summary: Facility Evaluation

raw_content:
Narrative:
Meeting was held at the request of Fresno County to discuss the pending UMC MOD C application licensing requirements regarding the identification of the Board of Directors or governing body for the Fresno County Transitional Shelter Care Facility. In attendance for Fresno County: Deputy Director: Kimberli Smith County Counsel: Daniel Cederborg Deputy County Counsel: Libby Hellwig Teague Deputy County Administrative: Amina Flores Becker Senior Staff Analyst: Pao Yang Staff Analyst: Jesse Ocegueda-Abarea In attendance for the California Department of Social Services (CDSS): Assistant Chief Counsel: Rachel M. Raymond Senior Staff Counsel: Lila Hollman-Dowty Assistant Program Administrator: Angela Carmack San Jose Regional Manager: Nelson Martinez Licensing Program Manager: Juanita Arroyo Licensing Program Analyst: Briana Placencia The LIC 9165, PUB 326 and board members accountability were discussed. The CDSS will provide on-going technical assistance to support the County. UMC MOD C Licensure is contingent on LIC 9165 being completed and signed by Board of Directors. A copy of this form will be forwarded for County signature and a copy will be provided to the County.


state: CA

facility_name: UMC MOD C

summary: Facility Evaluation

raw_content:
Narrative:
On October 30, 2024, Licensing Program Manager, Tamara Melikian and Regional Manager, Nelson Martinez met with UMC Mod C Administrator, Rita Bohannon and Deputy Director, Kim Smith, as well as other County personnel virtually. The purpose of the meeting was to provide technical assistance to UMC Mod C regarding the use of public health nurses and fingerprint clearances. Options were provided by the facility and discussed. The facility will notify and discuss further with Community Care Licensing once a decision has been made. A copy of this report was provided via email to Administrator, Rita Bohannon on this date.

report_type: Facility Evaluation

met_with: Rita Bohannon, Kim Smith


facility_name: WELCOME CENTER, THE

summary: Facility Evaluation

raw_content:
Narrative:
On June 6, 2022, a Virtual Teams Meeting for the purpose of component II for the Program Statement/ Plan of Operation to conduct a meeting to discuss and review the new Riverside County Transitional Shelter Program Statement submitted to Community Care Licensing on April 20, 2022. The following participants were in attendance, LaCresha Cook, Regional Manager; Darlene Almaraz-Oseguera, LPA; Natasha Dunlap, LPM, Nicole Ford, Riverside County Program Specialist; Heidi Lombardi, Administrator; Deputy Director, Bridgette Hernandez. During the meeting the following was discussed: Application and Supporting Documents, Plan of Operation, Program Statement, Core Services and Supports. County representatives were also reminded that all pages in the entire Program Statement should be numbered and all corrections and/or revisions highlighted for ease of reference during the review. Section A Forms: Application: # Missing property owner full name and address V. Utility Shut example shut off valves where? Application Information (LIC 215) missing Administrative Organization (LIC 309) missing Affidavit Regarding Client Cash Resources (LIC 400) missing Personnel Record (LIC 501) missing Health Screening Report (LIC 503) missing Criminal Record Statement (LIC 508) missing Fire Inspection (LIC 999) missing Board of Director Statement (LIC 9165) missing Section B Forms B1- Letter from Board of Supervisors authorizing approval to apply for license B Control of Property missing Neighborhood Complaint Policy First Aid Cards Program Description: Section A: 3. Purpose, Methods, Goals Types of screening missing Days of operations missing Did not mention optional services list of the community resources and consultants 4. Planned Activities/ Use of Community Resources Missing a monthly schedule for indoor and out door activities Add what staff title will conduct the activities Also missing list of community resources used by the facility 5. Special Services/ Program Offered How the training's are funded Mention "special services/programs" 6. Medical/Dental Did not mention TB test Did not mention MAR LIC 622A and Psychotropic Medication Administration Records PMAR622B Medical and dental insurance coverage information Mention consent forms and Written authorization of parents or guardian 7. Transporting How vehicles will be maintained and ensure how the vehicle registration and insurance will be maintained Will the facility maintain vehicle owned by the facility or will staff utilize their own vehicles to transport children 8. Admission/Intake What staff (title) missing pre-admission sign in and out procedures procedures for emergency placement's Admission agreements (Regional Center Agreement may be used) 9. Needs and Services Plan/Assestment How will the facility ensure that the needs identifed are consistent with Regional Center IPP 10. Discharge/Removal Policies and Procedures being provided to Children & authorized representatives Signed policies and procedures maintained in the child's record 11. Visitation Rules & Policy Home visits/overnight visit policies? 13. Discipline Policies Discipline Policies provided to Placing Agency Mention last resort emergency physical control techniques 14. Emergency Intervention Plan What early intervention techniques maximum time limits, when techniques not used expected outcomes Name and qualifications of the individual who designed the Emergency Intervention Plan and will be providing training to staff If use of manual restraints then how will facility respond to crisis? 16. Children's Complaint/Grievance Procedures Where (location) Complaint/Grievance box 17. Handling of Children's Funds, Allowances & Salaries Allowance policies 20. Clothing & Incidentals Just add the wording age-appropriate 22. Staff Qualifications abuse reporting requirements did not mention 24. In services Training for Staff/Administrator How special training needs are identified and then how will they be met Facility manager training plan Intervention training missing 25. Administration Name of all the board of directors Names and positions of any paid staff who are board members 27. Control of Property Name address of owner copy of signed lease or rental agreement Deed or property tax bill 29. Board of Director's Statement Missing Administrator Certificate A copy of this report was emailed for signature.

visit_type: Case Management

met_with: Heidi Lombardi


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera conducted an unannounced inspection to the facility. LPA met with facility supervisor Araceli Iniguez-Reyes. There were eight staff and nine clients present at the facility during this inspection. Community Care Licensing (CCL) received information concerning potential safety hazards. LPA observed three different houses of different addresses on the 85-acre lot/premise. There were no dogs roaming the property at this time. However, staff reported that there are two small dogs and one medium size dog that are friendly and belong to one of the other property occupants. LPA also observed several exposed wires that are part of another property on the premise. It appeared that there were new electrical wires put in and the old wires were exposed. The facility was advised to reach out to maintenance to have the old wires removed as soon as possible. The facility will notify CCL once the exposed wires are removed. Exit interview conducted and a copy of this report was provided to Araceli Iniguez-Reyes.

met_with: Araceli Iniguez-Reyes


facility_name: WELCOMING CENTER, THE

summary: Facility Evaluation

raw_content:
Narrative:
On 8/16/2023 at 4:00PM, a virtual meeting was conducted with the applicant for the purpose of providing technical assistance after the initial application submission. Present at the meeting: Nelson Martinez - CCL Regional Manager (RM) Helga Wong, Licensing Program Manager (LPM) Selena Hood, CCL Licensing Program Analyst (LPA) Damion Wright - Assistant Director for Department of Family and Child Services (DFCS) of Santa Clara County (SCC) Brian Hawkinson - Legislative Files, DFCS SCC and CCL representatives discussed the pending application, including the fingerprint clearance, administrator duties, potential changes of location, and the essential terms. LPM provided SCC representatives with a previous sample of a Transitional Shelter Care Facility Essential Terms via email. The meeting concluded at 5:03PMAM. LIC809 will be sent virtually for signature.

met_with: Damion Wright


summary: Facility Evaluation

raw_content:
Narrative:
On 11/13/2023 at 2:00PM, a virtual meeting was conducted with the applicant for the purpose of providing technical assistance after the revision letter was sent for the application. Present at the meeting: Helga Wong, Licensing Program Manager (LPM) Selena Hood, CCL Licensing Program Analyst (LPA) Gina Jones - Policy and Technical Assistance Bureau, System of Care Branch (SOC) Alicia Bernstein - Policy and Technical Assistance Bureau, System of Care Branch (SOC) Damion Wright - Assistant Director for Department of Family and Child Services (DFCS) of Santa Clara County (SCC) Gilbert Murillo - DFCS Teana Box - DFCS Roxanna Martinez - DFCS SCC, SOC, and CCL representatives discussed the ongoing applications. CCL discussed recommendations and the recent revision letter. SCC asked about the 10-day waiver that was requested, LPM informed that they would follow-up with the CCL Program Office. SOC informed SCC of the assistance that they could provide and provided resources through chat. The meeting concluded at 3:00PM. LIC809 will be sent virtually for signature


summary: Facility Evaluation

raw_content:
Narrative:
On 4/8/2024 at 4:00pm, Licensing Program Analyst (LPA) Selena Hood and Licensing Program Manager (LPM) Helga Wong conducted a Microsoft Teams Meeting with Santa Clara County (SCC) Representatives. Present at the meeting: Alicia Bernstein, Manager for Policy and Technical Assistance Bureau, System of Care Branch (SOC) Chadwyck Moore, Analyst for Policy and Technical Assistance Section, System of Care Branch Maya Staheli, Analyst for System of Care Branch Gilbert Murillo, Acting Assistant Director Brian Hawkinson, Legislative Files Manager Temera Carson, Program Manager During the meeting, CCL, SOC, and SCC discussed the Guardian clearances for the facility. CCL informed that the facility would transfer the clearances to the new license when there is approval. CCL also informed that the contractor's files could remain in their position, but they need to be accessible to licensing during site visits. SCC informed LPA that the facility would not be utilizing manual restraints for the new application. This report is sent to SCC for virtual signature.

