summary: Facility Evaluation

raw_content:
Narrative:
On March 24, 2923 at 2: PM, Licensing Program Analyst (LPA) Regina Martin conducted a Case Management inspection at CATHOLIC CHARITIES/ANGEL'S FLIGHT for the purpose of obtaining signature and delivering amended Complaint Investigation Report. LPA met with Facility Administrator Patricia Chaidez. There are no deficiencies cited per California Code of Regulations, Title 22, during this inspection. Exit


state: CA

facility_name: CATHOLIC CHARITIES/ANGEL'S FLIGHT

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward met with Program Director Patricia Chaidez to commence the annual/random inspection. The facility is licensed for a Group Home with a capacity of 16. The census today is 7. The facility is an emergency shelter for children ages 10 through 17 with an average stay of 30 days per client.. Clients are placed in the shelter on a voluntary basis and usually no other placement agencies are involved however Catholic Charities/Angel's Flight does occasionally accept DCFS placements and unaccompanied minors. Facility is a two story building. All residents sleep on second floor. There is no signal system in place. Director Patricia Chaidez states that there is always at least one full time staff located on the second floor during the night or when children are in their bedrooms. During the day, clients are usually in the common area. There are a total of 10 bedrooms and 16 beds. All bedrooms have one or two twin beds with the required linens. Each bedroom has the required closet space. The kitchen area, bedrooms and bathrooms were all clean and well maintained. There is food available to meet the requirements of Title 22. There are no bodies of water on the premises. There are no security bars on windows of bedrooms. There is a complete first aid kit. Disaster drills are conducted on a monthly basis. The last drill was conducted on 04/24/2024. There is a working fire alarm panel and several fire extinguishers throughout the facility and on both floors. There are carbon monoxide detectors throughout the facility. A review of client records was conducted. Licensee was cited under sections 80069(a), 84070(c)(3), 84070(b)(12) and 84070(b)(13)(H). Staff files will be reviewed at a future date.

report_type: Facility Evaluation

visit_type: Annual

met_with: Patricia Chaidez, Program Director


summary: Facility Evaluation

raw_content:
Narrative:
On July 25, LPA J. Armstrong arrived to the facility at 12:15pm, CATHOLIC CHARITIES/ANGEL'S FLIGHT to deliver the findings for a complaint allegation. Upon arrival LPA spoke with Residence Attendant Christie Rubalcava who informed LPA she was the only staff present due to all staff being off site at a Staff Appreciation Event. LPA then received a phone call from the Facility Administrator Tracy Alvarez who informed LPA that the Staff Appreciation Event is in Marina Del Rey and she could leave the event to come back to the facility. The facility is being cited for not having a Facility Manager or Administrator present at the facility while clients are in care. Lpa J. Armstrong issued a citation in accordance with the Group Home Licensing Standards, Chapter Division Personal Requirments. The facility cited for violation of California Code of Regulations, as stated in Title 22 84065 (d)The licensee shall designate at least one facility manager to be present at the facility at all times when children are present this poses an potential health, health and safety An exit interview was conducted, a Plan of Correction was discussed, and a copy of the report was provided to the facility.

visit_type: Case Management

met_with: Christie Rubalcava


facility_name: CENTER FOR DISCOVERY-WHITTIER

summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Additional interviews reveal that clients are checked every 15 minutes; doors are required to be open and staff supervising clients in groups always have a line of sight. Due to high risk behaviors of some clients in placement, staff are on standby within the vicinity of restrooms if clients need to use the restroom. Clients are monitored when going inside and when coming out of restrooms. No statements were obtained from the alleged involved clients; parents did not grant consent for interviews. One client and parent requested one agency case to be closed and signed a complaint refusal form. Information obtained from additional records reviewed showed no evidence of any sexual acts between clients. Based on information obtained, there is insufficient evidence found to support the allegation, so the allegation is unsubstantiated. Although the allegation may have happened or is valid, the preponderance of evidence to prove the allegation was not met. An exit interview was conducted. A copy of this signed report, the Confidential Names Form and Appeal Rights forms were provided via electronic mail. There was no deficiency citation issued.

Investigation Findings:
13On September 2, 2021, Licensing Program Analyst (LPA) Irene Yamamoto delivered the finding of the allegation at the facility. LPA discussed the finding with the facility representative named above. The allegation was investigated by the Department's Investigations Branch (IB), assigned to Investigator Laura Garcia. Investigator Garcia conducted confidential interviews with staff, clients and other related parties (refer to Confidential Names Form LIC 811 dated September 2, 2021). Investigator Garcia also reviewed pertinent documents obtained from the client file, the facility complaint history, supervision check logs and other agency reports. It was alleged that there was lack of supervision resulting in clients engaging in inappropriate sexual activities. Confidential interviews reveal that a client engaged in inappropriate sexual behavior inside a bathroom due to peer pressure. No other client was present, and client did not engage in any sexual acts with other clients. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Irene Yamamoto LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: CENTER FOR DISCOVERY-WHITTIERFACILITY NUMBER: VISIT DATE: 09/02/2021

report_type: Complaint Investigation

met_with: Sam Edman, Administrator

complaint_status: unsubstantiated


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Confidential interviews revealed there was an incident. Client stated the incident occurred but provided inconsistent statements during interviews. Additional interviews revealed clients are checked every 15 minutes; doors are required to be open and staff supervising clients in groups always have a line of sight. Due to high risk behaviors of some clients in placement. No statements were obtained from the alleged perpetrator. Witness stated the clients did not disclose anything inappropriate at the time of incident. Based on information obtained, there is insufficient evidence found to support the allegation, so the allegation is unsubstantiated. Although the allegation may have happened or is valid, the preponderance of evidence to prove the allegation was not met. An exit interview was conducted. A copy of this signed report, the Confidential Names Form and Appeal Rights forms were provided via electronic mail. There was no deficiency citation issued.

Investigation Findings:
13On June 8, 2022 at 1:30PM, Licensing Program Analyst (LPA) Pedro Ramos conducted a follow-up complaint inspection to CENTER FOR DISCOVERY-WHITTIER and met with staff above. The purpose of the inspection was to deliver findings for the above complaint allegation. During the course of the investigation, LPA Ramos received pertinent documents. Confidential interviews were conducted with client and other relevant parties (see Confidential Names Form dated: 6/8/22). It was alleged inappropriate interactions between minors in care. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Pedro Ramos LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: CENTER FOR DISCOVERY-WHITTIERFACILITY NUMBER: VISIT DATE: 06/08/2022

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

met_with: Kelly Gonderman, Program Director


summary: Facility Evaluation

raw_content:
Narrative:
On July 20, 2021, at 11:05 am, Licensing Program Analyst (LPA), Belinda Gilmer conducted an unannounced Case Management Inspection to the above agency and spoke with Kelly Gonderman Assistant Program Director. The purpose of the inspection was to discuss and investigate a special incident reports Community Care Licensing (CCL) received on 07/14/21. The incident occurred on 07/03/21 but wasn't reported until 07/14/21. When the group home was made aware of the incident. The C2 and C3 weren't interviewed today as they were both discharged on 07/14/21. LPA spoke with C1 about the incident and C1 confirmed the incident took place between the time the staff conducted their 15 minutes rounds. LPA Gilmer also discussed a special incident report that Community Care Licensing received on 07/16/21. Involving C4 and C5 engaging in a sexual act. Both C4 and C5 were discharged after completing their program. An exit interview was held and copies of the facility evaluation form, confidential names list, and the technical assistant were emailed to Kelly Gonderman.

met_with: Kelly Gonderman


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by Licensing Program Analysts (LPAs) Carrie Palmer and Johanna Lofton on October 5, 2022 at 9:00am. During this visit, LPAs met with Facility Manager Samuel Edman and Kelly Gonderman Assistant Program Director. LPAs and staff toured the facility inside and out. The facility is licensed for a capacity of 25 clients. Current census is 19. The facility consists of two (2) buildings with addresses 119111 and 11913. Unit 11911 is the administrative building and therapy services for the clients. This building has a reception area, six (6) therapy rooms, a processing room, reception area, kitchen and restrooms. Building 11913 is the residential building which consists of fifteen (15) bedrooms, recreational rooms, nursing stations, bathrooms, laundry area, staff offices, outdoor activity space, dining room and kitchen. LPAs were able to see food supply and verified there was enough perishables and non-perishables items. The facility was observed to be clean, safe, sanitary, in good repair and passageways were unobstructed. There were no bodies of water on the premises. Cleaning solutions, poisons and sharp objects were locked and inaccessible to clients. Medication was observed to be double locked in a cart in the nurse's office. Smoke and carbon monoxide detectors were not tested today because it mainlines are wired directly to the fire department. Staff reported having a fire drill the day before (10/04/22). During the inspection LPAs observed the children's Personal Rights, Ombudsman flyer,emergency disaster plan, facility sketch and foster youth bill of rights were posted. LPAs received a copy of the LIC500 and the Client Roster. An exit interview was conducted and a copy of this report was provided to staff. This annual requires a continuation.

met_with: Samuel Edman- Administrator


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by Licensing Program Analysts (LPAs) Carrie Palmer and Johanna Lofton on October 27, 2022 at 10:30am. During this visit, LPAs met with Facility Manager Samuel Edman and Kelly Gonderman Assistant Program Director. LPAs reviewed staff training plans, training logs, records of restraints/logs in their electronic tracking system; as well as Quarterly Board Meeting Minutes. Current census is 21. During the inspection, LPAs completed the following domains: Emergency Intervention Plan and Operational Requirements. Both domains were in compliance. Exit interview was conducted and a copy of this report was emailed to administrators. .


