summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 11/25/24 at 10: AM and met with Tracy Edwards, Administrator, to discuss an incident report. LPA Hill met Ms. Edwards to discuss the incident dated 9/25/24 which details inappropriate contact between C1 and C2 (see LIC811 dated 10/25/24). Discussed during the inspection was that the agency conducted an internal investigation regarding the inappropriate contact. The Program Statement/Plan of Operation approved by the Department details that the agency investigates alleged inappropriate sexual contact following the PREA, Prison Rape Elimination Act, guidelines which is a zero tolerance policy for sexual abuse, sexual harassment, or unauthorized relationship between clients served by the facility. The agency initiated their internal investigation on 9/26/24 and concluded the investigation on 10/1/24, per their written guidelines. The investigation resulted in one youth moving facilities and the other being placed on a behavior contract due to the unauthorized/unwelcome contact. The agency followed their guidelines and did take appropriate action upon this incident being reported. As a result of the agency doing their due diligence, no citations were issued and no further investigation is needed at this time. Exit interview conducted with Ms. Edwards and documentation was provided.


state: CA

facility_name: ROP QUALIFYING HOUSE FREEL

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced annual inspection on 12/10/24 at 10: AM and met with Tracy Edwards, Program Administrator, to conduct the physical plant inspection of the facility as part of the annual inspection. LPA Hill observed that the facility has three dual occupancy bedrooms upstairs for clients in care but each of the youth currently are not sharing bedrooms with other youth. LPA Hill observed that the facility was clean, safe and sanitary during the annual inspection. LPA Hill observed that the smoke detectors and carbon monoxide detectors were functioning as required. Fire extinguishers were last inspected 1/23/24. LPA Hill observed one client restroom upstairs that had running hot water, paper towels, flushing toilets, and a shower that delivered hot water. The other restroom is downstairs and is for staff. LPA Hill observed that the client bedrooms were supplied with proper bedding including mattress cover, fitted sheets, blankets, pillows, closet space, and storage for belongings. LPA Hill observed that the facility had two days perishable food supply and seven days nonperishable food supply appropriate for the youth in care and had appropriate cook ware and dining supplies. LPA Hill observed that the facility was safe for youth, inside and out. LPA Hill informed Ms. Edwards that the client interviews were going to be conducted at the agency administrative offices as well as file reviews. LPA Hill conducted two interviews of youth during the annual inspection at the administrative site. One client refused to be interviewed. Document was provided to Ms. Edwards and exit interview was conducted.

report_type: Facility Evaluation

visit_type: Annual

met_with: Tracy Edwards, Program Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced inspection to the agency on 12/20/24 and met with Tracy Edwards, Administrator. LPA Hill made the inspection on this date to discuss with the agency changes in the intake procedures for the better assessment of youth being admitted into the facility and how the agency is looking to lower the incidents of calling on law enforcement partners. LPA Hill discussed that calls for law enforcement services has risen in comparison to previous years and requested that the agency provide a written assessment and training plan to address this rise in calls. LPA Hill is requesting that the agency assess how they can work with staff and agency management to mitigate the need for these calls. LPA Hill advised that it is imperative that the agency try to work with staff and local partners to reduce these calls for service. LPA Hill requested that the agency provide updated written intake procedures, update of the Neighborhood Complaint Procedures, and any/all procedures on how staff and management can mitigate the calls for service to Law Enforcement partners in the community. Exit interview was conducted and documents were provided.

