summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by LPA (Licensing Program Analyst) Reyna Martinez. LPA met with Candice Fulmer, Direct Care Staff and inspected the facility, inside and out. Facility Grounds are clean and free of debris or observable hazards. Adequate indoor and outdoor activity space and materials observed. Centrally stored medications are maintained in a locked closet in a locked cabinet. Sharps and Toxic chemicals are kept locked. The facility has a written emergency disaster plan. All facility smoke detectors were tested and appear to be in appropriate working order, fire extinguisher is properly charged and was last serviced July 2023. The facility is working on their accreditation with CARF and will keep CCL updated on this matter. MHPA was given an extended six months provisional to January 2, 2024 by CCL. The facility will keep CCL updated on final status. The house has 2 client bedrooms, one single occupancy and one double occupancy. Individual beds were observed with appropriate clean linens. There is at least one-week supply of nonperishable and a two-day supply of perishable foods. The facility is maintained at 75 degrees. Hot water temperature measures 110 degrees. Facility has no cameras in the facility. No firearms or weapons are allowed in the facility. Facility has a pool that is fenced with a self latching device and compliant with regulations. Appropriate staff/client ratios were verified during this inspection. The facility employs 1 administrator, 1 facility manager, and 10 direct care staff. -Continued on LIC809-C. Personnel Files are maintained at the main office. 5 staff files were reviewed. 1 staff was available to be interviewed. 3 records of clients were reviewed and 1 client was available to be interviewed. 1 client is on a 52/50 status and 1 client refused to speak with LPA. A review of Licensing Information System on July 18, 2023, indicates that all facility staff associated to the STRTP have DOJ, FBI, and child abuse index clearances. No deficiencies are being issued today. A copy of this report and appeal rights were discussed and left with the STRTP.

met_with: Candice Fulmer


state: CA

facility_name: MANUCH INC-RIVERPINE

summary: Facility Evaluation

raw_content:
Narrative:
On this date, Licensing Program Analysts (LPAs) Miriam Flores and Briana Placencia conducted a case management visit at the STRTP and met with Administrator, Levon Manucharyan. Incidents reports submitted to the Department on 5/24/24 were discussed and reviewed during this inspection. Technical Advisory was issued and discussed. An exit interview was conducted and a copy of this report was provided to Administrator, Levon Manucharyan.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Levon Manucharyan


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, An unannounced annual inspection was conducted by Licensing Program Analysts (LPAs), Miriam Flores and Briana Placencia at Manuch Inc-Riverpine STRTP in Fresno, CA. LPAs met with Administrator, Levon Manucharyan. A physical plant inspection was conducted and included the following checks. Facility grounds are clean and free of debris. Adequate indoor and outdoor activity space and materials observed. The facility is maintained at 72 degrees. Facility maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. 2 clients require medications currently, facility has the ability to keep Medications locked and centrally stored. Individual beds were observed with appropriate clean linens and are in good repair. Facility is CARF accredited until August 31,2025 and approved through the Department of Behavioral Health through January 16, 2025. Two technical advisors were discussed during this inspection. Facility was cited on ILS regulation 87087(d) and CCR 80088(b). Exit interview was conducted. A copy of this report was provided to the Administrator and Appeal of Rights

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
On September 5, 2024, Licensing Program Analyst (LPA) Miriam Flores conducted a case management visit at the STRTP and met with Facility Manager, Ana Soito. LPA reviewed and discussed the incident report dated 08/02/24. Facility Manager explained their daily procedure for room search and supervision. No deficiencies observed or cited during today's inspection. An exit interview was conducted and a copy of this report was provided via email to Facility Manager, Ana Soito due to technical issues.

met_with: Ana Soito


summary: Facility Evaluation

raw_content:
Narrative:
On May 15, 2025, Licensing Program Analyst (LPA) Miriam Flores conducted a case management visit Manuch Riverpine, STRTP and met with Ana Soito, Facility Manager to follow up on two incidents reports sent to the Licensing Department. Incidents reports submitted to the Department are dated 4/14/25 and 4/21/25. These incident reports were reviewed and discussed during this inspection. Incident reports included C1 and C2 (see LIC811) and copies of supportive documentation were provided during this inspection. There were no deficiencies cited at this time. An exit interview was conducted and a copy of this report was provided to the Facility Manager.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On April 3, 2025, Licensing Program Analyst (LPA) Miriam Flores conducted a case management visit at the Manuch Inc Riverpine and met with Facility Manager, Ana Soito. LPA reviewed and discussed the incident report dated 03/25/25. Facility Manager explained their plan of correction for direct care staff (S1). The Department determined this to be a potential risk to health and safety of the children in care at this time, therefore California Code of Regulations, ILS 87065.2(b)(1) PERSONNEL DUTIES are being cited on the attached LIC809D. An exit interview was conducted and a copy of this report was provided to Facility Manager, Ana Soito with Appeal Rights.

Deficiencies:
87065.2: (1) Supervision, protection, and care of children at all times, individually and in groups

title: PERSONNEL DUTIES (b) Direct care staff shall perform the following duties


summary: Facility Evaluation

raw_content:
Narrative:
On November 10, 2025, Licensing Program Analyst (LPA) Miriam Flores conducted a case management visit at the Manuch Inc Riverpine and met with Facility Manager, Ana Soito. LPA reviewed and discussed the incident report dated 10/01/25. C1 was not picked up due to facility being singled staffed. The Department determined this to be a potential risk to health and safety of the children in care at this time, therefore California Code of Regulations, Personnel Requirements 80065(a) are being cited on the attached LIC809D. An exit interview was conducted and a copy of this report was provided to Facility Manager, Ana Soito with Appeal Rights.


summary: Facility Evaluation

raw_content:
Narrative:
On September 30, 2021, Licensing Program Analyst (LPA) Lisa Slusher and Licensing travelled to the facility listed above to conduct a post licensing inspection. Facility Inspection conducted. Met at the facility by Administrator Levon Manucharyan and House Manager Liam Womack. 1. Facility Grounds are clean and free of debris or observable hazard. 2. Adequate indoor activity space and materials observed, and outdoor activity space was observed. Licensee noted that outdoor activity items would be added. 3. Chemicals appropriately locked. 4. Locked and centrally stored medications observed. 5. First aid kit complete with appropriate manual observed. 6. Adequate storage space observed. 7. Individual beds in good repair observed. 8. The house has 3 bedrooms, double occupancy, all located on one single level. Bedrooms are accommodating of all required furnishings. Only one bedroom is in use at this time. 9. Adequate food storage space observed. Supply of a week of nonperishable foods observed upon inspection. Facility also maintains an appropriate supply of two days of perishable foods. 10. Weekly menu posted and accessible to clients. 11. Dining room equipped with large table and chairs accommodating of all clients. 12.Facility has three full restrooms, one for client use, two for staff use, all are operable.. Hot water measured 105 degrees on this date. 13. On this date, refrigerator was in the midst of repair. Perishabe foods temporarily stored appropriately in ice chests. Facility maintains appropriate staff to client ratios. Administrator Levon Manuchryan is present at the facility a minimum of 20 hours per week. on this date a citation is issued for Training records, 87065.1


summary: Facility Evaluation

raw_content:
Narrative:
On April 14, 2026, Licensing Program Analyst (LPA) Miriam Flores, traveled to Manuch Riverpine located in Fresno, CA and met with Facility Manger, Isabel Lopez to conduct a Case Management Inspection. The purpose of inspection is to deliver Amended findings for a Case Management Citation dated December 22, 2025. No deficiencies observed or cited during this inspection. An exit interview was conducted, a copy of this report and the amended case management report were discussed and provided to the Facility Manager at the conclusion of the inspection.

met_with: Isabel Lopez


facility_name: MARY'S SHELTER - HOUSE 1

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
the allegation that C1 was assaulted by another minor while in care due to lack of supervision. Therefore, the allegation is unsubstantiated. An exit interview was conducted and appeal rights were discussed with Clete Menke, Operations Director. Due to printer malfunction, a copy of this report, along with the LIC 811, and appeal rights will be emailed to the Facility Administrator. A signed copy of this report will be kept in the Facility file.

