summary: Facility Evaluation

raw_content:
Narrative:
On January 15, 2026, at 9:05 am, Licensing Program Analyst (LPA) Gilbert Marquez arrived unannounced at the facility to conduct a post-licensing inspection of the facility. The facility was inspected inside and out with Marie Noel, Facility Administrator. The home is a single-story residence with a swimming pool in the backyard. There are no cameras located inside or outside of the facility. A physical plant inspection was completed and included the following checks: one living room, one family room, two restrooms, one dining room, one kitchen and three bedrooms. The garage is located next to the kitchen and leads to the driveway. Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. The living room is furnished with one couch, one love seat, and one chair with enough seating for four people. The living rooms has board games and arts and crafts activities available for the client's use. The family room is equipped with two desks, two computers and locked file cabinet and two telephones that were tested and were observed to be in working order. The kitchen is equipped with operable appliances, kitchen utensils, pot, pans and dishes. The facility had a two day supply of perishable food and a seven day supply of non-perishable food. The hot water in the kitchen was measured at 115.3 degrees Fahrenheit, which is within regulatory requirements. The kitchen's appliances were tested and were observed to be in working order. The facility's smoke detectors were tested and observed to be in working order. There are six smoke detectors, one in the dining room, one in the hallway, and one in each individual bedroom. There are two carbon monoxide detectors that are located in the hallway and in the dining room. The carbon monoxide detectors were tested and observed to be in working order. Fire extinguishers are properly charged and ***CONTINUED ON LIC809C*** **Continued from LIC809** serviced. There are a total of four fire extinguishers located in the laundry room, garage, under the kitchen sink, and in the hallway. The facility has a fully equipped first aid kit and first aid manual stored on top of the file cabinet in the family room. There are no guns or weapons in the facility as stated by the Administrator. Medications are locked and centrally stored in a medication cabinet in the family room. Disinfectants and cleaning solutions were stored locked in a locked cabinet in the garage. Sharp knives were made inaccessible and stored in a locked drawer in the kitchen. The staff and client files are maintained in a locked file cabinet in the family room. The following required posted items were observed accessible to clients: Fire Clearance, Grievance Procedures, Personal Rights, Visitation policies, Emergency Disaster Plan and current menu. The bedrooms are set up as follows: Bedroom #1 will be occupied by one resident; has one twin bed, all required linen, mattress is in good condition; Bedroom #2 will be occupied by one resident; has one twin bed, all required linen, mattress is in good condition; Bedroom #3 has one resident C2; has one twin bed, all required linen, mattress is in good condition, and there was one dresser and one TV; Bedroom #4 is occupied by one resident; has one twin bed, all required linen, mattress is in good condition, one dresser, and one tv, and personal desktop computer. Bedrooms are arranged so that no more than one client is in a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. The bathrooms were clean and in good repair. All bedrooms have a wall air-conditioning unit installed and in working condition. The facility outside grounds were also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. There is an in-ground swimming pool located in the backyard of the facility which is made inaccessible with a fence and two pool gates that swing away from the pool, self-close and have a self-latching device located no more than six inches from the top of the gate. The fence is constructed so that the fence does not obscure the pool from view. **Continued on LIC809C page 2** **Continued from LIC809C** LPA reviewed two of two client files. Two out of two client files did not contain the medical authorization form and admission agreement in the facility current name. LPA did not find an activities calendar posted in the dining room that was current, and both clients did not have a educational activities plan. Interviews revealed that staff support the clients to go to school, but that there is no official facility plan that described how the staff support clients with educational activities after school. Due to time restraints LPA was unable to review staff files. LPA will return at a later unannounced date to complete the inspection. Based on the facility inspection review, the facility is being given a technical violation for California Code of Regulations (CCR), Title 22, Chapter 5, Section 84079(a), due to not having activity calendar posted, and CCR, Title 22, Chapter 5, Section 84079(a)(4) for not having a written plan to support educational activities. Finally, a technical violation for CCR Title 22, Chapter 5, Section 84068.1(b)(4)(A) for clients not having an admission agreement under the new facility name. An exit interview was conducted, and a copy of this report with the appeals rights was given to Facility Administrator Marie Noel.

met_with: Marie Noel, Administrator


state: CA

facility_name: ARROW HOUSE, THE

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
educational qualifications for the therapist position. Confidential interviews reported S2 was the therapist for C2. Conflicting statements reported S2 was listed as the mentor/coach for C2 while waiting for another therapist to start working at the facility. Due to C2 not being able to verify in what capacity S2 was working with C2, it is unknown if S2 was working as a therapist or a mentor. Confidential interviews and records reviewed did not provide a preponderance of evidence to prove or disprove the allegation that unqualified staff is performing therapy for the minors while in care. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and appeal rights were reviewed with Brittany Schoeneck. Due to printer malfunction, a copy of this report, along with the LIC 811, and appeal rights will be emailed to the Facility Administrator. A signed copy of this report will be kept in the Facility file.

Investigation Findings:
13On April 18, 2023, at 11:35 am , Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Brittany Schoeneck, Program Director of The Arrow House, to discuss the investigative finding for the allegation noted above. LPA Charmaine Linley conducted an inspection of the facility on 02/13/2023 at 10:59 am and no deficiencies were observed. LPA Linley interviewed two staff (S1, S2) and was unable to interview one client (C2) despite multiple attempts to contact them. LPA reviewed the following documents during the investigation: (C2) Master Treatment Plan, (C2) Biopsychosocial assessment, and group therapy notes. On 02/07/2023, Community Care Licensing received an allegation that unqualified staff are performing therapy for the minors while in care. It was reported that S2 and S4 were performing individual therapy sessions with the residents. Based on confidential records, S4 has a CADAC degree and meets the qualifications. Based on records reviewed, S2 was listed as the therapist for C2 and does not have the UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: ARROW HOUSE, THEFACILITY NUMBER: VISIT DATE: 04/18/2023

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

report_type: Complaint Investigation

met_with: Brittany Schoeneck, Program Director

complaint_status: unsubstantiated


raw_content:
Narrative:
have private phone calls, staff open minors mail, staff are administering medications without a physician's order, staff take away family visits as punishment, unqualified staff working with minors, due to staff stealing medications, minors are missing medication, and staff do not seek timely medical care for minors. Confidential interviews revealed conflicting statements. Due to not having specific dates and details regarding the allegations, confidential interviews and records reviewed did not corroborate the allegations with a preponderance of evidence. Based on confidential interviews and records reviewed the allegations that staff do not allow minors to have private phone calls, staff open minors mail, staff are administering medications without a physician's order, staff take away family visits as punishment, unqualified staff working with minors, due to staff stealing medications, minors are missing medication, and staff do not seek timely medical care for minors, which may have occurred, however, they not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Ehsan Ebrahim. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights was emailed to the Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On July 17, 2024, at 1:55 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Ehsan Ebrahim, Program Director, to discuss the investigative finding for the allegations noted above. LPA conducted an inspection of the facility on May 7, 2024, and no deficiencies were observed. LPA Linley interviewed three clients (C2, C4, C5), nine staff (S1-9), two clients declined to interview (C1, C3), and LPA attempted to interview three staff (S10-12), however, LPA was unable to contact them despite multiple attempts to contact them. The following documents were reviewed during the investigation: Personnel Roster, Client Roster, Admission Agreements, Medication Logs, Centrally Stored Medication Records, Physician Reports, Nursing Notes, Master Treatment Plans, Needs and Services Plans, Degrees/Licenses, Timesheets, and employee schedules. On May 3, 2024, Community Care Licensing (CCL) received allegations that staff do not allow minors to UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: ARROW HOUSE, THEFACILITY NUMBER: VISIT DATE: 07/17/2024

