raw_content:
Narrative:
Confidential interviews were conducted with seven individuals, and attempted to interview four individuals, during the period of February 28, 2025, to June 05, 2025. LPA Martinez's interviews conducted, and records reviewed were inconsistent that facility staff rough handled C1. There was no corroboration for the allegation "Facility staff handled youth in a rough manner," as C1 declined to be interviewed. Additionally, two out of three children denied any mistreatment from facility staff. Two out of three facility staff reported C1 was not rough handled by them. One out three staff was informed of the altercation between S1 and C1, but they did not provide sufficient information to corroborate the allegation. Based on LPA Martinez's interviews conducted, and records reviewed, the preponderance of evidence standard has not been met; therefore, the above allegation is found to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted, and a copy of this report was provided to Naeem Brown (Assistant Administrator).

Investigation Findings:
13Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced complaint inspection with the above facility on June 16, 2025 at 9: AM and met with Naeem Brown (Assistant Administrator). The purpose of the inspection was to deliver complaint findings for the above allegation. On February 28, 2025, at 9: AM Licensing Program Analyst (LPA), Avelina Martinez, arrived unannounced at the agency for the purpose of initiating a complaint investigation related to the above allegation. LPA Martinez met with Joanna Barnhill, (Assistant Administrator). LPA requested the following documents for review: Client Roster, Staff Roster, and Schedule, Needs and Services Plan, CFTS notes/Preservation Plan, Safety Plans, Incident Reports for youth 1 (Y1) in care, and Training Records: (Proact and any other behavioral trainings completed) for staff 1, staff 2, and staff 3. LPA Martinez conducted an inspection of the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Avelina Martinez 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: PARADISE OAKS - OLIVINEFACILITY NUMBER: VISIT DATE: 06/16/2025

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

met_with: Naeem Brown (Assistant Administrator)


state: CA

facility_name: PARADISE OAKS - OLIVINE

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
LPA Martinez requested the following documents for review: Client Roster, Staff Roster and Schedule, Staff Census-include New Hires/Termination Records (01/01/2025 to Present), Harm Reduction Plans (01/01/2025 to Present), Needs and Services Plans (01/01/2025 to Present), CFT notes (01/01/2025 to Present), Safety Plans (01/01/2025 to Present), bedroom door/smoking/transportation policies, house meeting notes (01/01/2025 to Present), Activity Calendar (01/01/2025 to Present), Board Meeting notes (01/01/2025 to Present). Confidential interviews were conducted with eleven individuals, and attempted with two individuals, during the period of July 02, 2025, to August 28, 2025. Based on interviews conducted and records reviewed, it was determined the following allegations are substantiated: The facility does not have sufficient staff to meet the youth's needs and staff are not implementing Prudent Parenting Standards. A file review revealed that a staff member did not address a substance use incident due to lack of staffing. It was learned that a staff member refrained from addressing the substance use incident because they were the only staff on shift and there were multiple children smoking Marijuana. The investigation also revealed that reasonable prudent parenting standards are not being applied by direct care staff. P1 reported that direct care staff are not confident in making prudent parent decisions and refer to management to make all the decisions. When Interviewees were asked to define reasonable prudent parent standards, they were unable to define or explain prudent parent standards. Additionally, the interviewees could not recall any trainings dates pertaining to Reasonable Prudent Parent Standards. Due to the details provided during interviews, the facility does not always have at least one staff member on site that is able and has the ability to apply reasonable and prudent parent standard. As a result of this investigation of this complaint, the facility will be cited under 87065 (d)(1) Personnel Requirements and Personnel Requirements 87065(g). Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, are cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report and a copy of the appeal rights were left at the facility with Joanna Barnhill (Assistant Administrator). Confidential interviews were conducted with eleven individuals, and attempted with two individuals, during the period of July 02, 2025, to August 28, 2025. Based on interviews conducted and records reviewed, it was determined that the facility has a no smoking policy, and this policy is being implemented. Facility staff take corrective action when children violate the smoking policy on facility premises. Ten out of eleven interviewees reported staff do not listen to or record youth phone calls. Additionally, LPA Martinez reviewed the facility clothing requirements and clothing price range guidelines. Clothes are purchased when need, and during the summer and winter seasons. Based on multiple interviews it was reported that there were no clothing concerns. It was also learned that transportation is being provided to children in care, and confidential interviews corroborated that transportation is being provided. In regard to activities, staff members are conducting activities, and the children in care can attend facility meetings and submit activity requests. Activities can also be conducted individually when additional staffing is available. After conducting interviews with relevant parties, LPA Martinez determined that the facility has a bedroom open door policy. The children are able to leave their door cracked open. Lastly, there is not sufficient information or evidence to show that facility staff are not following their emergency intervention plan when youth leave without permission. Based on LPA Martinez's interviews conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED. 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. An exit interview was conducted with Joanna Barnhill (Assistant Administrator), and a copy of this report was provided to Joanna Barnhill (Assistant Administrator).

Investigation Findings:
13Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced complaint inspection with the above facility on October 16, 2025, at 1: PM and met with Joanna Barnhill (Assistant Administrator). The purpose of the inspection was to deliver complaint findings for the above allegations. On July 02, 2025, at 9: AM Licensing Program Analysts (LPA) Avelina Martinez arrived unannounced at the agency for the purpose of initiating a complaint investigation related to the above allegations. LPA Martinez met with Amanda Lee (Administrator) and Joanna Barnhill (Assistant Administrator). SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Avelina Martinez 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: PARADISE OAKS - OLIVINEFACILITY NUMBER: VISIT DATE: 10/16/2025

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

report_type: Complaint Investigation

complaint_status: unsubstantiated


summary: Facility Evaluation

raw_content:
Narrative:
On 06/18/21 at 1: PM, the second collaborative a quarterly meeting with Paradise Oaks Youth Services (POYS) was held to provide technical assistance and collaborative support to assist with and ensure POYS operates a successful program. The first meeting was held on March 19, 2020. POYS consists of nine locations: Olivine, Rosa Vista, Hazel, Hickory, Antelope, Mariposa, Old Auburn, Madison, and Sunset. The current census at all locations is 28. Two locations have closed, Linda Creek on 2/3/21 and Violets on 5/11/21. The following were present on an MS Teams virtual meeting: · CCL: Margo Castaneda, Regional Manager, Jodean Hall, Licensing Program Manager, Robin Sullivan, Licensing Program Analyst. · System of Care (SOC): Marjana Jackson, Stacie Kinney. · Sacramento County: Linda Abdelbaki · Department Health Care Services (DHCS): Brian Keefer · POYS: Robert Pye, CEO, Laynee Kuhn, Executive Director, Stephanie Fisher, Program Director, Thomas Harrer, Clinical Director POYS provided a status update of the CARF evaluation stating the accreditation approval is over two months out due to backlogs from covid. An extension of approval is in effect. The Mental Health review by Dept. of Health Care Service (DHCS) was completed in April 2021 and at this time POYS is working with DHCS in providing the plan of corrections. POYS reports numerous clients recently graduated from high school. Some graduates are enrolled in community college, some are working, some are seeking transitional housing programs, and some are still figuring things out. Distance learning challenges were reported to be with band-width issues both from the schools and at the facilities. Distance learning was embraced by about half of the clientele, with the other half preferring in-person learning. CCL reported a decrease in complaints and incident reports. POYS attribute the decline to a more deliberate intake process and screening for better compatibility with the current clients. They also reported they were revamping their level system. In addition, POYS is training house staff to participate more closely with each client and their overall treatment plan. Staff are eliciting more input from youth on what is working/not working with the program. Youth have responded with more engagement. POYS reported they are resuming a higher level of training for staff as more in-person training become available. They have contracted with Relias Learning for staff training. When asked about the status of overnight staff, POYS reported, they have two roamers that are assigned to three homes each. They also have one floater that helps out as needed or if someone calls out. This model is used both for the day shift and nighttime shift. The roamers and floaters meet regularly with staff to discuss client behaviors and needs. Sacramento County had no specific areas of concern. They complimented the discussed areas of change and the graduation of youth. DHCS discussed the pros/cons of the virtual Mental Health review and was appreciative for POYS' feedback on the process. Clarification on mask wearing requirements for POYS clients and staff will be provided as the Department receives details. POYS will submit an electronic Program Statement to include recent revisions. They next meeting is scheduled for September 17, 2021. A copy of this report will be emailed for signatures to Laynee Kuhn.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Executive Management


summary: Facility Evaluation

raw_content:
Narrative:
Due to technical difficulties, a handwritten report was issued. This is an electronic copy of the report issued to Amanda Lee, Administrator at the time of the law enforcement contact case management inspection conducted on 6/29/21. See handwritten copy for original signatures. Licensing Program Analyst Hugo Licea conducted a case management inspection on June 29, 2021 at 10:11am based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. 5 out of Direct Care Staff and 3 out of 4 youth files as identified on the LIC 811 confidential names dated June 29, 2021, were reviewed. 4 out of Direct Care Staff and 3 out of 4 youth were also interviewed. The Plan of Operation including policies and procedure were reviewed. A copy of this report was discussed and provided to Amanda Lee, Administrator.

