summary: Facility Evaluation

raw_content:
Narrative:
On 10/22/2024, Licensing Program Analysts, (LPAs) Connie Goldie and Michelle Silvas made an unannounced case management inspection at 11: AM. LPAs met with Tiauna Taylor who assisted with the inspection. During physical plant inspections of the facility on 10/11/2024. 10/16/2024 and 10/22/2024, LPA observed a broken dresser in bedroom 4. The third drawer down is missing and the top drawer and bottom two are off track. Staff stated they are waiting for a new dresser to be installed. Additionally, broken items including two chairs and basketball hoop were also observed on the above listed dates and were requested to be moved into the shed on 10/11/2024 and 10/16/2024 until they could be removed from the property and taken to the landfill. On 10/22/2024, the items were observed to still be accessible to residents in the back yard. The facility is being cited for two Title 22 deficiencies. See LIC 809D. A copy of this report along with appeal rights were discussed and provided to facility staff.

met_with: Tiauna Taylor Lead


state: CA

facility_name: MERAKEY - TENAYA

summary: Facility Evaluation

raw_content:
Narrative:
On 11/14/2024 at 12: PM, Licensing Program Analyst (LPA) Connie Goldie, conducted an unannounced case management inspection at the facility. The purpose of the inspection was to inquire about incident that was reported to the Department on 10/30/2024 and occurred on 10/28/2024. LPA met with Jronesha Brown, Administrator, who helped facilitate the inspection. Five staff are present in the facility and clients are at school. LPA conducted a walk through of the facility and two staff interviews. LPA obtained October MAR for C Program Administrator stated there was a mis-communication between NOC Lead S1 and AM Lead S2 which resulted in C1 not receiving his AM medications on 10/27/2024. The error was identified during an audit completed the following morning, 10/28/2024. C1's primary care physician was contacted immediately after the error was identified and stated a order could not be issued based on amount of time that had passed. The facility is being cited for one Title 22 deficiency. See LIC 809D. A copy of this report along with appeal rights were discussed and provided to facility staff, Jronesha Brown.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Jronesha Brown Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 11/27/2024 at 01: PM, Licensing Program Analyst (LPA) Connie Goldie, conducted an unannounced case management- deficiencies inspection at the facility. The purpose of the inspection was to inquire about incident that was reported to the Department on 11/19/2024 and occurred on 11/17/2024. LPA met with Tiauna Taylor, Facility Manager,(FM), who helped facilitate the inspection. Eight staff and four clients are present in the facility . LPA conducted a walk through of the facility and a staff interview. LPA obtained November MAR for C1. LPA observed that this is the second medication error in the facility within thirty days. FM stated S1 admitted to making an error in administrating medication to C1 on the morning of 11/17/2024. S2 observed during medication audit that medication (M1) was still in bubble pack and had not been given to C1 resulting in a medication error for client (C1). The facility is being cited for one Title 22 deficiency. See LIC 809D. A copy of this report along with appeal rights were discussed and provided to facility staff, Tiauna Taylor.

met_with: Tiauna Taylor, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced case management inspection at the facility and met with Administrator J'Ronesha Adams, who assisted LPA with the inspection, for the purpose of conducting a follow-up visit after CCL received the Department of Developmental Services' (DDS) Semi Annual Review, which they conducted 12/18/2025. LPA conducted a walk through of the facility with staff Marissa Corral and observed no deficiencies. LPA observed that the facility corrected some of the buildings and grounds issues such as: fixed the drawers/doors on the kitchen island, fixed the desk face, the mini trampoline was gone, and they cleaned the oven. However there still was no caulking done on toilet in bathroom #1, and the facility minivan still has registration tags that expired in June 2025. The grass outside was very wet, however Administrator let LPA know a work order for the yard drainage has already been placed, which LPA observed a copy of the request. Administrator informed LPA they are in progress with appointing a backup Administrator for when the Administrator is not present. The Administrator certificate for that staff person was recently approved/processed, and LPA observed it. Administrator informed LPA that that staff will go through the Valley Mountain Regional Center approval process and then they will submit their paperwork to CCL to be approved as well. Administrator explained to LPA that they had been the approved Administrator by DDS in the past, however there was a mix up when Administrator went out on leave. They came back after their leave and did not resubmit their documentation, which led to the confusion about qualifications. LPA observed a letter from DDS to Merakey on 12/19/2022, effective 11/30/2022, accepting Administrator as qualified. Administrator is a Registered Behavior Technician and LPA observed their certificate, which is current. LPA reviewed the Administrator file and confirmed the Administrator is a qualified Administrator per CCL's Title EBSH 89964(a) and 80064, however, did not meet the qualifications under 84064. LPA is issuing advisory notes today, which are not citations, on the following pages. An exit interview was conducted with Administrator and a copy of this report was provided to her.

met_with: J'Ronesha Adams


facility_name: MOSAIC MANOR

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Based on record review and confidential interviews, the youth has managed to elope from care, caused property damage, and caused injury to staff. Also based on record review and interviews, staff have followed facility protocols of de-escalation. Although the allegation that facility does not have control of minor may or may not be true, the allegation has not met the preponderance of doubt. Therefore the allegation is unsubstantiated. LPA conducted an exit interview with George Grant, Administrator at 3:00PM whose signature confirms the receipt of this document.

Investigation Findings:
13On 2/7/2023 at 1:06PM, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the facility. The purpose of this visit is to deliver the findings for the listed allegations. LPA met with Arden Pedrasa, Shift Lead. At the time of the visit, there was one youth and five staff present. One youth was at the hospital, accompanied by another staff member and another youth is staying offsite accompanied by another staff member. During the course of the investigation, LPA Hood conducted eight interviews between 1/9/2023 and 2/6/2023. LPA reviewed incident reports from 2023 regarding the youth involved. The youth involved declined to interview, LPA Hood conducted observations of the home interactions. LPA reviewed the youth's intake paperwork, including a compatibility analysis of the housemates. Based on record review, the youth has 2:1 staffing ratio and staff maintains supervision of the youth at all times. Based on confidential interviews, staff mitigate elopement and property damage. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Selena Hood LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: MOSAIC MANORFACILITY NUMBER: VISIT DATE: 02/07/2023

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

report_type: Complaint Investigation

met_with: Arden Pedrasa

complaint_status: unsubstantiated


raw_content:
Narrative:
and Ukeru trainings. There was a restraint done, and there was a restraint debriefing after the incident to discuss. Based on the facility's program plan, restraints will be done if there is imminent danger to staff or other clients. The youth was actively assaulting staff members prior to the restraint. At the time of the incident, there were seven staff involved and/or observing. Based on an internal review and LPA Hood's interviews, the staff did not see any other staff hit the client in care. Although the allegations that staff hit client in care and staff wrongfully restrained a client in care may or may not be true, the allegations have not met the preponderance of doubt and thus the allegation is unsubstantiated. LPA conducted an exit interview with George Grant, Administrator, at 3:25PM whose signature confirms the receipt of this document.