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

met_with: Ehsan Ebrahim


summary: Facility Evaluation

raw_content:
Narrative:
On April 21, 2022 at 2:00pm, Licensing Program Analyst (LPA) Charmaine Linley and Licensing Program Manager (LPM) Ann Valenzuela arrived at the facility to conduct a pre-licensing inspection of the facility. The facility was inspected inside and out with Administrator John Lieberman, and Operations Director, Emily Cohen. The home is a single-story residence with a front house and back house/main house, separated by the garage and driveway. There are cameras in the common areas and outside areas. The cameras are video only, no audio. This home provides awake night staff. The facility will be operating with the capacity of 20. The front house consists of one living room, three offices, two storage rooms, one restroom, one kitchen, and one dining area. The garage is located next to the storage area and leads to the driveway and the back house/main house. The front house will mainly be used for offices and for the intake area for clients. The back house/main house has a school room, recreation room, kitchen, dining room, staff room, two offices, medication room/Nurse's station, group room, laundry room, pantry, supply closet, four bathrooms, and ten -bedrooms. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. Living room, dining room, group home, recreation room, and school room are for clients to use. There is adequate indoor and outdoor activity space. Medication and the first aid kit will be kept locked in the medication room/Nurses' station, located in the "Main House." Medication room has a locking door, locking window, and a locking medication cabinet. The facility also has a refrigerator that locks to store medications that require refrigeration. *** The facility's smoke detectors and carbon monoxide detectors were tested and observed to be in working order. Fire extinguishers are properly charged and services. The facility has a fully equipped first aid kit and first aid manual. There are no guns or weapons in the facility as stated by Administrator. Disinfectants and cleaning solutions were stored locked in a supply room next to the laundry room. Sharp knives were made inaccessible and stored in a locked cabinet in the supply closet. The staff and client files will be maintained electronically stored. LPM advised Administrator that staff and client files are to be accessible to Community Care Licensing (CCL) at any time. The following required posted items were observed accessible to clients: Facility License, Grievance Procedures, Personal Rights, Visitation policies, Emergency Disaster Plan and current menu. The bedrooms are set up as follows: Bedroom #1 will be occupied by two residents; two twin beds, all required linen, mattresses in good condition. Bedroom #2 will be occupied by two residents; two twin beds, all required linen, mattresses in good condition. Bedroom #3 will be occupied by two residents; two twin beds, all required linen, mattresses in good condition. Bedroom #4 will be occupied by two residents, as needed; two twin beds,, all required linen, mattresses in good condition. Bedroom #5 will be occupied by two residents, as needed; two twin beds,, all required linen, mattresses in good condition. Bedroom #6 will be occupied by two residents, as needed; two twin beds,, all required linen, mattresses in good condition. Bedroom #7 will be occupied by two residents, as needed; two twin beds,, all required linen, mattresses in good condition. Bedroom #8 will be occupied by two residents, as needed; two twin beds,, all required linen, mattresses in good condition. Cont. on 809-C Bedroom #9 will be occupied by two residents, as needed; two twin beds,, all required linen, mattresses in good condition. Bedroom #10 will be occupied by two residents, as needed; two twin beds,, all required linen, mattresses in good condition. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. The bathrooms were clean and in good repair. The hot water in one of the client bathrooms was measured at 118 degrees, which is within regulatory requirements. The fire clearance has been approved. Based on the facility pre-licensing inspection review, no deficiencies were noted at the time of inspection. Upon Licensing Program Manager's final review, the license will be provided. An exit interview was conducted, due to printer failure. LPA emailed the Administrator and COO, John Lieberman, the LIC 9099's.

report_type: Facility Evaluation

visit_type: Prelicensing

met_with: John Lieberman, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On July 20, 2022, at 9:30 am, Licensing Program Analyst (LPA) Charmaine Linley arrived at the facility to conduct a Comprehensive Annual Post-Licensing Inspection visit. LPA and Facility Administrator Ehsan Ebrahim, and Operations Manager, Westley Cruz, inspected the facility inside and outside. The facility was licensed as a group home on April 22, 2022. The facility is a single-story residence with a front house and a back house/main house, separated by the garage and driveway. There is at least one week's supply of nonperishable, and two days' supply of perishable foods. There is a variety of snacks available for the clients. There are cameras in the common areas and outside areas. The cameras are video only, with no audio. This home provides awake night staff. The facility has a capacity of 20. The group home serves clients between the ages of 12-17 years old, both female and male. There were four clients at the facility during LPA's visit. The front house consists of one living room, three offices, two storage rooms, one restroom, one kitchen, and one dining area. The garage is located next to the storage area and leads to the driveway and the back house/main house. The front house will mainly be used for offices and the intake area for clients. The back house/main house has a school room, recreation room, kitchen, dining room, staff room, two offices, medication room/Nurse's station, group room, laundry room, pantry, supply closet, four bathrooms, and ten bedrooms. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris and observable hazards. The living room, dining room, group home, recreation room, and school room are for clients to use. There is adequate indoor and outdoor activity space. Medication and the first aid kit is kept locked in the medication room/Nurses' station, located in the "Main House." The *** medication room has a locking door, a locking window, and a locking medication cabinet. The facility also has a refrigerator that locks to store medications that require refrigeration. The facility has a fully equipped first aid kit and first aid manual. The facility's smoke detectors and carbon monoxide detectors were tested and observed to be in working order. Fire extinguishers are properly charged and services. There are no guns or weapons in the facility as stated by the Administrator. Disinfectants and cleaning solutions were stored locked in a supply room next to the laundry room. Sharp knives were made inaccessible and stored in a locked cabinet in the kitchen. The staff and client files are maintained and electronically stored. LPM advised the Administrator that staff and client files are to be accessible to Community Care Licensing (CCL) at any time. The following required posted items were observed accessible to clients: Facility License, Grievance Procedures, Personal Rights, Visitation policies, Emergency Disaster Plan, and current menu. All hazardous items have been properly made inaccessible. There are a total of ten bedrooms in the facility and two clients are assigned to each bedroom. There is one client per bed. All bedrooms in the units had adequate beds, lighting, shelf, dressers, and closet space for clients' belongings. There are sufficient linens, blankets, towels, and pillows. The bathrooms were clean and in good repair. The kitchen's water temperature was inspected and measured 125 degrees. Bathroom one's water temperature was inspected and measured 125 degrees. Bathroom two's water temperature was inspected and measured 110 degrees. LPA partially reviewed four out of four client files (C1-C4) (see confidential names list, LIC 811, dated 07/20/2022). Due to time constraints, LPA will return at a later date to review the remaining client files, staff files, and conduct interviews with clients and staff. An exit interview was conducted, and a copy of this report was discussed with Ehsan Ebrahim, Facility Administrator. Due to printer malfunction, LPA emailed the LIC 809, LIC 811, to John Lieberman. A copy of the report will be placed in the facility file.

visit_type: Annual

met_with: Ehsan Ebrahim, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On July 21, 2022, at 11: AM, Licensing Program Analyst (LPA) Charmaine Linley arrived at the facility to continue a Comprehensive Annual Post-Licensing Inspection visit that began on 07/20/2022. LPA met with John Lieberman, Facility Administrator. During the inspection, LPA reviewed staff files and client files. All the staff files are stored and secured electronically at the corporate office. LPA reviewed ten out of twenty staff files (see confidential name list, LIC811, dated 07/21/2022) via Zoom with Human Resources Director, Jennifer Richardson from 9:00 am-10:15 am. All staff that works at the facility have Department of Justice, FBI, and Child Abuse Index Clearances. LPA reviewed staff training records. During the inspection, LPA interviewed three out of five staff. LPA reviewed four out of five client files (C1-C4) (see confidential names list, LIC 811, dated 07/20/2022). LPA was unable to conduct interviews, due to clients attending group sessions. The client files are maintained in a locked cabinet in the medication room. LPA completed the component III Orientation and discussed Incident reporting, including incidents related to Assembly Bill 388 law enforcement contacts as well as incidents involving emergency interventions. The facility was informed that the address to this facility is available to the public. All special incident reports (SIRs) will be sent via e-mail to: cclpaccr@dss.ca.gov. The reporting requirements were reviewed with the Facility Administrator on this date. Please complete the LIC 500 and send it to LPA Linley within 30 days. Based on the facility's post-licensing inspection review, two deficiencies were issued for CCR 84070(b)(13) and CCR 80075(k)(7)(B) An exit interview was conducted, and a copy of this report and appeals were discussed with John Lieberman, Facility Administrator. Due to printer malfunction, LPA will email a copy of the the LIC 809, LIC 809D, LIC 811, and appeals form, to John Lieberman, Facility Administrator. A copy of the report will be placed in the facility file.

met_with: John Lieberman, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On April 11, 2024, at 9:45 am Licensing Program Analyst (LPA) Charmaine Linley arrived at the facility to conduct a Comprehensive Annual Inspection visit. LPA and Ehsan Ebrahim, Facility Administrator, inspected the facility inside and outside. The facility was licensed as a group home on April 22, 2022. The facility is a single-story residence with a front house and a back house/main house, separated by the garage and driveway. There is at least one week's supply of nonperishable, and two days' supply of perishable foods. There is a variety of snacks available for the clients. There are cameras in the common areas and outside areas. The cameras are video only, with no audio. This home provides awake night staff. The facility has a capacity of 20. The group home serves clients between the ages of 12-17 years old, both female and male. There were five clients at the facility during LPA's visit. The front house consists of one living room, three offices, two storage rooms, one restroom, one kitchen, and one dining area. The garage is located next to the storage area and leads to the driveway and the back house/main house. The front house is mainly used for offices and the intake area for clients. The back house/main house has a school room, recreation room, kitchen, dining room, staff room, two offices, medication room/Nurse's station, group room, laundry room, pantry, supply closet, four bathrooms, and ten bedrooms. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris and observable hazards. The living room, dining room, group room, recreation room, and school room are for clients to use. There is adequate indoor and outdoor activity space. Medication and the *** first aid kit is kept locked in the medication room/Nurses' station, located in the "Main House." The medication room has a locking door, a locking window, and a locking medication cabinet. The facility also has a refrigerator that locks to store medications that require refrigeration. The facility has a fully equipped first aid kit and first aid manual. The facility's smoke detectors and carbon monoxide detectors were tested and observed to be in working order. Fire extinguishers are properly charged and serviced. There are no guns or weapons in the facility as stated by the Administrator. Disinfectants and cleaning solutions were stored locked in a supply room next to the laundry room. Sharp knives were made inaccessible and stored in a locked cabinet in the supply closet. The staff and client files are maintained and electronically stored, as well physical files. The following required posted items were observed accessible to clients: Facility License, Grievance Procedures, Personal Rights, Visitation policies, Emergency Disaster Plan, and current menu. All hazardous items have been properly made inaccessible. There are a total of ten bedrooms in the facility and two clients are assigned to each bedroom. There is one client per bed. All bedrooms in the units had adequate beds, lighting, shelves, dressers, and closet space for clients' belongings. There are sufficient linens, blankets, towels, and pillows. The bathrooms were clean and in good repair. The kitchen's water temperature was inspected and measured 105 degrees. Bathroom one's water temperature was inspected and measured 108 degrees. Bathroom two's water temperature was inspected and measured 106 degrees. LPA reviewed five out of five client files (C1-C5) (see confidential names list, LIC 811, dated 04/11/2024). LPA conducted three out of five interviews (C1-C3). The client files are maintained in a locked office. LPA reviewed five out of five staff files (S1-5) (see confidential names list, LIC 811, dated 04/11/2024). LPA interviewed two staff. All staff that work at the facility have Department of Justice, Federal Bureau of Investigation and Child Abuse Index Check clearances. A review of administrative records indicates that the facility has paid their current licensing fees. No deficiencies were cited during today's visit. An exit interview was conducted, and a copy of this report was discussed with Ehsan Ebrahim. Due to printer malfunction, LPA emailed the LIC 809, LIC 811, and appeal rights to Ehsan Ebrahim. A copy of the report will be placed in the facility file.