visit_type: Case Management

met_with: Tracy Edwards, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 1/7/25 at 10: AM and met with Tracy Edwards, Administrator. LPA Hill informed Ms. Edwards that the purpose of the inspection was to discuss a serious law enforcement contact incident report that occurred on 12/30/24. The initial incident report was provided to the Department on 12/30/24. This incident resulted in the removal of two clients in care, C1 and C2 (see LIC811 dated 1/7/25). LPA Hill interviewed S2 who arrived after the incident had begun and after law enforcement was already on site at the facility. LPA Hill did obtain documentation for both youth while at the agency, including youths' Needs and Services Plans, Intake Assessments, and any risk assessments conducted upon placement for both youth. Placement was terminated for both youth at the time of their removal on 12/30/24. LPA Hill informed Ms. Edwards that this incident report needs further investigation at this time. Exit interview was conducted with Ms. Edwards and documentation was provided.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill conducted an unannounced case management inspection on 2/5/25 at 1: PM and met with Tracy Edwards, Administrator, to discuss the following issues: Cell phone policy. Cell phone policy includes discussions with youth during their Child & Family Team Meetings ensuring the policy is individualized for each youth in the program. When granted, youth must agree to usage policy including not having the phone until schooling, groups, and chores are done. Calling on law enforcement. The agency says they wait 30 minutes after losing sight of youth prior to calling law enforcement to assist, but there are exceptions such as when youth are seen getting into a vehicle or if youth are assessed to be at risk then they call immediately. Educating community partners for youth. LPA discussed how the agency is working and educating community partners about youth in their facilities. Ms. Edwards states they have not had an open of communication to bridge this gap, but is open to productive dialogue in hopes of forming working partnerships for the betterment of the youth served. Ms. Edwards states the agency is open to building a foundation of support within the community to ensure the safety and acceptance of the youth served. Discharge of youth following serious incidents. Ms. Edwards states that if a child has left the facility via law enforcement, they immediately contact the placing county to alert of what has transpired. If a client is deemed unable to return due to Health and Safety concerns with other youth, this is communicated to the placing county. Ms. Edwards reiterated that according to the regulations, they are able to make that determination if they feel it is unsafe for a youth to return to the facility and they make every effort to ensure the placing county is aware of the determination. Reimbursement for Services. LPA Hill spoke to Ms. Edwards about the communication related to unpaid or outstanding services for expenditures by the home county. Ms. Edwards states they have not received any communication from the county about any outstanding expenditures. Ms. Edwards indicated if they do get notification for any outstanding or unpaid expenses, they forward communications to the placing county where those expenditures are taken care of. Night Staffing Solutions. Ms. Edwards states that they are working on solution(s) to ensure situations involving youth during the hours of 10: PM to 6: AM are handled internally. Ms. Edwards hopes to provide viable solutions in the weeks to come. Agency wants to ensure they are following regulations set by statute but also understands the resource limitation. Youth Refuse to Return. Ms. Edwards asked about what happens if youth are walking away from the facility and are refusing to return to the facility despite staff following. Ms. Edwards states they continue to follow and provide support to youth but do not call law enforcement for assistance if they are with the youth or have the youth in sight. They continue to walk with youth and give them time to de-escalate. Should law enforcement happen on scene, they try to get youth to return with staff. Ms. Edwards states staff try to talk to youth while walking, giving support, and ask youth what they need in the moment. Ms. Edwards states they just sometimes need to walk until they are ready to return. There have been situations where youth request to go to juvenile hall refusing to return so some agencies oblige youth as many are in violation of their probation by leaving without authorization. Interventions. Ms. Edwards states they