raw_content:
Investigation Findings:
13On June 10, 2025, Licensing Program Analyst (LPA) Danny Macias conducted an unannounced visit to the Short Term Residential Therapeutic Program (STRTP) in order to deliver the findings of the above allegation and met with Program Manager (PM) Kyle Murray. On April 28, 2025, the above allegation was referred to Community Care Licensing for investigation. The investigation included an inspection of the Facility, confidential interviews, and review of records. Based on the investigation conducted, the department found that there was conflicting information regarding this issue. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation occurred. Therefore, the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted and a copy of this report and appeal rights was left with Kyle Murray at the conclusion. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Melikian LICENSING EVALUATOR NAME: Danny Macias LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


state: CA

facility_name: CCI BRAWLEY

summary: Facility Evaluation

raw_content:
Narrative:
On December 7, 2021, an unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Melikian at 1:00PM. During the inspection, LPA met with Kyle Murray, Administrator and Joey Gonzalez, Supervisor II and inspected the facility inside and out. LPA reviewed four children's records and reviewed two staff personnel records for the facility at 1:30PM. A medication count was conducted at 2:10PM. LPA interviewed two staff at 2:30PM. LPA interviewed one child at 2:50PM. The remainder of the children were not interviewed as there were no other minor dependents in placement at this time. No deficiencies to be cited at this time. LPA conducted exit interview with Kyle Murray, Administrator at 3:00PM. LPA provided the summary report to Kyle Murray, Administrator upon completion.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Kyle Murray


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, LPA (Licensing Program Analyst) Lisa Slusher conducted an annual inspection for the above facility. LPA reviewed personnel records, including training records. Met with Curtis Donovan. Prior to this inspection, LPA reviewed Personnel Report and Criminal Record Clearance Information for the above facilities. According to documentation reviewed, Facility is meeting regulatory staff/child ratios. All staff are fingerprint cleared or have current exemptions on file and are associated to the facility in which they work. Agency has current Mental Health Program Approval through Fresno County Department of Behavioral Health. MHPA is current through 1/27/23. Agency is accredited by CARF and accreditation is current and expires 6/30/ LPA Reviewed 14 personnel records. All staff have current Emergency Intervention, First Aid/CPR and Water Safety Certificates.

visit_type: Annual

met_with: Curtis Donovan


summary: Facility Evaluation

raw_content:
Narrative:
On 10/14/2022, an unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Melikian at 9:45AM. During the inspection, LPA met with Kyle Murray, Administrator and Lynn Tucker, Child Care Counselor I and inspected the facility inside and out. LPA did not review any children's records as there are no dependents in care and reviewed two staff personnel records for the facility at 10:00AM. LPA interviewed two staff at 10:30AM. LPA did not interview any children in the home as there are no dependents in placement at this time. No deficiencies to be cited at this time. LPA conducted exit interview with Kyle Murray, Administrator at 12:00PM. LPA provided the summary report to Kyle Murray, Administrator upon completion.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, LPA L Slusher conducted an announced case management with CCI Brawley. LPA met with Veronica Manzo and Jennifer Preston via an online format. The purpose was to review the agency's incident report forms, for routine incidents and then incidents specific to the use of Manual restraints and those involving law enforcement contact. LPA Provided information on requirements for reports as well as Provider information notice 23-02 discussing the new LIC 624-LE specifying new information required for law enforcement incident reports. LPA also provided information regarding an upcoming Guardian Webinar.

met_with: Veronica Manzo, Jennifer Preston


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Melikian on October 25, 2023 at 1:00PM. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPA met with Kyle Murray, Administrator and inspected the facility inside and out. LPA reviewed 0 child's records and 2 staff personnel files on site at the facility. The facility did not have any dependents in placement at this time that were on psychotropic medication other than a non-minor dependent. LPA reviewed 0 child's psychotropic medications and medication records as the facility. LPA interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPA interviewed 0 children on site. LPA provided a copy of the licensing report to Administrator, Kyle Murray. No deficiencies are being cited at this time. LPA conducted exit interview with Kyle Murray, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On this date, a case management inspection is conducted by LPA (Licensing Program Analyst) Lisa Slusher. LPA conducted follow up interviews regarding an incident report. There are no deficiencies noted or cited on this date.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Reyna Martinez and Briana Placencia on November 4, 2024 at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPAs met with Kyle Murray, Administrator and inspected the facility inside and out. LPAs reviewed 0 child's records and 2 staff personnel files on site at the facility as the facility did not have any dependents in placement at this time that qualify for review. LPAs reviewed 0 child's psychotropic medications and medication records as the facility did not have any dependents in placement at this time. LPAs interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPAs provided a copy of the licensing report to Kyle Murray, Administrator. No deficiencies are being cited at this time. LPAs conducted exit interview with Kyle Murray, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by LPA (Licensing Program Analyst) Reyna Martinez. LPA met with Kyle Murray, Administrator and inspected the facility, inside and out. LPA provided the Administrator the entrance checklist and requested the necessary documents. Centrally stored medications are maintained in a locked closet in a locked cabinet. Sharps and Toxic chemicals are kept locked. The facility has a written emergency disaster plan. All facility smoke detectors and carbon monoxide were tested and appear to be in appropriate working order, fire extinguisher is properly charged and was last serviced August 2024. Individual beds were observed with appropriate clean linens and are in good repair. The facility is CARF Accredited through 06/30/2025, and Mental Health Program Approval through 01/26/2026. There is at least one-week supply of nonperishable and a two-day supply of perishable foods. The facility is maintained at 69 degrees. Hot water temperature measures 106.3 degrees. Facility has no cameras. No firearms or weapons are allowed in the facility. Facility has pool, that is locked and gated. Appropriate staff/client ratios were verified during this inspection. The facility employs 1 administrator, 1 house supervisor, 2 counselor II's, and 6 counselors, and 4 mental health rehabilitation specialists. 5 staff files were reviewed and meet all regulatory requirements. 1 staff was available to be interviewed. LPA reviewed the facility's disaster plan, sampled medication and reviewed facility logs. 5 records of clients were reviewed. No clients were available for interview. A review of the Licensing Information System on January 27, 2024, indicates that all facility staff are associated to the STRTP had DOJ, FBI, and child abuse index check clearances. Administrator provided updated LIC 309 and LIC 500 forms to LPA. There were no deficiencies cited during this inspection. A copy of this report was left at the facility at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual continuation inspection was conducted by LPAs (Licensing Program Analysts) Reyna Martinez and Briana Placencia. LPAs met with Lorenzo Rodriguez, Administrator. The purpose of the inspection was to continue staff and client interviews. 1 staff was available to be interviewed. 2 clients were available for interview. There were no deficiencies cited during this inspection. A copy of this report was left at the facility at the conclusion of the inspection.

met_with: Lorenzo Rodriguez


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Briana Placencia on October 9, 2025 at 9:00am. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPA met with Kyle Murray, Administrator and inspected the facility inside and out. LPA reviewed 0 child's records and 2 staff personnel files on site at the facility. LPA reviewed 0 child's psychotropic medications and medication records. LPA interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPA was unable to interview any youth as they did not qualify. LPA provided a copy of the licensing report to Kyle Murray, Administrator. No deficiencies are being cited at this time. LPA conducted an exit interview with Kyle Murray, Administrator.

met_with: Kyle Murray- Administrator


facility_name: CCI DAKOTA

summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13On August 4, 2025, Licensing Program Analyst (LPA) Danny Macias conducted an unannounced visit to the Short Term Residential Therapeutic Program (STRTP) in order to deliver the findings of the above allegation and met with Program Manager (PM) Kyle Murray. On May 12, 2025, the above allegation was referred to Community Care Licensing for investigation. The investigation included an inspection of the Facility, confidential interviews, and review of records. Based on the investigation conducted, the department found that there was conflicting information regarding this issue. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation occurred. Therefore, the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted and a copy of this report and appeal rights was left with Kyle Murray at the conclusion. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Melikian LICENSING EVALUATOR NAME: Danny Macias LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

report_type: Complaint Investigation

complaint_status: unsubstantiated


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analysts (LPA) Lisa Slusher and travelled to the facility listed above to conduct an annual inspection. Met at the facility by Administrator Kyle Murray. The facility listed above is accredited through CARF and has current Mental Health Program Approval through Fresno County through January 21,2022. Arrived at the facility at 10:00 am. At the start of the inspection, LPAs discussed procedures for psychotropic medication, current census and other administrative questions. The following were observed upon inspection of the physical plant inspection conducted at 11:15 am : 1. Facility Grounds are clean and free of debris or observable hazard. 2. Adequate indoor and outdoor activity space and materials observed. 3. Chemicals appropriately locked. 4. Locked and centrally stored medications observed. Observed medication logs and discussed procedures for psychotropic medications. 5. First aid kit complete with appropriate manual observed. 6. Adequate storage space observed. 7. Individual beds in good repair observed. 8. The house has 3 bedrooms, all double occupancy. Bedrooms are accommodating of all required furnishings. 9. Adequate food storage space observed. Supply of two days of perishable foods and a week of nonperishable foods observed upon inspection. 10. Weekly menu posted and accessible to clients. 11.Dining room equipped with large table and chairs accommodating of all clients. 12.Facility has two full restrooms in the house for client use. 13.Appropriate forms posted in view of facility clients. 14.No firearms or weapons are allowed in the facility. The following items were discussed and reviewed by LPA during Inspection 1. LIC Reviewed to ensure appropriate staffing ratios, including Administrator, Social Work personnel, and Direct Care staff. 2. Administrator Kyle Murray is present on-site a minimum of 20 hours per week. 3. Personnel files reviewed (11) at 1:00 pm during today's inspection to ensure staff meet regulatory requirements. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Personnel Files are retained at the office, but were brought to the facility for review on this date. All staff are verified to have appropriate emergency intervention training and training hours are within regulatory guidelines. 4. Client files reviewed on this date (5) from 10:00 am-12:00 pm. The following are to be updated and submitted to CCL by 12/1/21- LIC 500 (Personnel Report), LIC 9020 (Client Roster), LIC 308, LIC 309, Board Meeting Minutes, current lease agreement for facility. No deficiencies noted in areas observed. Client (2) and staff (3) interviews conducted. No deficiencies noted in areas observed.


