summary: Facility Evaluation

raw_content:
Narrative:
On July 30th 2024, at 9: AM, Licensing Program Analyst (LPA) Guadalupe Munoz arrived at Sheila's small family home and met with licensee who granted LPA access to the home. The purpose of this visit is to conduct an annual required inspection of the small family home. Presently there is one child (C1) in placement and the child was present during time of inspection (See LIC 811). The home is a single story with four bedrooms and two bathrooms. Bedroom #1 has one twin bed; it is currently occupied by one client; Client 1 (C1) Bedroom #2 has two twin beds; it is currently vacant Bedroom #3 has a twin bed; it is currently vacant Bedroom #4 has a twin and a full bed; it is occupied by licensee Bedrooms are arranged so that no more than two children share a room, and there is one child per bed. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. There is adequate drawer and closet space for children's belongings. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The fireplace is properly screened. All hazardous items have been properly made inaccessible to areas where children will have access. The medications are locked and stored in the dining room cabinet. Cleansers/chemicals are locked and stored in the laundry room cabinet. Sharp knives are inaccessible and stored in a locked kitchen drawer. The first aid kit is in the dining room cabinet. There are no guns or weapons in the home as reported by Licensee. . The hot water temperature was within normal limits of regulatory requirements of 110 degrees. All facility smoke detectors and carbon monoxide detectors are synchronized and in appropriate working order; fire extinguisher is properly charged and serviced. LPA interviewed two staff. LPA attempted one client interview however unable to complete due to developmental functioning of client. A review of two staff records on this date indicated that all facility staff had received criminal record and child abuse index check clearances. In accordance with Title 22, Division 6, Chapters 1 & 4 there were no deficiencies being cited at this time. Exit interview was conducted and a copy of this report along with a Confidential Names List (LIC 811) was provided to Licensee.

met_with: Sheila Gomez


state: CA

facility_name: SHEILA'S SMALL FAMILY HOME

summary: Facility Evaluation

raw_content:
Narrative:
On 06/12/25, at 12: PM, Licensing Program Analyst (LPA) Gilbert Marquez met with Sheila Gomez, Administrator and Owner of Sheila's Small Family Home for the purpose of conducting an annual inspection of the facility. The Facility is licensed to serve four clients who are developmenatlly disabled, ambulatory, and ages six - 17 years old. The current census is one client. Facility licensing fees are current. The facility is a single story dwelling. A physical plant inspection was completed with Sheila and included the following checks: kitchen, dining room, living room, three client bedrooms, Administrator master bedroom, and outdoor living space. Current client bedroom contained two twin beds but only current client (C1 - See Confidential Names List LIC811) will occupy it, and other non-occupied bedrooms contained one twin bed. The facility has one client hallway bathroom, and a master bathroom adjacent to master bedroom. All beds were observed with appropriate bedding and mattress in good repair. Bedrooms contained adequate drawers and closet space. No bedroom occupied more than one client and not used for other purposes. The water temperature was tested in client hallway bathoom which measured 119.2 degrees Fahrenheit which is within the appropriate range of 105 degrees to 120 degrees Fahrenheit. The first aid kit was accessible to all staff and had all required supplies. All required forms are posted including Personal Rights and the License. Clients' medications were observed to be inaccessible and stored in medication cabinet. **Continued on LIC809C** **Continued from LIC809** 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; fire extinguisher was 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. All client files are stored in locked cabinet. LPA reviewed one of one client file (C1) to ensure client had all required documents per Title 22. Client file had education records, physical examinations, and behavior plans. LPA also reviewed one client medication record which had psychotropic medications on separate psychotropic medication administration records. All staff files are stored in a locked cabinet. LPA reviewed two out of two staff files (S1 and S2) to ensure staff had all required documents such as criminal record clearance or exemption, health screening and tb test, drivers license, personnel record LIC501, and updated First Aid and CPR training. LPA conducted two staff interviews (S1 and S2) and one client interview (C1). Per facility staff, no firearms or weapons are allowed in the facility. An exit interview was conducted, this report was discussed, and a copy of this report was provided to Sheila Gomez. A copy of this report will be placed in the facility file.

report_type: Facility Evaluation

visit_type: Annual

met_with: Sheila Gomez, Administrator


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
**(Continued from LIC9099A)** Based on confidential interviews and documentation received, the allegation that S1 pulled the hair of minor C1 in care may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights were explained, and a copy of this report and LIC 811 were provided to Licensee, Sheila Gomez.

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

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

report_type: Complaint Investigation

met_with: Licensee Sheila Gomez

complaint_status: unsubstantiated


summary: Facility Evaluation

raw_content:
Narrative:
On April 16, 2026, at 12: PM, Licensing Program Analyst (LPA) Gilbert Marquez met with Sheila Gomez, Licensee for the purpose of conducting an annual inspection of the facility. The Facility is licensed to serve four clients who are developmentally disabled, ambulatory, and ages six - 17 years old. LPA spoke to Licensee regarding facility licensing fees due in May. The facility is a single-story dwelling. A physical plant inspection was completed with Licensee Sheila and included the following checks: kitchen, dining room, living room, three client bedrooms, master bedroom, and outdoor living space. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. All the required linens were on every bed. The two bathrooms and four bedrooms are arranged the following way: Bedroom #1 will sleep one client, and has one twin bed, dresser and closet Bedroom #2 sleeps one client and has two twin beds, TV, dresser, and closet space Bedroom #3 will sleep one client and has one twin bed, dresser and closet Bedroom #4 is the Master Bedroom and sleeps the Licensee and Mother who is a supporting care giver Bathroom #1 is located in the hallway adjacent to Bedroom #2 and #3, and has a jack and jill sink, toilet, and shower Bathroom #2 is connected to the Master Bedroom, and has a sink, toilet, and shower **Continued on LIC809C** **Continued from LIC809** The water temperature was tested in bathroom #1 which measured at 105.3 degrees Fahrenheit, and in the kitchen which measured at 107.2 degrees Fahrenheit, which is within the regulatory range of 105 degrees to 120 degrees Fahrenheit. The first aid kit was accessible to all staff and had all required supplies. All required forms are posted including Grievance Procedures, Personal Rights, and the Emergency Disaster Plan. Client's medications were observed to be inaccessible and stored in medication cabinet. 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 extinguisher was 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. All client files are stored in locked cabinet. LPA reviewed one of one client files (C1, see Confidential Names List LIC811) to ensure client had all required documents per Title 22. C1's file had Individual Person Plans (IPPs), education records, physical examinations, and behavior plans. LPA also reviewed one client medication record which had psychotropic medications on separate psychotropic medication administration records. LPA also reviewd the required court documents for psychotropic medications. All staff files are stored in a locked cabinet. LPA reviewed two out of two staff files (S1 and S2) to ensure staff had all required documents such as criminal record clearance or exemption, health screening and TB test, driver's license, personnel record LIC501, and updated First Aid and CPR training. LPA conducted two staff interviews (S1 and S2) and one client interview (C1). Per facility staff, no firearms or weapons are allowed in the facility. No deficiencies were found at the time of this inspection. An exit interview was conducted, this report was discussed, and a copy of this report was provided to Licensee Sheila Gomez. A copy of this report will be placed in the facility file.

met_with: Sheila Gomez, Licensee


facility_name: SHELTON SMALL FAMILY HOME

summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
It was alleged that the facility refused to pick up youth from the hospital. The investigation revealed a behavioral incident involving the youth on 5/24/24 which escalated to verbal and physical aggression towards staff and the Director. The incident resulted in a law enforcement response to the facility, and the youth being assessed, then hospitalized. When the youth was cleared for discharge from the hospital on 5/25/24, the facility refused to pick up the youth. Instead, the facility submitted a 24-hour notice of emergency removal citing that the youth needed a higher level of care and the youth's needs could not be met. A review of records revealed that Shelton SFH was aware of the youth's basic and targeted needs, as outlined in a county placement agency document (Letter of Commitment) and the youth's needs and services plan. The document stipulated that in the event the youth's needs cannot be met, a 30-day written notice is required. Furthermore, the facility plan of operation indicated that a client care conference is conducted prior to discharge/eviction to ensure involvement by all interested parties to prevent transfer trauma. There was no 30-day written notice submitted to the county placement agency and no record of any attempt for a client care conference prior to discharge of the youth. Based on information obtained during the investigation, there is a preponderance of evidence found therefore, the allegation is substantiated. The facility is cited under California Code of Regulations 80022(k) Plan of Operation - the facility shall operate in accordance with the terms specified in the Plan of Operation. Refer to LIC9099-D for the deficiency citation issued. This requirement was not met as evidenced by the facility not following its plan of operation when the facility refused to pick up youth from the hospital. This poses a health, safety and personal rights risk to children in care. A Plan of Correction was discussed with the licensee, and copies of the following reports were provided at the conclusion of the inspection: LIC9099, LIC9099-C, LIC9099-D and LIC Confidential Names dated 1/17/25. The reports were also emailed to licensee. Appeal rights forms were given and explained.