Investigation Findings:
13On January 23, 2023, at 12:25 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Clete Menke, Operations Director, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 11/01/2022 at 10:15 am and no deficiencies were observed. LPA Linley interviewed two clients (C1, C2), two clients declined to be interviewed (C3, C4), and six staff (S1-5, S7), one staff was unable to be interviewed (S6), despite multiple attempts to contact them. LPA reviewed the following documents during the investigation: child history report, client roster, October 2022 staff schedule, special incident report, and shift notes. On 10/27/2022, Community Care Licensing received an allegation that C1 was assaulted by another minor while in care due to lack of supervision. Based on record reviews and confidential interviews, C3 pulled C1's hair. The details gathered for the incident did not provide a preponderance of evidence to prove or disprove UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: MARY'S SHELTER - HOUSE 1FACILITY NUMBER: VISIT DATE: 01/23/2023

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

report_type: Complaint Investigation

met_with: Clete Menke, Operations Director

complaint_status: unsubstantiated


raw_content:
Narrative:
Confidential interviews revealed facility staff verbally advised C1 of a 14-day notice during a Child and Family Team meeting held on January 05, 2022, however, facility failed to operate in accordance with their plan of operation and submit notification to authorized representative within seven days. On January 20, 2022, CCL received an allegation staff did not provide minor with clothing allowance. Specifically, it was reported that C1 was not provided C1's clothing allowance for the month of January 2022. Confidential interviews revealed in January 2022, facility had high cases of COVID and staff asked C1 to wait a couple weeks until the COVID cases had dropped prior to going shopping with monthly allowance. Confidential record review revealed C1 would go shopping in the beginning of the month and at the time of discharge C1 still had not gone shopping and was not given monthly allowance of $75.00 at time of discharge. Based on confidential interviews and record review, the allegations unlawful eviction of C1 and staff did not provide C1 with clothing allowance are substantiated and the facility is being cited for violation of Short Term Residential Therapeutic Interim Licensing Standards Version 4. Plan of Operation 87022(f). An exit interview was conducted, and a copy of this report and appeal rights were provided to facility representative. Confidential interviews revealed client was unable to take all personal belongings at the time of discharge as the car was full. Confidential interviews shared minor was given all confidential and personal documents at the time of discharge in a binder. Confidential interviews also revealed facility staff followed-up with C1 after discharge and provided C1 with all remaining belongings and any mail that was received after discharge. Another confidential interview stated that C1 was not provided C1's birth certificate. Based on confidential interviews and record review, the allegation that staff did not provide C1 with personal belongings may have occurred, however, it is not supported or proven by evidence. Therefore, this allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this report and appeal rights were provided to facility representative.

Investigation Findings:
13On June 15, 2022 at 03: PM, Licensing Program Analyst (LPA), Lisi Leon, met with Mary's Shelter's, Quality Assurance Specialist, Iman Farooqui, to deliver the finding for the above stated allegation regarding the Short Term Residential Therapeutic Program (STRTP). LPA spoke with Facility Administrator by telephone who authorized Iman Farooqui to sign and receive report. On January 27, 2022, LPA Leon completed a safety and health inspection and no immediate health & safety concerns were observed. LPA Leon conducted interviews with Facility Administrator (FA), one Staff Manager (SM), one County Social Worker (CSW), one Agency Social Worker (ASW), three staff Staff #1 (S1), Staff #2 (S2) and Staff #3 (S3), one After-Care Director (AD), and two residential clients Client #1 (C1) and Client #2 (C2). LPA Leon obtained copies of the facility and client roster including schedules and reviewed client records. On January 20, 2022, Community Care Licensing (CCL) received an allegation that staff did not provide minor with personal belongings. Specifically, it was reported that C1 was not provided C1's birth certificate. ****This is an amended report of the report issued on 06/15/2022**** UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Lisi Leon 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 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE This is an official report of an unannounced visit/investigation of a complaint received in our office on 01/20/2022 and conducted by Evaluator Lisi Leon PUBLICCOMPLAINT CONTROL NUMBER: 22-CR- FACILITY NAME:MARY'S SHELTER - HOUSE 1FACILITY NUMBER: ADMINISTRATOR:ELLEN ROYFACILITY TYPE: ADDRESS: E. 17TH STREETTELEPHONE: (714) 730- CITY:SANTA ANASTATE: CAZIP CODE: CAPACITY:17CENSUS: 13DATE: 06/15/ UNANNOUNCEDTIME BEGAN: 03: PM MET WITH:Quality Assurance Specialist, Iman FarooquiTIME COMPLETED:05: PM Staff did not provide minor with clothing allowance INVESTIGATION FINDINGS: 13On June 15, 2022 at 03: PM, Licensing Program Analyst (LPA), Lisi Leon, met with Mary's Shelter, Quality Assurance Specialist, Iman Farooqui to deliver the finding for the above stated allegations regarding the Short Term Residential Therapeutic Program (STRTP). LPA spoke with Facility Administrator by telephone who authorized Iman Farooqui to sign and receive report. On January 27, 2022, LPA Leon conducted a safety and health inspection was completed on January 27, 2022 and no immediate health & safety concerns were observed. LPA Leon conducted interviews with Facility Administrator (FA), one Staff Manager (SM), one County Social Worker (CSW), one Agency Social Worker (ASW), three staff, Staff #1 (S1), Staff #2 (S2) Staff #3 (S3), one After-Care Director (AD), and two residential clients, Client #1 (C1) and Client #2 (C2). LPA Leon obtained copies of the facility and client roster including schedule and reviewed client records. On January 20, 2022, Community Care Licensing (CCL) received an allegation the facility conducted an unlawful eviction. Specifically, it was reported that C1 was not given notice of discharge and was asked to leave prior to notice being submitted. R- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: MARY'S SHELTER - HOUSE 1FACILITY NUMBER: 306000793

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

met_with: Iman Farooqui, Quality Assurance Specialist


raw_content:
Narrative:
witnessed minor smoking in the facility. Confidential interviews revealed that C1 smoked in the bathroom and bedroom and posted pictures on social media. Confidential interviews revealed C1 hid vaping devices under their clothing. Confidential interviews revealed C1 would hear staff opening doors during room checks and would hide the vaping pen next to their body when staff completed room checks. Records reviewed revealed vaping devices were found in C1's bedroom. Conflicting interviews revealed C1 was not observed smoking in the facility. The allegation that facility staff did not prevent C1 from smoking may or may not have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted and appeal rights were discussed with Clete Menke, Operations Director. Due to printer malfunction, a copy of this report, along with the LIC 811, and appeal rights will be emailed to the Facility Administrator. A signed copy of this report will be kept in the Facility file.

Investigation Findings:
13On October 6, 2022, at 9:40 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility and met with Clete Menke, Operations Director of Mary's Shelter, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 07/28/2022 and no deficiencies were observed. LPA Linley interviewed six clients (C1-C6), seven staff (S1, S2), one County Social Worker (CSW1) and one County Social Worker (CSW2) was unable to be interviewed, despite multiple attempts to contact them. LPA reviewed the following documents during the investigation: Staff Schedule, Staff Contact List, Shift Notes, Client Roster, C1's Needs and Services, C1's Special Incident Report, and C1's transition notice. On June 9, 2022, Community Care Licensing (CCL) received an allegation that facility staff did not prevent minor from smoking. It was reported that staff have suspected minor has a marijuana pen tucked in their clothing, minor posts pictures on social media smoking, and other minors have UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: MARY'S SHELTER - HOUSE 1FACILITY NUMBER: VISIT DATE: 10/06/2022

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


raw_content:
Narrative:
individuals, although multiple attempts were made, confidential interviews did not corroborate the allegation with a preponderance of evidence. Based on confidential interviews and records reviewed the allegation that staff did not provide transportation to C1 in care, which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Kelli Strickland. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights was emailed to the Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On August 27, 2024, at 4:12 pm, Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced complaint inspection at the above facility. LPA Linley met with Kelli Strickland, After Care Director. The purpose of the inspection was to deliver the findings of the complaint investigation. LPA Linley conducted an inspection of the facility on February 21, 2024, at 9:10 am and no deficiencies were found. LPA Linley interviewed eight staff (S1-8) and was unable to interview one client (C1), despite multiple attempts to contact them. During the investigation, the following documents were reviewed: Grocery Receipts, Menu, Staff Schedule, and Special Incident Report. On February 15, 2024, Community Care Licensing (CCL) received an allegation that staff did not provide transportation to C1 in care. It was reported that C1 ran away from staff at the doctor's office and when staff was driving back to the facility, S1 saw C1 walking, and did not pick them up and take them back to the facility. Confidential interviews revealed conflicting statements. Due to being unable to interview all UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: MARY'S SHELTER - HOUSE 1FACILITY NUMBER: VISIT DATE: 08/27/2024

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

met_with: Kelli Strickland


raw_content:
Narrative:
stations in the facility and there are extra diapers stored in the garage. Some interviews indicated C1 requested a specific formula brand for their child and C1 was given formula by staff. Other interviews indicated the brand of formula was in short supply and the facility provided another brand of formula. There was not a specific date provided for when C1 requested the specific brand of diapers or formula. It was also reported that C1 left personal belongings in the bathroom, staff threw C1's belongings out, and S1 yelled at C1. Confidential interviews provided conflicting statements. Some interviews indicated staff asked C1 to clean up their hygiene items in the bathroom and C1 refused, so staff bagged the items in a trash bag and set it aside, and the trash bag was thrown away. Confidential interviews indicated staff was unaware the trash bag was thrown away and once staff became aware, staff was able to retrieve the bag from the trash and gave C1's items back to them. Some interviews indicated S1 was frustrated when C1 yelled at them and walked away from talking to C1. Other confidential interviews denied S1 yelled at C1 and could not recall what S1 said to C1. Thus, confidential interviews did not corroborate the allegations with a preponderance of evidence. Based on confidential interviews and records reviewed the allegations that staff are not allowing C1 to have access to their personal belongings while in care, staff are not safeguarding C1's personal belongings while in care, and S1 antagonize C1 in care, which may have occurred, however, they are not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report and appeal rights were provided to Kelli Strickland. A copy of this report will be placed in the facility file.

