriously during an incident in which they were in a mental crisis. No injuries were sustained although C1 was taken to the hospital as a precaution. In interviews conducted with clients in the home, the clients all stated that they felt safe in the home and felt that the staff were able to meet their needs. The clients all denied feeling dismissed by the staff members in the facility and any time issues were brought up were addressed in a timely manner. In an interview conducted with C1, C1 stated that S1 was their favorite staff member in the facility and denied ever feeling dismissed by S1. S1 was always helpful and took their comments seriously. In interviews conducted with staff, the above comments were corroborated. S1 stated that on the date of the incident, they stayed with C1 the whole time that they were in a state of crisis and played games with them to try and redirect them per their individualized safety plan. S1 denied being dismissive of C1's feelings and stated that the facility had procedures in place to try and redirect clients in crisis prior to calling emergency services. An interview conducted with the facility social worker confirmed these statements. The social worker stated that they had never seen or heard of any staff members in the home being dismissive of clients and they had no concerns about it. Comments made by clients during times of crisis were always taken seriously. A review of C1's Needs and Services Plan and Admissions Agreement confirmed that C1 was known to have episodes of mental crisis and that attempts to redirect them prior to calling emergency services was standard. Based on interviews, redirection procedures for C1 involved constant supervision, board games, car rides, and more. Based on interviews conducted and records reviewed, there is not a preponderance of evidence to prove that the above allegation occurred. Although the allegation may have happened or may be valid, the preponderance of evidence standard has not been met. Therefore, the allegations are deemed UNSUBSTANTIATED. An exit interview was conducted and a signed copy of this report, along with the Licensee's Appeal Rights (LIC 9058 01/16) was provided to the Licensee.

Investigation Findings:
13On September 03, 2021 at approximately 12: PM, Licensing Program Analyst (LPA) Raymond Wu conducted a follow-up complaint inspection with the facility to deliver the findings of a complaint investigation concerning the allegation above. LPA discussed the finding with the facility representative named above. During the course of the investigation, LPA interviewed the facility social worker on 08/27/21, the facility clients on 07/19/21 and staff members on 07/19/21 and 08/09/21. LPA also reviewed documents on 08/09/21 and 08/27/21 including but not limited to the client's admissions agreement, their Needs and Services Plans, their medication log, and Special Incident Reports. (Continued) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Yan Yeung LICENSING EVALUATOR NAME: Raymond Wu LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200a Monterey Park, CA Facility Name: James Penny House INC.FACILITY NUMBER: VISIT DATE: 09/03/2021

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

met_with: Facility Manager Joshlyn Sanders


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Narrative:
It was reported staff (S1) used inappropriate language toward a client (C1) in care. S1 admitted the reported alleged incident occurred. S1 stated C1 asked another client at the facility to bring her water. S1 reported she asked the other client to not bring C1 water. C1 became escalated and began cursing at S1. S1 reported she was triggered by C1 cursing at her and cursed back at C1. Based on information obtained from interviews conducted and records reviewed the allegation was Substantiated. C1's personal rights were not afforded as require by the Interim Licensing Standards (ILS) Ver. 3. Sec. 87072(d)(11). The allegation is valid because the standard of the preponderance of evidence has been met. Facility cited for violation of Interim Licensing Standards (ILS) Ver. 3. Sec. 87072(d)(11): Personal Rights. Statements obtained from interviews conducted corroborated the allegation that a staff used inappropriate language toward a client in care. Exit interview conducted and a copy of this report along with a LIC9099D and LIC811 were provided to the facility representative. Appeals rights were discussed and provided.

Investigation Findings:
13An unannounced follow up complaint inspection was conducted by Licensing Program Analyst (LPA) Christopher Larios on 9/24/21 at 12: PM. During the inspcetion LPA Larios met with Unit Coordinator Danyelle Jones. The purpose of the inspection was to deliver findings for the above-mentioned complaint allegation. During the course of the investigation LPA Larios conducted a record review on 4/12/21 and copies of the following documents were obtained: Staff Roster, Client Roster, Clients' Needs and Services Plans, Special Incident Reports from March - April 2021. LPA Larios conducted interviews with one staff (S1) on 4/23/21, three clients on 4/12/21, two clients on 4/23/21 and three County Social Workers (CSWs) on 8/19/21. One client declined to provide a statement regarding the allegation and two CSWs were unavailable for an interview. (Reference Confidential Names list LIC811 dated 9/24/21) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Deborah A Santos LICENSING EVALUATOR NAME: Christopher Larios LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200a Monterey Park, CA Facility Name: James Penny House INC.FACILITY NUMBER: VISIT DATE: 09/24/2021

