summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Monica Pavia conducted a pre-licensing inspection on August 1, 2024, 10:00am, at the address listed above. Hanna Boys Center STRTP, Bldgs 403 and 404, has submitted an application for a Short-Term Residential Therapeutic Program (STRTP), to be licensed for a capacity of 16 ambulatory children ages 14-17, plus nonminor dependents (NMDs). This site inspection was conducted with Scott Singer. The following was observed: The entire Hanna Center campus is sprawled over 100 plus acres, with several multi-use buildings. The campus also includes a swimming pool, soccer field, outdoor basketball court, baseball field, tennis court, kitchen and dining hall, school/classrooms, recreation building, gymnasium, administration offices, health center, staff buildings, along with many congregate care/residential buildings. Building 403 (Carmel House), will be the initial house that receives STRTP placements. Bldg 403 has 10 total bedrooms. There will be an initial 6, single occupancy client bedrooms and 4 staff bedrooms, to be modified if needed for a maximum capacity of 8 clients for bldg 403. There is one dormitory style client bathroom with 4 toilet stalls, 3 urinals and 4 individual private showers. Four staff bedrooms each have a private bathroom. Medications will be kept in a lock box, locked in the staff office. Washer, dryer and cleaning supplies are kept locked in the laundry room. There is a large living room area with several couches, chairs, a television and closet of games. The clients will eat meals in the dining hall and meals will be prepared for them. There is a kitchenette in bldg 403 with a sink, dishwasher, stove, microwave, standard size refrigerator and cupboards. Perishable and nonperishable foods will be kept in bldg 403, along with food in the main kitchen and dining hall. Food for bldg 403 will be stocked, once clients are placed. New dishware, utensils and other kitchen cook ware for bldg 403 was ordered on 7/31/24. Sharps will be kept locked in the office. Individual beds and accommodating furniture were observed in each bedroom. Extra bedding and linens are housed in a warehouse on campus and will be moved into bldg 403, once clients are placed. First aid kit is in the office. Fire extinguishers are throughout the building. This building has been empty (no residents) for many years and the pilot light was turned off. Hot water to be tested prior to placements. Building 404 (Alverno House), is the exact same floor plan as building 403. Bldg 404 currently has live in staff in this building. Staff will be moved to a different building, once applicant is ready to accept additional 8 clients, after bldg 403 is at full capacity. Staff and client files are kept in a locked filing cabinet, in a locked office, in the administration building on campus. All signs and required forms to be posted, prior to placements. The following items listed below were discussed and need to be completed. Applicant will notify LPA Pavia when completed. 1. Submit a waiver request for Naloxone (Narcan), to LPA Pavia. 2. Bathrooms and kitchen will have paper towels. (Use of common towels is prohibited.) 3. All trash and recycle bins are required to have secure lids. 4. Facility will post foster child's rights (2021) in common area of each building. 5. Add specific information to grievance/complaint policy on how/where a complaint form is to be submitted to staff. 6. Add Ombudsperson information to grievance/complaint policy. LPA Pavia will email instructions to request Narcan waiver. LPA will email medication forms. Reporting requirements were reviewed. An initial report for all reportable incidents is to be made by the next working day, either verbal or written. A full written report is to be remitted within 7 days via email to crpincsantarosa@dss.ca.gov. The submitted STRTP Plan of Operation/Program Statement (POO/PS) is under review. A copy of this report was given Scott Singer.

visit_type: Prelicensing


state: CA

facility_name: HANNA CENTER

summary: Facility Evaluation

raw_content:
Narrative:
At 11:30AM, Licensing Program Analyst (LPA) Mariah Hawkins conducted a visit to the facility for a post-licensing inspection. LPA met with Director of Residence Jeremiah Presinal and Director of Transitional Programs Trisha Goodwin Directors informed LPA that the STRTP is not currently in operation. There is no set opening date at this time. There are no STRTP clients in care and none who have been served since licensure. There are no STRTP staff designated at this time. As such, no client or staff files were reviewed, and no interviews were conducted. LPA toured the facility sites. Based on LPA's observations, the facility sites are maintained in safe condition and the environment provides multiple options for recreation. Using the CARE Inspection Tool, no deficiencies were observed. An exit interview was conducted, and a copy of this report and the licensee's appeal rights were provided to Director of Residence, whose signature on this form confirms receipt.

report_type: Facility Evaluation

met_with: Director of Residence Jeremiah Presinal; Director of Transitional Programs Trisha Goodwin


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Kimberly Hall and Brian Bertoli conducted an unannounced inspection to the facility for the purpose of conducting an Annual inspection. Due to the facility not being currently active, the first part of the care tools were completed for the physical plant domain only. Others sections were not completed. LPAs met with Jerimah Presinal,Sr. Director of Residence and Penn Chourre, Group Home Administrator. LPAs toured the facility, inside and out. Adequate indoor and outdoor activity space was observed. The house has eight client bedrooms, single occupancy. Personal rights are posted in the hallway. Facility has one communal restroom for client use, two client rooms each have a private bathroom. Each staff bedroom has a private bathroom. Cameras are installed throughout the property (inside and outside). There are currently no clients in care. They are working with the County on the Mental Health Program approval, accreditation will follow. Advisory note was issued for 80087(g), 80087(g)(1) and 87009(a). Facility is aware these will need to be addressed prior to having clients. Exit interview conducted and a copy of the report was left at the facility.

visit_type: Annual

met_with: Jerimiah Presinal, Penn Chourre


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA) Brian Bertoli made an unannounced visit to the facility and met with Senior Director of Residence Jeremiah Presinal. The purpose of the inspection was to confirm that the facility is not operating as a Short-Term Residential Treatment Program and has no youth in placement. On April 20, 2026 the facility informed the department that they would be closing and no clients were present. The facility has been licensed since December 13, 2024, but no youth have been placed there during that time. LPA inspected the facility and confirmed no youth were present and removed the license. LPA will process the closure as requested.

visit_type: Case Management

met_with: Jeremiah Presinal


facility_name: HARMONY HOUSE

summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Lidia Tinoco traveled to the Creative Alternatives-Mereced office due to Harmony House being closed and met with Program Director, Brandi Boehme to deliver the findings on this complaint. During the course of investigating the allegations, LPA conducted file reviews and interviews. The interviews revealed inconsistencies in explanations of the above allegations. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the above allegations occurred as reported, therefore the above allegations are unsubstantiated at this time. No deficiencies were cited. A copy of the report was left with Brandi Boehme. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lidia Tinoco 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

report_type: Complaint Investigation

met_with: Brandi Boehme

complaint_status: unsubstantiated


investigation_findings: 13On the above date, Licensing Program Analyst (LPA) Lidia Tinoco traveled to the Creative Alternatives-Mereced office due to Harmony House being closed and met with Program Director, Brandi Boehme to deliver the findings on this complaint. During the course of investigating the allegations, LPA conducted file reviews and interviews. The interviews revealed inconsistencies in explanations of the above allegations. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the above allegations occurred as reported, therefore the above allegations are unsubstantiated at this time. No deficiencies were cited. A copy of the report was left with Brandi Boehme. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lidia Tinoco 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


raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Lidia Tinoco traveled to the Creative Alternatives-Mereced office due to Harmony House being closed and met with Program Director, Brandi Boehme to deliver the findings on this complaint. During the course of investigating the allegations, LPA conducted file reviews and interviews. The interviews revealed inconsistencies in explanations of the above allegations. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the above allegations occurred as reported, therefore the above allegations are unsubstantiated at this time. No deficiencies were cited. A copy of the report was left with Brandi Boehme. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lidia Tinoco LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2


