summary: Facility Evaluation

raw_content:
Narrative:
On November 10, 2025, Licensing Program Analyst (LPA) Jessica Peete, Licensing Program Manager (LPM) Cheraki Davis, and Regional Manager Natasha Dunlap met via Microsoft Teams with Makade Behavioral Center Short Term Residential Therapeutic Program (STRTP) Chief Operating Officer (CEO) Jorge Cervantes and Director Akila Crane to discuss and review the STRTP's Plan of Operations and Program Statement submitted to Community Care Licensing on June 30, 2025. System of Care Manager Marjana Jackson and Systems of Care Manager Tony Cao also joined the call. The meeting covered the Application and Supporting Documents, including the LIC Monthly Operating Statement. Other topics included the Plan of Operation, staff training plan, Social Worker qualifications, Program Statement, and Administrator Qualifications. It was discussed that the facility does not currently have a qualified Administrator. The CEO and Director were informed that the facility must have a qualified Administrator before the Department can issue a license. They were also told that all pages in the Program Statement and Plan of Operations should be numbered, tabbed, clearly titled, and that corrections or revisions should be highlighted for easy reference during the review. The 1st revised Plan of Operation and Program Statement will be due November 14, 2025 (per facility request) The following is a summary of the review of the Plan of Operations and Program Statement completed by LPA Jessica Peete and Systems of Care Manager Tony Cao: (Continued on LIC 809C) Application and Supporting Documentation (LIC 281E)1. Application for a Community Care Facility (LIC 200) Standard Met 2. Orientation Certificate (Reference CCR § 80018(b))- Standard Met 3. County Letter of Recommendation (Reference HSC § 1562.01(f) ILS § 87018(c)(6))- Standard Met 4. Designation of Facility Responsibility (LIC 308) (Reference CCR § 80064) Standard Not Met 5. Affidavit Regarding Client Cash Resources (LIC 400) (Reference HSC § CCR § 80018)- Standard Met Facility number not provided 6. Surety Bond (LIC 402)(Reference CCR § 80018(d))- Standard Met 7. Monthly Operating Statement (LIC 401) (Reference HSC § 1520(c) CCR § 80018- Standard Not Met The following estimated amounts noted for a six bed STRTP do not appear to be sufficient Food Cost-Line Household Supplies- Line Recreational Activities- Line Newspapers, Magazines, Cable TV ( Possible Internet Service)-Line Client Transportation- Line Salaries and Wages- Line Payroll Taxes and Employee Benefits- Line General Transportation- Line Contract Labor ( Part-time Case Manager, Social Worker Support)-Line Indirect Overhead ( Cooperate Office Expenses ) -Line Gas- Line Electricity- Line Water- Line Garbage- Line Repair and Maintenance (Building)-Line Repair and Maintenance (Furniture and Equipment)-Line 34 8.Supplemental Financial Information (LIC 401A) (Reference HSC §1520(c) CCR § 80018)- Standard Not Met Information is not consistent with LIC Balance Sheet (LIC 403) (Reference HSC § 1520(c), CCR § 80018)-Standard Not Met Information is not consistent with LIC 403(a) 9. Balance Sheet supplemental Schedule (LIC 403A) (Reference HSC § 1520(c), CCR § 80018)- Standard Not Met Information is not consistent with LIC 403 10.Financial Information Release and Verification (LIC 404) (Reference HSC § 1520(c), CCR § 80018) Standard Met, current bank statement (September 2025) provided 11. Personnel Report (LIC 500) (Reference HSC § 1522, CCR § 80018)- Standard Met 12. Health Screening Personnel (LIC 503) (Reference CCR § 80018(d))- Standard Met 13. Criminal Record Statement (LIC 508) (Reference CCR § 80019)- Standard Met 14. Emergency Disaster Plan (LIC 610C) (Reference CCR § 80023)- Standard Met 15. Fire Inspection Authority (LIC 9054) (Reference CCR § 80018(d), CCR § 87018(d))- Standard Met Fire Clearance granted for both STRTP locations; fire inspection completed 08/20/2025 16. Board of Directors Statement (LIC 9165) contained in PUB 326) (Reference CCR § 87018(d))- Standard not met The LIC 9165 was not signed by all the board members identified on the Resolution of Borad Orgainization 17. Control of Property (Reference CCR § 80018(c)- Standard Met Rental propery; rental agreement provided 18. Bacterial Analysis of Water (Reference CCR § 80021)- Standard met The STRTP water supply will not be private 19. Application or Documentation of Accreditation (Reference ILS § 87089)- Standard Met This section meets standards as a short-term residential therapeutic program shall have up to 24 months from the date of provisional licensure to obtain accreditation ILS 97089(b). However, if the applicant has started the accreditation process; the applicant shall submit documentation of accreditation, a copy of its application for accreditation, or a declaration of accreditation status with its application for licensure ILS 87089(c) (Continued on LIC 809C) 20. Administrator Qualifications ILS87064(c) Carmen Porches Makade Behavioral Center 1 #337900294- Will address at Technical Assistance Meeting Laura Hartney Makade Behavioral Center 2 #337900295- Will address at Technical Assistance Meeting 21. Social Worker Qualifications ILS 87065(c)- Rachel Post-Broussard - Standard Not Met Provide Transcripts from an accredited school Social work staff hired on or after January 1, 2017 shall meet the following education and experience requirements: A master's degree from an accredited or state approved graduate school, as defined by the Department of Education, in social work or social welfare, marriage, family and child counseling, child psychology, child development, counseling psychology or social psychology Completion of at least three (3) semester units or 100 days of field practice or experience in a public or private social service agency at the master's degree level. At least nine (9) semester units of course work related to children and families, or 18 months' experience in working with children and families. At least three semester units in working with minority populations, or six months of experience in working with minority population; or six months in-service training in working with minority populations within the first year of employment as a condition of employment. At least three semester units in child welfare, or two years' experience in a public or private child welfare social services setting. 22. LIC Administrative Organization- Standard Not Met Clarification is needed, as section I #9(a) indicates there are Directors/Managers and Managing members. The Resolution relating to the board organization lists 6 individuals. Section I #10 is incomplete; complete this section if applicable Plan of OperationThe Program Statement and Plan of Operation should be written in a narrative format, not just as a list of bullet points. This approach clearly shows how the program meets licensing requirements, explains how services and procedures are implemented, and identifies and defines staff roles. The narrative should also describe how trauma-informed principles are used throughout the program and set clear, measurable expectations for accountability and staff training. Providing these details in a narrative form will provide the clarity needed to see that the SRTP has a complete and effective structure for delivering required services and supports. (Continued on LIC 809C) Section A Purpose and Goals STRTP ILS Section Standard Not Met The section states that it will provide care for children ages 10 to 17. However, other areas in the Plan of Operations and the Program Statement mention non-minor dependents (NMD) provide clarification on whether non-minor dependents will be admitted into care. • Under Program Beliefs, Page 10, please explain how numbers 2-4 are program beliefs? Clarify how "Highly professional staff trained in child welfare with a focus on clinical expertise" is a program belief (Page 10). What is the belief? Section B Administrative Organization STRTP ILS Sections 87022, 87063, 87064, 87064.1, 87064.2, Standard Not Met Update to include the number of staff that will be employed to meets the needs of the clients in care specifically how the facility will ensure that at least one staff member is on site at all times to apply the reasonable and prudent parent standard to decisions involving the participation of a child in age or developmentally appropriate activities in accordance with Health and Safety Code section 1522.44(b) and Section 87067. Update to include a planned activities coordinator position, and the individual must meet the requirements as outlined in ILS 87065(e) Update the Facility Administrator required qualifications to align with one of the Administrator requirements as stipulated in ILS 87064(c). Supervisory experience must be specific to supervisory experience over social work, direct care, and/or support staff providing direct services to children in an agency or in a community care facility with a licensed capacity of six or more. Update to include or expand upon how administrator will accomplish their assigned duties, including the use of personnel. The description should include, but not be limited to, the following: How the Administrator will accomplish their assigned duties How facility staff will be utilized to support the Administrator How the Administrator ensures regulatory compliance and manages the day-to-day or program operations • Update Social Worker required qualifications to align with the accepted degrees, work experience, and requirements as outlined in ILS 87065(c). Criminal Justice degrees are not identified in the regulation as meeting the educational requirements for the position. The job description/qualifications should reflect that acceptable qualifications include degrees and experience in working with children and families, in social service agencies, with minority populations, and in public or private child welfare or social service settings. • Update to include a copy of the Administrator's certificate in this section Update the roles of the Governing Body section to expand upon the minimum duties of the board of directors or governing body as outlined in 87063(a)(1)-(12) (Continued on LIC 809C) Section C Facility Sketches STRTP ILS Sections 87022, 87087, 87087.1, 87087.2- Standard Not Met Update to include a sketch of the facility within this section that meets the requirements as outlined in ILS 87022(a)(4)-(5) • Update to include a written description of how the grounds meet the requirements of section 87087, Buildings and Grounds. It is recommended that the description be in narrative form and go beyond just listing the regulatory requirements in ILS 87087. The description should explain the facility's layout and how the use of the grounds, both inside and out, aligns with regulations and supports a safe environment for all children in care Section D Staff Plan STRTP ILS Sections 87022, 87065, 87065.1, 87065.2, 87065.5, 87078.2, 87095. Standard Not Met The staff plan must include a plan for the supervision, evaluation, and training of all staff that meets all ILS requirements referenced in this section. Describe how the staff training plan is trauma-informed and designed to ensure the provision of trauma-informed services and appropriate to meet the needs of staff and the population served. Include organizational strategies to enhance the well-being, retention, and resilience of staff. Explain how training will help staff understand and respect different cultures, use the right ways to support children who have been through trauma or abuse, and follow the best ways for addressing the permanence, well-being, and educational needs of children, including children with disabilities. Initial 24 hours of newly direct staff training ILS 87085.1(c)-(d) • The training plan shall address the initial 24 hours of training, consisting of 8 and 16 hours of training to be completed within 90 days of hire. It is recommended that this section be organized to clearly demonstrate compliance with the required training hours and completion timelines. The training plan shall address annual training for newly hired and existing direct care staff, as required by ILS 87065.1(c)(3). • The staff evaluation form is on pages 76-80. The training plan must identify when the Administrator or designee will evaluate each direct care staff member's understanding and ability to apply the training. The evaluation requirements