summary: Facility Evaluation

raw_content:
Narrative:
On November 17, 2021, an unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Melikian at 10:00AM. During the inspection, LPA met with Kyle Murray, Administrator and Alejandro Magana, Child Care Counselor II and inspected the facility inside and out. LPA reviewed three children's records and reviewed two staff personnel records for the facility at 10:30AM. A medication count was conducted at 11:30AM. LPA interviewed two staff at 12:10PM. LPA did not interview any children in the home as there are no dependents in placement at this time. No deficiencies to be cited at this time. LPA conducted exit interview with Kyle Murray, Administrator at 1:30PM. LPA provided the summary report to Kyle Murray, Administrator upon completion.


summary: Facility Evaluation

raw_content:
Narrative:
On 10/17/2022, an unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Melikian at 12:45PM. During the inspection, LPA met with Kyle Murray, Administrator and inspected the facility inside and out. LPA did not review any children's records as there are no dependents in care and reviewed two staff personnel records for the facility at 1:00PM. LPA interviewed two staff at 1:30PM. LPA did not interview any children in the home as there are no dependents in placement at this time. No deficiencies to be cited at this time. LPA conducted exit interview with Kyle Murray, Administrator at 2:00PM. LPA provided the summary report to Kyle Murray, Administrator upon completion.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, LPA L Slusher conducted an announced case management with CCI Dakota. LPA met with Veronica Manzo and Jennifer Preston via an online format. The purpose was to review the agency's incident report forms, for routine incidents and then incidents specific to the use of Manual restraints and those involving law enforcement contact. LPA Provided information on requirements for reports as well as Provider information notice 23-02 discussing the new LIC 624-LE specifying new information required for law enforcement incident reports. LPA also provided information regarding an upcoming Guardian Webinar

met_with: Jennifer Preston, Veronica Manzo


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analysts (LPA) Lisa Slusher and travelled to the facility listed above to conduct an annual inspection. Met at the facility by Administrator Kyle Murray. The facility listed above is accredited through CARF and has current Mental Health Program Approval through Fresno County through January 21,2024. Arrived at the facility at 8:15 am. At the start of the inspection, LPAs discussed procedures for psychotropic medication, current census and other administrative questions. Present at the facility during the inspection were two staff members and facility Administrator. Appropriate client/staff ratios were maintained. The following were observed upon inspection of the physical plant inspection conducted at 11:15 am : 1. Facility Grounds are clean and free of debris or observable hazard. 2. Adequate indoor and outdoor activity space and materials observed. 3. Chemicals appropriately locked. 4. Locked and centrally stored medications observed. Observed medication logs and discussed procedures for psychotropic medications. 5. First aid kit complete with appropriate manual observed. 6. Adequate storage space observed. 7. Individual beds in good repair observed. 8. The house has 3 bedrooms, all double occupancy. Bedrooms are accommodating of all required furnishings. 9. Adequate food storage space observed. Supply of two days of perishable foods and a week of nonperishable foods observed upon inspection. 10. Weekly menu posted and accessible to clients. 11.Dining room equipped with large table and chairs accommodating of all clients. 12.Facility has two full restrooms in the house for client use. 13.Appropriate forms posted in view of facility clients. 14.No firearms or weapons are allowed in the facility. Client files (5) were reviewed. Agency will forward LIC 308, 309, 500, Client and staff interviews Completed on this date. Staff files will be reviewed at a later time.

met_with: Alex Magana


summary: Facility Evaluation

raw_content:
Narrative:
Complaint Specialist C.K. Kinney(CS) traveled to CCI Dakota and met with Roger Thao to conduct collateral inspection. CS explained purpose of inspection and conducted confidential interviews related to a complaint CS is investigating. No deficiencies observed or cited during this inspection. Copy of this report left at facility at conclusion of inspection.

met_with: Roger Thao


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Tamara Melikian and Reyna Martinez on January 25, 2024 at 9:30AM. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPAs met with Kyle Murray, Administrator and inspected the facility inside and out. LPAs reviewed 0 child's records and 2 staff personnel files on site at the facility as the facility did not have any dependents in placement at this time. LPAs reviewed 0 child's psychotropic medications and medication records as the facility did not have any dependents in placement at this time. LPAs interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPAs provided a copy of the licensing report to Kyle Murray, Administrator. No deficiencies are being cited at this time. LPAs conducted exit interview with Kyle Murray, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On this date, LPA discussed with the facility a possible change of location application. The facility is reminded to allow at least 60 days for the processing of a change of location application The following documents are required for a change of location application · Change of Location fee (Fee Schedule available at ccld.ca.gov, no fee for FFA sub-offices) · LIC 200 (Application for a facility License)·If the licensee is a non-profit corporation, the LIC 200 must be accompanied by a Board Resolution approving the change of location and authorizing an individual to apply for the change (this should be the individual who signs the LIC 200) · LIC 308 (Designation of Administrative Responsibility)· LIC 309 (Administrative Organization) · LIC 400 (Affidavit Regarding Client Cash Resources) · LIC 401 (Monthly Operating Statement)· LIC 500 (Personnel Report) · LIC 610 (Emergency Disaster Plan)· LIC 999 (Facility Sketch) Control Of property (Lease agreement or Deed) Please ensure that control of property is in the name of the licensee, not an individual LIC 9054 (Fire Authority information) · Bacterial Analysis of Water Supply- only required when water for consumption is from a private source, such as a well.

met_with: Veronica Manzo, Annette Robles


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Reyna Martinez on January 24, 2025 at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPA met with Kyle Murray, Administrator and inspected the facility inside and out. LPA reviewed 0 child's records and 2 staff personnel files on site at the facility as the facility did not have any dependents in placement at this time. LPA reviewed 0 child's psychotropic medications and medication records as the facility did not have any dependents in placement at this time. LPA interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPA provided a copy of the licensing report to Kyle Murray, Administrator. No deficiencies are being cited at this time. LPA conducted exit interview with Kyle Murray, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On October 14, 2025, Licensing Program Analyst (LPA) Danny Macias conducted an unannounced random annual inspection at CCI Dakota Short Term Residential Treatment Program (STRTP) located in Fresno, CA. LPA met with Program Manager (PM) Kyle Murray. LPA provided PM the entrance checklist and requested the necessary documents. A physical plant inspection was completed and included the following checks. Adequate indoor and outdoor activity space and materials observed. The facility has a written emergency disaster plan. All facility smoke detectors and carbon monoxide detectors were tested and in appropriate working order. Fire extinguisher is properly charged and was last serviced April 2025. There is a one-week supply of non-perishable foods and a two-day supply of perishable foods available. The facility is maintained at 69°F. Hot water temperature measures 117.5°F. Facility has no cameras. No firearms are in the facility, per PM. There are no bodies of water at the facility. Centrally stored medications are maintained in a locked closet, in a locked cabinet. Sharps and toxic chemicals are kept locked. Individual beds were observed in good repair with clean linens. The facility is CARF Accredited through 06/30/2028, and Mental Health Program Approval through 01/26/2026. All required forms are posted. Appropriate staff/client ratios were verified during this inspection. The facility employs 1 administrator, 1 house supervisor, 2 counselor II's, 6 counselor I's, and 3 mental health rehabilitation specialists. 5 staff files were reviewed and met all regulatory requirements. 2 staff were interviewed. 5 client records were reviewed. 2 clients were interviewed. LPA reviewed the facility's disaster plan, sampled medication and reviewed facility logs. A review of the Licensing Information System on October 13, 2024, indicates that all facility staff are associated to the STRTP and had DOJ, FBI, and child abuse index check clearances. PM provided updated LIC 309 and LIC 500 forms to LPA. One Technical Violation is being issued on this date. A copy of this report was left with Kyle Murray at the conclusion of the inspection.


