summary: Complaint Investigation - Unsubstantiated - 1 deficiency

raw_content:
Narrative:
During another incident, one resident was downstairs in the front living room on a phone call monitored by the staff on duty. Another resident was upstairs, unsupervised. The front living room is visible from the upstairs landing and hallway, but the main kitchen/dining/family room area is not visible from the front living room. The resident upstairs came downstairs, entered the main kitchen/dining/family room, and exited the facility through the back sliding door. This resident then returned about 5 minutes later with contraband not visible to staff, and returned upstairs. The investigation found that the call the resident was on was not a required supervised call but that staff observe the resident on the phone to ensure the resident does not make unapproved calls afterward, as the resident does have a list of calls that need to be approved and/or supervised. Later, both residents were in one of their bedrooms and shared the contraband, which was learned to be a can of alcohol and a nicotine vaporizer pen obtained by the resident who exited the facility from an adult not affiliated with the facility. Additionally, multiple reports obtained described supervision at the facility as relaxed or that staff are disengaged or distracted on their phones. The incident report submitted for this incident also did not reflect that engagement or redirection was done. Lastly, the staff could have been stationed upstairs and had sight of the resident on the phone or could have engaged with the resident who exited the facility and continued listening for a break in the phone discussion or for redialing, or the facility could have increased staffing to meet the extra supervision needs of the resident with required monitored phone use. Regarding the third allegation above, the reports obtained indicate that due to a lack of supervision allowing residents to enter other residents' rooms, multiple residents have had their personal belongings stolen by other residents, and sometimes those items have been destroyed, including clothing, a journal, and a family photo. The preponderance of evidence standard has been met, and therefore the above allegations are found to be substantiated. LPA is issuing citations of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS), section Plan of Operation and 87065. Personnel Duties. See attached LIC 9099-D. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Tracy McWoodson, whose signature on this form confirms receipt.

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

Deficiencies:
87065.2: (1) Supervision, protection, and care of children at all times, individually and in groups.

title:
Personnel Duties
(b)(1) Direct care staff shall perform the following duties


state: CA

facility_name: LIGHTHOUSE MENTORING CENTER 4

raw_content:
Narrative:
Additionally, reports obtained indicate that supervision procedures are not being followed consistently, with some reporting that staff check on residents every 30 minutes, every hour, or less often. This does not align with the supervision model outlined in the POO. The preponderance of evidence standard has been met, and therefore the above allegations are found to be substantiated. LPA is issuing citations of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) sections Plan of Operation and 87065. Personnel Duties. See attached LIC 9099-D. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Tracy McWoodson, whose signature on this form confirms receipt. Personal inventory records reflect that the resident in question had a collection of clothes, and interviews with individuals who observed the resident did not support that the youth did not have enough clothes. Some reports obtained indicated that residents exchanged clothes and that this practice has continuously been discouraged by facility staff. Similarly, some reports obtained indicated that residents shared electronic devices, but that, since not all residents are permitted by their authorized representative to have certain devices, such as a cell phone or other other electronic communication device, that this practice is also discouraged by facility staff. Additionally, it was reported that the resident in question had their electronic device taken away by the facility. However, interview with the authorized representative and staff indicated that the resident did not have an electronic device while in the program, so no device could have been taken away. Lastly, the allowance records reflected regular allowance dispersal, and residents interviewed support that allowance procedures are followed. Although the allegations may have happened or are valid, based on LPA's observations and interviews, there is not a preponderance of the evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated. An exit interview was conducted, appeal rights discussed, and a copy of this report was left with Administrator Tracy McWoodson, whose signature on this form confirms receipt.

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

Deficiencies:
87065.2: (1) Supervision, protection, and care of children at all times, individually and in groups.

report_type: Complaint Investigation

met_with: Administrator Tracy McWoodson

complaint_status: unsubstantiated


raw_content:
Narrative:
The email chain does not reflect clear communication in responding to the request to confirm the correct details, but staff picking up the resident on Monday indicates agreement with the plan. There was mention that the resident was not picked up on Tuesday due to the facility not having enough gas in the van, which was not supported by all involved staff member(s) but which was supported by the email chain correspondence. The correspondence indicated that there was no issue with gas because the facility had only intended to pick up the resident from school on Monday and from the local BART station on Tuesday. Additionally, during that week, the care team noted that the resident had a wrapped ankle and had expressed that it had been hurting for a while. The care team asked the facility management about this, and management staff stated that there was no communication to staff about an ankle injury. However, review of the facility shift notes reveal that there was an entry on January 21, 2023 about the resident having leg pain, and the staff member requested that the facility schedule an appointment for the resident to make sure the resident did not sustain a sprain. However, the resident was not taken to see a physician, and the facility could not supply evidence of a medical visit for the resident regarding the matter. The preponderance of evidence standard has been met, and therefore the above allegations are found to be substantiated. LPA is issuing citations of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87074 and Section 87072 and California Code of Regulations, Title 22, Section 80075. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Tracy McWoodson, whose signature on this form confirms receipt.

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

Deficiencies:
87074: (3) Extracurricular, personal enrichment, cultural, racial, ethnic, and social activities...

title:
Transportation
(c) ...a licensee shall ensure transportation is provided to the following


summary: Complaint Investigation - Unsubstantiated

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


investigation_findings: UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:


met_with: Tracy Mcwoodson


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
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:


allegations: UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:


met_with: Administrator, Tracy McWoodson


raw_content:
Narrative:
Although the allegation may have happened or is valid, based on LPA's observations, interviews, and record review, there is not a preponderance of the evidence to prove the alleged violation did or did not occur. Therefore, the allegation is found to be unsubstantiated. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to the facility.

Investigation Findings:
13On September 26, 2025, at 10:10am, Licensing Program Analyst (LPA) Celeste Aparicio conducted an unannounced complaint inspection and met with Administrator, Tracy McWoodson. LPA disclosed the purpose of the inspection and was granted entry to the facility by the Administrator. The purpose of the visit is to deliver findings for the investigation on the allegation above. On the allegation mentioned above, LPA Aparicio conducted confidential interviews and reviewed documentation. Based on confidential observations and interviews, it was found that on August 22, 2025 there was a confrontation in the facility between a staff and child in care. After the review of documentation and interviews with relevant parties, LPA could not determine if staff handled minor in a physically inappropriate manner, due to inconsistent interviews and based on lack of documentation obtained. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Celeste Aparicio LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., SUITE FACILITY NAME: LIGHTHOUSE MENTORING CENTER 4FACILITY NUMBER: VISIT DATE: 09/26/2025

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


raw_content:
Investigation Findings:
13On 07/09/ Licensing Program Analysts (LPAs), Celeste Aparicio and Kristin Pierotti made an unannounced inspection to the facility for the purpose of delivering findings from a complaint investigation. LPAs met with Facility Manager, to informed on the purpose of this visit. The Department received a complaint alleging that facility is not following planned activities and staff have slept while on duty. LPA reviewed documentation and conducted confidential interviews. After the review of documentation and interviews with relevant parties, it was found that the allegations could not be corroborated due to inconsistent statements obtained. Although the allegation may have happened or is valid, based on LPA's observations and interviews, there is not a preponderance of the 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 was provided to facility, whose signature on this form confirms receipt UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Celeste Aparicio 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: 2 of 2

met_with: Sadrina Sims


summary: Facility Evaluation

raw_content:
Narrative:
On Friday 10/1/21 at 10:22AM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the Short-Term Residential Therapeutic Program (STRTP) for a required annual inspection. LPA was granted entry by Facility Manager Cheryl Scott, and Interim Administrator Tracy McWoodson arrived at 11:25AM. LPA used the Inspection Tool to conduct the inspection. LPA obtained copies of the following: Current LIC Personnel Report, LIC Emergency Disaster Plan. At 4:30PM, the inspection was not completed. Additional time is needed in order to finish the inspection and the report pages. LPA advised that an annual continuation inspection will be conducted at a later date. LPA inspection today included: 10:35AM Tour: The facility is clean and in good repair. There are some minor wear and tear damages that do not affect functionality and are being addressed with work orders, so repairs are pending. License is visibly posted in staff office. Personal rights and foster youth bill of rights are posted in the living room. First aid kit was observed to be complete. Chemicals and detergents are stored in locked cabinets in the laundry room and garage. Medications and sharps are stored in a locked closet in the living room. The facility is maintained at a comfortable temperature, and hot water in the upstairs hallway bathroom measured within permitted range, at 112. F. 1PM File Review: Files are well organized. Medication Administration Records (MARs) are orderly, and psychotropic medications are logged on the appropriate form. File review will continue during the annual continuation visit. During visit, LPA observed that staff S1 (See LIC Confidential Names) is not showing as associated to the facility but appears on the schedule (LIC 500). At 3:35PM, Assistant Director La Tanya Harper made the clearance transfer via Guardian so S1 appeared on the roster. S1 does not need to be removed from the schedule, but a citation of California Code of Regulations, Section 80019 was issued with a mandated civil penalty of $500. An exit interview was conducted, appeal rights provided, and a copy of this report left with Administrator Tracy McWoodson, whose signature on this form confirms receipt.