summary: Facility Evaluation

raw_content:
Narrative:
On this date, Licensing Program Analyst (LPA) Lidia Tinoco traveled to the Creative Alternatives Main Office in Merced and conducted an unannounced Case Management for the Harmony House and met with Director Brandi Boehme. The purpose of the inspection is to discuss multiple incident reports regarding medication errors by Staff. LPA Tinoco reviewed incident reports from the Harmony House facility. It was discovered that there have been 4 medication errors due to staff for this facility (See LIC812 for details) in 2021. LPA Tinoco discussed with Director Brandi the concerns with the amount of incident reports regarding medication errors being received, LPA also addressed what the licensee has been done at the agency level to prevent this from happening, and what the ongoing plans are moving forward to minimize these incidents. Director Brandi stated that a company wide training on administration of medication. An exit interview was conducted, and a copy of the report and appeal rights were provided to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst, Corina Carrillo, conducted a Case Management Inspection on September 22, 2021 at 9:35am, based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. 11 of Staff files and 5 of 5 youth files as identified on the LIC Confidential Names dated September 22, 2021 were reviewed, 4 direct care Staff and 5 youth were also interviewed. The Plan of Operation including policies and procedures were reviewed. A copy of this report was discussed and provided to Aaron Holloway, Facility Supervisor.

met_with: Aaron Holloway


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by Licensing Program Analyst (LPA) Cynthia Galindo traveled to the Harmony House STRTP in Merced, California. LPA met with Administrator Aaron Holloway and inspected the facility, inside and out. A physical plant inspection was completed and included the following checks. Facility grounds are clean and free of debris. Adequate indoor and outdoor activity space and materials observed. The facility is maintained at 75 degrees. All facility smoke detectors and carbon monoxide detectors are in appropriate working order. Facility maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. All required forms are posted. No client requires medications currently, facility has the ability to keep medications locked and centrally stored. Individual beds were observed with appropriate clean linens and are in good repair. Licensee has obtained Mental Health Certification Including the following: Mental Health Program Approval valid through September 24, 2021, a review was conducted on August 16-23, 2021 and have not been issued. Licensee has obtained National Accreditation through CARF valid through September 30, 2023. The facility has a county contract valid through June 30, 2022. Medical Certification valid through April 26, 2022. No firearms or weapons are allowed in the facility. Facility appears to be meeting the terms and conditions of their license. LPA reviewed three client files and conducted two staff and one client interviews. No Deficiencies were cited on today's visit. A copy of this report was left with Aaron Holloway.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Cynthia Galindo traveled to the Creative Alternatives main office in order to continue conducting the Annual Inspection for Harmony STRTP and met with Program Director, Brandi Boehme. LPA was advised the Harmony home closed on 11/19/2021. LPA conducted 10 staff file reviews. Two technical violations were issued. No other deficiencies were cited. A copy of this report was left with Brandi Boehme at the conclusion of inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA) Lidia Tinoco traveled to the Harmony House STRTP in Merced, California for the purpose of conducting an unannounced Annual Inspection. LPA met with Administrator Aaron Holloway and inspected the facility, inside and out. A physical plant inspection was completed and included the following checks. Facility grounds are clean and free of debris. Adequate indoor and outdoor activity space and materials observed. The facility is maintained at 75 degrees. All facility smoke detectors and carbon monoxide detectors are in appropriate working order. Facility keeps some canned foods and non-perishables in the home, there is no perishable food in the house at this time but has access to a full pantry located at Merced Ranch where they can stock the facility should they chose to open the house again. All required forms are posted. Facility has the ability to keep medications locked and centrally stored. Individual beds were observed with appropriate clean linens and are in good repair. Licensee has obtained Mental Health Certification Including the following: The Facility is currently under a Corrective Action Plan which was accepted by DHCS on February 14, 2022, the facility expects a review with DHCS in May 2022. Licensee has obtained National Accreditation through CARF valid through September 30, 2023. The facility has a county contract valid through June 30, 2022. No firearms or weapons are allowed in the facility. Facility appears to be meeting the terms and conditions of their license. Currently the facility is inactive, therefore no children or staff are in placement therefore no files were reviewed. No Deficiencies were cited on today's visit. A copy of this report was left with Aaron Holloway.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analysts (LPAs), Lidia Tinoco and Cynthia Galindo met with Program Director Brandi Boehme. LPA's Received the board of resolution letter for Harmony house as the license is being forfeited. A copy of this report was left at the conclusion of the inspection.


facility_name: HART COMMUNITY HOMES

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
regarding the allegation. LPA was unable to make a determination regarding the allegation. Based on confidential interviews and record review, the allegation that Staff did not prevent minor from AWOLing may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. A copy of this report and Appeals Rights were provided and explained to Celia Vasquez, Facility Administrator.

Investigation Findings:
13On March 01, 2022 at 11:40 a.m., Licensing Program Analyst (LPA) Sarah Smith met with Hart Community Homes Short Term Residential Therapeutic Program (STRTP) Celia Vasquez, Facility Administrator to deliver the finding of the complaint investigation for the above allegation. LPA Cervantes conducted a health and safety inspection of the facility on July 07, 2021 at 2:30 p.m. and no immediate deficiencies were observed. During the course of investigating the allegation, LPA Cervantes and LPA Smith conducted confidential interviews with three staff (S1, S2, S3) and one witness. LPA reviewed reports and the records for the facility and clients (C1 and C2). On July 06, 2021, a complaint was received that staff did not prevent C1 and C2 from (absent without leave) AWOLing while in care. Information obtained from confidential interviews disclosed that proper AWOL procedures were followed while other information received reported that the allegation was true. C1 is deceased and unable to be interviewed. C2 was uncooperative and refused to provide information UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Sarah Smith LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: HART COMMUNITY HOMESFACILITY NUMBER: VISIT DATE: 03/01/2022

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

met_with: Celia Vasquez, Facility Administrator


raw_content:
Narrative:
This is an amended LIC9099 to the original dated 05/02/2022. All confidential interviews disclosed that the clients cell phones are taken from them as a form of discipline when they lose their privileges. Confidential interviews revealed that the clients are asked to turn their cell phones in and if they do not then the staff will confiscate the charging cord to the cell phone. Based on confidential interviews Personal belongings are taken away from residents is substantiated which poses a potential health, safety, and personal rights risk to clients in care. The preponderance of evidence standard has been met. Facility is cited for violation of Interim Licensing Standard (ILS) version 3.1 section 87072(d) PERSONAL RIGHTS. Exit interview was conducted. A copy of this report and appeal rights were given and explained to Celia Vasquez, Facility Administrator. With regard to the allegation that Facility manager does not work a sufficient number of hours, during confidential interviews it was revealed that there were times the facility manager was not working the correct number of hours due to a serious medical condition. LPA Smith was unable to interview the facility manager because they passed away. With regard to the allegation that Reporting procedures are fraudulent, during confidential interviews it was revealed that the procedures to submit a Serious Incident Report (SIR) is that the staff write the report and submit it to the facility administrator or clinician for review. Once the SIR is reviewed it is then submitted to the appropriate parties. All confidential interviews denied fraudulent reporting procedures and stated that the correct procedures are followed. Due to the lack of contact information being submitted, LPA was unable to obtain any clarifying information about this allegation. Regarding the allegation that Resident medicines are not locked, LPA Smith observed the resident medications were contained in a digital-lock safe. Confidential interviews revealed that prior to the facility keeping the resident medicines in the safe, the medications were contained in a locked file cabinet. Other confidential interviews stated that the medicine cabinet has been observed not being locked. Regarding the allegation that Residents are not treated with dignity, confidential interviews revealed that the clients are treated with respect and dignity. Additional confidential interviews revealed that clients have not witnessed staff being rude or disrespectful. Confidential interviews revealed that none of the staff members have ever cursed at the clients in care. During other confidential interviews it was revealed that the clients are being cursed at and not treated with dignity and respect. Based on confidential interviews, record review, and LPA observations, the allegations that Facility is out of ratio, Facility manager does not work a sufficient number of hours, Reporting procedures are fraudulent, Resident medicines are not locked, and Residents are not treated with dignity may have occurred, however are not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. A copy of this report and Appeals Rights were provided and explained to Facility Administrator, Celia Vasquez.