facility_name: CCI RIALTO

summary: Facility Evaluation

raw_content:
Narrative:
On October 7, 2025, Licensing Program Analysts (LPAs) Danny Macias and Briana Placencia traveled to CCI Rialto Short Term Residential Treatment Program (STRTP) located in Fresno, CA. LPAs were met by Director Jennifer Preston, Program Manager Kyle Murray and Program Manager Lorenzo Rodriguez for the purpose of a scheduled pre-licensing inspection. A general overview of their program and a tour of the facility was provided. The facility is a two story residence with seven bedrooms and 4 bathrooms; one bedroom serves as the office and another as a game room. Facility is to ensure water temperature is maintained between 105°F and 120°F. The facility does have a pool on site that meets regulatory standards. The agency employs one administrator and one program director. The facility is equipped with a first aid kit and fire extinguishers. All required LIC forms and personal rights are posted in a common area. Items discussed were the hot water temperature, outside debris, fence and retaining wall. LPAs advised licensee to ensure locked cabinets for client and staff files in order to ensure confidentiality. Licensee will be relocating clients beds', dressers and night stands from their previous location. At this time the rooms are not client ready. The licensee is being cited a Technical Advisory (TA) and a Technical Violation (TV), please see attached LIC 9102s. Upon completion of the TA and TV the facility will be ready for licensure. A copy of this report and appeal rights was provided to the Licensee.

visit_type: Prelicensing

met_with: Jennifer Preston


summary: Facility Evaluation

raw_content:
Narrative:
On January 13, 2026, Licensing Program Analysts (LPAs) Danny Macias and Briana Placencia conducted an unannounced post-licensing inspection at CCI Rialto Short Term Residential Treatment Program (STRTP) located in Fresno, CA. LPAs met with Program Manager (PM) Kyle Murray. LPAs provided PM the entrance checklist and requested the necessary documents. A physical plant inspection was completed and included the following checks. Adequate indoor and outdoor activity space and materials observed. The facility has a written emergency disaster plan. All facility smoke detectors and carbon monoxide detectors were tested and in appropriate working order. Fire extinguisher is properly charged and was last serviced April 2025. There is a one week supply of non-perishable foods and a two day supply of perishable foods available. The facility is maintained at 70°F. Hot water temperature measures 115.3°F. Facility has no cameras. No firearms are in the facility, per PM. The facility has an in-ground swimming pool. Centrally stored medications are maintained in a locked closet, in a locked cabinet. Sharps and toxic chemicals are kept locked. Individual beds were observed in good repair with clean linens. The facility is CARF Accredited through 06/30/2028, and Mental Health Program Approval through 01/26/2026. All required forms are posted. Appropriate staff/client ratios were verified during this inspection. Five staff files and five client files were reviewed and met all regulatory requirements. LPAs interviewed 2 staff and 2 clients on site. A review of the Licensing Information System on January 13, 2026, indicates that all facility staff are associated to the STRTP and had DOJ, FBI, and child abuse index check clearances. PM provided updated LIC309 and LIC500 forms to LPA. No deficiencies cited on today's visit. A copy of this report was left with Kyle Murray at the conclusion.


facility_name: CCJ HEART TO HEART

raw_content:
Narrative:
Investigation revealed the following: It was alleged facility staff did not adequately supervise minor while in care. Interviews conducted with staff had similar statements in that one child ran away from facility frequently. Staff stated when children look to run away staff try to talk to children to dissuade children from leaving. Staff stated they typically have outings on the weekends and that one child was identified as needing a higher level of care by having a one on one staff. Staff stated that typically staff have no issues with children but if a child is acting in a manner of running away staff will follow children and continue to talk and work with them to persuade them not to leave. Staff stated the one child who needs a higher level of care would runaway and hide from staff and sometimes destroy property due to not being able to express themselves properly. Staff stated they monitor child adequately and that staff continue to work with child in expressing themselves properly in a non-destructive manner. Interviews conducted with two children had similar statements in that facility has adequate staff and that children are never left unattended or not adequately supervised during outings or within the facility. Children did not state a specific time or issue with staff not being present. Two children in home were not interviewed due to one child being placed a day prior to LPA investigating at facility and one child declined to answer LPAs questions. Interviews conducted with county social worker to child in which investigation is related to stated that county was working on getting child a new placement that would better address child's needs. County social worker stated that they had no concerns with the facility regarding staff not adequately supervising children, but that children's needs weren't being met at this particular placement. Documents reviewed identified incident where child ran away, and actions taken by staff in addressing child's runaway. Documents also identified other incidents in where children have behaviors or act out inappropriately and staffs actions in addressing those incidents. Specified in the documents adequate staff were present to supervise and monitor children and took proper actions in addressing issues or concerns. Based on information received it is unclear what actually transpired during outing as child denied that staff were not adequately monitoring and staff denied not being present to properly supervise children. Although the allegations may have happened or may be true there is not a preponderance of evidence to support that the allegations did or did not happen. Therefore, this complaint is being closed Unsubstantiated. Exit interview was completed, no deficiencies cited, and a copy of this report was emailed to Administrator for review and signature.

Investigation Findings:
13On 2/24/ Licensing Program Analyst (LPA) Dawn Mahecha made an unannounced visit to the CCJ and Heart Facility for the purpose of concluding the above complaint investigation. LPA met with facility manager and discussed the identified findings. Investigation consisted of the following: On 1/27/ LPA met with and interviewed staff and three (3) children (see confidential names LIC811, dated January 27, 2023). Additionally, LPA requested copies of the following documents: current staff/ client roster, recently completed staff training, three (3) children's Needs and Service plans, activity logs for the month of December and January, incident reports regarding children having inappropriate interactions or being on Awol for December 2022 thru January 2023 and any complaints or case notes of incidents occurring on outings or in the home for the past two months. LPA contacted County social worker (CSW). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Yan Yeung LICENSING EVALUATOR NAME: Dawn Mahecha LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: CCJ HEART TO HEARTFACILITY NUMBER: VISIT DATE: 02/24/2023

met_with: Dennis Boyd, Facility Manager


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
It was alleged minor ingested an unknown substance while in care. Interviews conducted with staff revealed consistent statements as to Client#1 taking Marijuana edibles(Gummies). Staff interviewed stated that they were unaware of the clients taking the edibles. Staff interviewed stated they called medical services for the client when he was under the influence of the substance he ingested. Staff stated they checked on the clients every 30 minutes. Client#1 did not want to provide a statement. Client#2 stated they did take the edibles with staff not being aware. Clients interviewed stated they they felt safe at the facility. Based on information provided the incident occurred, but staff was not aware of the situation at the time. Although the allegations may have happened or may be true there is not a preponderance of evidence to support that the allegations did or did not happen. Therefore, this complaint is being closed Unsubstantiated. Exit interview was completed, no deficiencies cited, and a copy of this report was emailed to Administrator for review and signature.

Investigation Findings:
13On 6/15/ Licensing Program Analyst (LPA) Pedro Ramos made an unannounced visit to the CCJ Heart to Heart for the purpose of delivering the findings for the above allegation. LPA met with Dennis Boyd, Facility Manager and disccussed the findings. Investigation consisted of the following: LPA met with and interviewed staff and three (3) clients (see confidential names LIC811, dated June 15, 2023). Additionally, LPA requested copies of the following documents: current staff/ client roster, three (3) children's Needs and Service plans, incident reports regarding this incident. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Pedro Ramos LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: CCJ HEART TO HEARTFACILITY NUMBER: VISIT DATE: 06/15/2023

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


summary: Complaint Investigation - Unsubstantiated - 3 allegations

raw_content:
Narrative:
Page Staff denied the allegations. Statements obtained from interviews conducted with staff revealed C1 visited C2's bedroom and an altercation ensued. Staff reported they responded when they heard clients fighting. As staff walked toward the room, they heard C2 state "Hey. Don't touch my private." The clients were then separated. Staff reported observing both clients with their hands on each other's upper body and did not observe C1 inappropriately touch C2. Statements obtained from confidential interviews conducted did not support the allegations. Based on information gathered from interviews conducted and record review the allegations are unsubstantiated. Although the allegations may have happened or are valid, the standard of the preponderance of evidence was not met. Exit interview conducted. A copy of this report and Confidential Names form LIC811 dated 6/21/23 were provided to the above mentioned facility representative. No deficiencies were cited.