Investigation Findings:
13On February 24, at 12:15 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Kelli Strickland, After-Care Director, to discuss the investigative finding for the allegations noted above. LPA conducted an inspection of the facility on November 25, 2024, at 4:20 pm, and no deficiencies were observed. LPA Linley interviewed three Clients (C1-3) and eight Staff (S1-8). The following documents were reviewed during the investigation: facility documents. On November 22, 2024, Community Care Licensing (CCL) received allegations that staff are not allowing minor to have access to their personal belongings while in care, staff are not safeguarding minor's personal belongings while in care, and staff antagonize minor in care. It was reported that C1 was not allowed to have access to their diapers and formula when they needed them. Confidential interviews revealed conflicting statements. Some interviews indicated C1 requested a specific brand of diapers, and it is unknown if C1 received the specific brand of diapers. Other interviews indicated there are diapers provided at the changing UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: MARY'S SHELTER - HOUSE 1FACILITY NUMBER: VISIT DATE: 02/24/2025

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


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Based on confidential interviews the allegation that S1 did not treat C1 with respect is substantiated. The preponderance of evidence standard has been met. The facility is cited for violation of the Interim Licensing Standards STRTP 87072(c)(15) Personal Rights. An exit interview was conducted, appeal rights explained, and a copy of this report, LIC 811, and appeal rights were emailed to the Facility Administrator, due to printer difficulties. A copy of this report will be placed in the facility file.

Investigation Findings:
13On June 19, 2025, at 12:00 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility and met with Kelli Strickland, Clinical Supervisor and Derrick Perry, VIce President of Operations, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on March 26, 2025, at 10:05 am. No deficiencies were observed. LPA interviewed one Client (C1) and four Staff (S1-4). LPA reviewed the facility documents. On March 20, 2025, Community Care Licensing (CCL) received an allegation that staff did not treat minor with respect. It was reported that C1 was frustrated about the air conditioner being turned off and on throughout the night and went to the living room to turn off the air conditioner at which time S1 and C1 had an exchange of words, which entailed foul language. Confidential interviews supported the allegation that S1 cursed back at C1. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: MARY'S SHELTER - HOUSE 1FACILITY NUMBER: VISIT DATE: 06/19/2025

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

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
confidential interviews could not confirm or deny the allegation. Based on confidential interviews and records reviewed the allegation that staff did not seek medical treatment for C1 in care which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report and appeal rights were provided to the facility. A copy of this report will be placed in the facility file.

Investigation Findings:
13On July 21, 2025, at 12:00 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Kelli Strickland, After Care Director, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on April 21, 2025, at 11:05 am and no deficiencies were observed. LPA interviewed three Staff (S1-3), and LPA was unable to interview one Staff (S4), despite multiple attempts to contact them, and one Client (C1) declined to be interviewed. LPA reviewed the facility documents during the investigation. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: MARY'S SHELTER - HOUSE 1FACILITY NUMBER: VISIT DATE: 07/21/2025

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


summary: Facility Evaluation

raw_content:
Narrative:
On June 17, 2021, at 9: AM Licensing Program Analyst (LPA) Jesus Cervantes and Licensing Program Manager (LPM) Ann Valenzuela conducted an unannounced annual/post licensing inspection. The facility converted from a Group Home to a Provisional STRTP (Short Term Therapeutic Program) on June 27, 2019. LPA was met at the facility by Facility Director, Clete Menke. LPAs toured the facility inside and out at 9: AM. The facility is a one-story residence with six bedrooms and one communal bathroom for the clients. The bedrooms are arranged so that there are two clients sharing a room and one infant. There is adequate closet and drawer space for client's belongings. The bathrooms were clean and in good repair. The hot water was tested at 9: AM and registered at 112.6 degrees which is within the appropriate range of 105 degrees to 120 degrees. Cleansers/chemicals are locked and stored inside a locked cabinet in the laundry room and inside a locked cabinet in the kitchen. Sharp knives are inaccessible and stored inside a locked cabinet in the kitchen. The facility's smoke detectors were checked and were operable. There are no guns or weapons in the facility as stated by the Operations Director. LPAs observed facility posted items in the hallway that included: Disaster Plan, Personal Rights, Grievance Procedures, and Foster Care Ombudsman poster. Client's medications were observed to be inaccessible and stored inside a locked cabinet in the staff's office. Medication records were reviewed and observed to be completed with dates and staff initials on dispensing records. LPAs observed a minimum 7-day non-perishable and a 2-day perishable supply of food. There is one camera at the facility located on the wall in the kitchen/living room area. The facility outside grounds was also inspected and it was observed to be clean and well maintained. There are no bodies of water located on the premises. Emergency exits were free from obstruction. See Page Two The facility employs one Executive Director, one Operations Manager, one Program Coordinator, one Staff Manager, one Medical Coordinator, one Facility Coordinator, one Parenting Coordinator, one Clinical Director, one STRTP Clinician, one Social Worker, two Case Managers, and 30 youth support staff. Licensee obtained their Mental Health (MH) Certification on May 17, 2021 and it expires on May 17, 2022. Licensee obtained National Accreditation through COA and the accreditation is valid through October 31, 2024. Licensee has received written and verbal Medi-Cal approval. Per Facility Director, Clete Menke, official documentation of that approval has not been received. Licensing fee payments are current. All the client files are stored and locked in the file cabinet in the staff office. At 11: AM, LPA reviewed a sample of five clients files during the time of inspection. All files contained the required documentation per Title Regulations. At 11: AM, LPA reviewed sample of five staff files. All the staff have met the training and qualification requirements per regulations requirements. Per a review of the Community Care Licensing Information System (LIS), all staff met DOJ/FBI criminal record clearances and Child Abuse Index Check requirements. All staff have proof in file of acknowledging the child abuse reporting requirements. Two facility staff were interviewed during the inspection. Two clients were interviewed during the inspection. LPA discussed the following with the Administrator: Facility procedures related to requesting exceptions. Assembly Bill 388 law enforcement contacts as well as incidents involving emergency interventions. LPA discussed procedures for Child and Family Team (CFT) meetings, including an overview of required Core Services and Supports. LPA also discussed Reasonable and Prudent Parenting Standards, and resident involvement in development of planned activities. Based on the facility inspection and files reviewed on this date, there are no deficiencies found at this time. Note: The annual for Mary's Shelter 2 (#300613291) was also conducted during the time of this inspection. An exit interview was conducted, and a copy of this report was provided to the Administrator.

met_with: Clete Menke


summary: Facility Evaluation

raw_content:
Narrative:
On November 17, 2021, at 10: AM Licensing Program Analyst (LPA) Jesus Cervantes conducted an unannounced annual licensing inspection. The facility converted from a Group Home to a STRTP (Short Term Therapeutic Program) on December 27, 2019. LPA was met at the facility by Facility Director, Clete Menke. LPA toured the facility inside and out at 10: AM. The facility is a one-story residence with six bedrooms and one communal bathroom for the clients. The bedrooms are arranged so that there are two clients sharing a room and one infant. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. There is adequate closet and drawer space for client's belongings. The bathroom was clean and in good repair. The hot water was tested at 11: AM and registered at 111.3 degrees which is within the appropriate range of 105 degrees to 120 degrees. Cleansers/chemicals are locked and stored inside a locked cabinet in the laundry room and inside a locked cabinet in the kitchen. Sharp knives are inaccessible and stored inside a locked cabinet in the kitchen. The facility's smoke detectors were checked and were operable. There are no guns or weapons in the facility as stated by the Operations Director. LPAs observed facility posted items in the hallway that included: Disaster Plan, Personal Rights, Grievance Procedures, and Foster Care Ombudsman poster. Client's medications were observed to be inaccessible and stored inside a locked cabinet in the staff's office. Medication records were reviewed and observed to be completed with dates and staff initials on dispensing records. LPA observed a minimum seven-day non-perishable and a two-day perishable supply of food. There is one camera at the facility located on the wall in the kitchen/living room area. The facility outside grounds was also inspected and it was observed to be clean and well maintained. There are no bodies of water located on the premises. Emergency exits were free from obstruction. See Page Two The facility employs one Executive Director, one Operations Director, one Staff Manager, one Medical Coordinator, one Facility Coordinator, one Parenting Coordinator, one Head of Service, two Clinicians, two Case Managers, two Mental Health Counselors, and 23 youth support staff. Licensee obtained their Mental Health (MH) Certification on May 17, 2021 and it expires on May 17, 2022. Licensee obtained National Accreditation through COA and the accreditation is valid through October 31, 2024. Licensee has received Medi-Cal approval on April 29, 2021. Licensing fee payments are current. LPA discussed the following with the Administrator: Physical Plant, Operational Requirements, Disaster Preparedness, Emergency Intervention Plan, and Core Therapeutic Services. Due to time constraints and the need to conduct client/staff file reviews and staff/client interviews, LPA will return at a later time to complete the annual inspection. Based on the facility inspection on this date, there are no deficiencies found at this time. Note: The annual for Mary's Shelter 2 (#300613291) was also conducted during the time of this inspection. An exit interview was conducted, and a copy of this report was provided to the Operations Director.