met_with: Gilbert Murillo


facility_name: BILL WILSON CENTER

summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
Evidence for the allegation "Facility staff failed to provide a safe environment for a resident", as follows: On 6/14/2021 at 9: PM C1 was in a fight with another resident at the facility, Client 2 (C2) DOB: 1/28/2005. There was a video of the fight. Based on observations of the video by this LPA, C1 pushed resident, C2. C2 then punched C1 in his face several times, and the staff stood watching C1 get hurt. Staff reached their arm out then drew it back. The residents were chanting hit him harder! drop him on the floor! teach him a lesson! Then staff yelled, the cops were called. The other residents at the facility video typed the fight and posted it on social media: Snap Chat and Instagram. Shortly after the fight, C1 was taken to the emergency. C1 had sustained injuries, which include a broken nose, a cut behind his ear, and his arm was hurt. Based on interviews with staff members it was known that C1 and C2 are associated to an opposing gang, C2 is associated with blue (Sureno gang) and C1 is associated with red (Norteno gang). Interviews with PO and CSW confirmed that C1 is associated with red (Norteno gang). The Program Description states, "Examples of when a youth may be screened out may include a youth who is a sexual perpetrator if there is a victim(s) already in placement that would potentially be put at risk or an entrenched gang member who is in an opposing gang of a youth already in placement...Having two Safety Net Shelter locations allows flexibility to make the most appropriate placement match" (PD, Page 13). Based on interviews with staff members, moments before the fight, three (3) residents and the aggressor (C2) were making gang gestures in order to intimidate C1. The Program Description states, "NO GANG ACTIVITY. Any gang related activity, including throwing gang signs, wearing gang related clothing, or having gang related conversation, is unacceptable. Tagging of any kind is NOT allowed in the program" (PD, Page 25). A review of the staff schedule (Crisis Residential Staff Schedule: Week June 13, 2021- June 19, 2021) obtained from the agency administrator revealed that there were supposed to be three (3) staff members on shift. During the time of the incident there were only two (2) staff members for eleven (11) clients. Interviews with staff members confirmed that there is supposed to be three (3) staff members during the night shift and that there were only two (2) staff members during the time of the incident. Furthermore, the Program Description states, "Clients identified as high risk for behavior issues receive additional monitoring from program staff, which increase the client to staff ratio" (PD, Page 36). Investigation interviews, and a review of documents, which include the Program Description and Staff Schedules prove that the agency did not provide adequate supervision for the clients in care and did not follow the Program Description by screening out opposing gang members and increasing the client to staff ratio in order to provide additional monitoring. Therefore, the compliant is Substantiated. Based on LPA Raissi's observations, records reviewed, and interviews, the preponderance of evidence standard has been met, therefore the allegation, "Facility staff failed to provide a safe environment for a resident" is found to be SUBSTANTIATED. Deficiencies (Type A) were cited. An exit interview was conducted, appeal rights discussed, and a copy of this report was given to Cheryl Rouse, whose signature acknowledges receipt.

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

report_type: Complaint Investigation

met_with: Cheryl Rouse

complaint_status: SUBSTANTIATED


summary: Facility Evaluation

raw_content:
Narrative:
Attendees of the facility: Cheryl Rouse, Eva Haile CCL: Helga Wong and Carolyn Flynn - Licensing Program Manager, Selena Hood and Vaishali Singh-Soon Licensing Program Analyst Discussion: - Current substantiated complaint received on 6/29/21 re facility staff failed to provide a safe environment for a client. Two clients from different gangs physically fought in the facility resulting a client being punch multiple times in the head and sustained bleeding and a fracture nose in the facility. - Facility did not following their program statement/plan related to gang activities and affiliation -Facility did not follow their program plan on assaultive behavior to control of environment, removing other youth from situation, lowering lights and volume to reduce stimuli, maintaining safe distance from youth while using calming, verbal skills to de-escalate. -Staffing Facility will do the following and submit them to Licensing Office by December 31, 2021: - Lic 500 form on current staff schedule to ensure the facility have adequate staffing to meet the needs of the clients - Update facility program plan to ensure staff response and take action on assaultive behavior and address gang activities and affiliation - Training and Plan on de-escalation and intervention on client behaviors The Department informed facility representatives today that this complaint/incident will be refer to the Legal Division for ECP.


summary: Facility Evaluation

raw_content:
Narrative:
On June 21, 2022 at 12: PM, Licensing Program Analyst (LPA) Vaishali Singh-Sood met with Cheryl Rouse, Administrator, in order to assess an Enhanced Civil Penalty (ECP) regarding a substantiated incident. On 09/30/2021, the department concluded an investigation into the allegations that facility staff failed to provide a safe environment for a resident which resulted in C1 (see LIC811 - Confidential Names List dated July 7, 2021) sustaining a broken nose, scratches behind their ears, and a hurt arm. The allegations were found to be substantiated and the facility was cited per ILS, Personal Rights (a)(b)(1). Per confidential interviews, Bill Wilson Center staff were aware that C1 and C2 were associated with opposing gangs. Per staffing records, the facility was understaffed the evening of the incident.The department has concluded an analysis and has determined that an Enhanced Civil Penalty is warranted for the serious bodily injury. Pursuant to the Enhanced Civil Penalty law, Health and Safety (H&S) code section 1548 (f)(1)(c), the Department will be issuing an immediate civil penalty of $2,500.00 on today's date, June 21, 2022. Continued on LIC809C... The above information was reviewed during the meeting and appeal rights were provided. A copy of this report, the LIC811-Confidential Names List, Civil Penalty Assessment, and Appeal Rights were sent to Administrator, Cheryl Rouse, who agreed to sign the report and email it back to LPA Singh-Sood. Email was sent with a read receipt notification.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Vaishali Singh-Sood made an unannounced case management inspection to the above facility on February 15, 2023, at 10: AM. LPA Singh-Sood met with Receptionist, Santa Madrigal, who assisted with the inspection. The purpose of this inspection was to discuss the detailed information regarding an incident report which was received by Community Care Licensing on January 30, 2023. The report indicated two clients had been caught having oral sex in the bathroom. LPA Singh-Sood attempted to discuss the incident with Ms. Madrigal who did not have any specific details regarding the incident. As such, LPA Singh-Sood will later discuss the incident with Administrator, Debbie Pell. An exit interview was conducted at 3: PM, and copy of this report were emailed to Ms. Pell.

met_with: Santa Madrigal


summary: Facility Evaluation

raw_content:
Narrative:
On October 24, 2023, at 9: AM Licensing Program Analyst (LPA) Vaishali Singh-Sood conducted an unannounced inspection to the facility for the purpose of conducting an Annual/Required inspection. LPA Singh-Sood met with Program Director, Eva Haile, and both toured the facility, inside and out. During the inspection, there were only two clients in the facility, both with COVID, so interviews on clients were not conducted. The facility is a two story building that includes: 10 bedrooms upstairs; 5 bathrooms upstairs; laundry room upstairs; living room upstairs; game room upstairs; staff office upstairs; snack room upstairs; and, kitchen, dining, and recreation room downstairs. First aid kits was observed. Food supply, linens and fire extinguisher were observed. Toxins and sharps are properly stored. Staff and client files are kept locked to ensure confidentiality. LPA Singh-Sood observed at the time of this inspection, the facility to be clean, safe, and sanitary. All fire alarms, and carbon monoxide detectors were in good working condition, and the fire extinguisher is current. This LPA reviewed the staff and client files, medication logs, and they had the necessary forms. There is sufficient perishable food for over two days and nonperishable food for over seven days. Medication storage and procedures were also reviewed. The following documents are posted in the facility: facility license, emergency disaster plan, facility sketch, menu, activity calendar and personal rights. The hot water temperature was at (Kitchen Sink - 110.1, Hall Bathroom 111.3, and Bedroom Bathroom 111.3 degrees). According to Ms. Madrigal, there are no weapons, and/or bodies of water at the facility which meets title 22 regulations. There are no exceptions on file, and there have not been any deficiencies cited in the past year. A review of Licensing Information System (LIS)/ Guardian October 24, 2023 indicates that all facility staff are associated to the facility had DOJ, FBI, and child abuse index check clearances. LPA used a physical copy of the CARE tool to document client file information. LPA will relay the information onto the digital CARE tool after the visit. There were no deficiencies cited during this inspection. LPA conducted an exit interview with Ms. Haile at 3: PM, whose signature confirms the receipt of this document.