Investigation Findings:
13On 2/22/2023 at 11:45AM, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the facility. The purpose of this visit is to deliver the findings for the listed allegations. LPA met with Arden Pedrasa, Lead on Shift. During the course of the investigation, LPA conducted eight confidential interviews. LPA conducted observations of the home. The youth involved declined to interview multiple times. LPA reviewed pertinent incident reports, Needs and Services Plans for all youth, training records of staff, the staff schedule, and facility's Program Statement. Based on review of the staff schedule and incident reports, the staffing was within ratio. The youth involved in the allegations has a staffing ratio of 2:1. All staff that were present at the time had current Pro-Act UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Selena Hood LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: MOSAIC MANORFACILITY NUMBER: VISIT DATE: 02/22/2023

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

met_with: George Grant


raw_content:
Narrative:
The allegations that staff speak inappropriately to youth in care, staff engage in inappropriate sexual discussions in front of youth, and staff are smoking in the facility may or may not be true. The allegations have not met the preponderance of doubt and are therefore unsubstantiated. No deficiencies were cited at this time. LPA conducted an exit interview with George Grant, Administrator, at 4:15PM.

Investigation Findings:
13On 3/15/2023 at 4:05PM, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the licensed facility. The purpose of this visit was to deliver the findings on the above allegations. LPA met with George Grant, Administrator. During the course of the investigation, LPA Hood conducted twelve interviews between 2/22/2023 and 3/10/2023. The two youth involved declined to interview. LPA reviewed the administrator clock-in schedule, incident reports, and employee expectations documentation. Based on confidential interviews, eleven out of twelve of the interviewees stated that they had never heard staff curse or say inappropriate things in front of the youth. Eleven of the twelve interviewed stated that they had not heard staff talking about their personal sexual experiences in front of the youth. Eleven of the twelve interviewed said they had not suspected any staff of smoking on the premises. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Selena Hood LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: MOSAIC MANORFACILITY NUMBER: VISIT DATE: 03/15/2023

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


raw_content:
Narrative:
Based on confidential interviews and incident reports, staff was visually observing both residents while they were watching the content. At the time of the incident, the facility was in appropriate staff-to-resident ratio. Based on program statement and case management notes, the protocol for both residents is to not intervene unless there is imminent danger. Prior to this, the non-minor dependent was showing staff appropriate videos on their phone, so the staff did not assume it was an inappropriate video. Based on confidential interviews, the residents were watching the content for less than one minute, and staff immediately intervened after one resident told them what type of content they were watching. After learning about the nature of the content on the phone, the staff separated the two residents. Although the incident did happen, the allegation that due to staff not intervening, resident was exposed to inappropriate content on a phone from another resident in the home may or may not be true. The allegation has not met the preponderance of doubt and therefore the allegation is unsubstantiated. LPA conducted an exit interview with George Grant at 2:47PM whose signature confirms the receipt of the document.

Investigation Findings:
13On 3/30/2023 at 2:32PM, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the licensed agency. The purpose of this visit was to deliver the findings for the above allegations. LPA met with Administrator, George Grant. During the investigation, LPA Hood conducted seven confidential interviews between 2/6/2023 to 3/27/2023. LPA reviewed the residents' Individual Behavior Service Plan, case management summaries, incident reports, and the facility program statement. Based on confidential interviews and incident report, an incident did occur on 1/29/2023 where a non-minor dependent resident showed a minor resident inappropriate content on their cell phone. Per confidential interviews and the recent IBSP, sexualized behavior was not a core support for the non-minor dependent because there had not been sexualized behavior from their time in the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Selena Hood LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: MOSAIC MANORFACILITY NUMBER: VISIT DATE: 03/30/2023

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


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with George Grant, Administrator (ADM) at 1: PM on 4/30/24. Based on confidential interviews conducted and observations it was determined that the allegations listed above are Unsubstantiated. Witnesses interviewed stated that the facility has a two staff to one client ratio and that clients are supervised at all times. They mentioned that staff are always present to deescalate any peer-to-peer aggression. Witnesses stated that staff always attempts to encourage clients to go to school and that some clients decline. LPA observed a safe environment for clients while visiting the facility unannounced multiple times. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was provided to ADM. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: George Grant, Administrator


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with George Grant, Administrator (ADM) at 11: AM on 5/24/24. Based on confidential interviews conducted it was determined that the allegations listed above are Unsubstantiated. Based on witnesses interviewed, LPA was unable to find evidence that staff were abusing clients or treating clients in care in an agressive manor. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was provided to ADM. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with George Grant, Administrator (ADM) at 10: AM on 6/26/24. Based on confidential interviews conducted it was determined that the allegations listed above are Unsubstantiated. Based on witnesses interviewed, LPA was unable to find evidence that staff were not providing adequate supervision. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was provided to ADM UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with George Grant, Administrator (ADM) at 12: PM on 8/15/24. Based on confidential interviews conducted and record reviews it was determined that the allegation listed above is unsubstantiated. There was not enough evidence to determine if the facility violated any regulations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was provided to ADM. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: George Grant, Administrator (ADM)


raw_content:
Investigation Findings:
13At 11: AM on 10/22/ Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with George Grant, Administrator (ADM). Based on confidential interviews conducted it was determined that the allegations listed above are Unsubstantiated. Based on witnesses interviewed, the facility made attempts to meet the individual's hyigene needs but those attempts were rejected by the individual. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was provided to ADM UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with George Grant, Administrator (ADM) at 10: AM on 1/6/ On 9/19/24, the San Jose Children's Residential Regional Office (RO) received a complaint regarding the above allegations. The RO referred this case to the Investigations Branch on 9/19/24, and Investigations Branch Investigator (IB) James Santos was assigned to investigate this allegation on 9/20/24. Based on IB Santos's investigation and confidential interviews conducted 10/17/24-12/16/24 there was no evidence to prove the above allegations occurred. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was provided to ADM. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with Paul Llanos, RBT/DSP Lead at 1: PM on 5/2/ Based on confidential interviews conducted it was determined that the allegations listed above are Unsubstantiated. Based on witnesses interviewed, LPA was unable to find evidence that staff were not providing adequate supervision. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was provided to Geroge Grant, Administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Paul Llanos, RBT/DSP Lead


raw_content:
Investigation Findings:
13At 10: AM on 7/1/ Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with George Grant, Administrator (ADM). Based on confidential interviews conducted it was determined that the allegations listed above are Unsubstantiated. The majority of indviduals interviewed stated that the facility has procedures to prevent self-harming and eloping. The majority of indviduals interviewed stated that the facility encourages clients to engage in hygiene, dental, eating, and grooming routines. LPA couldn't find any evidence of facility not properly reporting incidents or not following the proper restrain plan. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was provided to Geroge Grant, Administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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


raw_content:
Investigation Findings:
13At 12: PM on 7/16/ Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed to inform them of the findings for the above listed allegations. LPA met with George Grant, Administrator (ADM). Based on confidential interviews conducted it was determined that the allegations listed above are Unsubstantiated. Based on witnesses interviewed, LPA was unable to find evidence of staff abusing minors in care, not preventing minors from harming other minors, and not meeting minor's clothing needs. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was provided to Geroge Grant, Administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Shikya Belfield conducted an announced case management inspection (tele-inspection due to COVID 19 via Microsoft Teams). The purpose of this inspection is to discuss concerns regarding C1 ( see LIC 811 dated 4/23/2021). LPA Belfield, Administrator George Grant and Licensee Yasmin Faraj, discussed C1 turning 18 years old in November 2021. Based on his dangerous behaviors and staffs' inability to manage them safely, which potentially causes a health and safety concern to any other children residing in the facility, LPA Belfield recommends the facility begin working closely with the placement agency to locate an appropriate Adult Residential Facility for C1 to move to upon his 18th birthday. Based on his behaviors, this may be difficult to find, which is why the search for an adult placement is being recommended this far in advance. Unless there is a significant change to his behaviors, C1 would likely not be compatible to remain in care with children or remain in a Group Home beyond his 18th birthday." Licensee Faraj stated to LPA Belfield that conversations regarding C1's future placement have already begun. There were no violations of California Code of Regulations, Title 22, Division Six, cited during this inspection. An exit interview was conducted and a copy of this report will be sent to Licensee Yasmin Faraj.

