raw_content:
Narrative:
Confidential interviews revealed that no one falsifies signatures or documents. The facility has an internal compliance manager which conducts random audits to ensure proper documentation of facility documents. However, confidential interviews and documents obtained revealed discrepancies in past documents as a result of procedural errors, not falsification of signatures. Confidential interviews revealed conflicting statements regarding S5 sleeping on shifts. It is rumored S5 has been found sleeping on shifts, but it has not been witnessed by staff. Confidential interviews revealed S7 did not secure a cleaning spray in a chemical closet, however confidential interviews revealed S7 secured the cleaning spray in a locked staff office away from clients in care. Based on confidential interviews and record review, the allegations that staff would often falsify signatures on documents in an effort to cover mistakes resulting in inadequate record keeping, S5 is sleeping on shifts, and S7 is leaving harmful chemicals unattended and within reach of minors in care may have occurred; however, it is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report along with appeal rights was provided to Alvin Brown.

Investigation Findings:
13On July 23, 2021, at 2: PM, Licensing Program Analyst (LPA) Jesus Cervantes made an unannounced visit at the facility. LPA met with Alvin Brown, to issue the investigative findings of the allegations listed above. On March 29, 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 six of twelve staff (S1, S4, S5, S7, S8, and S12). Six staff members (S2, S3, S4, S6, S9, S10, and S11) could not be located for interviews. During the investigation, LPA reviewed facility records and obtained copies of the following documents: Facility inspection logs, facility staff rosters, employee files. On March 17, 2021, Community Care Licensing received the allegations that staff would often falsify signatures on documents to cover mistakes resulting in inadequate record keeping, S5 is sleeping on shifts, and S7 is leaving harmful chemicals unattended and within reach of minors in care. SEE PAGE 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: 2 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: ROP PARAGON HOUSEFACILITY NUMBER: VISIT DATE: 07/23/2021

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

met_with: Alvin Brown


state: CA

facility_name: ROP PARAGON HOUSE

summary: Facility Evaluation

raw_content:
Narrative:
On September 7, 2021, at 10: AM, an unannounced annual inspection was conducted by Licensing Program Analysts (LPA), Jesus Cervantes. LPA met with House Manager, Diana Bustamante and Program Director Dana Centanni. LPA inspected the facility inside and out. There are currently six residents in placement. One resident is on AWOL status. Two clients were present at the facility, three clients were at school. Two staff members were present at the facility. A physical plant inspection was conducted at 10: AM and included the following checks: Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors are in appropriate working order and fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster. The exterior of facility was also inspected and observed to be clean and the landscape well maintained. There is no swimming pool or other body of water located on the facility grounds. Cleaning solutions and hazardous items were observed to be stored in a locked cabinet inside of the garage and in a locked cabinet inside of the laundry room. Sharp knives were observed to be inaccessible and stored in a locked cabinet inside of the staff's office. Medications are stored in a locked cabinet inside of the staff's office. There are no guns or weapons in the facility as stated by House Manager, Diana Bustamante. There are three bedrooms and one bathroom for the residents. The bedrooms are set up so that there are two residents to a bedroom and one resident per bed. There is adequate drawer space for the resident's belongings. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. At 11: AM, the hot water in the resident's bathroom was registered to be 114.4 degrees Fahrenheit which is within the appropriate range of 105 degrees to 120 degrees. During time of inspection, LPA interviewed two of two staff. Due to the need to conduct staff/client interviews, and continue staff/client file reviews, this inspection will need to be continued at later date. An exit interview was conducted, and a copy of this report was provided to Facility Director, Dana Centanni.

report_type: Facility Evaluation

visit_type: Annual

met_with: Diana Bustamante


summary: Facility Evaluation

raw_content:
Narrative:
On September 08, 2021, at 9: AM, Licensing Program Analysts (LPA), Jesus Cervantes continued the unannounced annual inspection, which was started on September 07, 2021. LPA met with House Manager, Diana Bustamante. All the client files are stored and locked in the file cabinet in the staff office. At 09: AM, LPA reviewed a sample of six clients files during the time of inspection. All files contained the required documentation per Title Regulations. Three facility staff were interviewed during the inspection. One client was interviewed during the inspection. Personnel files are located at ROP Corporate Office located at N. Tustin Ave. Suit #120. Santa Ana, CA 92705. At 1: PM, LPA met with Director, Dana Centanni. LPA reviewed sample of five of ten staff files. The five 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. All staff have proof in file of acknowledging the child abuse reporting requirements. Due to the need to conduct client interviews, and continue staff file reviews, this inspection will need to be continued at later date. An exit interview was conducted, and a copy of this report was provided to Facility Director, Dana Centanni.

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
On September 09, 2021, at 9: AM, Licensing Program Analysts (LPA), Jesus Cervantes continued the unannounced annual inspection, which was started on September 07, 2021. LPA met with Facility Director, Dana Centanni at the ROP Corporate Office located at N. Tustin Ave. Suit #120. Santa Ana, CA 92705 . Licensee obtained their Mental Health (MH) Certification on May 17, 2021 and it expires on May 17, 2022. Licensee obtained National Accreditation through CARF and the accreditation is valid through August 31, 2022. Licensee has received a Medi-Cal approval through March 24, 2022. Licensing fee payments are current. At 9: AM, LPA reviewed sample of the five of ten remaining staff files. All files did not contain the necessary documents per Title Regulations and ILS. Technical Advisory notes were issued for the following: One of ten staff did not have a health screening as specified in Section 80065(g) as per California Code of Regulations (CCR) 80066(a)(10). Three of ten staff file did not contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g) as per CCR 80066(a)(11). 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. All staff have proof in file of acknowledging the child abuse reporting requirements. At 3: PM, LPA returned to the facility to complete client interviews. LPA interviewed two additional clients. Overall, three of six clients were interviewed during the annual inspection. Technical Advisory notes were issued and no citations at this time. A copy of this report, LIC 811, and LIC AT were reviewed and given to House Manager Diana Bustamante.

met_with: , Dana Centanni


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) David Torres conducted a case management inspection July 26, 2022 at 9:09 am 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, 10 out of Direct Care Staff and 6 out of 6 youth files were reviewed. 3 out of Direct Care Staff and 4 out of 6 youth were interviewed. (See the Confidential Names List, LIC 811, dated July 26, 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 David Torres 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 Rabah Mahmoud, Administrator.

met_with: Rabah Mahmoud, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On April 18, 2023 1: PM Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced visit at the facility listed above. The purpose of the visit was to interview one client regarding an incident at a prior placement. No other information needed at this time. No deficiencies were cited. Exit interview was conducted and a copy of this report was explained to Reyna Salas, Facility Administrator.. Due to printer malfunction, this report will be emailed to Reyna Salas.

met_with: Reyna Salas


summary: Facility Evaluation

raw_content:
Narrative:
On this date at 3:15 pm, Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced case management inspection to this facility. LPA Linley met with Yeraldina Polanco, House Parent. LPA conducted a walk through of the facility and no deficiencies were observed. A case management has been opened regarding information in an Incident Report submitted to CCL. LPA interviewed two clients and one staff. Further information and interviews are required, therefore this case management is being extended. The outcome of the investigation will be provided to the Facility Administrator. The facility is reminded not to discuss the ongoing investigation with any interested parties. An exit interview was conducted and due to printer malfunction, a copy of this report will be emailed to the Facility Administrator.