Investigation Findings:
13On January 17, 2025 at 11:00am, Licensing Program Analyst (LPA) Irene Yamamoto conducted a subsequent complaint inspection at the Shelton small family home (SFH) to deliver the finding of a complaint received by the Department on 9/5/24. LPA met with Licensee/Administrator Gregory Shelton. The allegation was investigated by the undersigned LPA which includes confidential interviews with county placement agency staff on 9/6/24, school personnel on 9/12/24 and licensee on 9/12/24. LPA reviewed an interview completed by the LPA on 7/26/24 with the licensee of another SFH, who is the Director of this SFH. The interview pertains to the same youth, who was previously placed in the other SFH. Between 9/11/24 to 1/15/25, pertinent records were reviewed including, but not limited to, county placement agency documents, county placement agency investigative report, client needs and services plan, incident report, emergency request for removal, law enforcement report and facility plan of operation. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Irene Yamamoto LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: SHELTON SMALL FAMILY HOMEFACILITY NUMBER: VISIT DATE: 01/17/2025

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

met_with: Gregory Shelton, Licensee/Administrator

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
LPA contacted various county placement agency staff on 8/15/24, 8/21/24, 8/26/24, 9/6/24 and 10/9/24. LPA was unable to obtain a statement from the identified minor due to being removed from placement. However, LPA obtained and reviewed additional records from the county placement agency and law enforcement. The investigation revealed that the allegations came about after the minor had a couple of behavioral incidents between 5/22/24 and 5/24/24. Minor was alleged to be often disrespectful to staff and during the aforementioned dates, minor engaged in verbal and physical aggression towards the caregiver and one staff. During an incident on 5/24/24, minor continued with verbal and physical aggression and bit the staff, despite efforts by caregiver and staff to de-escalate the minor. Law enforcement and a mental evaluation unit responded to the facility and after a safety assessment of the minor was completed, the minor was involuntary detained and hospitalized. Records show that the minor claimed the allegations occurred. Minor described ongoing issues between minor and caregiver which caused minor's escalated behaviors such as disrespectful comments, threats of hospitalization and law enforcement involvement. Although some parties interviewed observed the bite mark sustained by the staff, there were no witnesses to the incidents of the reported dates. There were inconsistent statements obtained regarding observed interactions between caregiver and minor. Based on the information gathered during the investigation, the allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence found to prove that the alleged violations occurred. The finding of the allegations was discussed with the licensee and copies of the following reports were provided at the conclusion of the inspection: LIC9099, LIC9099-C and LIC Confidential Names, dated 1/17/25. Appeal rights forms were also given and explained. Copies of the reports were also emailed to the licensee. There was no deficiency citation issued.

Investigation Findings:
13On January 17, 2025 at 11:00AM, Licensing Program Analyst (LPA) Irene Yamamoto conducted a complaint inspection at Shelton Small Family Home (SFH). The purpose is to inform the facility of an investigation regarding the above allegations. LPA met with the Licensee/Admonistrator Gregory Shelton. LPA informed the licensee that the allegations were initially received by the Department on May 28, 2024 against another facility. At the conclusion of the investigation against the other facility, it was determined that the allegations involving the identified minor, caregiver and staff occurred during minor's placement at Shelton SFH. The allegations were discussed and the findings were explained below: The undersigned LPA investigated the allegations. It consisted of a review of records including, but not limited to, the minor's Needs and Services Plan, Admission Agreement, Identification and Emergency Information, Incident Report, and confidential interviews with the caregiver on 7/26/24, four staff on 8/13/24, two staff on 8/19/24 and school personnel on 9/12/24. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Irene Yamamoto LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: SHELTON SMALL FAMILY HOMEFACILITY NUMBER: VISIT DATE: 01/17/2025

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


summary: Complaint Investigation - Unsubstantiated - 3 allegations

raw_content:
Narrative:
On April 28, 2025, the Department received a complaint alleging that staff (PS2) engaged in physical altercations with a minor in care, and staff (PS2) spoke inappropriately to a minor in care. During the interview(s) with FD and S1 (both who reported to the LPA that they were not made aware, nor had any knowledge of the alleged incident), it was discovered that PS2 is no longer employed by the SFH. LPA attempted to contact PS2 on 5/8/2025, 5/9/2025, and 5/19/2025 via phone call to discuss the allegations against him. But to no avail. Contact number for PS2 was no longer in service. On 5/02/2025, LPA attempted to meet with and interview C1, however, FD informed LPA that C1's placement at the SFH had been terminated and C1 had been transported to the Welcoming Center (WC) in San Jose, CA. On 5/16/2025, an LPA from the San Jose Regional Office arrived at the WC and attempted to meet with and interview C1. But to no avail. C1 refused to meet with and speak to the LPA. On 5/20/2025, LPA (Christopher J. Williams) attempted a phone/virtual interview with C1 (at the WC). But to no avail. Per staff (Robert-Manager) at the WC, C1 refused to speak with LPA regarding the allegations. During the investigation, it was determined that the information gathered by the LPA was limited due to PS2 not being available for interview, and C1 refusing to be interviewed, making the findings of the allegations difficult to determine if true or false. The LPA's investigation revealed that due to conflicting statements gathered from confidential interviews via documentation, phone call(s) and in person, the preponderance of evidence standard has not been met, therefore the above allegation is found to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not enough preponderance of evidence to prove the allegation. A signed copy of this report was discussed and provided to the Facility Representative. Exit interview conducted. No deficiencies cited at this time. Appeal rights was provided to the SFH.

Investigation Findings:
13On May 23, 2025, at 8:45 a.m., Licensing Program Analyst (LPA) Christopher J. Williams conducted a follow-up inspection at the Shelton Small Family Home (SFH) for the purpose of delivering findings on the above allegations. LPA met with Ayan Hill, Facility Director (FD). LPA's investigation consisted of reviewing a statement from the Reporting Party (RP) on 04/29/2025 and a 10-day visit conducted with the SFH on 5/02/2025, where LPA met with and interviewed the FD concerning the allegations (See LIC811 - Confidential Names list dated: 5/02/2025). On 5/08/2025, LPA interviewed staff (S1) via phone call due to S1 not being available during the initial 10-day visit. On 4/29/2025, LPA conducted a review of the RFH's complaint history, reviewed documentation obtained from other agencies and Guardian / LIS systems. On 5/02/2025, LPA obtained and reviewed the LIC500 (Personnel Report), current client roster, initial needs and services plan for C1, and any relevant documentation such as Special Incident Reports (SIRS), if applicable. Continued on LIC9099c. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Christopher J Williams LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: SHELTON SMALL FAMILY HOMEFACILITY NUMBER: VISIT DATE: 05/23/2025

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 25

met_with: Ayan Hill, Facility Director


raw_content:
Narrative:
It was also alleged that licensee does not ensure that staff has criminal record clearance prior to working with residents. Staff denied the allegation. Staff stated that everyone that has been working or worked within the facility has been fingerprint cleared. Staff stated that everyone associated to facility lives or works at facility. Documents reviewed identified no incidents of smoking in a facility or issues with client smoking cigarettes or marijuana. Additionally, documents identified no staff unclear working in facility. LPAs tried to reach county social workers; however, LPA was unable to reach social workers or additional witnesses. Based on information gathered, although the allegation may have happened or is valid, the preponderance of evidence to prove the allegation was not met, therefore the allegation is unsubstantiated. An exit interview was conducted. A copy of this report Confidential Names Form, and Appeal Rights were provided to the facility representative. There were no deficiencies cited during this inspection

Investigation Findings:
On 6/18/ Licensing Program Analyst (LPA) Johanna Aracena made an unannounced visit to the Shelton SFH on behalf of LPA Dawn Mahecha for the purpose of concluding the above complaint investigation. LPA met with representative and discussed the following findings to complaint investigation. Investigation consisted of the following: On 2/27/ LPA Demetris Teal conducted initial 10-day inspection to SFH. LPA Teal requested documents be emailed to LPA Mahecha. LPA Mahecha reviewed the following received documents: NSP, LIC500, trainings, incident reports, discharge paperwork. LPA Aracena interviewed staff and children. Investigation revealed the following: It was alleged Staff do not prevent a minor from smoking marijuana inside of the facility. Staff denied the allegation. Staff stated nobody smokes at the facility staff or client. Staff stated their client is 9yrs old and not verbal. He has total care and he does not leave the facility unless accompanied by a staff or licensee. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Johanna Aracena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: SHELTON SMALL FAMILY HOMEFACILITY NUMBER: VISIT DATE: 06/18/2025

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

met_with: Gregory Shelton- Administrator


raw_content:
Narrative:
It was alleged that minor sustained unexplained injuries while in care. Confidential staff interviews were consistent. C1 has self-harming behaviors. Review of C NSP and IP it is documented that C1 exhibits daily episodes of severe self-injurious behaviors that include scratching, biting and pinching himself and staff should keep a log and document injuries. The SFHs log for behavior and body checks documented the bruise in question on June 18, 2025. Based on the information gathered during confidential interviews the allegation is unsubstantiated. Although the allegation may have happened or are valid, the standard of the preponderance of evidence was not met. An exit interview was conducted, and a signed copy of this report was provided to the facility licensee along with LIC9099C. Appeal rights explained.