Investigation Findings:
13An unannounced inspection was conducted by Licensing Program Analyst (LPA) Christopher Larios on 6/21/23 at 5: PM. During the inspection LPA Larios met with Lead Youth Counselor, Shadonna Pickett and delivered findings regarding the above-mentioned complaint allegations. During the course of the investigation LPA Larios interviewed five clients between 4/12/23 and 4/17/23, interviewed three social workers between 4/13/23 and 6/14/23 and interviewed three staff between 4/12/23 and 6/20/23. LPA Larios also conducted a file review on 4/12/23 and obtained copies of staff and client rosters, staff contact information and incident reports. The Department received a complaint regarding Neglect/Lack of Supervision by staff. The complaint alleged staff did not prevent two clients (C1, C2) from engaging in an altercation and staff did not prevent C1 from touching C2 on his genitals during the altercation. (Continued on page 2) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Christopher Larios LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: CCJ HEART TO HEARTFACILITY NUMBER: VISIT DATE: 06/21/2023

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0

met_with: Shadonna Pickett


raw_content:
Narrative:
The investigation revealed that the facility made efforts to re-fill the facility client's medication by contacting the facility client's psychiatrist, placing agency social worker, pharmacy and healthcare provider in order to get the prescription filled. The facility resorted to taking the facility client to a hospital emergency room in order to re-fill the facility client's medication prescription. Based on the information gathered, the allegation is unsubstantiated as the preponderance of evidence to prove the allegation was not met although the allegation may have happened or is valid. A copy of this report, Confidential Names Form and Appeal Rights were provided to the facility representative. There were no deficiencies cited during this inspection.

Investigation Findings:
13On March 6, 2024 at 1: PM, Licensing Program Analyst (LPA) Joshua Rarela conducted a follow-up to deliver the findings of a complaint investigation concerning the allegation above. The facility is now closed and the license ended effective February 9, 2024. The findings will be mailed to the address on file. During the course of the investigation, LPA obtained the statements of the facility administrator on 10/6/23, 10/9/23 and 10/12/23, the facility client on 10/13/23, and a facility staff on 10/13/23 (see Confidential Names Form dated March 6, 2024). LPA also reviewed documents including e-mail correspondence of the facility with the placing agency, placing agency reports, medication records and incident reports. It was alleged that staff did not ensure minor's medication is refilled. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Joshua Rarela LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: CCJ HEART TO HEARTFACILITY NUMBER: VISIT DATE: 03/06/2024

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

met_with: Not Available - Facility Closed


summary: Facility Evaluation

raw_content:
Narrative:
On 1/11/22 at 9: AM, Licensing Program Analysts (LPAs) Timika Martin and Jenny Mundo conducted an announced Pre-licensing inspection and Component lll at the above facility address. This facility will CCJ Heart to Heart Inc. LPAs met with Ashley Oshilaja, who will be the Administrator for this facility. LPAs and Administrator toured the facility. This is a one-story home that has three bedrooms, two bathrooms and an attached garage used as a recreation room for clients. Inside the home the following was observed: The facility has a two story ADU located in the backyard used for a staff office and storage. There are locking filing cabinets, a desk, a chair and computer monitors inside the upstairs staff office. There is a living room, dining and kitchen area. There were sofas and a television in the living room and there is a table and chairs in the dining area. There is a recreational room with televisions, gaming systems, a pool table, a computer desk with a chair and a small sofa. Each bedroom has two beds with beddings, linens, drawers and closet space for the clients' use. There are 4 cameras located in the following areas: living room area, recreational room and two outside of the facility (near the front door and near the garage). There was a refrigerator, an electric stove, kitchen utensils, plates and dinnerware in the kitchen drawers/cabinets. The first aid kit was observed to be new and complete. The home has working telephones. There were working smoke/carbon monoxide detectors in the dining area, living room, hallway and in each bedroom. The centralized heating and air were working. All medications will be stored in a cabinet with a lock located in the staff office. All client, staff and facility files will be stored in a locked cabinet in the staff office as well. Also observed was computers, a fax/copy machine in the office for staff use. Prior to today's inspection the facility received fire clearance on 2/3/21. LPAs did not observe the following: -Staff schedule (LIC 500), Emergency Disaster Plan (LIC 610C), Foster Youth Rights, Personal Rights and activity schedule, facility menu and complaint procedures. -The water temperature in the bathroom sinks was tested 131 degrees Fahrenheit) not within the temperature allowed by Title Regulations. - Resident hygiene products were not available. -All cleaning solutions were observed under-sink cabinet unlocked. -There were no trash bins observed in the kitchen and in bathroom #2. The trash bin in room #1 did not have a lid. -The sliding door in the living room area was missing a screen. -There was dust throughout the facility (Ceiling fans in bedrooms/bathrooms and floors, the closet door in bedroom #1 need to be fixed, replaced, or curtains. In bedroom #2 and bedroom #3 place a closet door/curtains on the closet with rods secured. Crawl space in the backyard must be secured (located near side of the house). The facility is not ready to accept clients. The facility was issued Seven (7) Technical Assistance and that will need to be corrected by 1/25/22. An exit interview was conducted, and a copy of the report was provided to the administrator.

met_with: Administrator, Ashley Oshilaja


summary: Facility Evaluation

raw_content:
Narrative:
On 6/23/22 at 8: AM, Licensing Program Analyst (LPA) Timika Martin conducted an unannounced Post Licensing Inspection at the facility. LPA met with Ashley Martinez, Administrator. The facility currently has a provisional Short Term Residential Therapeutic Program (STRTP) license. The STRTP's Mental Health Program Application is pending approval. This STRTP is licensed to serve up to six (6) ambulatory male children ages 10-17 years of age. The facility also provides services to non-minor dependents pursuant to W&I Code 16501.1 (C)(1). There are six (6) minors currently in placement. This facility is a one-story home that has three (3) bedrooms, two (2) bathrooms, a kitchen, dining, a living room, a laundry room, and an attached garage used as a recreation room for clients. The facility also has a two story ADU located in the backyard used for a staff office and storage. There are no bodies of water on the premises. There are no firearms or ammunitions in the facility. At 00: AM, LPA conducted a walk-through of the entire facility. Physical Plant The license, facility sketch, personal rights, emergency disaster form, complaints poster, emergency phone numbers and food menu are posted in a prominent, publicly accessible location in the facility. Disinfectants, cleaning solutions and sharps are kept inaccessible in a locked in a cabinet located in the kitchen. Facility has non-perishable food for at least one week and perishable food for at least two days. Medications are centrally stored in a locked storage room. Smoke and carbon monoxide detectors were tested and in proper working order. Fire extinguishers were fully charged. First Aid Kits were checked and found to be complete. Room temperatures are maintained at 76 degrees F. The hot water temperature was tested and measured at 115 degrees F. All sinks, showers and toilets were in working order. Each bedroom has two beds with beddings, linens, drawers and closet space for the clients' use and no more than two (2) children share a bedroom. All beds are in good repair; equipped with good springs, clean mattresses and pillows. Adequate supply of beddings and linens were observed. Facility provides age-appropriate clothing items and hygiene products. There are 4 cameras located in the following areas: living room area, recreational room and two outside of the facility (near the front door and near the garage). Overall, facility is clean, safe, sanitary and in good repair. Operations Facility maintains a register of clients and the register is available upon request. The board of directors regularly conduct meetings to review and discuss the STRTP's operation. The facility administrator and manager are the responsible and capable staff for communicating with emergency personnel in the facility. The facility has developed, maintained and implemented written complaint procedures. Disaster Preparedness Plan Facility maintains a current, written disaster and mass casualty plan of action. Facility conducts disaster drill at least quarterly for each shift. The drills are documented, and the documentation is maintained in the facility for at least a year. Facility maintains an emergency and disaster plan, register of clients, Needs and Services Plan for each client, medication records, and contact information for each client's responsible party and physician. The post-licensing inspection will completed at a later date. There are no deficiencies to be cited at this time. An exit interview was conducted, and a signed copy of this report were provided to the facility administrator.

met_with: Administrator, Ashley Martinez


summary: Facility Evaluation - 2 deficiencies

raw_content:
Narrative:
On 7/26/22 at 9: AM, Licensing Program Analysts (LPA's) Timika Martin and Jenny Mundo conducted an unannounced Post Licensing Continuation Inspection at the facility. LPA's met with Ashley Martinez, Administrator. The following components were reviewed and addressed during this inspection: Physical Plant: During the tour, LPA's observed that the facility did not have non-perishable food for at least one week and did not have perishable food for at least two days. LPA's observed that the clients did not have access too a lock on the refrigerator and two locked cabinets which contained snacks for clients. LPA's observed a wall near the refrigerator peeling, due to the refrigerator not being able to open all the way (refrigerator is too large for the space provided). Client's Records: LPA's reviewed 6 client records (See LIC 858). Each child record contains admission agreement, medical/dental history, consent forms. Client records did not contain all of the required documents. LPA's did not observe proper documentation of safeguards for cash resources/property and Needs and Services Plans. LPA's discussed the deficiencies observed with the Administrator. An exit interview was conducted, and a signed copy of this report and appeal rights were provided to the facility administrator via email.

