summary: Facility Evaluation

raw_content:
Narrative:
On Thursday October 28, Licensing Program Analysts (LPA) Isabel Mendoza made an unannounced annual required inspection to this facility. LPA met with Administrator (Maria Baris), Assistant Administrator (Elizabeth Franco), and House Manager (Melissa Ferreras). The facility consists of six bedrooms (four single rooms for clients, one staff bedroom and one staff office), and three bathrooms. The facility is licensed for a capacity of 4, and currently three clients are in care. No clients were in care during today's inspection. At 9: AM LPA did a walk thru the facility is clean, safe and sanitary and in good repair. All passageways are unobstructed. There is an outdoor space for the clients, and no hazards or broken items. There are no pools or bodies of water. All disinfectants, cleaning solutions and poisons are locked in cabinet in the garage. Per Administrator Maria there are no firearms in the facility. The inspected bedrooms were furnished accordingly. The kitchen is clean and sanitary. Sharp objects are locked away. Water temperature measured 105 degrees. The facility has sufficient two day perishable and seven day nonperishable food supply. Personal Rights and Emergency Disaster Plans are posted and in clear view in the dining room. Medications are located in a locked cabinet in the staff office. LPA inspected all medications and found no issues. LPA inspected MAR binder and advised the facility to use LIC B to ensure that the psychotropic MAR has all required items on each MAR. Currently, the MAR is missing quantity prescribed, and number of refills. However, all this information is listed on the facilities Centrally Stored Medication Log. The Administrator and House Manager confirmed that the facility will start using CCL's Psychotropic (MAR) effective 11/1/21. [Please Cont. To Lic 809-c...] At 9: AM LPA Mendoza reviewed all 3 client files and during file review LPA was unable to locate a written authorization of the child's parent or guardian, for each psychotropic medication. The facility confirmed that they do not have this on file and will contact all authorized representatives. At 10: AM LPA Mendoza reviewed (10) staff files and all files were complete. All staff training hours meet the minimum requirements. All staff are showing association to the facility. During inspection, LPA interviewed all three staff members. LPA obtained copies of the following documents: LIC Emergency Disaster Plan, LIC 500, LIC 308, LIC 309, and Maria's Group Home Administrator Certificate. No deficiencies were cited during todays inspection, but (2) Technical Violations 84070(b)(12) Children Record's, and 84070(b)(13)( C) Children Record's were issued. A copy of the report was left with the Administrator.

met_with: Maria Baris- Administrator


state: CA

facility_name: LIZA'S HOME

summary: Facility Evaluation

raw_content:
Narrative:
On 10/28/22 at 11:15AM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility for a required annual inspection. LPA met with Licensee Maria Barris, Administrator Melissa Ferreras, and Lead Staff Maricris Valenzuela and informed of the purpose of the visit. LPA used the CARE Inspection Tool to conduct this inspection. LPA conducted a tour, interviews of staff, an observation of present resident, and a review of facility, personnel, and resident records. Three of the four residents were still at school at the end of the visit. The facility is clean and kitchen and bathrooms are organized and sanitary. Food is of good quality, within date, and in a quantity to meet the needs of residents in care. Residents medications and prescribed supplements are stored in a central location where inaccessible to residents. Medication records reflect accurate administration and storage. Sharp and/or dangerous items and chemicals are kept locked and inaccessible to residents. The facility has the license, emergency plan, personal rights, food menu, and activity schedule posted. Bedrooms are clean, and each resident has their own room with their own bed, each with clean linens and mattress pad, and ample personal storage. Smoke and carbon monoxide detectors are functioning. All staff have clearances associated to the facility and have valid first aid and emergency intervention certificates as well as have received required hours of annual training. The tool found no deficiencies. No citations were issued at today's visit. An exit interview was conducted, and a copy of this report was provided to Licensee Maria Barris, whose signature on this form confirms receipt.

report_type: Facility Evaluation

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, an unannounced annual inspection was conducted by LPA (Licensing Program Analyst) Celeste Aparicio and Licensing Program Manager (LPM) Lidia Tinoco at Liza's Home And met with Administrator Melissa Ferreras. LPA inspected the facility, inside and out. Centrally stored medications are maintained 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. Individual beds were observed with appropriate clean linens and are in good repair. There is at least one-week supply of nonperishable and a two-day supply of perishable foods. The facility is maintained at 76 degrees. Facility has cameras in common areas of the facility. No firearms or weapons are allowed in the facility. Administrator is present at the facility a minimum of 20 hours a week, as verified by staff schedule and interviews. Appropriate staff/client ratios were verified during this inspection. The facility employs 12 direct care staff. 4 records of personnel/ staff members were reviewed to ensure staff meet regulatory requirements. All personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Personnel Files are maintained on-site. 4 records of clients were reviewed. Interviews with clients were not conducted as they are non-verbal. Inspection included an overview of required Core Services and Supports and based upon inspection of facility records and interviews of staff, Licensee appears to be meeting requirements. There were no deficiencies to be cited on this date.

met_with: Melissa Ferreras


summary: Facility Evaluation

raw_content:
Narrative:
On 10/15/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a required annual inspection. LPA met with Administrator Melissa Ferreras and informed of the purpose of the visit. LPA used the CARE Inspection Tool and conducted a tour of the facility site, review of 5 personnel records and 4 resident records, and confidential interviews with 2 staff members. All 4 residents in care are nonverbal. LPA observed the residents' condition and interactions with staff. LPA observed the facility to be clean and well organized. Kitchen and bathrooms are sanitary. The facility is currently at the licensed capacity of 4 residents, and each resident has their own bedroom with individual beds and plenty of storage for personal items. The rooms and common spaces are nicely decorated and furnished with activity sets and toys appropriate for the served population. Medications, sharps, and chemicals are stored where inaccessible to the residents. Cameras are posted in public spaces, and the licensee recently submitted program statement revisions with surveillance camera procedures, as requested. LPA observed personnel and resident records to be complete. Staff have full background clearances, valid intervention and first aid training certifications, and have completed their annual training hours. Residents' records contain current emergency contact information, complete care plans, and accurate medication and cash records. LPA observed interviewed staff to be knoweldgeable of facility policies, mandated reporting, and intervention procedures. LPA observed residents to each be provided 1:1 supervision, to be dressed in well-fitting, appropriate, and clean clothes, and to appear comfortable in care, showing no hesitation around staff or in responding to staff guidance. No deficiencies were observed. An exit interview was conducted, and a copy of this report was left with Administrator.

met_with: Administrator Melissa Ferreras


summary: Facility Evaluation

raw_content:
Narrative:
On 10/2/25, Licensing Program Analyst (LPA) Mariah Hawkins conducted a required annual inspection. LPA met with Administrator Melissa Ferreras and informed of the purpose of the visit. LPA conducted a tour of the facility site and observed the facility to be in clean and safe condition. The kitchen is well stocked with food supply to meet the needs of the clients in care, including special dietary requirements. The facility grounds are free of hazards and maintained in safe condition. Bedrooms are clean and organized and offer individual beds and clean linens. Medications and chemicals are secured. LPA inspected facility records, including 5 personnel files and 4 client files. All staff listed on the staff schedule have a valid background clearance. Files reflect complete and accurate records, including current training certifications in personnel files and current cash resource records in client files. LPA conducted confidential staff interviews and client observation.. Clients in care are nonverbal or limited-verbal. Using the CARE Inspection Tool, no deficiencies were found and no citations were issued. An exit interview was conducted, and a copy of this report was provided to Administrator.


facility_name: MALABAR HOUSE

summary: Facility Evaluation

raw_content:
Narrative:
At 12:28PM, Licensing Program Analyst (LPA) Madi Fremont traveled to the home above for the purpose of conducting an unannounced Required Annual Inspection. LPA met with Executive Assistant Anu Sahota, who helped facilitate this inspection. The current census is 0. Two staff were present at the time of this inspection. Due to the possibility of recent exposure to COVID-19, one staff member (Administrator Anne Randolph) is still waiting for their test results, so LPA Fremont will be conducting this inspection on two separate days. On 09/01/2021, LPA conducted the file review portion of the annual inspection. During this inspection, there were not any clients in placement. LPA inquired about full client files and was informed by Ms. Sahota that due to the facility being more of an emergency shelter than a group home, they often do not receive all required documents for all youth in placement. LPA did not review any client files. All staff files are kept in the Licensee office, and will be brought to the home when LPA Fremont returns to finish this inspection once all staff are cleared from COVID-19. At this time, no deficiencies were observed or cited. An exit interview was conducted, and a copy of this report was emailed to Executive Assistant Anu Sahota, whose signature on this form confirms receipt.