visit_type: Annual

met_with: Eva Haile


summary: Facility Evaluation

raw_content:
Narrative:
On November 6, 2024, at 10: AM, Licensing Program Analyst (LPA) Vaishali Singh-Sood made an unannounced Case Management inspection to the above facility. LPA Singh-Sood met with Division Director Angeleena Yeldell, who assisted with the inspection. The purpose of this inspection was to discuss a serious incident that had occurred earlier in the morning. Ms. Yeldell had reported the incident to this LPA, as well as to Community Care Licensing immediately. At this time further investigation is needed. As such, an exit interview was conducted at 12: PM, and copy of this report was provided to Ms. Yeldell.

met_with: Angeleena Yeldell


summary: Facility Evaluation

raw_content:
Narrative:
On May 29, 2025, at 9: AM, Licensing Program Analyst (LPA) Vaishali Singh-Sood made an unannounced Case Management inspection to the above facility. LPA Singh-Sood met with Brenda Cervantes, Program Assistant, who assisted with the inspection. The purpose of this inspection was to discuss the changes occurring in the facility with Ms. Garcia. Ms. Garcia indicated she would like assistance with various areas in the facility, for the THPP, as well as the homes, and the Homeless Shelter. Ms. Cervantes also indicated a willingness to work with the Departments' Technical Support Program (TSP). This LPA informed Ms. Cervantes that a referral would soon be sent to TSP. As such, and exit interview was concluded at 10: AM.

met_with: Brenda Cervantes


summary: Facility Evaluation

raw_content:
Narrative:
A meeting was held on June 20, 2025 at 2: PM with the above facility. The purpose of this meeting is to discuss concerns regarding the plan of operation. Present in the meeting: Licensing Program Manager, (LPM) Carolyn Flynn, Licensing Program Analyst (LPA) Shikya Belfield, and Chief Program Officer (CPO) Daniel Gutierrez of the Bill Wilson Center. The following was discussed: Facility had administrative changes, including change of administrator and this information was not reported to the department. During this meeting LPA requested forms LIC Administrative Organization, LIC Facility Personnel Report, and any changes made to the program statement and plan of operation. This information is required to be submitted to the department by July 21, 2025. At that time a tentative board resolution will be submitted designating an administrator for the facility. An exit interview was conducted and a copy of this report was sent to Chief Program Officer Daniel Gutierrez.

met_with: Daniel Gutierrez


facility_name: CASA NUESTRA

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Continued... The report detailed that while C1 was placed at the facility, C1 disclosed an incident in which another minor entered C1's room and hit C1. The report included that on September 18, 2024, C1 absconded from the facility after notifying staff that C1 would be going to wash their clothing at a laundromat, despite the facility having a washer and dryer onsite. Additionally, the report detailed that C1 was not currently enrolled in or actively attending school. During the investigation, LPA Saeteurn interviewed clients (C1-C5), Staff (S1- S5), Witnesses (W1-W4) and reviewed pertinent facility records. In response to the allegation that staff did not prevent physical altercation between children, confidential interviews did not reveal any physical altercations between C1 and any other resident. Confidential interviews revealed that C1 was a client that enjoyed participating in multiple activities, was engaged in services, and was described as being friendly with staff and peers. Confidential interviews did, however, share that early into C1's arrival at the facility there were some situations in which C1 and C2 engaged in exchanging looks and made comments to one another during group activities, but interviews did not reveal that any physical altercations occurred. Confidential interviews revealed that there were situations in which some clients went into C1's room to take things. Confidential interview indicated that the clients were redirected and reminded by staff that they are not allowed in other clients' rooms; however, none of the incidents resulted in a physical altercation. A review of Special Incident Reports sent to CCL from the facility did not reveal any reports of a physical altercation occurring. In response to the allegation that staff did not supervise minor resulting in the minor being absent without leave from the facility, confidential interviews revealed that on the evening of September 18, 2024, C1 requested to wash their clothes. Confidential interviews revealed that during that time, staff were attempting to deescalate a client in care. Confidential interviews revealed that C1 entered the laundry room and staff were able to hear C1 starting their laundry while the door was open. A conflicting confidential interview revealed that the laundry room door leading to the inside of the home was closed which prompted staff to check in on C1. Confidential interviews revealed that S5 noticed that C1 was not in the laundry room and immediately began the facility's unauthorized leave protocol. Continued... Continued... A confidential interview revealed that the door to the laundry room must be left open for staff to observe clients. A review of a Special Incident Report submitted to CCL on 09/28/2024 revealed that while C1 was in the laundry area, "C1 made the choice to AWOL through the side door of the facility". A walk through performed by LPA Saeteurn on September 27, 2024, revealed that the facility has a washer and dryer on premises which is located in a room between the facility kitchen and garage/office area. The laundry room has three doorways, one leading to the garage/office area, one leading to the inside of the home kitchen area and a door leading to the outside of the home. LPA Saeteurn was able to see that the door leading to the side of the home gives access to an additional gate that leads to the driveway. Confidential interviews revealed that although clients are assigned a specific date to wash, C1 requested to use the washer on this day and staff approved it due to C1 having minimal clothing. A confidential interview confirmed that C1 was granted permission to use the laundry room on site and C1 proceeded to leave the facility to abscond. Confidential interviews revealed that C1 planned to abscond from the facility and communicated this to other residents. Confidential interviews revealed that clients were aware of C1's intentions to leave the facility, but it was not communicated to staff. Confidential interviews revealed that after S1 and S5 searched facility grounds for C1, an unauthorized protocol was enacted in which all parties were notified of C1 absconding. In reference to the allegation that staff did not ensure that minor attended school, confidential interviews and review of relevant client records confirmed that C1 was waiting for permanent placement to begin with Job Corps after being accepted into their program. The review of client records showed that C1 was attending school, however, conflicting confidential interview revealed that C1 was not enrolled in school. Confidential interviews revealed that C1 only attended the achievement center while placed at the facility which allowed for C1 to participate in education activities, sports, and field trips. A conflicting confidential interview revealed that the facility was allowed to complete the school enrollment process for C1 however, a conflicting confidential interview revealed that only the Authorized Representative and Educational Rights holder can make those decisions for minors in care. Confidential interviews revealed that C1's Education Rights Holder and Authorized Representative were contacted by the facility in an effort to help facilitate the process, however, neither C1's authorized representative nor educational rights holder ever completed the process. Continued... Continued... A review of the facility Program Statement revealed that if a client is not enrolled in school upon intake, the facility will work with the family to accomplish this goal and will include it on the service plan. Additionally, the program statement also included that the client would have free time at the facility to complete homework or can receive tutoring whether at a tutoring center or at the achievement center. Based on interviews conducted, LPA observation and record review, the allegations that staff did not prevent a physical altercation between children, staff did not supervise minor resulting in the minor AWOL'g from the facility and staff did not ensure that minor attended school are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove the alleged violations occurred. An exit interview was conducted with Xavier Martinez,Program Director. A copy of this report and appeal rights were provided and reviewed with Xavier Martinez, Program Director whose signature on this report confirms receipt of these documents.