are different for the 8-hour and 16-hour trainings; the training plan must clearly specify the evaluation process within both the 8-hour and 16-hour training sections. • Describe how the 8 and 16-hour training requirement in ILS 87085.1(d)(4)(A)(1) will be met through coursework in a workshop, seminar, classroom, individual, or small group setting. • Describe the policy and procedures for documenting successful completion of training in the personnel record for each direct care staff ILS 87065.1(d)(5). (Continued on LIC 809C) Include the policy and procedures for amending the training plan, when necessary, to meet the needs of direct care staff and the population (children in care) ILS87065.1(C)(5)-(6). Update to include a statement that the Initial is in addition to CPR and first aid training, and Emergency Intervention Staff Training ILS 87065.1(d)(6)(A), 87095.65, and cannot be counted towards the minimum training requirement. Completion of cardiopulmonary resuscitation (CPR) and first aid training shall be demonstrated by current and valid CPR and first aid cards issued by the American Red Cross, the American Heart Association, a training program approved by the State Emergency Medical Services Authority pursuant to Health and Safety Code Section 1797.191, or from an accredited college or university Hour Training ILS 87065.1(d)(1) • The 8-hour training shall include trauma-informed training as specified in Section 87078.2(a)(3). • Include a statement requiring new direct care staff to complete training before being left alone or counted in the staff-to-child ratio ILS 87065.1(d)(A)(1)-(2) • Up to 4 of the required 8 training hours may be fulfilled through successful job shadowing. When the training plan includes job shadowing activities as described in Section 87065.1(d)(1)(D), the training plan shall include the specific activities and job classification of the individual being shadowed. Time spent on each activity, and the skills to be developed through each job shadowing activity (This is briefly mentioned on page 68). Include how the experienced facility personnel being shadowed will verify the completion of the job shadowing. The verification must address the specific activity observed, the dates and times of the shadowing, and the training topic from ILS 87065. (d)(3)(A) through (Z) that the job shadowing has satisfied. • Include policy and procedures describing how newly hired direct care staff are to be supervised until the eight hours of training are completed ILS 87065.1(d)(1)(B) • How and when the administrator or administrator's designee will assess each direct care staff member's understanding and ability to apply the training, or if re-training is required ,how training will be documented in each direct care staff personnel record ILS 87065.1(d)(1)(E)(1)-(3). Hour Training 87065.1(d)(2) •Include time lines for completion as stipulated in ILS (d)(2)(A)-(B). Clearly distinguish the training timeline for new direct care staff who work a maximum of 20 hours per week. How and when the administrator or administrator's designee will assess each direct care staff member's understanding and ability to apply the training, or if re-training is required ,how training will be documented in each direct care staff personnel record ILS 87065.1(d)(B)(1)-(3) (Continued on LIC 809C) Training shall include, at a minimum, all of the following topics as listed in ILS 87085.1(d)(3)(A)-(DD). The licensee shall determine how much time is spent on each topic, and shall ensure that direct care staff have the appropriate skills necessary to supervise and protect the health and safety of children in care. Annual Training 87065.1(e) • All direct care staff shall complete a minimum of 40 hours of annual training. Include time lines for completion ILS 87065.1(e). At least 20 of the 40 hours of annual training shall consist of course work from an entity other than the short-term residential therapeutic program such as an accredited educational institution, workshops, seminars, or other direct training provided by an individual who is qualified, who meets the requirements specified in Section 87065.1(d)(4)(A)1, who is not affiliated with the short-term residential therapeutic program licensee. • Include a statement specifying that newly hired direct care staff shall complete a minimum of 16 hours of annual training within the first 12 months of employment, for a total of 40 hours of initial and annual training. After the first 12 months of employment, direct care staff shall complete a minimum of 40 hours of annual training. For newly hired direct care staff at least 4 hours of the annual training shall consist of course work from an entity other than the short-term residential therapeutic program such as an accredited educational institution, workshops, seminars, or other direct training provided by an individual who is qualified and meets the requirements specified in Section 87065.1(d)(4)(A)1 who is not affiliated with the short-term residential therapeutic program licensee ILS 87065.1(e )(2)(A) • The Annual training must include all the topics as outlined in ILS 87065.1(e)(3)-(4). • Describe how the training requirement in ILS 87085.1(e)(6) will be met through course work in a workshop, seminar, classroom, individual, or small group setting. • Describe how the annual training will be verified and documented in the personnel record for each direct care staff ILS 87065.1(e)(6)(A) and 87065.1(e)(7). • Within the annual training plan, include that the Annual training is in addition to first aid and CPR training, and other training as required in Section 87095. ILS 87065.1(e)(8)(A). Training for Peer Partners and Volunteers 87065.1(f) (1)-(2), 87065.1(g)(1)-(2) If using peer partners and/or volunteers, provide, as part of the training plan, the training requirements and the minimum training as outlined, including timelines for completion. ILS 87065.1(f) (1)-(2) and 87065.1(g)(1)-(2). Specify the requirements that must be met before peer partners and volunteers are allowed to work with the children in care ILS 87065.1(f)(1) and ILS 87065.1(g)(1). (Continued on LIC 809C) Facility Manager Training 87065.1(b) The training plan needs to be revised to include the training plan for Facility Managers. Include the policy and procedures for amending the training plan, when necessary, to meet the needs of direct care staff and the population (children in care) ILS87065.1(b)(4). Include all the training topics outlined in ILS 87065.1(b)(5)(A)-(M) Describe how the training requirement in ILS 87085.1(b)(6)(A) will be met through course work in a workshop, seminar, classroom, individual, or small group setting. Describe how the training will be verified and documented in the personnel record for each staff member ILS 87065.1(b)(6)(A) and 87065.1(b)(7). Within the Facility Manager training plan, include that the training is in addition to first aid and CPR training, and other training as required in Section 87095.65; ILS 87065.1(b)(8)(A). Within this section, it is recommended that a training matrix be arranged in a way that clearly shows staff ( specify role and position) that must attend the training, including the following for each training as outlined in ILS 87065.1(b)(2), ILS 87065.1(c)(4): Course title and subject matter Learning objectives and activities Qualification of the trainer How the training will be evaluated. Training shall include an evaluation of the trainer and course content to determine if the training is meeting the needs of staff. Descriptions for each training within the matrix table would benefit from revisions for clarity. Currently, some descriptions contain typos, run-on sentences, and punctuation/spacing consistency issues. (Example training to aid parents in identifying how to...." (Pg 70) Pages 74-75 of the training matrix do not provide the description or learning objectives. Update staff plan to include how staff will engage members of the child's family and community, including parents, siblings, caregivers, other relatives, and unrelated extended family members, and other supportive adults consistent with the law and any applicable court orders. On Page 68, clarify the length of the training titled "Participation of Family Members in Child's Treatment". Currently, this training does not have a time frame listed. Describe the facilities procedures on supporting caregiver staff in identifying and accessing services and supports to heal from trauma, including. Examples may include training, open-door policies to discuss and debrief, or providing additional time off. (Continued on LIC 809C E Policies Regarding Child Abuse/Neglect Reporting STRTP ILS Section 87022-Standard Not Met Update to include a copy of the STRTP's written Polices and Procedures on mandated reporting and a copy of the Mandated Reporter Acknowledgement Form F. Administrative Policies and Procedures STRTP ILS Sections 87022, 87063- Standard Met G. Admission Determination Procedures STRTP ILS Sections 87022, 87068.05-Standard Not Met This section of the Plan of Operations was not provided. The information provided in section G is a duplicate of section F. This section needs to be corrected to include the specific admission determination procedures as required by ILS 87022 and 87068.5, and remove the duplicate content. H Intake Polices and Procedures Title CCR Sections 80069, 80070; STRTP ILS 87022, 87068.1, 87068.11, 87068.12, 87078.2 87068.5-Standard Not Met This section is incomplete and should be updated to include and/or expand upon the intake procedures outlined in ILS 87068.1. This section should provide detailed policy and procedures for when a child is accepted for emergency and non-emergency placement. The policies and procedures should be developed in a way that is aligned with the ILS regulations, and clearly demonstrate how all aspects of the intake procedures are trauma-informed and address the following: the list is not exhaustive, and it is recommended that the information in the above referenced sections be carefully reviewed to ensure full compliance with the requirements: Protocols for coordinating with placement agencies and information to be obtained from the placement agency and/or the child's authorized representative for the client record when a child has been accepted for non-emergency placement in a short-term residential therapeutic program. as specified in ILS 87070(b)(1) through (b)(14) and California Code of Regulations, Title 22, Section 80070(b)(1) through (5), (7), (8) and (10). If this information can not be obtained, include a statement that confirms that if the information is not completed or provided by a placement agency, the facility shall make a telephone call and/or written requests for the information to the child's placement agency and/or authorized representative and shall record and retain the details of those requests. Please include a statement that confirms that if the information is not received within 15 days of the request, the licensee shall obtain the information necessary to complete a standard appraisal form from other sources per 87068.1(c)(2) Policy and procedures for completing the needs and services plan within 30 days of placement as specified in ILS 87068.2(a) (Continued on LIC 809C) An admission agreement shall be completed and signed no later than seven (7) calendar days following admission as specified in CCR, Title 22, Section Policies and procedures require that the administrator or their designee, along with the child and their authorized representative, sign copies of the removal or transfer policies ILS 87068.4(a), discipline policies ILS 87072.1(a), and complaint procedures ILS 87072.2(a) to confirm they have received this information. Initial crisis management assessment required prior to placement in, or immediately after admission to, a short-term residential therapeutic program as specified ILS 87068.1(d)(1)-(3). Be sure to describe how the components of the assessment that include input from the child shall be conducted in a manner that is consistent with trauma-informed practices and the requirements in ILS 87078.2. Describe how and when the initial crisis management assessment will be completed, how will the assessment be used, and who must attend the assessment. The policy and procedures for obtaining a written medical assessment for clients in care as specified in Title CCR 80069 (a) and (c), including tuberculosis