met_with: Amanda Lee, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Robin Sullivan conducted unannounced required annual inspection on 6/30/2021 at 8: AM with Amanda Lee, Administrator. The facility follows Covid-19 entrance protocol with a sign-in log and temperature check conducted at the entrance. The facility's status of some requirements are as follows: · Accreditation review with CARF International was conducted 4/26/21-4/28/21 and new certificate is pending. · Medi-Cal Certification completed. · Mental Health Contract is annual with Sacramento County. · Mental Health Program is currently in process of renewal. The facility censes is four. Three client files were reviewed and two client interviews were conducted.The following items were observed and evaluated by LPA Sullivan: Posted items in the facility: Facility License, Emergency Mass Casualty Disaster Plan, Foster Youth Personal Rights, Foster Youth Ombudsman, exit routes, COVID-19 handwashing instructions, and health and safety information are posted. .Kitchen- Two refrigerators tested below 40 degrees F; two freezers tested at below six and below 2 degrees. Hot water temperature tested within the regulatory range of 105-120 degrees. Knives and Sharps are stored and locked inside the staff office. Adequate food supply including 2 days of perishable and 1 week of non-perishable items were observed. Dishwasher is operable. Adequate dishware and cooking utensils are present to meet capacity. There are no refrigerated medications. The trash can is covered. Living Area-. There is a sofa and over-sized chair for seating. Smoke & Carbon monoxide detectors are present and operable. Windows have screens. Carpet/flooring are in good repair. Bedrooms- 3 of 3 client bedrooms were observed to have all had the required furnishings, including storage space. Each bed has the required mattress pad, fitted sheet, top sheet, blankets and pillow bed covering. Two rooms are currently single occupancy, with the capacity of 2, and one room is double occupancy. Additional linen supplies are stored in the hall closet. Windows have screens and coverings. Smoke detectors are operable. Buildings and Grounds- Carbon monoxide detector and smoke detector were tested and are working. Facility was clear of hazards and observed to be clean and safe. Telephone: Available and in operable condition. Cleaning & Chemical Supplies: Adequate, locked and stored in a hall closet. Doors and Passageways: Clean and free of obstructions. Facility has no bodies or water, cameras, or firearms on the premises. Facility vehicle has current registration and insurance. The tires observed to be new and all seat belts function. Exterior was clean and free of debris. Sunflowers were planted by a An exterior building was observed to have a large conference table with chairs to be used for trainings and meetings. Medication- Medication is stored in a locked container, inside a locked filing cabinet, inside the locked staff office. Documentation of dispensing medication was reviewed. Facility has copies court approval for dispensing medications. First aid kit (manual, tweezers, scissors, dressings, bandages, adhesive tape, thermometer, antiseptic solution) was available and had an adequate supply of items. LPA Sullivan will review employee files located at the Administrative office. An exit interview was conducted and the inspection discussed with Amanda Lee. Copies of documentation were provided to the facility. No Title 22 deficiencies were cited.

visit_type: Annual

met_with: Amanda Lee


summary: Facility Evaluation

raw_content:
Narrative:
LPA Sullivan made a visit on 6/30/2021 at 2: PM to Paradise Oaks Administrative Office at Sunrise Vista Drive, Suite 2100, Citrus Heights, CA 95610. The licensee provided a current copy of the LIC 500. Four Staff records were reviewed after the physical inspection at the facility. See LIC 859.

met_with: Lisa Garceau, HR Director


summary: Facility Evaluation

raw_content:
Narrative:
On 09/17/21 at 1: PM, the third collaborative quarterly meeting with Paradise Oaks Youth Services (POYS) was held to provide technical assistance and collaborative support to assist with and ensure POYS operates a successful program. POYS consists of nine locations: Olivine, Rosa Vista, Hazel, Hickory, Antelope, Mariposa, Old Auburn, Madison, and Sunset. The current census at all locations is 27. Three locations: Madison, Sunset and Old Auburn currently have no foster youth placed. The following were present on an MS Teams virtual meeting: · CCL: Jodean Hall, Licensing Program Manager, Robin Sullivan, Licensing Program Analyst (LPA), Cindy Johnson, LPA, Tammy Hill, LPA · System of Care (SOC): Marjana Jackson, Stacie Kinney. · Sacramento County: Linda Abdelbaki · Department Health Care Services (DHCS): Brian Keefer · POYS: Robert Pye, CEO, Laynee Kuhn, Executive Director, Stephanie Fisher, Program Director POYS reported a staff and family moved into Sunset after their home burned down approximately 2 weeks ago. Annual inspections were completed for all their facilities in June and July, resulting in Technical Advisory/Advisory Notes and no deficiencies cited. CCL will provide the electronic program statement revisions to System of Care. Program statement revisions for the SAY population was submitted but still needs to be reviewed and approved. LPA Marla Horne will review by October 20, 2021. Incident reports regarding smoking on grounds was discussed. Both trauma-informed practices and harm reduction protocols were discussed. Harm reduction practices have not been approved by the Department. POYS is reminded that incident reports should document interventions including staff discouraging youth from smoking. CCL pointed out youth smoking in the backyard is still smoking on grounds which may require additional case management inspections. CCL requested program statement revision to Transportation services to add details of exceptions to provide transportation to youth when extreme weather, youth not feeling well or after hours. CCL requested incident reports be typed due to the difficulty of reading the handwritten reports. At this time there are multiple POYS staff that still hand write reports. This has been an ongoing conversation between POYS and CCL. CCL requests all reports be typed by November 1, 2021. POYS declined this request. CCL requested all youths' names be included in one incident report rather than referring to other involved youth as "peer". CCL recommended using a legend to submit the report to CCL and redacting the names for POYS purposes. POYS declined the request due to confidentiality. The CCL request was requested and approved through upper management and noted not to be a HIPPA violation. CCL requested incident reports and timeframes be more specific. Antecedent information is specific and thorough, yet more follow up details or resolution information is needed and requested. CCL recommended POYS to Technical Support Program (TSP) for incident report writing. POYS approved the recommendation. Sacramento County had no specific areas of concern. DHCS had no specific areas of concern. Due to the upcoming impact of FFPSA on program statements, a deadline for the revisions was not determined and will be included at the time of the FFPSA changes. No further meetings are scheduled.

met_with: Robert Pye, CEO, Laynee Kuhn, Executive Director, Stephanie Fisher, Program Director,