Investigation Findings:
13On December 12, 2024 at 10: AM, Licensing Program Analyst (LPA) Abby Saeteurn made an unannounced visit to Casa Nuestra and met with Xavier Martinez, Program Director to deliver the findings for the above-stated allegations. LPA Saeteurn initiated a complaint inspection at the facility on September 27, 2024, at 2: PM and no immediate deficiencies were observed. On September 20, 2024, Community Care Licensing (CCL) received a complaint alleging staff did not prevent a physical altercation between children, staff did not supervise minor resulting in the minor AWOL'g from the facility and staff did not ensure that minor attended school. The report detailed that C1 was placed at the facility awaiting to start at Job Corps. It was reported that C1 was placed at the facility as it was believed that C1 would have staff assigned and would be supervised and watched 24/7. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Abby Saeteurn 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Casa Nuestrafacility Number: Visit Date: 12/12/ Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32continued... The report detailed that while C1 was placed at the facility, C1 disclosed an incident in which another minor entered C1's room and hit C1. The report included that on September 18, 2024, C1 absconded from the facility after notifying staff that C1 would be going to wash their clothing at a laundromat, despite the facility having a washer and dryer onsite. Additionally, the report detailed that C1 was not currently enrolled in or actively attending school. During the investigation, LPA Saeteurn interviewed clients (C1-C5), Staff (S1- S5), Witnesses (W1-W4) and reviewed pertinent facility records. In response to the allegation that staff did not prevent physical altercation between children, confidential interviews did not reveal any physical altercations between C1 and any other resident. Confidential interviews revealed that C1 was a client that enjoyed participating in multiple activities, was engaged in services, and was described as being friendly with staff and peers. Confidential interviews did, however, share that early into C1's arrival at the facility there were some situations in which C1 and C2 engaged in exchanging looks and made comments to one another during group activities, but interviews did not reveal that any physical altercations occurred. Confidential interviews revealed that there were situations in which some clients went into C1's room to take things. Confidential interview indicated that the clients were redirected and reminded by staff that they are not allowed in other clients' rooms; however, none of the incidents resulted in a physical altercation. A review of Special Incident Reports sent to CCL from the facility did not reveal any reports of a physical altercation occurring. In response to the allegation that staff did not supervise minor resulting in the minor being absent without leave from the facility, confidential interviews revealed that on the evening of September 18, 2024, C1 requested to wash their clothes. Confidential interviews revealed that during that time, staff were attempting to deescalate a client in care. Confidential interviews revealed that C1 entered the laundry room and staff were able to hear C1 starting their laundry while the door was open. A conflicting confidential interview revealed that the laundry room door leading to the inside of the home was closed which prompted staff to check in on C1. Confidential interviews revealed that S5 noticed that C1 was not in the laundry room and immediately began the facility's unauthorized leave protocol. SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Abby Saeteurn LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 3 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Casa Nuestrafacility Number: Visit Date: 12/12/ Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32continued... A confidential interview revealed that the door to the laundry room must be left open for staff to observe clients. A review of a Special Incident Report submitted to CCL on 09/28/2024 revealed that while C1 was in the laundry area, "C1 made the choice to AWOL through the side door of the facility". A walk through performed by LPA Saeteurn on September 27, 2024, revealed that the facility has a washer and dryer on premises which is located in a room between the facility kitchen and garage/office area. The laundry room has three doorways, one leading to the garage/office area, one leading to the inside of the home kitchen area and a door leading to the outside of the home. LPA Saeteurn was able to see that the door leading to the side of the home gives access to an additional gate that leads to the driveway. Confidential interviews revealed that although clients are assigned a specific date to wash, C1 requested to use the washer on this day and staff approved it due to C1 having minimal clothing. A confidential interview confirmed that C1 was granted permission to use the laundry room on site and C1 proceeded to leave the facility to abscond. Confidential interviews revealed that C1 planned to abscond from the facility and communicated this to other residents. Confidential interviews revealed that clients were aware of C1's intentions to leave the facility, but it was not communicated to staff. Confidential interviews revealed that after S1 and S5 searched facility grounds for C1, an unauthorized protocol was enacted in which all parties were notified of C1 absconding. In reference to the allegation that staff did not ensure that minor attended school, confidential interviews and review of relevant client records confirmed that C1 was waiting for permanent placement to begin with Job Corps after being accepted into their program. The review of client records showed that C1 was attending school, however, conflicting confidential interview revealed that C1 was not enrolled in school. Confidential interviews revealed that C1 only attended the achievement center while placed at the facility which allowed for C1 to participate in education activities, sports, and field trips. A conflicting confidential interview revealed that the facility was allowed to complete the school enrollment process for C1 however, a conflicting confidential interview revealed that only the Authorized Representative and Educational Rights holder can make those decisions for minors in care. Confidential interviews revealed that C1's Education Rights Holder and Authorized Representative were contacted by the facility in an effort to help facilitate the process, however, neither C1's authorized representative nor educational rights holder ever completed the process. SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Abby Saeteurn LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 4 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Casa Nuestrafacility Number: Visit Date: 12/12/ Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32continued... A review of the facility Program Statement revealed that if a client is not enrolled in school upon intake, the facility will work with the family to accomplish this goal and will include it on the service plan. Additionally, the program statement also included that the client would have free time at the facility to complete homework or can receive tutoring whether at a tutoring center or at the achievement center. Based on interviews conducted, LPA observation and record review, the allegations that staff did not prevent a physical altercation between children, staff did not supervise minor resulting in the minor AWOL'g from the facility and staff did not ensure that minor attended school are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove the alleged violations occurred. An exit interview was conducted with Xavier Martinez,Program Director. A copy of this report and appeal rights were provided and reviewed with Xavier Martinez, Program Director whose signature on this report confirms receipt of these documents. SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Abby Saeteurn LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 2 of 4

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

met_with: Xavier Martinez, Program Director

complaint_status: unsubstantiated


raw_content:
Narrative:
It was reported that on March 10, 2024, C1 was threatening to kill and cut up Casa Nuestra staff and another minor in care. It was reported that on March 8, 2024, facility staff found a box cutter in the front yard of the facility and C1 put a metal wire in one of the facility's outlets causing a spark. Confidential interviews revealed that C1 and C2 were the only clients of the facility during the time frame reported. Confidential interviews and a review of pertinent facility records revealed that on March 10, 2024, C1 experienced a behavioral episode in which C1 was escalated and making threats of wanting to harm others. Confidential interviews revealed that the reason C1 was escalated was unknown, however, a review of facility records revealed C1 became escalated when refusing to turn over their cellphone for safeguarding. Confidential interviews revealed that C1 threatened to harm staff and C2, despite C2 not engaging with C1. Confidential interviews revealed that during C1's escalated behavior, C1 proceeded to stick a metal object into a facility outlet causing it to spark. A confidential interview revealed that days prior to the incident, facility staff found a knife outside of the facility which they believed belonged to C1. Confidential interviews revealed that the behavior C1 displayed was not something common and that there was no known history of C1 engaging in these kinds of behaviors. Confidential interviews revealed that in situations in which clients experience escalated behaviors, staff will attempt to help clients de-escalate prior to involving other mental health services. Confidential interviews revealed that staff attempted to help C1 de-escalate however, attempts were unsuccessful. A confidential interview revealed that due to the threats being made to C2 by C1, Staff each went separate ways with a client to create separation. Confidential interviews reveal that staff maintained contact with upper management and contacted the County of San Diego Mobile Crisis Response Team (MCRT) to assist. Confidential interviews revealed that staff followed MCRT's recommendation to contact the Psychiatry Emergency Response Team (PERT) due to the level of severity resulting in C1 being placed on a psychiatric hold. Based on confidential interviews and record review, the allegation that staff did not prevent minor from being threatened by another minor is unsubstantiated. Although the allegation may have happened or is valid there is not a preponderance of the evidence to prove the alleged violation occurred. Continued... An exit interview was conducted with Xavier Martinez, Program Director. A copy of this report and appeal rights were provided and reviewed with Xavier Martinez whose signature on this report confirms receipt of these documents.

Investigation Findings:
13On February 13, 2025, at 3: PM, Licensing Program Analyst (LPA) Abby Saeteurn, made an unannounced visit to Casa Nuestra and met with Xavier Martinez, Program Director, to deliver findings to the above stated allegation. LPA Carol Anderson initiated a complaint inspection at the facility on March 20, 2024, at 10: AM and no immediate deficiencies were observed. During the investigation, LPA Abby Saeteurn interviewed staff (S1-S3), Authorized Representative (AR2) and reviewed pertinent facility records. In addition, LPA Saeteurn attempted to interview clients (C1-C2), staff (S4), and authorized representative (AR1). AR1 declined to be interviewed and declined to allow C1 to be interviewed. Despite multiple attempts, C2 and S4 were unable to be reached. On March 11, 2024, Community Care Licensing (CCL), received a complaint alleging that facility staff did not prevent minor from being threatened by another minor. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Abby Saeteurn 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: CASA NUESTRAFACILITY NUMBER: VISIT DATE: 02/13/2025

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


summary: Facility Evaluation

raw_content:
Narrative:
On April 20, 2023, at 8: AM, Licensing Program Analyst (LPA) Gloria Meza-Gonzalez conducted an announced inspection at the above facility. LPA Meza-Gonzalez met with Department Director (DD) Sandy Keaton. The purpose of the inspection is to conduct a pre-licensing inspection The applicant is applying for a Youth Homelessness Preventer Center (YHPC) with the capacity of five ambulatory clients ages 13 to 17 years old. The facility is a five-bedroom, two-bathroom single-family home, with an attached garage. LPA Meza-Gonzalez inspected the interior and exterior of the facility with DD Keaton. Recreation room, dining room, kitchen, family room, four bedrooms, mental health room, two bathrooms, staff office, and laundry room. The YHPC is set up as follows: The garage was converted into a staff office. The staff office has five desks, five computers, a small table, and eight chairs. There is one large cabinet, one large filing cabinet, and two small filing cabinets. All the cabinets have locks. The medication will be locked in a cabinet in the staff's office. The client files will be located in the staff office in a locked filing cabinet. Sharp knives will be locked in a cabinet in the staff office. The first aid kit with the first aid manual and has all the required items. The client files will be electronically stored on a computer database and will be accessible for Community Care Licensing (CCL) to review at any time. There will be some portion of client files locked in a cabinet in the staff office. The staff office will be locked when not in use. Next to the staff's office is the laundry room with a washer, dryer, and large cabinet. The disinfectants and cleaning solutions are located in the locked cabinet. See LIC 809c page The recreation room is the living room. The recreation room has a desk and a game table for clients' use. The dining room has a table with six chairs, a water cooler, and a trash can with a tight-fitting lid. The kitchen has a stove with an oven a refrigerator and a microwave. The family room has two tables with four chairs, two sofas, and a single-seat sofa. There is a fireplace that will not be in use. Bedrooms are set up as follows: Bedroom #1 has two twin beds and a closet with a dresser. Bedroom #2 has two twin beds and a closet with a dresser. Bedroom #3 has two twin beds and a closet with a dresser. Bedroom #4 has two twin beds and a closet with a dresser. Bedroom #5 will be used for the mental health room. Bedrooms #1 through #4 all have adequate closet space. Each bed has a mattress, mattress pad, bedding, pillow, and pillow cover. One client per bed. There are two bathrooms for clients' use. Hot water temperature reading at 120 degrees F which is within Community Care Licensing Regulations. There are two closets in the hallway for extra linen. The Backyard is set up as follows: The backyard has patio furniture, two tables and eight chairs. A locked storage shed with maintenance supplies. There is a large area with grassy area with a lemon tree and an orange tree. There is ample lighting throughout the YHPC. There are ten ceiling fans throughout the house, one in each bedroom, recreation room, and dining room, and three in the family room. There are two fire extinguishers, one located in the staff office and the other in the dining room. The house has central heating and air conditioning. Clients will be allowed to make and receive confidential telephone calls. There are seven smoke detectors and two carbon monoxide throughout the house. The smoke detectors and carbon monoxide were checked and operating. The fire extinguishers are properly charged and serviced. Fire clearance was approved. Staff files will be located off-site at the facility's corporate office. Personal rights, emergency disaster plan, facility sketch, complaint/grievance policy, Menu, and discharge policy are posted. There is no weapon in the home. There are no cameras located inside or outside of the facility. See LIC 809c Page The applicant has been informed that the address of 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 applicant on this date. Based on the facility pre-licensing inspection and facility records review, no deficiencies were noted at the time of the inspection. Upon Licensing Program Manager's final review, the license will be provided. An exit interview was conducted and a copy of this report was given to DD Keaton.