met_with: Yasmin Faraj


summary: Facility Evaluation

raw_content:
Narrative:
On 6/17/2021 at 1: PM, Licensing Program Analyst (LPA) Shikya Belfield conducted and unannounced Annual / Required inspection at the above facility. During this inspection there were five staff and one client. LPA Belfield met with administrator George Grant who assisted with the inspection. Currently, there are two clients in placement. During this visit LPA Belfield reviewed client files. A review of medication and medication records for both clients in care were in compliance. A review in the Licensing Information System, showed that all staff had current clearance. LPA Belfield and administrator Grant toured the facility inside and out. Observed during a tour of the facility; license, personal rights, disaster plan and all other required forms were posted, including food menus and dietary suggestions and instructions. Also observed by this LPA, was a sufficient food supply, located in three locations in the facility, along with an emergency food supply. The facility was observed to be clean and in good repair. Clients bedrooms were kept at a good temperature and clients had appropriate bedding. C1 ( see LIC 811 dated 6/17/2021) bathroom is missing the top cover to the toilet, facility issued advisory for section 80088 (e)(3) Furniture, Fixtures, Equipment, and Supplies. LPA discussed with administrator Grant the C1 removed the lid to the back of the toilet and was attempting to use it as a weapon, there is an incident report on file with the department. Administrator Grant states there is a plan in place to replace the toilet with a non-removable cover. Administrator also states that the toilet is fully functioning. LPA observed and tested the toilet during the inspection LPA tested the water temperature which measured at 112 degrees. This temperature is between 105 and 120 degrees which is within the requirement. At this time, a staff file review must be conducted in order to complete the annual inspection. Advisory issued. California Code of Regulation, Title 22, Division Six, section 80088 (e)(3) Furniture, Fixtures, Equipment, and Supplies. An exit interview was conducted with administrator Grant and a copy of this report will be sent to administrator Grant and Licensee Yasamin Faraj.

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
On 03/09/2022 at 2:00PM, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the above licensed facility for the purpose of conducting a case management. LPA met with Yassamin Faraj, Licensee, and conducted a walk through of the facility. LPA spoke with C1 regarding the allegations made in an incident report delivered to the department on 03/08/2022 (see LIC812). The Licensee will send LPA information on the staff member who has not been employed in the facility since 8/24/2021. An exit interview was conducted with Yassamin Faraj, Licensee, at 2:30PM whose signature confirms the receipt of this document.

met_with: Yassamin Faraj


summary: Facility Evaluation

raw_content:
Narrative:
On 6/23/2022 at 9:00AM, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the above licensed facility. The purpose of this visit was to conduct the required annual inspection. There were six staff members and two clients present at the time of the inspection. LPA met with George Grant, Administrator, and conducted the physical plant inspection. LPA observed the up-to-date posted license and neighborhood policy. LPA observed the facility to be clean, sanitary, and in good repair. LPA observed an adequate food supply and all cleaning supplies were kept in locked cabinets. There are four rooms in the facility, two of which are occupied by clients. The facility had working carbon monoxide detectors. LPA observed that the locked medication binder has the client's medication properly labeled and organized. LPA did not observe any deficiencies during the physical plant inspection. LPA and Administrator reviewed the files in the backyard of the home. Most of the files are kept on an online server, the client portion is accessible to direct care staff via agency cell phones. LPA observed the facility's disaster plan, staff roster, face sheets, and centrally stored medications binder. LPA did not observe any deficiencies regarding the file review. LPA conducted interviews with two staff members. LPA did not interview clients because they were both sleeping. There are no Title 22 deficiencies to be delivered at this time. LPA conducted an exit interview with Licensee, Yassamin Faraj, at 11:30AM, whose signature confirms the receipt of this document.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Selena Hood conducted a case management visit to the above facility on 9/12/2022 at 2:00PM. This case management was done in response to an incident reported by George Grant, Administrator and Yassamin Faraj, Licensee on 9/9/2022. On 9/9/2022, a staff member found a piece of marijuana on the floor while cleaning underneath the staff lockers. The staff member immediately showed this to George Grant, Administrator, who disposed of the marijuana outside of the facility. LPA met with Administrator, George Grant at 2:20PM. Administrator explained the steps that were taken to understand how the marijuana would have gotten into the facility. Clients do not have unsupervised access to the garage area where the lockers are at any time. LPA conducted an exit interview with George Grant, Administrator, at 2:25PM, whose signature confirms the receipt of this document.


summary: Facility Evaluation

raw_content:
Narrative:
On 12/12/2022 at 2:25PM, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the licensed facility. The purpose of this visit was to follow up on an incident that occurred on 12/7/2022. At the time of the visit, there were seven staff and one client present. On 12/12/2022, Licensee Yassmin Faraj informed LPA Hood that a client alleged that during a restraint on 12/7/2022 a staff member had hit them. Licensee had conducted an internal review and did not believe that the staff member had hit them. LPA conducted three confidential interviews (see LIC 812). LPA requested the restraint training for the staff member involved. Of the three interviews, three interviewees stated that the staff member did not punch the client. Based on confidential interviews, the staff members involved followed facility protocol on de-escalation and manual restraints. LPA conducted an exit interview with George Grant, Administrator, at 3:15PM, whose signature confirms the receipt of this document.


summary: Facility Evaluation

raw_content:
Narrative:
On 2/1/2023 at 1:27PM, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the listed facility. The purpose of this visit was to follow up on an incident reported to CCL by Licensee, Yassamin Faraj on 1/30/2023 where one non-minor dependent youth showed a minor client inappropriate content on their phone. LPA met with Steven Knop, RBT. Two of the youths were on outings, one youth is currently staying in a hotel. There were no clients and three staff present in the home at the time of the inspection. LPA conducted one interview. LPA discussed the facility's plan with Licensee via phone call (see LIC812). LPA conducted an exit interview with Steven Knop, RBT at 1:45PM, whose signature confirms the receipt of this document.

met_with: Steven Knop


summary: Facility Evaluation

raw_content:
Narrative:
On 6/14/2023 at 12:25PM, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the licensed facility. The purpose of this visit was to conduct the required annual inspection. LPA met with Administrator, George Grant, at 12:43PM. The facility currently has two youth in . At the time of the inspection, there was one youth present and five staff present. During LPA's inspection, one youth arrived back home from school so round 2:30PM, one youth went on a walk. LPA conducted a physical site inspection. LPA observed the home to be clean, tidy, and in good repair. LPA measured the hot water at 107 degrees. LPA conducted three staff interviews and one client interview. LPA reviewed the files with George Grant, Administrator, for the two clients in care. LPA reviewed the files for five staff members. LPA also observed facility files. LPA found no deficiencies in the files. LPA conducted an exit interview with George Grant, Administrator, at 2:59PM, whose signature confirms the receipt of this document.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility. The purpose of this visit was to conduct a Case Management inspection. LPA discussed this with George Grant, Administrator (ADM) at 10: PM on 10/4/23. This case management was opened to discuss an incident report (IR) the department received for an incident that occurred on 9/14/23. The incident report stated, in summary, that C1 unexpectedly exited the facility van during a drive in the community. This happened despite staff trying to prevent C1 from exiting the facility van. While outside the van, C1 ran into the street. To prevent C1 from getting hit from an oncoming car, staff used a non-FEIP/IEIP approved restraint to pull C1 out of the street and preventing him getting seriously injured. The facility created a plan of corrective action to avoid this type of incident in the future. The plan includes: The facility will refraining from outings unless a third person (admin) is available to assist. Submitted a licensing exception for use of a seatbelt buckle guard. Staff have been notified that the staff sitting in the middle row and providing the duty of primary staff should be a male staff (due to Dominic's preference, not ability level of staff). Staff will repeat additional emergency intervention training refresher. LPA also discussed with the facility about the frequency of IRs related to restraints/incidents related to C1. LPA also informed facility that they needed to identify staff members in IRs. LPA requested C1's NSP (Needs and Service Plan.) Exit interview was conducted with George Grant, ADM.