summary: Facility Evaluation

raw_content:
Narrative:
On January 27, Licensing Program Manger (LPM) Dara Campos, Regional Office Manager Margo Castaneda, and Licensing Program Analyst (LPA) Stephannie Verna held an Informal Conference Meeting from 1: PM to 2: PM to discuss concerns. The meeting was facilitated by LPM Campos. Attendees included (in-person) Paradise Oaks Youth Services staff, Laynee Kuhn (Executive Director), Stephanie Fischer (Administrator), Amanda Lee (administrator) and Board Member Al Werner, as well as (Via Teams Meeting), Shawn Wade Fresno County Social Worker, Julie Leong, Case Manager Mateo County Behavioral Health, Khoa Nguyen Stanislaus County Social Worker, and Tia Carter Sacramento County Social Worker. The topics discussed included: Absent without Permission Temporary Release (TR) Communication with local law enforcement Cancelling Missing Person reports Incident Report details No deficiencies were cited during today's meeting. A copy of this report was provided to, Amanda Lee, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On September 20, 2023 at 10: A.M. Licensing Program Analyst Stephannie Verna arrived at the above facility and conducted an unannounced annual facility inspection. LPA met with, Aubrey Douglas, Facility Manager and Amanda Lee, Facility Administrator who assisted LPA with the inspection. LPA and the Licensee conducted a joint inspection of the interior and exterior areas of the facility's physical. The facility is licensed for a capacity of six ambulatory clients, ages 0 to 17 years old. The census is currently three. There were one to two clients present at certain times during the time of the inspection. There were multiple staff present at the time of the inspection, three or more, and there was a facility staff meeting occurring in the external/educational building. The facility license, Emergency Disaster plan, Facility Sketch, Client Personal Rights postings, Client menu, Client Daily Activity Schedule, and a boards of resources and flyers were posted in a prominent location in the facility. The home is one story and consists of three bedrooms, two bathrooms, kitchen, dining room, living room, recreation room, a garage, and a backyard with an exterior building utilized for meetings and educational purposes, and no swimming pool or pond. There are no cameras utilized in the home or exterior cameras posted. LAP observed that the living room contained two couches along with a television and a cabinet which contained games. Also, while the facility had a binder in the living room which stored facility grievance forms, the facility's policy regarding procedures was not posted in a location in the facility which is accessible to children and their authorized representatives. continued on 809-c LPA observed two locked hall closets which stored art supplies, soaps and hygiene products and hair styling tool. There were cabinets also located in the hallway which contained extra linens, pillows, towels, and paper supplies, and cabinets for client's personal property. The recreation room contained a couch and a desk. There is a fireplace in the recreation room, that is covered, and not used. The garage contained storage supplies and holiday decor. LPA observed that the dining area was off of the kitchen and the table had six six chairs. LPA observed that the kitchen area was located off the dining and recreation room area of the facility and that the kitchen area had the stove, oven, dishwasher, microwave and refrigerator/freezer. The kitchen contained a working landline phone. The kitchen cabinets and drawers were in good repair. Sharps were locked in the staff office in a locked box. The pantry was located off of the kitchen in the laundry room. LPA observed sufficient amounts of food in the pantry, refrigerator and freezer and fresh fruits and snacks on the counter. Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days were observed. LPA also observed three expired food items in the facility refrigerator that youth have access to. The items that were expired included milk, grape jelly, and deli meat. The facility had extra inventory of these items in another food storage area of the facility, and removed the expired items immediately and replaced them with fresh items. LPA observed that the facility has three bedrooms with double-occupancy floor plan, each client in care had a bed and clean bedding provided including mattress cover, fitted sheet, top sheet and blanket, and pillows. Dressers with operational drawers for personal items, lighting and ample closet or storage space was provided. Windows and screens were in good repair. There were two bathrooms observed in the facility. One bathroom was located in a client bedroom, and the other bathroom was located in the hallway. The bathrooms had a working toilet, shower/tub, and sink faucet. The water temperature was measured to be at 109.5 degrees Fahrenheit. The bathrooms contained soap and paper towels for hand washing. LPA observed a laundry room, which contained a washer and dryer, and refrigerator and freezer with extra food storage; shelving for storage of small kitchen appliances, and locked cabinets. Cleaning supplies and detergents were locked in the cabinets. Cabinets also stored extra cleaning supplies, tools and paper products. At the rear of the laundry room is one staff Social Worker office, and the food pantry, and a locked door to the backyard. continued on 809-c The backyard contained a small patio with a shaded cover, facility trash cans, the exterior/educational building, and a large grassy area, with a basketball court at the back of the yard. There were no areas of damage to the surrounding fenced area. The front and back yards were free of clutter; and the passageways and egress were unobstructed. The backyard can be accessed by the two side access points on either side of the facility. There was an area of the grass that had a one to two foot hole, filled halfway with water, LPA Verna was informed by Facility Manager that the facility was in the process of repairing the issue and the area is to be cautioned off while repairs are being made. It was observed that three indoor trash cans located in the kitchen (1) and restrooms (2) did not have tight-fitting covers kept on the trash cans. LPA observed working Carbon Monoxide and smoke detectors, and they were tested and in working condition. LPA observed that there was a fire extinguisher in the kitchen and exterior/education building of the facility. The fire extinguishers were charged and last inspected in August 2023. LPA observed the first aid kit were stored in the staff office. The first aid kit was in tact, with the exception of it not including a current edition of a first aid manual. The confidential client medication and records were stored in the staff office in a locked filing cabinet. While the facility had a binder in the living room while stored facility grievance forms, it was observed that the facilities policy regarding procedures was not posted in a location in the facility which is accessible to children and their authorized representatives. While the facility conducts emergency disaster drills quarterly, it was observed that the documentation of the drills conducted does not include the names of staff who participated in the drill and documentation of all drills conducted in the last year were not maintained at the facility. The Administrator provided LPA with documentation of the drill conducted in August 2023. Upon review of past licensing reports, the Administrator stated that they do not store the facility's past licensing reports for the past three years at the facility and they are stored at another facility office, Rosa Vista. LPA conducted one client interview. LPA Verna completed the following domains of the inspection: Physical Plant, Operations, Core-Therapeutic Services, and Disaster Preparedness. The inspection was not completed on today's date and will be completed, including the following domains: Staff records, Client Records, and Emergency Interventions, on another date. The facility is being issued three citations related to deficiencies to Title Regulations, sections 80076(a)(18) and 80088(f)(1); and Health and Safety Code, section 1538.5(a)(3); and four Technical Advisories related to: Title Regulations, sections 80075(g)(1)(A)and 80023(d)(2); STRTP ILS Regulations section 87072.2(a)(3), and Health and Safety Code, section 1565(c). An exit interview was conducted and a copy of this report, technical deficiencies, and LIC-809D and appeal rights was provided to Amanda Lee, Facility Administrator and Naeem Brown, Assistant Administrator.

met_with: Amanda Lee, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On September 25, 2023 at 11: A.M. Licensing Program Analyst Stephannie Verna arrived at the above facility to complete unannounced required annual facility inspection. LPA met with, Amanda Lee, Facility Administrator, who assisted LPA with the inspection. During the review, the HR Director Tennies Gentry arrived with the personnel records for five staff. The personnel records are not maintained at the facility site and are maintained at an agency office located at: Sunrise Vista Dr. Suite Citrus Heights, CA 95610. LPA Verna completed the following domains of the inspection: Staff records and Emergency Interventions, and began the inspection of the Client Records domain on today's date. Upon request to inspect the monthly intervention log on 09/20/2023, the log was not present at the facility and was then made available for review on 09/25/2023, and will be maintained at the facility. Upon review of five staff files, it was observed that: Three out of five staff files (S2, S S4) reviewed did not include documentation of a criminal record clearance and two out of five staff (S2 and S4) did not have documentation regarding a transfer request on file, as S2 and S4 are currently not associated to the facility, and are associated to another licensed facility. In review of Guardian, all staff had a criminal record clearance on record with the Department. continued on 809-c This report (page 1) was amended, signed by and a copy was given to Aubrey Douglas, Facility Manager. It was observed that while the facility had a "New Employment Confirmation" document in the staff files pertaining to initial staff training, the document did not include the exact date of completion and length of each initial (8 hour and 16 hour) of each training/topic. It was observed that S1's and S3's staff file did not contain all annual training documentation for the past year, 2022. Completion of the annual training could not be confirmed for S1 and S3. LPA Verna was informed by the Administrator that training was completed fully online in 2022. It was observed that one out of five staff files (S5) did not contain a current and valid CPR/first aid certificate or card, and (S2) had an expired CPR/first aid card filed in their staff file (expiration date of 07/12/2023) It was observed that one out of five staff (S5) files reviewed was missing the health screening and TB test document. It was observed that one staff file (S1) had an incorrect employee rights and the Employee Rights (LIC 9052) was not signed by the employees (S1 and S4) and filed in their file. LPA conducted one staff interview. The facility is being issued three citations related to deficiencies to STRTP ILS sections, 87065.1(e)(7), 87065.1(d)(6)(A) and Title Regulations, section 80066(a)(12)(B); and multiple Technical Advisories. LPA Verna completed the following domains of the inspection: Staff records, and Emergency Interventions, and will complete the domain Client Records on another date. An exit interview was conducted and a copy of this report, technical deficiencies, and LIC-809D and appeal rights was provided to Amanda Lee, Facility Administrator.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On October 05, 2023 at 12: P.M. Licensing Program Analyst Stephannie Verna arrived at the above facility to complete an unannounced required annual facility inspection. LPA met with, Amanda Lee, Facility Administrator, who assisted LPA with the inspection. LPA Verna completed the Client Records domain on today's date. Upon review of three client files, it was observed that: Two out of three (C2 and C3) medical assessments or LIC 620 forms were not present in the client records. One out of two youth records (C2) had documentation of youth's refusal to attend medical appointments. There have been no other refusals documents since 06/02/2023 to complete the medical assessment/TB test. C3 attended a physical in November 2023, however the document does not include all required information. Two out of three (C2 and C3) medical assessments or LIC 620 forms were not present in the client records and there were no records of required information, TB test results, physical restrictions, determination of child's ambulatory status and prescribed medications. One out of two youth records (C2) had documentation of youth's refusal to attend medical appointments. C3 attended a physical in November 2023, however the document does not include all required information including TB test results, physical restrictions, determination of child's ambulatory status and prescribed medications. continued on 809-c This report (page 1) was amended, signed by and a copy was given to Aubrey Douglas, Facility Manager. One out of three client initial NSP (C1) was not due yet, however was completed, and three out of three initial NSP did not contain required signatures (C1, C2, C3). C2's initial NSP (05/09/2023) was not signed by the client, and C3's initial NSP (11/17/2022) was completed within 30 days, however the NSP in the file was not signed by the client or their authorized representative. It was observed that NSP were not updated every 30 days following the initial date of placement, including for NSPs for C2 and C3. Additionally, some NSP were missing from the youth records for some months the youth was in care (C2 and C3). C2 was missing documented NSP for July-September 2023, and C3 was missing documented NSP for December 2022, February 2023, and May-September 2023. It was observed that three out of three youth had NSPs filed in their client records which were missing signatures, including the client and Authorized Representative signatures. In some cases, there was record/emails of the facility requesting signatures from the Authorized Representatives, but only once attempt was documented in each case. The facility is being issued three citations pertaining to deficiencies to STRTP ILS sections, 87070(c)(1), 87068.2(f), and 87068.3(a); and technical advisories related to Title 22 regulations, sections 80069(a) and 80069(c) LPA Verna completed the required annual inspection on today's date. An exit interview was conducted and a copy of this report, technical deficiencies, and LIC-809D and appeal rights was provided to Amanda Lee, Facility Administrator.