met_with: Yeraldina Polanco


summary: Facility Evaluation

raw_content:
Narrative:
On October 2, 2023, at 10: AM, an unannounced annual inspection was conducted by Licensing Program Analyst (LPA), Charmaine Linley. LPA met with Program Manager, Cedric Jones and Lead Child Care Worker, Purshay Harris. LPA inspected the facility inside and out. There is currently one resident in placement. Two staff members were present at the facility. A physical plant inspection was conducted at 10: AM and included the following checks: Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors are in appropriate working order and fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster. The exterior of facility was also inspected and observed to be clean, and the landscape well maintained. There is no swimming pool or other body of water located on the facility grounds. Cleaning solutions and hazardous items were observed to be stored in a locked cabinet inside of the garage and in a locked cabinet inside of the laundry room. Sharp knives were observed to be inaccessible and stored in a locked cabinet inside of the staff's office. Medications are stored in a locked cabinet inside of the staff's office. There are no guns or weapons in the facility as stated by Lead Child Care Worker, Purshay Harris. There are three bedrooms and one bathroom for the residents. The bedrooms are set up so that there are two residents in each bedroom and one resident per bed. There is adequate drawer space for the resident's belongings. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. At 10: AM, the hot water in the resident's bathroom was registered to be 105 *** degrees. At 10: AM, the hot water in the kitchen was registered to be 105 degrees, which is within the appropriate range of 105 degrees to 120 degrees. During time of inspection, LPA interviewed two of two staff and one of one client. LPA reviewed one client file during the time of inspection. The file contained the required documentation per Title Regulations. Due to the need to conduct staff file reviews, this inspection will need to be continued at a later date. An exit interview was conducted and due to printer malfunction, a copy of this report will be emailed to Program Manager, Cedric Jones.

met_with: Purshay Harris


summary: Facility Evaluation

raw_content:
Narrative:
On October 4, 2023, at 11: AM, Licensing Program Analyst (LPA), Charmaine Linley continued the unannounced annual inspection, which was started on October 2,2023. LPA met with Program Director, Dana Centanni and Compliance Manager, Sylvia Carballo. LPA reviewed five staff files (S1-5). The five 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. All staff have proof in file of acknowledging the child abuse reporting requirements. The facility's Mental Health (MH) Certification expires on March 23, 2024. Licensee obtained National Accreditation through CARF and the accreditation is valid through August 31, 2025. Licensing fee payments are current. No deficiencies were found. Exit interview was conducted with Dana Centanni and Sylvia Arballo. Due to printer difficulties, a copy of the report will emailed to Dana Centanni. A copy of this report will be placed in the facility file.

met_with: Dana Centanni


summary: Facility Evaluation

raw_content:
Narrative:
On January 5, 2024, at 2:40 pm, Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced case management inspection of the facility. LPA conducted a walk through of the facility, and no deficiencies were observed. The purpose of the inspection was to follow up on a case management visit on 09/11/2023. LPA Linley met with Purshay Harris, Senior Coach Counselor. Community Care Licensing (CCL) received information that S1 made an inappropriate comment to C2. Confidential interviews reported conflicting information. Thus, no deficiencies were noted, and the facility is in compliance. An exit interview was conducted with Purshay Harris. Due to a printer malfunction, a copy of this report was sent to the Facility Administrator. A copy of the signed report will be placed in the facility file.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPA) Guadalupe Munoz and Joon Cho on 02/09/2024 at 09: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the visit, LPAs Munoz and Choi met with Administrator Alvin Brown and conducted a health and safety inspection of the facility. No immediate health or safety risks were observed. LPAs reviewed 2 of child's records and 3 of staff personnel files on site at the facility. LPAs reviewed 2 of child's psychotropic medications and medication records. LPAs interviewed 2 of staff on site to discuss the facilities policies and procedures of operation. LPAs will interview 2 children currently prescribed psychotropic medication, at their schools, after the facility visit.. LPA provided a copy of this licensing report to, Administrator Alvin Brown. No deficiencies are being cited at this time, but the facility was provided with a Technical Assistance (TA) note. LPAs conducted exit interview with Administrator Alvin Brown. and provided a copy of this report and the TA.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPA) Guadalupe Munoz on 02/12/2024 at 1:00pm . This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the visit, LPA Munoz met with Purshay Harris, Senior Life Coach and designee and conducted a health and safety inspection of the facility. No immediate health or safety risks were observed. The visit was a follow up visit to the case management inspection conducted on 2/09/24. LPA interviewed 2 children currently prescribed psychotropic medication, at this facility visit.. Due to printer malfunction, LPA will email a a copy of this report to designee, Purshay Harris.


summary: Facility Evaluation

raw_content:
Narrative:
On June 25, 2024 at 4:30 pm, Licensing Program Analyst (LPA) Charmaine Linley made an unannounced visit at above facility. LPA met with Julia West, Senior Coach Counselor. LPA toured the facility and no deficiencies were observed. The purpose of the visit was to conduct a collateral interview for a complaint that does involve this facility. LPA conducted one interview with one staff. An exit interview was conducted with Julia West. Due to printer malfunction a copy of this report will be emailed to the Facility Administrator.

met_with: Julia West


summary: Facility Evaluation

raw_content:
Narrative:
On this date at 2:45 pm, Licensing Program Analyst (LPA) Licensing Program Analyst (LPA) Charmaine Linley made an unannounced visit at above facility. LPA met with Julia West, Senior Coach Counselor. LPA toured the facility and no deficiencies were observed. The purpose of the visit was to conduct a collateral interview for a complaint that does not involve this facility. LPA conducted one interview with one staff. An exit interview was conducted with Julia West. Due to printer malfunction a copy of this report will be emailed to the Facility Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On July 18, 2024, at 11:30 am, Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced case management inspection of the facility. LPA Linley met with Kayla Dembek, Facility Administrator. LPA conducted a walk through of the facility, and no deficiencies were observed. The purpose of the inspection was to follow up on information reported to Community Care Licensing. Community Care Licensing (CCL) received information that the facility is searching clients without reasonable cause or suspicion. LPA interviewed two staff (S1-2) and two clients (C1-2), and reviewed five clients (C1-5) Needs and Services Plan. Records reviewed indicated C1-5's Needs and Services Plans were signed by each client and Authorized Representative authorizing the facility to conduct searches, as needed. Thus, no deficiencies were noted, and the facility is in compliance. An exit interview was conducted with Kayla Dembek. Due to a printer malfunction, a copy of this report was sent to Kayla Dembek. A copy of the signed report will be placed in the facility file.

met_with: Kayla Dembek


summary: Facility Evaluation

raw_content:
Narrative:
On July 18, 2024, at 11:45 am, Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced case management inspection of the facility. LPA Linley met with Kayla Dembek, Facility Administrator. LPA conducted a walk through of the facility, and no deficiencies were observed. The purpose of the inspection was to follow up on a Special Incident Report for Client #1 (C1), dated 07/14/2024. It was reported that C1 was not given their prescribed medication from 07/14-07/18/2024, due to the facility did not ensure that C1's prescription was refilled in a timely manner. The facility was issued a technical assistance notice. An exit interview was conducted with Kayla Dembek. Due to printer malfunction a copy of this report will be emailed to the Facility Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On November 27, 2024, at 10:00 am, Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced annual inspection. LPA was met at the facility by Purshay Harris, Senior Coach Counselor. There are currently six residents in placement. LPA toured the facility with Purshay Harris. 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. 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. LPA observed a minimum 7-day non-perishable and 2-day perishable supply of food. The water was tested in the kitchen at 10:30 am at 123 degrees which is within the appropriate range of 105 degrees to 120 degrees. All required forms are posted including 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. There is one ring doorbell camera at the facility in the front of the home. Individual beds were observed with clean linens, pillows, comforters, and mattress 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 and measured at 10:30 am at 109 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. *** All client files are stored and locked in the file cabinet in the staff office. LPA reviewed five client files to ensure clients had all required documents per Title 22. LPA reviewed five client medication records. The facility is being cited for violations of the STRTP Interim Licensing Standards 87070(b)(14)(C) and 87070(b)(14)(H) Children's Records. Client #5's Medication Administration Record for Sertraline documented that C5 had two refills left, however the pharmacy label documented there were no refills and C5's Medication Administration Record for Guanfacine ER documented there are two refills left, however the pharmacy label documented there is one refill. Additionally, there are no staff signatures on C5's Medication Administration Records for 11/23/2024 for C5's Sertraline and Guanfacine ER. Please refer to LIC 809(d). LPA will return on another day to review employee files. The licensing fee payments are current. An exit interview was conducted, and a copy of this report and appeal rights were provided to Purshay Harris. A copy of this report will be placed in the facility file.