testing, which enables the licensee to determine their ability to provide necessary health-related services to the client. The assessment shall be used in developing the Needs and Services Plan. Include policy and procedures if a child is placed in the facility under emergency circumstances, ensure that the following requirements, as listed in ILS 87068.1(e)(1)-(4), are addressed. If orientation interviews will be part of the intake process. The orientation interview procedures must include practices, techniques, and supports that are trauma-informed, culturally relevant, and age and developmentally appropriate. The policy and procedure should algin with ILS 87068.1(f)(1)-(2) Policy and procedures regarding children that have a propensity for behaviors resulting in harm to themselves and others, describe how the facility shall take precautions to protect other children, NMD, and staff Non Minor Dependents (NMD) ILS 87068. Elaborate on the emergency and non-emergency placement procedures it's recommended that this section be organized around NMD intake procedures. The procedures in this section must fully comply with all the requirements of ILS 87068.11(a)-(n). I Admission Agreement Title CCR Sections 80018, 80068; STRTP ILS Sections 87022, 87068.1, 87068.11, 87095. Standard Not Met The STRTP Admission Agreement SOC 154C provided in this section is outdated. The most recent version was approved for use in January 2024 and must be utilized. The admission agreement must also include a written statement regarding the type(s) of emergency interventions the licensee has been approved to use. (Continued on LIC 809C) If the facility accepts non-minor dependents, a copy of the admission agreement for NMDs, including procedures for modifying the agreements. J Removal and/or Transfer Policies and Procedures STRTP ILS Sections 87022, 87061, 87068.4, 87068. Standard Not Met This section is incomplete and needs revision to ensure the policy and procedures for removing or transferring children and NMD in care are trauma-informed. In addition to providing the emergency removal procedures, the following must also be addressed. The list is not exhaustive, and it is recommended to carefully review the above sections to ensure full compliance with requirements: Procedures to ensure that children and their authorized representatives are informed of removal/transfer policies in an age and developmentally appropriate manner. Explain the policy and procedure explaining how the licensee will ensure that the child, and their authorized representative(s) are offered the opportunity to participate in the development of a transfer plan for the child ILS 87068.4(b)(1) Page 122 of the Plan of Operations states, "All policies and procedures are explained to youth and their placement workers during intake. Youth and employees are required to sign acknowledgement forms confirming their understanding." (Pg. 122). Beyond gathering a signature, how will a youth's full understanding of the policies and procedures be evaluated; and what measures will be taken to ensure that the policies are explained to youth in an age and developmentally appropriate manner? How will these documents be made accessible for youth and case workers? Explain how a signed copies of the Policy and Procedures are to be maintained in the child's record ILS 87068.1. Include a description of how the facility will mitigate against potential impacts to a child as a result of removal or transfer, including but not limited to per ILS 87068.4)(a) how the licensee will assist in preventing delays or gaps in the delivery of services types of trauma-informed support and transition services to be provided and best practices for staff communication with the child during the transition As required by Health and Safety Code 1562.01, the short-term residential therapeutic program shall provide trauma-informed support and transition services to children as part of a planned or unplanned removal or transfer ILS 87068.4(c)(1)-(2). Please provide the policy and procedures that describe how support and transition services will involve participation in county-level or state-level meetings. Include a statement which confirms that the licensee shall engage with the county placing agency regarding the placement preservation strategy prior to a change in placement per 87068.4(d)(2) Continued on LIC 809C The engagement may include, but is not limited to, conflict resolution practices and facilitated meetings. Include the procedures for when the facility is concerned that it cannot meet a child/NMD's needs or when there is an indication that the placement may be disrupted, including doing the following ILS 87068.4(e)(1)(A)-(F) Notify authorized representative(s) of the concern. Communicate the concern to the county placing agency. Request additional support services from the community if necessary. Request a Child and Family Team (CFT) Meeting. Make a reasonable good faith effort to engage in the development and implementation of placement preservation strategies in collaboration with the county placing agency and in consultation with the CFT. If it is determined that the facility cannot meet the needs of the child, the licensee shall notify the authorized representative(s) of the determination and request that the child be placed elsewhere. The requests shall be submitted to the county placing agency and shall contain the following information as required in ILS 87068.4 (e)(2)(A)(1)-(6) If it is determined that the facility cannot meet the child's needs, the licensee shall notify the authorized representatives of the determination and request that the child be placed elsewhere. The request will be submitted to the county placing agency and shall contain all of the information as listed in ILS 87068.4(e)(2)(A)(1)-(6). Please include a statement that confirms requests that the child be placed somewhere else, shall be accompanied by a statement, signed by the facility's Mental Heath Head of Service, providing an explanation of why the facility was unable to meet the needs of the child, including all of the information in ILS 87068.4(e)(2)(B)(1)-(4). Include a statement that confirms requests that the child be placed somewhere else, shall be accompanied by a statement, signed by the facility's Mental Heath Head of Service, providing an explanation of why the facility was unable to meet the needs of the child, including all of the information in ILS 87068.4(e)(2)(B)(1)-(4). How the facility will notify and work with a child to develop a trauma-informed plan that supports a successful transition to the child's next placement. Provide policy and procedures that describe the social work staff's responsibilities for developing and maintaining the written removal or transfer record, containing all the information required in ILS 87070(d) through (d)(3). Include the removal and/or transfer procedures for NMD that fully comply with all the requirements of ILS 87068.4(g)-(h) (Continued on LIC 809C) K Rate Setting and Refunds Policy STRTP ILS Section 87022-Standard Met L Handling of the Child's Money,Personal Property, and/or Valuables Title CCR Sections 80025, 80026; STRTP ILS Sections 87022, 87026- Standard Not Met This section of the Plan of Operations is missing. Section L duplicates Section K. Please revise this section to include the required policy and procedure for handling the child's money, personal property, and valuables as specified by Title CCR 80025, 80026, and ILS regulations 87022 and 87026. Remove the duplicate contentM Consultant and Community Resources Utilized ILS Section 87022 -Standard Not Met Update to include how each consultant and community resource helps the facility meet the specific needs of the children in care N Trauma Informed and evidenced based interventions STRTP ILS Section 87022- Standard Not Met This section must provide a detailed description of de-escalation techniques that trained staff will use in crisis situations to prevent escalation when a client is in crisis. The information in this section should not focus on the therapies provided at the STRTP. This section is specifically about trauma-informed evidence-based behavioral interventions and de-escalation methods used to maintain the youth's safety. This section should include, but not be limited to, how staff will apply the STRTP's behavioral intervention strategies. How will staff de-escalate and/or prevent crises How will staff maintain a safe environment? How are staff trained to do this What interventions will be used ( Pro-Act, CPI) Also, explain how the emergency intervention techniques will promote the safety of everyone in the facility, including children who may be at risk of harming themselves or others. O Plan for Use of Delayed Egress Devices Title CCR Section 80020; STRTP ILS Section 87022- Standard Met ·The facility does not plan to use delayed Egress Devices P Conflict of Interest Mitigation Plan STRTP ILS Section 87022- Standard Met This section is not applicable as Makade will not be a county run facility (Continued on LIC 809C) K Rate Setting and Refunds Policy STRTP ILS Section 87022-Standard Met L Handling of the Child's Money,Personal Property, and/or Valuables Title CCR Sections 80025, 80026; STRTP ILS Sections 87022, 87026- Standard Not Met This section of the Plan of Operations is missing. Section L duplicates Section K. Please revise this section to include the required policy and procedure for handling the child's money, personal property, and valuables as specified by Title CCR 80025, 80026, and ILS regulations 87022 and 87026. Remove the duplicate contentM Consultant and Community Resources Utilized ILS Section 87022 -Standard Not Met Update to include how each consultant and community resource helps the facility meet the specific needs of the children in care N Trauma Informed and evidenced based interventions STRTP ILS Section 87022- Standard Not Met This section must provide a detailed description of de-escalation techniques that trained staff will use in crisis situations to prevent escalation when a client is in crisis. The information in this section should not focus on the therapies provided at the STRTP. This section is specifically about trauma-informed evidence-based behavioral interventions and de-escalation methods used to maintain the youth's safety. This section should include, but not be limited to, how staff will apply the STRTP's behavioral intervention strategies. How will staff de-escalate and/or prevent crises How will staff maintain a safe environment? How are staff trained to do this What interventions will be used ( Pro-Act, CPI) Also, explain how the emergency intervention techniques will promote the safety of everyone in the facility, including children who may be at risk of harming themselves or others. O Plan for Use of Delayed Egress Devices Title CCR Section 80020; STRTP ILS Section 87022- Standard Met ·The facility does not plan to use delayed Egress Devices P Conflict of Interest Mitigation Plan STRTP ILS Section 87022- Standard Met This section is not applicable as Makade will not be a county run facility CONTINUED ON LIC 809C Q Continuous Quality Improvement (CQI) STRTP ILS 87022, 87068.3, 87081- Standard Not Met • Within this section, the written policies, procedures, and practices must be comprehensive and detail how the CQI will be culturally relevant, trauma-informed, and age and developmentally appropriate. The CQI plan must detail how the facility will use and interpret qualitative and quantitative data to evaluate and improve the quality of care for children in placement. This section must align with ILS regulations 87022,87068.3, 87081,and clearly show the facility's CQI process, including, but not limited to, data collection and analysis, policies and procedures for the monthly review and adjustment of the needs and services plan, and how the facility will collaborate with the Department on the CQI program by responding promptly to meeting requests, correspondence, and other CQI-related requests. • Page 157 states MBC employs quantifiable performance measures to ensure accountability and continuous improvement." Elaborate on 'quantifiable performance measures." Define each quantifiable performance measure and how this information informs the development of continuous improvement and accountability. • Please detail what qualitative and quantitative data will be collected that is related to