are constantly speaking with youth in an attempt to get them to stay and not leave the facility. Facility staff engage with youth, remind them of the program and goals, follow them so the facility does not have to report them in violation to their placement agencies. Ms. Edwards states a training is planned that would include Managing Runaway Behavior where staff are trained on immediate interventions to de-escalate situations in an attempt to get youth to stay. Collaboration Meeting. Ms. Edwards states the agency is open to working on communication and collaboration with the local law enforcement and Probation Department to provide information about youth served and how better to collaborate and work together on a community solution to issues and solutions that would serve the community while assisting the agency in serving the youth in care. Ms. Edwards states they would greatly appreciate CCL's assistance and attendance to initiate this process with the local law enforcement. Ms. Edwards states the agency is open to bridging gaps in the community and finding viable solutions including bridging gaps in communication and collaboration in all of these identified areas. LPA Hill did request that the agency supply a cell phone policy discussed during this inspection. No citations were issued during this inspection and this document was provided.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill conducted an unannounced case management inspection on 2/18/25 at 10: AM and met with Tracy Edwards, Administrator. LPA Hill conducted the inspection to provide findings related to an incident that took place at the facility on 12/30/24 in which C1 and C2 (see LIC811 dated 2/18/25) assaulted S1, were involved in property destruction and theft of staff's personal belongings resulting in S1 being unable to contact law enforcement or other staff for assistance in managing criminal behaviors of youth in care. The end result of this incident being C1 and C2 were arrested and charged with multiple crimes. Confidential interviews with staff about the state of the house included staff understood youth were hyper, but neither S1 or S2 thought things in the house would escalate as they did the evening of 12/29/24 into the early morning hours of 12/30/24. In discussing the incident with staff, information provided that youth were escalated, but were starting to calm down prior to S2 leaving the evening of 12/29/24. Shortly after S2 left, S1 and S2 were texting about youths' behaviors for over an hour, but S1 did not respond to S2's final text message. S2 did not notify anyone of S1's silence and learned of the reason for S1's lack of response in the morning hours of 12/30/24. As a result of C1 and C2's destruction in the facility, assault and threat to S1's safety and life, C1 and C2 were arrested and immediately removed from the agency and prohibited from returning to the facility. As a result of this incident, the staff stated they are hyper vigilant now with the youth and have a deeper understanding of their role and dangers in working with the vulnerable youth. The agency is acutely aware of the need of the youth and are staffing the facility according to the heightened need, including having additional staff in the house as needed, having additional on-call staff, and having a roaming supervisor to assist in either facility as needed on each shift. While the agency was staffed below the required ratio as they only had three youth in the facility during the overnight shift, they did underestimate this situation and vulnerability of the staff. Further review of incidents and interviews with staff indicated that S1 had been struggling with supervision of C1 and C2 in the facility since at least early December 2024 but did not request additional support nor did the agency recognize the need for additional staffing until after this serious incident. LPA Hill discussed with Ms. Edwards possibly implementing a plan of evaluation of direct care staff (coach counselors) by senior coach counselors to ensure staff are meeting expectations and additional training and/or counseling can be provided prior to encountering a serious incident such as this again. Administrator states they have provided all soothing plans to be in hard copy form and in the houses for all staff to review. This would help the staff who are not familiar with new youth or even existing youth and changes to their soothing plans. The plan includes student triggers and coping skills as identified by the youth in care and worked out by their therapist. LPA Hill issued a Technical Advisory (LIC AN). Exit interview was conducted with Ms. Edwards and documentation was provided.