report_type: Facility Evaluation

visit_type: Annual

met_with: Interim Administrator Tracy McWoodson


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 10/13/21 at 2:10PM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the Short-Term Residential Therapeutic Program (STRTP) for a case management - annual continuation to complete the required annual inspection started on 10/01/21. LPA met with Administrator Tracy McWoodson and informed of the purpose of the visit. The Inspection Tool, CARE Tool, was used to complete the inspection. The tour and file review were completed during the initial visit. Also, a citation and civil penalty were issued for one staff member not having a background clearance and association to the facility. Refer to LIC Annual/Required, dated 10/01/2021. The following additional deficiencies were found during the inspection: 1. Staff S1 (See LIC Confidential Names, dated 10/13/21) does not have a health screening and TB test. Staff is no longer employed by the facility. LPA issued an advisory, per STRTP Interim Licensing Standards (ILS) Section 80066. 2. Residents R1 and R2 (See LIC 811) had allowance logs that were not documented for part of July and for August. Per residents, they did receive their allowance; this is only a documentation error. LPA issued an advisory, per STRTP ILS Section 80026. 3. Bedroom sharing arrangements are not documented in the resident records. LPA issued an advisory, per STRTP ILS Section 87087. 4. Staff S1 through S9 (See LIC 811) are missing emergency intervention training documentation. LPA issued a citation of STRTP ILS Section 87095.65. 5. Staff S2 through S9 (See LIC 811) are missing annual training documentation. All staff had initial training documentation. LPA issued a citation of STRTP ILS Section 87066. 6. Residents' needs and services are not updated every 30 days. Resident R1's (See LIC 811) needs and services was dated 8/3/21. R2's plan was dated 9/24/21 and previous plan dated 6/24/21. R3's plan was dated 7/12/21. R4's plan was dated 9/13/21 and previous plan dated 6/25/21. LPA issued a citation of STRTP ILS Section 87068.3. An exit interview was conducted, appeal rights provided, and a copy of this report left with Administrator Tracy McWoodson, whose signature on this form confirms receipt.

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

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Britanee Windom conducted a case management inspection on 04/27/22 at 9: AM based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 7 out of Direct Care Staff and 5 out of 5 youth files were reviewed. 4 out of Direct Care Staff and 5 out of 5 youth were interviewed.(See the Confidential Names List, LIC 811, April 27, 2022). The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, monthly assessments, and crisis intervention plans, 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 Windom observed documentation of completed training on 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 Tracy McWoodson.

met_with: Adminsitrator Tracy McWoodson


summary: Facility Evaluation

raw_content:
Narrative:
On 6/17/22, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility for a case management visit. LPA met with facility staff Danielle Rosenbaum and Administrator Tracy McWoodson, who arrived at 11:55AM. LPA attempted interviews with present youth, but two residents refused, and one resident was asleep and did not respond to staff. The other two youth are currently on unauthorized absences. LPA interviewed staff Danielle and Administrator Tracy. An exit interview was conducted, and a copy of this report was left with Administrator Tracy McWoodson, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 9-15-22 at 10: AM, , Licensing Program Analysts (LPA) George Karkazis and Licensing Program Manager (LPM),Isabel Mendoza , conducted an unannounced Annual/Required inspection at listed facility. LPA's met with Daniel Rosenbaum Facility Manager and toured the facility inside and out. Safety precautions were taken including screening call and mask wearing. The Short Term Therapeutic Program is licensed to serve six clients.Present during the inspection were two staff and one client, however client left during inspection. Client appeared in good spirit and was watching TV in the living room and greeted LPA and LPM. At 10: AM, LPA Karkazis toured the facility. LPA Karkazis observed four bedrooms and three bathrooms. LPA observed facility license, personal rights, facility sketch, meal menu, and other forms posted on the walls throughout the facility.LPA's observed outdated personal rights form. Lpa's printed updated copy and Facility Manager posted them. LPA Karkazis tested the water temperature and found it to be 120 degrees which is in range. The thermostat read 68 degrees which is within range. Sharps were locked and chemicals were safely stored. There were two days of perishable foods and seven days non-perishable foods present. The medication was also stored and locked.. The facility is in good repair and clean. However, during the inspection LPA and LPM observed the upstairs bathrooms having several markings/stains on the bathroom walls and cabinets. Also, observed stains and debris in several kitchen cabinets. However, during inspection staff members cleaned the kitchen cabinets. LPA Karkazis interviewed two staff. During the tour, the client left, therefore no client interviews. At 1:00PM, LPA Karkazis toured the backyard. There were no open bodies of water. The backyard was in good repair and clean. At 1: PM LPA Karkazis reviewed staff files and during file review several staff files did not have their degrees in the personnel files. LPA reminded the facility to ensure they keep each staff members education experience/degree in each file due to it being difficult for LPA to confirm education. Please refer to 809c form for continuation Also, during review LPA reminded the facility to keep all training material in the facility staff training binder, due to several training materials missing. At 2PM LPA Karkazis reviewed clients files and files were complete and all clients had updated personal rights LIC 613 and required forms. At this time there were deficiencies however the facility received two Technical Violations, Title 22 regulations, Building and Grounds, and 87065(g)(1)(A)(1) Personnel Requirements. An exit interview was conducted, and a copy of this report was left at the facility.

met_with: Facility Manager, Danielle Rosenbaum


summary: Facility Evaluation

raw_content:
Narrative:
On 9/30/22 at 1:03PM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility to discuss an amended report and obtain staff signature. LPA met with Administrator Tracy McWoodson and informed of the purpose of the visit. The amendment was discussed and the report signed. A copy was provided at visit. An exit interview was conducted, and a copy of this report was left with Administrator Tracy McWoodson, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 12/14/22 at 3:05PM, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit at the facility. LPA met with Administrator Tracy McWoodson and Clinical Director Phyllis Ritter and informed of the purpose of the visit. Per the noncompliance conference (NCC) held on August 11th, 2022, the facility will be subject to increased inspections, will submit a LIC 500 on a quarterly basis, and will provide staff training and reminders, documenting everything, on all required topics, including supervision, facility policies and procedures, communication, personal rights, and emergency intervention. During visit, LPA inspected personnel files. LPA has received the submitted LIC 500. Staff have received training on the required training topics, including complete initial training and facility manager training, and are on-track to complete 40 hours of annual training if not already met. LPA conducted confidential interviews with three staff and one resident. Other residents either were unavailable for interview or did not wish to be interviewed at this time. No deficiencies were found. An exit interview was conducted, and a copy of this report was provided to the facility. Administrator Tracy McWoodson's signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 12/28/22 at 2: PM, Licensing Program Analyst (LPA) Alyssa Ng conducted a case management visit. LPA met with Tracy McWoodson, Administrator and discussed the purpose of the visit. The purpose of the visit was to discuss an incident involving two clients getting into a physical altercation resulting in property destruction and one client getting placed on a 5150 hold. Based on confidential interviews at the facility, the incident occurred on 10/29/22. LPA Ng reviewed the incident report and discussed what happened. LPA Ng asked Administrator Tracy, what the procedures for incidences like this and how staff are able to use de-escalation techniques and trauma informed care to ensure clients are safe and protected. Administrator Tracy stated that staff do a lot of verbal redirection, checking in with the Clinician, attempt to do conflict resolution, and have additional staffing to ensure clients are safe. At this time, no deficiencies were cited, an exit interview was conducted, and a copy of this report was left with Tracy McWoodson, Administrator whose signature on this form confirms receipt.