Deficiencies:
87068.3(a): Modifications to The Needs And Services Plan

(a) The needs and services plan specified in Section 87068.2 shall be updated at least every 30 days to determine the following


summary: Facility Evaluation

raw_content:
Narrative:
On November 08, 2023 at 10: AM Licensing Program Analyst (LPA) Stephannie Verna arrived unannounced at the facility for the purpose of a case management inspection. LPA Verna met with Aubrey Douglas, Facility Manager. During the review of an Incident Report received from the facility where a reportable incident occurred on 10/31/2023 and 11/02/2023, and involved FC1 and FC2, a case management visit was warranted to gather further information regarding the incidents. LPA Verna requested and reviewed documentation, including the facility event calendar. LPA discussed the incidents with Aubrey Douglas, Facility Manager and Administrator, Amanda Lee. LPA gathered further information, including information about the youth involved and facility schedule, antecedents and outcomes of the incidents, and safety measures taken or plans created or implemented by the facility staff surrounding the incidents. LPA conducted a health and safety inspection and observed no deficiencies. LPA completed three interviews. The case management was completed on today's date. An exit interview was conducted and provided to Aubrey Douglas, Facility Manager.

met_with: Aubrey Douglas, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On December 28, 2023 at 01: PM Licensing Program Analyst (LPA) Stephannie Verna arrived unannounced at the facility for the purpose of a case management inspection. LPA Verna met with Joanna Barnhill, Assistant Administrator. During the review of an Incident Report completed by a staff of the facility (S1), where a reportable incident occurred on 10/02/2023, and involving FC1 and S2, a case management inspection was warranted to inquire if the incident had been reported to Community Care Licensing (CCL) as required. LPA Verna discussed the incident with Joanna Barnhill, Assistant Administrator, and gathered further information. LPA Verna inquired with Laynee Kuhn, Director, regarding the submission of the incident report, who confirmed the incident was not reported to CCL. The facility was issued a technical advisory regarding CCR Title Regulations, section 80061(b), Reporting Requirements. A signed copy of this LIC-809 report was provided to Joanna Barnhill, Facility Manager, and an exit interview was conducted.

met_with: Joanna Barnhill, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On January 05, 2024 at 1: PM Licensing Program Analyst (LPA) Stephannie Verna arrived unannounced at the facility for the purpose of meeting with Administrator, Amanda Lee. LPA arrived and waited for the Administrator to arrive at the facility. LPA Verna met with Amanda Lee, Administrator, who signed the Civil Penalty Assessment Form (LIC421FC) regarding a visit made to the facility on December 28, 2023. LPA Verna provided a copy of the signed LIC421FC and this report to Amanda Lee, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On March 04, 2024 at 02: PM Licensing Program Analyst (LPA) Stephannie Verna arrived unannounced at the facility for the purpose of a case management inspection. LPA Verna met with Justin Le, Facility Manager. During the review of an Incident Report (IR) received from the facility on 02/21/24, it was reported that on 02/20/2024 a client in care (C1), made an allegation to Law Enforcement of a personal rights violation that had occurred while in care. LPA Verna conducted confidential interviews, discussed the incident and confirmed further information and interventions taken by parties involved, including the facility staff and Law Enforcement. Further information is to be documented in an addendum incident report, and will be submitted by the facility Administrator to the Department regarding the outcomes of the incident. LPA conducted an inspection of the facility, and no deficiencies were observed at the facility during today's case management inspection. No citations are being issued. The case management inspection was completed on today's date. An exit interview was conducted with Justin Le, Facility Manager, and the facility was provided a copy of this report.

met_with: Justin Le, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Missed Medication Inspection was conducted by Licensing Program Analyst (LPA) Kayla Green on 6/26/2024 at 10:05AM. During the inspection, LPA Green met with Joanna Barnhill, Assistant Administrator. During the review of an Incident Report (IR) received from the facility on 06/03/24, it was reported that on 05/31/24 a client in care (C1), the sfaff only initialed and signed for 1 bubble instead of 3-indicating C1 was only given one tablet instead of three as prescribed. LPA reviewed one child's records on site at the facility at 10:15 am. During the review of one child's records, LPA Green didn't notice any missing initials with the medication logs. The Administrator Amanda Lee provided the LPA with document showing the staff who missed giving the full medication to the client got retrained with information on the medication policies. LPA reviewed 2 of staff personnel files on site at the facility at 10:15AM. LPA interviewed 2 staff on site at 11:00AM. No deficiencies being cited at this time. LPA inspected the facility inside and out with Amanda Lee, administrator. The case management inspection was completed on today's date of 6/26/ LPA conducted exit interview with Amanda Lee, Administrator Facility Manger at 11:30AM, and provided the Summary Report.

met_with: Joanna Barnhill Assistant Administrator


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced case management was conducted by Licensing Program Analyst (LPA) Kayla Green on 9/5/2024 at 01: PM. During the inspection, LPA Green met with Naeem Brown, Assistant Administrator. During the review of an Incident Report (IR) received from the facility on 08/13/24, it was reported that on 08/12/24 a client in care (C1), the sfaff did not go with youth to hospital when the youth passed out. LPA interviewed 1 staff on sight at 1:45PM. LPA is requesting for staff schedule for this month, and for the medical report to be sent to email. No deficiencies being cited at this time. LPA inspected the facility inside and out with Naeem Brown, Assistant Administrator. The case management will need to be completed another day.