Investigation Findings:
On August 12, 2025, Licensing Program Analyst (LPA) Angelina Garibaldo conducted an unannounced follow up complaint inspection visit at Shelton Small Family Home and met with Direct Care Staff, Shasta Stubbs for the purpose of delivering findings for the above allegation. During the course of the investigation, LPA Garibaldo conducted confidential interviews with three school personnel on 6/24/25, two staff on 6/25/25, one staff on 7/11/25, and one staff on 8/11/25. LPA also reviewed documents including but not limited to staff training and certificates, special incident reports (SIRs), Needs and Services Plans (NSPs), Intervention Plan: for Reduction of Severe Self Injurious Behavior (IP) and SFH group chat. C1 was unable to be interviewed due to their diagnosis of non-verbal autism. (Reference Confidential Names list LIC811 dated0 8/12/25). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Angelina Garibaldo LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: SHELTON SMALL FAMILY HOMEFACILITY NUMBER: VISIT DATE: 08/12/2025

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

met_with: Shasta Stubbs - Direct Care Staff


summary: Facility Evaluation

raw_content:
Narrative:
Shelton Small family home On April 5, 2024, Licensing Program Analyst (LPA) Johanna Lofton conducted a video conference/meeting via Teams at 2:30 pm with the purpose of conducting Component II of the licensure of Shelton Small Family Home. Meeting participants were: · Johanna Lofton - Licensing Program Analyst (LPA) · Gregory Shelton - Administrator/Licensee · Anya Hill - Hill Small Family Home During the meeting the following were discussed: · Program Statement and Plan of Operations didn't need any corrections. · SFH Administrator to adjust activities according to the clients' needs. · Anya Hill will be Gregory Shelton's designee. Ms. Hill reported she has five (5) employees that she will make available to Mr. Shelton when he needs it. These five employees give Ms. Hill the flexibility to be the designee at Shelton's Small Family Home. · Mr. Shelton will send LPA Lofton a new LIC 500 listing all the employees that Ms. Hill will make available to him to be associated to his facility. · LPA Lofton informed Mr. Shelton the fire clearance specifies the clearance is for un-ambulatory clients. · Reasons for client relocation/notice Parties in attendance agreed to conduct the pre-licensing inspection visit on 04/10/2024 at 9:00am. Ms. Hill requested to be present during the pre-licensing inspection. Exit interview was conducted and a copy of this report was provided to Mr. Shelton.

met_with: Gregory Shelton- Facility Admistrator


summary: Facility Evaluation

raw_content:
Narrative:
On 04/10/2024 at 9:00am, Licensing Program Analyst (LPA) Johanna Lofton conducted a pre-licensing inspection visit at the Shelton Small Family Home. LPA Lofton met Facility Administrator and Ayan Hill, Facility Designee and together toured the home. The home is a one story home with four (4) bedrooms, two (2) bathrooms, kitchen, dining room, living room, laundry room, garage and backyard. Bedroom 1 is equipped with a queen size bed drawers and closet space, Bedroom #2 is equipped with two (2) twin beds, drawers and closet space for clients. Bedroom #3 is equipped with a full size bed, drawers and closet space and it will be used as a spare bedroom/clients as seem necessary. Bedroom #4 (Master Room) is equipped with a king size bed and furniture, a crib, drawer and closet space. The master bedroom will be occupied by the administrator. During the inspection visit LPA Lofton verified the lights were on and there is running water at the home. There is a serviced fire extinguisher located in the laundry room. Smoke detectors in the home were tested and proved to be working properly. There is a locked medication box which will be locked in a locked file cabinet located in Bedroom #3 along with client's files. LPA Lofton inspected the first aid kit which proved to be complete. During a walk through the backyard, it was observed to be free of debris and/or obstructions. During the pre-licensing inspection visit LPA Lofton discussed Component III with the Administrator. He was advised that all visits once he is licensed will be unannounced including annual inspections. Serious Incidents Reports (SIRs) are to be reported to the Department within 24hrs from the incident and written report within seven (7) days. Exit interview was conducted. There were no citations. A copy of this report was provided to the Administrator.

visit_type: Prelicensing

met_with: Faility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On November 20, 2024, Licensing Program Analyst (LPA) Johanna Aracena, conducted an unannounced Post-Licensing Inspection at Shelton Small Family Home (SMH) and met with Facility Administrator Gregory Shelton. The purpose of the visit was to conduct a post licensing inspection of the facility. informed to the facility representative. During the inspection a copy of the Register of Facility Clients and Personnel Report were provided to the LPA. A tour of the facility was conducted along with the facility representative. The License was placed in a prominent place. LPA Aracena observed that the facility is clean, safe, sanitary and in good repair. The passageways inside and outside of the home are unobstructed. Disinfectants and cleaning solutions were stored in a locked container in the garage. LPA observed plenty of perishable and non-perishable food. Medications are locked and accessible only to the Licensee and staff. The temperature in the rooms that clients occupy are maintained between 68 and 85 degrees (F) and the hot water temperature was at 120 degrees (F). LPA Aracena reviewed the one (1) client file records and located the admission Agreement, Medical Assessment, Consent Forms, Emergency Information, Appraisal & Needs Service Plan, Immunization Record, current JV-223 and Personal Rights. A total of 2 employees files were reviewed. Documents located in the files were: Abuse Index Checks/Department of Justice (DOJ)/Federal Bureau of Investigation (FBI) criminal record clearances, criminal record statement, health screening, tuberculosis test results, First Aid Certificate and Cardiopulmonary Resuscitation certificates, and Driver's Licenses. During the inspection review, LPA Aracena observed the facility maintained an updated roster of the clients with pertinent information and medication record. The Licensee and Director are the responsible and capable for communicating with emergency personnel if needed. There were no citations during this visit. Exit interview was conducted and a copy of this report was provided to the licensee.

met_with: Gregory Shelton- Licensee


summary: Facility Evaluation

raw_content:
Narrative:
On January 17, 2025 at 11:00am, Licensing Program Analyst (LPA) Irene Yamamoto conducted an unannounced case management inspection at Shelton Small Family Home (SFH). LPA met with the Licensee/Administrator Gregory Shelton. The purpose of the inspection is to inquire about an incident that occurred on April 21, 2024 that was not reported to the Department. The incident involved a client who is no longer in placement. Further follow up is needed. A copy of this report and the LIC Confidential Names Form was provided at the conclusion of the inspection.

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
On 03/14/2025 at 12: PM Licensing Program Analyst (LPA) Olena Maico conducted unannounced case management inspection at the above facility and met with Gregory Shelton, Licensee. The case management was warranted by the report of another LPA who was visiting the facility for a complaint investigation and noted some items that needed monitoring LPA's attention. On February 27, 2025, LPA D. Teal conducted a walk through of the SFH and observed chemicals under the sink in the kitchen, an open laundry room with liquid detergents on a shelf, which were exposed. The door to the laundry room does not have a lock on it. In bedroom 2, LPA did not observe any dresser drawers. There is one client in the room. There was a container in the closet, on the floor of the closet. I asked the administrator/licensee if there were any drawers in the room and administrator/licensee said they are going to get some. LPA observed multicolor containers in a cabinet, in the kitchen over the refrigerator. The containers were locked, and LPA was advised that they contained the client's medicine. The cabinet was not locked and did not have locks on it. LPA Maico conducted a walk through the Small Family Home and found it to be in good condition and repair. LPA conducted tour of the kitchen, the medications and the sharps were locked in the kitchen cabinet above the fridge in the lock boxes. LPA checked all the kitchen drawers and cabinets, the kitchen sink cabinets have a lock on it and all the chemicals were moved to the garage. The detergent from the laundry room was moved to the garage box as well and is locked and inaccessible. LPA also observed rooms to be in good repair and LPA checked the licensee's bedroom and the licensee bedroom has a lock, so the items in licensee's room (chemicals) are inaccessible to the clients). Bedroom # 2 has a drawer with the space for the client to store items, as well as a closet space for private use of a client. LPA also observed no chemicals in the bathroom accessible to clients. The backyard is free of hazards. Living room has TV and a furniture for clients to use. LPA observed perishable and non-perishable food supply to comply with the regulations. No deficiencies cited at this time. The copy of this report was given and explained to the Facility Director.

met_with: Gregory Sheltonl, Licensee


summary: Facility Evaluation

raw_content:
Narrative:
On April 17, 2024 at 9: AM Licensing Program Analyst (LPA) Olena Maico conducted an unannounced Annual Licensing Inspection at Shelton Small Family Home (SMH) and met with Licensee Gregory Shelton and Ayan Hill, Facility Director. Prior to the inspection LPA sent out an e-mail request to the facility's Director for LIC Personnel Report, LIC Register of Clients, LIC 610C Emergency Preparedness plan and LIC Designation of Administrative Responsibility. The documents were provided to the LPA. A physical plant inspection was completed. The facility license, facility sketch, emergency disaster form and personal rights form were all prominently displayed in the home. All exits and hallways were observed to be free and clear of hazards and obstruction. Smoke detectors and carbon monoxide detectors were tested are in working order. LPA observed Emergency Intervention Plan, Menu, Facility sketch in the kitchen in the binders. LPA Maico observed that the facility is clean, safe, sanitary and in good repair. The passageways and entrances inside and outside of the home are unobstructed. Disinfectants and cleaning solutions were stored in a locked container in the garage. LPA observed an amount of perishable and non-perishable food required by CCL in the kitchen fridge and cabinets. Medications are locked in the kitchen and accessible only to the Licensee and staff. Sharps are locked in the kitchen cabinets. The temperature in the rooms that clients occupy are maintained at 70 degrees and the hot water temperature was at 120 degrees (F). Ms. Hill confirmed there are no weapons and/or ammunition in the home. Individual beds in the client bedrooms were observed with appropriate clean linens, pillows, comforters, and mattresses in good condition. Each bedroom has sufficient drawer and closet space. There are 2 full bathrooms in the home, all in working order and floors and bathtub has non-slip rugs. There are four (4) direct care staff available at the facility and Facility Directors. Licensee is still the main caretaker for the clients. Clients and staff files are electronic and kept on the licensee's computer. The licensee and facility director have access to them. Emergency disaster drills are conducted at least every six (6) months and LPA reviewed the record on the laptop of all the drills. Emergency disaster plan is in the binder and available for the review. LPA reviewed 2 client files, which contained medical assessments, TB test, personal Rights Acknowledgement and Admission Agreements all signed and dated or have records of refusal to sign. LPA reviewed medication logs with psychotropic medications for client and it has all the necessary fields completed and signed, as well as JV 223 attached. LPA also reviewed Needs and Services Plan for clients. LPA reviewed 5 staff files, . Criminal record and Child Abuse Index clearance were reviewed and confirmed for all the adults at the facility. LPA also reviewed Guardian website for clearances. Staff files had staff Health screening and TB test, training records (initial 8 hours and 16 hours), CPR certificates, duties and responsibilities, resumes, etc. LPA interviewed 2 staff. No clients have been interviewed due to one client being non-verbal and one being on AWOL status. No deficiency citations were issued during the annual inspection. One technical advisory was issued to the facility. An exit interview was conducted and a copy of this report was provided to the licensee and facility director along with the LIC 811.