met_with: Tracy McWoodson


summary: Facility Evaluation

raw_content:
Narrative:
On 2/10/23 at 2: PM, Licensing Program Analyst (LPA) Alyssa Ng made an unannounced inspection to listed facility. The purpose of the is inspection is to conduct a case management regarding criminal record clearances. During a review of the guardian system, it was observed that S1 (see LIC 811 dated 2/10/2023) is not criminally record cleared to work in the facility. It shows "In Process". S1 is cleared at all their sister facilities but not the listed one. Administrator Tracy McWoodson stated that they have been working with Guardian to try and get S1 cleared at the listed facility. LPA will assist and reach out to Guardian to see what the delay is. At this time, the facility was given a technical assistance. An exit interview was conducted, and a copy of this report was left with Administrator Tracy McWoodson, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 3/10/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit at the facility. LPA met with Administrator Nina Davis and informed of the purpose of the visit. Per the noncompliance conference (NCC) held on August 11th, 2022, the facility will be subject to increased inspections, will submit a LIC 500 on a quarterly basis, and will provide staff training and reminders, documenting everything, on all required topics, including supervision, facility policies and procedures, communication, personal rights, and emergency intervention. During visit, LPA inspected facility and personnel files. LPA received a current LIC 500. Staff training is well documented, and staff are receiving training on the required topics. All staff are on track to completing their 40 hours of annual training, if not met already. LPA attempted a resident interview, but resident was asleep. LPA interviewed Administrator and Clinician, who reported that staff are implementing training well and following facility procedures. An exit interview was conducted, appeal rights discussed, and a copy of this report was provided to the facility. Administrator's signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Britanee Windom conducted a case management inspection on 03/14/23 at 10: AM based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 5 out of Direct Care Staff and 5 out of 5 youth files were reviewed. 3 out of Direct Care Staff and 2 out of 5 youth were interviewed.(See the Confidential Names List, LIC 811, March 14, 2023). The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, monthly assessment, and crisis intervention plans, 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 Windom observed documentation of completed training on 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 Tracy McWoodson.


summary: Facility Evaluation

raw_content:
Narrative:
On 6/23/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit at the facility. LPA met with Administrator Tracy McWoodson and informed of the purpose of the visit. Per the noncompliance conference (NCC) held on August 11th, 2022, the facility will be subject to increased inspections, will submit a LIC 500 on a quarterly basis, and will provide staff training and reminders, documenting everything, on all required topics, including supervision, facility policies and procedures, communication, personal rights, and emergency intervention. During visit, LPA inspected facility files and conducted confidential interviews with staff and residents. LPA obtained a current LIC 500. Personnel files reflected that staff have completed the necessary hours of training, often exceeding the requirement. Newly hired staff have complete initial training and are on-track to completing all required hours, and facility managers are trained for the role. LPA observed the facility to be clean and organized and residents and staff to engage well with each other. Interviews did not indicate any significant compliance issues. No deficiency citations were issued at today's visit. An exit interview was conducted, and a copy of this report was provided to Administrator Tracy McWoodson, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 7/12/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit at the facility. LPA met with Administrator Tracy McWoodson and informed of the purpose of the visit. The purpose of the visit was to conduct a confidential interview with a resident for an outside investigation. LPA conducted the one confidential interview. An exit interview was conducted, and a copy of this report was left with Administrator Tracy McWoodson, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 9/12/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a required annual inspection. LPA met with Administrator Tracy McWoodson and informed of the purpose of the visit. LPA inspected the facility site and facility records and interviewed two staff and two residents. LPA observed the facility to be clean and well-maintained, and facility records were available upon request. Using the CARE Inspection Tool, LPA observed the following deficiency. The kitchen refrigerator is leaking water and needs to be repaired. Its temperature measured above the allowed maximum temperature. LPA is issuing a citation of Short-Term Residential Therapeutic Services Interim Licensing Standards Section Food Service. See attached LIC 809-D. A continuation visit will be conducted to complete this inspection. An exit interview was conducted, and a copy of this report was left with Administrator Tracy McWoodson, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 9/13/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit to follow-up on a submitted incident report (IR). LPA met with Administrator Tracy McWoodson and informed of the purpose of the visit. An IR was submitted for an incident that occurred on 08/14/23. Per the IR, staff confiscated a resident's birth control medication (a plan b pill and condoms). During a visit to the facility on 9/12/23, Administrator confirmed that the medication had not been returned to the resident. During today's visit, Administrator further explained that the medication was a single pill not in any packaging, so staff were not sure if the medication was actually birth control. Administrator stated the resident has not asked for the medication and that if the resident were to ask, the facility would take the resident to the doctor to get the requested medication. The condoms had been returned to the resident the day of the incident. LPA advises that since one of residents' personal rights is to have access to birth control medication, if staff confiscated the pill due to not being sure it was birth control, and if the condoms were returned to the resident, these details should be included in the incident report. An exit interview was conducted, appeal rights discussed, and a copy of this report was left with Administrator, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 9/13/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit to continue the required annual inspection initiated on 9/12/23. LPA met with Administrator Tracy McWoodson and informed of the purpose of the visit. Using the CARE Inspection Tool, LPA found the following deficiency: 1) The administrator does not have a current and valid administrator certificate. LPA is issuing a citation of Short-Term Residential Therapeutic Program Interim Licensing Standards Section Administrator Qualifications and Duties. See LIC 809-D attached. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 9/26/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit at the facility. LPA met with Administrator Tracy McWoodson and informed of the purpose of the visit. During an investigation at the facility, LPA observed that there was some evidence that staff may be on their phones during their shifts, particularly if providing supervision upstairs, that staff may be working past their shift and paid hours, and that staff may not be assisting residents with accessing therapeutic services or activities, specifically requested outings to the gym, which would go against the facility policy that residents are able to request to go to the gym and be taken so long as other facility operations are not disrupted. While it could not be proven these were widespread violations or that the facility was out of operation, LPA advises as best practice that staff be trained on the following relevant sections: Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) sections 87065.2, subsections (a), (b)(1), and (b)(6). See the three LIC 9102s attached. An exit interview was conducted, appeal rights discussed, and a copy of this report was left with Administrator Tracy McWoodson, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 10/19/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit and met with Administrator Tracy McWoodson. LPA informed that the purpose of the visit was to conduct a quarterly inspection, per the agreed upon terms of the noncompliance conference (NCC). LPA conducted confidential interviews with one resident and one staff. LPA also reviewed staff training records and monthly meeting minutes. LPA observed staff to have complete training records, including intervention procedures, trauma-informed care, and initial/orientation training. Meeting minutes reflect monthly meetings are being held with staff to go over facility policies and any adjustments to supervision requirements or needs of the current residents. Administrator reported that staff have continued to improve in communication and working as a team and that there were no serious issues that needed to be addressed with staff regarding conduct or job performance. Based on LPA's observations, interviews, and file review during this inspection, the facility was observed to be operating in compliance with the NCC terms. No deficiency citations were issued at today's visit, and there are no outstanding plans of correction (POCs). An exit interview was conducted, and a copy of this report was left with Administrator, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 12/18/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit and met with Facility Manager Victoria Robinson. LPA informed that the purpose of the visit was to conduct a quarterly inspection, per the agreed upon terms of the noncompliance conference (NCC). LPA conducted confidential resident and staff interviews and reviewed resident and staff files. LPA observed resident and staff files to be complete and staff training records to reflect that staff are on track with training hours and are receiving training on required topics. Interviews reflect that staff are knowledgeable of facility policies and are following supervision and intervention procedures. Based on LPA's observations, interviews, and file review during this inspection, the facility was observed to be operating in compliance with the NCC terms. No deficiency citations were issued at today's visit, and there are no outstanding plans of correction (POCs). An exit interview was conducted, and a copy of this report was left with Facility Manager Victoria Robinson, whose signature on this form confirms receipt.