Investigation Findings:
13This is an amended LIC9099 to the original dated 05/02/2022. On May 01, 2022 at 1:30 p.m., Licensing Program Analyst (LPA) Sarah Smith met with Hart Community Homes Short Term Residential Therapeutic Program (STRTP) Facility Administrator, Celia Vasquez to deliver the findings of the complaint investigation for the above allegations involving the Client1 (C1). LPA Cervantes conducted a health and safety inspection of the STRTP on June 28, 2021 and no immediate deficiencies were observed. During the course of investigating the allegations, LPA Smith conducted confidential interviews with one of two clients, the County Social Worker (CSW), and three staff (S1, S2, and S3). One client refused to be interviewed. LPA reviewed reports and the records for the STRTP, staff, and clients. On June 23, 2021, a complaint was received that alleged Personal belongings are taken away from residents. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Sarah Smith LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: HART COMMUNITY HOMESFACILITY NUMBER: VISIT DATE: 05/02/2022

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

met_with: Celia Vasquez, Faclility Administrator


raw_content:
Narrative:
did not make inappropriate comments towards the minors, more specifically "that the clients are trouble and annoying." Confidential interviews reported mental health staff tell the program administrator the clients medical diagnosis and discuss their diagnosis in front of the clients. Conflicting interviews reported that the clients diagnosis is discussed in weekly staff meetings with the purpose of discussing goals, interventions, and how to support the clients. Confidential interviews reported that the weekly staff meetings are held in the facility's garage while clients are in school. Confidential interviews revealed when confidential discussions are needed between staff in the facility, staff go into the staff office and close the door. Confidential interviews and records reviewed did not provide a preponderance of evidence to prove or disprove the allegations that staff made inappropriate comments towards minors and staff did not keep minors personal information confidential Therefore, the allegations are unsubstantiated. An exit interview was conducted, and appeal rights were reviewed with Celia Vasquez. Due to printer malfunction, a copy of this report, along with the LIC 811, and appeal rights will be emailed to the Facility Administrator. A signed copy of this report will be kept in the Facility file.

Investigation Findings:
13On March 21, 2023, at 2:15 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Celia Vasquez, Facility Administrator, of Hart Community Homes to discuss the investigative findings for the allegations noted above. LPA Charmaine Linley conducted an inspection of the facility on 12/06/2022 at 11:50 am and no deficiencies were found. LPA Linley interviewed four staff (S1-4), and interviewed two clients (C1-2). LPA reviewed the following documents during the investigation: Administrator's Certificate, Mental Health Staff resumes and degrees, staff schedule, and staff contact list. On 11/28/22, Community Care Licensing received allegations that staff made inappropriate comments towards minors and staff did not keep minors personal information confidential. It was reported that staff members say mean comments about the clients like they are "trouble and annoying." Confidential interviews reported staff gossip and say mean things about the clients. Conflicting interviews revealed staff UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: HART COMMUNITY HOMESFACILITY NUMBER: VISIT DATE: 03/21/2023

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

met_with: Celia Vasquez


raw_content:
Narrative:
provide adequate supervision to minors in care. It was reported that S1 took two clients to the park and S1 lost track of the clients, the clients were involved in a verbal altercation with individuals at the park, which resulted in Law Enforcement involvement. Due to not being able to interview all individuals, although multiple attempts were made, confidential interviews did not corroborate the allegation with a preponderance of evidence. Based on confidential interviews and records reviewed the allegation that staff is unable to provide adequate supervision to minors in care, which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Jasmin Mejia, Facility Administrator. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights was emailed to the Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On June 19, 2024, at 10:10 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Jasmin Mejia, Facility Administrator, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on October 20, 2023, at 11:25 am and no deficiencies were observed. LPA Linley interviewed five staff (S1-4, S6), and was unable to interview two staff (S5, S7), despite multiple attempts to contact them, LPA attempted to interview four clients (C1-4), however, was unable to interview them despite multiple attempts to contact them, LPA interviewed one County Social Worker (CSW2), and LPA was unable to interview three County Social Workers (CSW1, CSW3-4), despite multiple attempts to contact them. The following documents were reviewed during the investigation: Client Roster, Personnel Report, Staff Schedule, Special Incident Reports, Staff Log, Law Enforcement Incident Report, and S Training Records. On October 20, 2023, Community Care Licensing (CCL) received an allegation that staff is unable to UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: HART COMMUNITY HOMESFACILITY NUMBER: VISIT DATE: 06/19/2024

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

met_with: Jasmin Mejia


raw_content:
Narrative:
Due to being unable to interview all individuals, although multiple attempts were made, confidential interviews did not corroborate the allegations with a preponderance of evidence. Based on confidential interviews and records reviewed the allegations that staff spoke to minor in an inappropriate manner, staff does not keep minor's personal information confidential, and staff confiscates minor's personal items for an extended period of time, which may have occurred, however, they are not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Celia Vasquez. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights was emailed to the Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On July 9, 2024, at 11:20 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Celia Vasquez, Residential Director, to discuss the investigative finding for the allegations noted above. LPA conducted an inspection of the facility on December 21, 2023, at 2:45 pm and no deficiencies were observed. LPA Linley interviewed four clients (C2-5), eight staff (S1-7, S10) and LPA was unable to interview one client (C1) and two staff (S8-9), despite multiple attempts to contact them. The following documents were reviewed during the investigation: Personnel Roster, Staff Schedule, Client Roster, House Rules, Special Incident Report and Law Enforcement Incident Report. On December 18, 2023, Community Care Licensing (CCL) received allegations that staff spoke to minor in an inappropriate manner, staff does not keep minor's personal information confidential, and staff confiscates minor's personal items for an extended period of time. Confidential interviews revealed conflicting statements. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: HART COMMUNITY HOMESFACILITY NUMBER: VISIT DATE: 07/09/2024

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


raw_content:
Narrative:
Based on confidential interviews and records reviewed the allegations that staff yelled at minor in care and staff handled minor in an inappropriate manner, which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Celia Vasquez. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights was emailed to the Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On July 9, 2024, at 11:00 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Celia Vasquez, Residential Director, to discuss the investigative finding for the allegations noted above. LPA conducted an inspection of the facility on December 21, 2023, at 2:20 pm and no deficiencies were observed. LPA Linley interviewed four clients (C2-5), eight staff (S1-7, S10) and LPA was unable to interview one client (C1) and two staff (S8-9), despite multiple attempts to contact them. The following documents were reviewed during the investigation: Personnel Roster and Client Roster. On December 21, 2023, Community Care Licensing (CCL) received allegations that staff yelled at minor in care and staff handled minor in an inappropriate manner. Confidential interviews revealed conflicting statements. Due to being unable to interview all individuals, although multiple attempts were made, confidential interviews did not corroborate the allegations with a preponderance of evidence. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: HART COMMUNITY HOMESFACILITY NUMBER: VISIT DATE: 07/09/2024