summary: Facility Evaluation

raw_content:
Narrative:
On December 4, 2024, at 11:00 am, Licensing Program Analyst (LPA), Charmaine Linley continued the unannounced annual inspection, which was started on November 27, 2024. LPA met with Gavin Hager, Human Resources Generalist. Personnel and training files are located at ROP Corporate Office located at N. Tustin Ave. Suite #120. Santa Ana, CA 92705. LPA reviewed five staff files (S1-5). All staff met the minimum qualifications and training requirements. A review of records shows that all staff have FBI, DOJ, and Child Abuse Index Check clearances. All staff have proof in file of acknowledging the child abuse reporting requirements. Based on the file reviews on this date, there are no deficiencies found at this time. An exit interview was conducted with Gavin Hager. Due to printer difficulties, a copy of this report was emailed to the Facility Administrator.

met_with: Gavin Hager


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPA) Jacqueline Garcia on 07/16/2025 at 09: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the visit, LPA met with Purshay Harris-Senior Coach Counselor, Sylvia Arballo-Compliance Manager and Kayla Dembek-Program Administrator and conducted a health and safety inspection of the facility. No immediate health or safety risks were observed. LPA reviewed 4 of child's records and 3 of staff personnel files on site at the facility. LPA reviewed 4 of child's psychotropic medications and medication records. LPA interviewed 2 of staff on site to discuss the facilities policies and procedures of operation. LPA interviewed 1 of 4 children who are currently prescribed psychotropic medication who were present during inspection. LPA will return to continue child interviews at a later time. LPA provided a copy of this licensing report to, Kayla Dembek, Program Administrator. No deficiencies are being cited at this time, but the facility was provided with a Technical Assistance (TA) note. LPA conducted exit interview with Kayla Dembek, Program Administrator and provided a copy of this report, along with LIC 811 and the TA.

met_with: Kayla Dembek-Program Administrator


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPA) Jacqueline Garcia on 07/21/25 at 09: AM . This Case Management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the visit, LPA Garcia met with Program Administrator, Kayla Dembek, and conducted a health and safety inspection of the facility. No immediate health or safety risks were observed. This visit was a follow up visit to the Case Management inspection conducted on 07/16/25. LPA interviewed 2 client's and attempted 1 client interview who are currently prescribed psychotropic medication. Due to printer malfunction, LPA will email a a copy of this report to Kayla Dembek, Program Administrator.


facility_name: ROP QUALIFYING HOUSE FREEL

summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
As a result of the information obtained and interviews conducted, the complaint is SUBSTANTIATED at this time meaning that the allegation is valid because the preponderance of the evidence standard has been met. The facility was cited for violation of California Code of Regulations, Title Division Six, regulation 80087(a): Buildings and Grounds. Interview conducted demonstrated that staff knew about the trash but did not clean it up for approximately two hours. Exit interview was conducted and documents provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection at the facility on 8/17/21 at 10: AM but nobody was home. LPA then went to the administrative/nonpublic school location in Minden, Nevada and met with the administrator, Tracy Edwards. Interview with S1 (see LIC811 dated 8/17/21) on 8/17/21 demonstrates that S2 was aware of a bear leaving the property about 6: AM after having accessed the trash bins and caused the trash to be strung out in front of the facility and across the street. S1 states they received a text from S2 stating C1 (who is no longer residing in the facility) had taken out the trash the night prior as part of their chore and had not secured the trash bin as required to prevent wildlife from accessing the trash bin. S2 told S1 that C1 needed to clean up the trash themselves as they were at fault for it being left accessible to the bear. S2, being the newer staff, did not clean up the mess left behind by the bear until C1 woke up and was taken outside to clean up the mess, two hours later. Administrator arrived to the facility at approximately 9: AM to find S1 and C1 outside cleaning up the mess left by the bear, including the trash that was taken across the street. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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 23-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, NATOMAS PARK DR., STE FACILITY NAME: ROP QUALIFYING HOUSE FREELFACILITY NUMBER: 027202889

report_type: Complaint Investigation

met_with: Tracy Edwards, Administrator

complaint_status: SUBSTANTIATED


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
The allegation that staff did not prohibit youth from smoking on the grounds is related to an incident that took place on June 15, 2022, where an Alpine County Sheriff responded to the facility due to a youth in care running away from the facility. Upon arrival, Sheriff located S1 who informed Sheriff that the other youth from the facility were in the rear of the facility smoking. While S1 was present and supervising youth, Sheriff indicated that S1 made no attempts to direct the youth to stop smoking or extinguish their cigarettes. Sheriff indicated that they told youth to stop smoking and youth complied, but that S1 never told the youth that smoking was prohibited on the grounds of the facility nor did S1 indicate to youth the dangers of smoking for the youth's health or the dangers of fires to the community. LPA Hill made three attempts to contact the overnight awake staff on duty, (S1), on the date of the incident and was unable to interview S1 due to S1's work/sleep hours. LPA Hill interviewed other staff that are familiar with S1 and learned that S1 is not assertive with the youth in care and is not confrontational with youth. Staff stated that S1 would rather take daily points from youth for these types of behaviors/choices rather than confront the youth and counsel them to make better choices. LPA Hill also interviewed youth present and smoking and youth denied S1 telling them that they could not smoke or to put the cigarettes out. Youth further stated that S1 never told them about the dangers in the community, including wildfires. Youth stated that they knew that they were not to smoke but that information came from other staff and not S1. As a result of the information obtained and interviews conducted, the allegation that staff did not prohibit youth from smoking on the grounds is SUBSTANTIATED at this time meaning that the The "preponderance of the evidence" standard has been met. The facility was cited for 87087(c) Buildings and Grounds as the licensee shall prohibit smoking in the facility and on the grounds of the facility. Exit interview was conducted with Mr. Edwards and documents were provided via email.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 10/7/22 at 10: AM and met with Tracy Edwards, Administrator for the purposes of delivering findings for the allegation as stated. LPA Hill informed Mr. Woods that the complaint investigation included an initial inspeciton on July 5, 2022 and a subsequent inspeciton on September 1, 2022, where files were reviewed, documents obtained, and interviews were conducted with clients and staff. LPA Hill conducted additional interviews with staff on September 20, 2022 and made three attempts to contact S1 that sleeps during the daytime due to their work hours. LPA Hill was not successful in contacting S1 for this complaint investigation. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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 23-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, NATOMAS PARK DR., STE FACILITY NAME: ROP QUALIFYING HOUSE FREELFACILITY NUMBER: 027202889

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


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
coerced to take medications, even if prescribed by the doctor or psychiatrist. As a result of the confidential interviews conducted, the allegation that youth were pressured to take medications prescribed or authorized is UNSUBSTANTIATED meaning the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. The allegation regarding a lack of supervision is related to an incident during an outing which lead to a youth being harassed by other youth. During confidential interviews with staff and youth, seven out of eight youth stated that they were "rough-housing" with all of the youth during the outing and staff denied any youth indicating that they felt scared or threatened during the outing or after the outing. LPA Hill attempted contact with two youth identified as being possible witnesses but one is absent from care and their whereabouts are unknown and the other has not responded to requests for interview. During interviews with staff, all staff indicated that there were never reports made and they were not informed that any of the youth felt threatened or were harmed during this outing. As a result of the confidential interviews conducted, the allegation that a lack of supervision lead to youth feeling threatened during an outing is UNSUBSTANTIATED meaning the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. The allegation that staff did not provide a safe environment is related to the staff not being able to provide for youth's safety due to being new or inexperienced. During confidential interviews, youth confirmed that the majority of staff are new and/or lack experience in this field and may be immature. Youth confirmed however they trust the supervision that staff provide and fairness they demonstrate to youth. Confidential interviews indicated youth felt that staff are not perfect but are doing a good job protecting youth during incidents that happen in the facility, redirecting youth prior to physical incidents, supporting youths' mental health goals, trying to get to know youth, and supporting youth's transition goals. Confidential interviews indicated that staff did not always know when youth were going to "go off" thus leading to them not always being prepared. Staff indicated that there have been times when physical interventions have not been utilized when they should have been due to prior staff injuries which has lead to escalated behaviors with youth. As a result of the confidential interviews conducted, the allegation that staff did not provide a safe environment is UNSUBSTANTIATED meaning the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred Exit interview was conducted and documents, along with appeal rights were provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 1/26/24 at 1: PM and met with Alina Scott, Head of Service to discuss the complaint findings for the allegations. LPA Hill informed Ms. Scott that the complaint investigation included an initial inspection at the facility on 9/8/23, subsequent inspection on 11/17/23 and interviews of eight youth and six staff from 11/16/23 to 12/21/23. LPA Hill attempted to interview two past clients but was not able to secure those interviews. The allegation that staff pressure youth to take medications is related to over the counter medications that are authorized by youths' doctors to aid in youths' sleep. It was alleged that staff were forcing and/or enticing youth to take medications so that they sleep through the night and not wake or that youth were being given more than the authorized dosage of these sleep medications. In addition, it was alleged that medications were administered and not documented when given to youth. During confidential interviews with staff and youth in care, all staff and seven out of eight youth denied being given more medications than what was authorized. Seven out of eight youth and six out of six staff interviewed denied being forced, bullied, or UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE FREELFACILITY NUMBER: VISIT DATE: 01/26/2024