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection/file review was conducted by Licensing Program Analysts (LPAs) Carrie Palmer and Noubar Yerkatyan on December 21, 2022 at 9:15am. During this visit, LPAs met with Facility Manager Samuel Edman and Kelly Gonderman Program Director. The purpose of today's visit was to review 5 client files with Facility Manager and Program Director. During the clients file review LPAs were able to review the program statement, policies and procedures specific to cash allowances, children's phase sheets, menus and glucose logs. At the time of the inspection, one technical violation was observed and discussed with staff (CCR 84087(e) Building and Grounds). An exit interview was conducted and a copy of this report along with the LIC 811 was provided to staff via email.


summary: Facility Evaluation

raw_content:
Narrative:
On 01/06/23 at 1:50pm, Licensing Program Analysts (LPA) Carrie Palmer conducted an unannounced inspection at Center for Discovery - Whittier to complete a 2-Year Required inspection initiated on 10/05/22. LPA met with the Sam Edman, Facilities Manager, and stated the purpose of the inspection. LPA stated that the purpose of today's inspection was a continuation from the previous visit (12/21/22) and the focus would be staff and client interviews. LPA requested a copy of the Personnel Report and the and the phase sheet for all residents in care. LPA Palmer conducted 3 staff interviews and 3 client interviews. A copy of the LIC 809 and LIC 811 were discussed and provided to the facility representative. An exit interview was conducted.


summary: Facility Evaluation

raw_content:
Narrative:
On June 19, 2023, Licensed Program Analyst (LPA), Carrie Palmer conducted a Case Management visit. Upon arrival, LPA explained the nature of the visit. The facility has a current census of 23 clients. During the visit, LPA Palmer was able to interview one staff and one client. Documents were reviewed such as: shift notes from May 17, 2023 and one child's electronic file. LPA requested a printed file for the client. The Program Director made the request to the facilities Human Resources team. The Program Director was unable to provide documents during the visit. The documents will be emailed to the LPA on or before June 20, 2023. LPA also took photographs of the areas of where each incident took place. LPA requested copies of the staffing schedule for the weeks of May 8th and May 15th of 2023 and a copy of the discharge summary. Program Director unable to provide the staffing schedule during the visit. LPA was provided with the discharge summary. LPA requests that the schedule be sent via email to LPA on or before June 20, 2023. Additional time is needed to conduct this Case Management. A copy of this report has been provided to the Program Director. And a Form 811 and two 811c's were completed.


summary: Facility Evaluation

raw_content:
Narrative:
On June 23, 2023, Licensed Program Analyst (LPA), Carrie Palmer conducted a Case Management follow up visit. Upon arrival, LPA explained the nature of the visit to the Program Director. The facility has a current census of 21 clients. During the visit, LPA Palmer was able to conduct a follow interview with one client to ensure a comprehensive interviewing process. LPA Palmer requested a list of all current clients in care. The Program Director provided a list of clients to the LPA. Additional time is needed to conduct this Case Management. A copy of this report has been provided to the Program Director And form 811 has been completed.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by Licensing Program Analysts (LPAs) Carrie Palmer on 7/26/2023. During this visit, LPA Palmer met with Facility Manager Samuel Edman and Kelly Gonderman Program Director. The facility is licensed for a capacity of 25 clients. Current census is 14. The facility consists of two (2) buildings with addresses 119111 and 11913. Unit 11911 is the administrative building and therapy services for the clients. This building has a reception area, six (6) therapy rooms, a processing room, reception area, kitchen and restrooms. Building 11913 is the residential building, which consists of fifteen (15) bedrooms, recreational rooms, nursing stations, bathrooms, laundry area, staff offices, outdoor activity space, dining room and kitchen. The facility was observed to be clean, safe, sanitary, in good repair and passageways were unobstructed. There were no bodies of water on the premises. Cleaning solutions, poisons and sharp objects were locked and inaccessible to clients. Medication was observed to be double locked in a cart in the nurse's office. Smoke and carbon monoxide detectors were tested today in the front of the building only and are in good repair. Fire drills are being conducted monthly; evidenced by the Origami electronic tracking system, which the agency uses . Disaster drills are conducted quarterly. The following have been conducted: Natural Disaster of Hurricane in March 2023 and Earthquake in January 2023. LPA Palmer observed the children's Personal Rights, Ombudsman flyer, emergency Continued Pages 1 of 2 disaster plan, facility sketch and foster youth bill of rights were posted. LPA Palmer received a copy of the LIC 500 and the Client Roster. LPA Palmer reviewed Board Meeting Minutes from March 2023, Emergency Plan Binder, which included information on staff contacts, mandatory evacuations, response plans, hazardous materials, emergency food and water, shelter, emergency medication protocol, interim life safety protocol and fire prevention and instructions on water shut off valves. LPA also reviewed 5 electronic staff files, 5 electronic child's file, interviewed 5 clients and 5 staff. LPA was provided a copy of the administrators resume. During an interview with the Director and Administrator, it was determined that both have regularly scheduled hours (Monday - Friday) and are on call 7 days a week to ensure the safety of the clients and optimal service operations. Several electronic tracking systems continue to be used to track and monitor compliance relative to training's, scheduling, updates of the emergency disaster plans, staff files, and manual restraint usage. Client file reviews were conducted showing current immunization's, doctors reports, and written authorizations from parents to administer medication. During the staff file review and interviews, it was determined that staff receive a large amount of training. The Director also provided LPA Palmer with a the Gender Inclusive Rooming Policy. An exit interview was conducted and a copy of this report was emailed to administrators. No citations were issued at the time of the inspection. \ Page 2 of 2

met_with: Kelly Gonderman and Samuel Edman


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by Licensing Program Analysts (LPA) Carrie Palmer on 7/3/2024. During this visit, LPA Palmer met Kelly Gonderman, Program Director. LPA Palmer reviewed the following domain: Physical Plant and Disaster Preparedness. LPA Palmer received a copy of the LIC 500 and the Client Roster. The facility is licensed for a capacity of 25 clients. Current census is 17. The facility consists of two (2) buildings with addresses 119111 and 11913. Unit 11911 is the administrative building and therapy services for the clients. This building has a reception area, six (6) therapy rooms, a processing room, reception area, kitchen and restrooms. Building 11913 is the residential building, which consists of fifteen (15) bedrooms, recreational rooms, nursing stations, bathrooms, laundry area, staff offices, outdoor activity space, dining room and kitchen. The facility was observed to be clean, safe, sanitary, in good repair and passageways were unobstructed. There were no bodies of water on the premises. Cleaning solutions, poisons and sharp objects were locked and inaccessible to clients.. Fire drills are being conducted monthly and disaster drills are conducted quarterly. LPA Palmer observed the children's Personal Rights, Ombudsman flyer, emergency And exit interview was conducted and an 809 and 811 where issued to the administrator. No deficiencies cited at the time of inspection.

met_with: Kelly Gonderman, Program Director.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by Licensing Program Analysts (LPA) Carrie Palmer on 8/23/2024. During this visit, LPA Palmer met with Colleen Kunniff, Assistant Program Director. The purpose of todays visit was to interview staff and clients. LPA Palmer interview 4 staff. The clients were in a group session and were unavailable to interview. And exit interview was conducted and an 809 and 811 where issued to the assistant administrator. No deficiencies cited at the time of inspection.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced inspection was conducted by Licensing Program Analyst (LPA) Belinda Gilmer on 06/21/21 at 10:01 am. During this visit, LPA met with Facility Manager Samuel Edman and Kelly Gonderman Assistant Program Director toured the facility inside and out. LPA Gilmer reviewed six staff files, and five client files today. The facility has two (2) buildings 11913 is the residential area where clients live, eat and receive therapy. There are eight (8) bedrooms, three (3) bathrooms, three (3) staff offices, a kitchen, a dining room, and a common. 19111 is the administrative building there are therapy six (6) therapy rooms, a processing room, kitchen, restroom, and reception area. This facility is licensed for 25 children ages 12-17 both males and females there were 25 clients in placement. The sleeping areas at the time of this inspection were divided into three color sections based on the children's needs. The facility was observed to clean, safe, sanitary and in good repair, passageways were unobstructed and there were no bodies of water observed. Cleaning solutions, poisons, sharps, and medications are kept locked and inaccessible to clients. Staff states that there are no firearms on the premises. The facility has an adequate amount of perishable and nonperishable foods, and snacks available for clients. Smoke and carbon monoxide and smoke detectors were not tested today because it mainlines wirer that's directly linked to the fire department. LPA observed the children's rights, children's group home Ombudsman flyer, emergency disaster plan, and foster youth bill of rights were posted. As per Title 22, the following deficiencies were observed during this inspection and were cited, discussed. The facility was given two technical assistance advisory notes for the staff that did not have a first aid cardiopulmonary resuscitation card on file. The second one was for the staff that did not have a health screening in the file. The group home will also be assessed a $500.00 civil penalty for one of their staff that is working at this facility and not associated with this facility. An exit interview was held and copies of these LIC 809s LIC 858, LIC 859, LIC 9102, and civil penalty assessment -caregivers background check were provided during this exit interview.