summary: Facility Evaluation

raw_content:
Narrative:
On November 18, 2021, at 9: AM, Licensing Program Analysts (LPA), Jesus Cervantes continued the unannounced annual inspection, which was started on November 17, 2021. LPA met with Facility Director, Clete Menke. At 9: AM, LPA began to review a sample of ten staff files during the time of inspection. All ten staff files have met the training and qualification requirements per regulations requirements. Per a review of the Community Care Licensing Information System (LIS), all staff met DOJ/FBI criminal record clearances and Child Abuse Index Check requirements. All staff have proof in file of acknowledging the child abuse reporting requirements. Five of five facility staff were interviewed during the inspection. Due to the need to conduct additional client interviews, and continue client file reviews, this inspection will need to be continued at later date. Based on the facility inspection, staff interviews, and files reviewed on this date, there are no deficiencies found at this time. An exit interview was conducted, and a copy of this report was provided to Facility Director, Clete Menke. Note: The annual for Mary's Shelter 2 (#300613291) was also conducted during the time of this inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On November 19, 2021, at 9: AM, Licensing Program Analysts (LPA), Jesus Cervantes continued the unannounced annual inspection, which was started on November 17, 2021. LPA met with Facility Director, Clete Menke. All the client files are stored and locked in the file cabinet in the staff office. At 9: AM, LPA reviewed a sample of eight clients files during the time of inspection. All files contained the required documentation per Title Regulations. Four clients were interviewed during the inspection. Based on the facility inspection, client interviews, and client files reviewed on this date, there are no deficiencies found at this time. An exit interview was conducted, and a copy of this report was provided to Facility Director, Clete Menke. Note: The annual for Mary's Shelter 2 (#300613291) was also conducted during the time of this inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On July 27, 2022, Licensing Program Analyst (LPA), Lisi Leon, met with Facility Manager, Clete Menke, to obtain a signature for an amended report. A copy of this report was given to Facility Manager, Clete Menke.

met_with: Clete Menke, Facility Manager


summary: Facility Evaluation

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Narrative:
On August 25, 2023, at 3. PM, Licensing Program Analyst (LPA) Guadalupe Munoz arrived unannounced at the facility and met with Executive Director, Jill Dominguez. The purpose of the inspection is to conduct a Case Management in response to information received from the facility on 8/18/2023 regarding an incident that involved Client #1 (C1), Client #2 and Client #3 and Staff #1 (S1), please refer to the Confidential Names List dated 8/25/2023. LPA conducted an inspection of the facility, and no immediate health or safety concerns were observed. LPA interviewed C1 and client 2. Further review and information will be needed. Upon completion of the review, the outcome and/or recommendations will be provided to the licensee. An exit interview was conducted, and a copy of this report was provided to Executive Director, Jill Dominguez.

met_with: JIll Dominguez


summary: Facility Evaluation

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Narrative:
On September 1, 2023, at 11. AM, Licensing Program Analyst (LPA) Guadalupe Munoz arrived unannounced at the facility and met with Clete Menke, Operations Director . The purpose of the visit is to conduct a Case Management interview in response to information received from the facility on 8/18/2023 regarding an incident that involved Client #1 (C1), Client #2 and Client #3 and Staff #1 (S1), please refer to the Confidential Names List dated 8/25/2023. LPA conducted an inspection of the facility, and no immediate health or safety concerns were observed. LPA interviewed one staff. Further review and information will be needed. Upon completion of the review, the outcome and/or recommendations will be provided to the licensee. An exit interview was conducted, and a copy of this report was provided to Clete Menke, Operations Director


summary: Facility Evaluation

raw_content:
Narrative:
This is an amended report that was issued on November 07, 2023. On November 07, 2023, at 09: AM Licensing Program Analyst's (LPA) Darlene Almaraz-Oseguera and Jose Gonzalez conducted an unannounced annual random inspection at Short Term Therapeutic Program facility. LPA's was met with Facility Director, Clete Menke and Facility Coordinator Kathy McGinty. LPA's toured the facility inside and out. The facility is a one-story residence with six bedrooms and one communal bathroom for the clients. The bedrooms are arranged so that there are two clients sharing a room and one infant. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. There is adequate closet and drawer space for client's belongings. The bathroom was clean and in good repair. The hot water was tested and registered at 112.3 degrees which is within the appropriate range of 105 degrees to 120 degrees. Cleansers/chemicals are locked and stored inside a locked cabinet in the laundry room and inside a locked cabinet in the kitchen. Sharp knives are inaccessible and stored inside a locked cabinet in the kitchen. The facility's smoke detectors were checked and were operable. There are no guns or weapons in the facility as stated by the Operations Director. LPAs observed facility posted items in the hallway that included: Disaster Plan, Personal Rights, Grievance Procedures, and Foster Care Ombudsman poster. Client's medications were observed to be inaccessible and stored inside a double locked cabinet in the staff's office. Medication records were reviewed and observed to be completed with dates and staff initials on dispensing records. LPA observed a minimum seven-day non-perishable and a two-day perishable supply of food. There is one camera at the facility located on the wall in the kitchen/living room area. The facility outside grounds was also inspected and it was observed to be clean and well maintained. There are no bodies of water located on the premises. Emergency exits were free from obstruction. LPA's reviewed six client files and all required documents were in the files. LPA's reviewed six personnel records/files. Staff have Criminal Background and Child Abuse Clearances which are complete and current for all employees. The licensing fee payments are current. Based on the facility inspection on this date, there are no deficiencies found at this time. An exit interview was conducted, and a copy of this report was provided to Kathy McGinty.

met_with: Kathy McGinty


summary: Facility Evaluation

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Narrative:
The purpose of this LIC 809 continuation form was so that Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera can attach the inspection tool form used to complete the annual inspection. Due to FAS technical difficulties the care tools did not attach correctly.


summary: Facility Evaluation

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Narrative:
On January 5, 2024 at 10: AM, Licensing Program Analyst (LPA) Joon Choi arrived unannounced at Mary's Shelter STRTP and met with Lead Therapist Anjum Bari. The purpose of this visit was to conduct a collateral interview with Foster Child 1 (FC1) regarding an open investigation on one of the client's previous placements. LPA conducted a confidential interview with one client. A copy of this report was given to Lead Therapist Anjum Bari.

met_with: Anjum Bari, Lead Therapist


summary: Facility Evaluation

raw_content:
Narrative:
On November 7, 2024, at 10:00 am, Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced annual random inspection at the Short Term Therapeutic Program facility. LPA met with Vanessa McGinty, Facility Coordinator, and Jill Dominguez, Facility Administrator, and toured the facility with Vanessa McGinty. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. The facility is a one-story residence with six bedrooms and one communal bathroom for the clients. The bedrooms are arranged so that there are two clients sharing a room and one infant. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. There is adequate closet and drawer space for client's belongings. The bathroom was clean and in good repair. The hot water was tested at 11:00 am and registered at 118 degrees which is within the appropriate range of 105 degrees to 120 degrees. Cleansers/chemicals are locked and stored inside a locked cabinet in the laundry room and inside a locked cabinet in the kitchen. Sharp knives are inaccessible and stored inside a locked cabinet in the kitchen. The facility's smoke detectors were checked and were operable; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. LPA observed a minimum 7-day non-perishable and 2-day perishable supply of food. The hot water was tested in the kitchen at 11:14 am and registered at 118 degrees which is within the appropriate range of 105 degrees to 121 degrees. There are no guns or weapons in the facility as stated by the Facility Administrator. LPA observed facility posted items in the hallway that included: Disaster Plan, Personal Rights, Grievance Procedures, and Foster Care Ombudsman poster. *** Client's medications were observed to be inaccessible and stored inside a double locked cabinet in the staff's office. There is one camera at the facility located on the wall in the kitchen/living room area and one camera outside of the front door. The facility outside grounds was also inspected and it was observed to be clean and well maintained. There are no bodies of water located on the premises. Emergency exits were free from obstruction. All client files are stored and locked in the medication office. LPA reviewed five client (C1-5) files to ensure clients had all required documents per Title 22. LPA interviewed one client, two clients declined to be interviewed and two clients were on runaway status. LPA reviewed five staff (S1-5) files and interviewed four staff. All staff met the minimum qualifications and training requirements. A review of records shows that all staff have FBI, DOJ, and Child Abuse Index Check clearances. All staff have proof in file of acknowledging the child abuse reporting requirements. The licensing fee payments are current. Based on the facility inspection on this date, there are no deficiencies found at this time. An exit interview was conducted, and a copy of this report was provided to Jill Dominguez. LPA requested copies of an updated LIC 500 and LIC 308 to be emailed to LPA. A copy of this report will be placed in the facility file.