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

met_with: Alina Scott, Head of Service

complaint_status: unsubstantiated


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During confidential interviews, LPA Hill learned that there was "tension in the house" between C1 and C2. Staff in the facility decided to take youth on an outing to give the youth space due to this tension. C2 was on outing restriction due to behaviors but C1 chose not to go on the outing so the on-call staff made the decision to allow C2 to attend to create space for the day. When youth returned from the outing, C2 attacked C1 while C1 was in the den speaking with C3. C4 was present when the fighting started and, knowing that S1 could not intervene, C4 stepped in to assist in separating the youth and protect C1. C2 has a history of assaulting staff and youth since being placed with the agency. The agency's policy on restraints requires two staff to engage in physical restraints. Knowing that S1 could not engage in physical restraints as necessary and knowing C2's assaultive history, the agency did not provide an additional staff on 12/9/23, knowing that there was tension between the youth in the facility. As a result of the investigation and confidential interviews conducted, the allegation that staff did not provide adequate supervision resulting in C1 being assaulted by other youth at the facility is SUBSTANTIATED at this time meaning that the "preponderance of the evidence" standard has been met. The facility was cited for violation of Title Regulation Responsibility for Providing Care and Supervision as the facility has a responsibility to provide care and supervision to meet the clients' needs and the facility did not protect C1's safety while at the facility, despite knowing of the tension between the youth and knowing that staff was unable to engage as necessary in their emergency intervention plan to protect C1 as required. Exit interview conducted and documentation, along with appeal rights were provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill conducted an unannounced complaint inspection on 1/26/24 at 1: PM and met with Alina Scott, Head of Service to discuss the findings of the complaint allegations. LPA Hill informed Ms. Hill that the investigation included an initial inspection to the facility on 12/21/23. This investigation is related to an incident that happened at the facility on 12/9/23. LPA Hill conducted interviews of three staff and two youth on 12/21/23 while at the administrative office. LPA Hill also reviewed the camera footage of the incident while at the administrative offices on12/21/23. LPA Hill conducted a collateral inspection to the facility's administrative office on 1/17/24 where additional interviews were conducted. The allegation that staff did not provide adequate supervision is related to the incident on 12/9/23 where C1 (see LIC811 dated 1/26/24) was assaulted by C2 and C3. While there were two staff present in the facility supervising four youth, S1 was unable to assist in emergency interventions due to a medical condition. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE FREELFACILITY NUMBER: VISIT DATE: 01/26/2024

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


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Narrative:
housing or rough play with youth in care. The specific incidents included smearing mayonnaise on C1 in the facility (date unknown), pulling youth off a the facility sofa by their legs (date unknown), pulling on C1's seat belt during transport, S1 placing their lanyard over C1's head/neck during transport, forcibly removing C1's shoe(s) from their feet, and/or S1 placing their foot near C1's face during transport, S1 telling youth in the facility that staff can do what they want because they are staff but that youth cannot do the same things. During an interview with S1, S1 did admit to some of the reported incidents but stated that they were done in fun and not meant maliciously. S1 stated that C1 did get upset sometimes when playing around and when C1 got upset, S1 stopped horse playing. Regarding telling the youth that they can do anything they want, S1 stated that all the staff say this and is not just S1 themselves. S1 stated that they are aware of the grievance filed against them and since this, none of the horse play has happened between S1 and C1. As a result of the information obtained and interviews conducted, the allegation that Staff violated youths personal rights is SUBSTANTIATED at this time meaning the "preponderance of the evidence" standard has been met. The facility was cited under Short Term Residential Therapeutic Program, Interim Licensing Standards, Personal Rights, Section 87072(c)(1) as the licensee has a responsibility to ensure youth are accorded personal rights specified in Welfare and Institutions Code Section 16001.9 including the right to live in a safe, healthy, and comfortable home where they are treated with respect and this did not happen for C1 and other youth that were witness to these incident(s). Documentation was provided to Ms. Edwards along with appeal rights and exit interview was conducted. Licensing within the agency's next working day, during normal business hours as required, but the written report containing all of the required information was received within seven days following the receipt of the grievance, as required by regulation. Confidential interviews with the agency revealed that the agency was not handling the grievance as an incident initially but were investigating as a grievance until it was realized that it was a reportable incident. As a result of the information obtained and interviews conducted, the allegation that the facility failed to report a serious incident to the Department is UNSUBSTANTIATED at this time meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Facility was issued a Technical Advisory regarding the 24 hour reporting requirement. Exit interview conducted and documentation was provided to Ms Edwards.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 2/29/24 at 12: PM and met with Tracy Edwards, Program Director to discuss the complaint allegation as stated. LPA Hill informed Ms. Edwards that the complaint investigation included an initial inspection at the facility on 12/7/23 where one staff was interviewed. Subsequent collateral inspections were conducted from 12/20/23 to 1/17/24 where five staff and two youth were interviewed. In addition, LPA Hill obtained documentation related to C1, C2, S1 and S2 (see LIC811 dated 2/29/24). LPA Hill also received documentation related to a grievance filed related to the allegation(s) and incident(s). LPA Hill informed Ms. Edwards that the allegation that staff violated youths' personal rights is related to a series of incidents in the facility and facility transport vehicle between C1 and S1 which included rough SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE FREELFACILITY NUMBER: VISIT DATE: 02/29/2024

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: Tracy Edwards, Program Director


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youth in care are left vulnerable to physical attacks by youth and the agency not proactively addressing these issues for the safety of the other youth in care and staff working at the facility. LPA Hill informed Ms. Edwards that the investigation and confidential interviews show that when youth are accepted and have a history of violence, whether against adults or other youth, the facility is not staffing to the need of the youth by having additional staff in the facility until they are better familiar with the youth or ensuring that staff that are properly trained and/or without restrictions or limitations on mobility are present to work with the newly admitted youth. This was evidenced by one incident on 12/9/23 where a youth was attacked in the facility by another youth and one of the two staff present was unable to engage in physical restraints due to a medical restriction. Another incident happened on 11/5/23 where a youth attacked two staff present at the facility, resulting in at least one staff being hurt. There were two additional incidents where the same youth allegedly attacked staff at the nonpublic school site, 12/7/23 and 12/12/23. Confidential interviews revealed that while staff was within ratio at the time of the incident(s), most staff expressed not feeling appropriately trained or comfortable in the emergency intervention training, confronting youth, or preventing incidents from happening. Review of the documentation received related to C1 in particular (see LIC811 dated 2/29/24) indicates that the agency knew or should have known that youth was a risk to the health and safety of the other youth in care and staff as the youth had a history of verbal aggression and physical aggression resulting in violence. In addition, following the initial attack at the facility on 11/5/23, the licensee did not increase staffing at the facility when the agency suspected that situations were escalated, as seen in the 12/9/23 incident. As a result of the information obtained, documentation received, confidential interviews conducted, the allegation that staff do not prevent the minors from engaging in physical altercations is SUBSTANTIATED as the "preponderance of the evidence" standard has been met. The facility was cited under Short Term Residential Therapeutic Program, Interim Licensing Standards, Personnel Requirements, Section 87065(g) as the licensee shall employ the number of direct care staff necessary to meet the needs of children and provide adequate care and supervision, including staff needing to be able to administer discipline and setting of limits for behavior, consistent with trauma-informed standards. Documentation was provided to NAME and exit interview conducted.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 2/29/24 at 12: PM and met with Tracy Edwards, Program Director to discuss the findings of the complaint allegation. LPA Hill informed Ms. Edwards that the investigation included initial complaint inspections to the administrative office and facility on 11/16/3. Subsequent insections were conducted 11/17/23, 12/7/23, 12/21,23, 1/7/24, and 2/15/24 where eight youth and five staff were interviewed, including the Head of Service and administrator. In addition, documentation was obtained and reviewed related to incident reports of assaults, law enforcement calls, and how youth are assessed when being considered for acceptance. The allegation that staff do not prevent minors from engaging in physical altercations is related to youth not being assessed properly assessed prior to acceptance into the program and subsequently staff and other SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE FREELFACILITY NUMBER: VISIT DATE: 02/29/2024