met_with: Samuel Edman


summary: Facility Evaluation

raw_content:
Narrative:
On July 14, 2023, at 12:30PM, Licensing Program Analyst (LPA) Carrie Palmer conducted an unannounced Case Management visit with the above facility and met with Program Manager, Kelly Gonderman and Samuel Edman. The purpose of the visit is to follow up on a Case Management concerning information received regarding one client being inappropriately touched by another client over the clothes and kissing. On June 5, 2023, LPA conducted an in-person interview with Program Director Kelly Gonderman at Center for Discovery- Whitter. LPA Palmer asked the Program Director to explain her understanding of what happened. The Program Director stated on two separate occasions, that other clients distracted a teacher while clients were playing in the milieu. While the teacher was distracted, C1 (See confidential names list dated 7/14/23) leaned over to kissed C2. Further, the Program Director stated during school time, someone distracted the teacher and C1 touched C2 over the clothes. The Program Director shared that C1 was discharged from the facility, the day the kissing was reported and later C2 was interviewed by a sheriff. The Program Director shared that C2 was touched over the clothes at the table in the milieu and the kissing happened someplace else. The Program Director shared that after C1 left, C2 spoke to a staff member about what happened. The staff member shared with C2 that she should not be kissing boys and allowing them to touch her in private places because that is the number one rule for getting in trouble at the facility. The Program Director was unable to share the exact number of staff in the room for either of the instances, but stated there were approximated between 5-10 staff or less. On June 19, 2023, LPA Palmer met with C2. C2 stated the inappropriate touching and kissing happened on different days, both at the facility sometime in the early or middle of May. C2 shared, the first time she was touched over the clothes was on a Monday or a Tuesday, but she didn't report it to anyone until Friday. Per C2, on the following Monday, C1 kissed C2. This was the first day C1 and C2 did not sit together. C2 stated 3 other clients were siting at the table when the inappropriate touching happened, but C2 is unsure of the staff that were present because staff change daily. C2 reported, C2 being backed up against the wall when being kissed, which is how the kiss was able to happen, but C2 stated she moved out of the way because the tongue kiss was unpleasant. C2 stated, the kiss took place in the foyer. C2, elaborated; there are rooms and bathrooms in that area and no staff were present. C2 stated they were away from staff for about 5 minutes. On Monday, June 19, 2023, LPA Palmer interviewed a staff member (S1). The staff member stated, C2 wanted to talk about big track vs. green track. C2 also wanted to talk about C1. The staff member states C2 reported during the check in that all the clients on big track don't like her because of the kissing. The staff member also reported that C2 stated, she didn't kiss C1, but that C1 kissed her. The staff member stated, this conversation happened one day before or the day that C1 left. The staff member did not speak to C1 about the incident and did not report it to her supervisor. She only placed the information in her shift notes. The staff member states, in situations like this, there is no policy or procedure stating we must report to the supervisor. On June 23, LPA Palmer conducted a follow up visit to the facility to interview C2. C2 was able to show LPA the area where the kissing occurred, and the inappropriate touching occurred. LPA Palmer observed that the inappropriate touching happened in an open space, but the kissing happened in a secluded area away from the community areas of the facility. During this observation, the Program Director was also present. On 7/12/2023, LPA Palmer spoke to a family member of C2. C2 told her family member she was assaulted but didn't want to talk about it in detail. The family member stated, she looked distressed but wasn't crying. Based on the observations, interviews, and record review a citation was issued. The licensee did not, provide the appropriate care and supervision as necessary to meet the needs of the child, which poses an immediate risk to the Health and Safety or Personal Rights to clients in care. LPA was unable to interview C1. A copy of this report, LIC 809D and Appeal Rights were provided to the facility representative.


raw_content:
Narrative:
On July 3, 2025 the Department received a complaint alleging lack of staff supervision resulting in minors engaging in inappropriate sexual activity. The Vice President and Clinician interviewed denied the allegation and stated there was nothing reported by either client and staff interviewed did not recall any incidents with the two clients. LPA attempted to interview the clients involved, but they were not available to provide a statement. Staff that worked with the clients were not available to provide a statement. Based on the information gathered during confidential interviews and records reviewed, In addition staff denied any incident of neglect/lack of supervision. Therefore, the above allegation is determined to be unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation occurred. The resolution to this complaint was discussed with the agency representative and a copy of the licensing report was provided at the conclusion of the inspection. An exit interview was conducted and the Appeal rights were given and explained. No deficiencies were cited at this time.

Investigation Findings:
On December 29, 2025, Licensing Program Analyst (LPA) Pedro Ramos provided the findings for the above complaint allegation to Heather Marshall, Vice President. During the investigation, LPA Ramos conducted telephone interviews with Vice President on 7/11/25, Clinician, and Client's Parent on 12/16/2025, 2 clients were not available to be interviewed. Furthermore, LPA reviewed client rosters, staff records and incident reports. (Continued on Page 2). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Pedro Ramos LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: CENTER FOR DISCOVERY-WHITTIERFACILITY NUMBER: VISIT DATE: 12/29/2025

met_with: Heather Marshall, Vice President Of Operations


facility_name: CENTER FOR DISCOVERY - BRENTWOOD

summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13On 7/1/22, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the residential treatment group home facility to deliver findings of an investigation of the above allegation, which was conducted by the Licensing Agency's Investigations Branch (IB). LPA met with Mental Health Technician Latiesha O'Neal and informed of the purpose of the visit. Based on confidential interviews, an overnight staff member would kiss a client on the forehead when helping the client to bed and took another client out of their bedroom on their 18th birthday, kissed the client, and touched the client's buttocks, vagina, and breasts. The preponderance of evidence standard has been met, and therefore the above allegation is found to be Substantiated. LPA is issuing a citation of California Code of Regulations, Title 22, Division 6, Chapter 5, Article 6, Section Personal Rights. An exit interview was conducted, appeal rights provided, and a copy of this report left with Mental Health Technician Latiesha O'Neal, whose signature on this form confirms receipt. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Mendoza LICENSING EVALUATOR NAME: Mariah Hawkins LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, TRAEGER AVE., SUITE FACILITY NAME: CENTER FOR DISCOVERY - BRENTWOODFACILITY NUMBER: 075650136

complaint_status: SUBSTANTIATED


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
The preponderance of evidence standard has been met, and therefore the above allegation is found to be Substantiated. LPA is issuing a citation of California Code of Regulations, Title 22, Division 6, Chapter 5, Article 6, Section Personal Rights. An exit interview was conducted, appeal rights provided, and a copy of this form was left with Administrator Sara Stokes, whose signature on this form confirms receipt.

Investigation Findings:
SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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

met_with: Administrator Sara Stokes; Interim Administrator Virginia Parish


summary: Facility Evaluation

raw_content:
Narrative:
On Wednesday 5/18/22 at 9:51AM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility for a required 2-year inspection. LPA met with Interim Administrator Virginia Parish and informed of the purpose of the visit. Safety precautions were taken, including mask-wearing and pre-visit screening call. The CARE Inspection Tool was used to conduct this inspection. The facility is a house in a residential neighborhood. The yard and facility grounds are well maintained. There is a pool in the backyard secured by a fence and locked gate. There are three double-occupancy bedrooms. All residents have their own beds, and beds have clean linens. The kitchen is stocked with quality food that is stored safely and in a quantity to meet the needs of residents in care. Special diets are being followed. First aid kit was observed to be complete. Files were observed to be complete and contained required documentation. The following deficiencies were found (See LIC 809-D and LIC 9102s): 1) Seven (7) staff (S1, S2, S3, S4, S5, S6, and S7 -- See LIC Confidential Names) do not have a clearance associated to the facility and are therefore not cleared to work at the facility. LPA is issuing a citation of California Code of Regulations (CCR), Title 22, Section 80019(e) as well as an immediate civil penalty, per Section 80019(g), of $100 per day, for a maximum of 5 days, per individual in violation, for a total of $3,500. 2) One youth (R1 - See LIC 811) did not have a medical assessment on file and was admitted just over 30 days ago. LPA is issuing an advisory of CCR, Title 22, Section 80069(a). 3) There is one designated facility manager for this facility and nearby sister facility. LPA advises that there should be a facility manager present at all times children are present when the administrator is absent, and the facility may designate more than one facility manager. LPA is issuing an advisory of CCR, Title 22, Section 84065(d). 4) Hot water measured very slightly above the upper limit of the hot water range, at 120. F. LPA is issuing an advisory, in case of fluctuations in hot water that may result in hotter temperatures, of CCR, Title 22,... ...Section 80088(e)(1). 5) There is a pool on the premises, but staff do not have valid water safety certificates on file. LPA is issuing an advisory of CCR, Title 22, Section 80065(e)(2). 6) There was no bedroom sharing agreement documentation. LPA is issuing an advisory of CCR, Title 22, Section 84087(e). An exit interview was conducted, appeal rights provided, and a copy of this report was left with Program Director Virginia Parish, whose signature on this form confirms receipt.