visit_type: Prelicensing

met_with: Sandra Keaton


summary: Facility Evaluation

raw_content:
Narrative:
On August 4, 2023, at 10:10AM, Licensing Program Analyst (LPA) Carol Anderson conducted an announced inspection at the above facility. LPA Anderson met with Department Director (DD) Sandy Keaton and Xavier Martinez; Facility Administrator The purpose of the inspection is to conduct a Case Management inspection to increase the capacity from five to eight clients. Currently there are no clients residing at the facility at this time. The applicant is applying for a Group Home (Youth Homelessness Preventer Center (YHPC) with the capacity of eight ambulatory clients ages 13 to 17 years old. The facility is a five bedroom, two bathroom single-family home, with an attached garage. LPA inspected the interior and exterior of the facility with DD Keaton and FA Martinez. Recreation room, dining room, kitchen, family room, four bedrooms, mental health room, two bathrooms, staff office, and laundry room. The facility is set up as follows: The garage was converted into a staff office. The staff office has five desks, five computers, a small table, and eight chairs. There is one large cabinet, one large filing cabinet, and two small filing cabinets. All the cabinets have locks. The medication will be locked in a cabinet in the staff's office. The client files will be in the staff office in a locked filing cabinet. Sharp knives will be locked in a cabinet in the staff office. The first aid kit with the first aid manual and has all the required items. The client files will be electronically stored on a computer database and will be accessible for Community Care Licensing (CCL) to review at any time. There will be some portion of client files locked in a cabinet in the staff office. The staff office will be locked when not in use. The recreation room is the living room. The recreation room has a desk and a game table for clients' use. The dining room has a table with six chairs, a water cooler, and a trash can with a tight-fitting lid. The kitchen has a stove with an oven a refrigerator and a microwave. The family room has two tables with four chairs, two sofas, and a single-seat sofa. There is a fireplace that will not be in use. Next to the staff's office is the laundry room with a washer, dryer, and large cabinet. The disinfectants and cleaning solutions are in the locked cabinet. Bedrooms are set up as follows: Bedroom #1 has two twin beds and a closet with a dresser. Bedroom #2 has two twin beds and a closet with a dresser. Bedroom #3 has two twin beds and a closet with a dresser. Bedroom #4 has two twin beds and a closet with a dresser. Bedroom #5 will be used for the mental health room. Bedrooms #1 through #4 all have adequate closet space. Each bed has a mattress, mattress pad, bedding, pillow, and pillow cover. One client per bed. There are two bathrooms for clients' use. Hot water temperature reading at 119 degrees F which is within Community Care Licensing Regulations. There are two closets in the hallway for extra linen. There is ample lighting throughout the facility. There are ten ceiling fans throughout the house, one in each bedroom, recreation room, and dining room, and three in the family room. There are two fire extinguishers, one located in the staff office and the other in the dining room. The house has central heating and air conditioning. Clients will be allowed to make and receive confidential telephone calls. There are seven smoke detectors and two carbon monoxide throughout the house. The smoke detectors and carbon monoxide were checked and operating. The fire extinguishers are properly charged and serviced. Fire clearance was approved. Staff files will be located off-site at the facility's corporate office. Personal rights, emergency disaster plan, facility sketch, complaint/grievance policy, Menu, and discharge policy are posted. There is no weapon in the home. There are no cameras located inside or outside of the facility. The Backyard is set up as follows: The backyard has patio furniture, two tables and eight chairs. A locked storage shed with maintenance supplies. There is a large area with grassy area with a lemon tree and an orange tree. Based on the facility case management inspection, there are no deficiencies were noted at the time of the inspection. An exit interview was conducted, and a copy of this report was given to DD Keaton and FA Xavier Martinez.

met_with: Sandy Keaton


summary: Facility Evaluation

raw_content:
Narrative:
On March 20, 2024, at 12:33PM, Licensing Program Analyst (LPA) Carol Anderson conducted an unannounced annual/required of the above facility. LPA met with Program Director (PD) Xavier Martinez and Department Director Sandy Keaton. Currently there are no clients residing at the facility. LPA inspected the interior and exterior of the facility with PD Martinez. Recreation room, dining room, kitchen, family room, four bedrooms, mental health room, two bathrooms, staff offices, and laundry room, garage was converted into a staff office, medication locked in a cabinet in the staff's office. Staff files are stored on the computer database, sharp knives locked in a cabinet in the staff office. The first aid kit with the first aid manual and has all the required items. The facility's smoke detectors and carbon monoxide detectors were tested and were observed to be in working order; the fire extinguisher is properly charged and serviced. Hot water temperature reading at 108 degrees F which is within Community Care Licensing Regulations. . LPA reviewed staff files via Zoom with Human Resources Araceli Ramos. All the necessary forms were in the files. LPA interviewed one staff. Bedrooms are set up as follows: Bedroom #1 has two twin beds and a closet with a dresser. Bedroom #2 has two twin beds and a closet with a dresser. Bedroom #3 has two twin beds and a closet with a dresser. Bedroom #4 has two twin beds and a closet with a dresser. Bedroom #5 will be used for the mental health room. Bedrooms #1 through #4 all have adequate closet space. Each bed has a mattress, mattress pad, bedding, pillow, and pillow cover. One client per bed. There are two bathrooms for clients' use. The Backyard is set up as follows: The backyard has patio furniture, two tables and eight chairs. A locked storage shed with maintenance supplies. There is a large area with grassy area with a lemon tree and an orange tree. Personal rights, emergency disaster plan, facility sketch, complaint/grievance policy, Menu, and discharge policy are posted. There is no weapon in the home. There are cameras located outside of the facility. A review of Guardian on March 20, 2024, indicates that all facility staff associated to the facility had DOJ, FBI, and child abuse index checks clearances. Based on observations made during the inspection, no deficiencies observed during today's visit. An exit interview was conducted, and a copy of this report was given to PD Martinez.

met_with: Xavier Martinez


summary: Facility Evaluation

raw_content:
Narrative:
On February 20, 2025 at 4: PM, Licensing Program Analyst (LPA) Abby Saeteurn conducted an unannounced case management visit at the facility and met with Veronica Castro, Residential Associate . There were no deficiencies cited during the visit. An exit interview was conducted with Veronica Castro, Residential Associate and a signed copy of this report was provided.

met_with: Veronica Castro, Residential Associate


summary: Facility Evaluation

raw_content:
Narrative:
On March 4, 2025 at 2: PM, Licensing Program Analyst (LPA) Abby Saeteurn conducted an unannounced case management visit at the facility and met with Xavier Martinez, Program Director. The purpose of the case management visit is to obtain a signature and deliver an amended version of the LIC 9099 originally delivered on February 13, 2025. An exit interview was conducted with Xavier Martinez, Program Director. Copies of this report, the amended report, and appeal rights were provided to Xavier Martinez at the end of the visit.