met_with: Jill Dominguez


summary: Facility Evaluation

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Narrative:
On the date listed above at 11:30 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Kelli Strickland, After Care Director, for a case management visit to obtain additional information regarding a Incident Report submitted to Community Care Licensing. LPA conducted a record review. No deficiencies were cited. An exit interview was conducted and a copy of this report was provided to the facility. A copy of this report will be placed in the facility file.


summary: Facility Evaluation

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Narrative:
On 08/21/25, at 9: AM, Licensing Program Analysts (LPA) Gilbert Marquez and Stefanie Mutialu met with Clinical Supervisor, Kelli Strickland and Vice President of Operations, Derrick Perry, for the purpose of conducting an annual inspection of the facility. The Facility is licensed to serve 11 ambulatory residents 12-21 years old and six infants 0-24 months of age. The current census is five clients. The facility is current with licensing fees. The facility is a single-story dwelling. A physical plant inspection was completed with Vice President of Operations, Derrick Perry and included the following checks: six bedrooms, one communal bathroom for the clients, kitchen, medication room, dining room, living room, seven staff offices, visitation room, sensory room, and outdoor living space. All beds were observed with appropriate bedding and mattresses were in good repair. Bedrooms contained adequate drawers and closet space. No bedroom occupied more than one client and one infant and not used for other purposes. The water temperature was tested in the clients' main bathroom which measured 117 degrees Fahrenheit which is within the appropriate range of 105 degrees to 120 degrees Fahrenheit. The first aid kit was accessible to all staff and had all required supplies. All required forms are posted including Grievance Procedures, Visitation Policies, Personal Rights form, and the Emergency Disaster Plan. Clients' medications were observed to be inaccessible and stored in medication room. **Continued on LIC809C** **LIC809** Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. All facility smoke detectors and carbon monoxide detectors were tested by fire clearance; fire extinguishers are properly charged and serviced. The Facility maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. LPA observed a minimum seven-day non-perishable and two-day perishable supply of food. LPA observed a bottle of "ALL" laundry detergent accessible to clients located on the closet top shelf in client bedroom #1 and a bottle of Clorox bleach spray, two containers of Lysol wipes accessible to clients in an unlocked cabinet in the unlocked laundry room. Per Facility Manager, Kathy McGinty, all cleaners, disinfectants, and toxic chemicals are locked up and inaccessible to clients, however, staff give these items to clients for use but sometimes clients do not return them. For this, the facility is receiving a type A citation. LPA also reviewed one of five client medication records. Per facility staff, no firearms or weapons are allowed in the facility. Due to time constraints, LPA will return on another day to conduct client and staff interviews, and review staff and client files. Based on LPA observation of cleaning chemicals being unlocked in client bedroom #1 and accessible in laundry room, the facility is receiving a type A citation for violation of Title Section 80087(g) Physical Plant. An exit interview was conducted with the Clinical Supervisor, Kelli Strickland to explain this report, the LIC809D page, and a plan of correction for the deficiency. The appeal rights were discussed. A copy of the Facility Evaluation Report, along with LIC809D pages, the Confidential Names List LIC811, and the appeal rights were given to Clinical Supervisor, Kelli Strickland and additionally will be kept in the facility file.

met_with: Derrick Perry, Vice President of Operations


summary: Facility Evaluation - 1 deficiency

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Narrative:
On August 22, 2025, at 10: AM, Licensing Program Analysts (LPA), Stefanie Mutialu and Gilbert Marquez continued the unannounced annual inspection, which was started on August 21, 2025. LPAs met with Clinical Supervisor, Kelli Strickland. During the inspection LPAs reviewed five staff files (S1-S5). Five out of five files contained the required documents including verification of criminal background check clearance, signed acknowledgment of mandated child abuse and neglect reporting requirements, and health screening. During inspection and Guardian verification, LPAs discovered S6 did not obtain required background clearance as required by Title 22 regulations. LPA's were unable to review client files as the facility did not make client records accessible. During the Annual Inspection on 08/21/25, upon arrival LPAs requested client records be accessible for review by 12: PM, after 12: PM LPAs were advised the files will be available electronically as the Quality Assurance Specialist (QAS) was working on sending the electronic files. After 2: PM LPAs were advised the QAS was having challenges sending the files, LPAs then received three client files but unable to open and review while in the field, Vice President of Operations (VPO), Derrick Perry then offered to go and pick up files at the corporate office that is a mile and a half away. Due to time constraints, LPAs were unable to wait and advised VPO to ensure all client records were available for review first thing on 08/22/2025. Upon LPAs arrival today, 08/22/25 at AM, QAS and VPO were not onsite, and the present staff did not have access to client files.The facility is receiving a citation during today's visit. *Continued on Page 2* CONTINUED FROM PAGE LPAs conducted interviews with three staff (S1- S3) and with two clients (C1-C2). The facility is being cited for one type B citation for violation of California Code of Regulations, Title Division six, regulation 80070(d)(1): Client Records and one type A citation for Health and Safety Code 1522(c)(1):Administration and civil penalties of $500 ( X $100) will be assessed as per California Code of Regulations, Title Division six, regulation 80051(a)(2): Serious Deficiencies An exit interview was conducted with Clinical Supervisor, Kelli Strickland. A copy of this report and confidential names (LIC 811) dated 08/22/2025 was provided to Clinical Supervisor, Kelli Strickland.

Deficiencies:
80070(d): Client Records

(d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements

met_with: Clinical Supervisor, Kelli Strickland


summary: Facility Evaluation

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Narrative:
On 09/04/2025, at 3: PM, Licensing Program Analysts (LPA) Gilbert Marquez and Charmaine Linley met with Residental Staff Manager Vanessa Ruiz, for the purpose of continuing the annual inspection of the facility that started on 08/21/25. Facility is licensed to serve five ambulatory pregnant or parenting females ages 12-17 years old and six infants 0-24 months. Facility provides service to nonminor dependents. The current census is four clients. A health and safety tour of the facility was conducted, and no deficiencies were observed at this time. All the client files are stored on a secured database. LPA reviewed five client files (C1 - C5). Three out of five client files contained education records, physical examinations, Needs and Services plans, and mental health notes. C1 and C3 file sdid not have a TB recorded in her health records that was within the regulation time frame. Interview with S1 indicated that staff could not find TB records for these two clients and was going to have a plan of correction created so that this would not occur again. Based on LPA file review and interview, a type B deficiency is given today regarding C1 and C3 not having a TB test recorded in their file at the time of inspection. This is not in compliance with California Code of Regulations Title 22, Division 6, Client Records, Section 80069(c)(1) which poses a potential health and safety risk to persons in care. **Continued on LIC809C** [Deficiency Statement] Based on interview and record review, the licensee did not comply with the section cited above in one out of five clients (C1 and C3) which poses a potential health and safety risk to persons in care. [PLAN OF CORRECTION] In 30 days, Licensee shall email Community Care Licensing proof of attempts to obtain a tuberculosis exam for all two clients listed on this report were either successful or refused. **Continued from LIC809** An exit interview was conducted with the Residental Staff Manager Vanessa Ruiz to explain this report, the LIC809D page, and a plan of correction. The appeal rights were discussed. A copy of the Facility Evaluation Report, along with LIC809D page, the Confidential Names List LIC811, and the appeal rights were given to Licensee/Administrator, and additionally will be kept in the facility file. Note: The annual for Mary's Shelter 2 (#300613291) was also conducted during the time of this inspection.

met_with: Residental Staff Manager Vanessa Ruiz


summary: Facility Evaluation

raw_content:
Narrative:
On September 4, 2025, at 4:10 pm, Licensing Program Analysts (LPAs) Charmaine Linley and Gilbert Marquez conducted an unannounced inspection at the facility and met with Vanessa Ruiz, Residential Staff Manager. LPAs inquired where the Administrator was and were told the Administrator is off site at a training. This inspection is to discuss information that was reported to the Department and based on LPAs observations on August 21 and August 22, 2025. On August 21, 2025, LPAs Gilbert Marquez and Stefanie Mutialu arrived at the facility for an Annual Inspection and were at the facility from 9:31 am-5:15 pm and the Facility Administrator was not at the facility and did not arrive during the Annual Inspection. On August 22, 2025, LPAs Marquez and Mutialu arrived at the facility for a continuation of the Annual Inspection and were at the facility from 10:00 am-1:00 pm, the Facility Administrator was not at the facility and did not arrive during the Annual Inspection. LPAs inquired if the Facility Administrator would arrive during the Annual Inspections and were told the Facility Administrator was only available via phone contact. Confidential interviews indicated that the Facility Administrator is not at the facility twenty hours per week as required; the Facility Administrator is present one day a week at the facility. Facility Administrator/CEO and Vice-President of Operations called LPA and stated they would drive to the facility and arrive at 5:00 pm and arrived at 5:05 pm. Based on confidential interviews and LPA's observations, the facility is being cited for a Type B violation of the Interim Licensing Standards STRTP 87064(b)(1) Administrator Qualifications and Duties. Refer to LIC809D. An exit interview was conducted, and appeal rights were reviewed with Jill Dominguez and Derrick Perry.. A copy of this report and appeal rights were provided to the facility.