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


raw_content:
Narrative:
Description for Care Coordinator which indicates the position shall meet the following requirement, "At least a baccalaureate degree and four years of experience as a specialist in the fields of physical restoration, social adjustment or vocational adjustment." Confidential interviews and records reviewed indicated S5 only had six months as a substitute Teacher, prior to being employed as a Direct Care staff with the facility and thus does not have four years of experience as a specialist in the fields of physical restoration, social adjustment or vocational adjustment. Based on confidential interviews and record review the allegation that unqualified staff providing care to minors is substantiated. The preponderance of evidence standard has been met. The facility is cited for violation of the STRTP Interim Licensing Standards 87022(c)(3)(A) Plan of Operation. An exit interview was conducted, appeal rights explained, and a copy of this report, LIC 811, and appeal rights were provided to Jasmin Mejia. A copy of this report will be placed in the facility file. Based on confidential interviews and records reviewed the allegation that the facility staff are not providing nutritious meals to minors in care, which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report, LIC 811, and appeal rights were provided to Jasmin Mejia. A copy of this report will be placed in the facility file.

Investigation Findings:
13On March 26, 2025, at 12:30 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility and met with Jasmin Mejia, Facility Administrator, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on January 13, 2025, at 9:57 am and no deficiencies were observed. LPA interviewed three Clients (C1-3) and five Staff (S1-5). LPA reviewed the facility documents during the investigation. On January 3, 2025, Community Care Licensing (CCL) received an allegation that unqualified staff is providing care to minors. It was reported that S1 and S5 are not qualified for their positions. Confidential interviews and records reviewed that on 10/26/2023, S1 was approved by Community Care Licensing as the Facility Administrator. Confidential interviews and records indicated S5 has worked at the facility as a Direct Care staff member since July 2022 and as of October 2023 has moved into the position of Mental Health Rehabilitation Specialist and Care Coordinator. LPA reviewed the Program Statement with the Job SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: HART COMMUNITY HOMESFACILITY NUMBER: VISIT DATE: 03/26/2025

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


raw_content:
Narrative:
Based on confidential interviews and records reviewed the allegations that staff is utilizing a vape pen in the presence of minors, staff spoke to minor in an inappropriate manner, and staff are not following the facility's runaway plan, which may have occurred, however, they are not supported or proven by the evidence. An exit interview was conducted, appeal rights explained, and a copy of this report, LIC 811, and appeal rights was provided to the Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On March 26, 2025, at 12:15 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Jasmin Mejia, Facility Administrator, to discuss the investigative finding for the allegations noted above. LPA conducted an inspection of the facility on January 29, 2025, at 3:40 pm, and no deficiencies were observed. LPA interviewed three Clients (C1-3) and three Staff (S1-3). LPA reviewed the facility documents during the investigation. On January 24, 2025, Community Care Licensing (CCL) received allegations that staff is utilizing a vape pen in the presence of minors, staff spoke to minor in an inappropriate manner, and staff are not following the facility's runaway plan. It was reported that S1 has vaped around the clients, S1 has referenced C1 "jacking off" after the clients were calling each other gay, and S1 allows the clients to run away as long as they return to the facility by the next shift change. Confidential interviews revealed conflicting statements. Thus, confidential interviews could not confirm or deny the allegations. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: HART COMMUNITY HOMESFACILITY NUMBER: VISIT DATE: 03/26/2025

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

met_with: Jasmin Meiji


summary: Facility Evaluation

raw_content:
Narrative:
On June 15, 2021, at 1: PM Licensing Program Analyst (LPA) Jesus Cervantes conducted an unannounced annual inspection. The facility converted from a Group Home to a Provisional STRTP (Short Term Therapeutic Program) on June 25, 2020. LPA was met at the facility by Administrator Celia Vasquez. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster, the Emergency Disaster Plan was also posted. Clients medications were observed to be inaccessible and stored in a locked file cabinet in the staff office. Medication records were reviewed and observed to be completed with dates and staff initials on dispensing records. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. There are two client bedrooms that contain one twin bed and two client bedrooms contain two twin beds. The facility has one client bathroom and one staff restroom located in a staff office. The water temperature in the bathroom one was tested at 12: PM and registered at 119.1 degrees which is within the appropriate range of 105 degrees to 120 degrees. Per facility staff, no firearms or weapons are allowed in the facility. Administrator Celia Vasquez is present at the facility a minimum of 20 hours a week, as verified by staff schedule and interviews. Appropriate staff/client ratios were verified during this inspection. The facility employs one Clinical Director, one in-house Social Worker, one Care Coordinator, one House Manager, two Administrators, and ten direct care staff that are used in accordance with regulatory requirements. Licensee is in the process of obtaining their Mental Health (MH) Certification and expects issuance by the end of June 2021. Licensee is in the process of obtaining National Accreditation through CARF and expects accreditation by the end of 2021. Licensing fee payments are current. All the client files are stored and locked in the file cabinet in the staff office. At 2: PM, LPA reviewed a sample of four clients files during the time of inspection. Two facility staff were interviewed during the inspection. Four clients declined to be interviewed. All the staff files are stored in the back house/staff office area. At 3: PM, LPA reviewed sample of five staff files. All the staff have met the training and qualification requirements per regulations requirements. Per a review of the Community Care Licensing Information System (LIS), all staff met DOJ/FBI criminal record clearances and Child Abuse Index Check requirements. LPA discussed the following with the Administrator: Facility procedures related to requesting exceptions. Assembly Bill 388 law enforcement contacts as well as incidents involving emergency interventions. LPA discussed procedures for Child and Family Team (CFT) meetings, including an overview of required Core Services and Supports. LPA also discussed Reasonable and Prudent Parenting Standards, and resident involvement in development of planned activities. No deficiencies were found. Exit interview was conducted and a copy of this report was provided to the Administrator Celia Vasquez.