met_with: George Grant, Adminisrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility. The purpose of this visit was to conduct a Case Management inspection. LPA discussed this with George Grant, Administrator (ADM) at 12: PM on 3/8/24. This case management was opened to discuss an incident report the department received on 2/29/24 regarding potential personal rights violations. LPA also discussed the increase in peer-to-peer physical incidents. Please see LIC 812 for details. Exit interview was conducted and a copy of this report was provided to ADM, whose signature on this form confirm receipt of these documents.

met_with: Geroge Grant, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On March 13, 2024, at 3:30PM, a meeting was held between Community Care Licensing (CCL) San Jose Regional Office, San Andres Regional Center, Brite Horizons School, Santa Cruz County Office of Education (SCCOE), Monterey County Dept. of Social Services (MCDSS), and Facility Representatives. The attendees were as follows: Nelson Martinez - Regional Manager, Community Care Licensing (RM) Helga Wong - Licensing Program Manager, Community Care Licensing (LPM) Paul Simien - Licensing Program Analyst, Community Care Licensing (LPA) Durriya Anwar - QBMP, BCBA, SARC Yassmin Faraj - Support Services, License/BCBA, Mosaic Manor Harold Thomas - LCSN Specialist, Mosaic Manor Greeshma Sanchula, BCBA, SARC Maria Aleman - District Manager Transition Unit, SARC Mike Keeley - Director of Consumer Services, SARC Arushie Nugapitiya - Associate Director of Consumer Services, SARC Devin Stark - Director of Special Education, SCCOE Matt Peterson - Site Director/Behavior Analyst, Brite Horizons School Jessica Little - Executive Director of North Santa Cruz SELPA Stephanie Krol Vieira - Clients' Rights Advocate Attorney for Catchment Clients OCRA/DRC, SARC Lisa Hartley - Associate Director, SARC Brandon Ayala - Support Service Admin. Program assistant, Mosaic Manor Janice Frederick - Director Clinical Services, Brite Horizons Dr. Azelin Ellis - ASD & Clinical Manager, SARC Continued on LIC 809-C... Matthew Torres - I.D.E.A Specialist, SARC Evelyn Benitez -Socail Worker, MCDSS During the meeting the attendees discussed Brite Horizons and SCCOE's concerns regarding a client expressing feeling unsafe at the facility due to peer-to peer aggressions. Facility representatives explained the processes they have to keep clients safe, data gathered showing a decrease in peer-to-peer aggression, and support services they provide clients to serve their needs. SARC representatives explained their involvement with the facility and how they help with providing services to support clients. SARC representatives also explained what an Enhanced Behavior Home (EBH) is and the oversight/support services that are required for these types of facilities. Representatives from Brite Horizon and the facility agreed to keep an open dialog via email or Google Document regarding client feeling unsafe. They also proposed having a quarterly meeting to further discusses this. CCL will conduct a follow up meeting with the group sometime in September to ensure the health and safety of clients. The meeting was adjourned at 5: PM. *Documents were signed digitally by facility representative on 3/21/24*


summary: Facility Evaluation

raw_content:
Narrative:
On 6/25/24 at 10: AM, Licensing Program Analyst (LPA) Paul Simien conducted an unannounced visit to the above facility. The purpose of this visit was to conduct the required annual inspection. LPA met with George Grant, Administrator, at the above facility to conduct the required annual inspection. LPA reviewed three staff files. At this time the inspection is not complete, LPA will return to complete the inspection. No deficiencies were cited at this time. LPA conducted an exit interview with George Grant, Administrator, at 4: PM.


summary: Facility Evaluation

raw_content:
Narrative:
On 6/26/24 at 1: AM, Licensing Program Analyst (LPA) Paul Simien conducted an unannounced visit to the above facility. The purpose of this visit was to conduct the required annual inspection. LPA met with George Grant, Administrator, at the above facility to conduct the required annual inspection. LPA Simien reviewed four employee files and completed the plant inspection. At this time the inspection is not complete, LPA will return to complete the inspection. No deficiencies were cited at this time. LPA conducted an exit interview with George Grant, Administrator, at 5: PM.


summary: Facility Evaluation

raw_content:
Narrative:
On 7/1/24 at 10: AM, Licensing Program Analyst (LPA) Paul Simien conducted an unannounced visit to the above facility. The purpose of this visit was to conduct the required annual inspection. LPA met with George Grant, Administrator, at the above facility to conduct the required annual inspection. LPA Simien reviewed Disaster Preparedness plan, client MAR, and IEIP. LPA interviewed two clients (one client declined to speak after one question.) and three staff. At this time the inspection is not complete, LPA will return to complete the inspection. No deficiencies were cited at this time. LPA conducted an exit interview with George Grant, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 7/5/24 at 11: AM, Licensing Program Analyst (LPA) Paul Simien conducted an unannounced visit to the above facility. The purpose of this visit was to conduct the required annual inspection. LPA met with George Grant, Administrator, at the above facility to conduct the required annual inspection. LPA completed Operations, Client Files, Staff Files, and Emergency Interventions sections of the CARE TOOL. At this time, the inspection is complete. Two technical violations were issued. LPA conducted an exit interview with George Grant, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility. The purpose of this visit was to conduct a Case Management inspection. LPA discussed this with George Grant, Administrator (ADM) at 11: AM on 10/16/24. CCL received a phone call expressing concern with the frequency of the above listed facility's phone calls to law enforcement. LPA Simien went over the facility's policy regarding law enforcement contact. ADM stated that there was an increased in calls mostly due to clients calling emergency services. ADM stated that sometimes clients call 911 on personal phones without staff knowledge or request the facility phone and then call 911. When staff witness a client call 911 they will inquire what the issues is. If appropriate, staff will try to redirect the client by either trying to solve the issue or provide an alternative resource (I.E. mental health hotline). If the client insists on calling 911 then that's within the clients' personal rights. ADM mentioned that sometimes when a client wants to go to the hospital they will reject using facility transport and insist on using emergency services. ADM stated that when staff calls emergency services, it's mostly due to clients needing medical attention. ADM stated that they use Ukeru pads to help prevent self-harming and will use restraints as a last resort if a client is in imminent danger but sometimes clients will still need medical attention after engaging in self harm. ADM mentioned that himself and staff have been confronted by local law enforcement officers about the increased calls. ADM stated that he has attempted to explain the regulations that facility works within to local law enforcement officers when confronted but has mostly been disregarded. LPA Simien reviewed the facility's incident reports involving law enforcement from August 2024 and September 2024 and found no violations of regulations. Exit interview was conducted and and a copy of this report was provided to George Grant, ADM whose signature confirms the receipt of this document.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility. The purpose of this visit was to conduct a Case Management inspection. LPA discussed this with George Grant, Administrator (ADM) at 12: PM on 5/21/25. This case management was opened to discuss an incident report the department received on 5/19/25 regarding a client being sent to the hospital and having major surgery. Please see LIC 812 for details. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was provided to ADM, whose signature on this form confirm receipt of these documents.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility. The purpose of this visit was to conduct a Case Management inspection. LPA discussed this with George Grant, Administrator (ADM) at 11: AM on 8/27/25. This case management was opened to discuss an incident report the department received on 7/25/25 regarding employees possibly smoking in the facility. Please see LIC 812 for details. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was provided to ADM, whose signature on this form confirm receipt of these documents.