Deficiencies:
87068.2(c): Needs and Services Plan

(c) The needs and services plan shall include a description of the services to be provided or arranged to meet the short- and long-term needs and goals of the child as assessed by the Qualified Individual, pursuant to Sections 4096 and 11462.01 of the Welfare and Institutions Code. The needs and services plan shall also include the following information regarding services necessary to meet the child's needs, consistent with the case plan prepared by the placing agency, if provided, and consistent with the Qualified Individual's assessment
11462.01: (2)


summary: Facility Evaluation

raw_content:
Narrative:
On 8/1/22 at 9: AM, Licensing Program Analysts (LPA's) Timika Martin, Jenny Mundo and Licensing Program Manager (LPM) Gustavo Garcia conducted an unannounced Post Licensing Continuation Inspection at the facility. LPA's met with Ashley Martinez, Administrator. LPA obtained and reviewed the following updated documentation: -LIC Personnel and client roster The following components were reviewed and addressed during this inspection: Disaster preparedness plan, emergency intervention, staffing and core-therapeutic services. Staff Records: LPA's reviewed 4 staff records. Based on a file review, LPA's did not observe tuberculosis testing for one staff (see LIC 811 confidential names form). Staff and client interviews were conducted by LPA Jenny Mundo. LPA's discussed the deficiency observed with the Administrator. An exit interview was conducted, and a signed copy of this report and appeal rights were provided to the facility administrator via email.


summary: Facility Evaluation

raw_content:
Narrative:
On August 15, 2022 at 9: AM, Licensing Program Analysts (LPAs) Timika Martin and Jenny Mundo conducted an unannounced Plan of Correction inspection to the above facility. The purpose of the inspection is to verify if deficiencies cited on July 26, 2022 and August 1, 2022, were corrected. LPA's met with Administrator, Ashley Martinez and informed her of the purpose for the inspection. At 10: AM LPA's conducted a tour of the facility along with the Administrator for verification of the plan of corrections (POCs). During today's inspection the LPAs reviewed each violation previously cited. LPA's observed (32) out the (32) deficiencies cited to the facility on July 26, 2022 and August 1, 2022 have been corrected as per plan of correction. Appeal rights were provided and discussed with the Administrator. An exit interview was conducted and copy of this report and Letters of Deficiency Citations Cleared were provided to the Administrator via email.

met_with: Ashley Martinez, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 10/27/22, Licensing Program Analyst (LPA) Timika Martin conducted a case management inspection to the above facility and met with Facility Manager,, Dennis Boyd. The purpose of today's case management was to discuss a special incident reported to Community Care Licensing (CCL) on September 19, 2022, regarding an incident that occurred with C1 (see Confidential Names, LIC 811 dated October 27, 2022). During the inspection, LPA toured the facility, reviewed C1's records and obtained copies of pertinent documents. LPA conducted interviews with 2 staff at the facility. The incident report stated that $10 of C1's allowance was deducted for refusal to attend school. Based on the information gathered and records reviewed, the facility did not deduct $10's from C1's base allowance but from an extra incentive given by the facility. CCJ uses an incentive system, which provides youth additional money if clients engage in positive behaviors, such as completing chores or attending school. LPA discussed on how to properly document information on special incident reports to avoid discrepancies. LPA also discussed that the facility should specify in the program statement (and with staff and to the clients) the difference between allowance and incentives. The revisions will be submitted to LPA by 11/10/22. A signed copy of this report was provided to the facility representative.

met_with: Facility Manager, Dennis Boyd


summary: Facility Evaluation

raw_content:
Narrative:
On 10/27/22, Licensing Program Analyst (LPA) Timika Martin conducted a case management inspection to the above facility and met the Facility Manager, Dennis Boyd The purpose of today's case management was to discuss the incident reported to Community Care Licensing (CCL) on October 24, 2022, regarding an incident that occurred with C1 and C2 (see Confidential Names, LIC 811 dated October 27, 2022) on October 23, 2022. During the inspection, LPA toured the facility, reviewed C1's and C2's records and requested copies of pertinent documents. LPA conducted interviews with 2 staff.. Additional time is needed to resolve the case. A signed copy of this report was provided to the facility representative.


summary: Facility Evaluation

raw_content:
Narrative:
On 10/27/22 at 11: AM, Licensing Program Analyst (LPA) Timika Martin conducted a case management inspection to the above facility and met the Facility Manager, Dennis Boyd. The purpose of today's case management was to discuss the incident reported to Community Care Licensing (CCL) on October 20, 2022, regarding an incident that occurred with C1 (see Confidential Names, LIC 811 dated October 27, 2022) on October 16, 2022. LPA also discussed the facility policies and procedures, safety plan, mental health services and reporting requirements. During the inspection, LPA toured the facility, reviewed C1's records and obtained copies of pertinent documents. LPA conducted interviews with 2 staff at the facility. Additional time is needed to resolve the case. A signed copy of this report was provided to the facility representative.

met_with: Facility Manager, Dennis Boyd,


summary: Facility Evaluation

raw_content:
Narrative:
On February 9, 2023 at 9: AM, Licensing Program Analyst's (LPA's) Timika Martin and Claudia Portillo made an unannounced visit to the CCJ Heart to Heart STRTP for the purpose of a Case Management-Inspection. LPA's met with Facility Manager, Dennis Boyd and toured the facility. There was one client and one facility manager present at the facility. Additional time is needed to resolve the case. An exit interview was and a copy of this report was left with the facility manager.


summary: Facility Evaluation - 2 deficiencies

raw_content:
Narrative:
On February 27, 2023 at 9: AM, Licensing Program Analysts (LPA's) Timika Martin and Pamela Silva conducted an unannounced annual inspection at the facility. LPA met with Ashley Martinez, Administrator. The facility currently has a provisional Short Term Residential Therapeutic Program (STRTP) license. The STRTP's Mental Health Program Application is pending approval. This STRTP is licensed to serve up to six (6) ambulatory male children ages 10-17 years of age. The facility also provides services to non-minor dependents pursuant to W&I Code 16501.1 (C)(1). There are six (6) minors currently in placement. This facility is a one-story home that has three (3) bedrooms, two (2) bathrooms, a kitchen, dining, a living room, a laundry room, and an attached garage used as a recreation room for clients. The facility also has a two story ADU located in the backyard used for a staff office and storage. There are no bodies of water on the premises. At 9:30AM, LPA's conducted a walk-through of the entire facility. Physical Plant The license, facility sketch, personal rights, emergency disaster form, complaints poster, emergency phone numbers and food menu are posted in a prominent, publicly accessible location in the facility. Disinfectants, cleaning solutions and sharps are kept inaccessible in a locked in a cabinet located in the kitchen. Facility has non-perishable food for at least one week and perishable food for at least two days. Medications are centrally stored in a locked cabinet in the game room. Smoke and carbon monoxide detectors were tested and in proper working order. Fire extinguishers were fully charged. First Aid Kits were checked and found to be complete. Room temperatures are maintained at 76 degrees F. The hot water temperature was tested and measured at 126 degrees F. All sinks, showers and toilets were in working order. Each bedroom has two beds with beddings, linens, drawers and closet space for the clients' use and no more than two (2) children share a bedroom. During the tour of the facility, LPA's observed that a box spring is missing under one client mattress in the bedroom, the knob on one of the bedroom doors is missing, there are broken handles on clients drawers, the closet door in game room is broken and the inside of the closet is unorganized, the oven is missing a middle knob, the light switch does not have a switch cover in the bathroom. Six (6) deficiency citations and one (1) Technical Advisory were issued during today's inspection. LPA's discussed the deficiencies and technical assistance observed with the Administrator along with the plan of corrections. A continuation inspection is required at a later date. An exit interview was conducted, and a signed copy of this report and appeal rights were provided to the facility administrator via email.

Deficiencies:
87065(f): (f) The licensee shall designate at least one facility manager to be present at the facility at all times when one or more children are present
87065.5: (1) During the hours of 7 am to 10 pm, there shall be one awake and on duty direct care staff for every three children, or fraction thereof, present, at a minimum.

title: (a) In a facility with a licensed capacity of six or fewer children, there shall be coverage by direct care staff as follows


summary: Facility Evaluation

raw_content:
Narrative:
On March 6, 2023 at 9: AM, Licensing Program Analyst (LPA), Timika Martin conducted an unannounced inspection to the above named STRTP to verify proof of corrections for the deficiencies cited on 2/27/23 with a Plan of Correction (POC) due dates of 2/28/23 and 3/6/23. Two (2) out of five (5) POC's were due on 2/28/23. As of today (3/6/23), the licensee has not submitted three (3) out of five (5) proof of corrections specified in the Facility Evaluation Reports dated 2/27/23. The licensee failed to correct two (2) deficiencies on or before the POC due date, therefore, civil penalties are assessed during this inspection. At 10: AM LPA conducted a tour of the facility along with the Facility Supervisor for verification of the plan of corrections (POC) that are due today (3/6/23). Licensee will have an extension of 3/9/23 to correct the deficiency related to Buildings and Grounds. A signed copy of this report was issued to the licensee along with LIC 421FC (Civil Penalty Assessment - Failure to Correct forms) with appeal rights.