met_with: Facility Manager Victoria Robinson


summary: Facility Evaluation

raw_content:
Narrative:
On May 21, 2024 at 10: AM, An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Shikya Belfield and Celeste Aparicio, pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Belfield and LPA Aparicio met with Executive Director Assistant LaTonya Harper who assisted with the inspection. During this inspection a file review was conducted and interviews were conducted with staff and clients. There were two staff and three clients present during this inspection. LPA reviewed 3 of child's records and 3 of staff personnel files on site at the facility. LPA reviewed 3 of child's psychotropic medications and medication records. LPA interviewed 1 of staff on site to discuss the facilities policies and procedures of operation. LPA's observed incomplete documentation regarding medication and client files and a full medication count could not be completed. At this time, due to more information needed to complete the inspection, the inspection could not be completed. LPA interviewed 2 of children currently prescribed psychotropic medication and the third client refused to be interviewed. LPA provided a copy of this licensing report to Executive Director Assistant LaTonya Harper . No deficiencies are being cited at this time. LPA conducted exit interview with Executive Director Assistant LaTonya Harper

met_with: LaTonya Harper


summary: Facility Evaluation

raw_content:
Narrative:
On 06/17/24, an unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Celeste Aparicio, pursuant to Health and Safety Code Section 1538.9 (a)(2). This inspection is a continuation of the inspection that began on May 21, 2024, at 10: AM. LPA Aparicio met with the facility Administrator who assisted with the inspection. LPA reviewed two staff files and conducted two confidential staff interviews. This inspection is complete. At this time, no deficiencies were cited. An exit interview was conducted and a copy of this report was sent to with Administrator, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 09/06/24, Licensing Program Analyst (LPA) Celeste Aparicio conducted a case management inspection regarding Personal Rights and Reporting Requirements related to a complaint investigation; control number 14-CR-20240625121741. LPA met with facility Administrator and facility Head of Service and informed on the purpose of the visit. During the investigation, confidential interviews and records review were conducted. Based on interviews and record review, LPA observed some incidents that needed to be discussed regarding residents right to participate in extracurricular activities and reporting requirements for unusual incidents which may threaten the physical or emotional health of a resident in care. LPA determined that the facility acted appropriately in addressing residents inability to participate in their preferred extracurricular activity by offering the youth alternatives. Facility staff regularly encourage residents to participate in extracurricular activities and community based programs. LPA discussed general regulation reporting requirements and identified an area in which a technical support may be beneficial. LPA is issuing an assistance for California Code of Regulations, Title 22, Section 80061(B)(E)(1) Reporting requirements. An exit interview was conducted, and a copy of this report was provided to facility Administrator, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 09/10/24, Licensing Program Analyst (LPA) Celeste Aparicio conducted a required annual inspection. LPA met with facility Administrator and informed the Administrator on the purpose of the visit. During the inspection, one resident was present at the facility. Resident declined to speak with LPA. The two other residents were not present at the facility due to being on an unauthorized absence since 09/07/24. During inspection, LPA toured the facility and inspected facility records. LPA observed staff and client files to be complete containing all the necessary documentation specified in the CARE Inspection Tool. LPA reviewed training binder and observed staff training logs to be well documented. All staff have background clearances and updated CPR certification. LPA conducted two staff interviews and attempted to interview one resident. Using the CARE Inspection Tool, LPA found no deficiencies. The facility is maintained in safe condition, and maintained at 75 degrees Fahrenheit. No hazards were observed. An exit interview was conducted, and a copy of this report was left with Administrator, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 09/10/24, Licensing Program Analyst (LPA) Celeste Aparicio made a visit to the facility to conduct the facility's final quarterly inspection, per the agreement established at the Noncompliance Conference (NCC) held on 8/11/22. LPA met with facility Administrator and informed Administrator on the purpose of the visit. The agreed upon terms were that the licensee would be subject to increased monitoring, and the licensee is to conduct training on any of these topics: trauma-informed care practices, safe vehicle operation, proper de-escalation procedures, and firearm storage and safety. Additionally, licensee would submit current LIC500 on a quarterly basis and facility will provide staff reminders during staff meetings about facility policies. LPA reviewed staff training records and personnel files. LPA observed complete training records reflecting the required hours being met and the required topics being covered, including trauma-informed care practices and verbal intervention/de-escalation. During the inspection, the facility provided an updated LIC500 to reflect new hires. Based on LPA's observations, record review, and confidential interviews, the facility was observed to be operating in compliance with applicable regulations/licensing standards and the NCC terms. No deficiencies were observed during today's visit, and there are no outstanding plans of correction (POCs). The facility has met the conditions of the 8/11/ NCC and will no longer be subject to noncompliance inspections. An exit interview was conducted, and a copy of this report was provided to Administrator, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 09/24/24, Licensing Program Analyst (LPA) Celeste Aparicio conducted an unannounced case management visit at the facility to provide technical advisory support related to a complaint investigation; control number 14-CR-20240701094516. LPA met with facility Administrator and informed the facility Administrator on the purpose of the visit. During the investigation, confidential interviews were conducted and an area in which technical support may be beneficial was identified. Based on interviews it was learned that S1 may have used language that suggested the residents to engage in physical altercation to resolve their issues after S1 exhausted all other verbal de-escalation tactics and redirection prompts. (See LIC Confidential Names List). LPA provided technical support in the form of an advisory for staff to set limits for behavior that are consistent with trauma - informed care standards. See LIC Technical Assistance. During the discussion, Facility Administrator indicated that staff regularly receive training around trauma informed care and staff are encouraged to swap places when handling an escalated resident. Facility Administrator added that they have checked in with S1 regarding trauma informed practices while identifying areas of improvement. LPA advised that Facility Administrator maintains this type of conversation and training with their staff. LPA obtained documentation of supervision check in between facility administrator and S1. An exit interview was conducted, and a copy of this report was provided to facility Administrator, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 10/09/24, Licensing Program Analyst (LPA), Celeste Aparicio made a visit to the facility and met with Facility Administrator, for the purpose of completing the annual inspection interview. LPA conducted a confidential interview regarding the annual inspection conducted on 09/10/24. No deficiencies were observed or cited during this inspection. An exit interview was conducted, and a copy of this report was given to the Facility Administrator whose signature confirms the receipt of this report.


summary: Facility Evaluation

raw_content:
Narrative:
On 2-20-25 3:23PM, Licensing Program Analyst (LPA) George Karkazis conducted an unannounced inspection at Lighthouse Mentoring Center and met with Tracy McWoodson, Administrator, who helped with the inspection. The purpose of the inspection was to interview a client who may have been a participant in an incident at their previous placement. LPA Karkazis was able to successfully interview the client. LPA toured the facility which was clean and in good repair. An exit interview was conducted and a copy of this report was given to Tracy McWoodson, Administrator.

met_with: Tracy McWoodson, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On September 26,2025, at 10:46am, Licensing Program Analyst (LPA) Celeste Aparicio conducted a case management inspection and met with Administrator, Tracy McWoodson. The purpose of the visit is to discuss and review reporting requirements. 2 clients and 2 staff were present in the facility during this inspection. During this inspection, the Licensing agency learned that an incident occurred between a client and staff on August 22, 2025. The incident was initially deemed by the facility to not qualify as a reportable incident. After further review by the licensing agency, it was learned that this incident did meet reporting requirements. The licensing agency received the incident report on September 14, 2025 which is past the reporting requirement regulations. Therefore the facility did not follow reporting requirements and submit an incident report to the Department in a timely manner. LPA issued a citation of California Code of Regulations, Title 22, Sections 80061(b) Reporting Requirements and a technical assistance for section 80061(b)(1)(E). An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On October 1, 2025 at 10:30am, Licensing Program Analyst (LPA) Celeste Aparicio conducted an unannounced case management inspection and met with Administrator, Tracy McWoodson. LPA disclosed the purpose of the inspection and was granted entry to the facility by Administrator. 1 client and 2 staff were present in the facility during this inspection. The purpose of this visit is to discuss an incident that occurred at the facility on August 28, 2025. It was found that on August 28, 2025, two clients in care got into a verbal and physical altercation which led to the staff on shift calling for assistance from another staff member located at a sister facility nearby. Based on confidential interviews and records review, it was found that staff did attempt to de-escalate the situation however the methods used by S1, S2, and S3 (See LIC811) did not apply interventions, techniques, and practices that are trauma - informed or consistent with a child's needs and services plan and treatment plan. LPA is issuing citations of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87065.2(b)(8) Personnel Duties. (See attached LIC9099-D). An exit interview was conducted, appeal rights were provided, and a copy of this report was left with the Administrator, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 10/19/22, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility regarding an investigation at the facility, during which a deficiency was observed and is being cited today. LPA met with Administrator Tracy McWoodson and informed of the purpose of the visit. During record review, LPA observed that some medications were not administered for a few days due to needing to be filled, and one medication was potentially administered incorrectly or logged incorrectly. A medication, Aripiprazole, was prescribed at 1 1/2 tablets at bedtime for 15 days and filled on 2/18/22 with 1 refill, administered for 15 days, and then filled on 3/18/22 with 0 refills. The facility continued administering daily until they ran out after 4/10/22. If the medication was only to be administered for 15 days, administration should have stopped after 4/1/22, and at 1 1/2 (1+1/2) dosage, the facility would be out of the medication after 4/1/22. However, after filling the 3/18/22 prescription, the records reflect that staff notated the medication was not administered due to needing to be filled. It is not clear from the records when the medication was filled, if the listed reason is accurate, or if the medication was administered correctly. The resident is no longer in care, so a medication count cannot be conducted. LPA is issuing a citation of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section Health Related Services. See attached LIC 809-D. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Tracy McWoodson, whose signature confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 1/9/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit at the facility. LPA met with Administrator Tracy McWoodson and Clinical Director Phyllis Ritter and informed of the purpose of the visit. During an investigation at the facility, LPA discovered that an incident in which a staff member was falling asleep while transporting a resident to school occurred on December 7, 2022 and was reported to the facility on December 8, 2022. However, an incident report was not sent to the Licensing agency until December 27, 2022. LPA is issuing a citation of California Code of Regulations, Title 22, Division 6, Chapter 1, Article 6, Section Reporting Requirements. See attached LIC 809-D. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Tracy McWoodson, whose signature on this from confirms receipt.