summary: Facility Evaluation

raw_content:
Narrative:
On April 28, 2026, at 9:05AM, Licensing Program Analyst (LPA) Lisa Bernabe conducted an unannounced annual/required of the above facility. LPA met with Program Director (PD) Xavier Martinez, Currently there are one clients residing at the facility. LPA inspected the interior and exterior of the facility with PD Martinez. Recreation room, dining room, kitchen, family room, four bedrooms, mental health room, two bathrooms, staff offices, and laundry room, garage was converted into a staff office, medication locked in a cabinet in the staff's office. Staff files are stored on the computer database, sharp knives locked in hallway closet. The first aid kit with the first aid manual and has all the required items. The facility's smoke detectors and carbon monoxide detectors were tested and were observed to be in working order; the fire extinguisher is properly charged and serviced. Hot water temperature reading at 119 degrees F which is within Community Care Licensing Regulations. LPA reviewed five staff and one client file, all the necessary forms were in the files. LPA conducted three staff. Bedrooms are set up as follows: Bedroom #1 has two twin beds and a closet with a dresser. Bedroom #2 has two twin beds and a closet with a dresser. Bedroom #3 has two twin beds and a closet with a dresser. Continuation on LIC 809-C Continuation of LIC Bedroom #4 has two twin beds and a closet with a dresser and one bed is currently occupied by client. Bedroom #5 will be used for the mental health room. Bedrooms #1 through #4 all have adequate closet space. Each bed has a mattress, mattress pad, bedding, pillow, and pillow cover. One client per bed. There are two bathrooms for clients' use. An exit interview was conducted with Xavier Martinez, Program Director and a signed copy of this report, LIC 811 was provided.

met_with: Xavier Martinez Program Director


facility_name: CSP INC YOUTH SHELTER

summary: Facility Evaluation

raw_content:
Narrative:
On October 25, 2022, at 9: AM Licensing Program Analysts (LPA's) Lucero Jauregui, Eduardo Barragan conducted an announced annual facility inspection. LPA's met with Melissa Whitworth, House Supervisor/Group Home Administrator who provided LPA's with a guided tour of the facility both indoors and outdoors. The facility is a Three bedroom three bathroom (for client use) in this three story home. The basement floor consists of a bathroom, a bedroom, office space, a basement room (recreational room) and a laundry room. The common floor consisted off a Living room, kitchen, dinning area, and staff office. The third floor consisted of 2 bedrooms, 2 bathrooms and therapy room. All three bedrooms consisted of 2 bedrooms and all beds were observed with appropriate clean linens, pillows, comforters, and all mattresses were in good repair. The backyard consisted off a patio set, a basketball court and two small sheds on the side of the home. One of the sheds was used for tools and was locked the second shed was used for emergency food and belongings. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. The hot water temperature was measured in the main bathroom and is currently 110.0 degrees which is in ration. Facility has cameras in common areas of the facility (8 cameras were noted on the premies of this facility.) Continued... Facility does not have a pool. Per facility staff, no firearms or weapons are allowed in the facility. LPA's observed the following items posted Personal Rights, Grievance Procedures, Visitation Policy, Facility sketch, Menu, and Emergency Plan. Medications were centrally stored and locked. During the inspection LPA's reviewed three staff personnel files to ensure they contained all required documentation per Title Regulations. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. All licensing fees have been paid and are current at this time. LPA's also reviewed five client personal files and ensured that the client files contained all required documentation per Tittle Regulations. Based on the facility inspection and file reviews this date there was no deficiencies found at this time. However, one technical Violation is being administered per California Code of Regulations, (Title 22, Division 6, Chapter 1 regulation 80087(a)") A exit interview was conducted. A copy of the report was discussed and provided along with appeal rights to Melissa Whitworth, House Supervisor/Group Home Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On 04/02/2025 at 9: AM Licensing Program Analyst (LPA) Gilbert Marquez met with Melissa Whitworth, House Supervisor/Administrator, for the purpose of conducting an annual inspection of the facility. The Facility is licensed to serve six ambulatory children ages 11-17 years old. The current census is three youth. The Facility is current with their licensing fees. The Facility is a three story dwelling. A physical plant inspection was completed with House Supervisor and included the following areas: three bedrooms, kitchen, four bathrooms (three client, one staff), dining room, living room, computer and recreation room, three staff offices, and an outdoor activity space. All required forms are posted including License, Grievance Procedures, Visitation Policies, Personal Rights form, and the Emergency Disaster Plan. Clients medications were observed to be inaccessible and stored in staff office on the main floor. LPA observed cameras at the facility in the front of the home, and there are cameras placed around the facility. No cameras were found in bedrooms. Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order. The fire extinguishers are properly charged and serviced. 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. **Continued on LIC809-C**. **Continued from LIC809** Individual beds were observed with clean linens, pillows, comforters, and mattress in good repair. All three bedrooms contain two twin beds. The water temperature was tested in bathroom #3 which measured 117 degrees Fahrenheit which is within the appropriate range of 105 degrees to 120 degrees Fahrenheit. There is one facility van that is on lease. There were no maintenance lights on. All client files are stored and maintained on both a locked cabinet, and on a secure internet database. LPA reviewed three client files and medication records to ensure clients had all required documents per Title 22. LPA reviewed five out of 36 staff files to ensure staff had all required documents per Title 22 regulations. Staff records are stored in a locked cabinet. Per a review of Guardian, all staff have a criminal record clearance. LPA conducted two staff interviews, and all three clients refused to be interviewed. Per facility staff, no firearms or weapons are allowed in the facility. No deficiencies cited during today's inspection. An exit interview was conducted with House Supervisor. A copy of this report, and a Confidential Names List LIC811 were provided to House Supervisor. A copy of this report will be placed in the facility file


facility_name: DIAMOND YOUTH SHELTER

summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Appeal Rights were provided and discussed with the facility and deficiencies were cited under The Youth Homelessness Prevention Center (YHPC) Interim Licensing Standard (ILS) build on the current California Code of Regulations Title 22, Division 6, Chapter General Licensing Requirements and Chapter Group Homes. Exit interview conducted and a copy of the report was left with the facility Administrator.

Investigation Findings:
13On Thursday August 05, 2021 at 3: PM, Licensing Program Analyst (LPA) Isabel Mendoza made a visit to deliver findings for a complaint investigation for the above allegation. Due to the serious nature of the allegation, the investigation was conducted by the Investigations Branch (IB), Investigator Dinah Watkins. LPA met with Administrator, Asha Robertson. During the course of (IB) investigation IB Case # CD1424-03042 interviewed, clients, staff members, viewed the facility video footage, and obtained copies of medical records, police report, and other documentation. Based on the information obtained, there is preponderance of the evidence to prove that client C1 (See LIC 811, dated 08/05/21 for Confidential Names) was sexually assaulted by (C2) due to lack of supervision on 3/15/21. Therefore, the above allegation is substantiated. [Please refer to LIC 9099-A for cont.] SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: Isabel Mendoza LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, TRAEGER AVE., SUITE FACILITY NAME: DIAMOND YOUTH SHELTERFACILITY NUMBER: VISIT DATE: 08/05/2021

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

met_with: Administrator, Asha Robertson


raw_content:
Investigation Findings:
13On 11/28/23 at 11:30AM Licensing Program Analysts (LPA's) Celeste Aparicio and Mariah Hawkins made an unannounced inspection to the facility for the purpose of delivering findings from a complaint investigation. LPA's met with residential counselor Annola Powell and over the phone with Administrator Asha Robertson and informed them on the purpose of this visit. Although the allegation may have happened or is valid, based on LPA's observations and interviews, there is not a preponderance of the evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. An exit interview was conducted, appeal rights were provided, and a copy of this report was provided to the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lidia Tinoco LICENSING EVALUATOR NAME: Celeste Aparicio LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Annola Powell


summary: Facility Evaluation

raw_content:
Narrative:
On 3/9/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a 2yr required inspection. LPA met with Program Manager Patty Rahmer and informed of the purpose of the visit. LPA used the CARE Inspection Tool to conduct this inspection. LPA interviewed three staff and toured the facility site and grounds. No deficiencies were observed at today's visit. A continuation visit will be conducted at a later date. An exit interview was conducted, appeal rights discussed, and a copy of this report was left with Program Manager, whose signature on this form confirms receipt.

met_with: Program Manager Patty Rahmer


summary: Facility Evaluation

raw_content:
Narrative:
On 3/17/23, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility for a continuation of the 2yr inspection initiated on 3/9/23. LPA met with Residential Counselor Kevin Stevenson and informed of the purpose of the visit. LPA conducted a COVID-19 screening call with Kevin prior to the visit. The physical tour was completed at the initial visit. Three staff were interviewed, and no residents were present. During today's visit, no residents were in care. LPA requested to review personnel and resident files. Five resident files were reviewed, and personnel files will be reviewed at a later date. Resident records were complete. First aid kits were inspected and observed to be complete. Hot water was measured and observed to be at a safe temperature. No deficiencies were found during today's inspection. An exit interview was conducted and a copy of this report was left with Residential Counselor, whose signature on this form confirms receipt.