summary: Facility Evaluation

raw_content:
Narrative:
A meeting was held via Microsoft Teams on 2/19/25 at 1: PM with representatives of Community Care Licensing, including Angela Carmack, Assistant Program Administrator, Margo Castaneda, Regional Manager, Jodean Hall, Licensing Program Manager, and Tamara Hill, Licensing Program Analyst, and representatives of Rite of Passage (ROP) Qualifying Houses, Lawrence Howell, Executive Director, Rebekah Graham, Regional Director, Jerry Crandall, National Compliance Director, and Tracy Edwards, Administrator. This meeting is being held to collaborate solutions for ongoing community grievances regarding ROP's operation of Short Term Residential Therapeutic Facilities in Alpine County. During this meeting, the following items were discussed: Alpine County District Attorney Public Nuisance - Community Care Licensing did advise the agency of Alpine County's intent to file public nuisance charges against ROP due to the number of calls for services in the county and the limited resources available to assist ROP with these calls. Management and Operations of ROP - The county's concerns for the types of children being accepted at the facility and officers walking into the facilities without knowing what they may encounter. The county was educated on the acuity of youth placed in the facilities and discussed with ROP is what the agency can do to provide collaboration with the county to mitigate some of the calls even follow up after calls. Overnight Staffing and Alternative Plans of Supervision - ROP discussed plans including floater staff between houses, additional overnight staff staying in a facility when youth exhibit escalated behaviors. Law Enforcement Meetings with ROP - The agency is open to collaborative meetings and additional collaboration and follow-up discussions following law enforcement contacts. Ambulance Billing - If CCL gathers information related to any unresolved fiscal responsibilities as indicated by Alpine County, this information will be passed along to ROP for resolution. Next steps will be for CCL to communicate with Alpine County to garner dates to be distributed for a meeting between CCL, Alpine County and ROP. End of meeting.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced tele inspection visit with Peter Woods, Assistant Administrator on 3/5/21 at 11: AM to discuss the findings of the investigation related to an incident that took place on 1/30/21 at the facility involving law enforcement. This incident was self reported by the facility. LPA informed Ms. Edwards that this inspection will conclude the investigation initiated 2/8/21 which included interviews with staff S1, S2, S3, S4 and S5 (see LIC811 dated 2/22/21) and youth C1, C2, C3, C4 and C5 from 2/8/21 through 2/17/21. The incident being investigated happened on 1/30/21 where evidence supports that S1 conducted an unreasonable search of C1's personal belongings resulting in an assault of S1 by C1. LPA informed Ms. Edwards that the purpose of the inspection was to discuss concerns that need to be addressed as they affect the health and safety or personal rights of the youth in the facility. Some of the concerns discussed during the inspection are: Ratio - the facility did not have the required staff to client ratios required. Searches - investigation shows that the search of C1's personal property was an unwarranted search. Check-ins - Per the discussion with the administrator, staff should be checking in with staff present when arriving for shifts. Investigation shows that this did not happen when S5 arrived to the facility for S5's shift on 1/30/21. Follow up - following serious incidents, the facility should conduct reviews and debrief of incidents with the staff present to ensure that everyone acted appropriately or to see if the facility could do something different or better to mitigate incidents in the future. Video Footage - LPA reviewed video footage of the incident during the investigation which supports the concerns related to ratios, searches, staff check-ins, follow up of incidents when they occur. LPA informed Ms. Edwards that the facility is being cited for violation of Short-Term Residential Therapeutic Program, Interim Licensing Standards 87065.5(a)(1) Direct Care Staff/Child Ratios. Review of the video camera footage, statements from the staff and youth present at the facility, S1 was alone with the youth for approximately 30 minutes which is a direct violation of the standards. LPA informed Ms. Edwards that the facility is being cited for Short-Term Residential Therapeutic Program, Interim Licensing Standards 87072(d) Personal Rights as Welfare and Institutions Code Section 16001.9(a) which provides youth with the right to be free from unreasonable searches of personal belongings. Investigation shows that the search conducted of C1's property was an unreasonable search. LPA informed Ms. Edwards that the facility is being cited for violation of California Code of Regulations, Title Division Six, regulation 80065(a) Personnel Requirements. Facility personnel shall be competent to provide the services necessary to meet individual client needs. Based on review of video footage and interviews conducted, S5 did not check in with S1 upon arrival to the facility and thus was not aware of the crisis happening in the facility. S1 and S2 did request that S5 contact for additional support and law enforcement more than three times. The response from S5 was "You don't have to yell at me!" rather than calling for support as needed. Exit interview was conducted with Ms. Edwards and documents were provided via email for signature and return. End of report.