met_with: Interim Administrator Virginia Parish


summary: Facility Evaluation

raw_content:
Narrative:
On 9/21/22, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit at the facility. LPA met with Interim Administrator Virginia Parish and informed of the purpose of the visit. On 7/1/22, the facility was issued a citation of California Code of Regulations, Title 22, Section 84072(d)(11) Personal Rights, and on 9/16/22, the facility was issued another citation of Section 84072(d)(11). LPA is issuing a civil penalty for repeat violation of $250. See LIC 421FC, dated 9/21/22. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Interim Administrator Virginia Parish, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On January 11, 2023 at 2:30PM, Licensing Program Analyst (LPA) Mariah Hawkins, Licensing Program Manager (LPM) Isabel Mendoza, and Regional Manager (RM) Nelson Martinez conducted a scheduled Office Meeting in order to assess an Enhanced Civil Penalty (ECP) for a violation found during an investigation at the facility. LPA, LPM, and RM met with Division President Amy Brown, Chief Operating Officer James Bailey, Regional Director Monica Powers, Program Director Virginia Parish, and Administrator Sara Stokes. On 09/16/2022, the Department of Social Services, Community Care Licensing Division concluded an investigation into the allegation that the facility failed to provide care and supervision resulting in resident R1 being sexually assaulted by their roommate, resident R2 (See LIC Confidential Names List, dated 01/11/23). The assault included digital penetration of the vagina. Based on confidential interviews conducted during the investigation, the staff member on shift did not conduct bedroom checks per the facility procedures in the facility's plan of operation and did not check the room for a period of almost 2 hours, during which the assault occurred. Additionally, the facility was aware that R2 had a history of sexualized behavior toward other residents. On 09/16/2022, the Department issued substantiated findings and a citation of California Code of Regulations, Title 22, Division 6, Chapter 5, Article 6, Section 84072(d)(11). The Department has concluded an analysis of applicable laws and regulations and has determined that an Enhanced Civil Penalty is warranted for a violation resulting in physical abuse. Therefore, on this date (01/11/23), pursuant to Health and Safety Code section 1548(f)(1)(C), the Department has issued a civil penalty of $2,500. See LIC 421, dated 01/11/23. The above information and appeal rights were discussed during the meeting, and a copy of this LIC 809 report, the referenced LIC 811 and LIC 421, and the appeal rights were provided to Division President Amy Brown, Chief Operating Officer James Bailey, Regional Director Monica Powers, Program Director Virginia Parish, and Administrator Sara Stokes, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 4/19/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit at the facility and met with Administrator Sara Stokes. LPA informed Administrator that the purpose of the visit was to meet the requirement set during the noncompliance conference (NCC) for quarterly inspections to review staff training and knowledge of supervision and reporting requirements. The additional terms of the NCC were: (2) to ensure staff were fully trained, per applicable regulations, at hire and additionally on no less than a quarterly basis; (3) to designate two overnight staff each night with at least one being a facility manager, meeting this requirement by March 13, 2023; (4) to designate an administrator to oversee only one facility, meeting this requirement by March 13, 2023; (5) to revise the plan of operation / program statement (POO/PS) and/or develop an addendum to include discussion of the use and purpose of motion sensors in the facility, meeting this requirement by March 13, 2023; (6) to provide notification of desire to utilize technical support program (TSP) services by January 25, 2023; and (7), if desired, submitting a central administrative facility waiver by January 25, 2023. See the notes by the corresponding number below. (2) During the visit, LPA reviewed staff training and interviewed staff. Interviews and training records reflect that trainings are conducted at monthly staff meetings and include topics such as supervision, de-escalation, reporting requirements, and cultural competency. Staff interviewed were knowledgeable of facility procedures. The facility also has verbal de-escalation tips posted in the facility. (3) LPA obtained a current LIC 500. The facility has designated two staff for each night. There is at least one facility manager on each night shift. The facility is conducting 15-minute bed check rounds from 10PM to 6AM, and staff log and sign off on each check for each resident. The logs were available for LPA's review, and LPA observed checks each night for each resident. [] (4) The facility had a candidate for the administrator role who ended up leaving the organization. Another candidate has been hired but still needs to complete administrator training. (5) LPA has not received a POO/PS addendum or revision. LPA is granting one extension. The revision/addendum to meet the requirement as stated above and in the NCC report provided to the licensee is requested to be submitted no later than May 1, 2023. (6) The licensee was referred for TSP services. (7) The licensee has decided to not request a central administrative facility waiver at this time. An exit interview was conducted, appeal rights discussed, and a copy of this report was left with Administrator Sara Stokes, whose signature on this form confirms receipt.

met_with: Administrator Sara Stokes


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 4/19/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a required annual inspection. LPA met with Administrator Sara Stokes and informed of the purpose of the visit. The CARE inspection tool was used to complete this inspection. LPA conducted a tour of the facility and grounds, interviewed 2 staff and 2 residents, and reviewed 5 staff files. A continuation visit is required to complete the resident file reviews. Staff interviewed are aware of facility procedures and personal rights. Staff files reflect valid CPI and first aid. Residents appeared content and dressed in well-fitting, comfortable, and clean clothing. Residents interviewed reported finding the facility a safe and supportive environment. The facility was observed to be clean and tidy and kitchen and bathrooms sanitary. No hazards were observed outside or inside. The backyard pool has a tall fence around it with a locked gate, the key to which only staff have access to. Bedrooms are double-occupancy, and beds have clean linens. Staff and residents report linens are changed regularly. Knives and medications are locked away and inaccessible to residents. Food supply is plentiful with a selection of healthy, fresh, and within date foods. The following deficiencies were observed during today's visit. -- Two staff present during today's visit do not have a background clearance associated to this facility and have been working since 4/17/23 (3 days). LPA is issuing a citation of California Code of Regulations, Title 22, Section 80019 and assessing a civil penalty of $100 per day per individual for a total of $600. -- Hot water at the bathroom sinks measured above the permitted range, at F and 125. F. LPA is issuing a citation of Title 22, Section 80088. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator, whose signature on this form confirms receipt.

Deficiencies:
80019(e): Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility


summary: Facility Evaluation

raw_content:
Narrative:
On 7/28/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit as a follow-up to the January 2023 noncompliance conference (NCC), per the first NCC term. LPA met with Administrator Sara Stokes and informed of the purpose of the visit. Per the NCC terms and previous inspection(s), the following was required and reviewed: (2) Ensure staff were fully trained, per applicable regulations, at hire and additionally on no less than a quarterly basis. | The annual inspection was completed on 7/28/23, and based on review of personnel files were complete, and training records reflect complete training. (3) Designate two overnight staff each night with at least one being a facility manager. | The facility has staff hired to have two overnight staff but is currently waiting for the third staff to receive a background clearance. The facility continues to conduct 15 minute rounds during the overnight shift and document them on paper and electronically. (4) Designate an administrator to oversee only one facility. | The licensee had two candidates who did not remain in the role. The licensee has a third candidate who has been enrolled in the administrator training. (5) Revise the plan of operation / program statement (POO/PS) and/or develop an addendum to include discussion of the use and purpose of motion sensors in the facility. | An extension was granted. Administrator confirmed it was in progress, and the draft document was shown to LPA during visit. LPA is requesting submission no later than 8/31/23, allowing time for internal approvals. An exit interview was conducted and a copy of this report was left with Administrator Sara Stokes, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 7/28/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a visit to the facility for the annual continuation. LPA met with Administrator Sara Stokes and informed of the purpose of the visit. An agreement was made to have Administrator send copies of resident and personnel records to LPA for review. LPA reviewed files for 4 residents and 5 staff, including four direct care staff / lead staff (facility managers) and one therapist. LPA observed records to be complete. Administrator updated LPA that a plumber came to inspect the hot water and informed that when the water heater is turned down low enough for the faucets close to the water heater to be below the upper limit of the permitted temperature range, then the faucets, including the showers, on the opposite end of the facility do not meet the lower limit of the range. Administrator stated a plumber would be called to further inspect the plumbing system and agreed to provide updates to LPA. No deficiencies were observed. An exit interview was conducted, appeal rights discussed, and a copy of this report was left with Administrator Sara Stokes, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 12/5/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit at the facility to confirm the facility is closed. The licensee sent a notification on 11/30/23 that the facility was closed effective 11/10/23. The facility has not had any clients since. LPA spoke with Director of Regulatory Affairs Jeff Marshall over the phone. LPA confirmed closure at the facility site. Licensee agreed to locate and mail the facility license to LPA. An exit interview was conducted, and a copy of this report was provided to Administrator Sara Stokes.