met_with: Ayan Hill, Facility Director Gregory Sheton, Licensee


summary: Facility Evaluation

raw_content:
Narrative:
On March 5, 2026, Licensing Program Analyst (LPA) Amber Hunter conducted an unannounced case management inspection at the above-named Small Family Home (SFH). LPA met with Travis Bates, Facility Director. The purpose of this inspection was to issue citations related to record keeping. During records review and interviews with facility staff, it was revealed that the facility uses GroupMe chat as the primary method to communicate and document C1's behaviors, including sharing photos of bruises or injuries. It was further revealed that when C1 was discharged, the chat created for body checks was no longer accessible or retrievable by staff; therefore, conversations containing photos of bruises or injuries, as well as discussions regarding the child's behaviors, are no longer available for review. GroupMe is not a secure record system. It is a third-party messaging platform not designed to meet confidentiality and privacy standards. Staff may access client information outside of professional settings. The licensee cannot fully secure, restrict, or control the messaging platform and, therefore, is failing in its responsibility to safeguard the contents of client records. During today's inspection, the facility was cited for three (3) type B violations. LPA discussed the citations and Plan of Corrections with the Facility Director, Travis Bates. A signed copy of this report and 809D's were provided to the Small Family Home representative along with an LIC 811 (confidential names' list).

met_with: Travis Bates


raw_content:
Narrative:
It was alleged that the Licensee did not ensure minor's mental health needs were being met by not communicating with the County Social Worker regarding Applied Behavior Analysis (ABA) services. Investigation revealed that the client receives speech and occupational therapy and that the facility was attempting to obtain ABA services for C1 to meet the client's mental health needs. C1's biological mother has control over all developmental and education rights. Facility was in the process of obtaining ABA services for C1 and final consent for ABA services would be determined by the biological mother. It was alleged that Licensee did not provide incident reports to the proper county agency as requested regardless of if they were self-harm or not. Confidential staff interviews were consistent that C1 has self-harming behaviors. C1's Needs and Services Plan (NSP) and Intervention Plan (IP) documented that C1 exhibits daily episodes of severe self-injurious behaviors that include scratching, biting and pinching himself. According to the IP, staff are to maintain a behavioral log and document frequency, duration, and severity of self-injurious incidents. Based on staff interviews, a GroupMe app was implemented to track behaviors for C1. Although pictures of bruising were observed, staff explained that it was self-inflicted and did not require medical treatment. Facility was issued a technical advisory on 2/25/26 to provide advice on best log keeping practices and to ensure that any marks or bruises are documented on a behavior log as indicated on the child's IP. Based on the information gathered during confidential interviews the allegations are unsubstantiated. Although the allegation may have happened or are valid, the standard of the preponderance of evidence was not met. An exit interview was conducted, and a signed copy of this report was provided to the facility licensee along with LIC9099C. Appeal rights explained.

Investigation Findings:
13On March 5, 2026, Licensing Program Analyst (LPA) Amber Hunter conducted an unannounced follow-up complaint-inspection visit at Shelton Small Family Home and met with Travis Bates, Facility director for the purpose of delivering findings for the above allegations. During the course of the investigation, LPA Hunter conducted confidential interviews with one staff member on 12/9/25, one staff member on 12/12/25, and another staff member on 12/20/25. LPA conducted confidential interviews with previous and present Social Services Supervisor on 12/8/25, and County Social Worker on 12/12/25. LPA reviewed documents including but not limited to staff training and certificates, special incident reports (SIRs), Needs and Services Plans (NSPs), Intervention Plan: for Reduction of Severe Self Injurious Behavior (IP), and Child and Family Team Meeting notes. C1 was unable to be interviewed due to their diagnosis of non-verbal autism. (Reference Confidential Names list LIC811) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Amber Hunter LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: SHELTON SMALL FAMILY HOMEFACILITY NUMBER: VISIT DATE: 03/05/2026

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


facility_name: SHINE BLISS HOME

summary: Facility Evaluation

raw_content:
Narrative:
On June 10th,2025, at 10: AM, Licensing Program Analyst (LPA), Johanna Aracena conducted an announced pre-licensing inspection at the above address. LPA met with the applicants Ruth Nyanzwii and Grace Nyanzwii. A physical plant inspection was conducted. The following were observed at the time of inspection: This facility is a three- story home located in a residential community. This facility consists of four (4) bedrooms, three (3) full bathrooms upstairs and a half bathroom. On the first floor there is the entrance, Bedroom #1 with a full bathroom and the garage. Bedroom #1 is occupied by applicant #2. On the second floor there is the kitchen, living room and dining room. There is also a half a bathroom, desk/office set up, and a small patio. There is small closet in the patio which is used to keep the chemicals, cleaning and laundry supply storage. There are no cameras inside or outside the home. The third floor locates bedroom #2 and bedroom #3 which are equipped with queen beds, closet and drawer space for the use of foster children. Bedroom #3 needs closet cleaned out and extra mattress be taken out. Bedroom #4 is also located on the 3rd floor. Bedroom #4 has its own full bathroom. There is a third full size bathroom on the third floor for the use of the children. The facility is clean, sanitary and in good condition. There are no bodies of water on the premises. The facility has a centralized heat and air-conditioning unit. Temperatures in all rooms is comfortable. The hot water temperature was measured at 115 degrees (F). Carbon monoxide and smoke alarms were observed to be operational. There are two (2) fire extinguishers in kitchen and one by the main entrance of the home. Knives and sharps will be locked in a kitchen cabinet. The applicants will purchase locks for the cabinets where the knifes and sharps will be kept. The facility will have a working cell phone that will suffice as the home phone since it will be staying at the home at all times. The applicants reports no firearms on the premises. The grounds are free from obstructions and hazards. LPA observed plenty of perishable and non-perishable food. The applicants will purchase a lockbox for any medicine that will required refrigeration. Applicants are not looking into hiring anyone for help at the moment. Medications will be centrally stored and a lock will be put on the medicine cabinet. A complete first aid kit is readily available in a central location in the facility. Pending Items - Applicant will obtain a lock for medicine cabinet and lockbox for refrigerated medication. -Applicant will clean closed for bedroom #3 and take bed out of the room. -Posting of menu and activities will be posted in the kitchen, Emergency Plan (LIC 601). A follow up inspection will be conducted to finalize the inspection. An exit interview was conducted a signed copy of this report was provided to the applicant.

met_with: Ruth Nyanzwii- Applicant


summary: Facility Evaluation

raw_content:
Narrative:
On June 19, 2025, Licensing Program Analyst (LPA) Johanna Aracena, conducted a follow up inspection visit to Shine Bliss Small Family Home with the purpose of concluding the facility's pre-licensing inspection. During the visit LPA met with facility's Administrator Ruth Nyanzwii and Grace Nyanzwii. During the inspection visit LPA conducted a walk through of the facility and observed the following corrections: * Administrator obtained a lock for medicine cabinet and lockbox for refrigerated medication. * Closet for bedroom #3 has been cleared and extra mattres/bed was taken out of the room. * Facility's menu and activities have been posted along with the facility's Emergency Plan (LIC 601). * There is cell phone available for the children to use Exit interview was conducted and a copy of this report was provided to the administrator.

met_with: Ruth Nyanzwii- Afdministrator


summary: Facility Evaluation

raw_content:
Narrative:
On October 6, 2025, Licensing Program Analyst (LPA) Demetris Teal and conducted a Component II- and Component III in person meeting at the Monterey Park Regional Office. The following were present; Ruth Nyanzwii- Applicant of Shine Bliss Small Family Home. Purpose of the meeting was to review and discuss the program statement and application. LPA asked Applicant for their picture I.D. LPA called the meeting to order and introduced himself. LPA asked Applicant for orientation documents to sign the Component II and Component III. Copy was signed and given to applicant and placed in application file. LPA had previously asked for a copy of the Program Statement to be brought to the meeting. LPA asked that Applicant bring a copy of her program statement. Applicant did. LPA discussed and requested that Applicant place a table of contents in the program statement and tab the program statement. LPA had previously sent an email to the applicant to request this. Applicant agreed and will submit an updated copy. LPA discussed requested documents sent in an email on August 7, 2025, which were not included in the updated program statement submitted in the Monterey Park Regional Office, August 29, 2025. LPA discussed the "pretend time" located in the program statement and it's significance. Continued on page 2 page LPA discussed updates that are needed for children attending religious services. LPA discussed update for staff listed on the program statement, which are not listed on the LIC 500. Applicant will update how many children will reside in one room. LPA discussed incident reporting and including CCL as an agency that will receive incident reports. LPA discussed with Applicant the updates needed in the program statement. Updates were not originally received. Applicant understood and will make updates for all requested. Applicant will update program statement and bring updated copy to regional office. Component III was presented and Application understood. Exit interview conducted.