met_with: Residential Counselor Kevin Stevenson


summary: Facility Evaluation

raw_content:
Narrative:
On 3/24/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a 2yr inspection continuation visit. LPA met with Chief Talent and Equity Officer Chayla Gibson and informed of the purpose of the visit. Due to licensee storing personnel files at the administrative office, LPA is conducting this visit at this location rather than the facility location. LPA reviewed five personnel files and observed all files to be complete. The staff training certificates were maintained electronically, and staff pulled up each certificate for review. LPA observed files to be complete and staff to have taken 20 or more hours of training in the year 2022. LPA advised the facility that personnel files should be available for review at the facility site. While files can be maintained at an administrative location, they should be available upon request during normal business hours. In the future, files will need to be made available at the facility site rather than at the administrative location. During visit, LPA observed that no administrator certificate could be located. LPA connected to the internet to check the administrator certification section's (ACS) active administrator and pending applications lists, and LPA and Chayla observed that Administrator on record was not listed. Administrator confirmed that she has planned to attend continued education training but had not received any certificate or anything in writing from ACS about the certificate. LPA advised that certificates are valid for two years, so administrators will need to plan to complete all required components, including training, for recertification prior to the expiration date. No citations were issued during this visit. An exit interview was conducted, appeal rights discussed, and a copy of this report was left with Chayla Gibson, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 2/18/25, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit at the facility in order to deliver notice of the findings of an investigation of an incident report. LPA met with Relief Counselor (RC), who granted LPA entry, and Administrator Asha Robertson over the phone. LPA informed both of the purpose of the visit. In January 2025, the facility submitted an incident report regarding a grievance filed by a former client, who alleged a personal rights violation. The matter was referred to the Licensing agency's Investigations Bureau. Based on confidential interviews, observations, and record review, no evidence was found supporting the allegation. Therefore, no deficiencies were observed. At today's visit, no citations were issued. An exit interview was conducted, and Administrator Asha Robertson agreed to receive a copy of this report via email and return a signed copy to LPA to confirm receipt.

met_with: Administrator Asha Robertson; Relief Counselor


summary: Facility Evaluation

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Narrative:
On 2/21/25, Licensing Program Analyst (LPA) Mariah Hawkins conducted a random annual inspection. The facility's prior annual inspection was conducted on 3/9/23. LPA met with Relief Counselor, who granted LPA entry, and Administrator Asha Robertson over the phone. There were four clients in care, but none were present during LPA's visit. LPA toured the facility site and observed the facility to be maintained in safe and sanitary condition. The facility license is posted in the front of the facility, and throughout the facility are posted resources, including local food, housing, and employment resources. Grievance procedures and forms are also posted. The kitchen is clean and organized, and food storage reflects a large supply of varied, healthy food options. The bathrooms are sanitary, and linen storage reflects a large supply of clean linens ready for client use. Bedrooms offer each client an individual bed and are well-lit with natural lighting and indoor lighting. There are multiple sitting areas and a dining area in the kitchen. LPA discussed with Administrator that a continuation visit will be conducted in order to complete this inspection, including completing the review of facility records. LPA requested current versions of the following documents be sent to LPA by Wednesday 2/26/25: (1) LIC 500; (2) LIC 610C; (3) Staff Contact Sheet; (4) Client Roster [LIC 9020 or other List] with dates of birth and authorized representative names. At today's visit, no citations were issued. An exit interview was conducted, and Administrator Asha Robertson agreed to receive a copy of this report via email and return a signed copy to LPA to confirm receipt.


summary: Facility Evaluation

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Narrative:
On 4/8/25, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management annual continuation visit. LPA met with Interim Administrator Erick Romero and informed of the purpose of the visit. LPA inspected 5 client files and observed all files to be complete. No clients were present during LPA's visit. LPA provided technical assistance on forms and regulations and discussed facility procedures with Interim Administrator. LPA requested the following be emailed to LPA by 4/15/25: - Monthly Population Reports for March 2024 through March 2025 (per ILS 84561(g)) - Emergency Drill documentation for March 2024 through March 2025 (per Health and Safety Code 1565(c) and Title 22, 80023(d)) No deficiencies were observed during today's visit. An exit interview was conducted, and a copy of this report and the licensee's appeal rights were provided to Administrator.

met_with: Interim Administrator Erick Romero


summary: Facility Evaluation

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Narrative:
On May 5, 2026, Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced Annual Inspection at the above listed facility. LPA met with Erick Romero, Administrator, and explained the purpose of the visit. The Youth Homelessness Prevention Center is licensed to serve 20 clients. Currently the program has 6 clients. Present at the home during the inspection was 2 clients. During the inspection, LPA obtained an updated LIC 500 (Personnel Report) to ensure the facility's records are current. A review of the Guardian background check system on May 5, 2025, confirmed that all staff associated with the program had cleared Department of Justice (DOJ), Federal Bureau of Investigation (FBI), and Child Abuse Central Index (CACI) background checks. Administrator stated staff records are not kept on site and contacted HR to get staff files chosen by LPA Medina. At 12:45 p.m, LPA began the inspection by doing a walk through of the facility. Using the CARE inspection tool LPA Medina did not identify any deficiencies. The facility had an abundant amount of food that met regulatory standards. The facility premises are maintained clean and sanitary. LPA observed carbon monoxide detectors, requires postings on the wall including license, and complete first aid kit. LPA took a reading of the facility water temperature which was within the regulatory range at 118 degrees fahrenheit. LPA also observed a large amount of available clean linens and observed each client has access to individual bed. The back yard is mainly constructed with gardening areas, however Administrator stated the program will take youth to local park for outdoor activities. The facility has a licensed capacity of 20, however only has 16 beds on the premises. No deficiencies were observed in this section of the CARE inspection tool. Continues on LIC809-C At 1:30 p.m, LPA reviewed 5 client files at random. Monthly Population Report will be emailed to LPA Medina by Friday, 5/8/2026. LPA reviewed Medication Log which has client name, list of medications, time it was administered, date, and staff initials. Files also had signed consent forms, admission agreement, emergency contacts, record of clients needs, signed acknowledgement of personal rights, and grievance policy. No deficiencies were observed in this section of the CARE inspection tool. This inspection is not yet complete. A continuation visit will be conducted in order to complete this inspection, including completing the review of facility records. No deficiencies were observed. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to Erick Romero, Administrator. Signature on this report acknowledges receipt.

met_with: Erick Romero - Administrator


summary: Facility Evaluation

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Narrative:
On 05/08/2026 at 10:00am, Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced Annual Continuation Inspection at the above listed facility. LPA met with Nicholas Hester, Associate Director of Shelter Programs who assisted in the inspection. LPA Medina began the inspection by reviewing the disaster preparedness section of the CARE inspection tool. LPA reviewed a roster of clients, medication list, LIC610-C, and set of all keys for the facility. Unfortunately, there was no documentation of the emergency disaster drill conducted. Please refer to LIC809-D for additional details. At approximately 11:00am , LPA began the Operational Requirements and Emergency Intervention Plan sections of the CARE tool. Upon review of the monthly written report, LPA found areas of improvement to better document the specific number of youth served per month and the number of times a youth accesses the youth homelessness prevention center and services at the center per month. Please refer to LIC9102 pages for additional details. No other deficiencies were observed in this section. LPA Medina concluded the inspection by reviewing staff files. Files for 5 staff members were presented to LPA digitally on Microsoft Teams. Upon review LPA observed staff had all required documentation including current First Aid/CPR certifications, fingerprint clearances, educational verification, TB test results, criminal record statements, health screenings, personnel records, and employee rights documents. This program uses Crisis Prevention Institute (CPI) techniques as their de-escalation training. Crestina Scolaro, Program Director is the current CPI certified instructor. Continues on LIC809-C All other trainings identified in CARE tool was also present. No deficiencies were observed in this section. LPA conducted interviews with staff, however clients did not feel comfortable conducting an interview. As a result of this inspection, the program was cited for one type B deficiency, one Technical Violation, and one Technical Assistance. Please refer to LIC 9102 and LIC 809-D pages for additional details. An exit interview was conducted, appeal rights were provided, and a copy of this report was left with Nicholas Hester, Associate Director of Shelter Programs, whose signature confirms receipt.

met_with: Nicholas Hester - Associate DIrector of Shelter Programs


facility_name: DREAMCATCHER YOUTH SHELTER

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Narrative:
continued from LIC Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that staff do not ensure food of good quality is provided to youth Therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was given to Ashley Burns, Interim Program Director, whose signature confirms its receipt.

Investigation Findings:
13On 5-3-23 2:54PM, Licensing Program Analyst (LPA) George Karkazis conducted an unannounced inspection at Dreamcatcher Youth Shelter to deliver the complaint findings. LPA Karkazis met with Ashley Burns Interim Program Director, who helped with the inspection. Regarding the allegation that staff do not ensure food of good quality is provided to youth: On 4-28-23, LPA Karkazis toured the facility and inspected all food items in the facility. All foods are fresh and of good quality, except LPA observed 12 containers of spices and 6 cans of assorted foods. All items had "best by" dates, were dated beyond "best by" date. Today (5-3-23) LPA toured the facility and observed at least two days perishable and seven days non-perishable food supply. All foods observed were within expiration dates. Ashley Burns Interim Program Director, stated that the 12 containers of spices and 6 cans of assorted foods have been thrown away. continued on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: George Karkazis LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CENTRAL COAST SC/RES, TRAEGER AVE., SUITE FACILITY NAME: DREAMCATCHER YOUTH SHELTERFACILITY NUMBER: VISIT DATE: 05/03/2023

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

met_with: Ashley Burns Interim Program Director


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Narrative:
continued from LIC Regarding the allegation that staff did not attempt to reunite youth with parent: During the course of the investigation, LPA conducted confidential interviews with staff, clients, and representatives. LPA conducted document research. During confidential interviews, the client stated that they do not want to go home and is currently looking for foster home placement. During confidential interviews with staff and representatives, inconsistent information was provided, regarding various attempts for family reunification and communication. LPA conducted document research in the client's facility file and found multiple text messaging conversations between family and Dreamcatchers staff. The facility had conducted two family reunification meetings. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that staff did not attempt to reunite youth with parent. Therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was given to Drew Watkins, Wellness Center Coordinator.