met_with: Jason Cleveringa


summary: Facility Evaluation

raw_content:
Narrative:
On March 16, 2023 at 9: AM, Licensing Program Analyst's (LPA's) Timika Martin and Claudia Portillo conducted an unannounced annual continuation inspection at the facility. LPA's and met with Administrator Ashley Martinez. The following components were reviewed and addressed during this inspection: Operations, Emergency Intervention, Disaster Preparedness Plan LPA Martin reviewed the current LIC 500, LIC 309 current Board Meeting minutes and an updated copy of the emergency disaster plan. Additional time is needed to complete the annual inspection. An exit interview was conducted and a copy of this report was left with the Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On March 23, 2023 at 9: AM, Licensing Program Analyst's (LPA's) Timika Martin and Claudia Portillo conducted an unannounced annual continuation inspection at the facility. LPA's and met with Administrator Ashley Martinez. The following components were reviewed and addressed during this inspection: Client Records Additional time is needed to complete the annual inspection. An exit interview was conducted and a copy of this report was left with the Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On April 12, 2023 at 9: AM, Licensing Program Analyst's (LPA's) Timika Martin, Pamela Silva and Claudia Portillo conducted an unannounced annual continuation inspection at the facility. LPA's and met with Administrator, Ashley Martinez. The following components were reviewed and addressed during this inspection: Client Records (6), Staffing (2), Core Therapeutic Services. Additional time is needed to complete the annual inspection. An exit interview was conducted and a copy of this report was left with the Administrator.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On April 14, 2023, at 1: PM, Licensing Program Analyst (LPA) Timika Martin conducted an unannounced annual continuation inspection at the facility and met with Administrator, Ashley Martinez. The following is summary of components that were reviewed and addressed during the annual inspection: Licensing Program Analysts (LPA's) Timika Martin and Pamela Silva conducted an unannounced annual inspection at the facility on 2/27/23. The following components were reviewed and addressed during this inspection: Physical Plant. Upon entry, there was no facility manager on site and one direct care staff present at the facility with 4 clients. Six (6) deficiency citations and one (1) Technical Advisory (TA) were issued on 2/27/23. Four out of the six plan of corrections and TV were cleared on and cleared on POC's were cleared on 3/6/23. Two civil penalties were issued on 3/6/23 for failure to correct two citations. Fixtures, Furniture, Equipment and Supplies 80088(e)(1), 87088(c)(1) Buildings and Grounds 80087(a), 80087(c) Personnel Requirements 87065(f) and 87065.5- Civil Penalty Issued Food Service 87076(b) (Technical Violation) Licensing Program Analyst's (LPA's) Timika Martin and Claudia Portillo conducted an unannounced annual continuation inspection at the facility on 3/16/23. The following components were reviewed and addressed during this inspection: Operations, Emergency Intervention, Disaster Preparedness Plan. Two (2) deficiency citations, one (1) Technical Advisory (TA) and one (1) Technical Violation (TV) were observed on 3/16/23 and issued on 4/14/23. Operational Requirements - Technical Violation: CCR 80071(a)(1), Technical Assistance: ILS 87063(a)(8) Disaster Preparedness - Type B: Other Provisions HSC 1565(c) Emergency Intervention Plan - Type B: Documentation and Reporting Requirements ILS 87095.61(f) Licensing Program Analyst's (LPA's) Timika Martin and Claudia Portillo conducted an unannounced annual continuation inspection at the facility on 3/23/23. The following components were reviewed and addressed during this inspection: Client Records. On April 12, 2023, Licensing Program Analyst's (LPA's) Timika Martin, Pamela Silva and Claudia Portillo conducted an unannounced annual continuation inspection at the facility and the following components were reviewed and addressed during this inspection: Client Records, Staffing, Core Therapeutic Services and Clients with Special Health Care Needs. Five (5) deficiency citations, one (1) Technical Advisory (TA) and four (4) Technical Violations (TV's) were observed on 3/23/23 and 4/12/23 and issued on 4/14/23. Client Records - Type B: 87070(b)(12), 80069(a), 87068.3(a), 87070(b)(13), 87070(b)(13)(G)(1) Client Records - Technical Violation (TV): 80026(h), 80026(h)(1), 87026(c), 87068.2(c) Client Records - Technical Assistance (TA) : 87068.2(c)(2)(C) LPA Martin discussed the deficiencies observed with the Administrator (see LIC 809-D). LPA Martin issued Technical Violations (TV's) and Technical Assistance (TA's) (see LIC 9102TA/TV). Exit interview completed, the following deficiencies were cited, and a copy of this report was left with the representative above along with appeal rights.

Deficiencies:
87095.61(f): Documentation and Reporting Requirements

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


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On April 14, 2023, at 1: AM, Licensing Program Analyst (LPA) Timika Martin conducted an unannounced annual continuation inspection at the facility and met with Administrator, Ashley Martinez. The following is summary of components that were reviewed and addressed during the annual inspection: Licensing Program Analysts (LPA's) Timika Martin and Pamela Silva conducted an unannounced annual inspection at the facility on 2/27/23. The following components were reviewed and addressed during this inspection: Physical Plant. Upon entry, there was no facility manager on site and one direct care staff present at the facility with 4 clients. Six (6) deficiency citations and one (1) Technical Advisory (TA) were issued on 2/27/23. Four out of the six plan of corrections and TV were cleared on and cleared on POC's were cleared on 3/6/23. Two civil penalties were issued on 3/6/23 for failure to correct two citations. Fixtures, Furniture, Equipment and Supplies 80088(e)(1), 87088(c)(1) Buildings and Grounds 80087(a), 80087(c) Personnel Requirements 87065(f) and 87065.5- Civil Penalty Issued Food Service 87076(b) (Technical Violation) Licensing Program Analyst's (LPA's) Timika Martin and Claudia Portillo conducted an unannounced annual continuation inspection at the facility on 3/16/23. The following components were reviewed and addressed during this inspection: Operations, Emergency Intervention, Disaster Preparedness Plan. Two (2) deficiency citations, one (1) Technical Advisory (TA) and one (1) Technical Violation (TV) were observed on 3/16/23 and issued on 4/14/23. Operational Requirements - Technical Violation: CCR 80071(a)(1), Technical Assistance: ILS 87063(a)(8) Disaster Preparedness - Type B: Other Provisions HSC 1565(c) Emergency Intervention Plan - Type B: Documentation and Reporting Requirements ILS 87095.61(f) Licensing Program Analyst's (LPA's) Timika Martin and Claudia Portillo conducted an unannounced annual continuation inspection at the facility on 3/23/23. The following components were reviewed and addressed during this inspection: Client Records. On April 12, 2023, Licensing Program Analyst's (LPA's) Timika Martin, Pamela Silva and Claudia Portillo conducted an unannounced annual continuation inspection at the facility and the following components were reviewed and addressed during this inspection: Client Records, Staffing, Core Therapeutic Services and Clients with Special Health Care Needs. Five (5) deficiency citations, one (1) Technical Advisory (TA) and four (4) Technical Violations (TV's) were observed on 3/23/23 and 4/12/23 and issued on 4/14/23. Client Records - Type B: 87070(b)(12), 80069(a), 87068.3(a), 87070(b)(13), 87070(b)(13)(G)(1) Client Records - Technical Violation (TV): 80026(h), 80026(h)(1), 87026(c), 87068.2(c) Client Records - Technical Assistance (TA) : 87068.2(c)(2)(C) LPA Martin discussed the deficiencies observed with the Administrator (see LIC 809-D). LPA Martin issued Technical Violations (TV's) and Technical Assistance (TA's) (see LIC 9102TA/TV). Exit interview completed, the following deficiencies were cited, and a copy of this report was left with the representative above along with appeal rights.

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

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


summary: Facility Evaluation

raw_content:
Narrative:
On May 10, 2023 at 9: AM, Licensing Program Analyst's (LPAs), Timika Martin and Claudia Portillo conducted an unannounced inspection to the above named STRTP to verify proof of corrections for the deficiencies cited on 4/14/23 with a Plan of Correction (POC) due date of 4/28/23. Seven (7) POC's were due on 4/28/23. As of today, 5/10/23, the licensee has submitted seven (7) out of seven (7) proof of corrections specified in the Facility Evaluation Reports dated 4/14/23. At 10: AM LPAs reviewed six (6) client medical assessments and needs and services plans for verification of the POCs that were due. LPAs issued a Technical Violation (TV) regarding medical records under 80069(c) numbers 1- Client Medical Assessments. A signed copy of this report was issued to the licensee along with a TV.


summary: Facility Evaluation

raw_content:
Narrative:
On September 19, 2023 at 10: AM, Licensing Program Manager (LPM) Gustavo Garcia and Licensing Program Analyst (LPA) Timika Martin conducted an informal virtual meeting via Teams with the licensee's CEO-Charles Compton, Administrator-Cedric Jones, Quality Assurance/Therapist-Kei Dillard, Mental Health Coordinator-Darryl Sewell and CARF support from SB County Joshua Kennedy, Supervising Social Service Practitioner - CFS San Bernardino County, Hannah Gutierrez and Deputy Director with San Bernardino County CFS, Valerie Croyle and PRD CWSM, Ana Del Nogal. The purpose of the meeting was to discuss the facility's plans should it fail to obtain a MHPA approval, mental health contract with SB County, and CARF Accreditation by the end of the provisional license expiration date on February 10, 2024. Since issuance of provisional license, CCJ Heart to Heart has worked to secure a Mental Health contract and Medi-Cal Certification with no success with their host county. CCJ Heart to Heart did not submit an application for either procurement in February 2022 or May 2022. CCJ Heart to Heart submitted an application in March 2023 and were denied. The first CARF application was submitted in June 2023 and the survey was expected to be completed August 21, 2023. Based on what the CARF analyst observed on 8/21/23, CCJ Heart to Heart was not going to get approved. CARF gave CCJ Heart to Heart a list of recommendations to correct and asked for CCJ Heart to Heart to reschedule their survey once they complete the revisions. The facility currently has six (6) clients in placement, six (6) from San Bernardino from San Bernardino County. During the meeting, Administrator, Cedric Jones and Quality Assurance/Therapist, Kei Dillard stated that they have created a plan that applications will be submitted by September 30, 2023. After the CARF accreditation application is re-submitted, the CARF survey is expected to be completed between January 2024-February 2024. The MHPA is ready to submit and the procurement date for the contract is between now and December 2023. LPA will conduct follow-up calls with provider regarding updates. The meeting ended at 10: AM. A copy of this report was provided via email to the Administrator, Charles Compton.