identified outcomes, indicators, and practice standards per 87081(c)(3) • Include collecting data on the numbers and Types of complaints received and, if applicable, the resolution of each complaint, 87081(c)(7) • Consider including collecting data (qualitative and quantitative) about staff: training, workload, and performance, and peer review with a short-term residential therapeutic program that serves a similar population or a panel. ILS 87081(c)(3)(A) through (C) • Detail how MBC's CQI plan is developed based on the mission, vision, and values ILS 87081(b) • Include as part of the CQI process how the facility will ensure frequent review, documentation, and, if necessary, adjustment of the child's needs and services plan and treatment plan ILS 87078.1(c)(1) • For example, are there specific behavioral trends that may prompt a review or an adjustment to the child's needs and services plan? • Include the process by which the facility gathers/collects direct input from the staff at all levels of the facility, children, NMDs, families, and community resources • Describe how all direct input shall inform program development and improvement ILS 87081(b)(1) (Continued on LIC 809C) Program Statement 1. Population to be Served ILS Section 87022.1-Standard Not Met •This section identifies the population the facility will serve. It should specify the gender and whether the facility serves child welfare, probation, or privately placed children. The section mentions non-minor dependents, which contradicts the stated accepted age range of ambulatory 10 to 17-year-olds. It needs to be clear whether non-minor dependents will be accepted. This section should also clarify if the STRTP will serve male or female youth. •Page 163 states that "The program does not serve...individuals with profound self-care deficits..." Please define which behaviors constitute "profound self-care deficits". •Page 164 states that "Youth with HIV/AIDs are evaluated on a case-by-case basis..." Please clarify which cases are acceptable for the program and which are not. How is this determined? •As quoted above, MBC serves 17-year-old youth; please describe the plan once a youth approaches 18. Is the facility willing to continue placement, or will the facility ensure the transfer of the youth prior? • If MBC will serve probation youth/survivors of commercial sexual exploitation, please describe the treatment modalities aimed at addressing the needs of youth in this population per 87022.1( b)(2) (a) •If MBC intends to serve NMDs, the program statement shall include a description of the programs or services to be provided consistent with assisting an NMD in preparing for the transition to independent living. •If the facility intends to serve children or NMDs with special health care needs, it shall include a statement that it meets all requirements for a specialized STRTP, as defined in ILS Section 87001(s)(5), a description of its program or services to be provided to this population, and a description of how the programs and services meet the requirements as specified in the ILS including, but not limited to, ILS Sections 87010.2, 87064.1, 87065.6, 87066.1, 87068.12, 87069.2, 87070.2, 87072.3, and 87087.1. •The program statement shall include a description of how the facility program has the ability to support the following: •The individual needs of children, NMDs, and their families, with short-term, specialized, trauma-informed, and intensive treatment, including, but not limited to, treatment that implements child-specific short-and long-term needs and goals identified by the qualified individual's assessment of the child. Please include a description of how the facility will provide individualized care and treatment aligned with the needs of youth and NMDs as identified by the Qualified Individual - See ILS Section 87022.1(b)(3)(A) (Continued on LIC 809C) 2. Emergency and Disaster Response Services ILS Section 87022.1; Title CCR Section 80023-Standard Not Met Update to include a detailed Contingency plan for action during fires, floods, and earthquakes, including but not limited to the following: Completed LIC C Means of exiting the facility during an emergency; ensure it aligns with the LIC 610C Transportation arrangements for clients/staff Arrangements for supervision of clients during evacuation/ relocation, and for contact after relocation to ensure that relocation has been completed as planned. Means of contacting local agencies, including but not limited to the fire department and law enforcement agencies. Provide clear, reliable methods of contacting emergency agencies in case of an emergency. 3. Transportation Arrangements STRTP ILS Sections 87022.1, Standard Not Met Within this section the transportation plan needs to be detailed and describe the policy and procedures that explain the written rules and step-by-step instructions that describe how transportation is planned and approved. On page 173, it mentions that "transportation protocols adhere to stringent security measures". Explain the vehicle check-out procedures and how these procedures ensure safety and regulatory compliance. Explain how the STRTP's policy and procedures ensure that the transportation provided safeguards the health and safety of a child and shall not violate the personal rights of a child as required by Section 87072, including the right to have equal access to all available services and to not be subjected to discrimination based on actual or perceived race, ethnic group identification, ancestry, national origin, color, religion, sex, sexual orientation, gender identity and expression, mental or physical disability, or HIV status ILS 87074(e). The transportation plan should specify which staff members ( direct care staff, administrative) are responsible for client transportation Other than staff transportation, include all allowable means of transportation and the policies and procedures around the use of alternate transportation. If a third-party contractor will be used to provide transportation on a regular basis, a copy of the written agreement or contract with the chosen contractor(s) must be provided ILS 87074(f) How will the reasonable, prudent parent standard apply when approving youth over 16 to use public transportation, and how will approval decisions be documented in the needs and services plan? Provide detailed policies and procedures outlining the approval process for youth 16 and older to use public transportation. (Continued on LIC C) How will staff ensure there is adequate transportation to extracurricular activities, and how will staff apply the reasonable and prudent parent standard (RPPS) to approve the activity? Pages 173-174 describe return transportation procedures for youth who have left care or runaway. It is recommended that this be added to the runaway plan in section 26 of the Program Statement. · If a licensee provides transportation to a child or nonminor dependent, the licensee shall ensure that the vehicle used to transport the child or nonminor dependent is in safe operating condition ILS 87074(d). Pages 174-175 mention vehicle maintenance in a brief bulleted format. This section should be expanded to include, but not limited to: Who is responsible for completing and documenting maintenance and safety checks Describe the safety check before staff can transport youth in a facility vehicle Detail how maintenance records and repairs are documented How is mileage documented The transportation plan should be expanded to include, but not be limited to, the following: ·How will the facility ensure that all children get to their health-related services, visitations, court hearings, and social activities. Describe the contingency plan if additional staff are needed to provide transportation How many facility vehicles will be in use to transport the youth in care? What is the policy around STRTP staff using their personal vehicle to transport children in care Emergency response procedures staff must follow in case there is an accident, behavioral incident while transporting, or roadside assistance is needed. Page 176 provides a bulleted list regarding NMD transportation authorization and vehicle use. This section should be expanded to include clear policies and procedures that show how NMD transportation decisions are approved and documented Who approves NMD transportation and vehicle use? Insurance verification and vehicle registration requirements How will this be documented in the needs and service plans? 4.Core Services and Supports STRTP ILS Sections 87022.1, 87078. Standard Not Met Update to include or expand upon all of the core services and supports, as specified in ILS 87078.1, to be offered to children, non-minor dependents, and their families, and the practices used to ensure that they are trauma-informed, culturally relevant, and age and developmentally (Continued on LIC 809C) Describe how services will be delivered/provided and individually tailored to meet the needs of the children in care. If the facility plans to contract with any other organizations, this section needs to be updated to include a list of what specific agencies/organizations the facility will contact or plan to contract with, including the use of trauma response/crisis teams. Include a description of how the facility will ensure that the core services secured through agreements with other agencies are trauma-informed and culturally relevant. 87078.1(b)(1) and include the provision that documentation of agreements with other agencies shall be maintained by a short-term residential therapeutic program and be available upon request by the licensing agency as stipulated in ILS 8708.1(b)(2) · If applicable, provide the names of any existing relationships with community and county-based providers and describe the core services secured through agreements ILS 87078.1(b)(2) This may include local parks and recreation to support extracurricular activities, LGBTQ centers to support clients, colleges for NMD support in academic continuation, linkages to TAY programs, American Indian centers/programs, or, regional centers . · Describe how the facility will ensure that Indian children receive core services and supports in accordance with the Indian Child Welfare Act, as specified in Section 87078.1(c). Detail specific services and supports available to an Indian child placed in your facility. Examples may include referrals to native American educational centers, connecting them to Indian health services (counseling, medical , health, substance abuse services), connecting them to their tribe representative, and attendance in local pow wows. Page 178 mentions "Upon admission, a comprehensive assessment and evaluation are conducted within 30 days, utilizing standardized tools to assess the youth's mental health, behavioral challenges, and overall well-being." Elaborate on the assessments and evaluations that are conducted within 30 days; specifically, detail what each assessment and evaluation aims to collect data on. Also, elaborate on what is considered "standardized tools." 