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


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Narrative:
C1 was accepted in July 2023, during the time the agency was in the process of changing psychiatrists. The facility did not have a psychiatrist for the months of September 2023 and October 2023. Prior to this transition, C1 did see the psychiatrist 8/3/23 and 8/17/23. While the agency was unable to provide monthly consultation records from a psychiatrist as required for the months of September and October 2023, they were able to provide the Department with proof of active efforts in getting the selected doctor approved from July 2023 through October 2023. The new psychiatrist started in November 2023. C1 was receiving all other mental health services offered by the agency, including individual, family, and group therapy, as well as other mental health services despite not seeing a psychiatrist during the months of September and October. Investigation also showed that C2 was accepted despite knowing C2 had a history of violence. During the six weeks C2 was in placement, from October 2023 to December 2023, there were five incidents of violence, including attacks on staff and other clients in care. Subsequent to each of these incidents, Child and Family Team meetings were called to discuss the issues and how to resolve them. The facility continued to work with the placing agency on C2's placement until December 2023 when C2 was removed from this agency. Confidential interviews conducted with the HOS and Administrator revealed that when youth are referred for placement, most of them have some kind of violence in their history and as a result, it is not an automatic denial. Administrator states that youth with violent pasts are accepted if they agree to the program and are willing to abide by the program's expectations and rules. While the facility was within ratio of one staff to three clients during these episodes, staff knew, or should have known, there was a potential for violence and the agency should have augmented staffing in the facility, but this did not happen. During one specific incident on 12/9/23, staff knew that tensions were high between youth in care but one of the staff working was on light duty and unable to restrain or assist in a manual restraint as needed. When an incident did happen between youth in care, staff was unable to physically assist to break the youth up, resulting in another youth in care getting involved and assisting staff to break up the assault. (The facility was cited for this incident and lack of appropriate supervision on 1/26/24). As a result of the investigation, interviews conducted and documentation reviewed, the allegation that the facility did not follow their preplacement procedures when assessing youth for placement is SUBSTANTIATED meaning that the "preponderance of evidence" standard has been met. The licensee has a responsibility to augment staffing levels in the facility based on identified needs, behaviors or other factors but this did not happen. The facility was cited per STRTP Interim Licensing Standards, Section 87065.5(g) Direct Care Staff/Child Ratios as the facility shall increase the number of on-duty direct care staff if a child requires special care and supervision because of age, behavior or other factors. Exit interview was conducted with Ms. Edwards and documentation provided including appeal rights. Confidential interviews conducted demonstrated that the agency was given a 60-day notice in June 2023 that their current psychiatrist was terminating their contracted psychiatry services as of August 2023. In July 2023, the agency found and began the process of on-boarding a new psychiatrist, but the process was lengthy, and the agency did not have the new psychiatrist on board until November 2023, meaning the youth did not have the required monthly psychiatry appointments for the months of September 2023 and October 2023. The agency was able to provide documentation including emails and correspondence between the agency's HOS, Placer County, the new contracted provider, Health Link Now, and the psychiatrist from July 2023 through November 2023, indicating that the agency was actively trying to get the new psychiatrist through the contract and on-boarding process to provide services to youth in care. In addition, in anticipation of not having the psychiatrist in time, HOS did reach out to Barton Psychiatry in South Lake Tahoe on 8/5/23 but were informed that the wait time would be until January 2024, and Washoe County (Nevada) Behavioral Health but were informed they could not provide services to the agency's youth. HOS presumed it due to the youth being California youth and not from Nevada. The new psychiatrist was providing psychiatry services to youth in care as of November 14, 2023. LPA Hill learned that during the time without psychiatry services, the agency had prepared in advanced and did have prescription refills for all youths' medications and no youth went without medications or had lapses in medications during the months of September or October. As a result of the investigation, interviews conducted, and documentation received, the allegation that the facility did not provide clients in care with consultation from a psychiatrist as required for the months of September and October 2023, is UNSUBSTANTIATED as facility did employ active efforts in locating and on-boarding a replacement psychiatrist during the months of September and October 2023. This means that the allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. The allegation that the facility did not ensure client's medical and/or mental health needs were met is related to the same allegation as stated regarding the youth having the required psychiatry consultations prescribed in regulation. When interviewing C1's social worker, it was indicated that all medical and mental health services were provided except for the psychiatry consultations as described. Social worker states that the facility did ensure that youth had consultations with doctor, dentist, and optometry as needed while at the facility and that the agency did ensure that therapy, and other mental health services were being provided during this time. As a result of this information, the allegation that the facility did not ensure medical and/or mental health needs were met is UNSUBSTANTIATED at this time as the facility did employ active efforts in locating and on-boarding the new psychiatrist. This means that the allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. Exit interview was conducted with Ms. Edwards and documentation was provided along with appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 3/13/24 at 10: AM and met with Tracy Edwards, Program Director to discuss the complaint findings as stated. LPA Hill informed Ms. Edwards that the complaint investigation included an initial inspection to the agency on 10/27/23 where LPA Hill interviewed Head of Services (HOS) and Administrator and obtained documentation related to the allegations and LPA Hill obtained the agency's approved mental health program plan as approved by the Department of Health Services. Subsequent inspections were conducted on 11/17/23, 12/7/23, 12/20/23, 12/21/23, 1/10/24, and 2/15/24 to interview youth and staff related to the allegations. LPA Hill also interviewed a social workers and public health nurse related to the allegations. The allegation that the facility is not following their preplacement procedures when assessing youth to be accepted is related to the agency's process of assessing youths' compatibility for the facility. The original allegation is related to the accepting of youth knowing that the facility cannot meet the needs of the youths' mental health needs and specifically the psychiatry needs when admitted. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE FREELFACILITY NUMBER: VISIT DATE: 03/13/2024

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:


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Narrative:
Plan or treatment plan to C1's placing agency, but they were unable to provide proof that this happened. LPA Hill then questioned the agency about implementation of the Needs and Services Plan as the regulations require that a signature be obtained as evidence that the placement agency agrees prior to implementation and the administrator and Head of Service both indicated that the needs of C1 and treatment for C1 was discussed on multiple occasions as C1 had high needs. The facility/agency did acknowledge that C1's soothing plan was provided to the placing agency. As a result of the interviews conducted and documentation obtained and reviewed, the allegation that staff did not follow youth's treatment plan is SUBSTANTIATED meaning the "preponderance of the evidence" standard has been met. The facility was cited per STRTP Interim Licensing Standards Section 87068.2(g) Needs and Services Plan as the licensee shall obtain written approval from the child...and the child's authorized representative prior to implementing the child's needs and services plan. The allegation that staff speak inappropriately to youth in care is related to staff not using Trauma-Informed language when speaking with youth in the facility. Confidential interviews with staff and clients indicated that some staff would say things in a demanding tone, were rude, and argued with clients or would tell youth that they were staff, they could get away with speaking to youth in this manner or in other ways penalize youth in care for speaking up for themselves. As a result of the investigation and confidential interviews conducted, the allegation that staff speak inappropriately to youth in care is SUBSTANTIATED meaning the "preponderance of the evidence" standard has been met. The facility was cited per STRTP Interim Licensing Standards Section 80072(c)(1) Personal Rights as the licensee shall ensure that each child...is accorded the personal rights specified in Welfare and Institutions Code Section 16001.9 including the right to live in a safe, healthy, and comfortable home where they are treated with respect. Continued on LIC9099C. The allegation that youth are unable to make private phone calls is related to the youth not being able to make calls to whomever they choose, staff listening to calls, and youth overall not having privacy during calls. During confidential interviews with youth and staff in care, it was noted that youth are not allowed to have confidential calls in that all calls must be done in the facility den, with the door open, and some staff sit at the doorway and listen to the calls, regardless of who youth is speaking to on the phone. At the conclusion of the interviews with staff and clients on 11/17/23, LPA Hill informed the agency that this practice shall cease immediately and informed the staff and agency that youth have the right to call who they want unless there is a court order restricting their calls. In addition, LPA Hill advised the agency that staff cannot monitor the calls, listen to the calls, be in the room with youth while making calls, log their phone calls, write down the phone numbers of calls made or in any way question youth about who they were calling during the designated call time allotted to youth. LPA Hill did confirm during follow up inspections and interviews that the staff are no longer monitoring youths' calls and that the phone policy is changed so that youth are afforded privacy during calls. While the alleged violation has been remedied, it was true at the time that the initial complaint investigation was filed. As a result of the investigation and interviews conducted, the allegation that youth are unable to make private phone calls is SUBSTANTIATED at this time meaning the "preponderance of the evidence" standard has been met. The facility was cited per STRTP Interim Licensing Standards Section 80072(c)(1) Personal Rights as the licensee shall ensure that each child...is accorded the personal rights specified in Welfare and Institutions Code Section 16001.9 including the right to To make, send, and receive confidential telephone calls...unless prohibited by court order. While this allegation was remedied immediately, it still was a violation at the time the complaint was filed. Exit interview was conducted with Ms. Edwards and documentation including appeal rights were provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 3/13/24 at 10: AM and met with Tracy Edwards, Program Director to discuss the complaint findings as stated. LPA Hill informed Ms. Edwards that the complaint investigation included an initial inspection to the agency on 11/16/23 where LPA Hill obtained documentation. Subsequent inspections were conducted 11/17/23, and 2/15/24. Seven youth were interviewed and five staff, including Head of Services (HOS) and Administrator from 11/17/23 to 2/15/24. In addition, outside parties related to C1 (see LIC811 dated 3/13/24) were interviewed 2/28/24 and 2/29/24 as pertinent to the investigation. This allegation is related to the agency not providing C1's Needs and Services Plan and/or treatment plan to the placing agency to verify that the agency, facility, and staff are following it or updating it as necessary for C1. The placing agency states that they only received C1's Regulation and Soothing Plan and that it was not being followed either. LPA Hill requested proof that the facility/agency had provided C1's Needs and Services SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE FREELFACILITY NUMBER: VISIT DATE: 03/13/2024

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


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Narrative:
facility where C1 was restrained following an assault on two staff. The agency initially reported a different length of time for the restraint than what was reported on the final incident report. The discrepancy created some confusion regarding the agency policy and restraints provided but was later clarified. Another incident that took place on 12/7/23 between C1 and S1 was reported as an unnecessary restraint in that C1 was restrained for coloring on a wall. During interviews conducted, it was reported that C1 had put their hands on S1 during a confrontation about coloring on the wall and in return, S1 put C1 in a restraint of C1's hands until another staff walked in. S1 denies placing C1 in a full restraint. LPA Hill attempted to interview C1 about this incident but C1 refused an interview twice. As a result of the confidential interviews conducted and documentation reviewed, the allegation that staff conduct inappropriate restraints is UNSUBSTANTIATED at this time meaning that the allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. The allegation that youth is being sexually harassed is related to reports that C2 thought that new youths newly admitted were automatically dating them. C1 reported feeling uneasy about C2 coming into their room even for benign reasons, and C2 told other youth in the facility that they were dating C1. Youth in the facility reported that youth were uncomfortable around C1 to the point that the facility eventually put C2 in a room by themselves to help with this situation. While staff and clients knew about C2 tendency to approach all newly admitted youth and attempts to be romantically involved, there was no evidence that any youth in the home felt sexually harassed. As a result of the information obtained and confidential interviews conducted, the allegation that youth are being sexually harassed is UNSUBSTANTIATED at this time meaning that the allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. Exit interview conducted with Ms. Scott and documentation, including appeal rights were provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 3/25/24 at 3: PM and met with Alina Scott, Head of Service to discuss the complaint findings as stated. LPA Hill informed Ms. Scott that the complaint investigation included an initial inspection to the agency on 11/16/23 where LPA Hill obtained documentation. Subsequent inspections were conducted 11/17/23, and 2/15/24. Seven youth were interviewed and five staff, including Head of Services (HOS) and Administrator from 11/17/23 to 2/15/24. In addition, outside parties related to C1 (see LIC811 dated 3/13/24) were interviewed 2/28/24 and 2/29/24 as pertinent to the investigation. When discussing restraints with youth, staff, reporting party and other individuals, the youth are restrained only when they are a danger to themselves or other individuals in the home, it is a last resort and other de-escalation techniques have failed. The original allegation was related to an incident that took place at the UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE FREELFACILITY NUMBER: VISIT DATE: 03/25/2024

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


raw_content:
Narrative:
August 2024, not all youth were immediately assigned to the new therapist, S2. When it was finally decided to assign all youth to S2 and begin their transition, S2 noted that there were three to four weeks' of missing or undone therapy documentation to facilitate this change in therapists. S2 noted that in discussing this with the agency's management, S2 was directed to "start new" with all of the youth being added to S2's caseload, which was about half of all the youth they had in care at that time. S2 indicates that this meant going back and completing documents for all youth as if they were brand new, even if they had been in care for some time, as there were incomplete and/or undone documented therapy notes. Subsequent interviews with other agency personnel indicates that the agency will not be returning S1 to their employment position within the agency. As a result of interviews conducted and documentation reviewed, the allegation that staff did not ensure that youth are provided mental health services is SUBSTANTIATED at this time meaning the "preponderance of the evidence" standard has been met. The facility cited for Interim Licensing Standards for Short Term Residential Therapeutic Programs, regulation 87072(d): Personal Rights. Youth have the right to access and receive medical...mental health, and substance use disorder services...with reasonable promptness that meets the needs of the child...Confidential interviews conducted with staff and youth in care indicate that youth were without mental health services, specifically therapy sessions, for three to four weeks. Further interviews indicate when therapy sessions did resume for youth in care, there were therapy session notes not documented as required by the previous therapist for a reported period of up to four weeks. Exit interview was conducted and documentation was provided to Ms. Edwards.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 1/7/25 at 10: AM and met with Tracy Edwards, Administrator, to discuss the findings of this complaint investigation. LPA Hill informed Ms. Edwards that the complaint investigation included an initial inspection of the facility on 9/5/24, with subsequent collateral inspections to the administrative offices on 9/20/24, 10/25/24, and 11/26/24, where interviews were conducted with administrator, therapist, and youth in care. During the course of the investigation, LPA Hill also interviewed youths' social workers. The allegation that staff did not ensure that youth are provided mental health services is related to the youth in care not being provided therapy as dictated in the agency's program statement. While the documentation provided indicates that some youth were seeing the previous therapist, S1, who went out on leave in SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE FREELFACILITY NUMBER: VISIT DATE: 01/07/2025