met_with: Vanessa Ruiz


summary: Facility Evaluation

raw_content:
Narrative:
On January 14, 2026, at 9:00 pm, Licensing Program Analyst (LPA) Charmaine Linley was at the facility and received information that individuals were working at the facility from the Maxim agency. LPA Linley conducted two confidential interviews and noted there was one individual (A1) who did not have a criminal record clearance and was not cleared and associated prior to working at the facility. LPA reviewed Guardian to ensure that the individual did not have a criminal record clearance and record review indicated that A1 was not listed on the personnel report and was not listed in Guardian. LPA is administering one civil penalty during this visit. Based on record review and confidential interviews, the facility is being cited for the violation of California Code of Regulations, Title 22, Division Six, regulation 80019(a)(2)(d) Criminal Record Clearance (SEE LIC 809-D). An exit interview was conducted and appeal rights were discussed. A copy of this report and appeal rights were provided to the facility and a copy will be placed in the facility file

met_with: Christie Anderson


summary: Facility Evaluation

raw_content:
Narrative:
On December 22, 2022 at 10:30 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility . The purpose of this visit was to speak with a youth at this facility, while LPA was speaking with the client, LPA noted there were more babies residing in the facility than the facility was licensed. LPA Linley asked the census of the facility and was informed the facility has eight babies and the facility is licensed to have six babies. The facility plans to have one youth and baby move out on 12/23/2022 and the other youth and baby move out on 12/27/2022, which will bring the facility into compliance with six babies. Based on this information the, facility will be cited for exceeding their capacity. Refer to LIC-9099D for deficiency cited per Title 22 regulations. Exit interview conducted and appeal rights were discussed with Clete Menke. Due to printer malfunction, LIC 809 and appeal rights will be emailed to Clete Menke. LPA will confirm with Clete the forms and appeal rights have been received before leaving the facility.

met_with: Clete Menke, Director of Operations


summary: Facility Evaluation

raw_content:
Narrative:
On February 17, 2026, at 4:50 pm, Licensing Program Analyst (LPA) Charmaine Linley made an unannounced inspection to conduct a case management in regard to deficiencies observed at the facility during an inspection on February 9, 2026. LPA met with Christie Anderson, Program Manager. On February 9, 2026, LPA Linley observed bedroom two only had a mattress pad on the mattress and had a mattress that was in need of replacement, bedroom three did not have a mattress pad, bedroom four did not have any sheets or a mattress pad on the mattress that was in need of replacement and room four had two beds that did not have a mattress pad on one mattress and did not have a bottom sheet on the other mattress. On February 9, 2026, LPA Linley reviewed C4's Psychotropic Medication Administration Records for September 2025 and observed there were entries of medication refusal for medication #1 dated September 15-30, 2025 and medication #2 dated September 18-30, 2025, and during that time, the facility did not document the reason for the refusal, who was notified of the refusal and any observed results of the refusal. Based on LPA's observations and record review, the facility is being cited for two Type B violations of the Interim Licensing Standards STRTP 87088 (c)(1) and (c)(2) Fixtures, Furniture, Equipment, and Supplies and Interim Licensing Standards STRTP 87070 (b)(14)(G)(1) Children's Records. Refer to LIC809D. An exit interview was conducted, and appeal rights were reviewed with Christie Anderson. A copy of this report and appeal rights were provided to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On the date listed above, Licensing Program Analyst (LPA) Charmaine Linley was at the facility and met with Program Manager, Christie Anderson, who notified LPA there was a change in the Head of Service. LPA asked Ms. Anderson to send LPA Linley the changes on the agency letterhead with the name of the individual, mailing address, facility address and the date the new Head of Service started their position and an updated LIC 500. A copy of this report was provided to the facility.


raw_content:
Narrative:
medication until 09/15/2025. Records reviewed indicated that C1's prescribed medication was electronically submitted to the pharmacy on 08/27/2025 and the medication was not provided at the facility until 09/15/2025. Based on confidential interviews and record review the allegation that staff mishandled C4's medication is substantiated. The preponderance of evidence standard has been met. The facility is cited for violation of the Interim Licensing Standards (ILS), Section 87075(c) Health Related Services. An exit interview was conducted. A copy of this report, LIC 811, and appeal rights were provided to Christie Anderson. A copy of this report will be placed in the facility file. attempts were made, thus, confidential interviews could not confirm or deny the allegations. Based on confidential interviews and records reviewed the allegation that staff are not properly trained to meet a minor's needs, which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report and appeal rights were provided to Christie Anderson. A copy of this report will be placed in the facility file.

Investigation Findings:
13On March 18, 2026, at 4:00 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility and met with Christie Anderson, Program Manager, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on September 25, 2025, at 9:15 am. No deficiencies were observed. LPA interviewed four Clients (C1-4), fourteen Staff (S1-11, S16, S18), one Probation Officer (PO), and LPA was unable to interview four Staff (S13-15, S17), despite multiple attempts to contact them. LPA reviewed the facility documents. On September 18, 2025, Community Care Licensing (CCL) received an allegation that staff mishandled a minor's medication. It was reported that on August 27, 2025, C4 was prescribed two medications and the prescription was submitted to the pharmacy. Confidential interviews indicated that there was miscommunication between the Psychiatrist, S4 and S18, which resulted in C1 not receiving the prescribed SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: MARY'S SHELTER - HOUSE 1FACILITY NUMBER: VISIT DATE: 03/18/2026