met_with: Administrator Tracy McWoodson, Clinical Director Phyllis Ritter


facility_name: LIGHTHOUSE MENTORING CENTER 5

summary: Facility Evaluation

raw_content:
Narrative:
On 7/10/25 at 11am, Licensing Program Analyst (LPA) Celeste Aparicio met with Executive Director Assistant, La Tanya Harper and Executive Director, Jay Lightner for the scheduled Component II face-to-face meeting. The meeting was held over Microsoft Teams. The purpose of this meeting was to discuss the facility's Plan of Operation and Program Statement. The following items were discussed: - Goal/Purpose of the STRTP - Basic Services and Planned Activities - Needs and Services Plans - Care and Supervision Policies - Staff Training - Emergency Intervention Policies - Reporting Requirements - Visitation Policies - Background Clearance/Guardian Process LPA provided clarification on the next steps in the application process. LPA scheduled Component III for Monday August 4 at 10am. An exit interview was conducted, and a copy of this report was provided to Executive Director Assistant, La Tanya Harper via email.


summary: Facility Evaluation

raw_content:
Narrative:
On August 4, 2025 at 10am, Licensing Program Analyst (LPA) Celeste Aparicio conducted a virtual Teams Meeting with Lighthouse Mentoring Center to conduct Component III. The following were the attendees of the meeting: Celeste Aparicio, Licensing Program Analyst; La Tanya Harper, Executive Director Assistant; and Jay Lightener, Executive Director. During the meeting the presentation for Component III was presented. A copy of the presentation was emailed to the Lighthouse Mentoring Center. LPA provided clarification on the next steps for the Pre- Licensing inspection. LPA discussed with the licensee that the Pre-licensing will be conducted once the Systems of Care (SOC) branch finishes the second review of the program statement. An exit interview was conducted, and a copy of this report was provided to Executive Director Assistant, La Tanya Harper via email.

met_with: Executive Director Assistant, La Tanya Harper and Executive Director, Jay Lightner


summary: Facility Evaluation

raw_content:
Narrative:
On August 20, Licensing Program Analyst (LPA) Celeste Aparicio met with Executive Director Assistant, La Tanya Harper and Executive Director, Jay Lightner, for a prelicensing inspection. Using the CARE Inspection Tool, LPA toured the facility site and grounds and discussed the facility's application. 1. Facility grounds inspected. Grounds are clean and free from observable hazard. Clear passageways throughout the facility. The facility does not have a swimming pool or any bodies of water. Firearms are not allowed on facility premises. 2. Adequate indoor activity space and materials observed, and outdoor activity space was observed. 3. Procedures for locked and centrally stored medications observed. 4.Adequate storage space observed. 5. Individual beds in good repair observed. 6. The house is two story and has 4 client bedrooms. Bedrooms are accommodating of all required furnishings. 7. Adequate food storage space observed. Facility will add appropriate supply of required foods and emergency foods upon placement of youth in the home. 8. Sample menu posted. 9. All appropriate forms posted within client view. 10. Dining room equipped with large table and chairs accommodating of all clients. 11. Facility has 3 restrooms for client use, all are operable. 12. Client files will be kept in a locked filing cabinet, locked in the staff office. 13. Staff files will be kept locked at the facility main office, and will be available for review at facility, within a reasonable time frame of request by LPA. Applicant is associated through Guardian and has been fingerprint cleared. Prior to accepting placement's, all staff must be fingerprint cleared and associated to the facility. Discussed Guardian process with the facility. Based on this inspection, the facility will be ready for licensure. A copy of this report was provided to Executive Director Assistant, La Tanya Harper.

visit_type: Prelicensing


summary: Facility Evaluation

raw_content:
Narrative:
On 12/03/2025, Licensing Program Analyst (LPA) Celeste Aparicio conducted a post-licensing inspection. LPA met with Administrator Jasmine Jackson and explained the purpose of the visit. At the beginning of the inspection, two staff members were present, and no clients were in the facility as the clients were at school. At 3:22 p.m., two clients returned from school. LPA utilized the CARE Inspection Tool to complete the inspection. A tour of the facility was conducted, and facility records were reviewed. LPA also obtained the residents' school information and reviewed board meeting minutes. The facility was observed to be clean, well-maintained, and in safe condition. The kitchen and bathrooms were sanitary; resident bedrooms were appropriately furnished, provided clean linens, and offered adequate storage space. Potentially dangerous items-including chemicals, knives, and medications-were stored securely and were inaccessible to clients. A review of staff and client files found them to be complete and in compliance. LPA identified three areas where technical assistance may be beneficial. Please refer to the attached LIC Advisory Note for guidance related to Sections 87075(b), 87077(a)(3), and 87089.1(e). LPA conducted one staff interview and one client interview. LPA was unable to interview the second client, as the client was asleep. No deficiencies were observed or cited during today's visit. An exit interview was completed, and a copy of this report was provided to the Administrator.

met_with: Administrator, Jasmine Jackson


facility_name: LIGHTHOUSE MENTORING CENTER, THE

raw_content:
Narrative:
Although the allegation may have happened or is valid, based on LPA's observations and interviews with residents and staff, there is not a preponderance of the evidence to prove the alleged violation(s) did or did not occur. Therefore, the allegation is Unsubstantiated. An exit interview was conducted, appeal rights provided, and a copy of this report left with Administrator Maurice Jones, whose signature on this form confirms receipt.

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

met_with: Administrator Maurice Jones


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


met_with: Assistant Clinical Director Jason Braden


raw_content:
Investigation Findings:
13On 12/28/22 and 11: AM, Licensing Program Analyst (LPA) Alyssa Ng conducted a complaint inspection at The Lighthouse Mentoring Center located at Garden Court, Antioch, CA 94509 and spoke with Maurice Jones, Administrator. The purpose of the inspection was to deliver the findings for the above complaint allegations. During investigation, interviews were conducted, and incident reports were reviewed, and it was determined that facility did not meet reporting requirements, minors engaged in a physical altercation, minor sustained injury while in care, and insufficient staffing. Based on LPA's interview with staff, client, and record review(s), the preponderance of evidence standard has been met, therefore the above allegations, Facility did not meet reporting requirements, Minors engaged in a physical altercation, Minor sustained injury while in care, and insufficient staffing is found to be SUBSTANTIATED. Facility is being cited for violation of California Code of Regulations (CCR), Title 22, Division 6 & Chapter 1: 80061(b)(1)(D) Reporting Requirements, 80078(a) Responsibility for Providing Care and Supervision, and 80072(a)(3) Personal Rights. Please refer to attached 9099D. At this time, three deficiencies were given. An exit interview was conducted, appeal rights provided and discussed, and a copy of this report was sent to Maurice Jones, Administrator . SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Alyssa Ng LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, TRAEGER AVE., SUITE FACILITY NAME: LIGHTHOUSE MENTORING CENTER, THEFACILITY NUMBER: 075600414

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:

met_with: Maurice Jones


met_with: Eugene Denard


raw_content:
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:


met_with: Facility Manager, Eugene Denard


raw_content:
Narrative:
Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted, appeal rights discussed, and a copy of this report left with Administrator, whose signature on this form confirms receipt.