met_with: George Grant, Administrato


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility. The purpose of this visit was to conduct a Case Management inspection. LPA discussed this with George Grant, Administrator (ADM) at 12: PM on 10/24/25. This case management was opened to discuss an incident report the department received on 8/13/25 regarding a client finding a vape pen (suspected of containing weed liquid) in her bathroom. Please see LIC 812 for details. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was provided to ADM, whose signature on this form confirm receipt of these documents.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility at 1: AM on 12/19/2025. LPA met with George Grant, Administrator (ADM) in facility office for the purpose of conducting a case management visit regarding a Buildings and Grounds violation discovered. During another inspection visit, LPA Simien observed two holes in the walls of the facility. One was located in a client's bathroom. The other was located in the hallway in front of a client bedroom. As a result of this visit, there is one General Licensing Standards violation ( Buildings and Grounds(a)). The facility will be cited (see 809-Ds for details). Appeal rights were discussed and provided. Exit interview was conducted and a copy of this report was provided to ADM


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility. The purpose of this visit was to conduct a Case Management inspection. LPA discussed this with George Grant, Administrator (ADM) at 11: AM on 1/16/26. This case management was opened to discuss an incident report the department received on 1/12/26 regarding staff using unauthorized restraints. Please see LIC 812 for details. LPA interviewed four staff members. As a result of this visit, it was determined further investigation is required. Exit interview was conducted and a copy of this report was provided to ADM, whose signature on this form confirm receipt of these documents.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility. The purpose of this visit was to pick up video evidence. LPA discussed this with Harrison Fox, Lead RBT at 3: PM on 1/30/26. LPA picked up the video evidence. Exit interview was conducted and a copy of this report was emailed to George Grant, Administrator.

met_with: Harrison Fox, Lead RBT


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility to inform them that a new complaint had been filed with Licensing and that LPA Simien was opening an investigation for the above listed allegations. LPA discussed this with Brandon Ayala, Assistant Administrator (AADM) at 10: AM on 12/15/25. Based on LPA Simien's observations it was determined that the allegations listed above are Substantiated. LPA inspected the facility and observed the damage on the door frame of client's room and that two clients did not have dressers. The damage on the door frame was minor and not a health and safety concern. Adminstrator stated that they had already put in a work order and showed LPA documentation. Clients' clothes were neatly folded and stacked in cubbies place on the floor in the rooms. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. As a result of this visit, there are two technical violations issued. Exit interview was conducted and a copy of this report was provided to AADM. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Brandon Ayala, Assistant Administrator

complaint_status: SUBSTANTIATED


facility_name: PEOPLE'S CARE 116TH STREET

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward made an unannounced licensing visit to conduct the annual/required inspection. The inspection began at 3: PM and was conducted with the assistance of administrator Azeez Lamina. The following was observed. The facility is implementing COVID Screening as required. This is three bedroom, two bathroom home located in the City of Inglewood, CA. There are currently two clients in care. Both clients are non-verbal and considered non-ambulatory although they are both capable of walking. Children's records were complete. The parents of both clients maintain medical rights, therefore no JV 220 paperwork is required. There are no bodies of water, firearms or fireplaces on the premises. There are no security bars on windows. The yard area is free of visible hazards. LPA observed a generator in the backyard, All bedrooms are equipped with one full sized bed each, including all required linens. The windows in bedroom #2 are covered in decorative paper rather than blinds or curtains due to the resident's tendency to tear down window coverings. There is a complete supply of first aid items. Smoke detectors and carbon monoxide detectors are working and properly placed. There is a fire extinguisher near the kitchen; it is recommended that this unit be recharged. All knives, household chemicals and medicines are stored under lock and key. The following were posted as required: Notice if Personal Rights, employee schedule, COVID 19 postings, and floor plan. There is a current menu; However the menu is not posted. The last disaster drill was conducted 11/23/21. There were no deficiencies cited on this date. LPA will return at a later date to review staff records.

met_with: Azeez Lamina


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward made an unannounced licensing visit to conduct the annual/required inspection. The inspection began at 3: PM and was conducted with the assistance of administrator Azeez Lamina. The following was observed. The facility is implementing COVID Screening as required. This is three bedroom, two bathroom home located in the City of Inglewood, CA. There are currently two clients in care. Both clients are non-verbal and considered non-ambulatory although they are both capable of walking. There are no bodies of water, firearms or fireplaces on the premises. There are no security bars on windows. The yard area is free of visible hazards. LPA observed a generator in the backyard. All bedrooms are equipped with one full sized bed each, including all required linens. The windows in bedroom #2 are covered in decorative paper rather than blinds or curtains. The administrator was advised to obtain drapes or blinds for the window. There is a complete supply of first aid items. Combination smoke detectors and carbon monoxide detectors are installed. However the home needs a carbon monoxide detection unit that makes a distinct sound as required by Title 22. Facility was advised to obtain a CO unit that meets regulations, There is a fully charged fire extinguisher in the dining area All knives, household chemicals and medicines are stored under lock and key. The following were posted as required: Notice of Personal Rights, employee schedule, COVID 19 postings, and floor plan. There are two current menus because one client has food allergies. The last disaster drill was conducted on 03/08/22. LPA will view client and staff records at a later date. There were no deficiencies cited as a result of this inspection


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst met with lead staff Vera Adidi to complete the annual inspection by reviewing staff and client files. In total 2 client and 3 staff files were reviewed. LPA also noted that the previous smoke detectors were replaced by combination smoke/CO detectors that meet the requirements of the Health and Safety code 13262 and that there were new blinds place over the window in bedroom # Parents maintain medical rights over each client, therefore no medical court orders are required. There were no deficiencies cited as a result of this investigation.

met_with: Vera Adidi, RBT


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward made an unannounced licensing visit to conduct the annual/required inspection. The inspection began at 9: AM and was conducted with the assistance of administrator Azeez Lamina. The following was observed. The facility is still implementing full COVID Screenings upon entry. This is three bedroom, two bathroom home located in the City of Inglewood, CA. There are currently two clients in care. Both clients are non-verbal and considered non-ambulatory due to lack of awareness. However, they are both capable of walking. There are no bodies of water, firearms or fireplaces on the premises. There are no security bars on windows. The yard area is free of visible hazards. LPA observed a generator in the backyard. All bedrooms are equipped with one full sized bed each, including all required linens. All windows are operational and covered with blinds in good condition. There is a complete supply of first aid items. There are working smoke and carbon monoxide detectors in the home. There is also a fully charged fire extinguisher. All knives, household chemicals and medicines are stored under lock and key. The following were posted as required: Notice of Personal Rights, employee schedule, COVID 19 postings, floor plan and grievance procedurs. The last disaster drill was conducted on 09/30/23 at 10: AM & 3: PM There are two current menus because one client has religious based dietary requirements. There are separate food storage areas and a separate microwave oven to accommodate these requirements. The facility van passed visual inspection of tires, headlights, tail lights, turn signals, horn and seat belts. LPA reviewed the records of both clients and five staff members. The parents of both children hold medical rights. Therefore there were no court orders for psychotropic medications. LPA interviewed three staff members. Both clients are non-verbal. This completes the Annual Inspection. There were no deficiencies cited.