met_with: Naeem Brown, Assistant Administrator


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced case management was conducted by Licensing Program Analyst (LPA) Kayla Green on 9/5/2024 at 10:05AM. During the inspection, LPA Green met with Naeem Brown, Assistant Administrator. During the review of an Incident Report (IR) received from the facility on 07/26/24, it was reported that on 07/25/24 the staff listened to a phone call a client in care (C1) was having. LPA interviewed 2 staff on site and 1 youth at 1:45PM. No deficiencies being cited at this time. LPA inspected the facility inside and out with Naeem, Brown. LPA is requesting the court order documents be provided by email. The case management inspection is being investigated. LPA conducted exit interview with Naeem Brown Assistant Administrator at 03: PM, and provided the Summary Report.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Jean Stidman and Maie Soliman on 12/10/24 at 10:30am. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs Stidman and Soliman met with Amanda Lee, Administrator, and inspected the facility inside and out. LPA reviewed one child's records and five staff personnel files on site at the facility. LPA reviewed one child's psychotropic medications and medication records. LPA interviewed five staff on site to discuss the facilities policies and procedures of operation. LPA interviewed one child currently prescribed psychotropic medication. LPA provided a copy of this licensing report to Amanda Lee, Administrator. No deficiencies are being cited at this time. LPAs conducted exit interview with Amanda Lee, Administrator

met_with: Amanda Lee Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Avelina Martinez made an unannounced annual inspection on May 07, 2025, at 8: AM. During the inspection LPA met with Amanda Lee Administrator and Joanna Barnhill, (Assistant Administrator) who assisted with the inspection. LPA Martinez conducted a walk-through of the facility inside and out with Amanda Lee on May 07, 2025. Facility staff-client ratio at time of inspection (2 staff- 2 children) Number of staff interviewed Number of clients interviewed LPA observed # 3 bedrooms, # 2 bathrooms LPA Martinez inspected and/or reviewed the following: Physical Plant Posting of license X Personal Rights X Disinfectants/Cleaning solutions inaccessible X Refrigerator Temperature at or below 45 degrees F Yes Freezer Temperature at or below 0 degrees Yes Nonperishable Foods one week and fresh perishable foods two days minimum Yes Menu present and posted Yes Working telephone Yes Carbon monoxide detectors Yes Smoke Detector Yes First Aid Kit fully stocked Yes Common Room available Yes Dining area (enough seating, furniture good condition, not broke or damaged) Yes Continued.. Medication centrally stored, locked/inaccessible Yes Office (locked and privacy) Yes Hot Water between 105-120 degree F (Properly labeled if over 125 degree F 115 degrees Fire Extinguisher (note inspection date) July Toilets wash basin, bath and shower fixtures in good repair/no leaks/hot water temperature Yes Soap and Paper towels Yes Laundry Facilities(available, work assign dates) Yes Bedrooms-required linen and furnishings Yes Motor Vehicle properly maintained , lights, tires, registration/insurance and working seat belts vehicle 1 is in good repair/Vehicle 2's back light is not in good repair Facility free of vermin Yes Locked Facilities (open locked storage area/building/sheds) Yes Bedroom (required bedding/furniture, furniture in good repair) Yes Operations Complaint Procedures For Youth Reviewed Yes Disaster Preparedness Disaster and mass casualty plan updated and available Yes Quarterly Drills conducted and documented Yes, Last fire drill 03/19/ Disaster preparedness supplies verified Yes Review of manual restraint log: Yes Staff training: Last training 03/19/25. Staffing Number of Staff files 6 reviewed Criminal record clearances verified Yes First Aid Certificate Yes Certified Administrators certificate valid and current Yes Job title/qualification verified Yes Hours required training verified Yes Hours required annual training verified Yes Client Records Number of Clients files reviewed Needs and Services Plan Centrally Stored Medication and log reviewed JV Reviewed psychotropic Medication and log reviewed Cash Resources (2) both maintained Compatible Assessment Yes Core/Therapeutic Services Trauma Informed Practices are implemented as needed (including specialty mental health services and extracurricular activities and social supports) Yes. As a result of this year's annual inspection, there were no deficiencies cited, and one technical violation was given. An exit interview was conducted, and copy of this report was provided to Amanda Lee.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Suzanne Martinez and Licensing Program Manager Stephen Kim conducted a case management inspection on July 22, 2025, at 12: PM based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 5 out of Direct Care Staff and 2 out of 2 youth files were reviewed. 2 out of Direct Care Staff and 0 out of 2 youths were interviewed. (See the Confidential Names List, LIC 811 (July 22, 2025). The Plan of Operation including policies and procedures were reviewed. Minutes from the Board of Directors' meetings related to the facility's incidents involving contact with law enforcement were emailed and reviewed. Based on the analysis of the confidential interviews and youth files review including the Needs and Service Assessments, Safety Plan, Risk Assessment and Treatment Plan, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Martinez observed documentation of completed training and policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Administrator, Carla Izzarelli.


summary: Facility Evaluation

raw_content:
Narrative:
On 11/21/2025 at 3:40 pm Licensing Program Analyst (LPA) Maie Soliman arrived unannounced at the facility above for the purpose of initiating a complaint investigation. LPA met with Naeem Brown, Administrator. While LPA was reviewing paperwork. LPA observed that one of the six staff members is not associated with the facility in Guardian and appears to be separated. LPA spoke to HR Director who stated the staff member was rehired two years ago and is cleared but maybe they have not re associate the staff member to the facility. LPA is issuing one Technical Violation for ILS 80019(e)(2). An exit interview was conducted and a copy of this report was left with Naeem Brown, Administrator.

met_with: Naeem Brown, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 12/30/2025 at 11:30 am Licensing Program Analyst (LPA) Maie Soliman conducted an unannounced visit to the above facility. The reason for the visit is to discuss Incident Report (IR Follow Up - 2526-FN) and CCIB Referral #0802-8199-1052-5035294. LPA met with Naeem Brown, Administrator who helped with the inspection. LPA interviewed three staff and one youth. LPA obtained a copy of the following to review: • Two Safety Plans for C1 • Youth Daily Responsibility Log from 12/14/2025-12/27/2025 • CFT notes dated 12/16/ No further follow up is needed regarding the IR and CCIB referral. C1 used the word "blackmail" in the wrong context. C1 is receiving appropriate services. An exit interview was conducted and a copy of this report was left with Naeem Brown, Administrator.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
Licensing Program Analyst (LPA) Avelina Martinez arrived at this facility unannounced on June 16, 2025 at 9: AM to conduct a case management visit. LPA Martinez met with Naeem Brown (Assistant Administrator) and explained the purpose of the visit. The purpose of the visit today is to discuss the following deficiency: reporting requirements. During record reviews, it was learned that the facility has not reported incidents to the Department as required. The unreported incidents that occurred directly threatened the physical, emotional health, and safety of the clients in care. Documentation shows child 1 (C1) had seven incidents pertaining to aggression towards staff and youth. There were two incidents of verbal aggression towards staff and youth. Three inappropriate sexual behavior incidents towards staff. On February 07, 2025, an event occurred that was not reported to the Department. Staff 1 (S1) and child 1 (C1) were in a physical altercation. Upon the occurrence, the facility staff did not implement a safety plan that would entail de-escalation of physical aggression and the separation of S1 and C1. A February 07, 2025, facility notes, indicated this incident would not be addressed until February 13, 2025, CFT meeting. The lack of addressing the February 07, 2025, altercation in a timely manner resulted in a second physical altercation between S1 and C1 on February 09, 2025. Continued... Based on records review there were physical aggression commonalities between the unreported incidents and the physical altercations on February 07, 2025. However, the identified behavioral patterns were not addressed after the February 07, 2025, altercation. As a result, the Agency will be cited, and the 80061(b) reporting requirement deficiency can be found on the 809-D page. LPA Martinez will also return at a later date and time to follow up on the following: Open bedroom door policy, bedtime hours, and access to bedrooms. An exit interview was conducted with Naeem Brown (Assistant Administrator). A copy of this 809 report, 809D page, and appeals rights were given to the facility at the end of this visit.