summary: Facility Evaluation

raw_content:
Narrative:
On this date at 5:00 pm, Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced case management inspection to this facility. LPA Linley met with Ehsan Ebrahim, Program Director. LPA conducted a walk through of the facility and no deficiencies were observed. A case management has been opened regarding information reported to the Department. LPA interviewed one staff. Further information and interviews are required, therefore this case management is being extended. The outcome of the investigation will be provided to the Facility Administrator. The facility is reminded not to discuss the ongoing investigation with any interested parties. An exit interview was conducted and due to printer malfunction, a copy of this report will be emailed to the Facility Administrator.

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
On June 12, 2025, at 09: AM , Licensing Program Analyst (LPA) Stefanie Mutialu made an unannounced visit for the for the purpose of conducting an annual inspection of the facility. LPA met with Executive Director, Jackie Hoagland and Administrator, Ehsan Ebrahim . The Facility is licensed to serve twenty (20) ambulatory children ages 12-17 years old. The current census is nine (9) children. The facility is a one story ten-bedroom, four-bathroom home with a front house and a back house/main house, separated by the garage and driveway. A physical plant inspection was completed with Executive Director, Jackie Hoagland and included the following checks: The front house, one living room, three offices, two storage rooms, one restroom, one kitchen, and one dining area. The back house/main house, school room, recreation room, kitchen, pantry, dining room, staff room, two offices, medication room/nurse's station, group room, laundry room, pantry, supply closet, ten client bedrooms, three client bathrooms, one staff bathroom, kitchen, living room, dining room, Administrator office, outdoor garden, and laundry room. All required forms are posted including Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster, the Emergency Disaster ****Continued on Page 2**** Plan was also posted. Clients' medications were observed to be inaccessible and stored in the medication room. LPA observed eighteen (18) interior and nine (9) exterior cameras placed around the facility. No cameras are positioned in direct line of bedrooms, ,bathrooms, or any direction that would violate personal rights. Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. Fre extinguishers are properly charged and serviced on 05/18/2025. Fire inspection was completed on 01/14/2025 and LPA received a copy of the approved Fire Inspection to place in facility file. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. LPA observed a minimum seven-day non-perishable and two-day perishable supply of food. On staff chef prepares three meals a day tailored to each client. Individual beds were observed with clean linens, pillows, comforters, and mattress in good repair. All ten bedrooms contain two twin beds. The facility has three client bathrooms and five showers. The water temperature was tested in one bathroom and met the appropriate range of 105 degrees to 120 degrees Fahrenheit. LPA reviewed five client files to ensure client records had all required documents per Title 22 regulations. Client records are stored in a secured office. LPA reviewed nine client medication records. LPA conducted two staff interviews and two client interviews. No deficiencies cited. Per facility staff, no firearms or weapons are allowed in the facility. The licensing fee payments are current. An exit interview was conducted, and a copy of this report, confidential names (LIC811), and appeal rights were discussed and provided to Ehsan Ebrahim. A copy of this report will be placed in the facility file.

met_with: Administrator, Ehsan Ebrahim


summary: Facility Evaluation

raw_content:
Narrative:
On June 13, 2025, at 8: AM, Licensing Program Analyst (LPA), Stefanie Mutialu continued the unannounced annual inspection, which was started on June 06 ,2025. LPA met with Human Resource Director, Amanda Dicker via Zoom meeting. LPA reviewed five staff (S1-S5) files. Five out of five staff records reviewed have the verification of Department of Justice, Federal Bureau of Investigation, and Child Abuse Index Check clearances and were associated to the facility. Five out of five staff records reviewed have proof in file of acknowledging confidentiality and mandated child abuse reporting requirements. Staff files a kept on a secure online data base. No deficiencies cited. An exit interview was conducted, and a copy of this report, Confidential Names List (LIC811), and appeal rights were discussed and emailed to Human Resource Director, Amanda Dicker. A signed copy of this report will be placed in the facility file.

met_with: HR Director, Amanda Dicker


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On July 2, 2024, at 10:30 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with John Lieberman, Chief Executive Officer, to assess a Civil Penalty. LPA Linley conducted confidential interviews and a record review which indicted that there were two Adults (A1, A2) who did not have a criminal record clearance prior to working at the facility. LPA reviewed Guardian to ensure that the individuals had a criminal record clearance; review indicated that A1 was not listed on the roster and was not listed in Guardian, and A2's clearance was pending. LPA Linley asked for any supporting documents the facility may have and they were unable to provide it or what they provided was incomplete. LPA Linley is administering two civil penalties during this visit. Based on record review and staff interviews, the facility is being cited for the violation of California Code of Regulations, Title 22, Division Six, regulation 80019(e) Criminal Record Clearance. Record review confirms A1 and A2 have worked in the facility without a criminal record clearance. An immediate civil penalty is being issued for $1,000.00. A civil penalty shall be assessed for a maximum of 5 days for the first violation. For subsequent violations within 12 months, a civil penalty shall be assessed for a maximum of 30 days. An exit interview was conducted with John Lieberman. Due to printer malfunction, a copy of this report and appeal rights were emailed to John Lieberman. A copy of this report will be placed in the facility file.

Deficiencies:
80019(e): All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

met_with: John Lieberman

title:
1
2
3
4
5
6
7Criminal Record Clearance


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
This is an amended report to amend the 809-D page regarding regulations Title Division Chapter Article 6 84070(b)(16)(G) Children's Records, and Title Division Chapter Article 6 84070(b)(16)(F) Children's Records (refer to LIC 809D). On July 17, 2024, at 2:20 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Ehsan Ebrahim, Program Director, to discuss information that was reported to Community Care Licensing and records reviewed by LPA on June 27, 2024. LPA conducted confidential interviews with nine staff (S1-9), LPA also attempted to interview one staff (S10), and was unable to contact them despite multiple attempts. LPA also conducted a record review for three clients (C1-C3), which indicated that on June 4, 2024, S10 gave C C2's prescribed medication in error. The facility notified C1's Physician; however, the facility did not report the information and submit an Incident Report to Community Care Licensing until after LPA's visit on June 27, 2024. On June 27, 2024, while reviewing C1's Psychotropic Medication Administration Record or equivalent (PMAR), LPA observed C1's PMAR for May for medication #1 had an "R" (R = refers to a client refusal) recorded in the boxes for May 28, 29, and blank boxes for May 30, 31, and June 1-5. Records reviewed indicated that C1's Physician discontinued medication #1 on May 28. Additionally, LPA observed on C1's PMAR for June, C1's medication #2 did not have the times of the dosages listed. Confidential interviews and records reviewed, indicated that there was a change in the Chief Executive Officer, and the facility did not notify Community Care licensing within 10 working days. Lastly, records reviewed indicated that C3 turned 18 years old and remained at the facility for four days after turning 18. The facility is licensed for children between the ages of 12-17 and the facility did not request an exception from Community Care Licensing for C3 to remain at the facility beyond the age of 18. *** Based on confidential interviews and records reviewed, the facility is being cited for violating California Code of Regulations Title 22, Division 6, Chapter 1 Reporting Requirements, Title 22, Division 6, Chapter 5, Article 6 Children's Records, and Title Division Chapter Article 2 80010(a) Limitations on Capacity and Ambulatory Status, Title Division Chapter Article 6 84070(b)(16)(G) Children's Records, and Title Division Chapter Article 6 84070(b)(16)(F) Children's Records (refer to LIC 809D). An exit interview was conducted and a copy of this report and appeal rights were reviewed with Ehsan Ebrahim. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights were emailed to Ehsan Ebrahim. A copy of this report will be placed in the facility file.

