facility_name: SANCTUARY RECOVERY FOR TEENS

summary: Facility Evaluation

raw_content:
Narrative:
On October 21, 2020 at 11: AM, Licensing Program Analyst (LPA) Belinda Torres conducted a Short Term Residential Therapeutic Program (STRTP) pre-licensing inspection. The LPA met with Lauri Burns, Executive Director, Anasheh Safarian, Director of Operations, and Morgan Salmans, Facility Manager. The facility is a one story residential building with five bedrooms, four bathrooms, living room, staff office, family room, dining room, kitchen, laundry room and a two car attached garage. A physical plant inspection was completed and the following was observed by the LPA: The facility stores personnel files, client files, client cash resources, and medications in the staff office. The door to the staff office has a keyed locked. The office is kept locked when not in use and is only accessible to the facility staff. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris, observable hazards, and insects. There is adequate indoor and outdoor activity space. A television, board games, books, and puzzle were observed for client's recreation time. The family room will be used for clients to use for relaxation and visits with family and friends. The following required forms were posted in the facility: Weekly Menu, Personal Rights form, and Complaint Procedures. Each of the four client bedrooms has proper lighting, adequate drawer space, all six beds were observed with appropriate clean linens, pillows, blankets, comforters, mattress pads, and mattresses in good repair. The facility has telephone service on premises. The hot water was tested and measured to be 113 degrees Fahrenheit which is in the required range of 105-120 degrees Fahrenheit. The facility has a fully equipped first aid kits and a current first aid manual approved by the American Red Cross. Smoking is prohibited in the facility and on the grounds. *** *** Per Executive Director, no firearms or weapons are kept or allowed in the facility and smoking is prohibited. Licensee has previously been accredited through the Joint Commission, and once the facility is licensed the licensee will notify the commission to make them aware of the program change to update the certification. Current staff have caregiver background checks and have received criminal record and child abuse index clearance. LPA discussed the following: Reporting requirements, facility manager requirements, personnel rights and Assembly Bill 388 requirements. The LPA was provided Criminal Record Transfer documents for Lauri Burns, Anasheh Safarian and Morgan Salmans during this inspection. . The licensee will ensure that LIC 503s Health Screening Report-Facility Personnel are submitted for Lauri Burns and Anasheh Safarian. After final review of the application, the program will be submitted for licensure. The facility will be notified once they are provisionally licensed as a Short Term Residential Therapeutic Program (STRTP). A copy of this report was provided to Lauri Burns.

met_with: Lauri Burns, Anasheh Safarian & Morgan Salmans


state: CA

summary: Facility Evaluation

raw_content:
Narrative:
On December 1, 2022 at 10:14am, Licensing Program Analysts (LPA's) Adrian Mendez and Eduardo Barragan arrived unannounced at the facility to conduct an Required Annual inspection of the facility. LPA's met with Case Manager Lora Caldwell and Head of Service Mariam Mott. LPA Barragan inspected the facility inside and out with Head of Service Mariam Mott. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. There are five bedrooms in the facility. Four bedrooms are single rooms, one bedroom is set up for two clients. There is adequate shelf and closet space for client's belongings. Each bed room contained one desk as well. The bathrooms were clean and in good repair. The hot water in the client bathrooms were measured at 116 degrees, which is within regulatory requirements. All hazardous items have been properly made inaccessible. The medications were stored and locked in the staff office. Cleansers/chemicals are locked and stored in a locked closet in the hallway. Sharp knives are inaccessible and stored in a locked staff office. The First Aid Kit is located in the staff office and contained all required supplies. The facility's smoke/carbon monoxide detectors in the hallways were checked and were operable. There are no guns or weapons in the facility as stated by Head of Service Mariam Mott. The following required posted items were observed accessible to clients: Facility License, Grievance Procedures, Personal Rights, Visitation policies, Emergency Disaster Plan and current menu. The facility outside grounds was also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. LPA discussed and reviewed the following inspection components; Operational Requirements, Emergency Disaster Preparedness, and the Emergency Intervention Plan. Cont. on 809-C A sample of two client files were reviewed during the inspection. All client files had the required documents per Title Regulations. All client files are maintained on a secured internet database. All of the staff records are accessible and maintained at an off-site location. LPA's reviewed 5 staff files. All the staff have met the training and qualification requirements per regulation requirements. Per a review of the Community Care Licensing Information System (LIS), all staff met DOJ/FBI criminal record clearances and Child Abuse Index Check requirements. LPA's conducted a Post-Licensing inspection as well. Mental Health Program Approval for the facility is still currently pending. Based on the facility inspection, and files reviewed there are no deficiencies found at this time. An exit interview was conducted, and a copy of this report was explained to Case Manager Lora Caldwell. Due to printer malfunction, this report will be emailed to Case Manager Lora Caldwell.

report_type: Facility Evaluation

visit_type: Annual

met_with: Lora Caldwell, Mariam Mott


summary: Facility Evaluation

raw_content:
Narrative:
On 04/26/22 at 1: PM Licensing Program Analyst (LPA), Belinda Torres, met with Andrea Carmona, Administrator. The LPA was informed by Andrea that she started working as the administrator at the facility on 04/11/22 in preparation for the facility's first placement. Andrea worked for the corporation in their adult rehabilitation program facilities across the street from this facility. The LPA obtained a copy of the LIC Personnel Report, dated 04/15/22, which shows an employment date of 10/08/20 for Andrea and job title of Administrator. The Administrator on file with the Department is Anasheh Safarian. The LPA spoke by telephone with Lauri Burns, CEO, and received verbal authorization from Lauri for Andrea to sign for this licensing report. Lauri informed the LPA that the change of administrator notification was sent to the Department at the end of February of 2022. The LPA informed her that the notification was not received. Based upon a record review as of today's date, the licensee failed to notify the Department, in writing, within ten calendar (10) days of the hiring of a new administrator. The facility is cited for violation of the Interim Licensing Standards STRTP Article 6 87061(h) Reporting Requirements. A copy of this report, LIC Proof of Correction and appeal rights were provided to Andrea.

visit_type: Case Management

met_with: Andrea Carmona


facility_name: SANTA FE STATION

summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Lidia Tinoco conducted an unannounced visit to the Creative Alternatives main office in Merced in order to deliver the findings of the above allegations regarding Stanta Fe Station and met with Director Brandi Boehme. During the course of the investigation, Community Care Licensing (CCL) conducted interviews with facility staff and foster youth as well as conducted a review of records. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation occurred. Therefore, the allegation that the group home staff did not provide appropriate supervision resulting in inappropriate interactions is UNSUBSTANTIATED at this time. LPA Tinoco conducted exit interview with Brandi Boehme. A copy of this report was provided to the Facility Representative. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lidia Tinoco LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2

report_type: Complaint Investigation

met_with: Brandi Boehme

complaint_status: unsubstantiated


raw_content:
Investigation Findings:
13Complaint Specialist C.K. Kinney(CS) traveled to the facility and met with Amanda Fantazia to deliver findings of investigation. CS conducted investigation that included review of documentation, interviews of staff, clients and witnesses. CS was not able to come to a preponderance of the evidence that the allegations occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation occurred. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No deficiencies cited or observed during this inspection. Copy of this report and LIC Appeal Rights left at the facility at conclusion of inspection. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Charles Kinney LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2

met_with: Amanda Fantazia


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


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Eduardo Barragan on 5/03/2021, at 1: PM. During the inspection, LPA Barragan met with Hermilo Gandarilla, House Manager and inspected the facility inside and out. Due to restrictions of COVID-19, this inspection was conducted via FaceTime. All files and medication documents were sent to LPA Barragan before the inspection. A medication count was also conducted by FaceTime on this date. LPA reviewed 3 child's records at AM. LPA reviewed 2 staff personal files at PM. LPA interviewed 2 staff on-site at PM. LPA interviewed 3 children currently taking psychotropic medications at 3: PM. No deficiencies are being cited at this time. LPA conducted an exit interview with Hermilo Gandarilla, House Manager at 4: PM. LPA provided the summary report to Hermilo Gandarilla, House Manager upon completion by email with a request for signature and a scan back to this LPA on this date.

met_with: Hermilo Gandarilla


summary: Facility Evaluation

raw_content:
Narrative:
On 05/26/2021, Licensing Program Analyst (LPA) Tamara Melikian conducted a case management with Assistant Program Director Monica Alexander to discuss an incident that occurred on May 24, 2021 between staff (#1) and client (#2) resulting in a restraint that is not approved by the agency. Due to restrictions of Covid-19, this case management was conducted by teleinspection with this report being scanned to Ms. Alexander with a request for signature and a scan back to this LPA. Staff (#1) states that he did not intend to do a prone restraint, however, when assaulted by client (#2), staff (#1) attempted a childrens' control position and they both fell resulting in a prone restraint as staff (#1) attempted to gain control of the incident. The clinician was present and staff (#1) has been counseled by the agency. In addition, all clients were interviewed by the agency. Ms. Alexander will forward the memo of record for the discussion with staff (#1) and this LPA will request the report from law enforcement. There are no deficiencies to be cited on this date.