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:

met_with: Administrator, Maurice Jones


raw_content:
Narrative:
The preponderance of evidence standard has been met, and therefore the above allegation, staff did not prevent minor from being physically assaulted by other minors, is found to be SUBSTANTIATED. LPA is issuing citations of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87065.2 (b)(1) Personnel Duties. An exit interview was conducted, appeal rights provided, and a copy of this report left with Facility Manager.

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

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:

met_with: Facility Manager, Mimi Nitake


summary: Facility Evaluation

raw_content:
Narrative:
On 9/30/21 at 10AM, Licensing Program Analyst (LPA) Mariah Hawkins conducted an annual inspection. LPA met with Administrator Maurice Jones and informed of the purpose of the visit. Safety precautions were taken including screening call and mask-wearing. The Inspection Tool was used to conduct the inspection. There are two residents in care. LPA interviewed present residents and staff. The facility is maintained at a comfortable temperature, and hot water in the upstairs resident bathroom measured within permitted range, at 111. F. At 3:45PM, LPA completed the inspection. Additional time is needed in order to draft and finalize the report pages. An annual continuation will be required. LPA advised of return visit. An exit interview was conducted and a copy of this report left with Administrator Maurice Jones, whose signature on this form confirms receipt.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 9/30/21 at 10AM, Licensing Program Analyst (LPA) Mariah Hawkins conducted an annual inspection. LPA met with Administrator Maurice Jones and informed of the purpose of the visit. Safety precautions were taken including screening call and mask-wearing. The Inspection Tool was used to conduct the inspection. There are two residents in care. LPA interviewed present residents and staff. The facility is maintained at a comfortable temperature, and hot water at the upstairs resident bathroom measured within permitted range, at 111. F. The facility, per the tool, was in compliance in all areas other than those listed below, for which citations or advisories were issued. 1. Staff Ratios. During visit, two residents returned home, and there was only one staff (Administrator), and no additional staff showed at their arrival. LPA issued an advisory of STRTP Interim Licensing Standards (ILS) Section 87065.5(b)(1). 2. Staff Ratios. The current LIC Personnel Report indicates there is one overnight staff who works 12AM-8AM Monday through Friday and one overnight staff who works 12AM-8AM Saturday and Sunday. LPA issued a citation of STRTP ILS Section 87065.5(b)(2). 3. Needs and Services. Residents records contained needs and services plans that were not being updated every 30 days. R1's (See LIC Confidential Names, dated 10/7/21) plan was dated 5/28/21 and had a "re-evaluate" date of 7/21/21, and R2's plan was dated 8/22/21 and had a "re-evaluate" date of 11/22/21. LPA issued a citation of STRTP ILS Section 87068.3(a). 4. Smoking on Site. During tour of facility, LPA observed 10+ cigarette butts in the back and side yards. Per Administrator, staff are aware that residents are smoking in their rooms and throwing the cigarette butts out of the window. Staff are doing contraband checks, but cigarette butts have not been removed from grounds. LPA issued a citation of STRTP ILS Section 87087(c). 5. First Aid Certificates. LPA observed that 5 of 10 staff files reviewed [Refer to LIC Confidential Names for staff names] did not include a valid/current first aid certificate. LPA issued a citation of STRTP ILS Section 87065.1(c)(6)(A). 6. Staff Training. LPA observed that 9 of 10 staff files [Refer to LIC Confidential Names for staff names] did not contain training documentation. Some staff were missing all staff training and had no training record in the training binder. Some staff had the initial training log completely signed off. Staff work at multiple facilities, and LPA has prior knowledge that some staff have completed initial training based on copies of their files at other locations. However, the training records in the staff files at this site would indicate that less than 15 hours of training were completed in 2020. Additionally, there is a training record in staff files that indicates 20 hours were completed in 2021, completed over two days, with 10 hours done each day. The dates are 1/12/21 and 3/30/21. Per Asst. Director La Tanya Harper, these dates are the completion dates for mulitple days long training courses. There is no training material for this training in the record, breakdown of time spent on each topic or how the hours were calculated, nor a certificate. LPA issued a citation of STRTP ILS Section 87066(b)(4). 7. Bedroom Sharing Arrangement. LPA observed that the resident records do not contain documentation of the bedroom sharing arrangements. LPA issued an advisory per STRTP ILS Section 87087(e). 8. Condition of Site & Grounds. LPA observed minor damages, including a cracked microwave door, two fist sized holes (one in bedroom, one in upstairs hall), and cracked/punched doors to two bedrooms. Damages do not appear to cause an immediate risk, and all items are functioning. Administrator showed LPA a list of items, including these damages, that have been sent to the director for repairs but have not yet been repaired. Per Administrator, the licensee is taking steps to address these damages. The facility is otherwise in good condition. Additionally, LPA observed two bent and broken window screens in the side yard. Per Administrator, residents break these off of the windows in order to throw cigarette butts out. LPA observed the screens had not been removed from the side yard. The screens are made of metal, which can be bent and worked into a dangerous item. The screens also are in the walkway, and while light in weight, they are large and could obstruct the passageway in an emergency. LPA issued an advisory per STRTP ILS Section 80087(a). 9. Health Screenings. Two staff files were missing health screening with TB test. LPA issued an advisory of STRTP ILS Section 80066(a)(10). One staff does not work on site at this location. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Maurice Jones, whose signature on this form confirms receipt.

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 Friday 4/22/22 at 1:15PM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility regarding an incident report submitted to the Licensing agency. LPA met with Administrator Maurice Jones "MJ" and informed of the purpose of the visit. Safety precautions were taken, including mask-wearing and pre-visit screening call. LPA interviewed 1 staff and 2 residents, reviewed staff binder and staff training, and obtained copies of the residents' treatment plans/pre-placement assessment, staff contacts, staff termination letter and initial training for staff S1 (See LIC Confidential Names). Based on the submitted incident report, on 4/12/22 staff S1 came to work intoxicated. Second staff on shift observed S1's state, evidenced by S1's appearance, behavior, and throwing up, and notified management. Second staff removed present resident so resident would not be around S1. Interviews with Administrator and residents indicate that there were no prior incidences of this nor any indication that S1 would do this. S1 was directed to leave the facility that day, and did so, and S1 was terminated the following day. There are no deficiencies found at this time and no citations. An exit interview was conducted, and a copy of this report left with Administrator MJ, whose signature on this form confirms receipt.

met_with: Administrator Maurice Jones "MJ"


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst(LPA) Shikya Belfield and Lisa Schlembach made an unannounced inspection at the above facility on 6/29/2022 at 4: PM. LPA's Belfield and Schlembach met with staff Camara Walker who assisted with the inspection. LPA The purpose of this inspection is to discuss the facility being out of compliance in the following areas: During a walk through of the facility it was observed by LPA Belfield that the facility has four fire extinguishers and all extinguishers are out of date. Administrator Maurice Jones arrived at the facility and explained to this LPA that a recent incident between clients occurred and the fire extinguishers were sprayed. An incident report was submitted to the department and screen shots were submitted to LPA Belfield to show that the process to replace the fire extinguishers had begun. Fire extinguishers will be serviced or replaced by 7/13/2022. During a walk through of the facility it was observed by LPA Belfield that the beds being used by the clients are a trundle type of bed. These beds are prohibited. Facility issued a Technical advisory for violation of Interim Licensing Standards, version four, section 87088(c)(C) Fixtures Furniture and Equipment and Supplies. Advisory issued. No violations of Interim Licensing Standards, Version 4, were cited during this inspection. An exit interview was conducted and a copy this report along with appeal rights will be sent to staff Camara Walker and administrator Maurice Jones.