5.Trauma-Informed Interventions and Treatment Practices STRTP ILS Sections 87022.1, 87078.2, 87089. Standard Not Met Update this section to provide a more detailed description of how the STRTP will meet the needs of youth who have experienced trauma, including, but not limited to, descriptions of trauma-informed interventions, treatment practices, de-escalation, and harm reduction techniques. This section should establish a clear understanding of trauma and the interrelationship between trauma, including the neuro-cognitive problems and neuro-psychological issues. The written policies and procedures must describe how the STRTP will meet ILS requirements 87022.1 and 87078.2. Revise this section to include or expand upon the following: (Continued on LIC 809C) Neuro-cognitive problems, neuro-psychological issues expand to include the behaviors, challenges, and symptoms of trauma and impact on brain development. Describe how the interventions, including early interventions, are designed to address this and how they are trauma-informed, culturally relevant, and age-appropriate. • Describe how Interventions, techniques, and practices are consistent with the child's needs and services plan. The trauma-informed interventions and treatment practices utilized must demonstrate all of the requirements as listed in ILS 87078.2(a)(2) Recognition and understanding of the trauma that children have experienced and how trauma impacts children How observable behaviors will be identified and evaluated to assess the need for services; How will the interventions, techniques, and practices ensure maximization of physical and psychological safety for the child or NMD How are emergency interventions, including early interventions and de-escalation procedures are trauma-informed? Staff training as stipulated in ILS 87078.2(a)(3) must describe the training staff receive to on types of trauma experienced by children and nonminor dependents, the effects and impact of abuse, neglect and trauma; how trauma may manifest itself in daily functioning and behaviors,; how to provide care and supervision that is trauma-informed; how to facilitate healing; and how to reduce risk of re-traumatization. How will the trauma-informed intervention and treatment practices support children and non-minor dependents, their families, and caregivers in identifying and accessing services and supports to heal from trauma, reduce the risk of re-traumatization, and foster well-being and resiliency. This can include, but not be limited to:ILS 87078.2(a)(4) Development of coping, communication, and self-regulation skills Development of independent living skills that foster self-esteem, self-advocacy, and empowerment Training on how to access specialty health and community services Extracurricular activities Healing practices Engagement with the child's family and loved ones, and maintaining connections to important people in the youth's life Ensuring the provision of a positive, safe physical and emotional environment (daily schedules, routines, and how staff will ensure an overall consistency in daily living) as well as services which are strengths-based and promote positive development (Continued on LIC 809C) Provide the procedures for how the facility will access and make referrals for evidence-based and/or services and practices that are trauma-informed. Policies and procedures for collaboration with Child Welfare, Probation, County Mental Health, Child and Family Teams, and outside partners to ensure effective and consistent provision of care and services that are trauma-informed. Describe the procedures for maintaining consistency with TILPS. Page 183 mentions that the trauma-informed treatment practices include Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy (DBT), and mindfulness techniques are integrated into treatment plans. Expand upon this section to detail how these therapies are implemented and individualized to each child/NMD in care. Also, explain what mindfulness techniques are and how these techniques are applied. On page 183, provide an explanation of what general relaxation training, affect identification, and regulation techniques are and how they are trauma infromed, and applied to support the individualized needs of the children/NMD in care. Page 183 explain how the STRTP works with the youth's family, multi disciplinary teams to ensure that treatment plans are individualized. Page 185 "Our Needs and Services Plans (NSPs) and Treatment Plans are tailored to each youth's trauma history, focusing on individual strengths, coping strategies, and personal goals, elaborate further. How will assessments and screenings be used to inform treatment? Page 184, explain how staff and client interactions support trauma-informed care. Explain how staff interactions are guided by trauma-informed principles. Page 185 describes how the STRTP is designed to minimize triggers. Expand upon this to include how the design of the facility supports emotional regulation. Are any of these techniques evidence-based? 6.Nursing Services STRTP ILS Sections 87022.1, 87089.2, HSC Section 1562.01(n) Standard Not Met Describe how the facility will ensure that contracted nursing care is consistent with the facility treatment model. Expand upon this section to include how nursing services will support the therapeutic approach/treatment model outlined in the program statement. Demonstrate how the facility will ensure that if a child who is placed by a county placing agency requires regular onsite nursing care, the facility will provide the nursing care consistent with their treatment model, or shall partner with the county placing agency to arrange for the nursing care to be provided per Health and Safety Code Section 1562.01(n)(4) (Continued on LIC 809C) 7. Development, Implementation and, Modification of the Needs and Services Plans (NSP) ILS Sections 87022.1, 87068.2, 87068.22, 87078. Standard Not Met Update this section to include or expand upon the implementing, modification/updating, and required components of the NSP. Ensure that the written policy and procedures align with the referenced ILS regulations for this section. Outline the policy and procedures around who participates in creating the NSP. The needs and services plan shall identify the child's needs as specified in ILS 87068.2(b)(1)-(9) and include how the needs and service plan is trauma-informed, culturally relevant, and age and developmentally appropriate. Policy and procedures describing procedures for collaborating with the child's family team (CFT) and time lines for completion after admission. Include policy and procedures for conducting the initial assessment and how the assessment will be trauma-informed, culturally relevant, and age and developmentally appropriate. Policy and procedure regarding the NSP for children placed in the facility on an emergency basis and who will remain in placement for less than 7 days. If emergency placements are not accepted, this needs to be clearly stated. A plan to have discussions with the child regarding placement in the facility, needs and expectations while in placement, as well as any transitions to home-based care or to a less restrictive family environment. Discussions must be age and developmentally appropriate and documented in the child's or NMD's needs and services plan. The polices and procedures to ensure the child's needs and services plan is consistent with the case plans, including the needs as identified by the qualified individual, as developed by the county placing agency, and recommendations by the CFT. Include the information required to be part of the child's record as required by Title California Code of Regulations (CCR) Describe how staff will integrate the NSP into daily care, including coordination with, but not limited to, the STRTP clinical staff (social worker,case manager), and direct care staff, to ensure the NSP aligns with the treatment model ILS 87068.2 (c) Describe the policy and procedures to ensure treatment is consistent with the short- and long-term needs and goals for the child, as specified in the child's permanency plan. (Continued on LIC 809C) The services to be provided or arranged to meet the short- and long-term needs and goals of the child or NMD as assessed by the qualified individual pursuant to WIC Sections 11462.01 and 4096. The policy and procedures to support the reasonable and prudent parent standard, as specified in ILS Describe the policy and procedures to ensure that consistent progress is made toward the time frame and plan for transitioning the child or NMD to a less restrictive family environment. The NSP will include all of the required components as outlined in ILS 87068(c)-(i) The needs and services plan shall include the anticipated duration of treatment specified in Section 87068.4(b). Details regarding the anticipated duration of treatment. Please include the procedures for ensuring a child's NSP includes their individual anticipated treatment duration. Describe how it is determined (CFTS, QI assessments, etc.) and what factors influence the length of stay determination (functioning levels, current coping skills, specific behaviors AWOL, safety skills). Please ensure the anticipated treatment duration is individualized for each youth. Policy and procedures that detail how and when the NSP is reviewed Describe how changes in the child's needs or goals are identified and the required timelines for updating/modifying the NSP Non-Minor Dependents ILS 87068. This section is incomplete; if the facility plans to provide care to NMD's this section needs to be updated to include the policies and procedures regarding the development, implementation, and modification/updating and align with all the requirements as stipulated in ILS 87068.2. If NMD's are not accepted, this needs to be clearly stated. 8.Planned Activities ILS Sections 87022.1, 87065, 87067, 87068.2, 87068.22, 87078, Standard Not Met The activities plan does not include all the required activities as outlined in ILS 87079(a)(1)-(11). Update to include all the required activities, including the policy and procedures for allowing a child the opportunity to participate in the planning, preparation, selection, conduct, cleanup, and critique of planned activities as stipulated in ILS 87079(c) Describe how the planned activities will be trauma-informed, culturally relevant, and developmentally age-appropriate. Describe the policies and procedures for developing community support systems for children and NMD's to maximize use of non-mental health community services and resources. Describe the policy and procedures for using computers, technology, and the internet to ensure that the use aligns with the child's age, maturity, developmental level, court orders, and CFT decisions. (Continued on LIC 809C) Describe how the residential environment will be used to help the children and NMD'S learn, practice, and improve their community living skills. Describe how planned activities will be supervised; ensure the policy and procedures around supervision align with the client staff ratio for planned activities away from the facility ILS 87065(c) Update the policies and procedures regarding the reasonable prudent parent standard (RPPS) to include the planned activities approval process. Include the policy for retaining copies of the planned activities in the facility files ILS 87079(e)(1) If vocational services/training are not provided, the facility still must provide/allow access to existing information regarding available vocational and post-secondary educational options as specified in WIC 16001.9(a)(28). Update this section to include this provision and the required information to be made available to clients as outlined in ILS 87079(f)(1)-(6) and ILS 87079(g)(1)-(5) Non-Minor Dependent section is incomplete Pages 205-206, please explain the differences between Level 1- Sunset tiers. How are youth evaluated for participation in each sunset level? Page 202 states that MBC partners with "...Mental Health Rehabilitation Specialists to facilitate Casey Life Skills assessments and implement vocational topics during weekly one-hour group sessions tailored to individual needs." If the facility provides on-site vocational training, please describe the skills taught, the training goals, the hands-on experience provided, the materials provided, the number of hours per day/days per week, and the funding. Include activities which meet the training, money management, and personal care, grooming needs, and any other independent living skills identified in the children's needs and services plans, as specified in Section 87068.2(b)(3) through (5) and Section 87068.22(c)(1) 9.Services During Placement and After Discharge ILS Section 87022.1-Standard Not Met Update this section to list the agencies and community-based organizations that the facility uses to provide additional services to youth both during care and after. This can include agencies with which the facility has formally or informally partnered to provide additional supports and services to families and children, including non-minor dependents during care and post-permanency. Update to add the name, location, and the service they provide. This can include the name of specific agencies for crisis management, family/individual counseling, LGBTQ+ and CSEC community service agencies, or, cultural liaisons. The agencies or community-based organizations must be consistent with the STRTP treatment model and meet the needs of the population served •Please provide the written agreements with any contracted agencies.