met_with: Executive Assistant Anu Sahota


summary: Facility Evaluation

raw_content:
Narrative:
On 8/29/22 at 10: AM, Licensing Program Analyst (LPA) Alyssa Ng made an unannounced annual/required inspection to listed facility and met with Ann Marie Randolph, Administrator. The facility is licensed for six residents, and currently in placement are 0 clients. During this inspection, 0 clients and 2 staff were present in the home. Safety precautions were taken, including screening call, hand hygiene, and mask-wearing. LPA Ng toured the facility inside and out. The home is single storied and has three double occupancy bedrooms. All client bedrooms were equipped with comfortable furnishings which included ample storage space for clients' belongings and twin sized beds. Each bedroom has a closet with sliding doors for extra storage space. Client bathroom was clean and furnished with hygiene supplies for each client. The water temperature measured 119 degrees F. The thermostat measured 72 degrees. The facility is clean, safe and sanitary. The kitchen was observed to be clean and free of hazards or chemicals. Sharps were located in the staff office. Extra linens are located in a cabinet in the hallway. The weekly menu was posted in the kitchen. LPA observed at least 2 days of perishable foods and 7 days of nonperishable foods. The smoke detectors and fire extinguisher are in working order. No bodies of water on the premises. All walkways were free from debris or hazards. LPA Ng interviewed 2 staff and 0 clients. Clients in care are not placed for more than 48 judicial hours so therefore no client interviews or file reviews were done. Staff has a centralized binder that contained their training. Staff qualifications and other personal information are located in their individualized folders. LPA looked through all binders and were complete with all the required documentation. Staff records were observed to be complete and the facility in compliance. LPA Ng and Administrator Ann Marie discussed facility types like "Transitional Shelter Care" and "Youth Homelessness Prevention Center". LPA Ng gave Administrator copies of the Interim Licensing Standards for both facilities and discussed the different options. Administrator stated she would discuss it with the Director and Probation Department and will notify LPA Ng once a decision has been made. LPA Ng will also reach out to Administrator monthly to see if there are any updates. At this time, 0 deficiencies was cited. An exit interview was conducted, and a copy of this report was emailed to Ann Marie Randolph, Administrator.

met_with: Ann Marie Randolph


summary: Facility Evaluation

raw_content:
Narrative:
On 8/16/23 at 10: AM, Licensing Program Analyst (LPA) Alyssa Ng made an unannounced annual/required inspection to listed facility and met with Anne Marie Randolph, Administrator. The facility is licensed for six residents, and currently in placement are 0 clients. During this inspection, 0 clients and 2 staff were present in the home. Safety precautions were taken, including screening call, hand hygiene, and mask-wearing. LPA Ng toured the facility inside and out. The home is single storied and has three double occupancy bedrooms. All client bedrooms were equipped with comfortable furnishings which included ample storage space for clients' belongings and twin sized beds. Each bedroom has a closet with sliding doors for extra storage space. Client bathroom was clean and furnished with hygiene supplies for each client. The water temperature measured 119 degrees F. The thermostat measured 72 degrees. The facility is clean, safe and sanitary. The kitchen was observed to be clean and free of hazards or chemicals. Sharps were located in the staff office. Extra linens are located in a cabinet in the hallway. The weekly menu was posted in the kitchen. LPA observed at least 2 days of perishable foods and 7 days of nonperishable foods. The smoke detectors and fire extinguisher are in working order. No bodies of water on the premises. All walkways were free from debris or hazards. LPA Ng interviewed 2 staff and 0 clients. Clients in care are not placed for more than 48 judicial hours so therefore no client interviews or file reviews were done. Staff has a centralized binder that contained their training. Staff qualifications and other personal information are located in their individualized folders. LPA looked through all binders and were complete with all the required documentation. Staff records were observed to be complete and the facility in compliance. Last year, there was a conversation in regards to changing their facility type. LPA Ng will coordinate with Administrator Anne a time to meet via Teams. At this time, 0 deficiencies was cited. An exit interview was conducted, and a copy of this report was emailed to Anne Marie Randolph, Administrator.

met_with: Anne Marie Randolph


summary: Facility Evaluation

raw_content:
Narrative:
On 8/28/23 at 10: AM, CCL met with listed facility to discuss facility types. The following were in attendance: Carolyn Flynn- Licensing Program Manager Alyssa Ng - Licensing Program Analyst Anne Marie Randolph- Administrator Tiffany Tran - Facility Manager Carolynn Gray- Co-Founder The purpose of the meeting is to discuss the current facility type and how it applies to their current program. Anne who is the Administrator described the facility as a safe and no cost respite to youth in crisis. Youth are eligible if they are a Alameda County resident, 8-17 years old, not in foster care, and or probation. Youth can stay up to 48 judicial hours. CCL went through the different facility types and found that most of the facilities do not fall under what Malabar wants. CCL stated that they will discuss this further and get back to the facility when they have an answer/response. An exit interview was conducted, and a copy of this report was emailed to Administrator Anne Randolph with read receipt. Administrator Anne Randolph will sign and return to LPA Ng over email.

met_with: Anne Randolph


summary: Facility Evaluation

raw_content:
Narrative:
On 10/22/24 at 11: AM, Licensing Program Analyst (LPA) Shikya Belfield made an unannounced annual/required inspection to above listed facility and met with Administrator Anne Randolph. The facility is licensed for six residents, and currently in placement are 0 clients. During this inspection, 0 clients and one staff were present in the home. LPA Belfield toured the facility inside and out. The home is single storied and has three double occupancy bedrooms. All client bedrooms were equipped with comfortable furnishings which included ample storage space for clients' belongings and twin sized beds. Each bedroom has a closet with sliding doors for extra storage space. Client bathroom were clean and furnished with hygiene supplies. The thermostat measured 71 degrees. The facility is clean, safe and sanitary. The kitchen was observed to be clean and free of hazards or chemicals. Sharps were located in the staff office. Extra linens are located in a cabinet in the hallway. The weekly menu was posted in the kitchen. LPA observed at least 2 days of perishable foods and 7 days of nonperishable foods. The smoke detectors and fire extinguisher are in working order and were up to date in being serviced. There are no bodies of water on the premises. All walkways were free from debris or hazards. LPA Belfield interviewed one staff and 0 clients. Clients in care are not placed for more than 48 judicial hours so therefore no client interviews or file reviews were done. During a review of the facility files the board meeting minutes were not present. Administrator to submit copies of the most two recent board meeting minutes to LPA Belfield by end of business 10/24/24. At that time the inspection will be concluded. There were no violations of California Code of Regulations, Title 22, Division Six cited during this inspection. An exit interview was conducted and a copy of this report was left with Administrator Anne Randolph.


facility_name: MARKS HOUSE

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
LPA obtained statements from five (5) clients, (1 of the five being the alleged victim) and Five (5) staff. LPA obtained written letters from a client indicating her support from S1 and how well she is benefiting from the program; a thread of emails from S1 and the RP communication issues and concerns regarding C5's treatment plan and clinical diagnosis, informed RP of evidence of S1 communicating with her via email. The interviewed client's statements were congruent to S1's Multi-Family Group Therapy sessions were intense and that S1 tone of voice was loud, firm and confronting, but was not directed toward C5 or any other client; neither was it deemed to be intimidating manner that trigger an uncomfortable environment for clients to obtain proper treatment. LPA confirmed that the clients did not have an issue with S1 being "Loud" and identified her tone as form of caring gesture. LPA observed the clients at the facility appeared to comfortable in placement. LPA obtain numerous emails of from RP communicating with S1 regarding C5's treatment. RP did not identify any other client other than C5 that reportedly had issues and concerns about the treatment of other clients. However C5 denied that the allegations occurred and did not have any issues or concerns to report other than she was pleased with placement and did not have an issue with S1's tone of voice and stated that S1 "Cares Loud". LPA obtained several emails of communication with RP and various documents: C Progress in treatment, Discharge/Transfer Summary and a Hillcrest Adolescent Treatment Center Family Agreement: Digitally Signature/s, timestamp in agreement by: Dated 05/01/2021; C5's Clinical Treatment Plan that included clinical diagnosis (Dated 05/11-and 05/19/2021; Progress Notes; and emails communication between S1 and RP. C5 was discharged prior to expectation to successful in achieve all treatment goals. LPA assessed that Marks House Clinical Treatment Team, Administration and Management Team assess all client needs and provide services to ensure that clients have the necessary tools and interventions in place to treat specific diagnosis. Although the allegations may have happened are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations Personal Rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. Per California Code of Regulations, Title Regulations, Division 6, Chapters 1 & 5 (GROUP HOMES), There are no deficiencies noted or cited. An exit interview was conducted, and a copy of this report was left at the facility.