met_with: Director of Regulatory Affairs Jeff Marshall; Administrator Sara Stokes


summary: Facility Evaluation

raw_content:
Narrative:
On 7/1/22, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the residential treatment group home facility for a case management visit. LPA met with Mental Health Technician Latiesha O'Neal and informed of the purpose of the visit. During an investigation at the facility, it was discovered that a youth made a disclosure of inappropriate sexual behaviors from a staff toward the youth, but the facility did not report this incident due to not believing the youth's statement. Additionally, during the investigation, an investigator with the Licensing agency's Investigations Branch (IB), after introducing self and requesting to interview residents, was denied permission to do so. The investigator went over the Licensing agency's inspection authority and was still denied. Lastly, during today's visit, LPA was informed that Interim Administrator Virginia Parish is out on sick leave, and the facility manager is working "virtually." There are currently four (4) residents and three (3) staff, including two (2) direct care staff (mental health technicians) and one (1) therapist. The therapist was in a session and not able to provide supervision on the floor nor represent the facility during today's visit. The facility was previously issued an advisory on 05/18/2022 that the facility needs to ensure there is always a facility manager present when children are present whenever the administrator is absent and that the facility may designate more than one facility manager at a facility. LPA is issuing three (3) citations of California Code of Regulations, Title 22, Division 6, Chapter 1, Article 6, Section Reporting Requirements, Section Inspection Authority of the Licensing Agency, and Chapter 5, Article 6, Section Personnel Requirements. See attached LIC 809-D pages. An exit interview was conducted, appeal rights provided, and a copy of this report left with Mental Health Technician Latiesha O'Neal, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 9/16/22, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit to deliver notice of deficiencies found during an investigation at the facility. LPA met with Administrator Sara Stokes and Interim Administrator Virginia Parish and informed of the purpose of the visit. During an investigation conducted by the Licensing agency's Investigations Branch (IB), the following deficiencies were discovered. Based on record review and confidential interviews, a resident was assaulted by another resident with whom they shared a bedroom, and the resident reported the assault the night of the incident to staff on the overnight shift. Staff did not report to police or facility management and advised the resident to report it to staff in the morning. The facility then reported the incident to the victim's authorized representative but did not report the incident to the police and instead advised the authorized representative to contact the police. When the police responded to the facility, staff initially did not permit the victim to be interviewed by the police until the authorized representative approved the interview, despite the police responding due to the authorized representative contacting the police, per the facility's direction. Additionally, four staff indicated they were unfamiliar with a suspected child abuse report (SCAR). Lastly, the facility did not submit an incident report to the Licensing agency until the IB investigator advised the facility of reporting requirements. LPA is issuing citations of California Code of Requirements, Title 22, Division 6, Chapter 5, Article 6, Sections Personnel Requirements and Reporting Requirements. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Sara Stokes, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 10/24/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a quarterly inspection (case management), per the agreed upon terms of the January 2023 noncompliance conference (NCC). LPA met with Administrator Sara Stokes and informed of the purpose of the visit. Per the NCC terms and previous inspection(s), the following was required and reviewed: (2) Ensure staff were fully trained, per applicable regulations, at hire and additionally on no less than a quarterly basis. | LPA reviewed five personnel records and observed all staff to have background clearances and up to date training, either surpassing required training hours or on track to complete training hours. (3) Designate two overnight staff each night with at least one being a facility manager. | The facility has continued to maintain two overnight staff, and staff conduct 15 minute rounds during the overnight shift and document them on paper and electronically. LPA reviewed rounds documentation at visit. (4) Designate an administrator to oversee only one facility. | The licensee has a candidate who has completed the administrator training and will be taking the exam soon. During file review, LPA observed that two incident reports were not received by the licensing agency, and evidence of faxed submission could not be supplied during visit. LPA is issuing a citation of California Code of Regulations, Title 22, Section Reporting Requirements. See attached LIC 809-D. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Sara Stokes, whose signature on this form confirms receipt.


facility_name: DISCOVERY-ORANGE

summary: Facility Evaluation

raw_content:
Narrative:
On the date listed above, Licensing Program Analyst (LPA) Charmaine Linley conducted Component III Group Home via Microsoft TEAMS with Administrator, Kendra Meija. A copy of the handout was emailed prior to Component III and the Pre-Licensing Inspection is waiting to be scheduled after a review of the Plan of Operations and Program Statement that LPA received on 11/03/2025. A copy of this report was emailed to the Administrator for a signature and a copy of the signed report will be placed in the facility file.

met_with: Kendra Mejia


summary: Facility Evaluation

raw_content:
Narrative:
*****This is an amendment to the original document dated 11/06/205***** The facility consists of a single level building with four wings. The first (100 unit) wing is currently not being used and will not be included in the license. On November 6, 2025, Licensing Program Manager (LPM) Ann Valenzuela and Licensing Program Analyst (LPA) Charmaine Linley arrived at the facility for an announced Pre-Licensing inspection. The facility was inspected inside and out with Operations Manager, Kendra Mejia, Jeff Marshall, Jenny Morey, and Hannah Dunn. The facility is located on a cul-de-sac behind a large multi-story medical building. The facility consists of a single level building with three wings. The building includes two school rooms, two group session rooms, therapy offices, kitchen prep area, kitchen, two laundry rooms, seven offices, tech room, pump rooms, staff break room, intake room and a total of 37 bedrooms. The facility will be operating with the capacity of 60. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. There is outdoor space that includes outdoor activities, including a putting ground, planting garden, cornhole game, and large Jenga game. The *** Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. The bathrooms were clean and in good repair. The facility has an industrial kitchen with one industrial sized refrigerator, one industrial sized freezer, one industrial sized oven and stove top. There is a storage room for dry goods and additional food. There is an industrial sized dishwasher and sink system. The dining hall is adjacent to the kitchen and has ample sitting space arranged with five large tables and chairs. There are a total of four fire extinguishers located in all three wing hallways and one in the kitchen. They were observed to be properly charged and inspected by the fire department. Client files will be maintained using the KIPU system which is a portal to store client files and keep all information confidential. Administrator stated licensing will have access to such portal when client files need to be reviewed for any purpose. Employee files are stored electronically and Facility was reminded that licensing will need access to the electronic files when they need to be reviewed for any purpose. The following required posted items were observed accessible to clients: Fire Clearance, Grievance Procedures, Personal Rights, Visitation policies, Emergency Disaster Plan and current menu. The fire clearance has been approved. Based on the facility pre-licensing inspection review, no deficiencies were noted at the time of inspection. Upon all employees being cleared to work at the facility and Plan of Operations and Program Statement revisions completed and approve and the Licensing Program Manager's final review, the license will be provided. An exit interview was conducted with Kendra Mejia. A copy of this report was provided to the facility. A copy of this report will be placed in the facility file. facility has inside activities, such as karaoke, piano, dominoes, and televisions that have streaming services to Netflix and Disney. The facility will provide additional games upon request. Medication and the first aid kit will be kept locked behind a locked door in the Nurse's office. Medication room has a locking door and a locking medication cabinet. The facility also has a refrigerator that locks to store medications that require refrigeration. The facility's smoke detectors are inter-connected with the carbon monoxide detectors and are hardwired. The smoke/carbon monoxide detectors were tested and observed to be in working order. There are no guns or weapons in the facility as stated by Kendra Mejia. Disinfectants and cleaning solutions were stored locked in each individual wing in a locked storage closet. Sharp knives were made inaccessible and stored in a locked toolbox in the kitchen. The following required posted items were observed accessible to clients: Grievance Procedures, Personal Rights, Visitation policies, Emergency Disaster Plan and current menu Wings has thirteen bedrooms and seven bedrooms have two twin beds in each bedroom, all required linen, and mattresses in good condition and six bedrooms have one single twin sized bed, all required linen, and mattresses in good condition. Each bedroom is equipped with drawer space and adequate closet space. There are bathrooms in each bedroom that includes one sink, one toilet, and one bath/shower stall. The hot water in one of the client bathrooms was measured at 105 degrees at 10:15 am, which is within regulatory requirements. Wings has fourteen bedrooms have two twin beds in each bedroom, all required linen, and mattresses in good condition and six bedrooms have one single twin sized bed, all required linen, and mattresses in good condition. Each bedroom is equipped with drawer space and adequate closet space. There are bathrooms in each bedroom that includes one sink, one toilet, and one bath/shower stall. The hot water in one of the client bathrooms was measured at 106 degrees at 10:35 am, which is within regulatory requirements. Wing has ten bedrooms with two twin beds in each bedroom, all required linen, and mattresses in good condition. Each bedroom is equipped with drawer space and adequate closet space. There are a total of six bathrooms on this wing that includes one sink, one toilet, and one bath/shower stall. The hot water in one of the client bathrooms was measured at 106 degrees at 10:51 am, which is within regulatory requirements. ***