(Continued on LIC C) 10. Plan for Participation in Child and Family Team (CFT) ILS Sections 87022.1, 87078.2]-Standard Not Met This section needs to be revised to expand on the facilities CFT plan, explaining how each facility will participate in CFT meetings in a manner that is trauma-informed, culturally relevant, and age- and developmentally appropriate. and expand upon the policy and procedures around the following: Initiation and ongoing participation Page 214: Details the steps for initiating the CFT process. Include procedures for notifying the placing agency, child, parents/guardians, and other required CFT team members. Include timelines for notification which staff are responsible for scheduling the first CFT meeting. This section states that the first CFT meeting is held within 60 days of placement. This contradicts section 11, that states the CFT is held within the first 30 days of placement. If a CFT is needed, clearly identify the responsibilities of the county and the facility when requesting a CFT. How will the facility initiate this process? ILS 87022.1(b)(11) Additional CFT meetings Page 214: Describe the policy/procedure around additional meetings. This section should include, but not be limited to, who can request the CFT meeting, timelines, and procedures regarding notification of the child and all required parties. How the need for more meetings was identified, and in what situations would additional CFT meetings be held. The CFT plan should include placement preservation. Facility Role in the CFT ProcessPage 214: Describe how the CFT aligns with the child's treatment plan and facility treatment model, and how staff participate and support the child and family during the meeting. This section can also include how the facility will ensure child/family engagement in the CFT process and how youth rights will be protected. Legal Considerations in the CFT Process Page 215: Within this section, describe how the facility will coordinate with county counsel and court-appointed advocates. This section should include procedures for notification of all required participants and timelines of notification. Include the policy and procedure for obtaining higher levels of approval. Tailored Advocacy for individualized needs Page 216: Expand this section to include how advocacy will be performed and how the CFT process will address the challenges of marginalized youth identified in this section. Describe how the facility will communicate and share information with all the required parties on the child family team. How will the CFT be documented in the child's record? This section should also include how the facility will ensure follow-through on the CFT. Describe how staff will be trained to effectively participate in the CFT process. The staff training plan should include who will be trained ( direct care staff, facility managers, etc.), detailed training topics, and timelines for training. (Continued on LIC 809C) Describe/ explain how the facility treatment and mental health services are aligned with the child's short- and long-term goals. Explain how this is done (treatment/interventions used) and how the skills learned while in care support the child's aftercare. This section should also include the process for reviewing progress toward these goals. Include how the facility will document the process by which the STRTP will implement treatment and services to support the short- and long-term, child-specific mental health goals identified by a qualified individual pursuant to WIC section 4096(g). 87022.1(12)(A)(3). 12. Family and Sibling Participation ILS Sections 87022.1, 87070, 87078.1-Standard Not Met Include how the facility will facilitate family members' (including siblings') participation in the child's treatment program, including but not limited to the needs and services plan and the transition plan. Detail how outreach efforts are made, maintained, and documented. Outreach efforts maintained. Will they be maintained physically, virtually, or both? MBC must engage the child/youth to determine preferred family members they would like to interact with, to the extent clinically appropriate. The child's preferred family members can either be biological or nonrelative extended family members of the child per 877022.1(13)(2)(1) Describe how family connections are documented in the treatment process per 87022.1(13)(a)(3) Section Complaints and Grievances ILS Sections 87022.1, 87072.2, 87078.2-Standard Not Met The inclusion of the "Psychological Security of Youth" and Personal Rights for Children with Special Health Care Needs, Foster Care Ombudsman should be removed as it does not pertain to complaints or grievances. In addition to the children in care, the grievance procedure must include how their authorized representatives, if any, are permitted to file complaints, without fear of retaliation, with the facility administrator regarding facility staff or operations. Include when staff will receive copies of the complaint and grievances procedures ILS 87065(m) If the facility accepts non-minor dependents, include when they are notified of the compliant/grievance procedures ILS 87068.11 Participation and Assistance in Initiatives to improve child Welfare System STRTP ILS Section 87022. Standard Not Met Update this section to include or expand upon how the facility will be a collaborative partner within the child welfare system. Page 236 stated the facility will participate in the Quality Improvement Project (QI). Include details on how the facility's participation will improve the use of psychotropic medication for children in care. • Expand upon how the facility will actively support the Quality Improvement Projects guidelines. Explain staff participation in Quality Improvement Project and Quality Parenting Initiative, specifying staff's role and responsibilities. (Continued on LIC 809C) Detail how the facility and staff participation in initiatives will be documented. Other than the Quality Improvement Project and Quality Parenting Initiative, will the facility participate in any other initiatives; if so please detail what those may be and how the facility will seek out other projects/initiatives to be a part of. Include how the facility and staff will participate in the initiatives Throughout this entire section, pages 235 - 237, the Quality Improvement Project or QIP is abbreviated as "QI". Please ensure the acronym for the Quality Improvement Project includes a P to avoid confusion with the Qualified Individual (QI) program. Family Visitation STRTP ILS Sections 87022.1, 87072, 87078.2, Standard Not Met Page 240 stated that the needs and service plan is updated every 90 days based on the youth's progress. Correct this to align with the ILS 87068.3, as the NSP is updated at least every 30 days Include in this section the requirements for posting the visitation policy, when and how the children in care will be notified of the facility's visitation policies, as required in Health and Safety Code How will policies and procedures addressing family visitation and other communication with children be culturally relevant, trauma-informed, and age and developmentally appropriate Update the policy and procedure to include staff supervision of visits and to outline how staff will ensure the child's physical and emotional safety during visits Explain how the facility will encourage active family participation in activities at the facility. Include the policy/procedures around family participation Explain how the family visitation policy will not violate the personal rights of children in care. Personal Rights STRTP ILS Sections 87022.1, 87072, 87072.3, 87078. Standard Not Met This section should describe how the policy and procedures mentioned in this section demonstrate compliance with personal rights. Update to include a child and their authorized representative will be informed of the personal rights at the request of the child, as required in ILS 87072(b)(1)(B) The policies and procedures demonstrating compliance with personal rights must include all the information to be provided to the child as required in ILS 87072(b)(2)(C)-(D) If the facility will admit children with special health care needs (SHCN), update this section to include the personal rights for children with SHCN as specified in ILS section 87072.3. If children with SHCN will not be admitted, this needs to be stated. (Continued on LIC C) House Rules for Children and Non Minor Dependents ILS Sections 87022.1, 87078.2-Standard Not Met Include a description of how trauma-informed practices are incorporated into the facility's house rules, and how the house rules are culturally relevant, and age and developmentally appropriate ILS 87022.1(b)(14)(E) A description of how trauma-informed, culturally relevant practices are incorporated into the provider's House Rules per 87022.1(b)(14)(E) The house rules mentioned on pages 256-259 detail instructions on curfews, visitations, individual privacy, physical contact, respectful communication, cleanliness, and for NMDs, Telecommunication and Digital Access ;include a Telecommunication and Digital Access rule for youth in MBC who are not NMDs It is recommended that this section be expanded to include additional house rules policies on on Alcohol, Drug, weapons & smoking; Appliances, Equipment, and Furniture; Cell Phones/Telephone; Computers and Internet Access; Curfew; Dating; Decorations; Dress Code:; Entertainment and Community Outings; food/drinks/meals/snacks; Gratuity and Gifts; Home Passes; Homework/tutoring; chores; laundry; Medications; Personal Hygiene; Personal Money and Valuables; Personal Vehicles; property damage/buildings and grounds; Resident and Staff Relations; bedroom sharing; Room Search/Search of Personal Belongings; Selling/Purchasing Personal Items; Sexual Behavior; Sign In/Sign Out Procedures; Sleeping Hours; Storage of Personal Belongings; Television Cable & Satellite; Transportation; Visitation. Positive Discipline Polices and Procedures ILS Sections 87022.1, 87065.2, 87072, 87072.1, 87078. Standard Not Met This section needs to be updated to align with the Discipline Policies and Procedures ILS 87072.1 and include all of the the acceptable forms of positive discipline as required in ILS 87072.1(d)(1)-(5) and what staff will do when a child is subject to positive discipline, as required in ILS 87072.1(e) to include conditions under which each type of discipline will be used. It should be clearly stated that any form of discipline that violates a child's personal rights as specified in Section 87072 shall be prohibited. Please include a description of discipline types that are not permitted Update prohibited forms of discipline to include licensee or staff shall not discipline a child for refusing to take their psychotropic medication ILS 87072.1(f), and that calls to law enforcement must be made in accordance with the facility's emergency intervention plan as specified in Section 87095.22. Calling or threatening to call law enforcement is prohibited as a form of discipline ILS 87072.1(c), ILS 87072(c)32(A)-(B) Please ensure that Staff, children, and authorized representatives shall sign and receive copies of discipline policies and procedures, and the signed copies shall be maintained in the child's record 87072.1 (a)(3-4) Include a description of how discipline policies are trauma-informed and include a description of how discipline policies account for specialized populations (CSEC youth). CSEC youth are briefly mentioned on page 265. Update to include how the polices are trauma-informed. Expectations and Consequences for Non Minor Dependents ILS Sections 87022.1, 87072.11, and 87078. Standard Not Met Update section to include all of the expectations and consequences policies and procedures for non-minor dependents as stipulated in 87072.11(c)-(g). This will include the types of disciplines permitted ILS 87072.11(e). Include the policy and procedures detailing staff actions when a non-minor dependent is subject to positive discipline, as required in ILS 87072.11(f) to include conditions under which each type of discipline will be used. Update to include when staff, non-minor dependents, and authorized representatives will receive copies of policies and procedures regarding the expectations and consequences for non-minor dependents. ILS 87072.11(b)(3) and that the signed copies of such policies and procedures shall be maintained in the nonminor dependent's record, as specified in ILS 87070.1(d)(11). The type of discipline not allowed shall include non-minor dependent not being subjected to consequences for refusing to take their