summary: Facility Evaluation

raw_content:
Narrative:
On July 06, 2021 at 9: AM, Licensing Program Analyst (LPA) Jesus Cervantes conducted an unannounced inspection with Facility Manager Celia Vasquez (S1). The purpose of the inspection is to conduct a case management to follow up on a preliminary report dated July 04, 2021 regarding the death of Client #1 (C1) at a nearby park. On July 03, 2021, at about 10: AM, the facility had reported Child #1 (C1) and Child #2 (C2) AWOL to City of Orange Police. Upon reporting C1 and C AWOL, facility staff discovered that a locked filing cabinet in the staff office had been broken into. In the cabinet was the clients cash resource book and medications. Facility staff accounted for all medications but discovered over $300 missing from the book. The facility suspects C1 and C2 may have broken into the locked cabinet and taken the money. The theft was also reported to City of Orange Police. The facility reported that on July 04, 2021, at about 6: AM, the facility was notified by an Orange County Sheriffs Coroners investigator that at about 5: AM, Orange Police Department responded to a local park regarding a found body. Upon police arrival, they located the deceased body of Child #1 (C1). Found next to C1 was two back packs, drugs, and drug paraphernalia. Investigative preliminary findings show this was a drug overdose per the Orange County Sheriffs Coroner's investigator. The facility inquired about C2, but there was no information about the whereabouts of C2 at that time. The facility upon learning of the death of C1 notified the following agencies; Orange County Social Services, C1's Social Worker, Orange County Probation Department, and Community Care Licensing. The facility has identified therapy and counseling services that are being provided to both clients and staff. C2 returned to the facility on July 5, 2021, at about 3: AM. LPA Cervantes conducted confidential staff and client interviews. LPA Cervantes will be requesting the police reports and incident reports to be submitted to Community Care Licensing (CCL). An exit interview was conducted, and a copy of this report was provided to Facility Manager Celia Vasquez.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Margaret Lentner conducted a case management inspection on April 27, 2022 at 9:44am 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, 7 out of Direct Care Staff and 5 out of 5 youth files were reviewed. 2 out of Direct Care Staff and 3 out of 5 youth were interviewed. (See the Confidential Names List, LIC 811, dated April 27, 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 Margaret Lentner 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 Celia Vasquez - Administrator.

met_with: Celia Vasquez - Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On September 13, 2023, at 10: AM Community Care Licensing (CCL) Licensing Program Manager (LPM), Ann Valenzula and Licensing Program Analyst (LPA) Guadalupe Munoz conducted an unannounced annual inspection. CCL were met at the facility by Administrator Celia Vasquez. The facility is licensed to care for a capacity of six clients ages 13 -18 years old and currently have a census of five clients. The facility has mental health approval that expires June 2024, and obtained accreditation through CARF which expires December 31, 2024. Licensing fee payments are current. The facility is a single story structure that consists of four bedrooms, three bathrooms, kitchen dinning area, and an open living room. The garage is located behind the facility and is utilized for the mental health team and used for Child and Family Team Meetings. In the backyard there is a separate structure that is the Head of Service's office. A physical plant inspection was completed using the Care Tools and included the following checks: Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguishers are properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, Foster Care Ombudsman poster, and the Emergency Disaster Plan. Clients medications were observed to be inaccessible and stored in a locked safe in the staff office. Medication records were reviewed and observed to be completed with dates and staff initials on dispensing records. ***Continued on Page 2*** ***CONTINUED FROM PAGE 1*** Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. There are two client bedrooms that contain one twin bed and two client bedrooms contain two twin beds. There were dressers for each client and additional cabinet space for storage. The facility has one client bathroom and one staff restroom located in a staff office. The hall was observed to have a large hole that was recently damaged and a work order is pending. There is an additional restroom located in the hall between the staff office and a client bedroom and across from another bedroom. The water temperature in the client bathroom in the hallway was tested and is within the appropriate range of 105 degrees to 120 degrees. Per facility staff, no firearms or weapons are allowed in the facility. Administrator Celia Vasquez is present at the facility a minimum of 20 hours a week, as verified by staff schedule and interviews. Appropriate staff/client ratios were verified during this inspection. All the client files are stored and locked in the file cabinet in the staff office. CCL reviewed a sample of five clients files during the time of inspection. Client files contained all required documents. Staff files are maintained at the corporate office and were transported to the facility by the administrator for review. CCL reviewed five staff files. All the staff have met the training and qualification requirements per regulations requirements. All staff met DOJ/FBI criminal record clearances and Child Abuse Index Check requirements. Two facility staff were interviewed during the inspection. and two clients. LPA discussed the following with the Administrator emergency interventions and disaster preparedness plan. No deficiencies were found. Exit interview was conducted and a copy of this report was provided to the Administrator Celia Vasquez.via email.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Joon Choi on 10/23/2023 at 07: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the visit, LPA Choi met with Residential Director, Celia Vasquez and conducted a health and safety inspection of the facility. No immediate health or safety risks were observed. LPA reviewed 2 of child's records and 3 of staff personnel files on site at the facility. LPA reviewed 2 of child's psychotropic medications and medication records. LPA interviewed 3 of staff on site to discuss the facilities policies and procedures of operation. LPA interviewed 2 of children currently prescribed psychotropic medication. LPA provided a copy of this licensing report to Celia Vasquez, Residential Director. No deficiencies are being cited at this time. LPA conducted exit interview with Residential Director Celia Vasquez and provided a copy of this report.

met_with: Celia Vasquez, Residential Director


summary: Facility Evaluation

raw_content:
Narrative:
On the date listed above at 11:30 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility for the purpose of conducting collateral interviews with one staff. LPA met with Jasmin Mejia, Facility Administrator, and explained that the complaint investigation is not on their facility. LPA conducted two interviews with one staff. LPA toured the facility and the facility was in compliance with Title 22 regulations, Chapter 5, therefore no deficiencies were cited. Due to printer malfunction, a copy of this report will be emailed to the Facility Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Guadalupe Munoz on 10/30/2024 at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the visit, LPA Munoz met with Facility Administrator, , Jasmin Mejia and conducted a health and safety inspection of the facility. No immediate health or safety risks were observed. LPA reviewed 2 of child's records and 3 of staff personnel files on site at the facility. LPA reviewed 2 of 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 one resident due to client leaving facility during inspection. LPA will interview client #2 currently prescribed psychotropic medication. at school at a later time. No deficiencies are being cited at this time. TechLPA conducted exit interview and provided a copy of this licensing report and LIC 811 dated 10/30/24 to Jasmin Mejia, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 04/24/25, at 9: AM, Licensing Program Analyst (LPA) Gilbert Marquez met with Celia Vasquez, Administrator, for the purpose of conducting an annual inspection of the facility. The Facility is licensed to serve six ambulatory children ages 13-18 years old. The current census is zero children. The Facility is current with their licensing fees. The Facility is a single story dwelling and contains four bedrooms, two bathrooms, kitchen dinning area, two staff offices, and open living room. The garage is located behind the facility and is utilized for the mental health team and used for Child and Family Team Meetings. In the backyard there is a separate structure that is the Head of Service's office. A physical plant inspection was completed with Celia (S1, see LIC Confidential Names list) and included the following checks: all rooms listed in first part of this paragraph, locked safe with medications, first aid kit, toiletries, and food in kitchen. All beds were observed with appropriate bedding and mattress in good repair. Bedrooms contained adequate drawers and closet space. All required forms are posted including Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster, and the Emergency Disaster Plan. Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of non-perishable foods to prepare the items on the posted sample menu. **Continued on LIC809-C** **Continued from LIC809** Individual beds were observed with clean linens, pillows, comforters, and mattress in good repair. The first aid kit was accessible to everyone and had all required supplies. LPA reviewed one staff file (S1) to ensure staff had all required documents per Title 22 regulations. Staff records are stored in administrators office. Per review of Guardian, Celia has a criminal background clearance transferred. LPA conducted one staff interview (S1). Per facility staff, no firearms or weapons are allowed in the facility. An exit interview was conducted, and a copy of this report and LIC811 were provided to Celia Vasquez, Administrator. A copy of this report will be placed in the facility file.

met_with: Celia Vasquez, Administrator


facility_name: HART COMMUNITY HOMES - BRADY HOUSE

raw_content:
Narrative:
Confidential interviews revealed that C1 and C2 were "horse playing" with each other and facility staff told stop. Confidential interviews revealed that C2 entered C2's room after being told to stop. C1 entered C2's room when facility staff was occupied and not looking. Confidential interviews revealed C2 then slapped C1 near C1's groin. However, confidential interviews revealed C2 did not slap C1 near C1's groin. Confidential interviews revealed that the incident was reported to staff by five days later. LPA received inconsistent information regarding the allegation. Based on confidential interviews and record review, the allegations that staff failed to supervise C1 and C2 resulting in C1 inappropriately touching C2 while in care may have occurred; however, it is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this report along with appeal rights was provided to Esmerelda Rodriguez.