visit_type: Prelicensing


summary: Facility Evaluation

raw_content:
Narrative:
On the date listed above, at 10:00 am, Licensing Program Analyst (LPA) Charmaine Linley and Licensing Program Manager (LPM) Ann Valenzuela met with Facility Administrator, Kendra Mejia, Jeff Marshall, Abby Handan, Jenny Morey, and Hannah Dunn via Microsoft TEAMS to discuss revisions needed for the Plan of Operations and Program Statement. The following questions were asked and answered: Allowance: The clients do not typically stay at the facility for more than 30 days, so a monthly allowance is not required. LPA suggested a statement with this information be included in the Allowance section. Electronic Documents: Can the organization submit the revisions electronically and LPA confirmed that was fine. Timeline after LPA receives the revisions, it is unknown at this time, however, LPA stated they are making the revisions a priority to review and approve so the Pre-Licensing Inspection could be scheduled. LPA reviewed the revisions and a letter with the revisions listed below was sent earlier in the day to Ms. Mejia. Please adhere to the following guidelines when submitting revisions and/or changes made to the plan of operation and program statement: 1) number all pages, 2) highlight all revisions and/or changes, 3) submit an updated table of contents, noting revision dates, for both the plan of operation and program statement 4) Submit electronically in a binder that is tabbed and divided to the Orange County Office located at The *** City Drive Ste. Orange, CA 92868. The revisions are due by October 28, 2025 before 5:00 pm. Should you have any questions regarding this letter, please contact Licensing Program Analyst Charmaine Linley at (951) 202-1850 or charmaine.linley@dss.ca.gov. Section A Documents: A1. Application (LIC 200):  Please include on the back of the LIC 200 or attach a sheet of any other licensed facilities.  Update applicant name to remove Whittier. A4. Administrative Organization (LIC 309):  Provide a copy of the By-Laws or Operating Agreement and any amendments. A5. Affidavit Regarding Client Cash Resources (LIC 400):  This form was not provided. A6. Surety Bond (LIC 402):  This form was not provided. A7. Monthly Operating Statement (LIC 401):  Please explain why there are no operating costs in the areas listed below: • Household Supplies • Laundry/Dry Cleaning • Personal Hygiene Items • Recreational Activities • Client Transportation • Telephone • Office Supplies • Property Taxes *** A9. Financial Information Release and Verification (LIC 404):  Please provide an updated LIC 404, this can be emailed to LPA Linley. A10. Personnel Report (LIC 500):  Who is designated as the facility manager when the Administrator is not present.  From 7 a.m. to 10 p.m., there shall be one on-duty child care staff person to each ten children, or fraction thereof, present. A11. Personnel Record (LIC 501):  Provide a copy of the LIC 501 for the Applicant/CEO.  Provide a copy of the LIC 501 for the Administrator. A12. Health Screening Report - Facility Personnel (LIC 503):  Provide a copy of the LIC 503 for the Applicant/CEO.  Provide a copy of the LIC 503 for the Administrator. A14. Emergency Disaster Plan (LIC 610C):  This form was not provided.  Provide a signed copy of the LIC 610 that shows two relocation sites away from the facility that are able to accommodate the number of clients/children in the facility.  If the use of the relocation site requires authorization from the agency or person currently in possession. This authorization needs to be verified in writing. A15. Facility Sketch (LIC 999):  This form was not provided.  Sketch must give dimensions of all rooms and designate their use.  Door and window exits must be shown. Indicate exit routes by number as shown on the LIC Emergency Disaster Plan.  A facility sketch is required for all indoor and outdoor space including driveways, fences, storage areas, gardens, recreation areas and other space used by clients/residents. ***  For facilities with multiple buildings on a single site, submit separate sketches for indoor and outdoor space for each building and one sketch showing entire facility and relationship between indoor and outdoor spaces of all buildings, as well as any other use of the building.  Sketch of outdoor space must show dimensions and location of major equipment and swimming pools. Sketch must also identify utility shut-off locations.  If Video cameras will be utilized, provide the following information: (2) The purpose of the video cameras. (3) How children and authorized representatives will be informed of the location of video cameras and their purpose. (4) How licensees will work with placing agencies to address situations in which a child objects to video cameras. (5) How video cameras will be used in a trauma-informed manner. (6) Whether video cameras will be livestreamed only or recorded. (7) If recorded, who will have access to the recordings and how will the recordings be stored and safeguarded. Section B Documents: B1. Partnership Agreement/Articles of Incorporation/Articles of Organization:  This section was not provided. Provide either the Articles of Incorporation, Articles of Organization, or Operating Agreement. B2. Verification of Administrator Qualifications and Certification:  Provide the name and residence and mailing addresses of the facility administrator, a description of the administrator's background and qualifications, and documentation verifying required education and administrator certification.  Provide a copy of the Administrator certificate. B2. Verification of Administrator Qualifications and Certification:  Provide the name and residence and mailing addresses of the facility *** administrator, a description of the administrator's background and qualifications, and documentation verifying required education and administrator certification.  Provide a copy of the Administrator certificate. B3. Verification of Social Worker Qualifications:  This section is missing the documents listed below:  LIC 501: Personnel Record  LIC 503: Health Screening Report  Verification of education and experience, copy of degree and transcripts, and resume  Photo ID  Copy of First Aid Certificate B4. Job Description - each position:  Describe the minimum qualifications for all positions that correspond to licensing requirements. This is to include any special licenses or certificates, or special skills needed to perform the job, cannot just state "meet minimum requirements according to Title 22."  Describe the duties for all positions.  Describe the lines of supervision (This is to include supervision given and to whom, as well as supervision received and from whom). B5. Personnel Policies:  This section was not provided.  Personnel policies are to describe those regulatory requirements commonly associated with personnel practices/policies such as staff coverage, staff qualifications, work schedules and conditions of employment.  The following areas are to be included in this section. • Work hours/shifts for documentation of positions to provide coverage with competent staff. To correspond with staff positions and work days and hours listed on all personnel reports. • Abuse reporting procedures. Documentation must indicate that employees will be informed of their responsibilities to report to the licensing agency as well as to the police and child/adult protective agency. *** • Hiring practices: Including screening of employees for necessary education and experience and informing employees that conditions of their employment include fingerprint clearance, statement of prior criminal convictions, TB clearance, physical examination/health questionnaire, child abuse index check. B6. In Service Training for Staff:  This section was not provided.  Please state specifically who will be conducting the training.  Provide details or a list of what is the New Employee Training and what is the ongoing training.  The training list needs to include the administrator continuing education units. The plan must include how often the training will be given and how the training will be documented for Regulations 80065 and 84065. B7. Program Description:  This section was not provided.  Provide a brief statement of the purpose, goals, and program methods (program philosophy).  Provide the days and hours of operation.  Provide the daily schedule of activities that should state who plans, conducts, and assists clients in participating in these activities.  Provide a one month schedule of planned social, educational, and recreational activities that should state who plans, conducts, and assists clients in participating in these activities.  Provide a description of the basic services.  Provide a description of the optional services provided as listed in the admission agreement.  Describe how the facility will handle medical emergencies if a client becomes ill or injured.  Describe the procedure for handing and assisting client with self-administered medications.  Describe the transportation arrangements and how the facility will ensure that employee do not smoke in the vehicles, whether or clients are in the vehicle.  Provide a description of the community resources and consultants to be used.  Provide the complaint/grievance procedure, where the form will be posted, how the client files a complaint, how the Administrator responds, the timeframe, how the Administrator will communicate with the client, and where the outcome will be stored. *** B8. Rules of Discipline/Personal Rights:  This section was not provided.  Provide a statement that discipline does not include a violation of personal rights.  Describe the types of discipline that will be used and under what conditions each type will be used. The discipline policies shall also address the following, when appropriate: types of discipline not permitted.  Describe the grounds for planned and unplanned/emergency discharges.  Provide a statement that there will be no corporal or unusual punishment used.  Describe how the client will sign the personal rights form at intake and each time a new right has been added.  Provide a copy of the discipline policy and describe how the client and Authorized Representative will sign the form. B9. Admission Policies:  This section was not provided.  Provide the ages of the clients, rates and refund policies, acceptance and retention limitations, pre-admission appraisals, needs and services plans, medical assessments and an admission agreement which contains the typical information a client or his/her authorized representative would need to know prior to entering a facility. A description of the following items must be included in this section. • Persons accepted for care, including age range and compatibility determination process, when necessary. • Intake procedures. • Criteria for assessing appropriateness of placement given an individual client's needs (i.e., interviews, procedures for obtaining and developing the necessary paperwork, etc.) • Needs and services plan. • Client's Rights/Personal Rights. • Medical assessment. • Medical assessment. • Pre-admission appraisal plan. • Emergency information. • Sign-in and sign-out procedures. *** • Immunization requirements. • Physical examination requirements (including TB testing). B10. Sample Menu:  This section was not provided.  Provide a sample menu that will include: • Planned meals and snacks for one week, foods used should be from the four basic food groups. • Portion sizes. • Times meals served. B12. Bacteriological Analysis of Private Water Supply (When Water for Human Consumption is from a Private Source):  This form was not provided. Provide a statement if the water is from public or private water supply. B16. First Aid Card:  Provide a CPR/1st Aid Card for the Administrator and Social Worker. B17. Orientation Certification:  This form was not provided. Provide the Group Home Orientation Certificate. B18. Group Home Program Statement:  Old Version of LIC 9106 was provided. Please provide an updated LIC 9106. Program Statement: Sec # Purpose, Methods and Goals {Ref: CCR: 80022(b)(1); MPP11-402.356(a)}.  Describe how results or outcomes will be measured and how often. Sec # Planned Activities/Use of Community Resources {Ref: CCR 80022(b)(13),84065(e), 84079}.  Identify the staff position responsible for planning, supervising, and conducting activities. ***  Provide an updated plan for indoor and outdoor activities, there are three plans dated 2015.  Provide a list of community resources used by the program specific to Orange County.  Provide an updated Sample Daily Activity Schedule for one week, that includes social, recreational, and educational activities.  Describe the program's planned educational activities and services. The forms provided are for Los Angeles County and dated 2016.  Include: • Special Education; • Use of public and/or private schools; • On grounds school; and • Tutoring, if applicable. Sec. # Special Services/Programs Offered  Describe any special services or programs which will be offered.  If the program provides vocational training, describe: • The skills taught; • Goals of the training program; • Hands-on experience received; • Materials provided; • Number of hours per day/days per week training is provided; and • How training is funded. Sec. # Medical and Dental. (Ref: CCR 80075 (a) (1)-(2).  Describe procedures used to identify and handle medical, dental, and psychiatric emergencies, other than calling the Program Director.  Page 9: Medical, Dental, and Psychiatric Emergencies needs to be updated as Los Angeles County Programs and services are listed.  Identify staff positions responsible for dispensing and destroying medications.  Describe how the facility will obtain a copy of the current court order, or written authorization of the child's parent or guardian, for each psychotropic medication. ***  Describe the use of Psychotropic Medication Administration Records (PMAR LIC 622B). A separate log for each psychotropic medication prescribed to the child documenting all the following in Title 22 83070(12).  Provide a statement that medication errors will need to be reported and documented to CCL, according to the timeframes for reporting requirements.  Provide a statement that any medication refusal by a client is considered a "Special Incident" and a report will be sent to Community Care Licensing. Sec. # Transportation (Ref: CCR 80022 (b)(10).  Provide a current list of vehicles the facility uses; the form has vehicles listed from 2016.  Does the facility have a checklist to ensure vehicles are in maintained in safe operating condition, if so, please provide.  Specify how the facility will ensure that only appropriately licensed program staff will transport clients. Sec. # Admission/Intake (Ref: CCR 80022(b)(2) 84068.1 84068.2).  This section is missing.  Describe the facility's program's admission/intake procedures.  