Investigation Findings:
13On 07/28/202110: AM (LPA) Licensing Program Analysts Rosslyn Gray arrived at the MARKS HOUSE CAMPUS to conclude the investigation on the above allegation/s and to deliver the findings. LPA met with the Program Administrator Based on the interviews and statements obtained during the investigation process, the allegation cannot be corroborated because supporting evidence includes the following: Supporting evidence obtained from the internal Investigation conducted revealed that there is no enough evidence to support the allegations that "Staff yells at minors; Staff are not providing a comfortable environment for minors; Staff are intimidating minors; S1 did not keep minors personal information confidential; Staff denied minors authorized representative from obtaining minors records; Staff did not keep minors authorized representative informed of minor's treatment plan; Staff are falsifying minors records. Evidence to support that C5 was provided with support to meet her needs and to within 30 days of placement. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Rosslyn Y. Gray 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 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: MARKS HOUSEFACILITY NUMBER: VISIT DATE: 07/28/2021

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

report_type: Complaint Investigation

met_with: STAFF #1

complaint_status: unsubstantiated


raw_content:
Narrative:
Documents evidence and records obtained indicate a weekly schedule of therapeutic activities including records of signature participation. Records obtained indicate that the facility followed proper discharge protocol. Evidence obtained show that the authorized representative was provided with medical records including treatment plans and delivered upon request. Due to lack of evidence and conflicting statements obtained during the investigation, LPA determines that the allegation of Neglect and Lack of supervision and three (3) allegations of Personal Rights are Unsubstantiated at this time meaning, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. There are no deficiencies cited at this time. An exit interview was conducted, and a copy of this report was left at the facility.

Investigation Findings:
13On August 26, 2022, at 3: PM Licensing Program Analyst (LPA), Rosslyn Gray made an unannounced visit to conclude the investigation and to deliver the findings. LPA conducted a Health and safety risk assessment upon arriving at the facility. During the investigation, LPA-Gray interviewed and accounted for all available relevant parties; and gathered pertinent information in reference to the allegations. The Licensee denied the allegations. Based on confidential interviews and review of documentary evidence there is no evidence or witnesses to support that the facility staff did not prevent minor from engaging in inappropriate behaviors, that the minor was not provided therapy in a timely manner, and that the staff did not follow proper discharge protocol and staff did not provide minors authorized representative with medical records. Documentary interviews were congruent that staff provided proper interventions, utilizing methods of crisis communication and therapy to redirect to prevent inappropriate behaviors such as self-harm. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Rosslyn Y. Gray 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 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: MARKS HOUSEFACILITY NUMBER: VISIT DATE: 08/26/2022

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: Administrator


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Based on witness and staff testimony evidence, LPA concludes that there have been times when the facility was operating out of ratio, which means that the facility did not have enough staff to provide adequate coverage and supervision of clients. Based on the available information LPA gathered from interviews, the preponderance of the evidence standard has been met; therefore, the allegations of "Facility does not provide adequate coverage and supervision of clients" are found to be substantiated. Allegation:"Staff do not keep minors information confidential." During the course of the investigation, LPA interviewed involved staff, clients, and witnesses. Multiple staff and witness testimonies confirmed that under the previous Administrator, the facility was using the "Teams App" to communicate. This included sharing client information and records that are supposed to be kept confidential. Staff interviews revealed that using the "Teams App" was a practice done by the previous Administrator, and that the current Administrator has removed the practice. Based on witness and staff testimony evidence, LPA concludes that the "Teams App" was used by the facility to communicate, send, and access private and confidential client information, which means the clients' personal rights of privacy and confidentiality was being violated. Based on the available information LPA gathered from interviews, the preponderance of the evidence standard has been met; therefore, the allegations of "Staff do not keep minors information confidential" are found to be substantiated. Allegation: "Facility does not create and send necessary reports." During the course of the investigation, LPA interviewed involved staff, clients, and witnesses. Witness interviews claimed that the facility is not creating or sending the necessary Incident Reports (IR)to Licensing for client incidents. Staff interviews also admitted that there were some events and incidents that were not reported to licensing. Staff interviews shared that there was an instance where a client was softly hitting their head against the wall, and that the client's guardian shared that this was normal behavior. Based on this information and the client's refusal for medical treatment, the facility admitted to not creating or sending an incident report. LPA informed the facility that, due to the unusual nature of the incident and the potential risk of harm caused by the client that the incident needed to be reported. Based on witness and staff testimony evidence, LPA concludes that an incident occurred that was reportable but was not reported by the facility. Facility staff admit to not reporting a specific incident that should have been reported.Based on the available information LPA gathered from interviews and records review, the preponderance of the evidence standard has been met; therefore, the allegation of "Facility does not create and send necessary reports" is found to be substantiated. An exit interview was conducted, during which LPA provided the Administrator with a copy of this report and a copy of their appeal rights.

Investigation Findings:
13On 7/18/25 at 2: PM, Licensing Program Analyst (LPA) Reagan Cohen arrived at the above facility and met with Administrator Julia Gindi for the purpose of delivering complaint findings regarding the above allegation. Allegations:"Facility does not provide adequate coverage and supervision of clients." During the course of the investigation, LPA interviewed involved staff, clients, and witnesses. Multiple testimonies confirmed that there were a number of times, while under the old Administrator, that the facility would operate out of ratio; therefore, the facility was not providing adequate coverage and supervision of clients. During the interviews, all parties admitted that operating out of ratio was a problem under the previous Administrator. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Reagan Cohen 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 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: MARKS HOUSEFACILITY NUMBER: 198209614

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

met_with: Julia Gindi Administrator

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
Staff are trained to talk to clients when clients express self-harm, record clients' words and actions, and report to the clinical team and the management team. If there is an immediate emergency with a client actively causing self-harm harm staff are trained to physically intervene without being hands-on and will make a call to the PET team to address the situation. When clients are having a physical altercation with each other, staff are trained to discourage any horseplay and de-escalate any aggression by talking with clients, removing them from any triggers, and offering alternative outlets to express their feelings. Some witness testimonies expressed satisfaction with the care and intervention provided by facility staff to care for the clients when they self-harm. LPA received multiple conflicting testimonies regarding the staff's response to client's physical actions. Most interviews stated that the facility staff did adequately intervene and respond to clients when they expressed/committed self-harm and had physical altercations. Based on the available information LPA gathered from interviews, the preponderance of the evidence standard has not been met; therefore, the allegations of "Staff do not intervene when minors self-harm & Staff do not intervene when minors have physical altercations with other minors" are found to be unsubstantiated. Allegation: "Facility did not help staff make mandated reports." During the course of the investigation, LPA interviewed involved staff, clients, and witnesses. A witness interview shared an experience where they were trying to make a report as a mandated reporter, but the facility was not giving them the information they needed to make the report. Staff who were also involved shared that the witness who was trying to write the report was requesting confidential client information via their personal phone while not being on shift or at the facility. Staff interviews state that HR recommended not sharing client information over personal phones, to a person who is not at the facility, for a case that was closed according to the client's social worker. LPA received multiple conflicting testimonies regarding the facility's response to helping staff make mandated reports. Staff interviews clarified the situation in question, that a staff member was trying to make a report based on a client's case that HR confirmed was closed via the client's social worker. Staff interviews share that the facility's response is and was to help mandated reporters make their reports without violating clients' privacy and confidentiality. Based on the available information LPA gathered from interviews, the preponderance of the evidence standard has not been met; therefore, the allegation that the "Facility did not help staff make mandated reports" is found to be unsubstantiated. Allegation: "Facility practices labor law violations." During the course of the investigation, LPA interviewed involved staff, clients, and witnesses. A witness testified that because of the facility being understaffed at times, staff working by themselves are not able to take their breaks, use the bathroom, or eat lunch. Some staff interviews confirmed that this was an issue under the previous administrator, but it is not a current issue. Other staff interviews did not express experiencing an issue with lunches and breaks. LPA is already separately citing for client supervision and will not cite for the same issue twice. LPA received multiple conflicting testimonies regarding staff's ability to take breaks and remain in compliance with supervision. While most staff did confirm that this was a problem, staff also confirmed that it was due to previous leadership and has been fixed under the new administrator. LPA is already citing and providing a POC under another allegation that addresses this issue. Based on the available information LPA gathered from interviews, the preponderance of the evidence standard has not been met; therefore, the allegation of "Facility practices labor law violations" is found to be unsubstantiated. An exit interview was conducted, during which LPA provided the Administrator with a copy of this report and a copy of their appeal rights.