Investigation Findings:
13On July 23, 2021, at 3: PM, Licensing Program Analyst (LPA) Jesus Cervantes made an unannounced visit at the facility. LPA met with Esmerelda Rodriguez, to issue the investigative findings of the allegation listed above. On January 19, 2021, Licensing Program Analyst (LPA), Jesus Cervantes, due to COVID-19, conducted a tele-inspection of the facility, and no deficiencies were noted. LPA Cervantes conducted interviews with one of two Foster Children (C1) and three of four staff (S1, S3, and S4). Foster Child #2 (C2) and Staff #2 (S2) did not respond to LPAs multiple request to interview. During the investigation, LPA reviewed facility records and obtained copies of the following documents: client needs and service plans, facility notes, and special incident report 01/05/2021. On January 07, 2021, Community Care Licensing received the allegation that staff failed to supervise C1 and C2 resulting in C1 inappropriately touching C2 while in care. SEE PAGE TWO UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Jesus Cervantes LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: HART COMMUNITY HOMES - BRADY HOUSEFACILITY NUMBER: VISIT DATE: 07/23/2021

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

met_with: Esmerelda Rodriguez


raw_content:
Narrative:
concerned of what the packages contained. However, S1 opened a letter that was addressed to C1. The CSW stated that they were not aware of a letter being opened, but they were aware of the issue with the client receiving a high volume of packages that were not addressed to C1. Regarding the allegation that Personal belongings are taken away from residents, all confidential interviews disclosed that the clients cell phones are taken from them as a form of discipline when they lose their privileges. Confidential interviews revealed that the clients are asked to turn their cell phones in and if they do not then the staff will confiscate the charging cord to the cell phone. Based on confidential interviews Staff open resident mail, and Personal belongings are taken away from residents are substantiated which pose a potential health, safety, and personal rights risk to clients in care. The preponderance of evidence standard has been met. Facility is cited for violation of Interim Licensing Standard (ILS) version 3.1 section 87072(d) PERSONAL RIGHTS. Exit interview was conducted. A copy of this report and appeal rights were given and explained to Esmeralda Rodriguez, Facility Administrator. With regard to the allegation that Facility manager does not work a sufficient number of hours, during confidential interviews it was revealed that there were times the facility manager was not working the correct number of hours due to a serious medical condition. LPA Smith was unable to interview the facility manager because they passed away. With regard to the allegation that Reporting procedures are fraudulent, during confidential interviews it was revealed that the procedures to submit a Serious Incident Report (SIR) is that the staff write the report and submit it to the facility administrator or clinician for review. Once the SIR is reviewed it is then submitted to the appropriate parties. All confidential interviews denied fraudulent reporting procedures and stated that the correct procedures are followed. Due to the lack of contact information being submitted, LPA was unable to obtain any clarifying information about this allegation. Regarding the allegation that Resident medicines are not locked, LPA Smith observed the resident medications were contained in a digital-lock safe. Confidential interviews revealed that prior to the facility keeping the resident medicines in the safe, the medications were contained in a locked file cabinet. Other confidential interviews stated that the medicine cabinet has been observed not being locked. Regarding the allegation that Residents are not treated with dignity, confidential interviews revealed that the clients are treated with respect and dignity. Additional confidential interviews revealed that clients have not witnessed staff being rude or disrespectful. Confidential interviews revealed that none of the staff members have ever cursed at the clients in care. During other confidential interviews it was revealed that the clients are being cursed at and not treated with dignity and respect. Based on confidential interviews, record review, and LPA observations, the allegations that Facility is out of ratio, Facility manager does not work a sufficient number of hours, Reporting procedures are fraudulent, Resident medicines are not locked, and Residents are not treated with dignity may have occurred, however are not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. A copy of this report and Appeals Rights were provided and explained to Facility Administrator, Esmeralda Rodriguez.

Investigation Findings:
13This is an amended LIC9099 to the original dated 05/02/2022. On May 01, 2022 at 1:30 p.m., Licensing Program Analyst (LPA) Sarah Smith met with Hart Community Homes Short Term Residential Therapeutic Program (STRTP) Facility Administrator, Esmeralda Rodrigures to deliver the findings of the complaint investigation for the above allegations involving the Client1 (C1). LPA Cervantes conducted a health and safety inspection of the STRTP on June 28, 2021 and no immediate deficiencies were observed. During the course of investigating the allegations, LPA Smith conducted confidential interviews with one of two Clients, the County Social Worker (CSW), and three staff (S1, S2, and S3). One client refused to be interviewed. LPA reviewed reports and the records for the STRTP, staff, and clients. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Sarah Smith LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: HART COMMUNITY HOMES - BRADY HOUSEFACILITY NUMBER: VISIT DATE: 05/02/2022

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


raw_content:
Narrative:
Confidential records reviewed the facility staff was out of ratio on three shifts in November. Confidential interviews reported the facility menu is posted on the front of the refrigerator. LPA observed the facility menu posted on the front of the refrigerator in December and the menu was dated May 2022. Based on observation and reviewed, the allegations that the facility is operating out of ratio and the facility doesn't post a food menu is Substantiated. The preponderance of evidence has been met. The facility is being cited under the following Interim Licensing Standards STRTP Direct Care Staff/Child Ratios 87065.5(a)(1) (refer to LIC 809D). A Technical Advisory is being given for the following: Title Division Food Services 80076(a)(5). An exit interview was conducted with Esmeralda Rodriguez, Facility Administrator. Due to printer malfunction, a copy of this report, along with the LIC 811, and appeal rights will be emailed to the Facility Administrator. A signed copy of this report will be kept in the Facility file. have been left out in the open in the garage. Conflicting interviews indicated paint and spray cans are locked in the office and chemicals, detergent, and bleach are locked in the cleaning closet, which is locked and accessible only by keys assigned to staff members. Confidential interviews did not provide a preponderance of evidence to prove or disprove the allegation that staff did not provide a safe environment. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and appeal rights were reviewed with Esmeralda Rodriguez, Facility Administrator. Due to printer malfunction, a copy of this report, along with the LIC 811, and appeal rights will be emailed to the Facility Administrator. A signed copy of this report will be kept in the Facility file.