met_with: Ruth Nyanzwii- Licensee/Applicant


summary: Facility Evaluation

raw_content:
Narrative:
On October 7, 2025, at 11: A.M. Licensing Program Analyst (LPA) Demetris Teal and conducted a Component II- and Component III in person meeting at the Monterey Park Regional Office. The following were present; Grace Nyanzwii- Applicant of Shine Bliss Small Family Home. Purpose of the meeting was to review and discuss the program statement and application. LPA asked Applicant for their picture I.D. LPA called the meeting to order and introduced himself. LPA asked Applicant for orientation documents to sign the Component II and Component III. Copy was signed and given to applicant and placed in application file. LPA had previously asked for a copy of the Program Statement to be brought to the meeting. LPA asked that Applicant bring a copy of her program statement. Applicant did. LPA discussed and requested that Applicant place a table of contents in the program statement and tab the program statement. LPA discussed requested documents sent in an email on August 7, 2025, which were not included in the updated program statement submitted in the Monterey Park Regional Office, August 29, Continued on page 2 page LPA discussed updates that are needed for children attending religious services. LPA discussed incident reporting and including CCL as an agency that will receive incident reports. LPA discussed receipt of the program statement via email. Component III was presented and Application understood. Exit interview conducted.

met_with: Grace Nyanzwii- Licensee/Applicant


summary: Facility Evaluation

raw_content:
Narrative:
On October 24, 2025, Licensing Program Analyst (LPA) Demetris Teal and conducted a second Component II- and Component III in person meeting at the Monterey Park Regional Office. The following were present; Ruth Nyanzwii- Applicant and Grace Nyanzwii-Applicant of Shine Bliss Small Family Home. Purpose of the meeting was to review and discuss the program statement updates. LPA discussed multiple areas of the submitted corrected program statement. LPA asked Applicants to please update the requested areas and submit to him via email, by October 27, 2025. LPA requested a new hard copy dropped of in the Monterey Park Regional Office during the week of October 27, 2025. LPA requested the hard copy contain tabs and table of contents. Email copy should have a table of contents. LPA discussed areas of the program statement which were, regarding the wording of "agencies", discipline policies, needs and services plan participants and property control information. LPA gave Applicants LIC 281 to review. LPA conducted a thorough review of what is expected and required for licensing. LPA discussed withdrawal of their application if updates cannot be completed. Applicants understood. Exit interview conducted.

met_with: RUTH MUTHEU NYANZWII AND GRACE MWENDE NYANZWII


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On November 18, 2025 at 12: P,M., Licensing Program Analyst (LPA) Demetris Teal conducted a follow up announced pre-licensing inspection at the above named facility. Purpose of the follow up inspection was to observe on site pool. LPA met with Applicant, Ruth Nyanzwii. A physical plant inspection was conducted. The following were observed at the time of inspection: This facility is a three- story home located in a residential community. This facility consists of four (4) bedrooms, three (3) full bathrooms and a half bathroom. On the first floor there is the entrance, Bedroom #1 with a full bathroom and the garage. Bedroom #1 is occupied by applicant #2. On the second floor there is the kitchen, living room and dining room. There is also a half a bathroom, desk/office set up, and a small patio. There is small closet in the patio which is used to keep the chemicals, cleaning and laundry supply storage. There are no cameras inside or outside the home. The third floor locates bedroom #2 and bedroom #3 which are equipped with queen beds, closet and drawer space for the use of foster children. Bedroom #4 is also located on the 3rd floor. Bedroom #4 has its own full bathroom. There is a third full size bathroom on the third floor for the use of the children. The facility is clean, sanitary and in good condition. There are no bodies of water on the premises. The facility has a centralized heat and air-conditioning unit. Temperatures in all rooms is comfortable. The hot water temperature was measured at 125 degrees (F) in the upstairs bathroom. LPA discussed with Licensee to make changes. Carbon monoxide and smoke alarms were observed to be operational. There are two (2) fire extinguishers in kitchen and one by the main entrance of the home. continued on page 2 ...page Knives and sharps were observed in a locked kitchen cabinet. The facility has a working cell phone as the home phone. This phone stays in the facility. The applicants reports no firearms on the premises. The grounds are free from obstructions and hazards. LPA observed perishable and non-perishable food. Applicants are not looking into hiring anyone for help at the moment. Medications will be centrally stored and a lock will be put on the medicine cabinet. A first aid kit is readily available in a central location in the facility but did not have the approved first aid book. Applicants will secure an approved manual. LPA observed daily activity and menu in the kitchen. LPA observed a gated pool on the premises. The pool is a community pool enclosed and accessible by a magnetic key. The fencing is over five (5) feet high. The pool is located more than a block away from the facility. There are no clients in care. A follow up inspection will be conducted. An exit interview was conducted and a signed copy of this report, LIC 811 and appeal rights were left with Applicant..

Deficiencies:
91754: Shine Bliss Homefacility Number: 367800037 Visit Date: 11/18/2025 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 32...page 2
Knives and sharps were observed in a locked kitchen cabinet.

met_with: Ruth Nyanzwii-Applicant

title: Facility Name


summary: Facility Evaluation

raw_content:
Narrative:
On February 6, 2026 at 10: A,M., Licensing Program Analyst (LPA) Demetris Teal conducted an unannounced Post Licensing Inspection at the above named facility. LPA met with Ruth Nyanzwii-Licensee. The facility currently has a Small Family Home (SFH) license. The SFH is licensed to serve up to two (2) clients ages 0 to 17. The facility can serve ambulatory developmentally disabled clients, Regional Center clients, County placed clients and provide one on one care. There are currently no clients in placement. The LPA requested the following: Personnel Report LIC500, Staff Files. The facility is a three- story town home with four (4) bedrooms, living room, kitchen, three (3) full bathrooms and a half bathroom with one (1) toilet in each. There are no firearms or ammunition in the facility. There are gated pools accessible to facility. At 11: A.M., LPA conducted a walk-through of the entire facility. Continued.... ....Continued Physical Plant The license, facility sketch, personal rights, emergency disaster form, complaints poster, emergency phone numbers are posted in a prominent, publicly accessible location in the facility. Disinfectants and cleaning solutions are kept inaccessible and locked in a storage area. Sharps/knives are inaccessible and stored in a locked storage area. Facility has non-perishable food for at least one week and perishable food for at least two days. There are no medications stored. Smoke and carbon monoxide detectors were tested and in proper working order. Fire extinguisher was fully charged. No children in the home. LPA did observe a First Aid Kit and checked the contents. Per the took, first aid kit was not required to be checked. Room temperatures are maintained at 76 degrees F. The hot water temperature was tested and measured at 120-125 degrees F. All sinks, showers and toilets are in working order. The SFH do not have any placed children. All beds are in good repair; equipped with good springs, clean mattresses and pillows. Overall, facility is clean, safe, sanitary and in good repair. Operations The facility Licensee's are responsible for communicating with emergency personnel in the facility. Client Records There are no clients in care. Staff Records There are no staff hired. Licensee's have all clearances. A signed copy of this report including LIC 811 (confidential names list) and appeal rights were left with Licensee. Exit interview conducted.

met_with: Ruth Nyanzwii-Licensee


facility_name: SIMONA GARCIA SMALL FAMILY HOME

summary: Facility Evaluation

raw_content:
Narrative:
On July 14, 2025, at 10: AM, Licensing Program Analyst's (LPAs) Claudia Portillo, Angelina Garibaldo and Emad Elias conducted an announced pre-licensing inspection and Component III meeting at Simona Garcia Small Family Home (SFH). LPAs met with licensee, Simona and toured the home. Physical Plant This facility is located in a quiet residential community. The facility consists of bedrooms (3) bedrooms, (2) bathrooms, kitchen, Livingroom, office, a 2-car garage, and a backyard. Overall, LPAs observed the back yard to have clutter, hazardous chemicals and in unsanitary condition. LPA also observed damage to the ceiling in the kitchen and in the client bedroom from a previous leak that has not been patched and painted. Passageways are free from obsment, and Suppliestruction. Fixtures, Furniture, Equip The home has toilets and wash basins for clients' use. Client bedrooms were observed to be clean, orderly, and contained two twin beds. LPAs observed clean pillows, bed sheets and blankets. The client's bedroom has an adequate closet and drawer space to accommodate the client's clothing and personal belongings Heath Related Services and Record Keeping The medication will be stored in a locked closet in the kitchen. First aid kit was not available for review. Client and staff files will be kept in locked drawers in the office. A Component III meeting was also conducted to familiarize the applicant with SFH Rules and Regulations as well as best practices. The purpose of Component III is also to prepare the applicants on how to maintain and operate their facility and provide information to avoid potential problem areas. A copy of the SFH Component III handout was provided. Prior to being licensed the following are still pending: - Fire Safety inspection (STD 850 form). LPA sent the San Bernardino Fire Protection Station 172 an email with a copy of the form to expedite the process. - First Aid Kit - Buildings and Ground: Clean-up of the backyard/Hazardous materials - Buildings and Ground: Repairs to the ceiling in kitchen and client bedroom LPA Portillo will mail and email a new license once the Rancho Fire Department completes their inspection. An exit interview was conducted, and a copy of this form was emailed to the Administrator.