Deficiencies:
80010(a): A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation.

title:
1
2
3
4
5
6
780010(a) Limitations on Capacity and Ambulatory Status


facility_name: ASCEND BEHAVIORAL HEALTH

summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13On March 8, 2023, Licensing Program Analyst (LPA) Wayne Aoki was met by Program Manager, Aaron Vargas for the purpose of closing the investigation and providing the agency with the findings for the above-mentioned allegation. Based on confidential interviews and other documents obtained during the investigation, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. The agency is being cited in Group Home, Title 22, Division 6, Chapter 5, Article Continuing Requirements, Section 84072 (d)(10) Personal Rights. An exit interview was conducted, and a copy of the report and appeal rights were provided to the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Wayne Aoki LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SIERRA CASCADE AC/SC, E SHAW AVE FACILITY NAME: ASCEND BEHAVIORAL HEALTHFACILITY NUMBER: 107207217

met_with: Aaron Vargas

complaint_status: SUBSTANTIATED


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13On June 22, 2023, Licensing Program Analyst (LPA) Wayne Aoki was met by Program Manager, Aaron Vargas for the purpose of closing the investigation and providing the agency with the findings for the above-mentioned allegations. Based on confidential interviews and other documents obtained during the investigation, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. The agency is being cited in Group Home, Title 22, Division 6, Chapter 5, Article Continuing Requirements, Section 84072 (d)(10) Personal Rights and Chapter 1, Article 6. Continuing Requirements, section 80075(b)(5)(B) Health Related Services An exit interview was conducted, and a copy of the report and appeal rights were provided to the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Wayne Aoki LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SIERRA CASCADE AC/SC, E SHAW AVE FACILITY NAME: ASCEND BEHAVIORAL HEALTHFACILITY NUMBER: 107207217


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Daiquiri Boyd conducted a follow up complaint inspection at the Short Term Residential Therapeutic Program (STRTP) and met with Aaron Vargas . The purpose of the inspection was to deliver the findings for the above complaint allegation. During the course of the investigation, LPA conducted interviews and reviewed documentation. Based on confidential interviews and documentation the allegation is SUBSTANTIATED. Citation was issued for lack of supervision. A copy of this report was left at the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Daiquiri Boyd LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FRESNO RO, E SHAW AVE FACILITY NAME: ASCEND BEHAVIORAL HEALTHFACILITY NUMBER: 107207217


summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Daiquiri Boyd conducted an unannounced visit to the Short Term Residential Therapeutic Program (STRTP) to deliver the findings of the above allegations and met with Program Manager, Aaron Vargas. The above allegations were referred to Community Care Licensing for investigation. The investigation included interviews and a review of facility and client records. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegations occurred. Therefore, the allegations are UNSUBSTANTIATED at this time. A copy of this report was discussed and provided along with appeal rights. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Daiquiri Boyd LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


raw_content:
Investigation Findings:
13On August 29, Licensing Program Analysts (LPA) Angelica Borja conducted a complaint inspection at Ascend Behavioral Health and met with Aaron Vargas. The purpose of the inspection was to deliver the findings for the above complaint allegation. During the investigation, LPA conducted interviews, a records review and reviewed supporting documents provided by the facility. Based on confidential interviews and other information obtained, the department has made the following determination. Although the allegation may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Melikian LICENSING EVALUATOR NAME: Angelica Borja 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: Aaron Vargas, Program Manager


raw_content:
Investigation Findings:
13On May 13, Licensing Program Analyst (LPA) Angelica Borja conducted a complaint inspection at Ascend Behavioral Health and met with Aaron Vargas. The purpose of the inspection was to deliver the findings for the above complaint allegation. During the investigation, LPA conducted interviews, a records review and reviewed supporting documents provided by the facility. Based on confidential interviews and other information obtained, the department has made the following determination. Although the allegation may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Melikian LICENSING EVALUATOR NAME: Angelica Borja 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: Program Manager, Aaron Vargas


summary: Facility Evaluation

raw_content:
Narrative:
On the above date a scheduled component II orientation was held virtually via the Microsoft teams platform. Present for the Department was Lisa Slusher, Licensing Program Analyst. Representing the Applicant were: Jason Christopherson, Alicia Alva, Devon Wayt, Jazmin Galvan and Christina Kiesselbach. Discussed review letter dated 7/1/22 and outstanding program items as well as status of the organization. LPA also discussed licensing environment and expectations. LPA stated that component III and pre-licensing inspection would be scheduled following program approval.

met_with: Matthew Tatum, Alicia Alva


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA) Lisa Slusher travelled to the facility listed above to conduct a pre-licensing inspection. The applicant submitted an application on 2/4/2022. The Program Statement has been reviewed and approved as meeting regulatory requirements. LPA met with Jason Christopherson, Brittany Farrell, Alicia Alva, Devon Wayt, Jazmin Galvan and Christina Kiesselbach 1. Facility grounds inspected. Grounds are clean and free from observable hazard. No bodies of water observed on the property. 2. Adequate indoor activity space and materials observed, and outdoor activity space was observed. 3. Chemicals were appropriately locked 4. Procedures for Locked and centrally stored medications observed. 6. Adequate storage space observed. 7. Individual beds in good repair observed. A supply of extra linens available for bed changes. 8. The house has 4 bedrooms, a mixture of single double occupancy, located on two levels. Bedrooms are accommodating of all required furnishings. 9. Adequate food storage space observed. Facility will add appropriate supply of foods upon placement of youth in the home. A supply of nonperishable foods were observed on this date. 10. Sample menu posted. 11. All appropriate forms posted within client view. 12. Dining room equipped with large table and chairs accommodating of all clients. 13.Facility has three full restrooms, two for client use, one for staff use, all are operable. Hot water measured within 105-120 on this date. Applicant does not have personnel associated through Guardian. Prior to initial license approval, the licensee (corporation owner) and Administrator must be fingerprint cleared and associated to the facility. Prior to accepting clients for care, the facility shall ensure that all personnel who will have client contact are cleared and associated. Discussed Guardian process with the facility. Discussed with the facility the process for changing the facility Administrator. The following documents are required: 1. LIC 308 (Designation of Facility Responsibility) designating new administrator. 2. Current Personnel Record for new Administrator. 3. Verification of Education and/or experience for new administrator. 4. Copy of current administrator certificate. 5. Current (within one year) health screening and TB test. 6. Board Resolution granting administrative responsibility to the new administrator. 7. Fingerprint association transfer request (if the Administrator is not already associated to the facility) 8. Exception request (if the Administrator does not specifically meet regulatory requirements, i.e. experience is in a facility with a capacity of six or fewer). Discussed Incident reporting. An initial report for all reportable incidents is to be made by the next working day to CCLFresnoIncidents@dss.ca.gov. A full report is to be remitted within 7 days and may also be made to the incident reporting email. The currently assigned analyst for the facility will be Wayne Aoki. Wayne.Aoki@dss.ca.gov or at (559) 978-9486. On this date, the facility will be approved for initial licensure, pending verification of guardian clearance and association for the Licensee and Administrator. Initial license will be issued on a provisional basis, expiring one year from effective date. License will be valid for up to 6 male and/or female youth ages 12 through 17.

met_with: Alicia Alva, Jason Christopherson


summary: Facility Evaluation

raw_content:
Narrative:
On March 8, 2023, Licensing Program Analyst (LPA) Wayne Aoki traveled to the Ascend Behavioral Health and met with Program Director, Aaron Vargas. The purpose of the inspection is to conduct a post-licensing inspection. LPA conducted a physical plant inspection and included the following observations: 1. Facility grounds inspected. Grounds are clean and free from observable hazard. No bodies of water observed on the property. 2. Adequate indoor activity space and materials observed, and outdoor activity space was observed. 3. Chemicals were appropriately locked 4. Procedures for Locked and centrally stored medications observed. 6. Adequate storage space observed. 7. Individual beds in good repair observed. A supply of extra linens available for bed changes. 8. The house has 4 bedrooms, a mixture of single double occupancy, located on two levels. Bedrooms are accommodating of all required furnishings. 9. Adequate food storage space observed. Facility will add appropriate supply of foods upon placement of youth in the home. A supply of nonperishable foods were observed on this date. 10. Sample menu posted. 11. All appropriate forms posted within client view. 12. Dining room equipped with large table and chairs accommodating of all clients. 13. Facility has three full restrooms, two for client use, one for staff use, all are operable. Hot water measured within 110 degrees on this date. Client and staff files are kept in locked filing cabinets. They facility employs: An Administrator, Program Manager, Clinical Supervisor, Clinicians, LVN, Medical Assistants, Mentors and a Case Manager LPA reviewed minors and staff files. LPA reviewed the CARE Tools with Mr. Vargas to ensure that they are prepared for Annual Inspections. No deficiencies were noted on this date. An exit interview was conducted, and a copy of this report was provided to Aaron Vargas at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On June 28, 2023, Licensing Program Analyst (LPA) Wayne Aoki travelled to Ascend Behavioral Health to conduct a Case Management Inspection regarding an Incident Report. LPA was met by Nikki Hill, Compliance Officer. LPA informed Ms. Hill that on the incident report it stated that the incident occurred on June 6, 2023 and Community Care Licensing received the incident report on June 19, 2023 which is past the 7 day reporting period. LPA also informed Ms. Hill that in the body of the incident report it stated that the incident occurred on June 12, 2023 which meets the regulatory standard for reporting an incident to the licensing agency. Ms. Hill explained that on the first page of the LIC 624 they provided the wrong date under the section of, "Date Occurred" and that the correct date should have been entered was June 12, 2023. Ms, Hill will correct the error and submit the amended LIC 624 to this LPA on June 28, 2023. There were no deficiencies cited during this inspection.