met_with: Azeez Lamina, administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward made an unannounced licensing visit to conduct the annual/random inspection. The inspection began at 11: AM and was conducted with the assistance of administrator Tiffany Murguia. The following was observed. This is three bedroom, two bathroom home located in the City of Inglewood, CA. There are currently three clients in care. All clients are non-verbal and considered non-ambulatory due to lack of awareness. However, they are all capable of walking. There are no bodies of water, firearms or fireplaces on the premises. There are no security bars on windows. LPA observed a generator in the backyard. All bedrooms are equipped with one full sized bed each, including all required linens. All windows are operational and covered with blinds in good condition. There is a complete supply of first aid items. There are working smoke and carbon monoxide detectors in the home. There is also a fully charged fire extinguisher. All knives, household chemicals and medicines are stored under lock and key. The following were posted as required: Notice of Personal Rights, employee schedule, floor plan and grievance procedures. The last disaster drill was conducted on September 4, 2024 at 1: PM. LPA observed that there were two separate menus because one client can only eat the food that his parents prepare at home and bring to the facility. Employee file review and staff interviews will be conducted at a future date. The licensee was cited under Title 22, Section 84088.3(e)

met_with: Tiffany Murguia, administrato


summary: Facility Evaluation

raw_content:
Narrative:
On October 14, 2025, Licensing Program Analyst Connie Jones-Steward met with lead staff Elizabeth De La Torre and LVN Zully Chan to follow-up on the special incident report of October 7, 2025. The Department received an incident report that S1 had placed C1's medications in his food on the morning of October 7th. LPA reviewed C1's Client Face Sheet which confirmed that C1 is non-verbal. LPA reviewed C1's medication record and noted that on the morning of October 7th, C1 was administered 4 medications. One of which should not be crushed, chewed or split. However, there was a letter from the prescribing doctor Stacy Shuai stating that C1 should be allowed to take his medication with food if he refuses it otherwise. Per Ms. De la Torre and Nurse Chan, the medication was never hidden and client indicated his agreement to take the medication on peanut butter. LPA suggested that the letter be updated to specify soft foods that do not require chewing in order to prevent an accidental overdose. LPA also spoke with administrator Tiffany Murguia, who stated that S1 was cleared to return to work after the doctor stated that it was safe for client to take his medication in food. However she has not yet been back to work. Ms. Murguia stated that she will send a copy of the investigation to the Dept. At this time no violation was cited. However LPA still needs to speak to the clients Regional Center Coordinator.

met_with: Lead Staff Elizabeth De la Torre, Zully Chan LVN


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward met with administrator Tiffany Murguia regarding a concern raised by the Department of Developmental Services that the facility does not always have a lead staff on duty. Ms. Murguia explained that there is always someone on duty with the qualifications of a lead staff. However in the past, sometimes a qualified lead staff, including herself, has had to act as a direct care staff as well. In those situations, the schedule is clear on who is in charge so that there is no confusion on whom the other staff are to take direction from. Per Ms. Murguia, there are currently only two clients in care. One is under 2:1 ratio 24/7 while the other is under 2:1 ratio during daytime hours. Therefore the facility does not currently have a staffing issue. Furthermore, before another client is accepted, the administrator will inquire about the necessary supervision level to insure that the facility can maintain adequate staffing. The facility is also in the process of hiring additional full-time and on-call lead staff so that they can maintain ratio according to Department of Developmental Services requirements LPA reviewed the work schedules for the Jan 2026 and December 2025 as well as the facility's job description for lead staff. At this time no deficiency is found in the areas of staffing per CCL requirements

met_with: Tiffany Murguia, administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward met with administrator Tiffany Murguia to conduct an investigation of an incident report concerning a medication error. The IR Follow-up case number is 0001671-FN. Per the incident report, two staff in charge of administering medications failed to give a client her medication because they did not notice that it was lodged in the bubble pack. The missed medication was discovered and reported by a member of the nursing staff as she was reviewing the medications. Per Ms. Murguia, the two staff who caused the error have undergone a medications administration hands on review and are in the process of completing five additional classes on the subject of medication handling. LPA Jones-Steward collected a photo of the missed medication, copies of the disciplinary write-ups, a copy of the hands-on medication review, and proof of completion for the trainings that have been completed. Per Ms. Murguia, the staff are not allowed to handle medications until they have completed all trainings. The facility was cited under Title 22 84775(b)(2).

met_with: Tiffany Murguia, Administrator


summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13Licensing Program Analyst Connie Jones-Steward met with administrator Tiffany Murguia to investigate the allegation that S2 hit C1 and caused an injury. During the investigation, LPA interviewed Ms. Murguia, District Manager Justin Villareal, S2 and C1. LPA also reviewed the investigative report from Westside Regional Center which was resolved as unsubstantiated. LPA was not able to obtain a police report in a timely manner. However Ms. Murguia provided a voicemail from the investigating sheriff deputy who said that he found no evidence of a crime and was closing his investigation as unsubstantiated. LPA is currently awaiting a physical copy of the sheriff's report. After interviewing the alleged victim and several staff as well as reviewing the investigations of other concerned agencies, LPA Jones-Steward resolved the above allegation as unsubstantiated. An unsubstantiated finding means that although an allegation may have happened, there in insufficient evidence to prove that it did happen. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Connie Jones-Steward LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


facility_name: POLARIS HOME

raw_content:
Narrative:
The agency has investigated the complaint allegations that the Youth was handled in a rough manner while in care and youth was slapped while in care. The incident was reported by staff and after the administrator viewed the video the staff was immediately terminated. The video footage that was submitted on March 22, 2021 shows the youth being handed in a rough manner and being slapped in the back of the head with an open palm by Staff 9. Based on video footage, LPA's observations, interviews which were conducted and record reviews(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is (ARE) found to be Substantiated. The facility is cited on the attached LIC 9099D under the California Code of Regulations, for Personal Rights ILS 88487.8(b)(2) A copy of this report and appeal rights were emailed to the agency. No title 22 regulations were cited during today's inspection.

Investigation Findings:
13Licensing Program Analyst (LPA) Mary Shelton conducted a tele visit at the agency on June 9, 2021 and LPA spoke with Fenina Pham, Administrator to deliver findings of the investigation on the complaint allegations as stated. LPA Shelton informed the complaint investigation included a tour of the facility on 3/16/2021. The initial 10-day complaint inspection was conducted by LPA Mary Shelton, at the agency on 3/16/2021 and included a review of the facility and obtaining of relevant documents: Needs and Services, monthly treatment plan, supervised visit log, certificate of approval, facility sketch, staff training records and staff roaster. LPA Shelton interviewed the facility administrator on 3/16/2021. Additional interviews were conducted by LPA Mary Shelton, which included Sheriff Deputy Neri, C1's Social Worker and Staff. between 3/16/2021 and 6/2/2021. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Mary Shelton 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 23-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, NATOMAS PARK DR., STE FACILITY NAME: POLARIS HOMEFACILITY NUMBER: VISIT DATE: 06/09/2021

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

met_with: Fenina Pham, Administrator


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Narrative:
Regarding the allegation that staff called minor inappropriate names, statements made during interviews by 4 of 4 staff corroborated that staff and C1 joked back and forth and often client called staff names but, staff did not. Additionally, C1 denied being called names by staff. However, one out of four staff stated that one time they called C1 fat. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 , Chapter 5 84072 (d) (10) , are being cited on the attached LIC 9099D." An exit interview was conducted at 11: PM, a copy of this report and appeal process was reviewed and provided to the Administrator.