met_with: Monica Alexander


summary: Facility Evaluation

raw_content:
Narrative:
On this date, Licensing Program Analyst (LPA) Lidia Tinoco traveled to the Creative Alternatives Main Office in Merced and conducted an unannounced Case Management for the Santa Fe and met with Director Brandi Boheme. The purpose of the inspection is to discuss multiple incident reports regarding medication errors by Staff. LPA Tinoco reviewed incident reports from the Santa Fe facility. It was discovered that there have been 2 medication errors due to staff for this facility (See LIC812 for details) in 2021. LPA Tinoco discussed with Director Brandi the concerns with the amount of incident reports regarding medication errors being received, LPA also addressed what the licensee has been done at the agency level to prevent this from happening, and what the ongoing plans are moving forward to minimize these incidents. Director Brandi stated that a company wide training on administration of medication. An exit interview was conducted, and a copy of the report and appeal rights were provided to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by LPA (Licensing Program Analyst) Lidia Tinoco on at Santa Fe Station. LPA met with Hermilo Gandarilla Facility Administrator and inspected the facility, inside and out. Currently the facility is inactive and has been inactive since September 16, 2021. All facility smoke detectors were tested and appear to be in appropriate working order, fire extinguisher is properly charged. The facility currently keeps their food supply at an off site warehouse where they store non-perishables, fresh foods, and dairy that would be ready to be transported to the home would they choose to become active again. Individual beds were observed with appropriate clean linens and are in good repair. The facility is maintained at 72 degrees. No bodies of water were observed. No firearms or weapons are allowed in the facility. Licensee has obtained Mental Health Certification Including the following: Mental Health Program Approval valid through September 24, 2021, Medical certification effective January 1, 2019 and a county contract since September 1, 2019. Licensee has obtained National Accreditation through CARF. The Accreditation is valid through September 30, 2023. Due to the facility being inactive no records of personnel/ staff members were reviewed and no records of clients were reviewed. There were no deficiencies to be cited on this date. A copy of this report was left with Hermilo Gandarilla.


facility_name: SANTA LUCIA PROGRAM

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
come back under the influence at the facility. Two staff were interviewed on 01/08/2021. The facility manager Leann Leon was interviewed at around 10:45am. The interview revealed and confirmed client statements that the facility staff do supervise clients at all times and check on them every 15 minutes over night. An interview was also conducted with the facility head of services Carolina Cortez at around 11:45 am. Interviews with the Carolina and LeeAnn revealed that as soon as the facility became aware of the allegation of inappropriate contact with clients the facility staff separated the youth in question and for the duration of their stay at the facility. The incidents of inappropriate contact allegedly occurred overnight between roommates C1 and C2 (Clients 1 and 3, see confidential names list LIC 811, dated 05/26/2021) at an unknown date. Clients reported using marijuana when they leave the facility on an unauthorized basis and do come back under the influence; however, they report that staff not only discourage that behavior they are asked to empty their possessions to search for contraband. An interview was conducted with C1 on 04/20/2021 at around 3:30pm. The interview further confirmed the statements clients made on 01/08/2021. Client confirmed that upon learning of the allegations staff separated client from C2 and shared a room with a different roommate. The C1 reported that C2 did not share a room with anyone else. The client stated that they pretended to sleep when staff were checking on them only to get up for the 15 minutes between when staff would come and check on them. C1 stated they were quiet when the incident happened and they were using a vape pen; which they hid after using. C1 reported this incident took place in the span of 3 -4 minutes. Interview with C2 on 01/08/2021 did not result with any information, the client denied participating or knowing anything about the allegations. Note that C2 was accused of being the perpetrator of the inappropriate contact and one of the instigators of using marijuana at the facility. An interview was also conducted with direct care staff Karolina Redondo on 05/13/2021 at approximately 3:30pm. The interview confirmed the staff check on clients every 15 minutes over night. Karolina indicated she was supervising clients when one of the incidents of inappropriate conduct occurred. Karolina stated that she had supervised the clients the whole time while at a car wash. She had taken clients to assist with washing the facility van as and activity and chore. Karolina was also cleaning the van with clients. She stated that nothing was reported to her or observed during the activity. It was alleged C2 had used the vacuum at the car wash to place near the C3's buttocks. Karolina stated that yes, clients used the vacuum but did not observe or hear the clients using the vacuum in an inappropriate manner. Although the allegations may have occurred or are valid, there is not a preponderance of the evidence that they occurred as a result of lack of supervision by staff; therefore, the allegations above are unsubstantiated. Appeal Rights were provided and discussed with the administrator Victoria Shannon. No deficiencies were cited. Exit interview conducted and a copy of the report was emailed for a signature to Victoria Shannon.

Investigation Findings:
13Licensing Program Analyst (LPA) Joel Segura conducted a follow-up complaint inspection to the STRTP (Short Term Residential Therapeutic Program) and met with the administrator Victoria Shannon via Microsoft Teams. The purpose of the inspection is to deliver the findings for the above complaint allegations. During the course of investigating these complaint allegations, LPA Segura conducted interviews with staff and clients. LPA interviewed three clients on 01/08/2021 at the facility at around 11:30-2pm. Interviews with these clients revealed that staff do supervise clients and did not report incidents where staff were not supervising clients. Clients reported that staff check on them every 15 minutes over night including searches of their personal belongings when contraband is suspected. Clients further reported that their marijuana usage usually doe not occur at the facility and sometimes Continued on 812c UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Joel Segura 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 26-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, N. First Street, Ste. FACILITY NAME: SANTA LUCIA PROGRAMFACILITY NUMBER: VISIT DATE: 05/26/2021

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

met_with: Victoria Shannon


raw_content:
Narrative:
On November 15, 2021, the Department received a complaint alleging facility staff do not prevent clients from bringing drugs into the home, and staff does not provide a safe environment for clients and staff does not treat clients equally. Based on confidential interviews, clients would come back to the facility already on drugs, not necessarily bring drugs into the facility. Staff did not ask the police to leave during an incident with a client. The client refused to talk with police. Staff treat clients as equally as possible. Some clients open up more to staff than others and this may lead to feelings of inequality. Based on confidential interviews conducted, the above allegations may have happened or are valid, however, there is not a preponderance of the evidence to prove that staff did not prevent clients bringing drugs into the facility, staff does not provide a safe environment and staff does not treat clients equally; therefore, the above allegations are unsubstantiated.

Investigation Findings:
13Investigations Branch (IB) Investigator (Inv) Maria Barragan and Licensing Program Analyst (LPA) Monica Pavia conducted a complaint investigation. Licensing Program Manager (LPM) Carolyn Flynn and LPA Selena Hood initiated a complaint investigation at the facility on November 18, 2021, at 12:30pm. The facility was toured, and records were reviewed, on this date. Inv Barragan and LPA Pavia conducted confidential interviews with staff, clients, and social workers. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Monica Pavia 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 26-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, N. First Street, Ste. FACILITY NAME: SANTA LUCIA PROGRAMFACILITY NUMBER: VISIT DATE: 03/03/2022

met_with: Steve Duran


raw_content:
Narrative:
received the requested Progress Notes. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was provided to Nic Briseno.

Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegation. LPA met with Nic Briseno, Administrator (AD) at 10: AM on 1/12/ Over the course of the investigation, LPA conducted confidential interviews and reviewed files during this investigation. Based on confidential interviews conducted it was determined that the allegations listed above are unsubstantiated. Most staff and clients feel like the facility does provide a safe enviorment. An individual was able to sneak a cell phone into the facility, which was against court orders, but was able to do it without staff knowing. When staff learned of this they attempted to locate the cell phone but the individual already removed the cell phone from the facility. The facility had to delay sending incident reports (IR) to the social worker due to IT issues. The social worker eventually recieved the IRs. Based on confidential interviews, the facility has policies staff use to prevent AWOLs. The delay in the Social Worker recieving progress notes was a misunderstanding with the facility. Once the misundersstanding was cleared up the social worker eventually UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien 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 26-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, N. First Street, Ste. FACILITY NAME: SANTA LUCIA PROGRAMFACILITY NUMBER: VISIT DATE: 01/12/2023

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

met_with: Nic Briseno, Administrator


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with Nic Briseno, Administrator at 11: AM on 9/22/23. Based on confidential interviews conducted it was determined that the allegations listed above are Unsubstantiated. Witness interviewed stated that there was appropriate supervision at the time of the incident. The individual injured during the incident confirmed that the facility offered medical treatment and to go to the local hosipital but declined that offer. LPA made multiple attempts to contact the other indivdual involed in the incident but as 9/22/23 has not gotten a response. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was provided to Nic Briseno, Administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