met_with: Nikki Hill


summary: Facility Evaluation

raw_content:
Narrative:
On June 30, 2023, Licensing Program Analyst (LPA) Wayne Aoki travelled to Ascend Behavioral Health to conduct a Case Management inspection to amend a civil penalty that was cited on June 22, 2023. LPA was met by facility representative Natasha Qualls. LPA amended the civil penalty to reflect the correct amount for the repeat violation and provided facility with LIC 421FC There were no deficiencies cited during this inspection.

met_with: Natasha Qualls


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by LPA (Licensing Program Analyst) Reyna Martinez. LPA met with Alicia Alva, VP Operations and inspected the facility, inside and out. Centrally stored medications are maintained in a locked closet in a locked cabinet. Sharps and Toxic chemicals are kept locked. The facility has a written emergency disaster plan. All facility smoke detectors were tested and appear to be in appropriate working order, fire extinguisher is properly charged and was last serviced October 2023. Individual beds were observed with appropriate clean linens and are in good repair. There is at least one-week supply of nonperishable and a two-day supply of perishable foods. The facility is maintained at 70 degrees. Hot water temperature measures 117.9 degrees. Facility has cameras outside of the facility only. No firearms or weapons are allowed in the facility. No pools. Staff files were reviewed and meet all regulatory requirements. Additional follow up required for annual inspection to complete client records, staff and client interviews. No Deficiencies were cited on today's visit. A copy of this report was left at the facility.

met_with: Alicia Alva


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection continuation was conducted by LPA (Licensing Program Analyst) Reyna Martinez. LPA met with Aaron Vargas, Program Manager. Appropriate staff/client ratios were verified during this inspection. The facility employs 1 program manager, 1 clinical supervisor, 2 clinicians, 1 case manager, LVN's, and 5 support staff. 5 records of clients were reviewed. Client files did not meet all regulatory requirements. Upon further review staff files did not meet (1) regulatory requirement. Facility did not have Disaster Preparedness Binder readily available with required documentation. Facility Residential Treatment Program Rules not consistent with Facility Program Statement. 2 staff were available to be interviewed. 2 clients available to be interviewed. Deficiencies were cited on today's visit. Technical Violation's and Technical Advisory were being issued on today's visit. A copy of this report was left at the facility, along with appeal rights.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA) Reyna Martinez and Licensing Program Manager (LPM) Lourey Bartolome, conducted an office visit at Community Care Licensing Fresno Children's Residential Unit with Ascend Behavioral Health for an informational meeting to provide further clarification on regulatory language and CCR 84070(b)(13) with the Licensee. LPA and LPM met with Jason Christopherson, Clinical Director, Alicia Alva, VP Operations, and Aaron Vargas, Program Manager. Discussed was LIC-622B Psychotropic Medication Administration Record (MAR) and the Licensee's electronic medical record keeping system. Further discussion and details are needed. LPM will elevate this issue for further clarification. No Deficiencies were cited on today's visit. A copy of this report was provided to the Licensee.


summary: Facility Evaluation

raw_content:
Narrative:
On November 20, 2024, Licensing Program Analysts (LPAs) Angelica Borja and Briana Placencia conducted a Case Management inspection at Ascend Behavioral Health and met with Program Manager Aaron Vargas. The purpose of this inspection was to discuss concerns with an incident report that was sent into the Department on 11/12/2024, the incident in question happened on 11/05/2024. LPAs conducted an interview and informed PM about report writing. Program Manger stated that it was an isolated incident, and both clients have transitioned out of the facility. It was determined this was an isolated incident and there was no citation warranted. A copy of this report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On August 21, 2025, Licensing Program Analyst (LPA) Briana Placencia conducted a Case Management inspection at Ascend Behavioral Health and met with Aaron Vargas-Program Manager. The purpose of this inspection was to discuss concerns with an incident report that was sent into the Department on 08/19/2025, the incident in question happened on 08/17/2025. LPA conducted an interview and discussed medication refill procedures. It was determined this was an isolated incident and there was no citation warranted. A copy of this report was left at the facility.

met_with: Aaron Vargas-Program Manager


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On October 23, 2025 an unannounced Annual/Random inspection was conducted by Licensing Program Analysts (LPAs) Briana Placencia and Angelica Borja. LPAs met with Aaron Vargas, LPAs inspected the facility, inside and out. Centrally stored medications are maintained in a locked closet in a locked cabinet. Sharps and Toxic chemicals are kept locked. The facility has a written emergency disaster plan. All facility smoke detectors were tested and appear to be in appropriate working order, fire extinguishers are properly charged and were last serviced October 9,2025. Individual beds were observed with appropriate clean linens and are in good repair. There is at least one week supply of nonperishable and a two day supply of perishable foods. The facility is maintained at 69 degrees. Hot water temperature measures 106.8 degrees. Facility has cameras outside of the facility only. Per Program Director there are no firearms or weapons at the facility. The facility does not have a pool. LPAs reviewed 5 staff files and 4 client files. LPAs interviewed two staff and one client. The facility is being cited a Type A violation (CCR 80019(e)) and a Type B violation (CCR 84070(b)(17)) at today's visit, along with a civil penalty for caregiver background check. A copy of this report and appeal rights is being left at the facility with Aaron Vargas.

Deficiencies:
80019(e): Criminal Record Clearance

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


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Corina Carrillo conducted a case management inspection November 4, 2025 at 10:05AM, based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 6 out of Direct Care Staff and 6 out of 6 youth files were reviewed. 3 out of Direct Care Staff and 1 out of 6 youth were interviewed. (See the Confidential Names List, LIC 811, November 4, 2025). The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, youth case plans, quarterly assessments, and crisis intervention plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Carrillo observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Program Director Aaron Vargas.


summary: Facility Evaluation

raw_content:
Narrative:
On October 1, 2025, Licensing Program Analyst (LPA) Briana Placencia conducted a Case Management inspection at Ascend Behavioral Health and met with Aaron Vargas- Program Manager. The purpose of this inspection was to discuss concerns with an incident report that was sent into the Department on 09/18/2025, the incident in question happened on 09/12/2025. LPA conducted an interview and discussed medication administration procedures. The Department determined this to be an immediate risk to health and safety at this time, therefore the Group Home is being cited on the attached LIC809-D under CCR, Health Related Services 80075(b). A copy of this report and appeal rights was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On December 3, 2025, Licensing Program Analyst (LPA) Briana Placencia conducted a Case Management inspection at Ascend Behavioral Health and met with Ciara Armstead-Program Manager. The purpose of this inspection was to discuss concerns with an incident report that was sent into the Department on 12/01/2025, the incident in question happened on 11/21/2025. LPA conducted an interview and discussed medication administration procedures. The Department determined this to be an immediate risk to health and safety at this time, therefore the Group Home is being cited on the attached LIC809-D under CCR, Health Related Services 80075(b). A copy of this report and appeal rights was left at the facility.

met_with: Ciara Armstead-Program Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 4/8/24, Licensing Program Analyst (LPA) Daiquiri Boyd made an unannounced visit to the Group Home. During this visit, LPA met with Program Manager Aaron Vargas. LPA discussed an incident that LPA was made aware of during confidential interviews, in which one client was able to bring a needle and a pencil into the home to make a weapon. Clients at the facility state that staff do not search them properly and they can bring items into the facility. Clients at the facility state that staff does not properly supervise them, allowing them to hide potentially dangerous items from staff. On the following page, the facility is cited under the California Code of Regulations, General Licensing Requirements for a Type A violation for 80078(a) Responsibility for Providing Care and Supervision. A copy of this report was left at the facility


summary: Facility Evaluation

raw_content:
Narrative:
On March 12, 2026, Licensing Program Analyst (LPA) Angelica Borja conducted a Case Management inspection at Ascend Behavioral Health and met with Ciara Armstead-Program Manager. The purpose of this inspection was to discuss concerns with an incident report that was sent into the Department on 2/19/26, the incident in question happened on 2/15/26. LPA conducted an interview and discussed medication administration procedures. The Department determined this to be an immediate risk to health and safety at this time, therefore the Group Home is being cited on the attached LIC809-D under CCR, Health Related Services 80075(b). A civil penalty was also issued for a repeat violation. A copy of this report, appeal rights and civil assessment was left at the facility.