Investigation Findings:
13On 7/18/25 at 2: PM, Licensing Program Analyst (LPA) Reagan Cohen arrived at the above facility and met with Administrator Julia Gindi for the purpose of delivering complaint findings regarding the above allegation. Allegations:"Staff do not intervene when minors self-harm & Staff do not intervene when minors have physical altercations with other minors." During the course of the investigation, LPA interviewed involved staff, clients, and witnesses. Witness interviews claimed that there were multiple instances when clients cause self-harm or clients fight with each other, and the staff do not intervene or prevent these events from happening. Client interviews state that staff are always caring and attentive to their needs, and when they are having mental health and self-harm issues. Client interviews did not admit to any fighting or horseplay. Staff interviews shared that staff are trained to prevent client self-harm while remaining physically hands-off. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Reagan Cohen 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 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: MARKS HOUSEFACILITY NUMBER: VISIT DATE: 07/18/2025

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


summary: Facility Evaluation

raw_content:
Narrative:
On 09/21/2021 9:30am Licensing Program Analyst (LPA) Rosslyn Gray made an unannounced to MARKS HOUSE for the purpose to conduct the Annual/Required licensing Inspection. LPA met with the Program Administrator, who granted access into the home, and who provided a tour of the entire physical plant inside and out. The facility is licensed to care for up to six (6) Male and Female children, ages 12-17 years, Ambulatory only. The facility acquired The National Accreditation through Commission on Accreditation of Rehabilitation Facilities (CARF) valid through 11/30/2022. The is a swimming pool (8 feet pool) that meets regulations. Staff confirmed that there are no firearms or dangerous weapons in the facility. Group Home Overview: This is a (2) two-story Group Home facility. There is three (3) car garage that has been converted in a game room and supply room with eleven (11) tall cabinets and eight (8) drawers for over stock toiletries, arts and craft. It has an extra freezer and a refrigerator, Ping-Pong table and an Air hockey table. There are total of four (4) operable fire places throughout the facility. All are were observed to be secure screens, glass doors and a gas key locked device. The Location of the fire places are in the "Oval office", main living room, entertainment and the master bedroom and a outside fire pit. Bedroom/ Bathrooms: All Located on the 2nd Floor of the facility. There is a total of four (4) bedrooms, (2 single, and 2 double occupancy bedrooms); equipped with Queen size beds in each room. LPA observed that each bedroom has its own, bathroom. Bedroom #4: The "Vegas Room" identified as the Master Bedroom is currently unoccupied. It is to be utilized in the event of an emergency and or crisis (i.e Quarantine room and or a separation room). The bedroom is equipped with a one (1) Queen sized bed, comfortable mattress, clean lines, a blanket, and pillows. It is equipped with 2 walk-in closets a storage closet, and a large vanity mirror. There is adequate lighting, ample drawer and closet space, the windows are slide locked with vertical shades; observed to be in good condition. This bedroom is equipped with its own a full-size walk-in bathroom, which has 2 entry doors; 1 door has access to a sink, toilet, and shower, and the 2nd door has access to a bathtub a toilet, a Bidet, jacuzzi tube and a double shower. The shower has 2 doors, that joins both sides of the master bathroom. LPA observed the balcony a double glass door with access to a balcony. The door is not used for an exit and always remains locked. The Director will ensure to inform LPA when this room is being utilized an (SIR) Special Incident Report will be documented and submitted. Bedroom # 3 -Currently occupied by one (1) child. There is one (1) Queen size beds, comfortable mattresses, linen, blankets and pillows. There is one (1) walk in closets. There is adequate lighting and the windows are slide locked with vertical shades observed to be in good condition. There is ample drawer and closet space. This bedroom is equipped with its own a full-size walk-in bathroom with a sink, toilet, and shower and tub. Bedroom # 2 -Currently occupied by one (1) child. There are (2) Queen size beds, comfortable mattresses, linen, blankets and pillows. There is one (1) walk in closet. There is adequate lighting and the windows are slide locked with vertical shades observed to be in good condition. There is ample drawer and closet space. This bedroom is equipped with its own a full-size walk-in bathroom with a sink, toilet, and shower, tube. Bedroom # 1 - Currently occupied by one (1) child. There are (2) Queen size beds, comfortable mattresses, linen, blankets and pillows. There is one (1) walk in closet. There is adequate lighting and the windows are slide locked with vertical shades observed to be in good condition. There is ample drawer and closet space. This bedroom is equipped with its own a full-size walk-in bathroom with a sink, toilet, and shower, tube. Group Home Overview continued: There is one main office, 1 therapy; a living room, dining room, kitchen, breakfast area, family room, laundry area, and a large backyard. LPA Gray observed 8 interior and 7 exterior cameras on the premises. LPA observed the camera monitor in a staff office on the lower level that monitors a view of the front door only. Facility has submitting camera waiver. There are 2 staircases that have access to the 2nd level of the home. There are no security bars on the windows. LPA observed carbon Monoxide alarms, located on each floor were observed and functional in the home. LPA observed five (5) fully charged fire extinguishers located throughout the facility. Water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. Page 2 of Upper Level: Two (2) closets were observed in the hallway; 1 closet was observed to be empty, and 1 closet was observed to be locked and observed ample stored hygiene supplies and feminine products. The Nurses Station was locked, located inside the Group Therapy Room. Group Therapy Room: equipped with adequate furniture in good repair. There is a walk-in closet designated as the Nursing station. LPA observed a large orange First Aid kit complete with scissors, tweezers, thermometer, gauzes, antiseptic and 1st Aid Manual. There is also a small refrigerator for storage of client medication that requires refrigeration. There is additional Group Therapy Room: used for yoga, meditation, breathing technique therapy. Individual & Family Therapy Room: located near the front entry staircase and is equipped with a desk, two (2) chairs and two (2) dressers. Lower Level: Located at the entrance there is a staff closet and a 1/2 bath: The closet is equipped with a fingerprint clock-in/out system for staff. Living Room: with securely covered fireplace with plenty of seating that has access to the backyard. Dining Room: equipped with a large table with twelve (12) chairs. There is a total of twelve (12) chairs in the main dining room; and the kitchen table has three (3) chair and two (2) high chairs. Kitchen: LPA observed the monthly/weekly menu posted on the wall. The kitchen. equipped with a refrigerator, 2 ovens, a five (5) functional gas burners, and an island that is not used for kitchen supplied other than knives and forks. The is plenty of cabinet space. The knives and sharp objects are stored in a locked drawer space within one of the lower kitchen cabinets. Chemicals and cleaning solutions are kept in locked cabinets located in the garage. A monthly/ weekly menu was observed and posted in the kitchen and food service adequate for breakfast, and snacks, lunch and dinner. Meals are prepared by a Private Chef. Breakfast area: is equipped with a table and six (6) chairs. LPA observed a control panel for the pool/spa, equipped with an intercom system that is non-functional. Family Room: equipped with a secure cover on the fireplace, and plenty of clean furniture in good repair. Grievance procedure, and Emergency Disaster Plan postings were observed to be posted here. Laundry area: equipped with a washer and dryer, and plenty of cabinet space where a fully charged fire extinguisher, and extra clean linens were observed. The laundry detergent is locked in a locked supply room and will distributed to the clients individually according to the load of their laundry. LPA observed a Laundry Chute that is used for towels and some bedding. Page 3 of School: Equipped with a portable air-conditioning, fully charged fire extinguisher, smoke alarm, 7 tables, 10 chairs, a printer, and whiteboard. Licensee reported that each client shall have access to his/her own laptop during school hours. When laptops are not in use, laptops are stored in the nursing station. Exterior: The large outdoor activity space is free of obstructions. There are three (3) lounge large patio spaces; equipped with a ceiling fans cover outdoor furniture; The backyard is equipped with an outdoor gas fireplace that has a screen that covers the fireplace, which consists of fake logs; 3/4 bathroom attached to the home; a built-in BBQ island with a small refrigerator and sink; a tennis court with a basketball court with a mounted hoop. A large detached air-conditioned building used as a pool/therapy room equipped with 1 large couch, 1/2-bathroom, closet space, a small kitchen with a small refrigerator, dishwasher, and sink; a locked wine cellar that is used only for storage, POOL: Located in the backyard, there is a fenced and gated pool on the premises that meets regulations. There is a bridge with rope railings crosses that leads to the Waterfall/Koi Pond that has been inspected and with an approved net covering. Licensee will ensure that individual supervising children in the pool area is Water Safety trained. This facility has no alarms active to alert when doors or windows have been opened. Facility appears to be clean, safe, sanitary, and in good repair. All posting requirements and Emergency Plan were met. Children will be accorded personal rights. The facility current License, Mental Health Certification; Ombudsperson Grievances and Personal Rights; are posted on the wall. Children are not restricted to make phones calls based on the court and or authorized representative. There is a private room available for the clients to make phones calls and the Phone Call Log is kept in the clients file. LPA observed the child's Needs and Services plans kept in the client's chart; (filed electronic medical records). Some outside extracurricular activities and social events that take persons into public or crowded places have been restricted. Alternate activities have been implemented based the compliance of the client. There were no deficiencies cited at this time. LPA will return to the facility at a later date to complete the inspection tool (i.e Staff Records review, Staff and client interviews and include information regarding the Emergency Preparedness.) LPA-Gray concluded the inspection and a copy of this report was left at the facility with the Program Administrator on 09/21/2021. Page 4 of 4

met_with: Program Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 09/23/2021 at 10: AM Licensing Program Analyst (LPA') Rosslyn Gray, made an announced visit to MARKS HOUSE GROUP HOME. LPA conducted a Case Management-Annual Continuation Inspection. LPA met with the Program Director, identified as Staff #1(S1), who granted access to the facility and provided the requested information. LPA reviewed following during the inspection: Clients Records Review: S1 displayed clients files electronically stored in the facilities online Portal with Kipuworks.com LPA reviewed three (3) clients records currently in placement according to the observed Census. Staff Records Review: S1 displayed Ten (10) active employees files stored electronically in S-Drive. LPA viewed the details of the information in the Staff records provided by S1. LPA ensured to thoroughly review the records of active primary staff; Program Director/Administrator, Primary Therapist, Clinical Director, Office Manager, Licensed Vocational Nurse and Five (5) Program Assistants. LPA conducted a confidential interview with five (5) on duty staff and three (3) clients that currently in placement were present. There were no deficiencies cited at this time. LPA concluded the Annual Inspection. An Exit interview was conducted, and a copy of this report was left at the facility with the Program Administrator.