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


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility to inform them of the findings for the above listed allegations. LPA met with Nic Briseno, Adminstrator (ADM) on 1/26/24. Based on confidential interviews conducted by IB Investigator Ruben Munoz it was determined that the allegations listed above are Unsubstantiated. An individual interviewed gave multiple inconsistent statements to school staff, facility staff, and investigators. The individual denied being drugged and stripped of their clothes. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was emailed to Nic Briseno, ADM. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Nic Birseno, Administrator


raw_content:
Investigation Findings:
Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility to inform them of the findings for the above listed allegations. LPA discussed this with Joyce Ponton, Administrator at AM on 6/20/25. Based on confidential interviews conducted it was determined that the allegations listed above are Substantiated. Most individuals interview stated that the perpetrator didn't speak and treat victim with respect. They also stated that the perpetrator didn't utilize trauma-informed and evidence-based de-escalation techniques. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. As a result of this visit, there are two Interim Licensing Standards violations ( Personal Rights (c)(1) and Personal Rights (c)(32)). The facility will be cited (see 809-Ds for details). Appeal rights were discussed and provided. Exit interview was conducted and a copy of this report was provided to Joyce Ponton, Administrator. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Paul Simien 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 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN JOSE RO, N. First Street, Ste. FACILITY NAME: SANTA LUCIA PROGRAMFACILITY NUMBER: 275202098

met_with: Joyce Ponton, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 2/23/22 at 11:03 am, Licensing Program Analyst (LPA) Paul Simien conducted an unannounced visit to the above facility. The purpose of this visit was to conduct the required annual inspection. LPA met with Steve Duran, Administrator, at the above facility to conduct the required annual inspection. LPA Simien proceeded to Administration office and met with Chris Shannon, Executive Director at 11:28 am. LPA Simien requested staff files, client files, and staff schedule. LPA reviewed three staff files and staff schedule. No deficiencies were cited at this time. LPA conducted an exit interview with Steve Duran, Administrator, at 2:45 pm.

met_with: Steve Duran, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 4/13/22 at 11:45 am, Licensing Program Analyst (LPA) Paul Simien conducted an unannounced visit to the above facility. The purpose of this visit was to continue the required annual inspection started on 2/23/22. LPA met with Lacisha Zapata-Smith , Facility Manager (FM), at the above facility to conduct the required annual inspection LPA interviewed two staff members. No deficiencies were cited at this time. LPA conducted an exit interview with Lacisha Zapata-Smith, facility manager, at 3:35 pm.

met_with: Lacisha Zapata-Smith


summary: Facility Evaluation

raw_content:
Narrative:
On 4/14/22 at 9:15 am, Licensing Program Analyst (LPA) Paul Simien conducted an unannounced visit to the above facility. The purpose of this visit was to continue the required annual inspection started on 2/23/22. LPA met with Lacisha Zapata-Smith , Facility Manager (FM), at the above facility to conduct the required annual inspection LPA interviewed one staff member, two clients, and reviewed client records. No deficiencies were cited at this time. LPA conducted an exit interview with Lacisha Zapata-Smith, facility manager, at 3:30 pm


summary: Facility Evaluation

raw_content:
Narrative:
On 4/15/22 at 9:35 am, Licensing Program Analyst (LPA) Paul Simien conducted an unannounced visit to the above facility. The purpose of this visit was to continue the required annual inspection started on 2/23/22. LPA met with Lacisha Zapata-Smith , Facility Manager (FM), at the above facility to conduct the required annual inspection LPA reviewed two client files, disaster preparedness, core-therapeutic services, and plant inspection. No deficiencies were cited at this time. LPA conducted an exit interview with Lacisha Zapata-Smith, facility manager, at 1:45 pm


summary: Facility Evaluation

raw_content:
Narrative:
On 4/20/22 at 9:35 am, Licensing Program Analyst (LPA) Paul Simien conducted an unannounced visit to the above facility's Administration Office ( West Gabilan Street Salinas, CA).The purpose of this visit was to continue the required annual inspection started on 2/23/22. LPA met with Steven Duran, Administrator (ADM), at the above facility's Administration Office to conduct the required annual inspection LPA reviewed Six Staff files (Three Direct Staff, Two Clinical/Social Worker, One facility Manager) No deficiencies were cited at this time. LPA conducted an exit interview with Jessica Ortiz, Director of Human Resources, at 2:45 pm

met_with: Steven Duran, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 4/22/22 at 9:40 am, Licensing Program Analyst (LPA) Paul Simien conducted an unannounced visit to the above facility's Administration Office ( West Gabilan Street Salinas, CA).The purpose of this visit was to continue the required annual inspection started on 2/23/22. LPA met with Steven Duran, Administrator (ADM), at the above facility's Administration Office to conduct the required annual inspection LPA completed the Operations, Emergency intervention, Staff and Client section of the CARE tools. One deficiency (ILS Title 22, Sections 80065(f)(1) through (6)) and one technical assistance were cited at this time. LPA conducted an exit interview with Steve Duran, Administrator, at 12:45 pm


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Britanee Windom conducted a case management inspection on 06/02/22 at 9: 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 5 out of 5 youth files were reviewed. 4 out of Direct Care Staff and 4 out of 5 youth were interviewed.(See the Confidential Names List, LIC 811, June 2, 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, monthly 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 Windom 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 Administrator Steve Duran.

met_with: Administrator Steve Duran


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility. The purpose of this visit was to conduct a Case Management inspection. LPA discussed this with Nic Briseno, Administrator (ADM) at 10: AM on 1/31/24. This case management was opened to discuss an incident report the department received for an incident that occurred on 1/29/24. The incident report stated that a staff member was attacked by clients in care. LPA Simien and ADM discussed the incident (see LIC Case Management Details 2/2/24 for details). ADM agreed to send LPA a detailed summary of clients time at the facility, client files, and photo evidence of the incident. LPA Simien reviewed client files at the facility. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was emailed to ADM. This document was amend on 2/2/24. confront or engage in a power struggle with C1 due to the client being new. Staff are instructed to not confront clients and to make behavioral notes instead. ADM stated that S1 has been working at the facility for 14 years and would not escalate with a client over an iPad. LPA Simien inquired if the facility knew if C1 had a history of violence or attacking staff. ADM stated that before accepting C1 as a client her social worker didn't inform them of C1 currently having five charges against her. C1 is charged with extensive property damage, unlawful force and violence upon a person, and resisting/delay/obstruct of a public officer/peace officer. ADM stated they were only informed of the charges when the client arrived at the facility on 1/25/24. ADM speculated that those charges may have come from her last placement. ADM stated that the social worker submitted an incomplete intake packet for C1 and has made several request for competition. ADM stated that upon C1's arrival on 1/25/24 that it was discovered that her social worker forgot her medication and that there was no approved JV-220 paper work, just a JV-220 request. C1's social worker also didn't provide the facility with any identifying information so they were unable to sign C1 up for school. ADM stated while they were aware C1 could be aggressive, they didn't know that it would be to the degree of attack that happened on 1/29/24. C1's social worker has been unresponsive to emails and phone calls. LPA Simien inquired if the facility knew if C2 had a history of violence or attacking staff. ADM stated that although C2 has a history of violence, she hasn't had any behavioral issues outside one AWOL at the facility. ADM stated he was shocked to find out that C2 was involved with the attack and completely out of charcter. He stated that C2 had no problems being incompliance with turning in her electronics at night. ADM stated that he is not sure exactly what happened during the incident and has not been able to debrief with S1 due to S1's hospitalization. As of 1/31/24, law enforcement has not provided any information regarding the incident to the facility. ADM agreed to send LPA a detailed summary of C1's time at the facility, client files, and photo evidence of the incident. LPA Simien reviewed C1 and C2's client files at the facility. Exit interview was conducted and a copy of this report was emailed to ADM.


summary: Facility Evaluation

raw_content:
Narrative:
On 9/4/24 at 11: AM, Licensing Program Analyst (LPA) Paul Simien conducted an unannounced visit to the above facility. The purpose of this visit was to conduct the required annual inspection. LPA met with Nic Briseno, Administrator, at the above facility to conduct the required annual inspection. LPA reviewed two staff files and conducted some of the Physical Plant. At this time the inspection is not complete, LPA will return to complete the inspection. No deficiencies were cited at this time. LPA conducted an exit interview with Nic Briseno, Administrator, at 4: PM.


summary: Facility Evaluation

raw_content:
Narrative:
On 9/5/24 at 11: AM, Licensing Program Analyst (LPA) Paul Simien conducted an unannounced visit to the above facility. The purpose of this visit was to conduct the required annual inspection. LPA met with Nic Briseno, Administrator, at the above facility to conduct the required annual inspection. LPA reviewed five staff files, completed the Physical Plant, and disaster preparedness sections of the CARE tool. At this time the inspection is not complete, LPA will return to complete the inspection. No deficiencies were cited at this time. LPA conducted an exit interview with Nic Briseno, Administrator, at 4: PM.