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


facility_name: MARY'S SHELTER - HOUSE 2

summary: Facility Evaluation

raw_content:
Narrative:
On June 17, 2021, at 9: AM Licensing Program Analyst (LPA) Jesus Cervantes and Licensing Program Manager (LPM) Ann Valenzuela conducted an unannounced annual/post licensing inspection. The facility converted from a Group Home to a Provisional STRTP (Short Term Therapeutic Program) on June 27, 2019. LPA was met at the facility by Facility Director, Clete Menke. LPAs toured the facility inside and out at 10: AM. The facility is a one-story residence with five bedrooms and two bathrooms for the clients. Four bedrooms are arranged so that there is one client and their infant in a room. One bedroom is arranged so that there are two clients' sharing a room and two infants. There is adequate closet and drawer space for client's belongings. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. The bathrooms were clean and in good repair. The hot water was tested at 10: AM and registered at 115.1 degrees which is within the appropriate range of 105 degrees to 120 degrees. Cleansers/chemicals are locked and stored inside a locked cabinet in the kitchen. Sharp knives are inaccessible and stored inside a locked cabinet in the kitchen. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguisher is properly charged and serviced. There are no guns or weapons in the facility as stated by the Operations Director. LPAs observed facility posted items in the hallway that included: Disaster Plan, Personal Rights, Grievance Procedures, and Foster Care Ombudsman poster. Client's medications were observed to be inaccessible and stored inside a locked cabinet next to the toddler play area. LPAs observed a minimum 7-day non-perishable and a 2-day perishable supply of food. There is one camera at the facility located on the wall in the kitchen/living room area. The facility outside grounds was also inspected and it was observed to be clean and well maintained. There are no bodies of water located on the premises. Emergency exits were free from obstruction. See Page Two The facility employs one Executive Director, one Operations Manager, one Program Coordinator, one Staff Manager, a Medical Coordinator, one Facility Coordinator, one Parenting Coordinator, one Clinical Director, one STRTP Clinician, one Social Worker, two Case Managers, and 30 youth support staff. Licensee obtained their Mental Health (MH) Certification on May 17, 2021 and it expires on May 17, 2022. Licensee obtained National Accreditation through COA and the accreditation is valid through October 31, 2024. Licensee has received written and verbal Medi-Cal approval. Per Facility Director, Clete Menke official documentation of that approval has not been received. Licensing fee payments are current. All the client files are stored and locked in the file cabinet in the staff office. At 11: AM, LPA reviewed a sample of five clients files during the time of inspection. All files contained the required documentation per Title Regulations. At 11: AM, LPA reviewed sample of five staff files. All the staff have met the training and qualification requirements per regulations requirements. Per a review of the Community Care Licensing Information System (LIS), all staff met DOJ/FBI criminal record clearances and Child Abuse Index Check requirements. All staff have proof in file of acknowledging the child abuse reporting requirements. Two facility staff were interviewed during the inspection. Three clients declined to be interviewed. LPA discussed the following with the Administrator: Facility procedures related to requesting exceptions. Assembly Bill 388 law enforcement contacts as well as incidents involving emergency interventions. LPA discussed procedures for Child and Family Team (CFT) meetings, including an overview of required Core Services and Supports. LPA also discussed Reasonable and Prudent Parenting Standards, and resident involvement in development of planned activities. Based on the facility inspection and files reviewed on this date, there are no deficiencies found at this time. Note: The annual for Mary's Shelter 1 (#306000793) was also conducted during the time of this inspection. An exit interview was conducted and a copy of this report was provided to the Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On November 17, 2021, at 10: AM, Licensing Program Analyst (LPA) Jesus Cervantes conducted an unannounced annual licensing inspection. The facility converted from a Group Home to a STRTP (Short Term Therapeutic Program) on December 27, 2019. LPA was met at the facility by Facility Director, Clete Menke. LPA toured the facility inside and out at 12: PM. The facility is a one-story residence with five bedrooms and two bathrooms for the clients. Four bedrooms are arranged so that there is one client and their infant in a room. One bedroom is arranged so that there is one client in a room and two infants. There is adequate closet and drawer space for client's belongings. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. The bathrooms were clean and in good repair. The hot water was tested at 12: PM and registered at 115.1 degrees which is within the appropriate range of 105 degrees to 120 degrees. Cleansers/chemicals are locked and stored inside a locked cabinet in the kitchen. Sharp knives are inaccessible and stored inside a locked cabinet in the kitchen. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguisher is properly charged and serviced. There are no guns or weapons in the facility as stated by the Operations Director. LPA observed facility posted items in the hallway that included: Disaster Plan, Personal Rights, Grievance Procedures, and Foster Care Ombudsman poster. Client's medications were observed to be inaccessible and stored inside a locked cabinet next to the toddler play area. LPAs observed a minimum 7-day non-perishable and a 2-day perishable supply of food. There is one camera at the facility located on the wall in the kitchen/living room area. The facility outside grounds was also inspected and it was observed to be clean and well maintained. There are no bodies of water located on the premises. Emergency exits were free from obstruction. See Page Two The facility employs one Executive Director, one Operations Director, one Staff Manager, one Medical Coordinator, one Facility Coordinator, one Parenting Coordinator, one Head of Service, two Clinician, two Case Managers, two Mental Health Counselors, and 23 youth support staff. Licensee obtained their Mental Health (MH) Certification on May 17, 2021 and it expires on May 17, 2022. Licensee obtained National Accreditation through COA and the accreditation is valid through October 31, 2024. Licensee has received Medi-Cal approval on April 29, 2021. Licensing fee payments are current. LPA discussed the following with the Administrator: Physical Plant, Operational Requirements, Disaster Preparedness, Emergency Intervention Plan, and Core Therapeutic Services. Due to time constraints and the need to conduct client/staff file reviews and staff/client interviews, LPA will return at a later time to complete the annual inspection. Based on the facility inspection on this date, there are no deficiencies found at this time. An exit interview was conducted, and a copy of this report was provided to the Operations Director. Note: The annual for Mary's Shelter 1 (#306000793) was also conducted during the time of this inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On November 18, 2021, at 9: AM, Licensing Program Analysts (LPA), Jesus Cervantes continued the unannounced annual inspection, which was started on November 17, 2021. LPA met with Facility Director, Clete Menke. At 9: AM, LPA began to review a sample of ten staff files during the time of inspection. All ten staff files have met the training and qualification requirements per regulations requirements. Per a review of the Community Care Licensing Information System (LIS), all staff met DOJ/FBI criminal record clearances and Child Abuse Index Check requirements. All staff have proof in file of acknowledging the child abuse reporting requirements. Five of five facility staff were interviewed during the inspection. Due to the need to conduct additional client interviews, and continue client file reviews, this inspection will need to be continued at later date. Based on the facility inspection, staff interviews, and files reviewed on this date, there are no deficiencies found at this time. An exit interview was conducted, and a copy of this report was provided to Facility Director, Clete Menke.. Note: The annual for Mary's Shelter 1 (#306000793) was also conducted during the time of this inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On November 19, 2021, at 9: AM, Licensing Program Analysts (LPA), Jesus Cervantes continued the unannounced annual inspection, which was started on November 17, 2021. LPA met with Facility Director, Clete Menke. All the client files are stored and locked in the file cabinet in the staff office. At 9: AM, LPA reviewed a sample of five clients files during the time of inspection. All files contained the required documentation per Title Regulations. Two clients were interviewed during the inspection. Based on the facility inspection, client interviews, and client files reviewed on this date, there are no deficiencies found at this time. An exit interview was conducted, and a copy of this report was provided to Facility Director, Clete Menke. Note: The annual for Mary's Shelter 1 (#306000793) was also conducted during the time of this inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On November 17, 2023, at 08:55 am, Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera conducted an unannounced annual random inspection at Short Term Therapeutic Program facility. LPA was met with Facility Coordinator, Kathy McGinty. LPA toured the facility inside and out. The facility is a one-story residence with five bedrooms and two communal bathrooms for the clients. The bedrooms are arranged so that there is one client and one infant in each of the bedrooms. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. There is adequate closet and drawer space for client's belongings. The bathroom was clean and in good repair. The hot water was tested and registered at 110.4 degrees which is within the appropriate range of 105 degrees to 120 degrees. Cleansers/chemicals are locked and stored inside a locked cabinet in the laundry room and inside a locked cabinet in the kitchen. Sharp knives are inaccessible and stored inside a locked cabinet in the kitchen. The facility's smoke detectors were checked and were operable. There are no guns or weapons in the facility as stated by the Operations Director. LPA observed facility posted items in the hallway that included: Disaster Plan, Personal Rights, Grievance Procedures, and Foster Care Ombudsman poster. There are no guns or weapons in the facility as stated by the Facility Coordinator. Client's medications were observed to be inaccessible and stored inside a double locked cabinet in the staff's office. Medication records were reviewed and observed to be completed with dates and staff initials on dispensing records. LPA observed a minimum seven-day non-perishable and a two-day perishable supply of food. There is one camera at the facility located on the wall in the kitchen/living room area. The facility outside grounds was also inspected and it was observed to be clean and well maintained. There are no bodies of water located on the premises. Emergency exits were free from obstruction. Continued on page On November 07, 2023, LPA reviewed six client files and all the files had the required documents per Title Regulations. LPA reviewed six personnel records/files. Staff have Criminal Background and Child Abuse Clearances which are complete. All the staff have met the training and qualifications per Title Regulations The licensing fee payments are current. Based on the facility inspection on this date, there are no deficiencies found at this time. An exit interview was conducted, and a copy of this report was provided to Kathy Mcginty.


summary: Facility Evaluation

raw_content:
Narrative:
The purpose of this LIC 809 continuation form was so that Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera can attach the inspection tool form used to complete the annual inspection. Due to FAS technical difficulties the care tools did not attach correctly.