met_with: Camara Walker


summary: Facility Evaluation

raw_content:
Narrative:
On 9/9/22 at 10:45AM, Licensing Program Analyst (LPA's) George Karkazis and Alyssa Ng conducted an annual inspection. LPA met with Administrator Maurice Jones and informed of the purpose of the visit. Safety precautions were taken including screening call and mask-wearing. The Short Term Residential Therapeutic Program (STRTP) is licensed to serve six clients, ages 10 -17 years. Currently in placement are 5 clients. The Inspection Tool was used to conduct the inspection. At 11:00AM LPA Karkazis toured the facility, inside and out. LPA's Ng and Karkazis observed at the time of this visit, the facility to be clean, safe and sanitary. The facility is maintained at a comfortable temperature, and hot water in the upstairs resident bathroom measured within permitted range, at 107. F. There a were total of five bedrooms and three bathrooms. One bathroom was designated for staff. All client bedrooms were observed to have ample storage space and adequate bedding. At 1:15PM LPA's Karkazis and NG reviewed the staff and clients files and they had the necessary forms. LPA Karkazis observed that one staff file did not contain training records. A citation was issued. LPA Karkazis interviewed one client. The following documents are posted in the facility: facility license, emergency disaster plan, facility sketch, menu, chores, activity calendar and personal rights. A review of Guardian on September 09, 2022 indicates that all facility staff associated to the facility had DOJ, FBI and child abuse index check clearances. A citation was issued ILS 87076(c)(1), two days of perishable food not present. Exit interview conducted and a copy of the report was left with the facility. The inspection is not complete at this time and a continuation of this inspection is necessary.


summary: Facility Evaluation

raw_content:
Narrative:
On 9-13-22, 10: AM, Licensing program Analysts (LPAs) George Karkazis and Alyssa Ng conducted an unannounced inspection. The purpose of the inspection was to continue the annual inspection from 9-9-22. We met with Norman Denard, Resident Counselor. Present were one client and clinician Jason Braden. At 11: AM we toured the facility and the facility was in good repair and clean. Two staff interviews were conducted with Resident Counselor Norman Denard and Administrator Maurice Jiones. No client interviews were conducted, all clients in school, except for client previously interviewed. LPA Karkazis observed two days of perishable food, in addition to copies of receipts and photos emailed, 9-12-22 from Maurice Jones to LPA Karkazis. The POC for the deficiency ILS 87076(c)(1) was cleared from 9-9-22. A technical advisory was issued for ILS 87065.1(d)(5), for one client file observed not containing training and employment history, for a newly hired staff member. Administrator Maurice Jones showed LPA Karkazis that training was completed and receipts were in route. An exit interview was conducted and a copy of this report was given to Maurice Jones.

met_with: Norman Denard


summary: Facility Evaluation

raw_content:
Narrative:
On 7/21/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit and met with Administrator Maurice Jones. LPA informed of the purpose of the visit. The purpose of the visit was to deliver a confidential letter and confirm an individual associated to the facility is not working at the facility. Administrator confirmed receiving the electronic notification and that the staff has been given their final check and is no longer employed by the licensee. An exit interview was conducted, and a copy of this report was left with Administrator Maurice Jones, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 9/29/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a required annual inspection. LPA met with Administrator Maurice Jones and informed of the purpose of the visit. During inspection, LPA toured facility and inspected facility records. All residents were at school. LPA observed the personnel files and resident files to be complete. Staff have background clearances. Medications are properly stored and administration appropriately documented. Using the CARE Inspection Tool, LPA found 1 deficiency. LPA observed that there were multiple shards of broken glass around the backyard activity space from the broken window upstairs. The window is scheduled for repair and has been made inaccessible to residents. LPA is issuing a citation of California Code of Regulations, Title 22, Section 80087. See attached LIC 809-D. A continuation inspection is required to complete interviews. An exit interview was conducted, appeal rights provided, and a copy of this report left with Administrator Maurice Jones, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 10/6/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted an annual inspection continuation. LPA met with Administrator Maurice Jones and informed of the purpose of the visit. LPA interviewed three residents and two staff. Using the CARE Inspection Tool, no deficiencies were found. An exit interview was conducted, and a copy of this report was left with Administrator Maurice Jones, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 05/08/24 at 1: PM, Licensing Program Analyst (LPA) Celeste Aparicio made an unannounced visit to the facility for the purpose of conducting a case management to follow up on an incident report received by the Department regarding an incident that occurred on 04/17/24. LPA met with Administrator Maurice Jones who helped facilitate the inspection and informed on the purpose of this visit. LPA conducted an interview with Administrator Maurice Jones, requested documentation, and conducted physical plant of the facility. No citations were issued during this visit. An exit interview was conducted, and a copy of this report was provided to Administrator Maurice Jones, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 11/20/24, Licensing Program Analyst (LPA) Celeste Aparicio made an announced collateral visit to the facility to conduct a confidential interview. LPA met with Administrator, and informed Administrator on the purpose of the visit. LPA conducted one confidential interview related to an outside investigation. No deficiencies were observed or cited. An exit interview was conducted, and a copy of this report was left with, Administrator whose signature on this form confirms receipt.

met_with: Facility Administrator, Maurice Jones


summary: Facility Evaluation

raw_content:
Narrative:
On 06/05/25, Licensing Program Analyst (LPA) Celeste Aparicio made an unannounced visit to the facility to conduct a case management inspection. LPA met with Administrator, Maurice Jones and informed the Administrator on the purpose of this visit. During the walk through of the facility LPA observed remodels being done to the facility. LPA observed new kitchen cabinets, counter tops, and flooring on the first level of the facility. LPA observed there to be no changes to the physical plant of the facility. LPA advised that facility submit in writing all the plans for the reconstruction, including a statement on how the staff plan to maintain client safety and limit disturbances for programming. A new staff member who is in training was present during the inspection. The new staff member, S1, (see LIC811) is not fully cleared on Guardian, but is under constant supervision for shadowing and not yet working with the clients in care. S1 has been in the Guardian system since November 2024. Due to the new staff being from out of state the Guardian process is taking longer. { Report continued on LIC809-C }. During a review of the programs House Rules, LPA observed a rule that does not allow residents to be in each other's bedrooms without the permission of staff. LPA discussed the importance of having residents obtain permission when hanging out in each other's bedrooms so that proper supervision can be provided. LPA identified areas in which a Technical Assistances would be beneficial, LPA is issuing a Technical Assistances for Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87088(j) Fixtures, Furniture, Equipment, and Supplies, 87022 (f) Plan of Operation, and 80019(e) Criminal Record Clearance. An exit interview was conducted, appeal rights provided, and a copy of this report left with the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On 07/24/25, Licensing Program Analyst (LPA) Celeste Aparicio conducted a random annual inspection. LPA met with Administrator, Maurice Jones and informed the Administrator on the purpose of the visit. LPA toured the facility site and observed that facility to be clean, free from obstruction, and in good repair. The facility is currently installing new fencing in the backyard. The facility has already provided LPA Aparicio with a renovation plan document detailing on how clients safety will be maintained throughout the renovation process. During the inspection LPA reviewed five client files and five staff files. LPA observed both client and staff files to be complete and secured in a locked cabinet located in the staff office. LPA identified an area in which a technical assistance maybe beneficial. LPA provided a technical assistance for California Code of Regulations Section 80069(c)(1). At the time of the inspection four clients were present at the facility. LPA conducted two client interviews and one staff interview. The CARE Inspection Tool was used to conduct the annual inspection. No deficiencies were observed or cited. An exit interview was conducted, and a copy of this report was left with the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On 12/22/22, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit. LPA met with Assistant Clinical Director Jason Braden and informed of the purpose of the visit. Based on confidential interviews and record review conducted during an investigation at the facility, on 09/15/2022 around 7PM, a police officer made a visit to the facility and observed that there were four residents present and only one staff member was present. Additionally, this was reported to have occurred on other occasions as well. Per Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87065.5, there should be two staff on shift when there are 2-4 residents present in a facility with a licensed capacity of 7 or more, and the facility's capacity is 8. LPA is issuing a citation of California Code of Regulations, Title 22, Section 87065. Direct Care Staff/Child Ratios. See attached LIC 809-D. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Assistant Clinical Director Jason Braden, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 9/29/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit to follow-up on a submitted incident report. LPA met with Administrator Maurice Jones and informed of the purpose of the visit. Based on the submitted incident report, two residents engaged in consensual sexual activity in the facility during the overnight shift after reportedly waiting for the night staff member to go downstairs and complete tasks downstairs. Administrator confirmed that the report was accurate and that there was only one staff on shift. LPA discussed the ratio requirement for facilities with a capacity of 7 or more, which applies even when the facility census is 6 or below. LPA also discussed that the licensee should continue to provide hiring updates but that the ratio requirements must be followed following this incident to ensure compliance. Lastly, LPA discussed the process of reducing the capacity, since the facility does not typically go over 6 residents, and doing so would make the ratio requirement for this facility the same as that for the licensee's other facilities. LPA is issuing a citation of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) section 87065. Direct Care Staff/Child Ratios. See attached LIC 809-D. An exit interview was conducted, appeal rights were provided, and a copy of this report was left with Administrator Maurice Jones, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 05/28/24 at 1:15PM Licensing Program Analyst (LPA) Celeste Aparicio made an unannounced inspection to the facility for the purpose of conducting a follow - up case management inspection regarding an incident that occurred on 04/26/24. Based on additional records review and confidential interviews, it was confirmed that information was omitted from the incident report that was submitted regarding the incident that occurred on 04/26/24 between a staff and client. LPA found that a physical restraint was utilized during the incident and was not reported to the Department. LPA discussed the facility's Emergency Intervention Plan (EIP) that was revised in August 2023 which states that was facility is a hands-off facility and will not utilize restraints to address assaultive and aggressive behaviors. LPA also discussed that if the facility chooses to utilize physical restraints as a last resort for the safety of staff and clients then the facility's EIP needs to be revised to reflect Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) section 87095.22(f) Emergency Intervention Plan. LPA is issuing a citation of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) section 87022(f) Plan of Operations and section 87061(i)(7) Reporting Requirements. See attached LIC809-D. An exit interview was conducted, appeal rights were provided, and a copy of this report was left with Administrator Maurice Jones, whose signature on this form confirms receipt.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 06/07/24, Licensing Program Analysts (LPAs) Celeste Aparicio and Kristin Pierotti made an unannounced visit to the facility for the purpose of conducting a case management inspection to follow up an incident that occurred on 05/22/24. Based on confidential interviews and records review, residents engaged in inappropriate sexual behavior due to a lack of supervision from overnight staff. Facility immediately acted and reported the incident to the Department in timely manner. LPA is issuing a citation of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87065.2(b)(1) Personal Duties. Licensee also received a Technical Assistance. See attached LIC 809-D and LIC9102. An exit interview was conducted, appeal rights were provided, and a copy of this report was left with Administrator Maurice Jones, whose signature on this form confirms receipt.