met_with: Simona Garcia


summary: Facility Evaluation

raw_content:
Narrative:
On August 5, 2025, at 10: AM, Licensing Program Analyst's (LPA) Claudia Portillo conducted a continuance announced pre-licensing inspection at Simona Garcia Small Family Home (SFH). LPA met with licensee, Simona and toured the home. The following items below were pending during a visit on 7/14/25. However, all items have been cleared and the the pre-licensing inspection is complete. - Fire Safety inspection (STD 850 form). Received 7/19/25 - First Aid Kit: complete/clear - Buildings and Ground: Clean-up of the backyard/Hazardous materials. : complete/cleared - Buildings and Ground: Repairs to the ceiling in kitchen and client bedroom: complete/cleared An exit interview was conducted, and a copy of this form was provided to the representative above.


summary: Facility Evaluation

raw_content:
Narrative:
On November 10, 2025, Licensing Program Analysts (LPA) Claudia Portillo conducted an unannounced inspection at the Small Family Home (SFH) facility and met with the licensee. The purpose of the inspection was in regard to a post licensing visit. This SFH is licensed to serve 2 non-ambulatory clients who are developmentally disabled, mentally fragile with special health care needs ages 0-5. There are currently no children in care. Physical Plan This facility is located in a quiet residential community. The facility consists of bedrooms (3) bedrooms, (2) bathrooms, kitchen, Livingroom, office, a 2-car garage, and a backyard. The bedrooms are ready for future placement and in compliance with all regulations. The licensee requested a change in age for placement. A new LIC 200 will be submitted. Changes to the license will be made to reflect the changes. An exit interview was conducted, and a signed copy of this report was provided to the facility representative along with LIC 809 report.


facility_name: SIR MIDAS

summary: Facility Evaluation

raw_content:
Narrative:
On September 07, 2023 at 10: AM, a Component II was conducted at the Monterey Park Children's Residential Program office with Sir Midas Small Family Home. Present at the Component II were applicant, Picolya Robinson, and Licensing Program Analyst (LPA) Pamela Silva. During the meeting, LPA went over the facility application and supporting documents. The applicant provided the following updated documents: 1. Revised Program Statement 2. Emergency Disaster Plan LIC610C and the Written Consent from the planned relocation site LPA discussed the following pending requirements with the applicant: 1. TB Test for applicant - pending 2. Written Disaster and Mass Casualty Plan of Action 3. Fingerprint/Live Scan Process for applicant 4. Fire Inspection LPA provided the applicant with the Program website where the SFH tool can be reviewed. www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process An exit interview was conducted, and a signed copy of this report was provided to the applicant.

met_with: Picolya Robinson


summary: Facility Evaluation

raw_content:
Narrative:
On 10/26/2023 at 8: AM, Licensing Program Analysts (LPAs) Pamela Silva and Timika Martin conducted an announced pre-licensing inspection at the above address. LPAs met with Picolya Robinson, applicant. A physical plant inspection was conducted. The following were observed at the time of inspection: This facility is a single level home located in a residential neighborhood. The facility consists of 3 bedrooms, 2 full bathrooms, a living room, kitchen, dining room, 2-car garage, laundry room, a small office, and a backyard. Overall, the facility is clean, sanitary and in good condition. The facility has no bodies of water. The facility has a centralized heat and air-conditioning unit. Temperatures in all rooms are maintained at 73 degrees (F). The hot water temperature was measured at 111 degrees (F). Carbon monoxide and smoke alarms were tested and observed to be operational. The fire extinguisher located in the office is fully charged. Knives and sharps are kept in a container locked in the garage. Disinfectants and cleaning solutions are kept in the cabinet located in the laundry room. The facility has a working telephone. The applicant reports no firearms on the premises. The grounds are free from obstructions and hazards. Clients will be utilizing bedroom #1. Bedroom #1 has 1 bed and has adequate closet and drawer space to accommodate client's clothing and personal belongings. Bedroom #2 will be occupied by applicant's bio children. Bedroom #3 will be occupied by applicant. Each bed has clean pillows, pillowcases, bed sheets and blankets. LPAs also observed extra linens stored in the hallway cabinet. Medications, client and staff records will be centrally stored and locked in the office. A complete first aid kit is readily available in a central location in the facility. Applicant reports that License, Emergency Plan (LIC 601) and facility sketch will be posted at the facility. The fire department is scheduled to conduct the fire clearance inspection on 10/30/23 at 10:00am. An exit interview was conducted a signed copy of this report was provided to the applicant.


summary: Facility Evaluation

raw_content:
Narrative:
On 12/06/23 at 8: AM, Licensing Program Analyst (LPA) arrived at the facility to conduct Component III and met with the licensee, Picolya Robinson. LPA provided the licensee with information on how to operate the facility within substantial compliance, and how to avoid common problem areas of facility operations. LPA provided licensee with the following Component III package/forms: · LIC 311E Records to be Maintained at a Small Family Home · LIC Personnel Report · LIC Personnel Record · LIC Health Screening Report (TB Clearance) · LIC Criminal Record Statement · LIC Identification and Emergency Information · LIC Physician's Report · LIC Identification and Emergency Information · LIC Preplacement Appraisal Information · LIC Consent for Medical Treatment · LIC Personal Rights · LIC Personal Rights · LIC Centrally Stored Medication and Destruction Record · LIC Unusual Incident/Injury/Death Report · LIC Appraisal/Needs and Services Plan · LIC Statement Acknowledging Requirement to Report Child Abuse A copy of this report was provided to the licensee.


summary: Facility Evaluation

raw_content:
Narrative:
On 09/11/24 at 9:35AM, Licensing Program Analyst (LPAs) Pamela Silva and Caitlin Chambers conducted an unannounced inspection at the Small Family Home (SFH) above for the purpose of conducting a Post Licensing inspection. LPAs met with the licensee of the home, Ms. Picolya Robinson. Currently, there are two (2) minor non-ambulatory clients in placement. There are no bodies of water on the premises. A physical plant inspection was completed. The facility license, facility sketch, emergency disaster form and personal rights form were all prominently displayed in the home. Temperatures in all rooms are maintained at 73 degrees (F). All exits and hallways were observed to be free and clear of hazards and obstruction. Smoke detectors and carbon monoxide detectors are in working order. First aid kit was readily available and complete. Food supplies, both perishable and non-perishable, were checked and found to be sufficient. Knives and sharps are kept in a container locked in the garage. Disinfectants and cleaning solutions are kept in the cabinet located in the laundry room. Medications are centrally stored and locked in the office. All exits, hallways and backyard were observed to be free and clear of hazards and obstruction. Ms. Robinson confirmed there are no weapons and/or ammunition in the home. Overall, the facility is clean, safe and sanitary. The following sleeping arrangements were noted: Bedroom #1 sleeps Client Bedroom #2 sleeps Client Bedroom # Master's Bedroom Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good condition. Each bedroom has sufficient drawer and closet space. There are two full bathrooms in the home, all in working order. The licensee is the main caretaker of the home. Client and staff files are stored under lock and key in the file cabinet in the office . Emergency disaster drills are conducted every month. LPAs reviewed two (2) client records and two (2) staff records. LPA checked required criminal record and child abuse index check clearance or exemption for all adults in the home. The client's files contained: Admission Agreement, Medical Assessment, Consent Forms, Emergency Information, Needs and Services Plan, Immunization Record and Personal Rights. LPA interviewed the licensee. Clients were not available for interview at the time of inspection. LPA will attempt to interview clients at a later time. No deficiency citations were issued during today's inspection. An exit interview was conducted and a copy of this report was provided to the licensee, Ms. Picolya Robinson.


summary: Facility Evaluation

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Narrative:
On 12/11/24 at 9: AM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced inspection at the Small Family Home (SFH) above for the purpose of conducting an Annual Inspection. LPA met with the licensee of the home, Ms. Picolya Robinson. Currently, there is one (1) minor non-ambulatory client in placement. There are no bodies of water on the premises. A physical plant inspection was completed. The facility license, facility sketch, emergency disaster form and personal rights form were all prominently displayed in the home. Temperatures in all rooms are maintained at 73 degrees (F). All exits and hallways were observed to be free and clear of hazards and obstruction. Hot water temperature was measured at above 120 degrees F. Smoke detectors and carbon monoxide detectors are in working order. First aid kit was readily available and complete. Food supplies, both perishable and non-perishable, were checked and found to be sufficient. Knives and sharps are kept in a container locked in the garage. Disinfectants and cleaning solutions are kept in the cabinet located in the laundry room. Medications are centrally stored and locked in the office. Telephone services are available through a cellphone in lieu of landline telephone. All exits, hallways and backyard were observed to be free and clear of hazards and obstruction. Ms. Robinson confirmed there are no weapons and/or ammunition in the home. Overall, the facility is clean, safe and sanitary. The following sleeping arrangements were noted: Bedroom #1 sleeps Client Bedroom #2 currently empty but is available for a potential client Bedroom # Master's Bedroom Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good condition. Each bedroom has sufficient drawer and closet space. There are two full bathrooms in the home, all in working order. The licensee is the main caretaker of the home. Client and staff files are stored under lock and key in the file cabinet in the office. Emergency disaster drills are conducted every month. LPA reviewed one (1) client records and two (2) staff records. LPA checked required criminal record and child abuse index check clearance or exemption for all adults in the home. The client's files contained: Admission Agreement, Medical Assessment, Consent Forms, Emergency Information, Needs and Services Plan, Immunization Record and Personal Rights. LPA interviewed the licensee. Client refused to be interviewed. No deficiency citations were issued during today's inspection. One Technical Violation was issued, see LIC9102TV. An exit interview was conducted and a copy of this report was provided to the licensee, Ms. Picolya Robinson.