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


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
It was alleged that around February 2025, a client brought alcohol back to the Facility, and both the staff and clients were drinking the alcohol together. It was alleged that the Staff member allowed the minors to consume alcohol, and that the Staff members behavior posed a risk to minors. Regarding the allegation that Staff allowed minors to consume alcohol, confidential interviews with three Youth (C1, C2, C3) corroborated that C2 brought alcohol into the facility, after being out on pass. The alcohol was in water bottles, and Staff member S1 allowed the Youth to drink the alcohol. All three Youth (C1, C2, & C3), stated that S1 knew, and allowed the Youth to consume alcohol. One Youth (C1) stated that S1 also drank with the Youth and became intoxicated while at work. C1 stated no other staff knew they were drinking alcohol, or that S2 was intoxicated. Regarding the allegation that staff behavior poses a risk to minors, a prior incident revealed that this same staff (S1), who allowed the Youth to consume alcohol, was walked in on by Staff member (S5), and discovered to be vaping with the Youth. S1 was terminated after this incident. Per the Facility Program Statement, this is a Facility that accepts Youth who struggle with substance abuse. On more than one occasion, the Staff member (S1) did not provide the proper care and supervision to keep substances out of the Facility. This Department has investigated the allegations that Staff allowed minor to consume alcohol, and Staff's behavior poses a risk to minors. Based on interviews, and record review, we have found that the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. A Type A citation for California Code of Regulations, Section 80078(a) RESPONSIBILITY FOR PROVIDING CARE AND SUPERVISION, is cited on the attached LIC 9099D. An exit interview was conducted with Tracy Edwards. A copy of this report, and appeal rights were given.

Investigation Findings:
13On Friday, October 10th, 2025, at 12PM, Licensing Program Analyst (LPA) Brittany Crass, conducted an Unannounced complaint investigation inspection to deliver findings for the allegations listed above. Due to the facility currently not being in operation, this inspection was conducted at the Administrative offices. LPA met with Administrator Tracy Edwards, who assisted with the inspection. LPA Hill conducted the initial, 10-day complaint investigation at the Facility's Administrative office on 7/18/2025. Between 7/18/25 and 10/9/25, LPA Hill interviewed the Administrator (A1), one CPS Social Worker (CSW1), one Staff Member (S6), and two Youth (C2 and C3). LPA Hill made three attempts to interview an additional, previous staff member (S1) but was unsuccessful. LPA Crass interviewed two CPS Social Workers (CSW1 & CSW2), one Youth (C1), and one Staff (S4). LPA made attempts to contact the Alpine County Sheriff Officer (PD), and three staff members (S1, S2, an S5). (Continued on LIC 9099-C). SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Jensen-Hill LICENSING EVALUATOR NAME: Brittany Crass 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE FREELFACILITY NUMBER: VISIT DATE: 10/10/2025

announced_status: Unannounced

met_with: Administrator Tracy Edwards


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection to the administrative offices for Rite of Passage on 8/17/21 at 1: PM and met with Tracy Edwards, Administrator to discuss incident reports received for this facility. The first incident discussed with Ms. Edwards is related to a report dated 7/2/21 involving C1 and S1 (see LIC811 dated 8/17/21). The incident took place at a swimming outing at Carson Valley Swim Center where S1 left their cell phone and facility vehicle keys unattended where C1 had access. C1 stole the facility vehicle and S1's phone and left the swim center. C1 was stopped by law enforcement and taken to juvenile hall. When questioned about staff discipline as a result of leaving items accessible to youth, Ms. Edwards states that there was a conversation with staff but that nothing was documented in S1's file. Ms. Edwards states that she is conducting a training with all staff regarding vehicles and will add this into the training already scheduled for 8/18/21 and shall provide proof to Licensing upon completion. The other two incidents, 7/2/21 and 7/3/21, were provided to Ms. Edwards as more informational in that additional informed was needed to be complete incidents. LPA explained that the incident reports should have a clear picture of the events leading up to, what happened during, and the resolution of/or the consequence(s) given to the youth/staff as a result of the incident(s). LPA also instructed Ms. Edwards that the incident reports should have all youth involved in the incident named in the report so as to have a clear picture of the events. No citations issued and exit interview conducted.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA Tamara Hill made an unannounced annual inspection on 11/30/21 at 11: AM and met with Tracy Edwards, Program Manager, who assisted with the inspection. LPA Hill conducted a walk-through of the facility inside and out. There were no clients present during the inspection due to school. LPA observed three, dual occupancy client bedrooms, two bathrooms, and one staff room during the inspection. LPA Hill inspected and/or reviewed the following: Postings of facility license, Personal Rights Poster Disinfectants/Cleaning solutions were inaccessible Refrigerator Temperature was at or below 45 degrees F and Freezer Temperature at or below 0 degrees Nonperishable Foods for one week and fresh perishable for foods two days minimum were present Menu was present and posted Working telephone was present Carbon monoxide detectors and Smoke Detectors were functioning First Aid Kit was present and had all required components Common Room (living room) was available as was a separate room for relaxing Dining area with enough seating was present and in good condition Medication was centrally stored, locked/inaccessible LPA observed a locked staff office/sleeping area. All documentation and equipment in the staff room is locked as is the staff room. Hot Water was between 105 -120 degree F Fire Extinguisher was observed to be last inspected on 2/15/ Toilets, wash basin, bath and shower fixtures appeared to be in good repair, no leaks and delivering hot water. LPA observed there to be soap and paper towels available in the bathrooms. Laundry Facilities were available and LPA observed posted assigned washing days for clients. Bedrooms appeared to be clean and organized with required linen and furnishings Motor Vehicle was observed to have working seat belts, lights and adequate tires. Facility appeared to be free of vermin LPA observed no citations during the physical plant inspection. LPA arrived to the Minden, Nevada school site location to conduct interviews with staff and clients. LPA was not able to complete the staff and client file reviews during the inspection but will return on another date to complete the file reviews as required. Exit interview conducted and documentation provided to Ms. Edwards.

met_with: Tracy Edwards, Program Manager


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 5/16/22 at 11: AM and met with Tracy Edwards, Administrator. LPA Hill made this visit to the Administrative office location in Minden, Nevada as the youth were already on site at this location in attendance at school. LPA Hill made the visit today to discuss the following incidents and obtain documentation related: * 1/3/ C1 disclosed that they had some medical concerns that C1 wanted to be tested for and when further pressed, C1 disclosed an incident that had occurred between C1 and a youth from another facility. C1 disclosed that the youth from the other facility was able to gain entry into this facility undetected on 12/22/21 and youth was able to leave the facility undetected as well. C1 further disclosed that the youth returned again to this facility on 12/23/21 and was able to gain undetected entry into the facility. The other youth overheard a staff from their facility discussing youth's absence with staff from this facility and left the facility undetected but went to the front door to be let in due to the snow and cold temperatures. Law enforcement was contacted. LPA informed Ms. Edwards that further investigation is needed regarding the staff actions on these two days. * 4/26/ C1 was found to have allowed another youth from the other facility into the facility in the early morning of 4/26/22. The other youth was found in the bed with C1 at 4: AM. LPA informed Ms. Edwards that further investigation is needed regarding the staff actions on this date. Exit interview conducted and document was provided via email.