Include: • Criteria for evaluating appropriateness of referrals for placement; • Information required to assess referrals for placement; • Timeframe for responding to referring agencies regarding acceptance or rejection of referral; • Staff position responsible for intake; and • Procedures for accepting emergency placements on a time-limited and/or trial basis. Sec. # Needs and Services Plan/Assessment {Ref:CCR 84022(b)(2)}.  Describe the policy regarding participation of the client and their Authorized Representative in developing, updating, and modifying the Needs and Services Plan and obtaining signatures. Sec # Discharge/Removal (Ref: CCR 84068.2, 84068,4).  Provide a copy of the discharge/removal form the client and Authorized Representative will sign. *** Sec. # Visitation Rules and Policies (Ref: CCR 80068 (b)(8) 80068,2 (b)(6), 84072).  Describe when and under what circumstances the clients is permitted to have home visits with parents and/or relatives.  Describe when and under what circumstances the clients is permitted to have overnight visits with parents, relatives, family members, friends. Sec. # House Rules.  Any restrictions of phone calls or monitoring of phone calls will need to be included in the Needs and Services Plan with the reason and the client and Authorized Representative will need to sign.  Provide/describe if clients are allowed to date other clients in placement. Sec. # Discipline Policies [Reference: CCR 80072(a)(3), (7) - (8), 84072, 84072.1]  Describe the types of discipline used, including "probationary period;"  Describe the conditions under which type of discipline will be used. Sec. # Emergency Intervention Plan (Ref: CCR 84800(d), 84801, 84802, 84802.1,84803, 84804 and 84808.  Qualifications of individuals who designed the Emergency Intervention Plan: Provide a copy of Greg Corbin's degree and license and Abby Hamdan's copy of degree and CPI trainer certification.  Please clarify if the facility will be using Pro-Act or CPI as both are mentioned. If using CPI, remove references to Pro-Act.  Admission Agreement must include a written statement regarding the type(s) of emergency interventions the licensee has been approved to use.  Describe all techniques (including manual restraints), when techniques are NOT used, and expected outcomes.  Describe the assessment of underlying or unknown medical or physical condition precluding use of restraints.  Describe the techniques of group and individual behavior management.  Describe the alternative methods of handling aggressive and assaultive behavior.  Describe the techniques for returning the child to planned activity following an emergency intervention. ***  As a reminder, 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. Please update this section.  As a reminder, restraints cannot be used as part of a discipline method.  The Emergency Intervention Staff Training Plan is to be included as a component of the emergency intervention plan. The plan must include the following in this section: (1) The type, title, and a brief description of the training that all facility personnel have completed. (2) Training requirements for new personnel. (3) The ongoing training required for existing personnel. (4) Training curriculum as specified in Section 84365(b). (5) Training schedule which identifies when staff training will be offered and provided. (6) The name(s) and qualification(s) of the instructor(s) who will provide the training.  Describe how any report of the use of manual restraints must be reviewed, for accuracy and completeness, and signed by the administrator or administrator's designee no later than the next working day following the incident.  Describe or provide a copy of the monthly log of each use of manual restraints.  Procedures for an internal biannual review of the use of emergency interventions must be developed. Such procedures must include at least the following: (1) A review is to be conducted by the administrator or the administrator's designee. (2) Analysis of patterns/trends of use of emergency interventions in the previous six (6) month period, based on: (A) Review of all records related to the use of emergency interventions for accuracy and completeness. (B) Review of the use, effectiveness and duration of each emergency intervention including, a determination of the effectiveness and appropriateness of the intervention technique used in each situation. (C) Review of the frequency of emergency interventions in the previous six (6) month period. (3) Corrective action plan, if needed. (4) The biannual review and corrective action plan must be submitted to the Department no later than the fifth (5th) day of the month following the review.  Describe the procedure of when and how to involve Law Enforcement. *** Sec. # Runaway Plan (Ref: CCR 84808).  Describe the continuum of interventions used.  Provide more information on "searches," and what does that entail.  Describe how the facility shall submit reports to the Department, using form LIC 624-LE or a report containing all the information required in LIC 624-LE, regarding any incident that involves law enforcement contact with a child residing in the facility.  Describe how the licensee shall make an initial report to the Department no later than the next business day following each incident and send a written report within seven days.  Describe how within six months of the incident, the licensee shall provide a follow-up report for each incident that includes the following information: (A) The type of incident. (B) Whether the incident involved an alleged violation of any crime, other than an age-based curfew law, by a child residing in the facility. (C) Whether staff, children, or both were involved in the incident. (D) The gender, race, ethnicity, and age of children involved in the incident. (E) The outcome of the incident, if known, including arrests, removals of children from placement, termination or suspension of staff, the filing of a Welfare and Institutions Codes Section 602 petition for the child, or revocation of or changes to the terms of probation. Sec. # Children's Complaint/Grievance Procedures [Reference: CCR 84072.2].  This section is missing.  Describe the procedures by which clients or their Authorized Representatives are informed of their rights and permitted to file complaints.  Describe or provide information on how the clients, Authorized Representatives, and staff receive copies of the written complaint/grievance procedures. Sec. # Handling Children's Funds, Allowances, and Salaries [Reference: CCR 80022(b)(12), 80025, 80026, 84026].  Describe the procedure for issuing allowances, including the amount.  Title 22 84077: Personal Services....... *** (2) Provision of an age-appropriate allowance to all children no less frequently than once per month except: (B) If the child is unable to manage their own money because of age or if the authorized representative determines that the child cannot manage their own money. 1. If the authorized representative considers the child incapable of money management, it must be specified in the needs and services plan. Sec. # Nutrition/Sample Menu  Provide a sample menu for seven days with portion sizes.  Describe the times when meals are served. Sec. # Clothing and Incidentals  Describe the "available clothing for use," given to a client. Sec. # Staff Schedule  This section is missing.  Provide a staff work schedule for each facility site which includes names, classifications, days and hours worked. (You may use the LIC Personnel Report.)  Specify the number of hours the program administrator will be at each facility each week.  Specify the number of facilities for which the administrator is responsible. Sec. # Staff Qualifications  Provide copies of resumes or job applications for all child care workers, social work staff, mental health treatment workers, administrators and consultants. If employees have not started work, provide a letter of acceptance/commitment for the position.  Specify the number of hours the program administrator will be at each facility each week, performing administrative duties. Sec. # Job Descriptions  Job descriptions are dated 03/22/2008, have the job descriptions been updated?  Please provide all updated Orange County job descriptions. *** Sec. #24. Inservice Training for Staff/Administrator  Describe the plan for providing initial and annual training for child care staff.  Include: • Position or person who will do the training and his/her qualifications; • Approximate length of training; • Initial and annual training curricula; and • How special training needs are identified and met  Describe the plan for the facility manager training. Please include the course titles and length of each training.  Describe the 5 hours of the annual training that shall consist of course work from an entity other than the group home such as an accredited educational institution, workshops, seminars, or other direct training provided by a qualified individual, who meets the requirements specified in Section 84065(i)(4)(A)1., who is not affiliated with the group home licensee.  Describe or provide a copy of the child care staff assessment within 7 and 30 days of the completion of the 8-hour training and that it will be stored in the personnel record.  Describe how special training needs are identified and then training met to address.  Describe the training for the Reasonable and Prudent Parent Standard.  Describe the initial training that needs to include: (A) Overview of the client population served by the group home; (B) Facility's program and services, including program philosophy, activities and community resources; (C) Facility's policies and procedures, including reporting requirements to the Department and as a mandated child abuse reporter; (D) Child care workers' job description, including roles and responsibilities; (E) Child care workers' self awareness; (F) Role of other facility personnel in service delivery, including case staffing; and the role and responsibilities of the onsite staff member designated to apply the reasonable and prudent parent standard as specified in Section 84065 (b)(1); (G) Discipline policies and procedures; (H) Disaster response *** (I) Medical emergency response; (J) Teamwork and interpersonal communication among facility personnel and clients and client family members; (K) Teamwork and intra-facility communication; (L) The role of placement workers; (M) Medication procedures, assistance with medication, universal precautions, recognition of early signs of illness and the need for professional assistance, and other health related issues ;including oversight and monitoring of psychotropic medications for children in foster care and related topics specified in Section 16501.4(d) of the Welfare and Institutions Code; (N) Group home children's adjustment to group care; (O) Housekeeping and sanitation principles; principles of nutrition, food preparation and storage and menu planning; (P) California Code of Regulations, Title 22; (Q) Availability of community services and resources; and (R) Recreation activities and resources. (S) A child's rights as specified in Welfare and Institutions Code section 6001.9 and Section 84072, including a child's right to have fair and equal access to all available services, placement, care, treatment, and benefits, and to not be subjected to discrimination or harassment on the basis of actual or perceived race, ethnic group identification, ancestry, national origin, color, religion, sex, sexual orientation, gender identity, and gender expression, mental or physical disability, or HIV status. (T) Instruction on cultural competency and sensitivity relating to sexual orientation, gender identity and gender expression, and best practices for, providing adequate care to lesbian, gay, bisexual and transgender children in out-of-home care. (U) The facility's policies and procedures concerning when and how to involve law enforcement in response to an incident involving a child residing in the facility. (V) A child's right to receive sexual and reproductive health care and information. (W) A child's right to have their sensitive health information kept confidential (X) The duties and responsibilities of the assigned case management worker and the licensee to ensure that children can obtain sexual and reproductive health services and information. *** (Y) Guidance about how to engage and talk with children about healthy sexual development and reproductive and sexual health in a manner that is medically accurate, age or developmentally appropriate, trauma informed, and strengths based. (Z) Information about current contraception methods and how to select and provide appropriate referral resources and materials for information and service delivery.  Submit a one-month training schedule and the length of each training. Sec. #25. Administration  Provide the following information: • Names, addresses (business and residence) and telephone numbers of all corporate officers or partners as appropriate; • Names of all members of the board of directors; • Names and positions of any paid staff who are board members or related to board members; • A current organizational chart which shows lines of administrative authority; and • Copies of the articles of incorporation and bylaws. Sec. #26. Volunteers.  Provide a statement if the facility will use volunteers. If so, describe how volunteers are utilized, screened and trained. Sec. # Facility Sketch  This form was not provided.  Sketch must give dimensions of all rooms and designate their use.  Door and window exits must be shown. Indicate exit routes by number as shown on the LIC Emergency Disaster Plan.  A facility sketch is required for all indoor and outdoor space including driveways, fences, storage areas, gardens, recreation areas and other space used by clients/residents.  For facilities with multiple buildings on a single site, submit separate sketches for indoor and outdoor space for each building and one sketch showing entire facility and relationship between indoor and outdoor spaces of all buildings, as well as any other use of the building. ***  Sketch of outdoor space must show dimensions and location of major equipment and swimming pools. Sketch must also identify utility shut-off locations.  If Video cameras will be utilized, provide the following information: (2) The purpose of the video cameras. (3) How children and authorized representatives will be informed of the location of video cameras and their purpose. (4) How licensees will work with placing agencies to address situations in which a child objects to video cameras. (5) How video cameras will be used in a trauma-informed manner. (6) Whether video cameras will be livestreamed only or recorded. (7) If recorded, who will have access to the recordings and how will the recordings be stored and safeguarded. An exit interview was conducted and a copy of this report was emailed to Ms. Mejia to obtain an electronic signature. A copy of this report will be placed in the facility application file.