met_with: Picolya Robinson, Licensee


summary: Facility Evaluation

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Narrative:
On 12/03/25 at 8: AM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced inspection at the Small Family Home (SFH) above for the purpose of conducting an Annual Required Inspection. LPA met with the licensee, Ms. Picolya Robinson. Currently, there is one (1) minor ambulatory client in placement. There are no bodies of water on the premises. A physical plant inspection was completed. The facility license, facility sketch and emergency disaster form are prominently displayed in the home. Temperatures in all rooms are maintained at 73 degrees (F). All exits and hallways were observed to be free and clear of hazards and obstruction. Hot water temperature was measured at 128 degrees F. LPA had licensee adjust the water heater. Smoke detectors and carbon monoxide detectors are in working order. First aid kit was readily available and complete. Food supplies, both perishable and non-perishable, were checked and found to be sufficient. Knives and sharps are kept in a cabinet locked in the office. Disinfectants and cleaning solutions are kept in the cabinet located in the laundry room. Medications will be centrally stored and locked in the office. Telephone services are available. All exits, hallways and backyard were observed to be free and clear of hazards and obstruction. Ms. Robinson confirmed there are no weapons and/or ammunition in the home. Overall, the facility is clean, safe and sanitary. The following sleeping arrangements were noted: Bedroom #1 sleeps Client Bedroom #2 currently empty Bedroom # Master's Bedroom Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good condition. Each bedroom has sufficient drawer and closet space. There are two full bathrooms in the home, all in working order. The licensee is the main caretaker of the home. Client and staff files are stored under lock and key in the file cabinet in the office. Emergency disaster drills are conducted every three months. LPA reviewed one (1) client records and one (1) staff records. LPA checked required criminal record and child abuse index check clearance or exemption for all adults in the home. LPA did not interview the client due to age and client being non-verbal. No deficiency citations were issued during today's inspection. One Technical Violation and four Technical Assistance were issued, see LIC9102TV. An exit interview was conducted and a copy of this report was provided to the licensee, Ms. Picolya Robinson.


facility_name: SLAUGHTER SMALL FAMILY HOME

summary: Facility Evaluation

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Narrative:
On September 12, 2022 at 9: AM Licensing Program Analyst (LPA) Anne Visaya returned and conducted a scheduled Annual inspection to the Slaughter Small Family home. LPA Visaya met with licensee Bernice Slaughter who let a tour of the home. The facility was toured inside and out and currently there is one client in the home and is at school at this time. The home is a two story home and consists of: Upstairs: Bedrooms are arranged so that no more than two children share a room and there is one child per bed. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. There is adequate shelf and closet space. Bedroom #1, furnished with 2 twin size bunk bed, a closet and plenty of storage space it is empty at this time Bedroom #2, furnished with 2 twin size bed, a closet and plenty of storage space and it is empty at this time Bedroom #3, furnished with 2 twin size bunk bed, a closet and plenty of storage space, it sleeps a 5 year old male client Bedroom # Master bedroom with a king size bed for Licensee. The master bedroom door will be locked at all times when there are children present. Game room area has tables and chairs for children, kids entertainment and have toys that are safe, clean, and age appropriate for the age group of the child being cared for. Downstairs: upon entry to the home, a furnished living room, a dining room with a large table and a locked closet under the stairs, kitchen with a pantry, a breakfast nook with small round table and 4 chairs, a family/den room with fireplace that is properly screened and secured, a half bathroom, and the garage. Bathroom number one downstairs hot water temperature measured to be 105.6 degrees Fahrenheit, bathroom number two upstairs hot water temperature measured to be 107 degrees F, bathroom number three is the bathroom that the licensee uses and is not accessible by the clients. The smoke detectors and carbon monoxide detectors were checked and are working properly. All hazardous items have been properly made inaccessible to areas where children will have access. Medications are locked in the master bedroom closet. Cleansers/chemicals are locked and stored in the stairs locked closet. The first aid kit contains all required items. Sharp knives are inaccessible and stored in the stairs locked closet. Telephone service and appliances are all in working order. There are no guns or weapons as stated by Mrs. Slaughter at this time. The Facility Sketch, Emergency Disaster Plan and visitation policy are posted at this time. Personal Rights is posted. The backyard where children will have access to play is completely fenced and free of hazards. There is no pool or other body of water. A review of one of one staff records indicates that all facility staff have received criminal record and child abuse index check clearances and CPR and first aid is up to date. Licensees had current CPR/ First Aid certificates. Licensee provided proof of 8 hours of continued education training. A review of one of one client files are noted to have documents required per regulations in file. Based on the facility inspection and file reviews this date, there are no deficiencies found at this time. Exit interview conducted and a copy of this report was discussed and provided to Licensee Bernice Slaughter this date.

met_with: BERNICE SLAUGHTER


summary: Facility Evaluation

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Narrative:
On April 18, 2024 at 12: PM, Licensing Program Analyst (LPA) Maya Chavez and Licensing Program Manager (LPM) Abdoulaye Traore conducted a Random Annual inspection to the Slaughter Small Family home. LPA and LPM met with licensee Bernice Slaughter who led a tour of the home. The facility was toured inside and out and currently there was not any client placement. The home is a two story home and consists of four bedrooms and 3 bathrooms. Bedrooms were arranged so that no more than two children share a room and there was one child per bed. No room commonly used for other purposes was used as a bedroom, and no bedroom serves as a passageway to another room. There was adequate shelf and closet space. Two children bedrooms were vacant and consisted of bunk beds. There was a vacant additional bedroom with two twin beds. The licensee sleeps in the master bedroom with a king size bed. The master bedroom door will be locked at all times when children present. LPA and LPM observed there was a loft used as play room area which had tables and chairs for children, kids entertainment and toys that were safe, clean, and age appropriate for future clients. The water temperature was measured to be 109.2 degrees Fahrenheit. The smoke detectors and carbon monoxide detectors were checked and were working properly. All hazardous items have been properly made inaccessible to areas where children will have access. Cleansers/chemicals were locked and stored in the stairs locked closet. Sharp knives were inaccessible and stored in the stairs locked closet. Telephone service and appliances were all in working order. There were no guns or weapons as stated by Mrs. Slaughter at this time. The Facility Sketch, Emergency Disaster Plan and visitation policy were posted at this time. Personal Rights is posted. The backyard where children will have access to play was completely fenced and free of hazards. There were no pool or other body of water. A review of the licensing records indicates that licensee has received criminal record and child abuse index check clearances, and CPR and First Aid is up to date. Based on the facility inspection and file reviews this date, there were no deficiencies noted at this time. Exit interview conducted and a copy of this report was discussed and provided to Licensee Bernice Slaughter this date.

met_with: Licensee- Bernice Slaughter


facility_name: SOUTH COUNTY CARE I

summary: Facility Evaluation

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Narrative:
On November 4,2025 at 12: PM, Licensing Program Analysts (LPAs) Guadalupe Munoz conducted an announced pre-licensing inspection visit for the change of location and change in capacity to the South County Care I, Small Family Home (SFH). The SFH will serve four ambulatory clients ages 5-18 years and non minor dependents. LPA met with licensee's daughter Nazanine Farshidian and conducted the inspection of the home. The facility is a four bedroom three bathroom single-family, two-story home with an attached garage. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. Clients will have access to a telephone in the living room to make and receive confidential telephone calls. The appliances were in a working order. All hazardous items have been properly made inaccessible to areas where children will have access. The facility smoke detectors and carbon monoxide detectors tested and were observed to be in working order; the fire extinguishers are properly charged and serviced. The facility has a first aid kit with all of the required items and a First Aid manual. The applicants stated there were no weapons in the facility. Disinfectants and cleaning solutions will be stored and locked in the laundry room. Sharp knives and medication will be stored in a locked in laundry room next to kitchen. The following required forms need to be posted in the facility: Personal Rights and LIC Emergency Disaster Plan. The facility is set up as follows The entry hallway leads to an open living room that flows into the dining area and attached kitchen. All shared living spaces have furniture in good condition. At the rear of the home is a sliding glass door that leads to the backyard which has outdoor seating and is free of debris. There are three client bedrooms that are designated for two clients per room with twin sized beds dresser and closet space for each client. Each room has adequate clean linens, pillows, blankets, comforters, mattress pads, and mattresses. Bedroom #1 is: designated for one client, with queen size bed and ample closet spaces. Bedroom #2 is designated for one client, with one full size bed and ample closet spaces. Bedroom #3 is designated for two clients, two twin beds and ample closet space. Bedroom #4 is designated as licensee's daughter's bedroom. It includes an en suite bathroom. The following items need to be completed prior to license approval: Removal of alcohol and/or lock on wine fridge Post Personal Rights, LIC Emergency Disaster Place lock on laundry room door Furnish bedroom #3 with bed(s) for client(s) Activate phone line repair window screen All special incident reports (SIR's) will be sent via e-mail to: cclpaccr@dss.ca.gov. The reporting requirements were reviewed with the Applicant on this date. LPA explained that once the license is approved, all employees shall have an approved criminal record clearance for CCL and be associated to this facility. An exit interview was conducted with Nazanine Farshidian and copy of this report was provided. .