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
On September 6, 2023 2: PM Licensing Program Analyst (LPA') Rosslyn Gray, made an announced visit to MARKS HOUSE GROUP HOME. LPA conducted a Annual/Random Inspection. LPA met with the Program Director, identified as Staff #1(S1), who granted access to the facility and provided a tour of the entire physical plant inside and out. The facility is licensed to care for up to six (6) Male and Female children, ages 12-17 years, Ambulatory only. The is a swimming pool (8 feet pool) that meets regulations. Staff confirmed that there are no firearms or dangerous weapons in the facility. Group Home Overview: This is a (2) two story Group Home facility. There is three (3) car garage that has been converted in a game room and supply room with eleven (11) tall cabinets and eight (8) drawers for over stock toiletries, arts and craft. It has an extra freezer and a refrigerator, Ping-Pong table and an Air hockey table. There are total of four (4) operable fire places throughout the facility. All are were observed to be secure screens, glass doors and a gas key locked device. The Location of the fire places are in the "Oval office", main living room, entertainment and the master bedroom and a outside fire pit. Bedroom/ Bathrooms: All Located on the 2nd Floor of the facility. There is a total of four (4) bedrooms, (2 single, and 2 double occupancy bedrooms); equipped with Queen size beds in each room. LPA observed that each bedroom has its own, bathroom. Bedroom #4: Is currently unoccupied. This bedroom is identified as the Vegas Room". It is equipped with a one (1) Queen sized bed, comfortable mattress, clean lines, a blanket, and pillows. It is equipped with a closet and a large vanity mirror. There is adequate lighting, ample drawer and closet space, the windows are slide locked with vertical shades; observed to be in good condition. Bedroom # 3 -Currently occupied by one (1) child. There is one (1) Queen size beds, comfortable mattresses, linen, blankets and pillows. There is one (1) walk in closets. There is adequate lighting and the windows are slide locked with vertical shades observed to be in good condition. There is ample drawer and closet space. This bedroom is equipped with its own a full-size walk-in bathroom with a sink, toilet, and shower and tub. Bedroom # 2 -Currently unoccupied. There are (2) Queen size beds, comfortable mattresses, linen, blankets and pillows. There is one (1) walk in closet. There is adequate lighting and the windows are slide locked with vertical shades observed to be in good condition. There is ample drawer and closet space. This bedroom is equipped with its own a full-size walk-in bathroom with a sink, toilet, and shower, tube. Bedroom # 1 - Currently occupied by one (1) child. This is identified as the Master Bedroom. This is are (2) Queen size beds, comfortable mattresses, linen, blankets and pillows. This bedroom is equipped with its own a full-size walk-in bathroom, which has 2 entry doors; 1 door has access to a sink, toilet, and shower, and the 2nd door has access to a bathtub a toilet, a Bidet, jacuzzi tube and a double shower. LPA observed the balcony a double glass door with access to a balcony. The door is not used for an exit and always remains locked. There is one (1) walk in closet. There is adequate lighting and the windows are slide locked with vertical shades observed to be in good condition. There is ample drawer space. Upper Level: Two (2) closets were observed in the hallway and observed to be locked. 1 closet was observed to have a supply of towels, linen an the other closet observed ample hygiene supplies and feminine products. School: Equipped with a portable air-conditioning, fully charged fire extinguisher, smoke alarm, three (3) tables, nine (9) chairs and a printer. Licensee reported that each client shall have access to his/her own laptop during school hours. When laptops are not in use, laptops are stored in the nursing station. Lic Page 2 of The Nurses Station was locked, located inside the Group Therapy Room. Group Therapy Room: equipped with adequate furniture in good repair. There is a walk-in closet designated as the Nursing station. LPA observed a large orange First Aid kit complete with scissors, tweezers, thermometer, gauzes, antiseptic and 1st Aid Manual. There is also a small refrigerator for storage of client medication that requires refrigeration. There is additional Group Therapy Room: used for yoga, meditation, breathing technique therapy. Individual & Family Therapy Room: located near the front entry staircase and is equipped with a desk, two (2) chairs and two (2) dressers. Lower Level: Located at the entrance there is a staff closet and a 1/2 bath: The closet is equipped with a fingerprint clock-in/out system for staff. Living Room: with securely covered fireplace with plenty of seating that has access to the backyard. Dining Room: equipped with a large table with twelve (12) chairs. Breakfast area: is equipped with a table and six (6) chairs and two (2) high chairs. LPA observed a control panel for the pool/spa, equipped with an intercom system that is non-functional. Kitchen: LPA observed the monthly/weekly menu posted on the wall. The kitchen. equipped with a refrigerator, 2 ovens, a five (5) functional gas burners, and an island that is not used for kitchen supplied other than knives and forks. The is plenty of cabinet space. The knives and sharp objects are stored in a locked drawer space within one of the lower kitchen cabinets. Chemicals and cleaning solutions are kept in locked cabinets located in the garage. A monthly/ weekly menu was observed and posted in the kitchen and food service adequate for breakfast, and snacks, lunch and dinner. Meals are prepared by a Private Chef. Family Room: equipped with a secure cover on the fireplace, and plenty of clean furniture in good repair. Grievance procedure, and Emergency Disaster Plan postings were observed to be posted here. Laundry area: equipped with a washer and dryer, and plenty of cabinet space where a fully charged fire extinguisher, and extra clean linens were observed. The laundry detergent is locked in a locked supply room and will distributed to the clients individually according to the load of their laundry. LPA observed a Laundry Chute that is used for towels and some bedding. LIC PAGE 3 of Exterior: The large outdoor activity space is free of obstructions. There are three (3) lounge large patio spaces; equipped with a ceiling fans cover outdoor furniture; The backyard is equipped with an outdoor gas fireplace that has a screen that covers the fireplace, which consists of superficial wood logs; 3/4 bathroom attached to the home; a built-in BBQ island with a small refrigerator and sink; a tennis court with a basketball court with a mounted hoop. A large detached air-conditioned building used as a pool/therapy room equipped with 1 large couch, 1/bathroom, closet space, a small kitchen with a small refrigerator, dishwasher, and sink; a locked wine cellar that is used only for storage, POOL: Located in the backyard, there is a fenced and gated pool on the premises that meets regulations. There is a bridge with rope railings crosses that leads to the Waterfall/Koi Pond that has been inspected and with an approved net covering. Licensee will ensure that individual supervising children in the pool area is Water Safety trained. This facility has no alarms active to alert when doors or windows have been opened. Facility appears to be clean, safe, sanitary, and in good repair. All posting requirements and Emergency Plan were met. Children will be accorded personal rights. The facility current License, Mental Health Certification; grievances and Personal Rights; are posted on the wall. There is a private room available for the clients to make phones calls and the Phone Call Log is kept in the clients file. Children make phones calls based on the their authorized representative. Staff accompanies children to outside extracurricular activities and social events Alternate activities have been implemented based the compliance of the client. LPA conducted a confidential interview with one (1)of the four (4) on duty staff and one (1)of the 2) clients that currently present in placement according to the observed Census. LPA will return to the facility at a later date to complete the inspection tool (i.e Staff Records review, Client records review (i.e child's Needs and Services plans and electronic medical records), and to interview three (3) staff and one (1) client. There were no deficiencies cited at this time. An Exit interview was conducted, and a copy of this report was left at the facility with the Program Director. LIC PAGE 4 of 4


summary: Facility Evaluation

raw_content:
Narrative:
On 09/14/2023 at 2:15PM Licensing Program Analyst (LPA') Rosslyn Gray, made an announced visit to MARKS HOUSE GROUP HOME. LPA conducted a Case Management-Annual Continuation Inspection. LPA met with the Administrator identified as Staff #1(S1), who granted access to the facility and provided the requested information. LPA reviewed following during the inspection: Staff/Clients Records Review: S1 displayed clients files electronically stored in the facilities online Portal with Kipuworks.com. S1 displayed four (4) active employees files stored electronically in S-Drive and three (3) clients records. LPA ensured to thoroughly review the records of active staff, Program Administrator, Program Director, Director of Education and a Program Assistant. LPA reviewed (i.e child's Needs and Services plans and electronic medical records). LPA conducted a confidential interview with three (3) staff and one (1) client. There were no deficiencies cited at this time. LPA concluded the Annual/Random Inspection. An Exit interview was conducted, and a copy of this report was left at the facility with the Program Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On February 21, 2024, at 11: AM, Licensing Program Analyst, Rosslyn Gray made an unannounced visit to Marks House for the purpose of conducting a Case Management Investigation. LPA met with Administrator/Christine Tonoli. A health and safety assessment was conducted prior to entering facility. The department received an Incident Report dated October 17, 2023. The Incident Report disclosed that Child #1 (C1) was found face down in shower. Incident report further indicated that C1 missed two doses of medication due to prescription not being available. During the investigation process, LPA conducted interviews, requested copies of Medication Administration Records (MAR) for Child #1 (C1), Incident Report, Staff #1 (S1) disciplinary action document, and medication administration protocols. Based on the information obtained during this visit, additional investigation is needed. Appeal Rights were issued, and a copy of this report was left at the facility Based on the information obtained during this visit, additional investigation is needed. Appeal Rights were issued, and a copy of this report was left at the Facility Administrator/Christine Tonoli.