summary: Facility Evaluation

raw_content:
Narrative:
On 9/6/24 at 10: AM, Licensing Program Analyst (LPA) Paul Simien conducted an unannounced visit to the above facility. The purpose of this visit was to conduct the required annual inspection. LPA met with Nic Briseno, Administrator, at the above facility to conduct the required annual inspection. LPA completed the staff, client, emergency interventions, operations, and core/therapeutic services sections of the CARE tool. LPA interviewed three staff members. No clients were available to interview. LPA will interview clients on another date. At this time, the inspection is complete. one technical assistance were issued. LPA conducted an exit interview with Nic Briseno, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On 10/30/24 at 11:15am, Licensing Program Analyst (LPA) Celeste Aparicio and LPA Kristin Pierotti conducted an unannounced visit to the listed facility. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs met with Nic Briseno, Facility Administrator and inspected the facility inside and out. LPAs conducted a walk through of the facility, LPAs observed the facility to be clean and in good repair. LPAs reviewed the locked medication and centrally stored medication binders. LPAs observed no deficiencies. LPAs reviewed 1 of child's records and found that parents hold medical and educational rights, therefore, the resident is not a dependent and does not qualify for the inspection. The second resident in the facility has been in placement for less than 30 days, therefore, does not qualify for the inspection. LPAs obtained a client roster, LIC500, and staff schedule. LPAs will discuss with Licensing Program Manager (LPM) to determine if staff file review and interviews are required to complete the inspection and reschedule if needed. LPAs conducted an exit interview with the facility Administrator, whose signature confirms the receipt of this document.

met_with: Administrator Nic Briseno


summary: Facility Evaluation

raw_content:
Narrative:
On 12/02/24 at 10:15am, Licensing Program Analyst (LPA) Celeste Aparicio and LPA Kristin Pierotti made a announced visit to facility Office for the purpose of completing a SB Psychotropic Medications Inspection initially started on 10/30/24 pursuant to Health and Safety Code Section 1538.9 (a)(2). LPAs met with Facility Administrator, Nick Briseno who facilitated the inspection. The facility currently does not have residents in care who meet the SB484 inspection criteria. During the inspection, LPAs reviewed four staff files and conducted one confidential staff interview. LPAs observed no deficiencies. An exit interview was conducted, and a copy of this report was given to Facility Administrator whose signature confirms the receipt of this report.

met_with: Facility Administrator, Nick Briseno


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Monica Pavia met with Steve Duran, to discuss Narcan being administered to a client by another client and administering Narcan without a waiver or prescription. These deficiencies are from several months ago and facility has since been in compliance. Deficiencies cited are 80075(b)(6), 80075(b)(5)(A), Health Related Services and 80024(a), Waivers and Exceptions. Appeal Rights were given and reviewed. This concludes the case management inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On 3/18/26 at 12: PM, Licensing Program Analyst (LPA) Paul Simien conducted an unannounced visit to the above facility. The purpose of this visit was to conduct the required annual inspection. LPA met with Alyssa Widick, Facility Manager (FM) at the above facility to conduct the required annual inspection. LPA reviewed two client files. At this time the inspection is not complete, LPA will return to complete the inspection. No deficiencies were cited at this time. LPA conducted an exit interview with FM

met_with: Alyssa Widick, Facility Manager


facility_name: SANTA MARIA HOME

raw_content:
Narrative:
that some facility staff are aware that specific clients may be using and bringing vape pens into the facility when the contraband is found. Per confidential interviews, staff will make an effort to prevent clients from using vape pens and bringing vape pens into the facility by having regular small group meetings with the clients to address these issues. Confidential interviews reported that if staff were concerned about a specific client and their use of vape pens and bringing vape pens to the facility, then the in-house therapist would be advised to address these issues in therapy. Confidential interviews reported that if a client has shown a history of bringing in contraband or is suspected of bringing in contraband, then facility staff will conduct a search of their room. Confidential interviews reported that vape pens had been found during room searches. Per facility policy, when clients return from leaving without permission and they were recently caught with vape pens or have a history of bringing back vape pens, the staff will search their items such as shoes, dresser drawers, closets, bags, and ask the clients to empty their pockets. In addition, confidential interviews stated that staff would knock on bathroom doors if clients were taking too long in the bathrooms from what the client stated the purpose for them to be in the bathrooms. Confidential interviews also reported that these concerns were addressed in clients' updated needs and service plans. Other confidential interviews reported that when facility staff encounters a client using a vape pen, they address the behavior immediately and confiscate the contraband. Based on inconsistent confidential interviews, the allegation that staff do not prevent minors in care from using nicotine vapes in the facility is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted. A copy of this report and appeal rights were explained and given to Administrator Francine Haynes.

Investigation Findings:
13On 1/11/2024, at 11: AM, Licensing Program Analyst (LPA) Joon Choi conducted an unannounced visit to Santa Maria Home Short Term Residential Treatment Program (STRTP) to deliver the investigative findings for the allegation listed above. On 10/10/2023, LPA Joon Choi conducted a health and safety inspection at the STRTP, and no immediate health and safety hazards were observed. On 12/26/2023, LPA Joon Choi conducted a follow-up visit to the facility to gather additional information. During the investigation, LPA Choi obtained documents pertinent to the investigation and interviewed Clients 1 - 6 (C1-C6) and Staff 1-7 (S1-S7). On 10/05/2023, Community Care Licensing received an allegation that staff (S1-S6) do not prevent minors (C1-C6) in care from using nicotine vapes in the facility. Confidential interviews reported that C1 uses nicotine vaporizers in the facility. Confidential interviews reported that some facility staff have not seen clients bringing vape pens into the facility and using vape pens in the facility. Other confidential interviews reported CONTINUED ON THE NEXT PAGE UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Joon R Choi 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 19-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, MAIN ST., SUITE FACILITY NAME: SANTA MARIA HOMEFACILITY NUMBER: VISIT DATE: 01/11/2024

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

met_with: Francine Haynes, Administrator


raw_content:
Narrative:
**Continued From Previous Page** called them a crybaby. C1 feels bullied and intentionally targeted by S1 who allegedly lies in order to get C1 in trouble. Confidential interviews and documentation review could not confirm or deny that C1 and/or any client was called a crybaby by S1. Confidential interviews and documentation review provided conflicting evidence of bullying occurring in the facility. Confidential interviews and record review could not provide consistent accounts of the alleged incident(s) occurring. Record review revealed staff have been trained to "hand off" the client to another staff to ensure redirection by staff does not result in a client feeling bullied and/or picked on. Confidential interviews could not confirm or dispute this training was used when S1 was working with C1. Confidential interviews and documentation review could not confirm or dispute that staff's behavior poses a risk to minor. Based on confidential interviews and documentation review the preponderance of evidence standard has not been met and the allegations that, staff verbally abuses a minor while in care, staff bullies a minor while in care and staff behavior poses as a risk to a minor, may have happened or are valid, but there is not a preponderance of evidence to prove that the alleged violations occurred. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of the report was provided along with appeal rights to Santa Maria Home STRTP,Tina Carrillo, Facility Coordinator.

Investigation Findings:
UnsubstantiatedEstimated Days of Completion: 90-Days Estimated Days of Completion: 90-Days Estimated Days of Completion: 90-Days

Allegations:
- UnsubstantiatedEstimated Days of Completion: 90-Days Unsubstantiated Estimated Days of Completion: 90-Days Unsubstantiated Estimated Days of Completion: 90-Days

met_with: Tina Carrillo, Facility Coordinator


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
**Continued from Previous Page** occurring at the facility, C1 was taken to the hospital and upon C1's release from the hospital facility staff refused to C1 back into care. Confidential interviews reported consistent statements that confirmed staff did not take C1 back into care. Confidential interviews reported that facility staff met and agreed to deny C1 reintegration to the facility. Further confidential interviews and records review revealed that facility staff did not follow their Program Statement. Based on confidential interviews and records review, the preponderance of evidence standard has been met, and the allegation that Staff (Unknown) refused to take minor, Foster Child (C1) back into care is substantiated. The facility is being cited for violation of Short-Term Residential Treatment Programs, Interim Licensing Standards, (ILS) Version 5, Program Statement 87022.1(d). The facility shall operate in accordance with the terms specified in the plan of operation. An exit interview was conducted, a copy of this report, confidential names report (LIC 811) along with appeal rights were given to Santa Maria Facility Coordinator Lavonta King.