Investigation Findings:
13Licensing Program Analyst (LPA) Connie Goldie arrived at the agency to conduct an unannounced complaint investigation inspection on 12/13/2022 at 10: AM. LPA Goldie spoke with, Andrew Nguyen, Interim Program Administrator, to discuss the findings of the complaint investigation and allegation stated above. LPA Goldie informed facility staff this case was investigated by LPA Goldie. The initial 10-day complaint investigation inspection was conducted by LPA Connie Goldie at the facility on 09/26/2022. LPA Goldie toured the facility and interviewed one facility staff. Copies of facility documentation provided to LPA Goldie included: Client register, one client's individual personalized plan, Staff Roster, staff schedules for September and staff contact Information. Interviews were conducted with one client, four staff, Regional Center worker and C1's mother between 09/26/2022 and 11/08/2022. Two clients were not interviewed as they are non-verbal. Records review of documents obtained was completed on 09/26/2022 and 10/19/2022. Continued on LIC9099C. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Connie Goldie 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 23-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, NATOMAS PARK DR., STE FACILITY NAME: POLARIS HOMEFACILITY NUMBER: VISIT DATE: 12/13/2022

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

met_with: Andrew Nguyen Interim Program Administrator


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Narrative:
Regarding the allegation that staff refused to provide minor with a snack, statements made during interviews all corroborate that snacks are scheduled but, clients can request and receive food at unscheduled times. The LPA found that while this allegation may have occurred or is valid, there was not a preponderance of evidence to prove that it did or did not occur, therefore LPA has found it to be unsubstantiated. An exit interview was conducted at 11: PM, a copy of this report and appeal process was reviewed and provided to the Administrator.

Investigation Findings:
13Licensing Program Analyst (LPA) Connie Goldie arrived at the agency to conduct an unannounced complaint investigation inspection on 12/13/2022 at 10 : AM. LPA Goldie spoke with, Andrew Nguyen, Interim Program Administrator, to discuss the findings of the complaint investigation and allegation stated above. LPA Goldie informed facility staff this case was investigated by LPA Goldie. The initial 10-day complaint investigation inspection was conducted by LPA Connie Goldie at the facility on 09/26/2022. LPA Goldie toured the facility and interviewed one facility staff. Copies of facility documentation provided to LPA Goldie included: Client register, one client's individual personalized plan, Staff Roster, staff schedules for September and staff contact Information. Interviews were conducted with one client, four staff, Regional Center worker and C1's mother between 09/26/2022 and 11/08/2022. Two clients were not interviewed as they are non-verbal. Records review of documents obtained was completed on 09/26/2022 and 10/19/2022. Continued on LIC9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Connie Goldie 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 23-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, NATOMAS PARK DR., STE FACILITY NAME: POLARIS HOMEFACILITY NUMBER: VISIT DATE: 12/13/2022

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


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Narrative:
The Department investigated the complaint that a minor sustained unexplained bruises while in care. Although minor did present with an injury, ( 6 inches long by 2 inches in width of multiple small red circle bruises in a row and scratch marks under his left under arm-), Licensing Program Analyst was unable to determine where injury occurred and who was responsible. Clients in facility are all non-verbal and unable to be interviewed. Facility staff and school staff interviewed all corroborate that C1 demonstrates self injurious behavior. Facility staff stated they did not observe any behavior by clients and/or staff that would have caused the injury. An investigation was completed at C1's school and staff did not observe behavior that would indicate how the injury in question occurred. Additionally, RP stated they are 95% certain the bruising did not occur at the facility based on "how fresh injuries looked" and C1 had been at school all day prior to injury being observed. Based on the investigation, records reviewed, and interviews conducted, the complaint finding is UNSUBSTANTIATED at this time meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No Title 22 deficiencies were cited. LPA Goldie provided a copy of report along with appeal rights and discussed with Administrator.

Investigation Findings:
13Licensing Program Analyst (LPA) Connie Goldie arrived at the agency to conduct an unannounced complaint investigation inspection on 05/23/2023 at 3: PM. LPA Goldie spoke with Andrew Nguyen, Program Administrator to discuss the findings of the complaint investigation and allegation stated above. LPA Goldie informed facility staff this case was investigated by LPA Goldie. The initial 10-day complaint investigation inspection was conducted by LPA Connie Goldie at the facility on 04/05/2023. LPA Goldie toured the facility and interviews were conducted with five facility staff. Copies of facility documentation provided to LPA Goldie included: Client roster, Staff roster, staff schedule for 03/19/2023-04/14/2023, one client's individual personalized plan, one client's body check logs, and incident reports for C1 for March 2023. Confidential interviews were conducted with eight staff, three witnesses, North Bay Regional Center coordinator between 04/03/2023 and 05/19/2023. Records review of documents and photos obtained was completed on 04/13/2023. Continued on LIC9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Connie Goldie 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 23-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, NATOMAS PARK DR., STE FACILITY NAME: POLARIS HOMEFACILITY NUMBER: VISIT DATE: 05/23/2023

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

met_with: Program Administrator, Andrew Nguyen


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Narrative:
The Department investigated the complaint that a minor sustained unexplained bruises while in care. Although minor did present with an injury, (a linear bruise on his thigh above the top of his knee about 2 inches long and ½ inch thick and a bruise to the kneecap about 3 inches wide, both were purple, brown in color.) C1 is non-verbal and non-ambulatory. C1 engages in self-harm behaviors. Both the school and home stated that C1 has SIB (Self Injury Behavior) The reporting party stated that C1 likes to hit his head with his leg but that this injury is different and was concerned about C1 receiving 1:1 care at home. The reporting party stated that the injury was noticed at approximately 10: AM on 7/24/2024 at C1's school. Facility staff and school staff interviewed all corroborate that C1 demonstrates self injurious behavior. The increase in C1's SIB (Self-injury-behavior) behavior could be the result of a medication change according to the Administrator. During confidential interviews with staff at the home C1 is receiving 1:1 care during the day and 1:2 care at night. This is also noted in C1's Needs and Service Plan. At school C1 is receiving 1:1 care. LPA Shelton observed C1 at school on 7/31/24 and notice a red mark on C1's noise and the injury to C1's was no longer purple or brown in color. Based on the investigation, records reviewed, and interviews conducted, the complaint finding is UNSUBSTANTIATED at this time meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No Title 22 deficiencies were cited. LPA Shelton provided a copy of the report along with appeal rights and discussed with Administrator.