met_with: CEO, Charles Compton


summary: Facility Evaluation

raw_content:
Narrative:
On March 16, 2023 at 9: AM, Licensing Program Analyst's (LPA's) Timika Martin and Claudia Portillo made an announced visit to CCJ Heart to Heart STRTP for the purpose of a case management inspection. Inspection was completed in conjunction with an annual inspection. LPA's met with the representative mentioned above and discussed the following observed deficiencies: 87072.2(a) Complaint Procedures (technical violation) (a)The licensee of a short-term residential therapeutic program shall develop, maintain and implement written complaint procedures by which children, or their authorized representatives are permitted to file complaints, without fear of retaliation, with the facility administrator regarding facility staff or operations. The Location in the facility where such procedures are accessible to children, NMDs and their authorized representatives was not available. 87087 (5) BUILDINGS AND GROUNDS (5) No bedroom shall be used as a public or general passageway to another room, bath or toilet. 80087(a) BUILDINGS AND GROUNDS (repeat violation) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. 87044 (c) INSPECTION AUTHORITY (technical violation) The department shall have the inspection authority specified in Section 1538.7 and 1538.9 of the Health and Safety Code. LPA's discussed the deficiencies observed with the Facility Manager. An immediate civil penalty of $250 will be assessed for a repeat violation. LPA's issued a Technical Violation (see LIC 9102TA). Exit interview completed, the following deficiencies were cited, and a copy of this report was left with the representative above.


summary: Facility Evaluation

raw_content:
Narrative:
On May 10, 2023, at 9: AM , Licensing Program Analysts (LPAs) Timika Martin and Claudia Portillo made an unannounced visit to CCJ Heart to Heart STRTP for the purpose of a Case Management-Deficiencies Inspection regarding several incidents that was not reported to the Department in the required time-frame. LPAs met with the facility representative mentioned above and discussed the following deficiency: 80061(b)(1)( E) Reporting Requirements. Based on SIRs submitted via email to LPA Martin, it was discovered that facility did not submit incident reports in the required time frame from October 2022-Present. An exit interview was conducted where the citations and plan of corrections were discussed. Appeals rights were provided and discussed with the representative facility representative mentioned above.


summary: Facility Evaluation

raw_content:
Narrative:
On 05/10/23, an unannounced Case Management inspection was conducted by Licensing Program Analyst (LPA) Heriberto Perez to follow up on an incident that was not reported to the Department. LPA Perez met with Dennis Boyd, Facility Manager. It was found that staff (S3) took a vape pen from client (C1) during a restraint. Information revealed that S3 took the pen from C1's hand by opening C1's hand because the vape pen was in C1's closed fist during the restraint.(Reference Confidential Names list dated 05/10/23). See LIC 809D for citation. An exit interview was conducted where the citation and plan of correction were discussed. Appeals rights were provided and discussed with the facility representative mentioned above.


summary: Facility Evaluation

raw_content:
Narrative:
On June 13, 2023, at 8: AM, Licensing Program Analyst (LPA) Timika Martin made an unannounced visit to CCJ Heart to Heart STRTP for the purpose of a Case Management-Deficiencies Inspection regarding the facility providing false statements to Community Care Licensing (CCL). LPA met with the facility representative mentioned above and discussed the following deficiency: 80012 (a) False Claims. Based on two staff interviews, one staff stated that the medical provider refused to fill out the LIC Physician Report Form during the clients initial physical assessment visit and one staff stated that they have never seen the LIC 602 form and was unaware that the physician was required to sign it. Both staff also revealed that the physician refused to conduct medical assessments during the medical assessment visits for two clients, Client 1 (C1) and Client 2 (C2) (see LIC 811 confidential names form). The two staff indicated the medical provider refused to conduct the initial physical assessment because the clients did not have medical insurance. The two staff stated that because of this, the clients were then taken, by staff, to be seen at a minute clinic (CVS). Based on a confidential interview and records reviewed the STRTP pre-dated/pre-filled out the LIC 602 forms with incorrect/incomplete information that did not reflect the date of service. A confidential interview revealed that the medical provider does not refuse the completion of forms with any patient and if a form is presented at time of service, it is completed. The confidential interview also revealed that the form will be completed even if it is brought in to be completed after the initial date of service. Records reviewed and confidential interviews also reflected that C1 is not in the medical provider system and has not been seen in that office for care. This contradicts the statements given by the two staff which indicated the clients were refused to be seen for their initial physical assessment at the medical provider location. Confidential interviews also revealed that C2 did have an appointment scheduled and had insurance during the date scheduled to be serviced. The STRTP was advised to change the primary care physician to one of the providers at the medical office in order to use the insurance for services rendered or to schedule an appointment with the assigned medical office. Based on a confidential interview the STRTP decided to not move forward with the appointment with the medical provider. A confidential interview also revealed that the STRTP often struggles in preparedness or in having complete information about the clients that are brought in for service with the medical provider. The medical provider was able to complete and provide copies of the LIC 602 forms for three (3) clients and emailed them directly to LPAs Martin and Portillo using the information the medical provider had in their database.


summary: Facility Evaluation

raw_content:
Narrative:
This is an amended report for a case management inspection conducted on 6/26/23. An unannounced case management inspection was conducted by Licensing Program Analysts (LPA) Christopher Larios and Angelina Garibaldo on 8/18/23 at 3: PM. During the inspection LPAs met with Supervisor, Jason Cleveringa. The purpose of the inspection was to issue a citation and assess an immediate civil penalty. Records review and statements obtained from interviews conducted with clients and staff revealed the facility failed to report an incident that occurred at the facility during March 2023. The incident was regarding an altercation between two clients (C1, C2) (See Confidential Names list LIC811 dated 6/21/23) where C2 alleged he was inappropriately touched by C1. Statements obtained from interviews conducted with staff revealed C1's social worker visited the facility and was informed of the incident by staff. The social worker stated he was not aware of the incident and did not receive an incident report. Statements obtained from interviews conducted with staff revealed the altercation did occur and C2 reported being touched on the genitals or buttocks during the incident. Although staff confirmed the incident occurred, they were unable to identify the staff responsible for writing the incident report and submitting it to the supervisor. The supervisor on shift stated the incident was reported to the administrator and facility manager. However, the supervisor did not recall receiving an incident report from staff. A record review conducted on 4/12/23 revealed one incident report regarding C2 which was unrelated to the above-mentioned incident. The facility is cited for violation of the California Code of Regulations, Title 22, Division Six regulation 80061(b)(1)(E) Reporting Requirements. In addition, an immediate civil penalty of $1,000 is assessed for repeat violation of regulation 80061(b)(1)(E) Reporting Requirements within a twelve month period. Exit interview conducted. A copy of this report, Confidential Names form LIC811 dated 6/21/23, LIC809D dated 6/21/23, and LIC421IM dated 6/26/23 were given to the above-mentioned facility representative. Appeals rights were discussed and provided.


summary: Facility Evaluation

raw_content:
Narrative:
On 8/18/23 at 3: PM Licensing Program Analysts (LPAs) Christopher Larios and Angelina Garibaldo conducted an unannounced case management inspection to the facility. During the inspection LPAs met with Supervisor, Jason Cleveringa. The purpose of the inspection was to issue a citation and assess a civil penalty. This citation and civil penalty supersede a citation and civil penalty issued on 6/26/23. The facility failed to report an altercation that occurred between two clients (C1, C2) (See Confidential Names list LIC811 dated 8/18/23) in March of 2023. Information obtained by the Department indicated that a case carrying social worker visited the facility and was informed by staff that C1 allegedly touched C2's genitals during the altercation. The social worker stated they were not provided a special incident report (SIR) by the facility. During a follow up visit to the facility on 4/12/23, the Department conducted a record review and an SIR regarding the altercation and inappropriate contact was not observed in the client's file. The facility is cited for violation of the California Code of Regulations, Title 22, Division Six regulation 80061(b)(1)(E) Reporting Requirements. In addition, an immediate civil penalty of $250.00 is assessed for repeat violation of regulation 80061(b)(1)(E) Reporting Requirements within a twelve (12) month period. Exit interview conducted. A copy of this report, LIC811 dated 8/18/23, LIC809D dated 8/18/23, and LIC421FC dated 8/18/23 were given to the above-mentioned facility representative. Appeals rights were discussed and provided.