Investigation Findings:
13On May 15, 2025, at 1: PM, Licensing Program Analyst (LPA), Jason Dalton met with Santa Maria Short Term Therapeutic Program (STRTP) Facility Coordinator Lavonta King, to deliver the investigation finding for the above stated allegation. On November 12, LPA Dalton, arrived unannounced to Santa Maria STRTP to initiate an investigation of the above stated allegation. A health and safety inspection was conducted, and no immediate health and safety concerns were observed. The investigation included interviews with eight facility staff members [Staff #1-Staff #6 (S1-S6), one Administrator (Admin), one Facility Coordinator (FC)] and one of two County Social Worker(s) (CSW1). In addition, facility and county records were reviewed. LPA's attempts to interview Foster Child (C1 and C2), County Social Worker 2 (CSW2) and Reporting Party (RP) were unsuccessful. On 11/07/2024, Community Care Licensing received an allegation that Staff (Unknown) refused to take minor, Foster Child (C1) back into care. Specifically, it was reported that after a behavior episode SubstantiatedEstimated Days of Completion: 90-Days SUPERVISORS NAME: Nicole Strickland LICENSING EVALUATOR NAME: Jason Dalton 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 61-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE N CRP RO, MAIN ST., SUITE FACILITY NAME: SANTA MARIA HOMEFACILITY NUMBER: VISIT DATE: 05/15/2025

Allegations:
- SubstantiatedEstimated Days of Completion: 90-Days Estimated Days of Completion: 90-Days Estimated Days of Completion: 90-Days

met_with: Facility Coordinator Lavonta King

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
staff do not prevent minors from having access to smoking products in the facility, staff do not ensure minor receives assistance with health care needs, staff do not ensure medications are dispensed as prescribed, and licensee does not ensure minor is enrolled and attending an educational program. It was specially alleged that staff speak to C1 inappropriately and try to put religion on C1, staff allow C1 to be picked on by other clients and staff say negative things about C1, staff do not ensure that clients do not use smoking products, staff is not ensuring C1 is treated for C1's mental health care needs, staff were not administering C1's medications as prescribed, and facility staff did not ensure that C1 was enrolled in school. Confidential witness statements revealed that staff did not speak to C1 in an inappropriate manner or put religion on C1. Furthermore, LPA was informed that C1 would speak to staff inappropriately at times. Also, disclosed to LPA was that C1 was religious and would ask staff questions regarding religion but staff did not put or force religion on C1. Another confidential witness informed LPA that staff would speak to C1 inappropriately and put religion on C1. Regarding the allegation that staff do not ensure that C1 was treated with dignity and respect by other clients and staff, confidential witnesses denied that occurred. LPA was provided with consistent statements that staff assured that C1 was not picked on by other clients and staff did not speak negatively regarding C1. Furthermore, LPA was informed that staff didn't allow C1 to be bullied. LPA was informed that C1 would act out and make other clients uncomfortable. Other confidential witnesses informed LPA that C1 was not treated respectfully by staff and staff would not always address when C1 was bullied. In reference to the allegation that staff do not ensure that clients do not use smoking products, confidential witnesses informed LPA that some clients placed at the facility smoked but staff did not allow it. Furthermore, LPA was informed that if staff found or suspected that a client was under the influence staff addressed it immediately and would write the client up and speak to the client about the negatives of smoking. Another confidential witness informed LPA that when some staff observed smoking devices, they would not confiscate the devices and allow clients to keep them. (...) Referring to the allegation that staff do not ensure minor receives assistance with health care needs, confidential witnesses informed LPA that C1 was seen by medical providers and provided with mental health treatment. Additionally, LPA was informed that all clients received therapy. Additional confidential witnesses informed LPA that though the clients received therapy at the facility they felt as though the therapist did not address the clients' mental health needs and clients needed more mental health treatment than they were provided. Pertaining to the allegation that staff were not administering C1's medications as prescribed. Confidential witnesses informed LPA that all clients that took medication were administered their medication appropriately. Additionally, LPA was informed that C1 did not arrive at the STRTP with medication and was taken to see medical professionals but was not prescribed medication. LPA received other information that staff were aware of C1's need to take medication but C1 did not have medication available. Concerning the allegation that licensee does not ensure minor was enrolled and attending an educational program, confidential witnesses informed LPA that C1 was enrolled in school but often refused school. Furthermore, LPA was informed that when clients refuse school, staff would encourage them not to refuse and attend school. Additionally, LPA was informed that there was confusion as to which grade C1 was in which delayed C1's school enrollment. An additional confidential witness informed LPA that when clients refused school staff did not encourage them to attend and allowed them to miss school. LPA received conflicting information regarding all allegations. Based on confidential interviews the allegations staff do not speak to C1 in an appropriate manner, licensee does not ensure C1 is treated with dignity and respect from staff and peers in the facility, staff do not prevent minors from having access to smoking products in the facility, staff do not ensure C1 receives assistance with health care needs, staff were not administering C1's medications as prescribed, and licensee does not ensure C1 is enrolled and attending an educational program, may have occurred, however, they are not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Courtney Brandon.

Investigation Findings:
13On October 16, 2025, at 12: PM Licensing Program Analyst (LPA) Michael Almaraz met with Santa Maria Home Short Term Residential Therapeutic Program (STRTP) Administrator, Courtney Brandon, to issue the finding for the above allegations involving client (C1) listed on the confidential names list (LIC 811) dated October 16, 2025. The complaint was jointly conducted by LPA Almaraz and LPA Jason Dalton. On January 21, 2025, at 8: AM LPA Dalton conducted a safety inspection of the facility, and no immediate health and safety hazards were observed. Furthermore, LPA Dalton conducted seven staff (S1, S2, S3, S4, S5, S6, S8) interviews, one county worker (CSW) interview, and five clients (C1, C2, C4, C5, C6) interviews. During the investigation LPA Almaraz interviewed six clients (C1, C2, C4, C5, C6, C7) and one staff (S9). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Michael Almaraz 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 61-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE N CRP RO, MAIN ST., SUITE FACILITY NAME: SANTA MARIA HOMEFACILITY NUMBER: VISIT DATE: 10/16/2025

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

met_with: Courtney Brandon


summary: Facility Evaluation

raw_content:
Narrative:
On 02/22/2021 at 1: PM, Licensing Program Analyst Cheraki Davis conducted a SB Psychotropic Medication tele-inspection and met with Francine Haynes, Facility Administrator. The tele-inspection was conducted via facetime due to COVID-19. A virtual health and safety inspection were conducted. All files and medication documents were sent to LPA Davis on dates prior to inspection. A medication count was also conducted via video conference on this date. LPA reviewed three client records and reviewed two staff records for the facility. LPA began two staff interviews via facetime at 1: PM. LPA interviewed three children currently taking psychotropic medication via facetime at 1: PM. No deficiencies being cited at this time. An Advisory Note for Technical Violation LIC 9102TV was provided to Ms. Haynes. LPA conducted an exit interview with Francine Haynes, Facility Administrator at 2: PM. LPA emailed the LIC809 & LIC811 to Francine Haynes, Facility Administrator upon completion with a request for signature for the LIC809. Original signed copies will be placed in the facility file.

met_with: Francine Haynes


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
An unannounced annual inspection was conducted by Licensing Program Analyst (LPA) Val Wilson, Licensing Program Analyst (LPA) Lorena Valenzuela, and Licensing Program Manager (LPM) Christina Barnes, on 11/08/2021 at 9:00am, at Santa Maria Home Short Term Residential Therapeutic Program (STRTP). Prior to the visit the facility file was reviewed for annual fees due and no annual fees are past due. Upon arrival, LPAs and LPM met with Facility Administrator, Francine Haynes, who led a tour of the facility. The home is a one story residence with three bedrooms and three bathrooms. LPAs and LPM toured the inside and outside of the facility at 10:15am. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. Bedroom #1 has a wall puncture and an unfinished repair to the ceiling. Bedroom #3 had water damage to the ceiling. There is adequate shelf and closet space for client's belongings. The bathrooms were in good repair. The hot water in the client bathrooms was measured to be 106* F bathroom #1 and 105.5*F bathroom #2. Facility walls need an overall cleaning/painting due to LPA's and LPM observing paint chips and the walls being dirty with foreign matter smeared. The therapist office behind the garage has a broken window Cleansers/chemicals are locked and stored in laundry area and storage room in the garage. Chemicals were also found in the food pantry. Sharp knives are inaccessible and stored in a locked box in a locked cabinet in the staff office. The facility's Smoke and Carbon Monoxide Detectors were checked and were operable. There are no guns or weapons in the facility as stated by Administrator. LPAs and LPM observed facility posted items in the kitchen area that included: Child's Personal Rights, Emergency Disaster Plan, and Foster Care Ombudsman poster. Clients medications were observed to be inaccessible and stored in a locked file cabinet within a locked cabinet in the staff office. LPAs observed a minimum 7-day non-perishable and a 2-day perishable supply of food. However, snacks are locked in a cabinet inaccessible to clients. During the inspection, there was one client present. Refer to LIC 809C for the continuation of this report. Based on the facility inspection, observation, the LPAs observed paint chips and the walls dirty with foreign matter smeared. The facility is cited under Title 22, Division 6, Chapter 1, Article 06, Section 80087(a) Buildings and Grounds. Based on the facility inspection, observation, documents, and interviews, LPAs obtained unsigned, incomplete, required Board Meeting Minutes. LPA observed that the minutes did not reflect there was a review and discussion of the documents required per the Health and Safety Code 1520.1(f). The facility will be cited under STRTP Interim Licensing Standards, Version 4, Section 87063(a)(9) Accountability. Based on the facility inspection and interviews, the facility did not ensure monthly logs of each manual restraint use was documented as required. The facility will be cited under STRTP Interim Licensing Standards, Version 4, Section 87095.61(f) Documentation and Reporting Requirements. Due to time constraints, LPAs will return to complete the staff and children's record review at a later time. Exit interview conducted. A copy of this report LIC 809Ds and LIC9102TA was provided to Administrator, Francine Haynes. Appeal rights were provided. The facility outside grounds was also inspected. LPAs observed boards missing in the backyard wooden fence. In addition, multiple wood boards and plywood were observed to be leaning at the side of the home near the backyard gate. Emergency exits were free from obstruction. Facility Administrator was unable to provide signed Board Meeting Minutes for the past year. LPAs interviewed 2 staff on cite. Based on the facility inspection, observation, and interviews Chemicals were observed by the LPAs in the food pantry by the therapist office. The facility will be cited under Title 22, Division 6, Chapter 1, Article 06, Section 80076(a)(16) Food Service. Based on the facility inspection, observation, and interviews, snacks were not accessible to the children in care. The facility will be cited under Title 22, Division 6, Chapter 1, Article 06, Section 80076(a)(4) Food Service. Based on the facility inspection and observation, LPAs observed boards missing from the wooden backyard fence. The facility will be cited under STRTP Interim Licensing Standards, Version 4, Section 87087.2(a)(4)(A) Outdoor Activity Space. Based on the facility inspection, observation, and interviews, LPAs observed punctures in walls, water damage to the ceiling, and facility walls need an overall cleaning/painting. The facility will be cited under Title 22, Division 6, Chapter 1, Article 06, Section 80087(a) Buildings and Grounds. Based on the facility inspection and observation, LPAs observed one window broken in the Therapists office. The facility is cited under Title 22, Division 6, Chapter 1, Article 06, Section 80087(a) Buildings and Grounds. Refer to LIC 809C for the continuation of this report.