summary: Facility Evaluation

raw_content:
Narrative:
On November 8, 2024, at 2:00 pm, Licensing Program Analyst (LPA) Charmaine Linley, conducted an unannounced annual random inspection at the Short Term Therapeutic Program facility. LPA met with Vanessa McGinty, Facility Coordinator and Jill Dominguez, Facility Administrator, and toured the facility with Vanessa McGinty. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. The facility is a one-story residence with five bedrooms and two communal bathrooms for the clients. The bedrooms are arranged so that there is one client and infant in each of the bedrooms. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. There is adequate closet and drawer space for client's belongings. The bathroom was clean and in good repair. The hot water was tested and registered at 109 degrees at 10:09 am, which is within the appropriate range of 105 degrees to 120 degrees. Cleansers/chemicals are locked and stored inside a locked cabinet in the laundry room and inside a locked cabinet in the kitchen. Sharp knives are inaccessible and stored inside a locked cabinet in the kitchen. The facility's smoke detectors were checked and were operable; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. LPA observed a minimum 7-day non-perishable and 2-day perishable supply of food. The hot water was tested and registered at 111 degrees at 11:11 am, which is within the appropriate range of 105 degrees to 120 degrees. There are no guns or weapons in the facility as stated by the Facility Administrator. LPA observed facility posted items in the hallway that included: Disaster Plan, Personal Rights, Grievance Procedures, and Foster Care Ombudsman poster. Client's medications were observed to be inaccessible and stored inside a double locked cabinet in the medication office. There is one camera at the facility located on the wall in the kitchen/living room area. The *** facility outside grounds was also inspected and it was observed to be clean and well maintained. There are no bodies of water located on the premises. Emergency exits were free from obstruction. All client files are stored and locked in the medication office. LPA reviewed four client (C1-4) files to ensure clients had all required documents per Title 22. LPA interviewed two clients. LPA reviewed five staff (S1-5) files and interviewed four staff. All staff met the minimum qualifications and training requirements. A review of records shows that all staff have FBI, DOJ, and Child Abuse Index Check clearances. All staff have proof in file of acknowledging the child abuse reporting requirements. The licensing fee payments are current. Based on the facility inspection on this date, there are no deficiencies found at this time. An exit interview was conducted, and a copy of this report was provided to Jill Dominguez. LPA requested copies of an updated LIC 500 and LIC 308 to be emailed to LPA. A copy of this report will be placed in the facility file.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 08/21/25, at 9: AM, Licensing Program Analysts (LPA) Gilbert Marquez and Stefanie Mutialu met with Derrick Perry, Vice President of Operations for the purpose of conducting an annual inspection of the facility. The Facility is licensed to serve five ambulatory clients ages 12-21 years old and six infants 0-24 months. The current census is four clients. The facility is current with licensing fees. The facility is a single-story dwelling. A physical plant inspection was completed with Kathy McGinty, Facility Coordinator, which included the following checks: five bedrooms and two communal bathrooms for the clients, kitchen, medication room, dining room, living room, one staff office, playroom for the infants, therapy room, and outdoor living space. One bedroom is approved for two infants; all other bedrooms are approved for one infant. All beds were observed with appropriate bedding and mattress in good repair. Bedrooms contained adequate drawers and closet space. The water temperature was tested in client bathroom #2 which measured 115.3 degrees Fahrenheit which is within the appropriate range of 105 degrees to 120 degrees Fahrenheit. The first aid kit was accessible to all staff and had all required supplies. There is one camera at the facility located on the wall in the kitchen/living room area. All required forms are posted including Grievance Procedures, Visitation Policies, Personal Rights form, and the Emergency Disaster Plan. Clients' medications were observed to be inaccessible and stored in medication room. Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. All facility smoke detectors and carbon monoxide detectors were **continued on LIC809C** **continued from LIC809** tested and observed to be in working order; fire extinguishers are properly charged and serviced. The Facility maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. LPA observed a minimum seven-day non-perishable and two-day perishable supply of food. During the inspection, LPA observed staff S4 change the diaper of a client's baby on a marble counter. The facility is receiving a type B violation. LPA also asked staff S5 if any of the babies were more than 24 months. S5 stated that one was 28 months old. The facility is receiving a type B violation. Medication Records of four clients out of four (C1 - C4) were reviewed with Vanessa Ruiz, Residential Staff Manager. Per facility staff, no firearms or weapons are allowed in the facility. Due to time constraints, LPAs will return on another day to conduct client and staff interviews, and review files for clients and staff. Based on LPA's observation of a staff changing a baby that was not on the floor or using a changing table, the facility is receiving a type B violation. This is not in compliance with Interim Licensing Standards Section 87096.77(d) Personnel Services. Based on LPA review of client roster and short interview with a staff stating that a baby was over 24 months old, the facility is receiving a type B violation. This is not in compliance with California Code of Regulations, Title 22, Division Section 80010(a) Limitations on Capacity and Ambulatory Status. An exit interview was conducted to explain the facility evaluation report, along with LIC809D page, the Confidential Names List LIC811, the plan of corrections, and the appeal rights were given to Licensee, and additionally will be kept in the facility file.

Deficiencies:
87096.77(d): Personal Services

(d) Staff shall diaper each infant on a changing table, or on a changing pad placed on the floor, which meets the following specifications


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On August 22, 2025, at 10: AM, Licensing Program Analysts (LPA), Stefanie Mutialu and Gilbert Marquez continued the unannounced annual inspection, which was started on August 21, 2025. LPAs met with Clinical Supervisor, Kelli Strickland. During the inspection LPAs reviewed five staff files (S1-S5). Five out of five files contained the required documents including verification of criminal background check clearance, signed acknowledgment of mandated child abuse and neglect reporting requirements, and health screening. During inspection and Guardian verification, LPAs discovered S6 did not obtain required background clearance as required by Title 22 regulations. LPA's were unable to review client files as the facility did not make client records accessible. During the Annual Inspection on 08/21/25, upon arrival LPAs requested client records be accessible for review by 12: PM, after 12: PM LPAs were advised the files will be available electronically as the Quality Assurance Specialist (QAS) was working on sending the electronic files. After 2: PM LPAs were advised the QAS was having challenges sending the files, LPAs then received three client files but unable to open and review while in the field, Vice President of Operations (VPO), Derrick Perry then offered to go and pick up files at the corporate office that is a mile and a half away. Due to time constraints, LPAs were unable to wait and advised VPO to ensure all client records were available for review first thing on 08/22/2025. Upon LPAs arrival today, 08/22/25 at AM, QAS and VPO were not on site, and the present staff did not have access to client files.The facility is receiving a citation during today's visit. *Continued on Page 2* CONTINUED FROM PAGE LPAs conducted interviews with three staff (S1- S3) and with one client (C1). The facility is being cited for one type B citation for violation of California Code of Regulations, Title Division six, regulation 80070(d)(1): Client Records and one type A citation for Health and Safety Code 1522(c)(1):Administration and civil penalties of $500 ( X $100) will be assessed as per California Code of Regulations, Title Division six, regulation 80051(a)(2): Serious Deficiencies An exit interview was conducted with Clinical Supervisor, Kelli Strickland. A copy of this report and confidential names (LIC 811) dated 08/22/2025 was provided to Clinical Supervisor, Kelli Strickland.

Deficiencies:
80070(d): (d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements


summary: Facility Evaluation

raw_content:
Narrative:
On 09/04/25, at 3: PM, Licensing Program Analysts (LPA) Gilbert Marquez and Charmaine Linley met with Residental Staff Manager Vanessa Ruiz, for the purpose of continuing the annual inspection of the facility that started on 08/21/25. Facility is licensed to serve five ambulatory pregnant or parenting females ages 12-17 years old and six infants 0-24 months. Facility provides service to nonminor dependents. The current census is four clients. A health and safety tour of the facility was conducted, and no deficiencies were observed at this time. All the client files are stored on a secured database. LPA reviewed four client files (C1 - C4). All files contained the required documentation per Title Regulations. Client files had education records, physical examinations, Needs and Services plans, and mental health notes. LPA Marquez attempted to interview one of four clients who had not been previously interviewed for this annual inspection, and none of the four clients were not present at the time of the inspection. This was the LPA's third attempt to interview clients from this facility. Based on the facility inspection, client interview, and client files reviewed, there are no deficiencies found at this time. An exit interview was conducted, and a copy of this report was provided to Residental Staff Manager Vanessa Ruiz. Note: The annual for Mary's Shelter 1 (#306000793) was also conducted during the time of this inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On September 4, 2025, at 4:30 pm, Licensing Program Analysts (LPAs) Charmaine Linley and Gilbert Marquez conducted an unannounced inspection at the facility and met with Vanessa Ruiz, Residential Staff Manager. LPAs inquired where the Administrator was and were told the Administrator is off site at a training. This inspection is to discuss information that was reported to the Department and based on LPAs observations on August 21, 2025, and August 22, 2025. On August 21, 2025, LPAs Gilbert Marquez and Stefanie Mutialu arrived at the facility for an Annual Inspection and were at the facility from 9:30 am-5:00 pm and the Facility Administrator was not at the facility and did not arrive during the Annual Inspection. On August 22, 2025, LPAs Marquez and Mutialu arrived at the facility for a continuation of the Annual Inspection and were at the facility from 1:01 pm-5:40 pm, the Facility Administrator was not at the facility and did not arrive during the Annual Inspection. LPAs inquired if the Facility Administrator would arrive during the Annual Inspections and were told the Facility Administrator was only available via phone contact. Confidential interviews indicated that the Facility Administrator is not at the facility twenty hours per week as required; the Facility Administrator is present one day a week at the facility. Facility Administrator/CEO and Vice-President of Operations called LPA and stated they would drive to the facility and arrive at 5:00 pm and arrived at 5:05 pm. Based on confidential interviews and LPA's observations, the facility is being cited for a Type B violation of the Interim Licensing Standards STRTP 87064(b)(1) Administrator Qualifications and Duties. Refer to LIC809D. An exit interview was conducted, and appeal rights were reviewed with Jill Dominguez and Derrick Perry. A copy of this report and appeal rights were provided to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On January 14, 2026, at 8:00 pm, Licensing Program Analyst (LPA) Charmaine Linley was at the facility and received information that individuals were working at the facility from the Maxim agency. LPA Linley conducted two confidential interviews and noted there was one individual (A1) who did not have a criminal record clearance and was not cleared and associated prior to working at the facility. LPA reviewed Guardian to ensure that the individual did not have a criminal record clearance and record review indicated that A1 was not listed on the personnel report and was not listed in Guardian. LPA is administering one civil penalty during this visit. Based on record review and confidential interviews, the facility is being cited for the violation of California Code of Regulations, Title 22, Division Six, regulation 80019(a)(2)(d) Criminal Record Clearance (SEE LIC 809-D). An exit interview was conducted and appeal rights were discussed. A copy of this report and appeal rights were provided to the facility and a copy will be placed in the facility file