Deficiencies:
80061(b): Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours...  1
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7Facility staff agrees to conduct an in-service training on reporting requirements by POC date: June 27, 2025. Facility staff agrees to email LPA Martinez training documents by June 30, 2025-5:00 PM.
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title:
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780061(b) Reporting Requirements


summary: Facility Evaluation

raw_content:
Narrative:
On 1/9/2025 at 2:00 pm, Licensing Program Analyst (LPA) Maie Soliman made an unannounced visit for the purpose of initiating a Case Management inspection. LPA met Joanna Burnhill Assistant Administrator who assisted LPA with the inspection. LPA conducted a walk through of the interior and exterior of the facility. On 12/30/2025, during an interview with C1, it was reported that C1 owned a personal e-bike prior to moving to the facility and that the e-bike was confiscated on or around the end of October 2025. Based on LPA interviews and record reviews, C1's e-bike has remained confiscated since that time. During the CFT meeting held on 12/16/2025, C1 expressed a desire to have the e-bike returned and agreed to comply with safety rules. CFT Records reviewed indicate that it was determined a safety contract would be developed and the e-bike would be returned. As of today's date, the e-bike has not been returned. A citation is being issued for violation of Interim Licensing Standard Article Continuing Requirement 87072 (c)(8)(C) Personal Rights: To be provided with and allowed to possess and use adequate personal items, consistent with Welfare & Institutions Code section 16001.9(a)(3), which includes their own: Personal belongings, including items that were a gift to the child unless prohibited by a discipline program. LPA conducted an exit interview with Joanna Burnhill and gave her a copy of that report and appeal rights.

met_with: Joanna Burnhill, Assistant Administrator


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Misty Valencia and Tina Thorn on 08/25/2023 at 08:45AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Valencia and Thorn met with Amanda Lee, Administrator and inspected the facility inside and out. LPA reviewed two of two (2 of 2) child's records and 2 of 2 staff personnel files on site at the facility. LPA reviewed two of two (2 of 2) child's psychotropic medications and medication records. LPA interviewed two of two (2 of 2) staff on site to discuss the facilities policies and procedures of operation. LPA interviewed two of two (2 of 2) of children currently prescribed psychotropic medication. During the inspection the LPAs observed four (4) deficiencies (see attached 809Ds), plan of corrections were discussed and appeal rights were provided. LPA provided a copy of this licensing report to Amanda Lee, Administrator.


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
During the course of the investigation, the following documents were gathered and reviewed: Client Roster, Staff Roster and Schedule, Needs and Services Plans, CFTS notes, Safety Plans, house meeting notes, training logs, Placement agreements and agency signed policies and procedures. Confidential interviews were conducted with nine individuals (C1, C3, S1, S2, S3, S4, S5, AD, RP) and attempted with two individuals (C2, C4) during the period of 11/20/2026 to 1/5/2026. Four out of four statements given during interviews were consistent that staff did not prevent minor on minor assault. Moreover, youths reported missing personal items for over two weeks and repeatedly requested a room search; these requests were denied, and no room search was conducted. The facility failed to develop or implement any plan to address the youths' ongoing reports of missing items. Records reviewed indicated C2's CFT notes dated 10/20/2025 document a history of violent behavior, including prior incidents in which C2 inflicted injuries on peers. Additionally, C2's safety plan dated 8/20/2025 identifies known triggers, including loud noises and being yelled at. Despite this documented history and identified triggers, facility staff failed to intervene or address concerns raised by C1 and C3 regarding missing personal items. As a result, the youth confronted C2 directly, and the situation escalated in the presence of known triggers that staff were required to be aware of and manage. The facility's failure to implement preventive measures, and follow the youth's safety plan resulted in an immediate risk to the health and safety of youths in care. The facility is being cited Type A citation for ILS Personal Rights 87072(c)(1). For details see attached D-Page Based on LPA documentation reviewed, and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. An exit interview was conducted with and a copy of this report and appeal rights were provided to Naeem Brown, Administrator.

Investigation Findings:
13Licensing Program Analyst (LPA) Maie Soliman conducted an unannounced complaint inspection with the above facility on 2/24/2026 at 10:00 am and met with Naeem Brown, Adminstrator. The purpose of the inspection was to deliver complaint findings for the above allegations. On 11/21/2025 at 1:45 pm Licensing Program Analyst (LPA) Maie Soliman, arrived unannounced at the facility for the purpose of initiating a complaint investigation related to the above allegation. LPA met with Naeem Brown, Administrator. LPA requested the following documents for review: Client Roster, Staff Roster and Schedule, Harm Reduction Plans, Needs and Services Plans, CFTS notes, Safety Plans, house meeting notes, training logs, Placement agreements and agency signed policies and procedures. LPA conducted an inspection of the facility. No citations were issued related to the complaint investigation. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Maie Soliman 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: PARADISE OAKS - OLIVINEFACILITY NUMBER: VISIT DATE: 02/24/2026

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

complaint_status: SUBSTANTIATED


facility_name: PARADISE OAKS - ROSA VISTA

raw_content:
Narrative:
Based on the interviews conducted and the documents reviewed the allegation that staff had a hit and run accident while transporting a foster child is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and a copy of this report, appeal rights and the LIC811 were discussed and emailed to Breana Gatson.

Investigation Findings:
13On 11/10/2021 at 11: AM, Licensing Program Analyst (LPA) Robin Sullivan went, unannounced, to the facility for the purpose of delivering findings on the allegation that staff had a hit and run accident while transporting a foster child. LPA met with Breana Gatson, Assistant Administrator. During the investigation LPA interviewed one staff (S4) on 7/26/21, three clients (C1-C3) and one staff (S3) on 10/21/21, two staff (S1, S2) on 10/25/21 and one client (C3) on 11/2/21. The following documents were obtained and reviewed: facility vehicle maintenance log, client rosters, and staff schedules and contact information. The investigation revealed that two of three clients have no memory of being in a facility vehicle that may have backed into a parked car or hit an object. Four staff have no knowledge of either facility van being involved in an accident. LPA observed two facility vehicles to have dents, dings, and scratches on the rear bumper. The facility vehicle maintenance log has no record of vehicle body repair between 10/03/2020 - 08/03/2021. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Robin Sullivan 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: PARADISE OAKS - ROSA VISTAFACILITY NUMBER: VISIT DATE: 11/10/2021

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

met_with: Breana Gatson, Assistant Administrator


summary: Complaint Investigation - Substantiated - 1 deficiency - 1 allegation

raw_content:
Narrative:
with staff and clients state the staff plan meals, grocery shop and prepare food and the clients only participation is when staff ask if the client wants something special on the grocery order. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. The facility is cited on the attached LIC 9099D under the California Code of Regulations, Interim Licensing Standards, Regulation Food Service for failing to have menus written at least one week in advance of the menus as served shall be dated and kept on file for at least 30 days and ... a child shall have the opportunity to plan meals, grocery shop, and store and prepare food. Exit interview conducted and a copy of this report and a copy of the appeal rights were left at the facility with Amanda Lee Administrator

Investigation Findings:
13Licensing Program Analysts (LPAs) Jean Stidman and Jessica Caplinger conducted an unannounced inspection to the facility on 4/29/22 at 10:45am to deliver complaint allegation findings. LPA met with Amanda Lee Admiistrator and discussed the above allegations. During the investigation of facility has expired food/fruits are old, LPA toured the facility with Amanda Lee, Administrator on 1/19/22. On this inspection, LPA inspected the physical plant and observed the facility has one refrigerator in the home as well as one refrigerator and one freezer in the garage. The garage also has two storage shelves full of non-perishable food in the garage. The kitchen refrigerator had a bowl of six watermelon slices dated 1/14/22 that were moldy and faded in color. LPA observed there was no fresh fruit available. On 1/19/ LPA obtained documentation for the complaint investigation of weekly grocery receipts for 12/1/21-1/20/22, and LPA conducted interviews with S2, S3, S AD, 1, C2, C3, C4 and C5 and observed the menu posted was dated July 2021. LPA reviewed the facility's program statement (PS) section 21 which states menus run on a four-week cycle and that all youth have the opportunity to plan meals, grocery shop and prepare food. However, based on interviews SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jean Stidman 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: PARADISE OAKS - ROSA VISTAFACILITY NUMBER: VISIT DATE: 04/29/2022

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

Deficiencies:
87076(a): (80076(A)(5) states Menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days. Menus shall be made available for review by the clients or their authorized representatives and the licensing agency upon request.

met_with: Amanda Lee Admiistrator

title: Food Service the following shall apply


raw_content:
Narrative:
the alleged violations did or did not occur. No title 22 regulations were cited. Exit interview conducted and a copy of this report was left with Amanda Lee Administrator.