Deficiencies:
87095.61(f): Documentation and Reporting Requirements

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

met_with: Facility Administrator, Francine Haynes


summary: Facility Evaluation

raw_content:
Narrative:
On November 9, 2021, at 11: AM, Licensing Program Analyst (LPA) Val Wilson, Licensing Program Analyst (LPA) Lorena Valenzuela, arrived at Santa Maria Home Short-Term Residential Therapeutic Program (STRTP). The purpose of the inspection was to complete the continuation inspection for STRTP annual inspection that was initiated on November 8, 2021. LPAs already completed the physical inspection of the facility on the first day of the annual inspection. The LPAs met with Facility Administrator, Francine Haynes, and Program Administrator, Denise Samano, and on the telephone Executive Director Larnel Jackson, PsychD. During this annual inspection continuation, LPAs reviewed ten personnel files to ensure they contained all required documentation per Title Regulations and Interim Licensing Standards (ILS). Personnel Files are maintained at the main office. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Eight of ten personnel files did not meet the annual training requirement for 2020. LPAs observed the training records for 2021 may not meet the training requirements. LPAs discussed that the Administrator is to ensure that the annual training requirements are met for 2021, which state all direct care staff shall complete a minimum of 40 hours annual training. Additionally, it could not be determined that staff 2 (S2) meets the direct staff personnel requirements based on education records and job history on file. Furthermore, four out of ten personnel records did not have valid CPR and first aid cards. Lastly, based on interviews, staff 3 (S3) and staff 4 (S4) are the designated Facility Managers. Based on training records review of S3 and S4, LPAs observed they did not meet the regulation training requirements. Based on the records review and interview, LPAs observed of S3 and S4 did not have the required training documentation needed to assume the role of a facility manager. The facility will be cited under STRTP Interim Licensing Standards, Version 4, Section 87065(f)(2) Personnel Requirements. Refer to LIC 809C for the continuation of this report. Based on the records review and interview, LPAs observed one of ten staff did not meet the direct staff personnel requirements based on education records and job history on file. The facility will be cited under STRTP Interim Licensing Standards, Version 4, Section 87065(g)(1)(A) Personnel Requirements. Based on the records review and interview, LPAs observed four of ten staff did not have a current and valid CPR and/or first aid cards. The facility will be cited under STRTP Interim Licensing Standards, Version 4, Section 87065.1(c)(6)(A) Training Requirements. Based on the records review and interview, LPAs observed eight of ten staff did not complete a minimum of 40 hours of annual training. The facility will be cited under STRTP Interim Licensing Standards, Version 4, Section 87065.1(d)(1) Training Requirements. Exit interview conducted. A copy of this report LIC809Ds and a copy of the appeal rights was provided to Administrator, Francine Haynes. Due to time constraints, LPAs will return at a later time to conduct a review of client records.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On November 18, 2021, at 09: AM, Licensing Program Analyst (LPA) Val Wilson, Licensing Program Analyst (LPA) Lorena Valenzuela, arrived at Santa Maria Home Short-Term Residential Therapeutic Program (STRTP). The purpose of the inspection was to complete the continuation inspection for STRTP annual inspection that was initiated on November 8, 2021. LPAs already completed the physical inspection of the facility on the first day of the annual inspection. The LPAs met with Facility Administrator, Francine Haynes, and Program Administrator, Denise Samano on the telephone. During this annual inspection continuation, LPAs reviewed five of five client files (Client 1- C1; Client 2- C2; Client 3- C3; Client 4- C4; Client 5-C5) to ensure they contained all required documentation per Title Regulations and Interim Licensing Standards (ILS). Client Files are maintained in the home and at the main office. There was five children present at the facility. LPAs conducted two children interviews, C1 and C4, the other three children refused to be interviewed, C2, C3, and C5. Based on the records review and interview, LPAs observed they did not meet the regulation and requirements.LPA's observed signed Copies of Child's removal/discharge and or transfer policies and procedures for C1, C2, C3, C4, and C5 are on file but did not reflect STRTP regulation standard and need to be updated. Additionally, discipline policy is not written to reflect STRTP regulation, including the facilities Emergency Intervention Plan not matching the facilities current crisis intervention program. Client's record for C1, C2, C3, and C5 do not document Tuberculosis results within 72 hours of the test. Client's cash record for C1, C2, C3, C4, and C5 did not include income, disbursement, balance, and receipts maintained in chronological order. Refer to LIC 809C for the continuation of this report. Based on Client's record and interviews allowance resources were taken in the form of fines by the facility for C1, C3, and C5 when there was property damage or loss made by the client. In addition, documentation of bedroom arrangement compatibility for C1, C2, C3, C4, and C5 are not maintained in the child's record. LPAs observed the Needs and Services Plan did not include educational needs and or goals for C1, C3, C4, and C5. LPA's also observed the Needs and Services Plan did not include money management needs and or goals, including maximum amount of money permitted in Client's possession at any one time for C1, C2, C3, C4, and C5. Lastly, the Needs and Services Plan for C1, C2, C3, C4, and C5's Client record did not include Needs and Services Plans updated at least every 30 days. Based on the records review and interview, signed copies of Child's removal/discharge and or transfer policies and procedures for C1, C2, C3, C4, and C5 are on file but did not reflect STRTP regulation and need to be updated. In addition, discipline policy is not written to reflect STRTP regulation, including the facilities Emergency Intervention Plan not matching the facilities current crisis intervention program. The facility will be cited under STRTP Interim Licensing Standards, Version 4, Section 87070(c)(2) Children's Records. Based on the records review and interview, client's record for C1, C2, C3, and C5 do not document Tuberculosis results within 72 hours of the test. The facility will be cited under Title 22, Division 6, Chapter 1, Article 06, Section 80069(c)(1) Client Medical Assessments. Based on the records review and interview, client's cash record for C1, C2, C3, C4, and C5 did not include income, disbursement, balance, and receipts maintained in chronological order. The facility will be cited under Title 22, Division 6, Chapter 1, Article 06, Section 80026(h)(1) Safeguards for Cash Resources, Personal Property, and Valuables. Refer to LIC 809C for the continuation of this report. Based on the records review and interview, client's record noted allowance resources were taken in the form of fines for C1, C3, and C5 on at least one occasion. The facility will be cited under STRTP Interim Licensing Standards, Version 4, Section 87026(c) Safeguards for Cash Resources, Personal Property, and Valuables. Based on the records review and interview, LPAs observed documentation of bedroom arrangement compatibility for C1, C2, C3, C4, and C5 are not maintained in the child's record. The facility will be cited under STRTP Interim Licensing Standards, Version 4, Section 87087(e) Buildings and Grounds. Based on the records review and interview, the Needs and Services Plan did not include educational needs and or goals for C1, C3, C4, and C5. The facility will be cited under STRTP Interim Licensing Standards, Version 4, Section 87068.2(b)(2) Needs and Services Plan. Based on the records review and interview, LPAs observed the Needs and Services Plan did not include money management needs and or goals, including maximum amount of money permitted in Client's possession at any one time for C1, C C3, C4, and C5. The facility will be cited under STRTP Interim Licensing Standards, Version 4, Section 87068.2(b)(5) Needs and Services Plan Based on the records review and interview, LPAs observed the Needs and Services Plan for C1, C2, C3, C4, and C5's Client record did not include Needs and Services Plans updated at least every 30 days. The facility will be cited under STRTP Interim Licensing Standards, Version 4, Section 87068.3(a) Modifications to The Needs And Services Plan. An LIC9102TA Technical Assistance was provided regarding ensuring the facility is planning and implementing activities with the children that meets their needs and includes the client's input. Exit interview conducted. A copy of this report LIC 809Ds, Appeal Rights, and LIC9102TA was provided to Administrator, Francine Haynes.