met_with: ADMINISTRATOR/CHRISTINE TONOLI


summary: Facility Evaluation

raw_content:
Narrative:
On September 05, 2024, at 10:30AM Rosslyn Gray, Licensing Program Analyst (LPA) arrived at the above facility for the purpose of conducting a Case Management - Incident investigation. LPA met with Dominique Baker- Program Director and a health and safety assessment was conducted prior to entering facility. The department received an Unusual Incident/Injury Report (LIC 624) dated August 20 2024. The Incident Report disclosed that Child 1 (C1) reported to Staff 1 (S1) that she stole the keys and took a mouthful of Benadryl. C1 was rushed to the Emergency room at Los Robles Regional Medical Center in Thousand Oaks. C1's vitals were reported fine and was given a bed in the Emergency Room and was put under an 8 hour observation. During the investigation, LPA interviewed Dominique Baker- Program Director requested Personnel Report, client roster, C1's Discharge Summary, Hospital Discharge report, and authorized representative contact information. Based on the information obtained during this visit, additional investigation is needed. There were no deficiencies cited at this time. Exit interview was conducted with Dominique Baker- Program Director and a copy of this report was left at the facility.

met_with: Dominique Baker- Program Director


summary: Facility Evaluation

raw_content:
Narrative:
2045-FN On August 14, 2025 at 9:34, LPA Kenrick Ellis made an unannounced visit to the above facility for the purpose of conducting a case management incident report. LPA met with Julia Gindi, Administrator to discuss the Case Management-Incident investigation. A health and safety assessment was conducted prior to entering the facility. The department received an incident report dated 08/05/2025. On 8/1/25 it was reported that C1 and C2 and another client engaged in inappropriate sexual contact with each other in the evening. Clients C1 and C2 disclosed that the the contact was mutual and consensual between the clients. During the investigation LPA obtained a copy of the LIC 500, client roster, and interviewed four staff members and two clients. Based on the information provided additional information is needed. There are no deficiencies cited at this time. Exit interview was conducted with Julia Gindi and a copy of the report was provided via email.

met_with: Julia Gindi, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On March 1, 2024, at 10: AM, Licensing Program Analyst, Rosslyn Gray made an unannounced visit to Marks House for the purpose of concluding a Case Management Investigation. LPA met with Program Director Dominique Baker. A health and safety assessment were conducted prior to entering the facility. The department received an Incident Report dated October 17, 2023. The Incident Report disclosed that Child #1 (C1) was found face down in shower and C1 missed two doses of medication. During the investigation process, LPA conducted interviews, obtained copies of C Medication Administration Records (MAR) C1, Incident Reports, Staff 7 (S7) documented disciplinary action, previous and current medication administration protocols. Statements indicated that medication was on back-order at the local pharmacy. Documentary evidence indicated that C1 medication ran out on October 16, 2023. Statements and documented evidence indicated that S7 did not refill C1 medication. C1 missed two doses of medication. Medication refill was not until received October 17, 2023. Facility cited for violation of California Code of Regulations, Title Division Six, regulation 80078(a) Providing Care and Supervision. Medication was not refilled timely. C1 missed two doses of medication and experienced a medical emergency. A copy of this report and the Appeal Rights was provided to the Licensee. An exit interview was conducted, and a copy of this report was left with the Program Director Dominique Baker


summary: Facility Evaluation

raw_content:
Narrative:
On September 25, 2024, at 11: AM Rosslyn Gray, Licensing Program Analyst (LPA) arrived at the above facility for the purpose of conducting a Case Management - Incident investigation. LPA met with Gina Mc Auley Executive Director and a health and safety assessment was conducted prior to entering facility. The department received an Unusual Incident/Injury Report (LIC 624) dated August 20, 2024. The Incident Report disclosed that Child 1 (C1) reported to Staff 1 (S1) that she stole the keys and took a mouthful of Benadryl. C1 was rushed to the Emergency room at Los Robles Regional Medical Center in Thousand Oaks. C1's vitals were reported fine and was given a bed in the Emergency Room and was put under an 8-hour observation. During the investigation, LPA interviewed staff, obtained the Personnel Report, client roster, resignation letters, Psychiatric Discharge/Aftercare report, Program Assistant Job Summary, and the facilities Master Nursing Manual-Hillcrest . C1 disclosed to S1 that she stole the facility keys from facility computer bag, unlocked the entrance door to the medication room and took a hand full of Benadryl. There was not an internal investigation conducted. C1 received medical attention, was placed on a hold, discharged to their parents, transported back to the facility and readmitted back into program. S1 counted the number of remaining Benadryl but there was no records of a previous medication count to determine the number Benadryl C1 ingested. There was no evidence of an addendum received regarding the outcome medical attention from the emergency room at Los Robles Regional Medical Center, neither when C1 was readmitted at the facility. The facility is cited for violation of California Code and Regulations, Title Division Six, Regulation 80075 (k) (1) Health Related Services as evidence by; C1 gained access to the medication room and ingested a hand full of Benadryl. An exit interview was conducted with Gina Mc Auley Executive Director and a copy of this report and Appeal Rights was left at the facility.

met_with: Gina Mc Auley Executive Director


facility_name: MARYVALE

summary: Facility Evaluation

raw_content:
Narrative:
On 9/28/2021 at 10:58 am, Licensing Program Analyst (LPA) Jenny Mundo conducted an unannounced SB (Senate Bill) Psychotropic Medication inspection to the Group Home. LPA Mundo met with the facility's President & CEO Steve Gunther. The facility is temporarily closed. Therefore, there are no staff and clients at the facility. At 11:13 am, LPA Mundo conducted a tour of the inside and outside of the facility. The facility is clean, safe, sanitary and in good repair. All medications would be centrally stored, locked and accessible only to employees responsible for stored medication in the Health Service Office. LPA Mundo reviewed one (1) staff file on site and interviewed the President & CEO. A copy of this report and LIC811 was provided to the Group Home representative upon completion. No deficiency was found. LPA Mundo conducted an exit interview with the Group Home representative.

met_with: Steve Gunther, President & CEO


facility_name: MC ALISTER INSTITUTE GROUP HOME EAST

raw_content:
Narrative:
Confidential interviews stated all clients were participating in the pinching and the pinching stopped due to staff intervention. Confidential interviews stated law enforcement was contacted due to concerns, however no crime had been committed and clients were reminded of the program rules. Confidential interviews contradicted the information provided and denied the allegations occurred however; other information provided alleged the incidents occurred. Based on confidential interviews, the allegations that that staff did not properly supervise clients while in care may have occurred, however are not supported or proven by evidence. Therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this signed report was provided to Program Administrator, Eric Blank

Investigation Findings:
13On 09/21/2021, at 11:45 a.m. Licensing Program Analyst (LPA) Marisol Lopez arrived at the facility unannounced and met with Program Administrator Eric Blank, of McAlister Institute Group Home East to discuss the investigative findings for the allegation noted above. On 04/02/2021 at 10:30 a.m., due to COVID 19, LPA M. Lopez conducted an initial tele-inspection complaint investigation with Program Administrator Eric Blank for the above allegation. LPA conducted a safety inspection and no deficiencies were observed at that time. During the investigation, LPA Lopez conducted confidential interviews with one administrator, three of five clients (C1 through C5), three staff (S1, S2, S3) and reviewed incident reports. On 03/29/2021, the Department received an allegation that staff did not properly supervise clients while in care. It was reported clients were pinching each other resulting in C1 having a bruise and staff intervened when it occurred. It was also reported C1 was slapped in the head by another client. Confidential interviews stated staff were present and re-directed clients from pinching while laughing, however it was reported clients continued to pinch each other when staff looked away. (see continuation form LIC9099-C dated 09/21/2021) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Marisol Lopez 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 08-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, METROPOLITAN DR. # FACILITY NAME: MC ALISTER INSTITUTE GROUP HOME EASTFACILITY NUMBER: VISIT DATE: 09/21/2021

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

met_with: Eric Blank


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Veronica Whitaker and Licensing Program Manager (LPM), Angela King conducted a case management inspection on August 23, 2022, at 11: AM, based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code Section 1538.7. During this inspection, 8 out of Direct Care Staff and 5 out of 5 youth files were reviewed. 3 out of Direct Care Staff and 3 out of 5 youth were interviewed. (See the Confidential Names List, LIC 811, dated 8/23/22). The Plan of Operation including policies and procedures were reviewed, Minutes from the Board of Directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the treatment plan, youth case plans, and personal safety plan, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPM Angela King observed training records showing staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Yuriko Grijalva, Program Manager.