Investigation Findings:
13Licensing Program Analysts (LPAs) Jean Stidman and Jessica Caplinger conducted an unannounced inspection to the facility on 4/29/22 at 10:45am to deliver complaint allegation findings. LPA met with Amanda Lee Administrator and discussed the above allegations. During the investigation of staff speak inappropriately to youth in care and the facility doesn't have enough food, LPA toured the facility with Amanda Lee, Administrator on 1/19/22. On this inspection, LPA inspected the physical plant and observed the facility has one refrigerator in the home as well as one refrigerator and one freezer in the garage. The garage also has two storage shelves full of non-perishable food in the garage. On 1/19/ LPA obtained documentation for the complaint investigation of weekly grocery receipts for 12/1/21-1/20/22, and LPA conducted interviews with S2, S3, S AD, 1, C2, C3, C4 and C5. Based upon interviews which were conducted, and records reviewed, LPA observed the facility has enough food and there was no evidence of staff speaking inappropriately to youth, therefore the preponderance of evidence standard has not been met, therefore the above allegations are found to be unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jean Stidman 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: PARADISE OAKS - ROSA VISTAFACILITY NUMBER: VISIT DATE: 04/29/2022

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


summary: Complaint Investigation - Substantiated - 1 deficiency

raw_content:
Narrative:
Based on LPAs observations and confidential interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Interim Licensing Standards v4, Regulation 87076(6) is being cited on the attached LIC 9099D. Exit interview was conducted and a copy of this report and a copy of the appeal rights were left at the facility with Amanda Lee, Administrator.

Investigation Findings:
13On 7/27/22, Licensing Program Analyst (LPA) Jessica Caplinger, conducted an unannounced inspection to deliver findings for a complaint with allegations of "Facility does not provide adequate food to clients." LPA met with Amanda Lee, Administrator, and discussed the above allegation. During the investigation, LPA Caplinger conducted unannounced inspections on 5/18/22, 6/10/22 and 6/15/22. LPA Caplinger obtained documentation for the complaint investigation of staff communication logs, team meeting notes, house meeting notes, and activity plans as well as reviewed three client files during inspection. LPA conducted ten confidential interviews regarding the complaint. Confidential interviews and record review revealed the facility was out of compliance with providing adequate food to clients. Based on five confidential interviews and record review, it was determined that clients are not given the opportunity to grocery shop for items. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jessica Caplinger 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: PARADISE OAKS - ROSA VISTAFACILITY NUMBER: VISIT DATE: 07/27/2022

Deficiencies:
87076: Based on confidential interviews and record review, five interviews revealed that clients1
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5
6
7Facility will ensure all youth have the opportunity to plan meals, grocery shop, and store and prepare food by discussing this during the weekly house meeting.

met_with: Amanda Lee; Administrator

title: (c) (6) As agreed upon with a licensee, a child shall have the opportunity to plan meals, grocery shop, and store and prepare food. This was not met as evidenced by


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
Based on LPAs observations and confidential interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Interim Licensing Standards v4, Regulation 87079(e) is being cited on the attached LIC 9099D. Exit interview was conducted and a copy of this report and a copy of the appeal rights were left at the facility with Amanda Lee, Administrator.

Investigation Findings:
13On 7/27/22, Licensing Program Analyst (LPA) Jessica Caplinger, conducted an unannounced inspection to deliver findings for a complaint with allegations of "Facility does not provide activities for clients." LPA met with Amanda Lee, Administrator, and discussed the above allegation. During the investigation, LPA Caplinger conducted unannounced inspections on 5/18/22, 6/10/22 and 6/15/22. LPA Caplinger obtained documentation for the complaint investigation of staff communication logs, team meeting notes, house meeting notes, and activity plans as well as reviewed three client files during inspection. LPA conducted ten confidential interviews regarding the complaint. Confidential interviews and record review revealed the facility was out of compliance with providing activities for clients. On 6/15/22, the facility did not have a weekly schedule of activities posted and copies of the weekly schedules were not available for review. Based on five confidential interviews and record review, it was also determined that clients are not given the opportunity to plan activities. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jessica Caplinger 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: PARADISE OAKS - ROSA VISTAFACILITY NUMBER: VISIT DATE: 07/27/2022


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Based on LPAs observations and interviews which were conducted and record review, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No title 22 regulations were cited during today's inspection. Exit interview was conducted and a copy of this report was left with Amanda Lee, Administrator.

Investigation Findings:
13On 7/27/22, Licensing Program Analyst (LPA) Jessica Caplinger, conducted an unannounced inspection to deliver findings for a complaint with allegations of "Facility gave a 14-day notice on client without sufficient reason." LPA met with Amanda Lee, Administrator, and discussed the above allegation. During the investigation, LPA Caplinger conducted unannounced inspections on 5/18/22, 6/10/22 and 6/15/22. LPA Caplinger obtained documentation for the complaint investigation of needs and service plan for client, team meeting notes, and correspondence regarding client as well as reviewed three client files during inspection. LPA conducted ten confidential interviews regarding the complaint. Confidential interviews and record review revealed the facility has a plan in place for removal and/or transfer of a client, but it is unclear if those procedures were being followed. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jessica Caplinger 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: PARADISE OAKS - ROSA VISTAFACILITY NUMBER: VISIT DATE: 07/27/2022


raw_content:
Narrative:
Investigator Borton conducted six confidential interviews and reviewed documentation of Citrus Heights Police Department (CHPD) report #CH22-04307, staff schedule, two client records, one employee record, incident reports and employee contact list. Three of the interviews validated the allegations of staff calling youth inappropriate names and threatening the youth with a weapon. Documentation was reviewed to include a video of the incident that validated the allegations. Based on Investigators observations, confidential interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Interim Licensing Standards v4, Regulation 87072(c)(11) is being cited on the attached LIC 9099D. Exit interview was conducted and a copy of this report and a copy of the appeal rights were reviewed and left at the facility with Carla Izzarelli, Administrator.

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

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

met_with: Carla Izzarelli; Administrator


raw_content:
Narrative:
Investigator Borton conducted six confidential interviews and reviewed documentation of Citrus Heights Police Department (CHPD) report #CH22-04307, staff schedule, two client records, one employee record, incident reports and employee contact list. One of six interviews recalled hearing a discussion of photographs being requested but did not have any additional details. Five of six interviews believed the allegations to be false including the youth that the allegations were regarding. Interviews conducted were not consistent regarding allegations of requesting inappropriate pictures or propositioning minor for sex acts. Based on LPA observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No title 22 regulations were cited during today's inspection. Exit interview was conducted and a copy of this report and a copy of the appeal rights were reviewed and left at the facility with Carla Izzarelli, Administrator.

Investigation Findings:
UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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


raw_content:
Narrative:
Based on LPAs observations and interviews which were conducted and record review, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview was conducted and a copy of this report and a copy of the appeal rights were reviewed and left at the facility with Stephanie Piring, Administrator.

Investigation Findings:
13On 10/4/2022, Licensing Program Analyst (LPA) Jessica Caplinger, conducted an unannounced inspection to deliver findings for a complaint with allegation of "Staff are making inappropriate comments to clients." LPA met with Stephanie Piring, Administrator, and discussed the above allegation. During the investigation of this allegation, LPA toured the facility with Administrator, Amanda Lee on 6/15/22 and 8/11/22. During these inspections, LPA inspected the physical plant inside and out, reviewed two client files, and obtained documentation for the complaint investigation including incident reports, client inventories, training, and meeting agenda. LPA conducted eleven confidential interviews during investigation. Five of the eleven interviews reported that staff comments are not trauma informed and have been interpreted to be rude or inappropriate. There is no documentation of comments being reported to staff or discussed during therapy. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jessica Caplinger 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: PARADISE OAKS - ROSA VISTAFACILITY NUMBER: VISIT DATE: 10/04/2022

met_with: Stephanie Piring, Administrator


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
Eight of the eleven interviews reported that this policy was not being followed due to clients not being informed of the search, not being present during the search, and not being informed of items removed during the search. Documentation observed stated that clients have the right to be present for the room search and that staff are to request approval from the social worker and document this request and the outcome of the search on the incident report. Incident reports reviewed for room searches for May and June 2022 documented that clients were not present for the room searches and do not indicate if approval was requested from the social worker before the search was conducted. Based on LPAs observations, confidential interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Interim Licensing Standards v4, Regulation 87072(c)(11) is being cited on the attached LIC 9099D. Exit interview was conducted and a copy of this report and a copy of the appeal rights were reviewed and left at the facility with Stephanie Piring, Administrator.