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

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


summary: Facility Evaluation

raw_content:
Narrative:
On December 8, 2021, Licensing Program Analyst's (LPA's) Lorena Valenzuela and Val Wilson arrived at Santa Maria Home and met with the Short-Term Residential Treatment Program (STRTP) Direct Care Staff, Sandra Alonzo. The Facility Administrator, Francine Haynes, arrived to the home around 3:15PM. The purpose of this case management is to discuss information received during a review of an incident that occurred at the facility. LPA's gathered additional information and obtained facility records. A copy of the LIC 809 was provided to Francine Haynes.

met_with: Francine Haynes, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On April 15, 2022, Licensing Program Analyst's (LPA) Lorena Valenzuela and Joon Choi arrived at Santa Maria Home and met with the Short-Term Residential Treatment Program (STRTP) Administrator Francine Haynes regarding an incident report received 03/05/2022 at Community Care Licensing (CCL). LPA's interviewed staff and child as listed on the Confidential Names List Form (LIC 811) dated 04/15/2022. LPA obtained client and staff records. A copy of the LIC 809 was provided to Francine Haynes.

met_with: Francyne Haynes, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On May 6, 2022, Licensing Program Analyst (LPA) Lorena Valenzuela and LPA Joon Choi arrived at Santa Maria Short-Term Residential Therapeutic Program (STRTP) to conduct a Plan of Correction (POC) follow up visit to determine compliance with a plan of correction (POC) plan for the deficiency cited on 05/03/2022. LPA's met with Administrator Francine Haynes. On 05/03/2022, the facility was cited for Interim Licensing Standards (ILS) Short-Term Residential Therapeutic Program (STRTP), Version 4, Section 87065.1 (a)(1) (c) Supervision, Evaluation and Training Requirements, due to the STRTP not ensuring staff have training in matters of emergency medical responses and recognizing the effects of drugs and/or medication on children. Based on observations and interviews, the POC plan where the facility was to have submitted a written plan to LPA Valenzuela on due date 5/4/2022 before 5pm, has not been completed. The facility is being assessed daily civil penalties, until the agreed POC is submitted to the Department, due to the correction not being completed by due date of 05/04/2022. A copy of this report, appeal rights and LIC 421FC was provided and discussed with Francine Haynes.


summary: Facility Evaluation

raw_content:
Narrative:
On May 19, 2022, Licensing Program Analyst (LPA) Lorena Valenzuela and LPA Joon Choi arrived at Santa Maria Short-Term Residential Therapeutic Program (STRTP) to conduct a follow up visit to the Plan of Correction (POC) visit conducted on 05/06/2022. LPA's met with Gregory Johnson, Head of Service. On 05/03/2022, the facility was cited for Interim Licensing Standards (ILS) Short-Term Residential Therapeutic Program (STRTP), Version 4, Section 87065.1 (a)(1) (c) Supervision, Evaluation and Training Requirements, due to the STRTP not ensuring staff have training in matters of emergency medical responses and recognizing the effects of drugs and/or medication on children. On 05/03/2022, the facility agreed to a plan of correction and due date of 05/04/2022. Since 05/06/2022, the facility began accruing daily civil penalties due to not submitting a plan of correction to LPA Valenzuela by the due date. On 05/11/2022, the facility contacted LPA Valenzuela and submitted the agreed upon plan of correction. The facility's daily civil penalty accrual shall cease as of 05/11/2022. A copy of this report, appeal rights and LIC 421FC was provided and discussed with Gregory Johnson, Head of Service..

met_with: Gregory V. Johnson, Head of Service LMFT


summary: Facility Evaluation

raw_content:
Narrative:
On December,5st 2022 at 9: AM, Licensing Program Analysts (LPA) Jessica Peete conducted an unannounced annual inspection at Santa Maria Home Short Term Residential Therapeutic Program (STRTP). LPA was met at by Administrator Francine Haynes and Facility Manager Carson Brooks. LPA began a physical plant inspection at 9: AM assisted by the Facility Manager and Administrator. The physical plant inspection included the following checks: The facilities kitchen, dining area, refrigerator/freezers, food storage areas, garage, living room, family room, staff office, therapy office, two client bathrooms and three client bedrooms (B1,B2,B3). Bedrooms are arranged so that no more than two clients are in a room, and there is one client per bed. Each client room has the appropriate linens, pillows, comforters, and mattresses are in good repair. Extra linens are stored in the hall closet. Additionally, there is adequate drawer space for each client's belongings. Cleansers, chemicals, and cooking knives are inaccessible to clients. Cleaners and chemicals are locked in a cabinet in the laundry room and in bathroom two. The cooking knives are locked inside of the staff office. Licensee maintains an adequate supply of food and a variety of snacks for clients. LPA observed a minimum seven day non-perishable and a two day perishable supply of food. Additionally, LPA observed the following postings: facility license, grievance procedures, personal rights, Ombudsman poster, visitation policies, and current menu. Age appropriate toys, games and books were observed for client's recreation time. The facility's outside grounds (front yard, backyard) were also inspected and were found to be clean, well maintained, and free of observable hazards. There is adequate indoor and outdoor activity space; all exits, and walkways were free from obstruction. Per Administrator there are no guns or weapons on facility grounds. The hot water in each client bathroom measured within 105-120 degrees Fahrenheit. (Continued on LIC C) The facility has an operable carbon monoxide detector located in the hallway and smoke detectors are located throughout the facility. Fire extinguishers are properly charged, serviced, and located in the kitchen and staff office. The medications are centrally stored in the staff office inside of a locked cabinet. The First Aid Kit is complete and kept in the kitchen. The washer and dryer are located inside of the facility next to the kitchen and accessible to clients with staff assistance. Per Administrator's statement clients are supervised while they do their own laundry and LPA observed detergents are kept locked in a cabinet. At 9: AM LPA observed the licensee was not in compliance with California Code of Regulations (CCR) 80088(f)(1) ...All containers, including movable bins, used for storage of solid wastes shall have tight-fitting covers kept on the containers; shall be in good repair, shall be leakproof and rodent-proof. Trash cans were observed, without lids, in B1, B2 and B3. At 10: AM LPA began review of the Operational Requirements and Emergency Interventions, assisted by the Administrator and Facility Manager, all the documentation pertaining to this area of the inspection was provided, and no deficiencies were noted. The facility has one vehicle used to transport clients to appointments and recreational activities. At 11: AM LPA observed multiple rips and tears in the vehicle's upholstery; placing the facility out of compliance with CCR 80074(c) Motor vehicles used to transport clients shall be maintained in a safe operating condition. At 11: AM , assisted by the Administrator and Facility Manager, LPA began review of the facilities Disaster Preparedness. The licensees Disaster Plan did not have procedures regarding the storage and perseveration of medication; placing the facility out of compliance with Health and Safety Code( HSC) 1565(a)(7)(E). A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (7) Procedures that address, but are not limited to, all of the following: (E) Storage and preservation of medications, including the storage of medications that require refrigeration. At 11: AM LPA observed the Disaster Preparedness Plan did not have documentation of the annual training provided to staff regarding staff responsibilities during an emergency or disaster. The facility is not in compliance with HSC 1565(b) If a facility employs staff, the facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster. (Continued on LIC C) At 12: PM, assisted by the Administrator and Facility Manager , LPA began review of five staff files (S1-S5). At 1: PM LPA observed the licensee was not in compliance with Interim Licensing Standards (ILS) 87065.1(e)(1) ... all direct care staff shall complete a minimum of 40 hours of annual training... S1 had 21.5 of the required 40 hours of annual training. Based on observations made during the inspection, see LIC D, deficiencies are being cited. Due to time constraints, LPA will return to complete the inspection at a later date. An exit interview was conducted, and a copy of this report and appeal rights was provided to Facility Manager Carson Brooks.

met_with: Administrator Francine Haynes, Facility Manager Carson Brooks


summary: Facility Evaluation

raw_content:
Narrative:
On December, 6 2022 at 9: AM, Licensing Program Analyst (LPA) Jessica Peete conducted an unannounced Annual Continuation visit at Santa Maria Home Short Term Residential Therapeutic Program (STRTP). LPA was met at by Administrator Francine Haynes LPA Peete visited the facility on 12/05/2022 to complete inspection of the Physical Plant, Disaster Preparedness, Operational Requirements, and Emergency Interventions. At 9: AM, assisted by the Administrator, LPA began the review of five client files and (C1-C5). Based on record review the licensee did not comply with the Interim Licensing Standards(ILS) 87087(e) In every situation where children share a bedroom, the licensee shall document that the bedroom sharing arrangement ensures the health and safety of each child and that the children are compatible... This documentation shall be maintained in the child's record. The licensee did not have documented bedroom sharing arrangements for C1,C4 and C5. At 12: PM LPA began review of Core Therapeutic Services. All the documentation pertaining to this area of the inspection was provided, and no deficiencies were noted. LPA conducted two staff interviews (S4, S5) and one client interview (C5). At the time of today's inspection, no other clients were on facility grounds. Based on observations made during the inspection, see LIC D, deficiencies are being cited. An exit interview was conducted, and a copy of this report and appeal rights was provided to Administrator Francine Haynes.