psychotropic medication ILS 87072.11(g), and law enforcement not being used as a threat ILS 87072.11(d) Page 273 lists examples of consequences; the temporary restriction on phone use is a violation of personal rights, as children in care can make, send, and receive confidential telephone calls and other electronic communications, unless prohibited by court order ILS 87072(c)(12). The consequences listed on page 273 must be approved in writing and in advance by the licensing agency. Page 273 states that all interventions align with Title Section 80075. Section 80075 refers to health-related services. This should be corrected to state that all interventions align with Title 22, section Personal Rights. Storage of Medications Title CCR Section 80075; STRTP ILS Sections 87022.1, Standard Not Met Medication storage should cover all circumstances in which the medication will be centrally stored, update to include all of ILS 80075(j) (Continued on LIC 809C) The labeling of medication containers needs to include all of the required information as listed in ILS 80075(k)(7)(A)-(G) Update pages 279- Medication Destruction Process and Timelines to include all of the information required to be in the medication destruction log as listed in Title 22 80075 (I)(1)(A)-(D). Page Documentation of Medication Logs needs updating to include all information required for a separate log for psychotropic medications prescribed to a child. The log shall document all the information as listed in ILS 87070(b)(14)(A)-(H) and the documentation of medication refusals. Page Self Administration of Medications mentions the use of birth control and as needed medications. This section needs to be updated to include all the requirements regarding the storage of birth control and contraceptives as noted in ILS 87075(b)(1)(A)(1). Possible personal rights violation; this section states that youth prescribed birth control can self-administer under staff supervision. ILS 87072(c)(26) states that children are allowed access to birth control and contraceptives; there is no mention of staff supervision. Page 276 under Administration and Documentation of Medications update to include the policy and procedures regarding psychotropic medications being administered to children without court order or parental authorization in an emergency. ILS 8705(c)(1) Safegaurds for Cash Resources, Personal Property, and Valuables ILS Sections 87022.1, Standard Not Met Allowance procedures on Page 284 should be updated to include or expand on how unissued allowances are stored and kept safe. Also recommended to add policy and procedures for children who are unable to handle their own money. Financial Accountability and Oversight, Pages 284-285, detail the policy and procedures for the internal review. Explain how the internal review and corrective action occur, the staff's role, and examples of the corrective action. Reporting and Investigating Lost or Stolen Property page 285 expand this section to detail the investigation process to include, but not limited to, the following: Clarify reporting timelines and staff responsible for completing the investigation. Describe the internal investigation process; specify what the investigation entails (staff /child interviews, documents review etc) How will the internal investigation be trauma-informed Explain what happens after the investigation, including any corrective/preventative actions. (Continue on LIC 809C) The safeguarding valuables page 286 includes the policy and procedures for auditing "high value" items. The Electronic Devices Policy should be removed from this section and added to the house rules. Ensure that this policy aligns with the youth's personal rights as stipulated in ILS 8702(c)(12)(A)(1)-(3) Include policy and procedures for addressing any discrepancies between the child's belongings and what is documented on the inventory form ( when it is reported, staff responsibilities, and how discrepancies will be resolved) Property Dispute, page 287: This should be in narrative form, explaining what the facility defines as a property dispute and detailing the process for handling property disputes at each step. This section should also include how staff will handle the disputes in a trauma-informed manner. Include policy and procedure for the children who have a bank account and manage personal income consistent with the child's age and developmental level, unless prohibited by the case plan ILS 87072(c)(11) The financial literacy for youth should be removed and placed in section 9 of the Program Statement. If this information is to be added, it should be presented in narrative form and explain how it relates to safeguarding cash, resources, valuables, and personal property. Children's Direct Input ILS Sections 87022.1-Standard Not Met Describe how the processes for gathering feedback from children and NMDs is age and developmentally appropriate. Documentation of Accreditation ILS Sections 87018, 87022.1, 87089-Standard Met This section meets standards as a short-term residential therapeutic program shall have up to 24 months from the date of provisional licensure to obtain accreditation ILS 97089(b). However, if the applicant has started the accreditation process, the applicant shall submit documentation of accreditation, a copy of its application for accreditation, or a declaration of accreditation status with its application for licensure ILS 87089(c) Mental Health Program Approval ILS Sections 87022.1, 87089.1- Standard Not Met Specify how often the youth in care will meet with the psychiatrist, or clinical psychologist, or licensed clinical social worker regarding the program of services, or more often as appropriate to the needs of the child or non-minor dependent. ILS 87089.1(g)(1) Detail how all mental health services and the policy and procedures regarding providing mental health services will be trauma-informed, age and developmentally appropriate, and culturally relevant MBC mentions throughout this section that they are contracted with the Riverside University Health System Behavioral Health (RUHS-BH). Please include a copy of the contract/MOU (Continued on LIC 809C). Food and Nutritional Plan/Sample Menus/Schedule Title CCR Section 80076; STRTP ILS Sections 87022.1, 87070-Standard Not Met The mention of youth with eating disorders on page 313, does not fit in this section. This section should focus on how the STRTP will meet the general nutritional needs of children in care. If the facility plans to provide services to youth with eating disorders, this should be added to section Mental Health Program Approval as a mental health treatment that the facility will directly provide. Provide a list of vendors contracted to provide nutritional services under ILS 87022.1. If the facility will not use a vendor, clearly state who prepares, plans, and serves meals On Page 311, the sample menu shows that the mid-morning snack is available on weekends only. The sample menu should show that all between-meal nourishment or snacks shall be available for all clients unless limited by dietary restrictions prescribed by a physician, Title CCR 80076(4) Revise the Food, Safety, and Storage and Sanitation Practices on page 308 to align with ILS 87076(c)(1)-(4) and Title CCR 87076(14) detailing how food will be stored to prevent spoiling. The facility plan for accommodating a child's special dietary needs will be updated to include modified diets prescribed by a client's physician as a medical necessity. The licensee shall obtain and follow instructions from the physician or dietitian on the preparation of the modified diet. Title CCR 80076(6)(A). Include how this will be documented in the needs and services plan ILS 87076(d) The mention of non-minor dependents participating in meal planning should be revised to include how facility staff will apply the reasonable and prudent parent standard as specified in Section 87067, when allowing a child to use kitchen appliances and utensils for food preparation and cooking ILS 87076(c)(5)(A). Will minor children be allowed to participate in meal planning, if so it should be stated, and the policy and procedures provided. Emergency Intervention Plan (Including Runaway Plan)ILS Sections 87001, 87022.1, 87061, 87063, 87072, 87072.1, 87072.11, 87078.2, 87095.00, 87095.01, 87095.22, 87095.23, 87095.24, 87095.61, 87095.65, 87095.68, 87095.69]-Standard Not Met The Emergency intervention plan is incomplete. It should be revised to narrative form and meet all the requirements specified in ILS 87095.22 and in all other referenced ILS sections. The plan must include detailed policies explaining the facility's rules and exceptions, along with procedures outlining the specific steps staff will take to implement them. Staff roles and responsibilities should be clearly defined. The plan must specify which intervention methods, such as Professional Assault Crisis Training (PRO-Act), Crisis Prevention Institute (CPI), or other approved methods, will be used to safely respond to and manage client behaviors. All aspects of the emergency intervention plan must show how the plan is trauma-informed, culturally relevant, and appropriate for the age, size, emotional, behavioral, and developmental level of the children in care. (Continued on LIC 809C) Emergency Intervention Plan Provide a signed copy of the Board of Directors approval and Procedure for the Board of Directors to approve, document, and receive copies of the plan as specified in ILS Section 87095.22(k). The emergency intervention plan must be designed and approved, in conjunction with the licensee, by an individual with the qualifications of a behavior management consultant, as defined in ILS 87001(b)(1). Provide the name and qualification of the behavior management consultant used to develop the emergency intervention plan. It is also recommended that the intervention methodology ( ProAct, CPI) or any other approved intervention method to be used be specified. Detail how all elements of the Emergency intervention plan, runaway plan, and plan for manual restraints are trauma-informed, as specified in Section 87078.2, culturally relevant, appropriate for the age, size, emotional, behavioral, and developmental level of the children, and account for the particular traumas of specialized populations, including but not limited to, commercially sexually exploited children. ILS 87095.22(a)(3) Include procedures that recognize trauma-informed principles, approaches, and trauma specific interventions, de-escalation, and harm reduction techniques (offer choices, non-threatening body language). Include descriptions and details in the written procedures to demonstrate how the licensee will ensure the prevention of personal rights violations. ILS 87095.22(a)(4) Provide a clear description of the continuum of interventions (least to most restrictive) the facility will use when a child is in behavioral crisis, as defined in Section 87001(e)(1), specifying the emergency intervention techniques to be used. For each type of emergency intervention, the plan must include all of the general provisions listed in ILS 87095.22(d)(2)(A)-(D) Provide a detailed statement specifying what emergency interventions will never be used. The statement should be specific to the behaviors identified in the Runaway Plan and Manual Restraint Plan. ILS 97095.22(d)(3) Include a description of the circumstances and the types of behaviors that may require the use of emergency interventions ILS 87095.22(d) Procedures for using emergency interventions if more than one child requires the use of emergency intervention at the same time. Include procedures to ensure that care and supervision are maintained in the facility when all available staff are required for emergency interventions. ILS 87095.22(d)(7)-(8). This is addressed on page 331, but should be more detailed and added to the Runaway and Manual Restraint plans. (Continued on LIC 809C) Elaborate on the procedures to include, but not limited to, the following: Be specific when defining staff roles in the interventions Explain how the child/staff ratio will be maintained? Procedures for contacting back-up staff if coverage is needed. If law enforcement is contacted, it must be in accordance with the facility's emergency intervention plan Provide more detailed procedures for re-integrating the child back into the facility routine after an emergency intervention has been used ILS87095.22(d)(9). The