met_with: Program Manger, Ciara Armstead


summary: Facility Evaluation

raw_content:
Narrative:
On April 9, 2026, Licensing Program Analyst (LPA) Angelica Borja conducted a Case Management inspection at Ascend Behavioral Health and met with Ciara Armstead-Program Manager. The purpose of this inspection was to discuss concerns with an incident report that was sent into the Department on 4/6/26, the incident in question happened on 3/30/26. LPA conducted an interview and discussed medication administration procedures. The Department determined this to be an immediate risk to health and safety at this time, therefore the Group Home is being cited on the attached LIC809-D under CCR, Health Related Services 80075(b). A civil penalty was also issued for a repeat violation. A copy of this report, appeal rights and civil assessment was left at the facility.

met_with: Program Manager, Ciara Armstead


summary: Facility Evaluation

raw_content:
Narrative:
On October 6, 2025, Licensing Program Analysts (LPAs) Angelica Borja and Briana Placencia traveled to Ascend Behavioral Health located in Clovis CA. LPAs were met by Administrator Alicia Alva and Program Director Aaron Vargas, for the purpose of a scheduled pre-licensing inspection for the Group Home. A general overview of their program and a tour of the facility was provided. The facility is a single story residence with five bedrooms, the bedrooms have all required furnishings, the facility has three and a half restrooms, one bedroom serves as the therapy room and the master bedroom serves as the office. Facility is to ensure water temperature is maintained between 105 and 120 degrees or post warning signs as today the hot water read 145 degrees. LPAs observed fixtures and furniture, equipment and supplies necessary for this operation. LPAs observed locked cabinets for client and staff files in order to ensure confidentiality. The facility does have a pool on site that meets regulatory standards. The agency employs one administrator and program director. The facility is equipped with a first aid kit and a fire extinguisher. All required LIC forms and personal rights are posted in a common area. Items discussed were the hot water temperature and outside debris. The Group Home has requested to submit a waiver to associate all staff to one facility number. The licensee is being cited two Technical Advisories (TA), please see attached LIC 9102s. Upon completion of the two TA's the facility will be ready for licensure. A copy of this report was provided to the Licensee.

met_with: Alicia Alva, Administrator and Aaron Vargas, Program Director


summary: Facility Evaluation

raw_content:
Narrative:
On February 18, 2026, Licensing Program Analyst (LPA) Angelica Borja conducted a post-licensing inspection at Ascend Behavioral Health and met with Program Manager, Aaron Vargas. A inspection of the facility was conducted indoors and outdoors. The group home currently has two clients in care. The group home currently employs one Administrator, one Facility Manager, eight Direct Care staff, Program Director, Clinical VP, Clinical Lead, Clinicians/Therapists, one LVN, and two Case Managers/Counselors. LPA reviewed 5 staff files and two client files. LPA interviewed two staff and one client. LPA observed individual beds with appropriate clean linens and in good repair. Cleaning chemicals inaccessible to clients. The facility is maintained at 70 degrees. All facility smoke and carbon monoxide detectors appear to be in appropriate working order, fire extinguisher is properly charged and was last serviced in April 2025. The Group Home currently has no firearms and one swimming pool. Medications are centrally stored and locked. A review of the Licensing Information System on February 18, 2026, indicates that all facility staff are associated to the Group Home and have DOJ, FBI, and child abuse index check clearances. At this time the Group Home is in the process of accreditation. One Technical Advisory was cited during todays inspection A copy of this report and appeal rights was left at the facility at the conclusion of this inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On March 12, 2026, Licensing Program Analyst (LPA) Angelica Borja conducted a Case Management inspection at Ascend Behavioral Health and met with Ciara Armstead-Program Manager. The purpose of this inspection was to discuss concerns with an incident report that was sent into the Department on 2/10/26, the incident in question happened on 2/09/26. LPA conducted an interview and discussed medication administration procedures. The Department determined this to be an immediate risk to health and safety at this time, therefore the Group Home is being cited on the attached LIC809-D under CCR, Health Related Services 80075(b). A copy of this report and appeal rights was left at the facility.

met_with: Ciara Armstead, Program Manager


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Manager (LPM) Yan Yeung and Licensing Program Analyst (LPA) Caitlin Chambers conducted a meeting with the applicant, Mr. Matthew Tatum, via Microsoft Teams for the purpose of a Component II discussion of the application. The virtual meeting was held due to this regional office being under renovation. The following pending issues were discussed during the meeting: · Bank information with adequate funding-applicant needs to provide LIC 404 with appropriate bank account information. Current funding shown is inadequate. · Revised LIC 401 (monthly operating statement) showing rate for each client and wages for staff listed on LIC 500 · Copy of lease showing monthly rent which should be matching the rent listed on LIC 401 · Fingerprint association or live scan for all staff names on LIC 500 · Proof of qualification for all staff listed on LIC 500 · Current CPR/first Aid and Health screening for all staff listed on LIC 500 · Copy of Component I with clear information of attendees · Organization chart that shows all line of supervision, with agency titles matching GH staff according to Title 22 listed positions · Updated protocols for infectious diseases · Handling of Cash resources and inventory according to Title 22 regulations 80026. · Revision of meal services and menu of a week according to Title 22 regulation 80076 · Revision of House rules to avoid blanket statements which could be personal rights violations. · List all visitation hours for clients. · List all reporting requirement to the Department. · List details of Runaway plan showing time requirement for contacting law enforcement and reporting timeframe for the Department. · List the writer and the qualification that wrote the emergency intervention plan · List who are the internal/external trainers used for the training of staff · Reorganization of table of contents to comprise with all the content of LIC 9106 (Table of contents for Group home program statement) Some of the above topics need a revision of the program statement which will be due to the department by February 7, 2025. An exit interview was conducted, and a copy of this report was emailed to the applicant, Mr. Tatum for signature. Mr. Tatum will need to sign and mail back a hard copy and a e-copy of this report to LPA Chambers.

met_with: Matthew Tatum


summary: Facility Evaluation

raw_content:
Narrative:
On 3/27/25, at 11: AM Licensing Program Analyst (LPA) Caitlin Chambers made an announced Prelicensing Inspection at the Ascend Behavioral Health Group Home. The LPA met with applicant Matthew Tatum and informed him that the purpose for the inspection was to assess the facility's physical environment prior to issuance of a license. LPA Chambers along with Mr. Tatum conducted an overall visual assessment of the inside and outside the Agency's physical plant. At the time of the inspection, LPA observed a one story home in a residential area. The facility is clean, safe, sanitary and in good repair. The Community Care Licensing Hotline complaint number and the Fresno Crisis Hotline number is framed on the wall where the client have a room to take there medication, located next to the classroom. The Emergency Disaster Plan for Children Residential Facilities (LIC 610C), Fire Evacuation/Escape plan and the Agency floor plan (sketch, with labeled rooms) is available near the front of the home. To the right of the home is a room for the therapist and clinicians to work. There is a menu of the fridge, and due to no clients being there, there is just snacks in the fridge. The facility has room for six clients. There are six beds for each of the clients in the bedrooms. Each bedroom has a dresser, night stand with drawers, a ceiling fan, and night lamps on the night stand. The bedrooms are as follows: Bedroom #1 has two beds, two dressers/ wardrobes. Bedroom #2 is a private bedroom meaning it has one full size bed, walk in closet, and a catty in the walk in closet. Bedroom #3 has two sinks, and a shower. Bedroom #4 has a private bedroom room meaning it has a full-size bed and shares a bathroom with Bedroom #2 and bedroom #3. The temperature of the water is in range in six sinks and 3 of the showers ranging from 111 degrees F to 119.3 degrees F. There is a full size bathroom outside Bedroom #2. There is a kitchen with 6 stools and a dining area for the clients to eat. There is a classroom/ multipurpose room where the Academic Case Manager will be. There are six large desks and six chairs with lighting for a classroom setting with windows. Next to the staff area is the medication room with all locked boxes and Medication folders to keep track of the medication checks. Outside of the classroom there is a closet for the clients to keep their personal items in security boxes. Next to the laundry room is locked closet full of colored coded towels of all sizes and well organized. There are two pairs of towels per client and two pairs of linens for each client. Also, inside the laundry room has the chemicals for cleaning clothes, and extra supplies for hygiene for the clients. Next to the classroom is for staff only area, with a shower, a sink, and a medication room. There is a garage that is turned into mobile workspace with new couches and new rugs and plenty of space. There are phones in the garage/mobile workspace to make phone calls. Outside there is a pool with a locked fence five feet tall. A ping pong table and space for clients to play in the grass, or cement. There are no firearms or ammunition in the facility. There is planned activities for the whole week. LPA Chambers checked the fire extinguisher next to the kitchen with current dates on the extinguisher and smoke detectors were checked in each bedroom. The home temperature is cool and comfortable at 70 degrees. Per applicant, written menus will be current and posted weekly in an area accessible to the staff and children, and the Planned Activity Schedule will be current and posted. An LIC 809 report was given to the Licensee. An exit interview was conducted