met_with: Nazanine Farshidian


summary: Facility Evaluation

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Narrative:
On December 17, 2025 at 10: AM, Licensing Program Analysts (LPAs) Guadalupe Munoz conducted an announced pre-licensing inspection visit to complete the change of location and change in capacity to the South County Care I, Small Family Home (SFH) that started on 11/04/25. The SFH will serve four ambulatory clients ages 5-18 years and non minor dependents. LPA met with licensee Sonia Dezham and licensee's daughter Nazanine Farshidian and conducted the inspection of the home. The purpose of the visit is to follow up on the corrections needed to complete the pre license process. The following items needed to be completed prior to license approval: Removal of alcohol and/or lock on wine fridge. Post Personal Rights, LIC Emergency Disaster Place lock on laundry room door Furnish bedroom #3 with bed(s) for client(s) Activate phone line repair window screen During physical plant inspection, LPA observed a lock on the fridge that contains alcohol. LPA also observed Personal Rights and the LIC Emergency Disaster form posted on the refrigerator in the kitchen. Laundry room was observed to have a lock on the door to make chemicals, knives, and medication inaccessible to children in home. SFH bedroom #3 has sufficient storage and two twin beds with necessary linens and blankets which meets the necessary requirements for two ambulatory clients. LPA also observed window screen on downstairs window to have a screen in good repair. In addition, LPA observed a working phone in SFH for client use. All special incident reports (SIR's) will be sent via e-mail to: cclpaccr@dss.ca.gov. The reporting requirements were reviewed with the Applicant on this date. LPA explained that once the license is approved, all employees shall have an approved criminal record clearance for CCL and be associated to this facility. An exit interview was conducted with Sonia Dezham and Nazanine Farshidian and copy of this report was provided to the designee.

met_with: Sonia Dezham and Nazanine Farshidian


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Narrative:
***Continued from LIC 9099*** No immediate deficiencies observed. The following documents were collected from the SFH: admission agreement, authorization for medical care, Individual program planning (IPP), incident report of FC1 injury, emails, behavior spreadsheet and behavior summaries. Interviews were conducted with Licensee, FC1's school personnel, staff 1, and bio child. FC1 social worker was not able to be contacted. LPA was unable to interview FC1 due to FC1's developmental age and non-verbal. In regard to minor sustaining injury while in care, a confidential interview stated that FC1 would obtain bruises from having tantrums by falling onto the floor. The confidential interview added that FC1 would have tantrum when things are not going FC1's way. Another confidential interview indicated that FC1 would have tantrum at school and could have sustained bruises. Confidential interviews did not elaborate how the bruises occurred. Regarding staff are not feeding minor allegation, confidential interviews stated that FC1 would eat breakfast every morning before school. FC1 would have a choice of what breakfast to eat. Another confidential interview stated that FC1 would arrive at school and eat breakfast as if FC1 had not eaten breakfast prior to going to school. It was added that FC1 previously would not eat breakfast and would throw away the breakfast and lunch the school provides in the trash. LPA received conflicting information. Based on confidential interviews, the allegations that FC1 sustained injury while in care and staff are not feeding FC1, may have occurred, however, there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, these allegations are unsubstantiated at this time. An exit interview was conducted, a copy of this report and appeal right was reviewed and provided to the licensee.

Investigation Findings:
13On December 18, 2023 at 11: AM, Licensing Program Analyst (LPA) Karen Beal arrived at South County Care Small Family Home (SFH) and met with Licensee Sonia Dezham to deliver the finding for the allegations stated above involving the SFH and foster child (FC1) as listed on the Confidential Names List (LIC 811) dated December 18, 2023. On June 26, 2023, Community Care Licensing (CCL) received a complaint alleging that minor sustained injury while in care and staff are not feeding minor. On June 29, 2023, Licensing Program Analyst (LPA) Karen Beal conducted an unannounced complaint inspection to the Small Family Home (SFH) and met with Sonia Dezham, Administrator (ADM). LPA initiated the investigation and conducted a health and safety inspection with ADM. ***continued on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Karen Beal LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SO. Region Ac/res., 770 the City Dr., SUITE FACILITY NAME: SOUTH COUNTY CARE IFACILITY NUMBER: VISIT DATE: 12/18/2023

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

met_with: Sonia Dezham, Licensee


summary: Facility Evaluation

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Narrative:
On November 17, 2021 at 10:47am, Licensing Program Analyst (LPA) Adrian Mendez arrived unannounced at the facility to conduct a Required Annual inspection of the facility. The facility was inspected inside and out with Administrator Nazanine Farshidian. The home is a two-story residence with five bedrooms, and three bathrooms. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. The bathrooms were clean and in good repair. The hot water in the client bathroom was measured and is within regulatory requirements. All hazardous items have been properly made inaccessible to areas where clients will not have access. The medications were stored and locked in a cabinet in the locked pantry in the kitchen. Cleansers/chemicals are locked and stored in the laundry room. Sharp knives are inaccessible and stored in a locked cabinet in the pantry in the kitchen. The First Aid Kit is located in the locked pantry in the kitchen and contained all required supplies. The facility's smoke/carbon monoxide detectors in the hallways were checked and were operable. There are no guns or weapons in the facility as stated by Administrator. The following required posted items were observed accessible to clients: Facility License, Grievance Procedures, Personal Rights, Visitation policies, Emergency Disaster Plan and current menu. The facility outside grounds was also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. LPA discussed and reviewed the following inspection components; Operations. All the client files are stored and maintained in a secured off-site location. A sample of three client files were reviewed during the inspection. All client files had the required documents per Title Regulations. Cont. on 809-C All the staff files are stored and secured at an off-site location. LPA reviewed five staff files. All the staff have met the training and qualification requirements per regulation requirements. Per a review of the Community Care Licensing Information System (LIS), all staff met DOJ/FBI criminal record clearances and Child Abuse Index Check requirements. During the inspection, LPA interviewed two facility staff and two children. Based on the facility inspection, there are no deficiencies found at this time. An exit interview was conducted, and a copy of this report was explained and provided to Administrator Nazanine Farshidian.


summary: Facility Evaluation

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Narrative:
On December 20, 2022 at 10:00am, Licensing Program Analyst (LPA) Eduardo Barragan arrived unannounced at the facility to conduct a Required Annual inspection of the facility. The facility was inspected inside and out with Administrator Sonia Dezham. The home is a two-story residence with six bedrooms, and three bathrooms. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. The bathrooms were clean and in good repair. The hot water in the client bathroom was measured and is within regulatory requirements. All hazardous items have been properly made inaccessible to areas where clients will not have access. The medications were stored and locked in a cabinet in the locked pantry in the kitchen. Cleansers/chemicals are locked and stored in the laundry room. Sharp knives are inaccessible and stored in a locked cabinet in the pantry in the kitchen. The First Aid Kit is located in the locked pantry in the kitchen and contained all required supplies. The facility's smoke/carbon monoxide detectors in the hallways were checked and were operable. There are no guns or weapons in the facility as stated by Administrator. The facility outside grounds was also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. LPA discussed and reviewed the following inspection components; Operations. All the client files are stored and maintained in a secured off-site location. A sample of three client files were reviewed during the inspection. All client files had the required documents per Title Regulations. Cont. on 809-C All the staff files are stored and secured on an off-site location LPA reviewed five staff files. Per a review of the Community Care Licensing Information System (LIS), all staff met DOJ/FBI criminal record clearances and Child Abuse Index Check requirements. Based on the facility inspection, there are no deficiencies found at this time. An exit interview was conducted, and a copy of this report and appeal rights was provided to Nazanine Farshidian, Staff and Sonia Dezham, Administrator


summary: Facility Evaluation

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Narrative:
On January 3,2024 at 10:00am, Licensing Program Analyst (LPA) Guadalupe Munoz and LPA Jacqueline Garcia arrived unannounced at the facility to conduct a Required Annual inspection of the facility. The facility was inspected inside and out with Administrator designee. Facility administrators was unavailable and administrator Sonia Dezham gave authorization for Maryam Ashayeri to sign for today's visit. The home is a two-story residence with six bedrooms, and three bathrooms.Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. The bathrooms were clean and in good repair. The hot water in the client bathroom was measured and is within regulatory requirements. All hazardous items have been properly made inaccessible to areas where clients will not have access. Cleansers/chemicals are locked and stored in the laundry room. Sharp knives are inaccessible and stored in a locked cabinet in the pantry in the kitchen. The First Aid Kit is located in the locked pantry in the kitchen and contained all required supplies. The facility's smoke/carbon monoxide detectors in the hallways were checked and were operable. There are no guns or weapons in the facility as stated by Administrator.The medications were stored and locked in a cabinet in the locked pantry in the kitchen. LPA attempted one client interview however due to disability and client being nonverbal interview was not completed. Staff and client files are located at business office. Due to client and staff file unavailability,annual inspection will need to be continued and completed at a later date. Based on the facility grounds inspection, a Type A deficiencies found at this time. LPA Munoz spoke with Facility Administrator on the phone and communicated the deficiency and created plan of correction to immediately correct deficiency. An exit interview was conducted, and a copy of this report was provided to designee.Maryam Ashayeri

met_with: Maryam Ashayeri