summary: Facility Evaluation

raw_content:
Narrative:
On September 8, 2023, at 8: AM, Licensing Program Analysts (LPAs) Timika Martin and Angelina Garibaldo made an unannounced visit to CCJ Heart to Heart STRTP for the purpose of a Case Management-Deficiencies Inspection regarding several incidents that was not reported to the Department in the required timeframe. LPAs met with the facility representative mentioned above and discussed the following deficiency 80061(b)(1)(E) Reporting Requirements and assess a civil penalty. This is the second civil penalty regarding reporting requirements. Based on SIRs submitted via email to LPA Martin, it was discovered that facility did not submit incident reports in the required time frame in August 2023. The facility is cited for violation of the California Code of Regulations, Title 22, Division Six regulation 80061(b)(1)(E) Reporting Requirements. In addition, an immediate civil penalty of $250.00 is assessed for repeat violation of regulation 80061(b)(1)(E) Reporting Requirements within a twelve (12) month period. Exit interview conducted. A copy of this report, LIC811 dated 8/18/23, LIC809D dated 8/18/23, and LIC421FC dated 8/18/23 were given to the above-mentioned facility representative. Appeals rights were discussed and provided.

met_with: Debra Richardson, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
This is an amended report for a case management inspection conducted on 6/13/23. On September 8, 2023, at 8: AM, Licensing Program Analyst (LPA) Timika Martin and Angelina Garibaldo conducted an unannounced inspection at CCJ Heart to Heart STRTP. The purpose of the visit was to conduct Case Management Inspection regarding the facility providing false statements to Community Care Licensing (CCL). LPAs met with the facility representative mentioned above. Based on two staff interviews, staff revealed that the physician refused to conduct medical assessments and fill out the LIC 602 forms the during the initial medical assessment visits for two clients, Client 1 (C1) and Client 2 (C2) (see LIC 811 confidential names form). Staff indicated, because of the physician's refusal, staff took the two clients to been seen at a minute clinic (CVS). Based on a confidential interview and records reviewed the STRTP did not take C1 to initial medical appointment and was listed as a "no show" on 10/25/22 and an appointment was canceled on 10/19/22. Based on a confidential interview and records reviewed the STRTP did not take C2 to initial medical appointment and had a canceled appointment on 3/27/23. The above information contradicts the statements given by the two staff which indicated the clients were refused to be seen for their initial physical assessment at the medical provider location. Based on a confidential interview the STRTP decided to not move forward with the appointments with the medical provider. A confidential interview also revealed that the STRTP often struggles in preparedness or in having complete information about the clients that are brought in for service with the medical provider. The incident(s) were discussed with the facility representative, and the facility is being cited for the following deficiency: 80012 (a) False Claims.


facility_name: CELESTE HOUSE

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

met_with: Victoria Granado


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Jessica Rodriguez conducted a complaint inspection and met with Program Manager, Fatima Gamez. The purpose of the inspection was to deliver the findings for the above complaint allegations. LPA conducted investigation that included interviews of staff and clients and review of documentation. Although the allegations may have happened or are valid, per information obtained during interviews there was not a preponderance of evidence to prove allegations occurred. Therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the Program Manager. There are no deficiencies to be cited on this date. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Jessica Rodriguez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 2 of 2

met_with: Fatima Gamez


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by Licensing Program Analyst (LPA) Jessica Rodriguez at Celeste House in Fresno, CA. LPA met with Program Manager, Fatima Gamez. A physical plant inspection was completed and included the following checks: Outdoor facility grounds are clean and free of debris. Adequate indoor and outdoor activity space and materials observed. All facility smoke detectors and carbon monoxide detectors are in appropriate working order, fire extinguisher is properly charged and serviced. Facility maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. All required forms are posted. Medications are locked and centrally stored. Individual beds were observed with appropriate clean linens and are in good repair. No firearms or weapons are allowed in the facility. Facility utilizes cameras without audio in common areas of the facility. There are no bodies of water. Facility appears to be meeting the terms and conditions of their license. LPA reviewed six client files. LPA conducted three staff interviews and two client interviews. An annual continuation will be completed at the facility main office to review staff files. It is requested that the licensee submit the following updated forms to CCL: LIC 308, 309, 500 and emergency disaster plan. In addition, the most recent minutes for the Board of Directors meeting. There are no deficiencies to be cited on this date.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Jessica Rodriguez conducted an unannounced annual inspection of staff records and training for the above facility. The inspection was conducted at the corporate offices of KYJO. LPA was met by Human Resource Assistant, Cameron Feraro. A review of staff records on 12/01/2021 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. LPA was unable to complete review of staff files due to technical issues. LPA was unable to leave a report with the agency as a result. The annual inspection will be completed at a later date.

met_with: Cameron Feraro.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Jessica Rodriguez conducted an unannounced annual inspection of staff records and training for the above facility. The inspection was conducted at the corporate offices of KYJO. LPA was met by Human Resource Assistant, Cameron Ferraro. A review of staff records on 12/01/2021 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Facility has a valid waiver on file dated November 7, 2016, to alternatively associate all staff to the central "Administrative File" which is the Barstow facility. LPA continued inspection of staff records and training. LPA observed a deficiency in regard to staff qualifications for two staff and discussed this with Human Resource Assistant, Cameron Ferarro. Interim Licensing Standards are being cited on the attached LIC 9099D. Additionally, it is requested licensee submit a closure plan to the Department, due to pending STRTP Mental Health Program Approval. Facility Provisional License Extension is due to expire December 13, 2021. An exit interview was conducted, and a copy of this report given to the agency.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Melikian on 03/04/2022 at 9:00AM. During the inspection, LPA Melikian met with Virginia Hernandez and Dekeydra Mothershed, Administrators, and inspected the facility inside and out. LPA reviewed three children's records on site at the facility at 9:30AM. LPA reviewed two staff personnel records on site at the facility at 10:15AM. LPA reviewed three children's psychotropic medications and medication records at 10:35AM. LPA interviewed two staff at 10:50AM. LPA interviewed one child at 11:00AM. The other two children were in school and will be interviewed at a later time. LPA conducted exit interview with Dekeydra Mothershed, Administrator at 11:15AM. LPA provided the summary report to Dekeydra Mothershed, Administrator upon completion. There were no deficiencies to be cited on this date.

met_with: Dekeydra Mothershed, Virginia Hernandez


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB484 follow up Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Melikian on 03/04/2022 at 2:45PM. Met at the facility by Residential Youth Counselor Irene Carrillo. Clients interviewed at 3:15PM. There are no deficiencies to be cited on this date.

met_with: Irene Carrillo


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Corina Carrillo conducted a case management inspection May 4, 2022 at 10:15AM, based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 5 out of Direct Care Staff and 3 out of 3 youth files were reviewed. 2 out of Direct Care Staff and 2 out of 3 youth were interviewed. (See the Confidential Names List, LIC 811, dated May 4, 2022. The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, youth case plans, quarterly assessments, and crisis intervention plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Carrillo observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Shayla Taylor.

met_with: Shayla Taylor


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Tamara Melikian and Jessica Rodriguez on February 10, 2023 at 9:00AM. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPAs met with Virginia Hernandez, Administrator and inspected the facility inside and out. LPAs reviewed 0 child's records and 1 staff personnel file on site at the facility. LPAs reviewed 0 child's psychotropic medications and medication records. LPAs interviewed 1 staff on site to discuss the facilities policies and procedures of operation. LPAs interviewed no children currently on psychotropic medication as the facility currently has no clients. LPAs provided a copy of the licensing report to Administrator, Virginia Hernandez No deficiencies are being cited at this time. LPA conducted exit interview with Virginia Hernandez, Administrator.

met_with: Virginia Hernandez


summary: Facility Evaluation

raw_content:
Narrative:
On this date, Licensing Program Analyst (LPA) Reyna Martinez conducted a Case Management inspection at Celeste House and met with Shayla Taylor. The purpose of the inspection was to conduct a tour of the facility. LPA inspected the home and ensured there are not children in the home. Licensee is surrendering their license effective March 29, 2023.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analysts (LPA's), Jessica Rodriguez and Briana Placencia traveled to Celeste House for the purpose of conducting an unannounced Case Management and met with Direct Care Counselor, Victoria Granado. LPA's informed Direct Care Counselor that during interviews LPA's were informed of a personal rights violation by staff towards one of the clients in the home. LPA's received information that staff had nudged a client with a shoe then also had taken a napkin and wet it, then squeezed it onto a client's face. Administrator, Virginia Hernandez had previously informed LPA's that the staff allegedly involved no longer work at the facility. Based on the above, Interim Licensing Standards are being cited on the attached 809D. A copy of this report was left at the facility at the conclusion of the inspection.


summary: Facility Evaluation

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

met_with: Adela Dominguez-Jordan