Investigation Findings:
13On 10/4/2022, Licensing Program Analyst (LPA) Jessica Caplinger, conducted an unannounced inspection to deliver findings for a complaint with allegation of "Facility is not following policy and procedures regarding room searches." LPA met with Stephanie Piring, Administrator, and discussed the above allegation. During the investigation of this allegation, LPA toured the facility with Administrator, Amanda Lee on 6/15/22 and 8/11/22. During these inspections, LPA inspected the physical plant inside and out, reviewed two client files, and obtained documentation for the complaint investigation including incident reports, client inventories, training, and meeting agenda. LPA conducted eleven confidential interviews during investigation. Eleven of the confidential interviews reported that it is the facility's policy to inform the clients of room searches, provide clients the opportunity to be present for the search, and to inform them when items are confiscated. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jessica Caplinger 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: PARADISE OAKS - ROSA VISTAFACILITY NUMBER: VISIT DATE: 10/04/2022


raw_content:
Narrative:
Two of the nine interviews reported that staff comments have been interpreted to be rude or inappropriate. There is no documentation of comments being reported to staff or discussed during therapy. Based on LPAs observations and interviews which were conducted and record review, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No title 22 regulations were cited during today's inspection. Exit interview was conducted and a copy of this report was left with Amanda Lee, Administrator.

Investigation Findings:
13On 10/28/22, Licensing Program Analyst (LPAs) Jessica Caplinger and Stephanie Lor, conducted an announced inspection to deliver findings for a complaint with allegations of "Facility staff are treating clients in a rude, hostile, and disrespectful manner." LPAs met with Laynee Kuhn, Executive Director, at the agency regional office and discussed the above allegation. The initial 10-day complaint investigation inspection was conducted at the facility on 07/19/2022 by LPA Burgess. A walk through of the facility was conducted and copies of agency documentation obtained include current client roster, needs and services plans, staff schedules, on call tracker, staff timecards, communication notes and daily logs for time period April - June 2022. Nine confidential interviews were conducted during the investigation. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jessica Caplinger 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: PARADISE OAKS - ROSA VISTAFACILITY NUMBER: VISIT DATE: 10/28/2022

met_with: Laynee Kuhn; Executive Director


raw_content:
Narrative:
Based on interviews and documentation observed, self-harming is occurring in the facility. However, there is no evidence that the staff were aware of the self-harming as it happened to prevent it. The facility provided documentation of resources provided to the youth regarding self-harming and discusses this with the youth during therapy. Self-harming is addressed in the youth's Needs and Services plan. Confidential interviews corroborated that staff supervise the youth and maintain a safe facility free of sharp objects to prevent self-harm. Based on LPAs observations and interviews which were conducted and record review, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No title 22 regulations were cited during today's inspection. Exit interview was conducted and a copy of this report was left with Laynee Kuhn, Executive Director.

Investigation Findings:
13On 10/28/22, Licensing Program Analyst (LPA) Jessica Caplinger, conducted an announced inspection to deliver findings for a complaint with allegations of "Staff did not prevent minor from self-harming." LPA met with Laynee Kuhn, Executive Director, and discussed the above allegation. The initial 10-day complaint investigation inspection was conducted at the facility on 08/11/2022 by LPA Caplinger. A walk through of the facility was conducted and LPA obtained copies of incident reports for one youth, case notes for two youth, needs and services for one youth and CFT meeting notes for one youth. Seven confidential interviews were conducted during the investigation. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jessica Caplinger 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: PARADISE OAKS - ROSA VISTAFACILITY NUMBER: VISIT DATE: 10/28/2022


raw_content:
Narrative:
Page 2. The records of 4/10/23 stated that FC1 refused this appointment and stated they want a new dentist. On the issue of court appointments, S2 stated that the facility has an agreement with the county that the county will pick FC1 up for court days as the facility does not participate in scheduling the hearings and are not made aware when those appointments are scheduled. Based on LPAs observations and interviews which were conducted and record reviews, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation #3. Staff are not picking up minor in a timely manner. During the interview, FC1 stated that staff does not pick them from school in a timely manner. FC1 stated they have had to wait more than 2 hours before being picked up on one occasion and 30 minutes or so on some other occasions. When staff was interviewed, S1 stated that staff was late to pick FC1 up one time that she remembers, and this incident was addressed in another complaint. When FC3 was interviewed at school, FC3 stated that they have not experienced staff picking them up late from school. When S6 was interviewed on 7/20/23, S6 stated that he picks up the child that gets off from school by 2:45 pm and that the staff that resumes work at 2:00 pm picks up the youth that gets out of school by 2:50 pm. S6 stated that there was never a conflict in picking up the kids that he remembers because FC1 rarely goes to school and when FC1 attends school, FC1 calls the facility randomly and other times in the morning hours to pick FC1 from school. S6 said when this happens, he is the one that picks FC1 up from school. During the second interview of FC1 on 5/25/23, FC1 stated that staff does not pick them up on time and because of this reason they do not attend school regularly. Based on LPAs observations and interviews which were conducted and record reviews, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Cont. 3. Page 3. Allegation # 4. Staff are making inappropriate comments towards minors. On 4/28/23, FC1 stated that there was an incident on 4/20/23 where S5 was inciting FC2. FC2 corroborated this this and stated that on 4/20/23, S5 was inciting them to become violent by telling FC2 to "run up or shut up." When S5 was interviewed on 5/10/23, S5 denied making the comment and stated that FC2 had shown her a tattoo gang carving on FC2's skin. S5 expressed the belief that FC2 was trying to intimidate her by the tattoo. S5 stated that during that incident, FC2 called their grandmother to report S5 and Staff could hear the grandmother uphold FC2's action. S5 stated she could hear grandma of FC2 telling FC2 to "show the Sacramento bitch what the 209 is all about." Facility Manager submitted an incident report to LPA about this incident. The report revealed the youths were aggressive towards staff without provocation. Based on LPAs observations and interviews which were conducted and record reviews, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation #7. Staff don't provide minors with privacy. When staff was interviewed regarding this allegation on 4/26/23 and 5/11/23, all staff stated that they provide the minors with adequate privacy, however whenever two minors that are not located together in the same room are seen together, the facility policy provides that staff should be close by to monitor and prevent them from fighting which happens very often when the clients stay close to each other. When FC2 was interviewed on 4/26/23, the youth stated that they, referring to the youths, are aware that when two youths who are not placed together in one room come together, a staff is required to be close by and this is because they fight when they come together, and staff is trying to prevent them from fighting. FC1 also stated they understand they could have gone outside to make the call, but they did not wish to take the call outside. Cont on 4. Page 4. Based on LPAs observations and interviews which were conducted and record reviews, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation #10. Facility is dirty. During the youths' interviews on 4/26/23 both FC1 and FC2 stated that the facility was left dirty for about 2 days. During the interview of the facility manager, S1 on 4/26/23, S1 stated that the youths fought in the living room and spilled ketchup all over the floor. LPA observed the carpet has been cleaned but there was still stain on the carpet from that incident. A picture of the evidence was obtained. S1 stated that due to the amount of spill, a work order was placed for the carpet to be deep cleaned. On 4/28/23 the carpet cleaned company cleaned the carpet, but the stain could not be completely removed. On 7/13/23, LPA visited the facility, and the Facility Manager informed the LPA that a work order has been issued to change the carpet and the company had come out to take measurements. LPA observed the stain on the carpet floor, and litters all over the office floor. Based on LPAs observations and interviews which were conducted and record reviews, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview was conducted and a copy of this report and appeals right was left at the facility.

Investigation Findings:
13Allegation #2. Staff are not ensuring minors are taken to appointments. During the interview of FC1 on 4/26, FC1 stated that staff does not regularly provide transportation to their dental and court appointments and that staff does not inform them in a timely manner about their appointments. FC1 said because they do not get this information on time, they are not able to prepare for their appointments. When FC2 was interviewed, FC2 stated that they have not been declined transportation to their appointments, but that staff has failed to take FC1 to some of their court appointments. When FC3 was interviewed on 5/9/23, FC3 stated they have not experienced staff not taking FC3 to their appointments. During the interview with FC1's case manager, the Case Manager stated that FC1 is the one refusing to attend their dental appointments. S2 provided CFT notes to corroborate this statement. The note showed that FC1 attended the checkup scheduled on 3/20/23 where the doctor referred them for orthodontist and fillings visit. The notes on 4/3/23 stated that FC1 refused to come out of their room or attend this appointment and it was rescheduled on 4/10/23. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Uchenna Ajaero 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: PARADISE OAKS - ROSA VISTAFACILITY NUMBER: VISIT DATE: 08/03/2023

met_with: Joanna Barnhill, Assistant Administrator