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

met_with: Danyelle Jones


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Narrative:
children left facility on unauthorized leave. Identified within those reports showed what transpired in the home with children and how staff were able to address any issues reported to them by clients. Staff denied not being present to provide services or meet the needs of client. Staff also denied any clients ever making complaints or notifying staff of issues. Child identified as being in the home during the time in which this incident occurred of staff not monitoring a child who was experiencing suicidal ideations denied allegation and stated that they were unaware of any issues with staff regarding a client with suicidal ideations. Interviews conducted with other children currently residing in the home had similar statements and denied the allegation and stated that staff are present to rectify any complaints or concerns. LPA was unable to contact county social worker, but no documents identified a problem with clients placed in the home or facility staff. Based on the information gathered, although the allegation may have happened or is valid, the preponderance of evidence to prove the allegation was not met, therefore the allegation is unsubstantiated. An exit interview was conducted. A copy of this report Confidential Names Form, and Appeal Rights were provided to the facility representative. There were no deficiencies cited during this inspection.

Investigation Findings:
13On 4/13/ Licensing Program Analyst (LPA) Dawn Mahecha made an announced visit to the James Penny House facility for the purpose of a complaint investigation. LPA met with Unit Coordinator (Raeanna Howard) regarding above identified allegation. Investigation consisted of the following: LPA met with and interviewed two (2) staff, unit coordinator and facility manager. Additionally, LPA obtained copies of current staff/client roster, clients needs and service plan, staff recently completed training, staff daily logs from July to August for one client and client discharge log. LPA attempted to interview two children identified as being in the home during the time of the identified incident one child declined to meet with LPA. LPA interviewed four (3) additional children in the home. Investigation revealed the following: It was alleged that minors were not properly supervised while in care. Interviews conducted with staff did not identify an issue with staff monitoring children. Staff had similar statements in stating that there are two (2) staff on duty during the day and one (1) overnight. Staff further stated that there have been no issues working with the children or overseeing the children in care. Staff provided documented incident reports, daily logs of incidents that occurred in the home and times in which UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Yan Yeung LICENSING EVALUATOR NAME: Dawn Mahecha LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200a Monterey Park, CA Facility Name: James Penny House INC.FACILITY NUMBER: VISIT DATE: 04/13/2022

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

met_with: Raeanna Howard, Unit Coordinator


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Narrative:
CONTINUED FROM PAGE The Department received a complaint alleging staff at the facility pulled a client by her hair, touched her chest underneath her clothing, pulled her pants down and threatened to lock her in a closet. Staff denied the allegations. Staff reported Ref. #1 (See Confidential Names List LIC811 dated 10/11/22) informed them she did not want to be placed at the facility and staff believe the allegations were made in order to move her to another facility. Statements obtained from interviews conducted with social workers revealed, while Ref #1 was in placement, she was not informed of the alleged incidents reported to the Department. Statements obtained from confidential interviews conducted were unable to corroborate the allegations. There were no witnesses to the alleged incidents. Based on information gathered from interviews conducted and record review, the allegations are unsubstantiated. Although the allegations may have happened or are valid the standard of the preponderance of evidence was not met. A copy of this report and Confidential Names Form LIC811 dated 10/11/22 were given to the above-mentioned facility representative. Exit interview conducted. No deficiencies were cited.

Investigation Findings:
13An unannounced follow up complaint inspection was conducted by Licensing Program Analyst (LPA) Christopher Larios on 10/11/22 at 2: PM. During the inspection LPA Larios met with Facility Manager Danielle Bell. The purpose of the inspection was to deliver findings for the above-mentioned complaint allegations. The investigation was conducted by Community Care Licensing Division (CCLD) Investigations Branch (IB) State Investigator Ruben Munoz and LPA Larios. During the course of the investigation Investigator Munoz conducted interviews with a facility staff on 07/05/22, a County Social Worker (CSW) and one client on 07/06/22 and a placing agency investigator on 07/12/22. LPA Larios conducted interviews with five clients on 07/12/22 and three facility staff on 10/07/22. LPA Larios conducted a record review and obtained copies of client daily logs, special incident reports, client roster and staff roster/contact list on 07/12/22. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Christopher Larios LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200a Monterey Park, CA Facility Name: James Penny House INC.FACILITY NUMBER: VISIT DATE: 10/11/2022

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

met_with: Danielle Bell