Deficiencies:
87065.2: Supervision, protection, and care of children at all times, individually and in groups.

title:
1
2
3
4
5
6
787065.2 Personal Duties
(b)(1) Direct care staff shall perform the following duties


summary: Facility Evaluation

raw_content:
Narrative:
On March 10, 2026 at 12:35pm, Licensing Program Analyst (LPA) Celeste Aparicio conducted a case management visit to the facility to follow up on an incident reported to the Department that occurred on February 14, 2026. At the time of the inspection, there was one (1) client and three (3) staff present in the facility. The Department received a report that on February 14, 2026, a resident poured water on a staff member after observing the staff member asleep during their shift. During the inspection, LPA reviewed relevant documentation including staff schedules, shift notes, internal communication records, staff corrective action documentation, and client day pass records related to the incident. In addition, LPA conducted one (1) client interview and two (2) staff interviews. Based on the documentation reviewed and interviews conducted, LPA determined that the facility maintained the required staffing ratio at the time of the incident. The facility addressed the brief lapse in supervision, estimated at approximately five (5) to ten (10) minutes, through appropriate internal corrective measures. Due to the short duration of the lapse and the facility maintaining the required staffing ratio, LPA did not determine there to be an immediate or potential risk to client safety. No deficiencies were observed or cited during this visit. An exit interview was conducted, and a copy of this report was provided to the facility representative.

met_with: Facility Manager, Mimi Nitake and Administrator, Maurice Jones


summary: Facility Evaluation

raw_content:
Narrative:
On March 11, 2026, at approximately 2:25 p.m., Licensing Program Analyst (LPA) Celeste Aparicio conducted a case management visit at the facility to follow up on an incident reported to the Department that occurred on March 3, 2026. The incident report indicated that staff discovered marijuana paraphernalia in a resident's bedroom during a routine room check. At the time of the visit, four (4) residents and three (3) staff members were present in the facility. During the inspection, the LPA reviewed the facility's incident report, the involved resident's Needs and Services Plan (NSP), and conducted one staff interview. The LPA observed that the NSP for the involved resident did not include: Descriptions of trauma-informed interventions and practices used to identify and address the resident's specific behavioral patterns related to the incident; and A description of the facility's plan in response to the incident, including any modifications to the resident's NSP. In addition, the LPA did not observe documentation showing that the facility reviewed the incident to determine whether modifications to the resident's NSP were necessary to address potential behavioral patterns.[Report continued on LIC809-C] Based on staff interview and record review, staff stated that room checks are part of residents' daily chores. Both the morning and evening shifts review residents' bedrooms to ensure they are tidy as part of the facility's daily chore system. Staff reported that the marijuana paraphernalia was in plain sight and was removed due to safety concerns. The practice of conducting room checks for cleanliness is outlined in the facility's approved program statement. Based on observation, interview, and record review, the LPA determined that resident personal rights were not violated, as the item was in plain view and the room check was conducted in accordance with the facility's established program practices. Technical assistance was provided for the following STRTP Interim Licensing Standards (ILS): ILS 87061(i)(3) - Incident reports must include descriptions of trauma-informed interventions and practices used to address the resident's behavioral response to the incident. ILS 87061(i)(5) - Incident reports must include a description of the facility's plan in response to the incident, including any modifications to the resident's Needs and Services Plan and an explanation of prior modifications if applicable. ILS 87068.3(c) - The facility must document the review and determination of whether the resident's Needs and Services Plan requires modification following an incident. (Reference related LIC 9102 forms dated March 11, 2026.) An exit interview was conducted with facility staff. Appeal rights were discussed, and a copy of this report was provided to the facility.


facility_name: LLU JOSHUA PLACE

summary: Facility Evaluation

raw_content:
Narrative:
On February 5, 2025, at 2:00 pm, Licensing Program Analyst (LPA) Charmaine Linley, met with applicant Ashley Martinez for Component II Orientation via Microsoft Teams Meetings. LPA went over revisions needed for the application prior to licensure. LPA sent a copy of the LIC 184, Notice of Incomplete Application, and additional correspondence to assist with the revisions needed to the application via email. A copy of this report was provided to the applicant along with the signed Orientation form indicating Component II has been completed via email. A copy of this report will be placed in the facility file.

met_with: Ashley Martinez


summary: Facility Evaluation

raw_content:
Narrative:
On April 23, 2025, Community Care Licensing (CCL) conducted an office conference with the Short-Term Residential Treatment Program (STRTP) applicant Ashley Martinez regarding their application denials for LLU Joshua Place (366000017) and LLU Joshua Place 2 (366000035). Present at the meeting was: LaCresha Cook, Regional Manager (RM), Ashley Martinez, Executive Director (ED), Ann Valenzuela, Licensing Program Manager (LPM), Charmaine Linley, Licensing Program Analyst (LPA) and Kimberly Abdul-Malik, Treasurer/Board Member, was present via cell phone. The meeting was called to address concerns regarding the applicants submission of an incomplete application and history of noncompliance. RM explained that CCL is denying the applicant's STRTP applications for both LLU Joshua Place (366000017) and LLU Joshua Place 2 (366000035). RM further explained that as of April 23, 2025, the STRTP applications would be officially denied. The denial of the application is based upon failure to provide satisfactory evidence that the applicant can meet or conform to the licensing requirements in Health and Safety Code Chapter 3, commencing with Section 1500; Title California Code of Regulations, Division 6, Chapter 1, commencing with Section 80000; and the CDSS Short-Term Therapeutic Program Interim Licensing Standards ("ILS"). This decision is based on the evidence set forth in the reports, statements, and other documentary evidence contained in the official files compiled by the department. The applicant disagrees with the information shared in the meeting and states that 90% of the information is included in the pending revisions. Applicant states she feels she is being unfairly treated and plans to follow up this matter with the chain of command within the Community Care Licensing Division. *** RM informed that a denial notice will be sent to the applicant explaining all reasons for the application denial and provided in Health and Safety Code Section 1526, an applicant may appeal a denial by submitting a written appeal within 15 days after the licensing agency mails the denial notice. The appeal should include the facility name, facility number, facility address and a copy of the denial letter. The appeal must be post marked or delivered on or before 15 days from the date of the denial letter. RM explained that if this decision is not appealed on or before the due date the denial will be final. RM informed applicant that the appeal request is sent to the following address: Jean Chen, Program Administrator, Statewide Children's Residential Program Office, P Street, MS 9-14-880, Sacramento, CA 95814. A copy of this report was provided to Ashley Martinez. The signed report will be placed in the facility application file.