met_with: Yuriko Grijalva, Program Manager


summary: Facility Evaluation

raw_content:
Narrative:
On August 01, 2022, at 10 am Licensing Program Analysts (LPA's) Eduardo Barrragan and Marisol Lopez conducted a case management at MC Alister Institute Group Home East and met with Sharayah Horne, Counselor. The purpose of this inspection was to follow-up on a few concerns that were noted on a previous visit on 08/23/2022. LPA Barragan spoke with 1 of 4 clients, due to 2 clients refusing and 1 client being at a doctors visit. LPA's spoke with 2 of 2 staff (See the Confidential Names List, LIC 811, dated 09/01/22). The Plan of Operation including policies and procedures were also reviewed. LPA 's reviewed the program statement and group home regulations and ensured that the concerns that were noted on their previous visit (08/23/2022) were in compliance. Based on the LPA's conversations with staff, youth, record reviews, file review including the treatment plan, youth case plans, and personal safety plan, the licensee uses trauma informed and evidence based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate that the licensee prohibits calls or threats to call law enforcement as a form of discipline. Staff and client rations are being met based off of their program statement and group home regulations. There are no deficiencies cited at this time LPA's conducted an exit interview and a copy of this report and appeal rights were provided to Sharayah Horne, Counselor

met_with: Sharayah Horne, Counselor


summary: Facility Evaluation

raw_content:
Narrative:
On September 01, 2022 at 10: AM, Licensing Program Analyst (LPA) Marisol Lopez and LPA Eduardo Barragan conducted an unannounced inspection at the facility above. LPA's met with Program Representative (P1) Sharayah Horne and Patrick Foley Youth Service Director. The purpose of the inspection was to conduct a required annual inspection. LPA's inspected the facility inside and out with facility representative. The group home has the capacity of six ambulatory clients and there was a census of four clients at the time of inspection. LPA's inspected the physical plant, operational requirements, disaster preparedness, emergency intervention plan and reviewed four of four client files (C1-C4) (see confidential name list, LIC811, dated 09/01/2022) and three of three staff files (S1-S3). LPA conducted two of two staff interviews (S1-S2) and all clients(C1-C4) refused interviews. The client and staff files are maintained off-site and were readily available. The facility residence is a single story home with three bedrooms, two bathrooms, staff office, kitchen and living room area. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. All hazardous items have been properly locked and made inaccessible to clients. The hot water was measured at 115.0 to be within the regulatory requirements. The medications, sharps, and first aid are stored in the staff office in the locked closet and locked in a cabinet. Toxic chemicals are locked in a cabinet in the garage. The facility's smoke detectors in the hallway and all bedrooms were checked and operable. A dual carbon monoxide detector located in the kitchen/common area was checked and operable. There is at least one week supply of nonperishable, snacks, and a 2 day supply of perishable foods. The monthly menu is posted on the refrigerator. Personal Hygiene, wash clothes and extra towels are available for client use. The facility is maintained clean and there were no exit obstructions or potential hazards. (See continuation form LIC 809-C dated 09/01/22) Based on record review, the licensee did not comply as 1 out of 4 client's do not have a copy of the current court order, or written authorization of the child's parent or guardian, for each psychotropic medication and each licensee shall have and maintain on file a current, written disaster and mass casualty plan of action which poses a potential health, safety or personal rights risk to persons in care. The facility is being issued a citation in accordance with the Title 22, CCR 84070(b)(12) Children's Records; CCR 80023(a) Disaster and Mass Casualty Plan. An exit interview was conducted, and this report, appeal rights and LIC 811 was reviewed with Youth Service Director Patrick Foley and a copy of this report was provided.

met_with: Sharayah Horne & Patrick Foley


summary: Facility Evaluation

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Narrative:
On October 13, 2023, at 10:00AM, Licensing Program Analyst (LPA) Carol Anderson conducted an unannounced inspection at the facility above. LPA met with Charles Phil Emrhein, Lead Staff. The purpose of the inspection was to conduct a required annual inspection. LPA inspected the facility inside and out with facility representative. The group home has the capacity of six ambulatory clients and there was a census of three clients at the time of inspection. LPA interviewed two clients and three staff at the facility. LPA reviewed three client files. The staff files are maintained at Mc Alister Inc. Administrative Office at North Johnson Avenue, Suite 101, El Cajon, CA 92020. The facility residence is a single-story home with three bedrooms, two bathrooms, staff office, kitchen and living room area. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. All hazardous items have been properly locked and made inaccessible to clients. The hot water was measure within the regulatory requirements. The medications, sharps, and first aid are stored in the staff office in the locked closet and locked in a cabinet. Toxic chemicals are locked in a cabinet in the garage. The facility's smoke detectors in the hallway and all bedrooms were checked and operable. A dual carbon monoxide detector located in the kitchen/common area was checked and operable. There is at least one week supply of nonperishable, snacks, and a 2-day supply of perishable foods. The monthly menu is posted on the refrigerator. Personal Hygiene, wash clothes and extra towels are available for client use. The facility is maintained clean and there were no exit obstructions or potential hazards. At 12: PM, LPA reviewed the staff files at the McAlister Inc. Administrative office at N. Johnson Avenue, #101, El, Cajon, CA 92020. LPA met with CEO Jeanne McAlister and Human Resources Service Director Cindie Torres. LPA reviewed five staff members files. LPA reviewed the board of directors' minute meetings. A review of Guardian on October 13, 2023, indicated that all facility staff associated to the facility had DOJ, FBI and child abuse index check clearances. Based on observations made during the inspection, no deficiencies were observed during today's visit. An exit interview was conducted, and this report was reviewed with Cindie Torres, Human Resources Service Director and a copy of this report was provided.

met_with: Charles Phillip Emrhein/CEO Jeanne McAlister


summary: Facility Evaluation

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Narrative:
On July 14, 2022 at 11: AM, Licensing Program Analysts (LPA) Marisol Lopez conducted a case management at the above facility and met with Program Representative (P1) Sharayah Horne.The purpose of the case management was to review medication records due to information received on 09/01/2021. Based on Client #1 (C1)'s medication record review and confidential interviews the facility did not ensure the prescription number and date filled were provided on the medication administration record (MAR); and instructions for medication dosage were inaccurate on the MAR. LPA reviewed the medication guide with the Administrator and the facility will be cited in violation for Title 22, California Code of Regulations, Division 6, Chapter 5, Children's Records 84070(b)(13)(E). See page LIC809D dated 07/14/2022 for the cited deficiencies. An exit interview was conducted, and a copy of this report and appeal rights was provided to program representative Sharayah Horne.

met_with: Sharayah Horne


summary: Complaint Investigation - Substantiated - 4 allegations

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Narrative:
...CONTINUED Confidential interviews and records reviewed indicated that facility management became aware of the alleged incidents involving S1 and that management terminated S1 immediately thereafter. A confidential interview indicated that S1 also brought alcohol to the facility for clients when S1 was the only staff working. Confidential interviews indicated that S1 provided marijuana to at least one client in care, and a review of client drug and alcohol test results confirmed that the client had marijuana in their system. Confidential interviews and a review of outside source records indicated that pictures of clients and staff drinking alcohol at the beach were taken and posted on S1's social media. Based on confidential interviews and records reviewed, the allegations that Staff gave alcohol to minors in care is substantiated because the preponderance of evidence has been met. This poses an immediate Health, Safety, or Personal Rights risk to children in care, and the facility will be cited for violating Health and Safety Code, Division 2, Chapter 3, Article 5, Section 1550(c). An exit interview was conducted, and a plan of correction was developed with Phillip Emrhein, Administrator. A copy of this report and appeal rights were provided to Phillip Emrhein, Administrator.

Investigation Findings:
13On December 23, 2024, at 4: PM, Licensing Program Analyst (LPA) Jacob Salem met with Phillip Emrhein, Administrator of McAlister Institute Group Home to deliver the findings for the above-stated allegation. LPA Salem initiated a complaint inspection at the facility on 8/7/2024 at 1: PM and no immediate deficiencies were observed. During the investigation, LPA Salem interviewed Clients (C1-C7) and Staff (S1-S9). LPA Salem obtained and reviewed pertinent records. On July 28, 2024, Community Care Licensing (CCL) received an allegation that Staff (S1 and S2) gave alcohol to minors (C2, C3, and another unnamed client) in care. It was reported that S1 and S2 bought clients alcohol on multiple occasions and took the clients to drink at the park instead of attending planned outings to addiction recovery meetings. Confidential interviews corroborated this information and indicated that S1 and S2 provided alcohol to four clients in care (C1-C3). SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Mcalister Institute Adolescent Group Home Southfacility Number: Visit Date: 12/23/ Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32...CONTINUED Confidential interviews and records reviewed indicated that facility management became aware of the alleged incidents involving S1 and that management terminated S1 immediately thereafter. A confidential interview indicated that S1 also brought alcohol to the facility for clients when S1 was the only staff working. Confidential interviews indicated that S1 provided marijuana to at least one client in care, and a review of client drug and alcohol test results confirmed that the client had marijuana in their system. Confidential interviews and a review of outside source records indicated that pictures of clients and staff drinking alcohol at the beach were taken and posted on S1's social media. Based on confidential interviews and records reviewed, the allegations that Staff gave alcohol to minors in care is substantiated because the preponderance of evidence has been met. This poses an immediate Health, Safety, or Personal Rights risk to children in care, and the facility will be cited for violating Health and Safety Code, Division 2, Chapter 3, Article 5, Section 1550(c). An exit interview was conducted, and a plan of correction was developed with Phillip Emrhein, Administrator. A copy of this report and appeal rights were provided to Phillip Emrhein, Administrator. SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 2 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: MCALISTER INSTITUTE ADOLESCENT GROUP HOME SOUTHFACILITY NUMBER: 374603052