summary: Facility Evaluation - 1 deficiency

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Narrative:
On October 30, 2025, at 08:50 a.m., Licensing Program Analysts (LPAs) Amber Hunter and Brent Lockhart, and Licensing Program Manager (LPM) Jean Herring, conducted an unannounced Post Licensing inspection at Ascend Behavioral Health Group Home (GH). LPAs and LPM met with Leroy Rickard, Clinical Supervisor. The facility currently has a provisional Group Home license and is licensed to serve six (6) ambulatory clients age 12 to 17 years old. There are currently 3 clients (1 male and 2 females) placed at the facility. LPAs and LPM reviewed the following domains of the Compliance and Regulatory Enforcement (CARE) tool: Physical Plant, Disaster Preparedness, Operational and initial review of Client Records. Physical Plant The license, facility sketch, personal rights, emergency disaster form, complaints poster, emergency phone numbers and food menu are posted in a prominent, publicly accessible location in the facility. Disinfectants, cleaning solutions, sharps and knives are kept inaccessible and in a locked room located off the kitchen hallway. Facility has non-perishable food for at least one week and perishable food for at least two days except milk products. Medications are centrally stored in a locked cabinet in the office. Smoke and carbon monoxide detectors were tested and in proper working order. Fire extinguishers were fully charged. Room temperatures are maintained at around 66-71 degrees F. The hot water temperature was tested and measured at 103 degrees F. All sinks, showers and toilets are in working order. All beds are in good repair; equipped with good springs, clean mattresses and pillows. Adequate supply of beddings and linens were observed. Overall, facility is clean, safe, sanitary and in good repair. Operations Facility maintains a current, written plan of operation that meets licensing standards. Facility maintains and implements written complaint procedures and the procedures are posted in a publicly accessible location in the facility. Disaster Preparedness Plan Facility maintains a current LIC610C - Emergency Disaster Plan. Written disaster and mass casualty plan is available at the facility. LPAs and LPM also initiated review of client records. During today's inspection, the facility was issued one (1) Type B deficiency citation (see LIC809-D) and provided six (6) Advisory Notes-Technical Violations/Technical Assistance (LIC9102s). An exit interview was conducted. A signed copy of this report, LIC809-D, LIC 811, LIC9102TVs, LIC 9102TA and appeal rights were provided to Leroy Rickard, Clinical Supervisor. A continuation inspection is required.

Deficiencies:
80087(b): (b)	All clients shall be protected against hazards within the facility through provision of the following

met_with: Leroy Rickard - Clinical Supervisor


summary: Facility Evaluation

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Narrative:
On November 13, 2025, at 10:45 a.m., Licensing Program Analyst (LPA) Brent Lockhart and Licensing Program Manager (LPM) Jean Herring, conducted an unannounced Post Licensing inspection (Continuation) at Ascend Behavioral Health Group Home (GH). LPA and LPM met with Monique Cleveland, Program Manager and Leroy Rickard, Clinical Supervisor. The facility currently has a provisional Group Home license and is licensed to serve six (6) ambulatory clients age 12 to 17 years old. There are currently 4 clients (1 male and 3 females) placed at the facility. LPAs and LPM reviewed the following domains of the Compliance and Regulatory Enforcement (CARE) tool: Client and Staffing Records, Emergency Intervention Plan, and completion of Operational Requirements. Client Records: LPA and LPM reviewed four (4) client records. All client records are available to the licensing agency to inspect, audit and copy upon demand. Client records reviewed include, but not limited to, consent forms, appraisal/needs and services plan, removal/discipline/complaint procedures; medical assessments; personal property and valuables; education records; personal rights forms; and medication administration records. Staffing Records LPA and LPM reviewed four (4) staff records. Staff records contain documentation of the required education and experience requirements and training. Emergency Intervention Plan LPA and LPM observed documentation of Emergency Intervention Training and on-going training. Operational Requirements Facility maintains a current, written plan of operation that meets licensing standards. Facility maintains a register of clients and the register is available upon request. Facility maintains and implements written complaint procedures and the procedures are posted in a publicly accessible location in the facility. During today's inspection, the facility was provided four (4) Advisory Note/Technical Violations (LIC9102TV), and one (1) Type B citation. An exit interview was conducted A signed copy of this report, Confidential Names list dated 10/30/25, LIC9102TVs, LIC809-D and Appeal Rights were provided to Leroy Rickard, Clinical Supervisor.


summary: Facility Evaluation

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Narrative:
On 04/08/26 at 01:00 p.m., Licensing Program Analyst (LPA) Brent Lockhart and Licensing Program Manager (LPM) Jean Herring made an unannounced inspection at the above-named facility. LPA and LPM met with Amanda Lilly, Program Manager. The purpose of the inspection was to evaluate the licensee's request to increase the facility's licensed capacity from six (6) to eight (8), based on the application submitted for a capacity increase. This facility is licensed to serve clients, ages 12-17 years old. Currently, the facility has four (4) minors in placement. The staff to client ratio at the time of inspection was 5:4. LPA and LPM toured the facility with the Program Manager. The facility consists of: 4 bedrooms; therapy office; 2 full bathrooms for clients and 1 bathroom for staff; multipurpose room; dining room; kitchen; laundry area; 2-car garage being used as a clinical office; front porch, covered patio and swimming pool. Overall, the facility is clean, safe, sanitary, and in good repair. All passageways are unobstructed and all doors open freely. Sharps, disinfectants, cleaning solutions and other toxic materials are locked in a closet located in the laundry area. At the time of inspection facility temperature was 70 degrees (F). Hot water temperature was tested and measured at 107 degrees (F). Bedrooms# 1 & 3 are equipped with 2 beds each and Bedrooms 2 & 4 are furnished with one (1) bed each. All client beds have clean linens. The carbon monoxide and smoke alarm were tested and observed to be operable. (Continued on 809-C) The facility has non-perishable foods for at least one week and perishable foods for at least two days. A review of weekly menu indicates that the facility provides nutritious meals and snacks. Medications are locked in a closet located in the multipurpose room and accessible only to employees responsible for stored medications. A new fire clearance for a capacity of eight (8) has been received by the Department prior to this inspection. Based on observation, the following furniture need to be added in order to increase the facility capacity to eight (8); Bedrooms # 2 & 4 need one additional bed, and one additional night stand. Bedroom #1 needs one additional closet/armoire. Multipurpose/study room needs two (2) additional study desks and 2 chairs. Two (2) Technical Advisory Notes (LIC 9102) were provided. A signed copy of this report was provided to the Program Manager.

met_with: Amanda Lilly - Program Manager


facility_name: ASCEND HEALTHCARE

raw_content:
Narrative:
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview was completed and copy of the report and appeal rights were discussed and provided to Facility Manager, Stefan Zeljkovic.

Investigation Findings:
13On 08/13/25, at 9: AM, Licensing Program Analyst (LPA) Andrea Aceves and Licensing Program Manager (LPM) Lakescia Smith made an unannounced visit to the above facility to conclude the investigation and to deliver the findings on the above allegations. LPA and LPM met with Facility Manager, Stefan Zeljkovic. During the investigation, LPA Andrea interviewed all available parties and reviewed LIC500-Personnel Report, Needs and Services Plan. It was reported that (1) Staff did not ensure that minor's needs were met while in care, (2) Staff did not follow minor in care's treatment plan, and (3) staff harassed minor in care. Based on interview statements from staff and review of client treatment plan, LPA Andrea was able to confirm that minor was engaged in therapy throughout her entire program. LPA was unable to confirm if parent of C1 was harassed by the facility regarding financial responsibilities however, parent was signed the Admission Financial Package which identifies the program's financial expectations. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Andrea Aceves LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: ASCEND HEALTHCAREFACILITY NUMBER: VISIT DATE: 08/13/2025