met_with: Administrator Francine Haynes


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst's (LPA's) Leslie Covarrubias, Sarah Lo, and Jose Gonzalez on August 20, 2024 at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Covarrubias, Lo, and Gonzalez met with Administrator, Courtney Brandon and inspected the facility inside and out. LPA's reviewed three of child's records and three of staff personnel files on site at the facility. LPA's reviewed three of child's psychotropic medications and medication records. LPA's interviewed three of staff on site to discuss the facilities policies and procedures of operation. LPA's interviewed zero of children currently prescribed psychotropic medication. LPA's will conduct interviews at schools. LPA provided a copy of this licensing report to Administrator, Courtney Brandon. No deficiencies are being cited at this time. LPA conducted exit interview with Administrator, Courtney Brandon.

met_with: Administrator, Courtney Brandon


summary: Facility Evaluation

raw_content:
Narrative:
On November 19, 2024, at 2: PM, Licensing Program Analysts (LPA) Jason Dalton conducted an unannounced annual inspection at Santa Maria Home Short Term Residential Therapeutic Program (STRTP). LPA was met at by Administrator Courtney Brandon. LPA began a physical plant inspection at 2: PM assisted by the Administrator. The physical plant inspection included the following checks: The facilities kitchen, dining area, refrigerator/freezers, food storage areas, garage, living room, family room, staff office, therapy office, two client bathrooms and three client bedrooms (B1,B2,B3). Bedrooms are arranged so that no more than two clients are in a room, and there is one client per bed. Each client room has the appropriate linens, pillows, comforters, and mattresses are in good repair. Extra linens are stored in the hall closet. Additionally, there is adequate drawer space for each client's belongings. Cleansers, chemicals, and cooking knives are inaccessible to clients. Cleaners and chemicals are locked in a cabinet in the laundry room and in bathroom two. The cooking knives are locked inside of the staff office. Licensee maintains an adequate supply of food and a variety of snacks for clients. LPA observed a minimum seven-day non-perishable and a two-day perishable supply of food. Additionally, LPA observed the following postings: facility license, grievance procedures, personal rights, Ombudsman poster, visitation policies, and current menu. Age-appropriate toys, games and books were observed for client's recreation time. The outside grounds of the facility (front yard, backyard) were also inspected and were found to be clean, well maintained, and free of observable hazards. There is adequate indoor and outdoor activity space; all exits, and walkways were free from obstruction. Per Administrator there are no guns or weapons on facility grounds. The hot water in each client bathroom measured within 105-120 degrees Fahrenheit. Client bathroom 1 measured 117 degrees and client bathroom 2 measured 115 degrees. The facility has operable carbon monoxide detectors located in the hallway and operable smoke detectors are located throughout the facility. Fire extinguishers are properly charged, serviced, and located in the kitchen **** **Continued From Previous Page** and staff office. The medications are centrally stored in the staff office inside of a locked cabinet. The First Aid Kits are complete and kept in the kitchen and the office. The washer and dryer are located inside of the facility next to the kitchen and accessible to clients with staff assistance. Per Administrator's statement clients are supervised while they do their own laundry and LPA observed detergents are kept locked in a cabinet. The facility has one vehicle used to transport clients to appointments and recreational activities. At 3: PM LPA observed the vehicle to be in good repair and in a safe drivable condition. Due to time constraints, LPA will return to complete the inspection at a later date. An exit interview was conducted, and a copy of this report and appeal rights was provided to Administrator Courtney Brandon.

met_with: Administrator Courtney Brandon


summary: Facility Evaluation

raw_content:
Narrative:
On December 3, 2024, Licensing Program Analyst (LPA) Jason Dalton arrived at Santa Maria Home Short-Term Residential Therapeutic Program (STRTP). The purpose of the inspection was to complete the continuation inspection for STRTP annual inspection that was initiated on 11/19/2024. LPA already completed the physical inspection of the facility on the first day of the annual inspection. Licensee has a current Mental Health Program Approval which expires on August 16, 2025. Licensee has obtained their National Accreditation through Commission on Accreditation of Rehabilitation Facilities (CARF). The Accreditation is currently valid through 12/31/2025. Licensing fee payments have been paid and there is currently a balance of $0. During this annual inspection continuation, LPA reviewed six personnel files to ensure they contained all required documentation per Title Regulations and Interim Licensing Standards (ILS). See Confidential Names List (LIC 811) dated 12/03/2024. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. LPA reviewed the Personnel Report (LIC 500) and work schedules to ensure appropriate staffing ratios. Administrator, Courtney Brandon is present at the facility a minimum of 20 hours a week, as verified by staff work schedule. Appropriate staff/client ratios were verified during this inspection. During Staff interviews Staff were able to provide sufficient information in relation to the facility's STRTP Program Statement, clients' Needs and Services plan, and Trauma- Informed care. The clients interviewed were able to provide sufficient information regarding food services, allowance, and telephone privileges, relationships with staff, daily schedule activities and visitation. An exit interview was conducted and a copy of this report, LIC 811 and appeal rights were provided to Executive Director Tina Collins.

met_with: Executive Director, Tina Collins


summary: Facility Evaluation

raw_content:
Narrative:
On December 4, 2025, Licensing Program Analyst (LPA) Raina Perez-Diaz arrived at Santa Maria Home and met with the Short-Term Residential Treatment Program (STRTP) Facility Coordinator, Lavonta King. The purpose of this case management is to discuss information received during a review of an incident that occurred at the facility. LPA gathered additional information and obtained facility records. A copy of the LIC 809 was provided to Facility Coordinator, Lavonta King.

met_with: Facility Coordinator- Lavonta King


summary: Facility Evaluation

raw_content:
Narrative:
On November 13, 2025, at 02: PM, Licensing Program Analyst (LPA) Raina Perez-Diaz arrived unannounced to East Valley Charlee Santa Maria Home, Short Term Therapeutic Program (STRTP) and met with Facility Coordinator- Lavonta King, to initiate a case management- deficiency. Community Care Licensing (CCL) obtained information from a Serious Incident Report (SIR) dated October 28, 2025, that Client #1 (C1) was not reported as a runaway to law enforcement after absconding from school grounds earlier in the day. Record review indicated C1 was away from the facility and his whereabouts were unknown for six hours. Additional record review revealed, the facilities program statement indicates a client is required to be reported to law enforcement after a two hour wait period. Therefore, the facility is being cited for violation of California Code of Regulations (CCR) PLAN OF OPERATION 80022 (k) The facility shall operate in accordance with the terms specified in the Plan of Operation and may be cited for not doing so. A copy of this report LIC- 811 and 809-D was provided to Facility Coordinator- Lavonta King.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 05/03/2022, Licensing Program Analyst (LPA) Joon Choi and Lorena Valenzuela met with Santa Maria Short Term Residential Therapeutic Program (STRTP) Administrator Francine Haynes. The purpose of this case management is to discuss information received during a review of an incident that occurred at the facility. The incident involved Child #1 (C1). See Confidential Names List form (LIC 811) dated 05/03/2022. On 04/15/2022, LPA Valenzuela conducted a review of facility records and conducted interviews. Interviews conducted revealed that on 03/05/2022, Child #1, ingested a non-prescribed medication. Interviews revealed it is unknown how C1 obtained the non prescribed medication. Per interviews and records review, on 03/05/2022, at 6:20pm, C1 had "convulsion like actions" and "was unable to speak to staff". Interviews and records revealed Staff #1 (S1) called the facility Administrator at 6:22 pm to speak with administrator regarding C1's condition. Per records review, at 6:24 pm, facility staff called 911 for C1's medical emergency. Interviews and records review indicate staff have not received training on medical emergency response procedures or topics related to the effects of medications on children. Based on interviews and records, the Department has determined there is a preponderance of evidence the facility did not ensure that direct care staff have appropriate skills to protect the health and safety of Child #1. The facility is cited for violation of the Interim Licensing Standards (ILS), Version 4, Section 87065.1 (a) (1) (C) Supervision, Evaluation and Training Requirements. An exit interview was conducted where the citation and plan of corrections were discussed. A copy of this report, LIC 809-D, LIC 811 and appeal rights was provided to Francine Haynes.

Deficiencies:
87065.1: Provide staff with the knowledge, skills, and support to ensure the health and safety of children in care and meet the individualized needs of children and families served.1
2
3
4
5
6
7Administrator Francine Haynes agrees to ensure an outside trainer provides training to all staff in the matters of proper emergency medical response is, as well as recognizing the effects of drugs and / or prescription medication on children. Administrator Francine Haynes agrees to provide to LPA Valenzuela, a written plan by 5/4/2022 before 5pm.
8
9
10
11
12
13
14

met_with: Francine Haynes, Adminsitrator

title:
(a)(1) (C) SUPERVISION, EVALUATION AND TRAINING REQUIREMENTS. The licensee shall develop, maintain and implement a written plan for the
supervision, evaluation, and training of staff that meets the requirements of this section... the plan shall do all of the following