Investigation Findings:
13On March 21, 2023, at 2:45 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Esmeralda Rodriguez, Facility Administrator, of Hart Community Homes to discuss the investigative findings for the allegations noted above. LPA Charmaine Linley conducted an inspection of the facility on 12/06/2022 at 11:15 am and no deficiencies were found. LPA Linley interviewed five staff (S1-5), interviewed two clients (C1-2), and attempted to interview two staff (S6, S7), however was unable to interview them, despite multiple attempts to contact them. LPA reviewed the following documents during the investigation: November 2022 staff schedule, November 2022 employee timecards, and facility menu. On 11/28/22, Community Care Licensing received allegations that the facility is operating out of ratio and the facility doesn't post a food menu. It was reported that sometimes there is one staff member with five clients. Confidential interviews reported that at times the facility staff have not been in ratio and attempts were made to bring in an additional staff member to help with ratio, which took approximately one to two hours. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: HART COMMUNITY HOMES - BRADY HOUSEFACILITY NUMBER: VISIT DATE: 03/21/2023

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


raw_content:
Narrative:
Confidential interviews reported all clients who run away from the facility are given consequences when they return to the facility, such as a level drop and they are not eligible to go on outings or purchase fast food. Conflicting interviews reported C1 did not receive the same consequences for running away as C2 received for running away. Conflicting interviews reported C2 did not run away from the facility, rather was not always at the school pick up location, which was considered to be "run away." Confidential interviews did not provide a preponderance of evidence to prove or disprove the allegation that staff do not treat minors equally. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and appeal rights were reviewed with Esmeralda Rodriguez, Facility Administrator. Due to printer malfunction, a copy of this report, along with the LIC 811, and appeal rights will be emailed to the Facility Administrator. A signed copy of this report will be kept in the Facility file.

Investigation Findings:
13On March 21, 2023, at 3:46 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Esmeralda Rodriguez, Facility Administrator of Hart Community Homes to discuss the investigative finding for the allegation noted above. LPA Charmaine Linley conducted an inspection of the facility on 12/06/2022 at 10:30 am and no deficiencies were found. LPA Linley interviewed five staff (S1-5), and interviewed two clients (C1-2), and was unable to interview two staff (S6-7), despite multiple attempts to contact them. LPA reviewed the following documents during the investigation: Staff Schedule, Staff Contact list, and Client Roster. On 11/28/22, Community Care Licensing received allegations that staff do not treat minors equally. It was reported that staff play favorites with the clients when they run away from the facility and one client will get in trouble and another client will not get in trouble. Confidential interviews revealed conflicting information. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: HART COMMUNITY HOMES - BRADY HOUSEFACILITY NUMBER: VISIT DATE: 03/21/2023

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


raw_content:
Narrative:
It was reported C1 spoke to their mother over the phone and disclosed to their mother that S9 said "why doesn't your mother want you?" however, confidential interviews revealed that was not said during a phone call. Other confidential interviews entailed that no staff has made any negative comments to C1, while other confidential interviews indicated that S9 made derogatory comments regarding C1's mother to C1. There were no witnesses to the alleged incident. Based on confidential interviews and records reviewed staff (S9) spoke inappropriately to minor (C1), which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this report along with appeal rights was provided to Administrator-Jasmin Mejia.

Investigation Findings:
13On May 15, 2024 at 09: AM, Licensing Program Analyst (LPA) Jacqueline Garcia arrived unannounced at the facility and met with Administrator-Jasmin Mejia, to discuss the investigative finding for the allegation noted above. On 11/28/ LPA conducted an inspection of the facility, and no deficiencies were noted. LPA interviewed one client (C1), eight staff (S1-S8), and C1's Mother. During the investigation, LPA reviewed the following documents: C1's photo, C1s Needs and services plan, C1s Special Incident Report, C1s Intensive care coordinator progress note, C1's contact information, Facility Personnel Report and Facility weekly staff schedule. On 11/21/23, Community Care Licensing (CCL) received allegation that staff spoke inappropriately to minor. Confidential interviews revealed conflicting statements regarding staff speaking to C1 in an inappropriate manner. ***Continued on to 9099-C page. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Jacqueline Garcia LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: HART COMMUNITY HOMES - BRADY HOUSEFACILITY NUMBER: VISIT DATE: 05/15/2024

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

met_with: Jasmin Mejia-Administrator


raw_content:
Narrative:
and staff did not ensure minor is provided a safe and comfortable environment. Confidential interviews revealed conflicting statements. In addition, due to being unable to interview all individuals, although multiple attempts were made, confidential interviews did not corroborate the allegations with a preponderance of evidence. Based on confidential interviews and records reviewed, the allegations that staff pushed minor in care, staff spoke to minors in an inappropriate manner, staff did not prevent minors from engaging in physical altercations with another minor in care, staff speak inappropriately in the presence of minors, staff do not ensure minor's mental health is being addressed, staff did not allow minor to attend outside activities, and staff did not ensure minor is provided a safe and comfortable environment which may have occurred, however, they are not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Mya Vasquez. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights was emailed to the Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On July 23, 2024, at 1:20 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Mya Vasquez, Facility Manager, to discuss the investigative finding for the allegations noted above. LPA conducted an inspection of the facility on December 21, 2023, and no deficiencies were observed. LPA Linley interviewed one client (C4), LPA was unable to interview four clients (C1-3, C5) despite multiple attempts to contact them, LPA interviewed nine staff (S1-3, S5-10), and was unable to interview one staff (S4) despite multiple attempts to contact them. The following documents were reviewed during the investigation: Personnel Roster, Client Roster, and a copy of the house rules. On December 21, 2023, Community Care Licensing (CCL) received allegations that staff pushed minor in care, staff spoke to minors in an inappropriate manner, staff did not prevent minors from engaging in physical altercations with another minor in care, staff speak inappropriately in the presence of minors, staff do not ensure minor's mental health is being addressed, staff did not allow minor to attend outside activities, UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: HART COMMUNITY HOMES - BRADY HOUSEFACILITY NUMBER: VISIT DATE: 07/23/2024

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

met_with: Mya Vasquez


raw_content:
Narrative:
revealed conflicting statements. Thus, confidential interviews did not corroborate the allegation with a preponderance of evidence. Based on confidential interviews the allegation that the facility did not ensure the facility was clean, safe, sanitary and in good repair, which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Mya Vasquez and Jasmin Mejia. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights was emailed to the Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On August 21, 2024, at 11:15 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Mya Vasquez, Facility Manager, and Jasmin Mejia, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on February 20, 2024, at 9:45 am and no deficiencies were observed. LPA Linley interviewed five staff (S1-5) and was unable to interview one staff (S6), despite multiple attempts to contact them. The following documents were reviewed during the investigation: Personnel Report and Pest Control Invoices. On February 16, 2024, Community Care Licensing (CCL) received an allegation that the facility did not ensure the facility was clean, safe, sanitary and in good repair. It was reported that there were cats and rodents that burrowed underneath the facility and the smells of the animals resulted in the air passing through the air vents to be unhealthy for individuals and it was recommended the facility replace the air vents. LPA did not observe any unusual smells or odors in the facility. Confidential interviews UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: HART COMMUNITY HOMES - BRADY HOUSEFACILITY NUMBER: VISIT DATE: 08/21/2024

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


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
interviews indicated that on 07/27/2024, the seat belts in the back of the facility car were not working properly while staff transported the residents, thus residents were not able to wear a seat belt while being driven to an outing. Based on confidential interviews and record review the allegations that S2 spoke inappropriately to a minor and staff did not provide safe transportation is substantiated. The preponderance of evidence standard has been met. The facility is cited for violations of the STRTP Interim Licensing Standards regulation 87072(c)(15) Personal Rights and California Code of Regulations, Title Division Six, regulation 80074(c) Transportation. An exit interview was conducted, appeal rights explained, and a copy of this report, LIC 811, and appeal rights were provided to Celia Vasquez. A copy of this report will be placed in the facility file.