reintegration plan on page 331 must include detailed, trauma-informed procedures for reintegrating children back into the facility routine. These procedures should be tailored to the specific behavior that triggered the intervention and should be included in the runaway and manual restraint plans. Partially Missing. Procedures for documenting, maintaining, and reviewing monthly restraint logs are detailed on pages 326-328 per 87095.6; however, the monthly log must also include the name of the youth, date of intervention, duration of the intervention, description of intervention, type used, and the result of licensee review. Provide more detailed procedures for re-integrating the child back into the facility routine after an emergency intervention has been used ILS87095.22(d)(9). The reintegration plan on page 331 must include detailed, trauma-informed procedures for reintegrating children back into the facility routine. These procedures should be tailored to the specific behavior that triggered the intervention and should be included in the runaway and manual restraint plans. Partially Missing. Procedures for documenting, maintaining, and reviewing monthly restraint logs are detailed on pages 326-328 per 87095.6; however, the monthly log must also include the name of the youth, date of intervention, duration of the intervention, description of intervention, type used, and the result of licensee review. Emergency Intervention Staff Training Include a provision that only trained staff, as specified in ILS 87095.65 will be allowed to use emergency interventions on children. ILS 87095.22(j) and provide a list of all the staff name(s) trained to use emergency interventions. ILS 87095.22(d)(1). The emergency intervention plan needs to include a detailed staff training plan that addresses and incorporates all elements outlined in ILS 87095.65. The staff training plan needs to align with the chosen intervention methodology (ProAct, CPI) (Continued on LIC 809C) The training must address all the areas/topics outlined in ILS 87095.65(b)(1)-(7) Documentation of staff training ILS 87095.65(d)(1)(A)-(C) Address staff must receive ongoing training, detailing when and how often training will be completed ILS 87095(e) Corrective action plans and staff retraining when an unjustified manual restraint technique is used during an emergency intervention ILS 87095.65(f)(1)-(2) Include a statement that the training must be provided by an individual who holds a valid instructor certificate from a program of managing assaultive behavior. ILS 87095.65(c) Runaway Plan Information about the Runway Plan can be found on multiple pages (320,321,332,333,335, and 337-340). It is recommended that the Runaway Plan section of the Emergency Intervention Plan be reorganized to keep all the related information together. The runaway plan needs to include a staff training plan, to include non-physical interventions, strategies to de-escalate a situation, ILS 87095.24(c)(4), and the requirements in ILS 87095.65 (b)(1)-(7). Expand upon the procedures for notifying the child's authorized representatives ILS 87095.24(c)(6), page 339, to include how the notification will be made (telephone, email), and what information will be included in the notification. Procedure for notifying staff that a child is absent without permission at the change of shift ILS 87095.24(c)(7). Time frames for determining when a child is absent are listed on pages 320-321; however, each child/youth's grace period to be determined absent should be based on an individualized treatment plan that is based on the child/youth's individual risk factors. The individualized plan must include a plan to prevent and discourage children from running away. How will the STRTP incorporate input from CFT when developing the individualized plan Please detail the continuum of interventions, including early interventions, to prevent runaways The actions listed for staff to take in Search and Recovery Efforts (Pages 320 - 321) seem minimal. Recommend including procedures such as calling the youth's cell phone, checking the last known locations, and, if the facility has a vehicle, having staff conduct a search using the company vehicle Procedure for complying with Reporting Requirements specified in ILS 87061(i), page 334, must include the requirements as listed in ILS 87061(i)(1)-(6). Procedures for management review of incident reports, policies, and practices to determine the cause of, and to develop strategies to address, runaway children, both on an individual and facility-wide level. Procedures must include regular management reviews to be conducted at least once a year. (Continued on LIC 809C) Policies and procedures for discussing runaway plan with each child and their authorized representative at time of admission, as well as how an individualized plan will be developed for a child with a history of running away or of commercial sexual exploitation on page 337 need to detail the procedures that facility will take to carry out the policy and include that the individualized plan for that particular child, take into consideration any recommendations provided by the child and family team. ILS 87095.24(e)(1)(A)-(B) Missing. All instances in which Law Enforcement may be contacted must be approved by a staff supervisor. Please include a statement in your policies detailing this required approval step. Manual Restraint Plan In addition to the requirements in California Code of Regulations, Title 22, Section 80068, the admission agreement must include a written statement regarding the type(s) of emergency interventions the licensee has been approved to use. Include when the facility's policy regarding the use of emergency intervention must be reviewed with the child and their authorized representative, and when a copy of the approved emergency intervention plan will be provided to the child and their authorized representative, ILS 87095.22(i)(1)(A) Explain the procedures for determining and using age and size-appropriate emergency intervention techniques ILS 87095.22(d)(5) Include a description of how assessments for each child, as required in ILS 87068.1(c) and 87068.11(f), which includes the needs and services plan per ILS 87068.2 and 87068.22, will be used to inform the licensee's emergency intervention plan. ILS 87095.22(d)(6) Page 332 should include more detail on when and how the emergency intervention plan will be reviewed, changed, or terminated. This section should list all conditions that indicate the plan may no longer be appropriate or effective, such as when interventions become unsafe for children in care or for staff, or when other factors clearly demonstrate the intervention does not achieve the desired result. ILS 87095.22(d)(10) Page 322 needs to be more detailed and provide the criteria when the facility does not have adequate resources to meet the needs of a specific child, along with how the facility will move forward to address those needs ILS 87095.22(d)(11) .This section should include the reasons or factors the facility will consider in determining that the child's needs cannot be met, including, but not limited to, the child's behaviors. This section should also include detailed procedures outlining the actions the facility will take when this happens. Staff roles and responsibilities should be clearly stated. Include or expand upon the facility's policies and procedures concerning when and how to involve law enforcement in response to an incident in the facility, consistent with the ILS Section 87072(c)(32). (Continued on LIC 809C) There is no mention of a protective separation room ILS 87095.23. If the facility will use a protective separation room, the emergency intervention plan needs to be updated to include its use. If a protective separation room is not used, this needs to be clearly stated. Page 326 mentions the roles of staff during a manual restraint. Clarify the procedures for ensuring a child's safety when a manual restraint is being used, including, but not limited to, the titles of staff responsible for checking the child's breathing and circulation. ILS 87095.22(f)(1) Page 326 needs to include all the reasons as required in ILS 87095.69, the administrator or the social work staff will be responsible for obtaining a physical examination during or after an incidence of emergency intervention. Including the documentation in the child's record. Procedures for ensuring that the amount of time a child is restrained on page 325 need to include all the requirements as listed ILS 87095.22(f)(2)(A)-(I) Include procedures for documenting each use of manual restraints in the child's record ILS 87095.22(f)(3) The debriefing and review of manual restraint use on pages 329-330 are incomplete. Procedures should specify how the facility will conduct, document, and review manual restraint incidents, ensuring compliance with all requirements of 87095.68(b)(1)-(2), including when the child involved in the restraint chooses to attend the debriefing. The debriefing process with the child shall take place and be facilitated in a trauma-informed manner and include the child who was manually restrained; the child's authorized representative, if applicable; the mental health head of service; and the administrator or their designee. Include the procedures for debriefing each use of manual restraints with the child's authorized representative, if any, or parent ILS 87095.22(f)(5) The debriefing and review of manual restraints shall also include the administrator or the administrator's designee's documented review of the manual restraint. The review must determine whether the emergency intervention action taken by the staff member(s) was consistent with the emergency intervention plan and document the findings in the child's record and facility monthly log as specified in Section 87095.61. The manual restraint review must evaluate and document all the information listed in ILS 87095.68(c)(1)-(6) Staff debriefing on page 330 is incomplete and needs to include all the requirements as specified ILS 87095.68(a)(1)(A)-(D) The emergency intervention staff training plan is to be included as a component of the emergency intervention plan 87095.22(g). The emergency intervention staff training plan for manual restraints must include the following, as specified in ILS 87095.22(g)(1)-(6) (Continued on LIC 809C) Include the procedures for an internal biannual review of the use of emergency interventions as specified in ILS(h)(1)-(5) Facility staff may be justified in using restraints as an emergency intervention if all the conditions listed in ILS 87095.00(c)(1)-(7) are met; update page 323 to include this information. Page 323 must be updated to address all reasons manual restraints are not used as outlined in ILS 87095.01(c)(1)-(8) and 87095.1(d) Procedures for accessing community emergency services, including, but not limited to, law enforcement, if the use of emergency interventions is not effective or appropriate ILS 87095.22(f)(6). The plan should specify when to contact law enforcement or other emergency services. It should also list the other services to be used and how they will support the emergency intervention. The section on prohibited manual restraints on page 327 is incomplete and needs to be revised to include all the emergency intervention techniques that will not be used on a child at any time as required in ILS 87095.01(a)(1)-(15). In addition to techniques specified in Section 87095.01(a)(1)-(15), any emergency intervention technique not approved for use as part of the licensee's emergency intervention plan must not be used at any time ILS 87095.1(b) The manual restraint plan must include the policy and procedures for reporting the manual restraint to the department. Each use of manual restraints must be reported to the Department and the child's authorized representative by telephone no later than the next working day following the incident. A written incident report must be submitted to the Department within seven (7) days, as required by California Code of Regulations, Title 22, Section 80061. Revise the manual restraint plan to include all of the required documentation and reporting requirements as outlined in ILS 87095. This report was emailed to CEO Jorge Cervantes for signature. The original, signed reports will be placed in the facility file.

met_with: Chief Operating OfficerJorge Cervantes, Director Akila Crane