Investigation Findings:
13On 5-9-23 11:39AM, Licensing Program Analyst (LPA) George Karkazis conducted an unannounced inspection at Dreamcatcher Youth Shelter to deliver complaint findings. LPA Karkazis met with Drew Watkins ,Wellness Center Coordinator, who helped with the inspection. Regarding the allegation that staff violated youth's personal rights: During the course of the investigation, LPA conducted confidential interviews with clients, staff, and representatives. LPA conducted document research. During confidential interviews with clients, staff and client representatives, inconsistent information was provided. No one could recall any specific personal rights violations against the client but stated there were some. LPA conducted document research and found no evidence of staff violating client's personal rights. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that staff violated youth's personal rights. Therefore, the allegation is UNSUBSTANTIATED. continued on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: George Karkazis LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CENTRAL COAST SC/RES, TRAEGER AVE., SUITE FACILITY NAME: DREAMCATCHER YOUTH SHELTERFACILITY NUMBER: VISIT DATE: 05/09/2023

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


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Narrative:
continued from LIC LPA conducted document research in the facility's program statement. There is no clause in the program statement where the facility must contact the parents when a youth returns to the facility. Client safety and confidentiality are critical and come first. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the facility did not follow program statement regarding communication with authorized representative. Therefore, the above allegation is UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was given to Dara Stanton, Residential Manager.

Investigation Findings:
13On 9-6-23 1:07PM, Licensing Program Analyst (LPA) George Karkazis made an unannounced inspection at Dreamcatcher Youth Shelter. The purpose of the inspection was to deliver the findings to the above complaint allegation. LPA met with Dara Stanton, Residential Manager, who helped facilitate the inspection. During the course of the investigation, LPA Karkazis conducted confidential interviews with staff, clients, and conducted document research. During confidential interviews with staff and clients, inconsistent information was provided. The client stated they did not want to be reunited with their family. The facility representatives stated they normally contact authorized representatives once a client returns from extended AWOL. The authorized representative has made threats against the client, the facility, and its employees. Facility representatives stated they did not contact authorized representatives due to safety concerns and confidentiality. (continued on LIC 9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: George Karkazis LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO ASC, TRAEGER AVE., SUITE FACILITY NAME: DREAMCATCHER YOUTH SHELTERFACILITY NUMBER: VISIT DATE: 09/06/2023

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

met_with: Dara Stanton, Residential Manager


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Christopher Rollins conducted an unannounced annual inspection at Dreamcatcher Youth Shelter. During the inspection, LPA met with Amba Johnson Administrator, Ami Rowland Chief Operating Officer (COO) and Paida Ndemera-Senior Vice President (SVP) and inspect the facility inside and out. The facility is licensed to served runaway and homeless youth. The facility consists of 5 bedrooms and Bathrooms (5 for client and Staff). The facility is a two level building with 3 kitchens, living room and conference rooms for meeting. The facility is licensed for 24 residents (all can be non-ambulatory) and currently 5 clients reside in facility. No more than four clients share a bedroom. At 02: PM LPA Rollins, Administrator, COO and SVP conducted a walk through of the facility inside and out. The kitchens is clean. License and signs are up to date and hanging up in clear sight. The hot water measured 114.6 degrees F in the sink,bathroom and bath tub. The facility has plenty of nonperishable and perishable food supply. Medication and knives are locked away. Medication logs are up to date. There are enough folks, spoons, plates and cups. All passageways are unobstructed. All smoke detectors are update and working. The home is clean, safe, and sanitary. There are no firearms on the property. The fire extinguisher has been checked and is up to date. First aid kit is complete and fully stock. There are no bodies of water on the property. At 2: PM, LPA Rollins reviewed 5 client files with Administrator, COO and SVP. LPA observed all 5 client files to be complete, all documents were up to date and LPA found no deficiencies. At 3: PM, LPA observed 16 staff files with Administrator, COO and SVP. LPA observed staff files to be complete and documentation was update. LPA found no deficiencies. LPA observed all facility staff have completed there 20 hours annual training. LPA observed all training to be up to date and all certificates to be complete. During inspection, LPA receive an updated copy of the LIC Personnel Report to maintain their file current. A review of Licensing Information System on October 19, 2021 indicates that all facility staff associated to the facility had DOJ, FBI and child abuse index check clearances. Per Title Regulations, no deficiencies were cited during the inspection. Exit interview was conducted and a copy of the report was left at the facility.

met_with: Amba Johnson- Administrator, Ami Rowland-Chief Operating Officer and Paida Ndemera-Senior Vice President


summary: Facility Evaluation

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Narrative:
On 5-5-23, Licensing Program Analyst (LPA) George Karkazis conducted an unannounced inspection at Dreamcatcher Youth Shelter. Dara Stanton, Residential Manager, Paidad Ndemera, Senior Vice President, helped with the inspection. The purpose of the inspection was to conduct additional staff and client interviews for complaint #14-CR-20230320140458, dated 3-20-23. At this time four staff and one client interviews were conducted. An exit interview was conducted and a copy of this report was given to Dara Stanton, Residential Manager.

met_with: Dara Stanton, Residential Manager, Paida Ndemera, Senior Vice President.


summary: Facility Evaluation - 1 deficiency

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Narrative:
On 12-11-23 10:27AM, Licensing Program Analysts George Karkazis conducted an unannounced Annual/Random inspection at listed facility. LPA met with Ashley Burns, Program Director, and toured the facility inside and out. The Group Home is licensed to serve 24 clients. Present during the inspection were 5 staff and 2 clients. At 10:30AM, LPA Karkazis reviewed client and staff files. Client files were complete and in good order. Staff files were not complete. S1 missing LIC 508, LIC 9052. S2 missing LIC 503, LIC 508, LIC 9052. S3 missing LIC 503, LIC 9052. S4 missing LIC 503, LIC 508. S5 missing Fingerprint Clearance, LIC 503, LIC 508. Staff training records were not present in files. At 2:30PM, LPA Karkazis toured the facility. LPA Karkazis observed 5 bedrooms and 4 bathrooms. LPA observed facility license, personal rights, facility sketch, meal menu, and other forms posted on the walls throughout the facility. LPA Karkazis tested the water temperature and found it to be 111 degrees which is in range. The thermostat read 68 degrees which is within range. Sharps were locked and chemicals were safely stored. There were two days of perishable foods and seven days non-perishable foods present. The medication was also stored and locked in the office. The facility is in good repair and clean. LPA Karkazis interviewed 2 staff and no clients. Clients declined interviews There is no backyard. There were no open bodies of water. continued on LIC 808-C continued from LIC The facility receiving four citations and one civil penalty. California Code of Regulations (CCR) 80066(a)(10) Personnel Records, CCR 84065(i)(2) Personnel Requirements, CCR 84065(j)(7) Personnel Requirements, and CCR 80019(e) Criminal Record Clearance, including civil penalty. An exit interview was conducted, appeal rights discussed and a copy of this report was given to Ashley Burns, Program Director.

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

met_with: Ashley Burns, Program Director


summary: Facility Evaluation

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Narrative:
On 1-11-24 10:00AM, Licensing Program Analyst (LPA) George Karkazis made an unannounced inspection at Dreamcatchers for the purpose of interviewing clients from T&T House of Champions, complaint dated 1-8-24, #14-CR-20240108164030. LPA met with Case Manager Taleah Leung and toured the facility, which was clean and in good repair. Clients were transferred to another temporary shelter, and unavailable for interview. LPA will travel in attempt to interview the clients at their current location. An exit interview was conducted and a copy of this report was given to Taleah Leung, Case Work Manager.

met_with: Taleah Leung, Case Work Manager


summary: Facility Evaluation

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Narrative:
On 5-14-24 11:15AM, Licensing Program Analyst (LPA) George Karkazis conducted a Case Management Inspection at Dreamcatchers. The purpose of the inspection was to provide information regarding their temporoary closure which will commence July 1, 2024. Ashley Burns provided LPA with a letter of notification of closure. In addition, LPA conducted interviews for REFUGE 3 complaint dated 3-29-24, #14-CR-20240329140947. Clients fled from REFUGE 3 to Dreamcatchers on 3-28-24. An exit interview was conducted and a copy of this report was given to Ashley Burns, Director.

met_with: Ashley Burns, Director