Investigation Findings:
13On November 6, 2024, at 11:15 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility and met with Celia Vasquez, Facility Administrator, to discuss the investigative finding for the allegations noted above. LPA conducted an inspection of the facility on August 21, 2024, at 10:19 am and no deficiencies were observed. LPA interviewed four residents (R1-4), one resident declined to be interviewed (R5), and LPA interviewed six staff (S1-6). The following documents were reviewed during the investigation: Personnel Report, Staff Schedules, C Needs and Services Plan, and S2's Counseling Notice. On August 12, 2024, Community Care Licensing (CCL) received allegations that staff spoke inappropriately to a minor and staff did not provide safe transportation. It was reported that S2 called R1 a "bitch" and the facility vehicle did not have seat belts that fastened properly, and the back seat was not secured. Confidential interviews indicated that on 07/27/2024, S2 spoke inappropriately to the residents when S2 called them "bitches," and S2 told the residents, "what the fuck do you want me to do." Confidential SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: HART COMMUNITY HOMES - BRADY HOUSEFACILITY NUMBER: VISIT DATE: 11/06/2024

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

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
another client. While other interviews indicated C1 became upset and walked away from S1 and did not ask other staff members to take them to school. Thus, confidential interviews did not corroborate the allegation with a preponderance of evidence. Based on confidential interviews and records reviewed the allegation that staff did not provide transportation to minor, which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report, LIC 811, and appeal rights were provided to Celia Vasquez. A copy of this report will be placed in the facility file.

Investigation Findings:
13On March 26, 2025, at 11:15 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Celia Vasquez, Program Director, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on January 29, 2025, at 2:05 pm and no deficiencies were observed. LPA interviewed four Staff (S1-S4) and was unable to interview one client (C1) despite multiple attempts to contact them. LPA reviewed the facility documents during the investigation. On January 28, 2025, Community Care Licensing (CCL) received an allegation that staff did not provide transportation to minor. It was reported that on 01/28/2025, C1 woke up late and wanted to go to school around 1:00 pm and when C1 asked S1 to take them to school, S1 told C1 they had work to do and could not take C1 to school. Confidential interviews revealed conflicting statements. Some interviews indicated that S1 told C1 they could not take C1 to school because they were working on paperwork and needed to pick up UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: HART COMMUNITY HOMES - BRADY HOUSEFACILITY NUMBER: VISIT DATE: 03/26/2025

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


raw_content:
Narrative:
Confidential interviews revealed conflicting statements, some interviews revealed S3 shoved C1 in the face while C1 and S3 were alone in the office, while other interviews revealed C1 followed S3 into the staff bathroom and grabbed the video gaming system and S3 held onto the gaming system for a few minutes before letting go. There are no other witnesses to the incident. As for the allegation that staff did not keep hazardous items inaccessible to minor, there is conflicting information. Some interviews revealed bleach bottles were always locked and inaccessible to clients, except when doing laundry, other interviews revealed bleach was left on top of the washing machine, while other interviews revealed C1 and C2 broke into the chemical closet to obtain the bleach, however, there are no witnesses that saw C1 with bleach in the facility during the incident. Based on confidential interviews and records reviewed that staff handled C1 in a rough manner and staff did not keep hazardous items inaccessible to C1, which may or may not have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted and appeal rights explained. Due to printer malfunction, a copy of this report, along with the LIC 811, and appeal rights will be emailed to the Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On September 22, 2022, at 10:40 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Esmaralda Rodriguez, Facility Administrator, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 07/28/2022 at 11:15 am and no deficiencies were observed. LPA Linley interviewed three of three clients (C1-3), six out of six staff (S1-6), and one County Social Worker (CSW1). LPA reviewed the following documents during the investigation: Client Roster, C1's Safety Plan, C1's Treatment Plan, Medical Reports dated 07/12/2022 and 07/18/2022, and Special Incident Reports, dated 06/26/2022 (2), 06/27/2022, LIC 500, and staff schedule. On July 21, 2022, Community Care Licensing (CCL) received allegations that staff handled minor in a rough manner and staff did not keep hazardous items inaccessible to minor. It was reported that minor was pushed and scratched by a group home staff and minor threatened to swallow bleach. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 3 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: HART COMMUNITY HOMES - BRADY HOUSEFACILITY NUMBER: VISIT DATE: 09/23/2022

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


summary: Facility Evaluation

raw_content:
Narrative:
On April 21, 2021, Licensing Program Analyst (LPA) Abdoulaye Traore conducted SB Psychotropic Medication tele-Inspection via Microsoft Teams. The tele-meeting was held with the Facility Administrators Esmeralda Rodriguez. and Celia Vasquez LPA conducted a virtual health and safety inspection with the Administrators. During the inspection, LPA guided and observed a medication count and interview with staff and the client (C1) taking psychotropic medication. All file and medication documents were sent to LPA Traore prior to inspection. LPA reviewed 1 client (C1) record and reviewed three staff records. LPA began three staff interviews including the Administrator at 10: AM LPA interviewed C1 at 11: AM. There were no deficiencies cited at this time. LPA conducted an exit interview with Administrator Esmeralda and Celia. LPA scanned and emailed this LIC 809 to Esmeralda with a request for signature. Signed copies will be placed in the facility file.

met_with: Esmeralda Rodriguez


summary: Facility Evaluation

raw_content:
Narrative:
On June 2, 2021, at 12: PM Licensing Program Analyst (LPA) Jesus Cervantes conducted an unannounced annual inspection. The facility converted from a Group Home to a Provisional STRTP (Short Term Therapeutic Program) on June 25, 2020. LPA was met at the facility by Administrator Celia Vasquez. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. A pool is located in the backyard. The pool is gated and secured with a locking gate. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster, the Emergency Disaster Plan was also posted. Clients medications were observed to be inaccessible and stored in a locked file cabinet in the staff office. Medication records were reviewed and observed to be completed with dates and staff initials on dispensing records. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. All three bedrooms contain two twin beds. The facility has two client bathrooms. The water temperature in the bathroom one of two was tested at 12: PM and registered at 117.1 degrees which is within the appropriate range of 105 degrees to 120 degrees. Per facility staff, no firearms or weapons are allowed in the facility. Administrator Esmeralda Rodriguez is present at the facility a minimum of 20 hours a week, as verified by staff schedule and interviews. Appropriate staff/client ratios were verified during this inspection. See Page Two. The facility employs one Clinical Director, one in-house Social Worker, one Care Coordinator, two Administrators, and eight direct care staff that are used in accordance with regulatory requirements. Licensee is in the process of obtaining their Mental Health (MH) Certification and expects issuance by the end of June 2021. Licensee is in the process of obtaining National Accreditation through CARF and expects accreditation by the end of 2021. Licensing fee payments are current. All the client files are stored and locked in the file cabinet in the staff office. At 1: PM, LPA reviewed a sample of five clients files during the time of inspection. Two facility staff were interviewed during the inspection. Two clients declined to be interviewed. Four clients were not present at the facility during the inspection. All the staff files are stored in the back house/staff office area. At 2: PM, LPA reviewed sample of five staff files. All the staff have met the training and qualification requirements per regulations requirements. Per a review of the Community Care Licensing Information System (LIS), all staff met DOJ/FBI criminal record clearances and Child Abuse Index Check requirements. LPA discussed the following with the Administrator: Facility procedures related to requesting exceptions. Assembly Bill 388 law enforcement contacts as well as incidents involving emergency interventions. LPA discussed procedures for Child and Family Team (CFT) meetings, including an overview of required Core Services and Supports. LPA also discussed Reasonable and Prudent Parenting Standards, and resident involvement in development of planned activities. No deficiencies were found. Exit interview was conducted and a copy of this report was provided to the Administrator Celia Vasquez.