Investigation Findings:
13Licensing Program Analyst (LPA) Mary Shelton arrived at the agency to conduct an unannounced complaint investigation inspection on 08/16/2024 at 1:00PM. LPA Shelton spoke with Margarita Hernandez, Shift Lead to discuss the findings of the complaint investigation and allegation stated above. LPA Shelton informed facility staff this case was investigated by LPA Shelton. The initial 10-day complaint investigation inspection was conducted by LPA Shelton at the facility on 07/31/2024. LPA Shelton toured the facility and interviews were conducted with the Administrator, reporting party, school staff and seven facility staff. Copies of facility documentation provided to LPA Shelton included: Client roster, Staff roster, staff schedule, C1's individual personalized plan, C1's body check log, and incident reports for C1 for July 2024. Confidential interviews were conducted with the Administrator, School Behavior Specialist, staff, and LPA Shelton observed C1 at school on 7/31/2024. Records review of documents and photos obtained was completed on 8/2/2024. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Mary Shelton 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: POLARIS HOMEFACILITY NUMBER: VISIT DATE: 08/16/2024

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

met_with: Margarita Hernandez, Shift Lead


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Narrative:
The Department has investigated the allegation that a client sustained an unexplained injury while in care. During confidential interviews, it was revealed that five out of the five staff members interviewed, did not know how the client sustained bruises and scratches on both biceps. Record review indicated that on 10/15/24, the scratches were noted on the client's Injury Log, with the cause listed as, "unknown". The client has a history of self injurious behavior. Based on the investigation, records reviewed, and interviews conducted, the complaint finding is UNSUBSTANTIATED at this time meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted with Benjamin Rimorin. A copy of this report and appeal rights were provided.

Investigation Findings:
13On Wednesday, December 4th, 2024, Licensing Program Analyst (LPA), Brittany Crass, made an unannounced complaint investigation visit to deliver findings. LPA met with Benjamin Rimorin, Lead Staff. The initial 10-day complaint inspection was conducted at the facility by LPA Crass on 10/30/2024. On that date, LPA obtained copies of the client's Body Scan forms, Incident Log, and Staff Schedule. In between 10/30/2024 and 11/15/2024, LPA interviewed 5 staff members (S1-S5), the Licensee, three of the clients Teachers (T1-T3), and the Behavioral Specialist (S4). The client was unable to be interviewed as he is non-verbal. (Continued on LIC9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Brittany Crass 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: POLARIS HOMEFACILITY NUMBER: VISIT DATE: 12/04/2024

met_with: Benjamin Rimorin


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Narrative:
LPA Silvas received an email from Administrator, Benjamin Rimorin, on 12/23/2024 indicating that the accused staff, Joha Thomas, will no longer be working at Polaris. Regarding the allegation that staff hit and kicked youth, staff yelled at youth and staff threw objects at youth, statements made during interviews by 2 of 6 staff and video footage of client pointing to alleged staff, corroborated that staff did hit and kick youth, staff yelled at youth and staff threw objects at youth. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. An exit interview was conducted, a copy of this report and appeal process was reviewed and provided to the Administrator.

Investigation Findings:
13Licensing Program Analyst (LPA) Michelle Silvas arrived at the agency to conduct an unannounced complaint investigation inspection on 1/16/2025 at 9: AM. LPA Silvas spoke with Benjamin Rimorin, Administrator, to discuss the findings of the complaint investigation and allegation stated above. LPA Silvas informed facility staff this case was investigated by LPA Silvas. The initial 10-day complaint investigation inspection was conducted by LPA Michelle Silvas at the facility on 12/16/2024. LPA Silvas toured the facility and interviewed six staff. Copies of facility documentation provided to LPA Silvas included: staff schedule for the next two weeks, contact information for the noc shift staff, daily shift notes for the child, daily notebook notes and body scan notes. Interviews were conducted with six staff and ongoing communication via email with Amir Cruz-Khalili from the Department of Developmental Services. Four clients were not interviewed as they are non-verbal. LPA Silvas observed all four clients on 12/16/2024. Records review of documents obtained was completed on 12/16/2024. Continued on LIC9099C. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Michelle Silvas 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: POLARIS HOMEFACILITY NUMBER: VISIT DATE: 01/16/2025

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

met_with: Benjamin Rimorin, Administrator


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Investigation Findings:
13On 3/3/2025 at 3:25PM, Licensing Program Analyst (LPA) Michelle Silvas conducted an unannounced visit at the facility. The purpose of the visit was to Issue a citation that was inadvertently left out for the complaint delivered on 1/16/2025 which was found to be substantiated involving the allegations listed above. For details of this investigation, please see complaint number; 23-CR-20241216104956. LPA Silvas met with Benjamin Rimorin and discussed the citation. type A violation is being cited during today's visit. An exit interview was conducted, and reports discussed and provided to facility along with the appeal rights. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Michelle Silvas 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: POLARIS HOMEFACILITY NUMBER: 487006088

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


raw_content:
Narrative:
The incident occurred on January 11, 2025, at 9:30AM, it was stated that S7 took C1 on a van ride alone and when leaving the facility, C1 appeared to be fine with no signs of injuries. Upon his return from the outing around 11AM, C1 was given his lunch and laid down for a nap. When S9 woke up C1 from his nap at 2pm, he observed C1 to have bruising on his head. When S2 observed C1, a big fresh bruise was noticed on the right side of C1's head, redness on C1's nose which appeared worse than it was when observed in the morning at 7:30AM. During the shift change, S7 told S2 that the minor had redness on his nose, a red mark on his neck and bruising around his eye. S2 stated S7 did not appear concerned about the injuries. S2 checked the body scan from the previous day, January 10, 2025, and stated that it did not mention any bruising on C1's head. Record review by LPA of body data documentation indicates that there was not bruising on C1's head on 01/10/2025. LPA conducted a record review of C1's file. It is indicated on C1's IBST (Individualized Behavior Support Team) which was conducted on 12/14/2024, that he is a 1:1 ratio. Within this report, it was stated that Polaris will "provide additional staff support during changing, bathing and riding in the van. Outings are to be planned in advance with the lead staff or other available staff to support the outing and at least one staff person should be seated in the back of the van with C1." Additionally, it is indicated on Polaris' "key strategies document" under the section labeled, "things we should always do to help", it was indicated that C1 will have additional staff present during van rides. This was not being implemented. Three out of twelve staff who were interviewed stated, "some don't react as fast" and "they are not quite sure when to intervene" but they do intervene. Twelve out of twelve staff interviewed state that they do get continuous training's to help clients who engage in self injurious behaviors. Due to the clients in the home being non-verbal, they were unable to make any statements during this investigation. Based on LPAs observations, record review and interviews which were conducted, the preponderance of evidence standard has been met, therefore, the above allegation(s) is found to be SUBSTANTIATED. An exit interview was conducted, and appeal rights discussed. A copy of all reports along with the appeal rights were provided to the facility.

Investigation Findings:
13On 4/17/2025 at 3: PM, Licensing Program Analyst (LPA) Michelle Silvas initiated an unannounced complaint inspection at the above listed facility. LPA met with Benjamin Rimorin, Administrator, who assisted with the inspection. The purpose of the inspection was to deliver findings for the above listed allegations. On 1/16/2025, LPA initiated a complaint investigation at the facility and conducted a health and safety inspection and conducted six staff interviews. On 1/27/2025, LPA conducted six staff interviews at the facility. A total of twelve staff interview were conducted. Client interviews were attempted but unsuccessful as all clients in the home are non-verbal. Regarding the allegations, minor sustained unexplained injuries while in care and staff do not intervene when minor self-injures. The department received a complaint on January 15, 2025, regarding C1 sustaining an unexplained injury and staff not intervening when C1 is engaging in self-injurious behaviors. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Michelle Silvas 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: POLARIS HOMEFACILITY NUMBER: VISIT DATE: 04/17/2025

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