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Based on confidential interviews and records reviewed, the S1 and S2 engaged in conduct inimical to the health and safety of
- clients in care in the facility (C1-C3), which poses an immediate health, safety, or personal rights risk to persons in care.

met_with: Phillip Emrhein, Administrator


summary: Complaint Investigation - Substantiated - 6 allegations

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Narrative:
...CONTINUED A conflicting confidential interview indicated that only S1 drove clients while under the influence. Confidential interviews indicated that S1 told the clients they were also taking medication, such as Percocet or Xanax, before driving clients but was not seen taking anything besides alcohol. Confidential interviews and records reviewed indicated that S1 lost the company car keys during one of the incidents when S1 was intoxicated while with the clients. Confidential interviews indicated that S1 often appeared tired and "zoned out" while working in the facility but was not seen sleeping at work. CCL also received the allegation that Staff (unnamed) does not keep the facility free from substances. It was reported that clients in care have continued access to substances. A review of the facility's program statement reveals that a primary goal of the facility is to provide a safe environment for clients, which includes keeping clients separated from drug and/or alcohol use and supported in recovery and abstinence. Confidential interviews indicated that after returning from the outings intoxicated, the clients (C1-C3) and staff (S1 and S2) brought alcohol back into the facility and hid it in the clients' rooms while the other staff were in the back office. A confidential interview indicated that S1 also purchased alcohol and brought it back to the facility for clients to consume when S1 and S2 were the only staff working. A confidential interview indicated that staff did not search clients' rooms during the time they had alcohol. Confidential interviews and records review indicated that S1 was previously admonished and demoted for allegations that former clients made involving S1 not reporting drug use in the facility. A confidential interview indicated that, during that time, S1 also witnessed a client using a marijuana vape pen and did not confiscate it or report it to S1's supervisor. Confidential interviews indicated that former clients were able to sneak contraband into the facility because staff do not search clients upon admission. Conflicting confidential interviews indicated that staff search clients' possessions upon admission, as well as use a metal detecting wand to search the clients' person. CCL also received the allegation that Staff (unnamed) do not ensure that children (unnamed) are following their needs and services plan. It was reported that staff were taking clients to the park to hang out with friends rather than taking the clients to addiction recovery meetings. A review of needs and services plans for clients involved in the above incidents revealed that clients would maintain sobriety by, in part, attending daily addiction recovery meetings for the duration of their stay in the program. Confidential interviews indicated that while S1 and S2 were taking the clients to drink, the clients were scheduled to be attending nightly recovery meetings. Continued... ...CONTINUED Confidential interviews and records reviewed indicated that S1 also allowed former clients to miss addiction recovery meetings, despite these clients' needs and services plan including daily attendance in recovery meetings. Based on confidential interviews and records reviewed, the allegations that Staff conduct poses a risk to children in care and Staff does not keep the facility free from substances pose an immediate and Health, Safety, or Personal Rights risk to children in care, and the allegation that Staff do not ensure that children are following their needs and services plan poses a potential Health, Safety, or Personal Rights risk to children in care. The allegations are substantiated because the preponderance of evidence has been met and the facility will be cited for violating California Code of Regulations, Title 22, Division 6, Chapter 1, Section 80078(a), Section 80022(k), and Chapter 5, Section 84078(b). An exit interview was conducted, and a plan of correction was developed with Phillip Emrhein, Administrator. An exit interview was conducted and a signed copy of this report and appeal rights were provided to Phillip Emrhein, Administrator.

Investigation Findings:
13On December 23, 2024, 3: PM, Licensing Program Analyst (LPA) Jacob Salem met with Phillip Emrhein, Administrator of McAlister Institute Group Home to deliver the findings for the above-stated allegations. LPA Salem initiated a complaint inspection at the facility on 7/17/2024 at 1: PM and no immediate deficiencies were observed. During the investigation, LPA Salem interviewed Clients (C1-C7) and Staff (S1-S9). LPA Salem obtained and reviewed pertinent records. On July 8, 2024, Community Care Licensing (CCL) received an allegation that Staff (unnamed) conduct poses a risk to children (unnamed) in care. It was reported that a staff member was drunk while working at the facility and drove away with facility keys, as well as fell asleep at work after taking a pill. Confidential interviews and records reviewed indicated that S1 and S2 drank alcohol while on outings with clients (C1-C3), and that S1 and S2 drove clients in the facility car while under the influence. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Mcalister Institute Adolescent Group Home Southfacility Number: Visit Date: 12/23/ Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32...CONTINUED A conflicting confidential interview indicated that only S1 drove clients while under the influence. Confidential interviews indicated that S1 told the clients they were also taking medication, such as Percocet or Xanax, before driving clients but was not seen taking anything besides alcohol. Confidential interviews and records reviewed indicated that S1 lost the company car keys during one of the incidents when S1 was intoxicated while with the clients. Confidential interviews indicated that S1 often appeared tired and "zoned out" while working in the facility but was not seen sleeping at work. CCL also received the allegation that Staff (unnamed) does not keep the facility free from substances. It was reported that clients in care have continued access to substances. A review of the facility's program statement reveals that a primary goal of the facility is to provide a safe environment for clients, which includes keeping clients separated from drug and/or alcohol use and supported in recovery and abstinence. Confidential interviews indicated that after returning from the outings intoxicated, the clients (C1-C3) and staff (S1 and S2) brought alcohol back into the facility and hid it in the clients' rooms while the other staff were in the back office. A confidential interview indicated that S1 also purchased alcohol and brought it back to the facility for clients to consume when S1 and S2 were the only staff working. A confidential interview indicated that staff did not search clients' rooms during the time they had alcohol. Confidential interviews and records review indicated that S1 was previously admonished and demoted for allegations that former clients made involving S1 not reporting drug use in the facility. A confidential interview indicated that, during that time, S1 also witnessed a client using a marijuana vape pen and did not confiscate it or report it to S1's supervisor. Confidential interviews indicated that former clients were able to sneak contraband into the facility because staff do not search clients upon admission. Conflicting confidential interviews indicated that staff search clients' possessions upon admission, as well as use a metal detecting wand to search the clients' person. CCL also received the allegation that Staff (unnamed) do not ensure that children (unnamed) are following their needs and services plan. It was reported that staff were taking clients to the park to hang out with friends rather than taking the clients to addiction recovery meetings. A review of needs and services plans for clients involved in the above incidents revealed that clients would maintain sobriety by, in part, attending daily addiction recovery meetings for the duration of their stay in the program. Confidential interviews indicated that while S1 and S2 were taking the clients to drink, the clients were scheduled to be attending nightly recovery meetings. SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 2 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Mcalister Institute Adolescent Group Home Southfacility Number: Visit Date: 12/23/ Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32...CONTINUED Confidential interviews and records reviewed indicated that S1 also allowed former clients to miss addiction recovery meetings, despite these clients' needs and services plan including daily attendance in recovery meetings. Based on confidential interviews and records reviewed, the allegations that Staff conduct poses a risk to children in care and Staff does not keep the facility free from substances pose an immediate and Health, Safety, or Personal Rights risk to children in care, and the allegation that Staff do not ensure that children are following their needs and services plan poses a potential Health, Safety, or Personal Rights risk to children in care. The allegations are substantiated because the preponderance of evidence has been met and the facility will be cited for violating California Code of Regulations, Title 22, Division 6, Chapter 1, Section 80078(a), Section 80022(k), and Chapter 5, Section 84078(b). An exit interview was conducted, and a plan of correction was developed with Phillip Emrhein, Administrator. An exit interview was conducted and a signed copy of this report and appeal rights were provided to Phillip Emrhein, Administrator. SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 3 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: MCALISTER INSTITUTE ADOLESCENT GROUP HOME SOUTHFACILITY NUMBER: 374603052

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Based on confidential interviews and records reviewed, the licensee did not provide care and supervision as necessary to meet the needs of
- clients in care (C1-C3), which poses an immediate health, safety, or personal rights risk to persons in care. Based on confidential interviews and records reviewed, the licensee did not operate in accordance with the terms specified in its Plan of Operation in
- clients in care (C1-C3), which poses an immediate health, safety, or personal rights risk to persons in care. Additionally, LPA Salem will receive proof of training by 12/24/24. Based on confidential interviews and records reviewed, the licensee did not provide services identified in each child's needs and services plan in
- clients in care (C1-C3), which poses a potential health, safety, or personal rights risk to persons in care.