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

met_with: Facility Manager Stefan Zeljkovic


summary: Facility Evaluation

raw_content:
Narrative:
On January 26, 2023, at 9: AM, Licensing Program Analyst (LPA), Charmetha White arrived at Ascend Healthcare, for the purpose of conducting a Year Annual Inspection. LPA met with Facility Compliance Manager, Dave Trice and the Director of Facilities, Zackary Hale and was granted access into the facility. The facility was toured at 9: AM both inside and out. The facility is a private pay therapeutic treatment program licensed to provide care and supervision services for six (6) children, ages 12-17 years old, ambulatory only. The census at the time of the inspection was six (6). The facility is a two story, 3-bedroom, 5-bathroom house which includes a Living room, Dining room, Kitchen, Laundry room, Staffing/Medical office, a Garage, and a Backyard. The facility is set up as follows: Living room: is furnished with sectional sofa, 2 chairs, and has an non-operating fireplace equipped with an iron screen. Dining room: is furnished with a wooden table and six (6) chairs. Kitchen: is equipped with a 4-burner gas operated stove, a microwave, refrigerator/freezer, a dishwasher, and a toaster. Laundry room: is located in the garage and is equipped with a washer and dryer. Staffing/Medical office: is located on the first floor near the garage. The office is equipped with a computer, chair, and desk. LPA observed the room to have a locked cabinet which are used to stores medication, PPE supplies. Additionally, medications that require refrigeration is stored in a double locked refrigerator located inside the office. The office is locked and made inaccessible to clients in care. Pool: is located in the backyard and is equipped with a fence that meets regulations. Garages: is attached to the home and is equipped with a desk, chair, and gym equipment. There are also two (2) small rooms used staff and client meetings. Backyard: contained a swimming pool equipped with a five foot fence with a self-latching lock, a ping pong table, ½ court basketball, and a sitting area. The backyard was observed to be free of debris and hazardous materials. Report continued on LIC 809C (page 1 of 2) Bedroom 1: is named Warrior and it is equipped with 2 full size beds. There are adequate drawers, closet space, and lighting in this room. Bedroom 2: is named Sunrise and it is equipped with 2 full size beds. There are adequate drawers, closet space, and lighting in this room. Bedroom 1 & Bedroom 2 shares a Jack and Jill bathroom. Bedroom 3: is named Horizon and it is equipped with 2 full size beds. There are adequate drawers, closet space, and lighting in this room. The room also has a separate bathroom, and French doors, which remain locked at all times, leading to the backyard. All bedrooms were equipped with comfortable mattresses, clean linen, blankets, and pillows. Bathrooms: bathrooms had a toilet, sinks, tub/shower. The bathrooms were clean and in operating condition. Water temperature was observed to be within 105 - 120 degrees Fahrenheit. LPA observed the home to be clean, safe, sanitary, and in good repair. The home has a linen closet located on the second floor which stores additional towels and sheets. Knives are locked in box located under the stove and made inaccessible to the clients. Disinfectant and cleaning solutions are locked in a storage closet located off of the entrance and made inaccessible the clients. The first aid kit is located in the staff office and was found to be complete with scissors, tweezers, gauzes, antiseptic, 1st Aid Manual, and a thermometer. There are no firearms or dangerous weapons located in the home. The smoke alarms and carbon monoxide detectors were tested and found to be in working order. The home has 3 fire extinguishers. There are no security bars on the windows. There is a camera waiver on file. Facility operates within license conditions and limitations including capacity limitations. Facility has a current written plan of operation. All posting requirements were met. Clients are provided three nutritious meals and snacks per day. Clients in care are in accorded personal rights. Clients in care are supported, encouraged to participate in extracurricular activities. Clients in care can contact the licensing agency or Foster Care Ombudsman person in confidence without threats or punishment for making complaints. Clients in care are accorded dignity in personal relationships with others in the home. Clients in care are not restricted in telephone use except by court order. LPA will return at a later date to review Staff and Client flies. There were no deficiencies cited per California Code of Regulations, Title Regulations, Division 6, chapters 1 & 5. Exit interview was conducted and a copy of this report was left at the facility.

met_with: Facility Compliance Manager - Dave Trice and Director of Facilities - Zackary Hale


summary: Facility Evaluation

raw_content:
Narrative:
On May 9, 2023 at 9: AM, Licensing Program Analyst (LPA) Charmetha White made an unannounced visit to Ascend Healthcare for the purpose of conducting a Case Management for Special Incident Report #05-2023-34-CM-01. The incident occurred 04/26/2023 and the incident report was received by the Department on 05/01/2023. LPA met Director of Operations, Jacqueline Marshall Waldron and discussed the incident. During this visit, confidential interviews were conducted. Additional interviews will be conducted on a later date. LPA requested a copy of the following documents: Current LIC 500, Staff #2's training records, and Client #1's intake paperwork. Additionally, LPA was informed that Client #1 is no longer in placement as of 04/29/2023. Based on interviews and information gathered, this case management needs further investigation. Exit interview was conducted, and a copy of this report was emailed to the Director of Operations.

met_with: Director of Operations - Jacqueline Marshall Waldron


summary: Facility Evaluation

raw_content:
Narrative:
On June 20, 2024, at 12: PM, Licensing Program Analyst (LPA) Regina Martin conducted a Case Management - Incident inspection at ASCEND HEALTHCARE Group Home, met with Facility Representative and later with Emely Hernandez, Facility Manager and Jack Waldron, Facility Director in response to an Incident Report submitted to Community Care Licensing (CCL) on June 12, 2024. The incident, reports in part alleged violation of personal rights as a youth was reportedly touched inappropriately by a staff member. During this inspection, LPA Martin informed the incident has been referred to CCL Investigations Branch, Investigator Lorraine Patterson for assignment. Upon completion of the investigation, the investigation findings will be delivered and discussed. LPA Martin requested and/or obtained the following documents from facility records and subject client files: Client Roster (obtained during visit), Personnel Report (Schedule) LIC500, Client Needs and Services Plan, discharge documentation and all incident reports concerning subject youth (if applicable). Please submit requested documents to LPA Regina Martin at regina.martin@dss.ca.gov The incident requires further investigation. Upon completion, the Department's findings will be issued and discussed. There are no deficiencies cited per California Code of Regulations, at this time. Exit Interview conducted, and a copy of this report was left with Facility Representative.

met_with: Facility Representatives


summary: Facility Evaluation

raw_content:
Narrative:
On 05/30/2025, Licensing Program Analyst (LPA) Andrea Aceves and Licensing Program Manager (LPM) Lakescia Smith, made an announced visit to Ascend Healthcare #1 for the purpose of a Case Management- Incident Report. LPA and LPM met with Acting Facility Manager, David Hurwitz to discuss an incident regarding the lack of supervision. The department received an incident report dated 05/22/25. The incident report disclosed that two clients engaged in inappropriate sexual behavior and staff was asleep during the incident. During the investigation LPA obtained copy of LIC 500, client roster, and interviewed Acting Facility Manager, David Hurwitz. Staff #1 was not available for an interview. Staff #1 will be contacted at a later date. LPA informed David Hurwitz that more information is needed. LPA will return at a later date to conclude the investigation. Exit interview was conducted and a copy of this report was provided to Acting Facility Manager, David Hurwitz.

met_with: Acting Facility Manager-David Hurwitz


summary: Facility Evaluation

raw_content:
Narrative:
On September 24, 2025 at 12:10pm, Licensing Program Analyst (LPA) Emelyn Sanchez P. conducted an unannounced visit to Ascend Healthcare for the purpose of conducting an Initial 10-day Complaint Investigation visit. LPA Sanchez P. met with Stefan Zeljkovic, Facility Manager who granted access into the facility. LPA Sanchez P. conducted a Health and Safety Risk assessment upon arriving at the facility. LPA Sanchez P. requested the LIC 500- Personnel Report and current client roster. After reviewing requested documents LPA Sanchez P. was able to confirm that the complaint investigation was recorded under the wrong facility. LPA Sanchez P. will be conducting a complaint investigation visit at Ascend Healthcare 3 #198209719. No deficiencies were cited at this time. An exit interview was conducted, and a copy of this report was left with Stefan Zeljkovic, Facility Manager

met_with: Stefan Zeljkovic, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 05/30/2025, Licensing Program Analyst (LPA) Andrea Aceves and Licensing Program Manager (LPM) Lakescia Smith, made an announced visit to Ascend Healthcare #1 for the purpose of a Case Management- Deficiency and met with Acting Facility Manager, David Hurwitz. While initiating a visit at the facility, LPA and LPM requested a copy of the LIC500-Personnel Report. LPA Andrea reviewed the Personnel Report and Guardian roster. LPA and LPM advised Acting Facility Manager, David Hurwitz that Staff #1 was not associated to the home per licensing regulations. In addition, LPM and LPA reminded Acting Facility Manager that all staff working in the home must obtain a criminal record clearance and associated to the facility prior to working in the home. Note: LPM informed staff regarding the Central Administrative Facility Waiver to designate one facility to associate all staff for clearance purposes. LPA will send instructions on submitting the waiver request via email. In addition, LPA will send Provider Information Notice regarding camera use in the facilities. Due to staff not being associated to the facility a deficiency is being cited. See LIC 809D. Exit interview completed and copy of the report and appeal rights were provided to acting facility manager, David Horwitz.

met_with: David Hurwitz-Acting Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 08/12/25, at 9: AM, Licensing Program Analyst (LPA) Andrea Aceves and Licensing Program Manager (LPM) Lakescia Smith made an unannounced visit to Ascend Healthcare for the purpose of conducting a Case Management for Incident Report dated 05/21/25 (#0001797-FN). LPA Andrea and LPM Lakescia met with Facility Manager, Stefan Zeljkovic. During the investigation, LPA Andrea interviewed all available parties, requested and received LIC500-Personnel Report and client roster. The incident occurred on 05/19/25 and the report was received on 05/22/25. Per Facility Manager and S1, LPA was able to confirm that a staff was asleep while on shift. However, due to conflicting statements, LPA was not able to confirm if two clients engaged in inappropriate sexual behavior as reported. No further investigation or interviews are required on the above incident. As a result, the facility is being cited (see LIC809D). Exit interview was completed and copy of the report and appeal rights were discussed and provided to Facility Manger, Stefan Zaljkovic.