summary: Facility Evaluation

raw_content:
Narrative:
On March 25, 2026, at 9:05 am, Licensing Program Analysts (LPAs) Charmaine Linley and Stefanie Mutialu arrived unannounced at the facility for a Post-Licensing inspection. The facility was inspected inside and out with Chief Executive Officer, Jenny Morey. The facility is located on a cul-de-sac behind a large multi-story medical building. The facility was licensed on December 2, 2025. The group home serves clients between the ages of 11-17 years old, both female and male for a capacity of 60 clients. There are eleven clients at the facility. The facility consists of a single level building with four wings. The first (100 unit) wing is licensed by the Department of Public Health and is not licensed through Community Care Licensing. The facility includes two school rooms, two group session rooms, therapy offices, kitchen prep area, kitchen, two laundry rooms, seven offices, tech room, pump rooms, staff break room, intake room and a total of 37 bedrooms. A physical plant inspection was completed and included the following checks: Facility grounds were clean and free of debris. There is adequate indoor and outdoor activity space. There is outdoor space that includes outdoor activities, including a putting ground, planting garden, cornhole game, and large Jenga game. The Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. The bathrooms were clean and in good repair. The facility has an industrial kitchen with one industrial sized refrigerator, one industrial sized freezer, one *** industrial sized oven and stove top. There is a storage room for dry goods and additional food. There is an industrial sized dishwasher and sink system. The dining hall is adjacent to the kitchen and has ample sitting space arranged with five large tables and chairs. The facility has inside activities, such as karaoke, piano, dominoes, and televisions that have streaming services to Netflix and Disney. Medication and the first aid kit are kept locked behind a locked door in the Nurse's office. Medication room has a locking door and a locking medication cabinet. The facility also has a refrigerator that locks to store medications that require refrigeration. The facility's smoke detectors are inter-connected with the carbon monoxide detectors and are hardwired. The smoke/carbon monoxide detectors were tested and observed to be in working order. There are no guns or weapons in the facility as stated by Jenny Morey. Disinfectants and cleaning solutions were stored locked in each individual wing in a locked storage closet. Sharp knives were made inaccessible and stored in a locked toolbox in the kitchen. The following required posted items were observed accessible to clients: Fire Clearance, Grievance Procedures, Personal Rights, Visitation policies, Emergency Disaster Plan and current menu. Wings has thirteen bedrooms and seven bedrooms have two twin beds in each bedroom, all required linen, and mattresses in good condition and six bedrooms have one single twin sized bed, all required linen, and mattresses in good condition. Each bedroom is equipped with drawer space and adequate closet space. There are bathrooms in each bedroom that includes one sink, one toilet, and one bath/shower stall. Wings has fourteen bedrooms have two twin beds in each bedroom, all required linen, and mattresses in good condition and six bedrooms have one single twin sized bed, all required linen, and mattresses in good condition. Each bedroom is equipped with drawer space and adequate closet space. There are bathrooms in each bedroom that includes one sink, one toilet, and one bath/shower stall. The hot water in one of the client bathrooms was measured at 105 degrees, which is within regulatory requirements. *** Wing has ten bedrooms with two twin beds in each bedroom, all required linen, and mattresses in good condition. Each bedroom is equipped with drawer space and adequate closet space. There are a total of six bathrooms on this wing that includes one sink, one toilet, and one bath/shower stall. There are no clients residing on this wing at the time of this inspection. There are a total of four fire extinguishers located in all three wing hallways and one in the kitchen. They were observed to be properly charged and inspected by the fire department. Client files are maintained using the KIPU system which is a portal to store client files and keep all information confidential. LPAs reviewed five out of eleven client files and LPA's were unable to conduct client interviews, due to time constraints. Employee files are stored electronically and LPAs reviewed five out of fifty five staff files. LPAs were unable to conduct staff interviews, due to time constraints. All staff that work at the facility have Department of Justice, Federal Bureau of Investigation and Child Abuse Index Check clearances. LPA's will return to complete the inspection and continue reviewing the client and employee files at a later date. An exit interview was conducted and a copy of this report was provided to Jenny Morey. A copy of this report will be placed in the facility file.

met_with: Jenny Morey