met_with: Tracy Edwards


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced annual inspection on 11/22/22 at 11: AM. LPA initially attempted an inspection at the facility but there were no clients or staff present at 10: AM. During the annual inspection on 11/22/22, LPA interviewed clients as part of the annual and reviewed client files. LPA informed the agency that an additional inspection will be necessary at a later date. Exit interview conducted and documents were provided at the conclusion of the inspection today.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced annual inspection on 12/13/22 at 10: AM and met with Tracy Edwards, Administrator to continue the annual inspection at this location. LPA Hill toured the facility inside and out and did find that the facility was in substantial compliance with the regulations with the exception of one of the walls in the bathroom that needs to be repaired. The wall was damaged when a child fell against the wall and was seen at the hospital. LPA advised the facility to make the necessary repairs as soon as possible. Ms. Edwards states that it will be repaired by January 30, 2023 as they are currently hiring for a handy man for the houses. LPA found that the smoke detectors in the house work as required and that the carbon monoxide detector was tested and works as required. LPA observed that the fire extinguisher located right off the kitchen area was last inspected on 2/9/22. LPA observed that there is one bathroom for client use on the second floor and that there is one restroom for staff use on the first floor right off the kitchen area. LPA observed that the bathrooms were equipped with the required supplies as necessary for general hygiene, bathing and grooming. LPA observed that the restrooms had the required hot water as necessary. LPA observed that the kitchen area is clean and tidy and all items are stored appropriately. LPA observed that the food in the facility is appropriate for the three clients in the facility. LPA did not issue any citations during the inspection and conducted an exit interview with Ms. Edwards.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Misty Valencia on 09/14/2023 at 8:15am. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Valencia met with Alina Scott, Therapist and inspected the facility inside and out. LPA reviewed two of four (2 of 4) child's records and two of seven (2 of 7) staff personnel files on site at the facility. LPA reviewed two of four (2 of 4) child's psychotropic medications and medication records. LPA interviewed two of seven (2 of 7) staff on site to discuss the facilities policies and procedures of operation. LPA interviewed one of two (1 of 2) children currently prescribed psychotropic medication. One of two (1 of 2) did not qualify for interview due to not being a dependent. LPA provided a copy of this licensing report to Alina Scott, Therapist No deficiencies are being cited at this time. LPA conducted exit interview with Alina Scott, Therapist

met_with: Alina Scott, Therapist


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced annual inspection on 12/20/23 at 10: AM and Monica Guzman, Coach Counselor assisted with the physical plant inspection at the facility. LPA Hill toured the inside of the facility and noted that there are three, dual occupancy client rooms, and one staff room in the facility. All of the client bedrooms have the required furniture and equipment as required. LPA Hill observed that the facility had the required supply of perishable and nonperishable food as required by regulation and that the house was clean and tidy. LPA Hill observed that there is one bathroom accessible to clients in the facility and one staff bathroom. LPA Hill observed that the toilets flushed, showers worked and had hot water, and that the sinks were working and had hot water. LPA Hill observed that the facility had a washer and dryer for laundering of clothing, a dishwasher to sanitize and clean dishes, and that the facility has a den off of the kitchen area for client relaxation and separation for quiet and phone calls. LPA Hill requested that the facility provide the following documents to be updated in the facility file: LIC308, LIC500, LIC610. LPA Hill also reminded the facility that the program statement update is due 2/2/16/24. LPA Hill cited the facility as follows: 87070(c)(2) Children's Records: LPA Hill observed during the review of the records that there are no Removal or Transfer Policy or Discipline Policy signed by the placing agency. 87068.2(f) Needs and Services Plan: LPA Hill observed that the facility is not obtaining the signature of the placing agency on the Needs and Services document or the modifications when this document is updated, changed, or modified. LPA Hill concluded the inspection at the facility and resumed the inspection at the business office located in Minden for review of files and interviews of staff and clients. End of report.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an announced case management annual continuation review at the business offices of Rites of Passage located in Minden, Nevada, on 12/21/23 at 9: AM and met with Tracy Edwards, Administrator who assisted in records review. LPA Hill reviewed staff and client records, reviewed restraint records, and requested board meeting minutes, and conducted interviews. LPA Hill requested the Emergency and Disaster Plan but the needed requirements were not available for review (Technical Violation was provided). LPA Hill conducted the exit interview with Ms. Edwards and documents were provided.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 2/29/24 at 12: PM and met with Tracy Edwards, Program Director to discuss an incident report received by the Department. LPA Hill informed Ms. Edwards that the incident report was not clear in the explanation as to why C1 (see LIC811 dated 2/29/24) needed to go to the hospital for medications or due to the lack of medications if medications were refilled at the facility just eight days prior. When LPA Hill inquired about this, LPA Hill was informed that due to the type of medication C1 was taking, insulin, C1 requires this medication to be refilled on a weekly basis. Staff working at the facility failed to inform the administrator that C1 was out of or running low on the necessary medications the week prior to the emergency room visit. The agency now has C1's medications set up in such a manner that the medications are on reorder weekly and should C1 run low on these essential medications, the agency now has access to reorder the medication without having to contact the doctor, causing potential delays. LPA Hill also inquired about a Health Care Plan or other additional medical support and/or documentation necessary per Interim Licensing Standards, 87075. Emergency Medical Assistance, Injections, and Self-Administration of Medications for this youth as, given the medical condition of this youth, there is monitoring that is required and specific dietary needs and limitations that the facility inherently agrees to by accepting the youth into their program. LPA Hill also cautioned about the staff training that needs to be documented in the staff training plan and individual staff files per Health and Safety Section 1507.25. LPA Hill obtained a copy of C1's Needs and Services Plan and any other documentation related to C1's health condition and monitoring that is required. No citation were issued and documentation was provided during the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 3/13/24 at 10: AM and met with Tracy Edwards and Jim Amaral, Program Directors to discuss client phone calls as a result of recent inquiries and citations related to this issue. LPA Hill advised Ms. Edwards and Mr. Amaral that the privacy and access to calls is an essential part of the personal rights of the youth in care and that any interference in clients' access to the phone is strictly prohibited unless there is a court order indicating that there is a need for this. In addition, any restriction related to access to the phone or issues relating to privacy must be discussed with the placement agency and documented in the Needs and Services Plan. LPA Hill did advise that the agency can use Prudent Parent Standard as it relates to phone calls if youth are exhibiting behaviors that necessitate this need, i.e., a client in care used the phone to contact an individual to come to the facility and pick them up. If the client should then leave on an unauthorized absence, when the client returns to the facility, a natural consequence for inappropriate use of the phone might be to monitor who the client is calling for a set period of time (keeping track of phone numbers dialed), with the placing agency's agreement/approval. The Prudent Parent Standard is not a blanket restriction for the time that the client remains in care of the facility but for a set amount of time, i.e., a week. The discipline for this could be progressive and discussions should be held with the placing agency each time clients break rules or violate policies set by the facility to ensure that the team is in agreement of the consequences established. In addition, the practice of not answering the phone at the facility unless a staff member is alerted or expecting a prearranged call to the facility shall cease. The placing agency, family, and other individuals involved in clients' care have the right to contact the facility to speak to youth in care as needed and this should not have to be prearranged or scheduled. No citations were issued during the inspection today. Exit interview was conducted and documentation was provided to Ms. Edwards and Mr. Amaral.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 3/25/24 at 3: PM and met with Alina Scott, Head of Service to discuss a recent incident report provided to the Department on 3/23/24. The incident reported includes a possible inappropriate sexual interaction between two clients in care. LPA Hill interviewed one youth while at the facility's administrative offices since the clients were in attendance for school. LPA Hill also interviewed Head of Service regarding the incident. Other concerns raised was that one youth admitted to spitting in another youth's food while preparing meals for youth in care. LPA Hill informed Ms. Scott that further investigation is needed at this time and that LPA Hill would return at a later date to complete interviews and investigation. Exit interview conducted and document provided.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 5/1/24 at 10: AM at the agency's administrative site and met with MacKenzie DeBoer, Case Manger to discuss an incident report dated 4/27/24. LPA Hill explained that the inspection was to discuss C1's (see LIC811 dated 5/1/24) unauthorized absence from the program, property destruction, and subsequent return on 4/27/24. LPA Hill observed that the incident report indicates that C1 was able to return "undetected" and was in their room, without staff knowledge, when law enforcement arrived on site to conduct a visual of the damages caused by C1. LPA Hill attempted to interview C1 but they are not currently at the facility as C1 attends an all day off-site educational/vocational schooling Tuesday through Saturday. LPA Hill informed Ms. DeBoer that an interview may be scheduled for later this same day, when C1 returns from the program. S1 was also not available for interview today as S1's shift does not start until 1: PM today. Jim Amaral, Program Director was not available for interview today due to another youth's CFT being conducted off site. LPA Hill did obtain an additional description of S1's details of the incident and LPA Hill requested that the camera footage showing C1's return to be provided to LPA Hill today. Exit interview conducted and document was provided to Ms. DeBoer.

met_with: MacKenzie DeBoer, Case Manger