met_with: Peter Woods, Assistant Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 9/1/22 at 1: PM and met with Tracy Edwards, Administrator. LPA Hill made this visit to the Administrative office location in Minden, Nevada as the youth were already on site at this location in attendance at school. LPA Hill made the visit today to conclude an investigation related to an incident that took place on 4/26/22 in the facility in which a male youth from another facility was able to enter the facility undetected. The male youth was in the facility for a couple of hours without staff knowledge. The initial inspection for this incident was conducted on 5/16/22. This report concludes the incident investigation. On 4/26/ C1 was found to have allowed another youth from another facility into this facility in the early morning of 4/26/22. The other youth was found in the same bed with C1 at 4: AM. Upon further investigation of the incident at this location and the other facility, investigation shows that staff were not performing the bed checks per the company policy in that they were to observe bed checks every 15 minutes and seeing skin. Staff present at the facility on the evening of 4/25/22 to 4/26/22 did not observe that two of the youth in this facility were not in their respective beds or rooms nor did staff investigate further when noticing that there was a "bulge" in the bed covers that later turned out to be a male youth in the bed with C1. The male youth then went out the bedroom window and left this facility and returned to their own facility. Based on the investigation, interviews conducted and incident reports reviewed, staff did not supervise the youth as necessary. As a result of this, the facility was cited for Title 22, California Code of Regulations, General Regulations, 80078(a) Responsibility for Providing Care and Supervision as staff failed to supervise youth appropriately on 4/26/22 leading to a male youth being able to enter and be at the facility for approximately four hours. Exit interview was conducted and documents and appeal rights were provided to Ms. Edwards via email.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 7/25/23 at 9: AM and met with Tracy Edwards, Program Manager. The purpose of the inspection is to discuss an incident that took placed at the facility on 7/10/23, in which C1 (see LIC811 dated 7/25/23) was removed from the facility by local law enforcement and taken to juvenile hall. The report received by the agency details that there were three staff present when an altercation ensued with C1 being found to be in possession of a weapon and threatening other youth in the house with this weapon. Law enforcement was called and when C1 failed to respond to law enforcement's instruction to put the weapon down, C1 was arrested and taken to juvenile hall. LPA Hill also learned that during this incident, S1 restrained C2 during the original incident with C1 as C2 was instigating the incident with C1 and S1 was attempting to remove C2 from the area where C1 was at. LPA Hill obtained all staffs' written accounts of the incident during the inspection. LPA Hill observed that S1's description of their part in the incident and S1's account of their own behavior is not in align with the policies and procedures of the facility nor an appropriate intervention supported or taught by the agency as S1 detailed that they "pulled [C2] from [their] shirt" so C2 took off their shirt. S1 then "tried to pull [them] from [their] bra" and C2 then took off one side of their bra. S1 then grabbed C2 by the waist to pull them from the room without being able to get C2 out of the room. S1 then "pushed [C2] with all [S1's] force" to get C2 out of the room. S1 resigned their position with the agency. When interviewed, Ms. Edwards states that S1 had already given a resignation notice when this incident took place, but did work for two additional shifts. LPA Hill informed Ms. Edwards that as a result of the investigation into this incident, the facility was cited for 87095.61(a) Documentation and Reporting Requirements because regulations require that each use of manual restraints must be reported to the Department and the child's authorized representative by telephone no later than the next working day following the incident. There is no evidence that a report was submitted for the restraint, regardless of the restraint not being an agency approved restraint.

met_with: Tracy Edwards, Program Manager


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an announced case management inspection to the administrative offices for Rite of Passage in Minden, NV to meet with Tracy Edwards, Program Director to discuss the following issues: LPA Hill informed Ms. Edwards that the inspection is related to the follow up on an incident involving C1 (see LIC811 dated 4/10/24) spitting in other youths' food while at the facility and/or putting chemicals used in the cleaning of the facility in the youths' foods. During confidential interviews, it was revealed that during the evening program in the house with the youth, staff usually are busy trying to get chores completed, complete paperwork necessary for the shift, supervising youth, allowing phone calls, etc. and that in doing all of these things, are not constantly supervising youth in the kitchen. It was reported that it is normal to have two staff on the PM shift and that in having these two staff, one is usually doing paperwork while seated at the computer desk in the living room and the other is either upstairs supervising youth, in the den, assisting with chores, or other tasks that leave the youth frequently unsupervised in the kitchen while preparing dinner for the youth in the house. In addition, staff and youth interviews concluded that chemicals used in the cleaning of the facility are usually taken out and left accessible to youth in care until the end of the PM shift or until all chores are completed making them accessible to put in youths' food. As a result of the investigation, interviews conducted and documentation reviewed, it is the conclusion of CCL that the facility has demonstrated a lack of supervision that allowed these incident(s) to happen. The facility was cited per California Code of Regulations, Title 22, General Licensing Standards, Section 80087(a) Responsibility for Providing Care and Supervision as the licensee shall provide care and supervision that meets the needs of the clients in care. Due to a repeat violation within 12 months, an immediate civil penalty is assessed in the amount of $250 and $100 per day until the violation is corrected. See LIC FC. In addition, during the investigation of these incident(s), it has come to Licensing's attention that staff were aware of some inappropriate activities happening in the facility including some of the youth exposing their buttocks while in the facility and outside of the facility during walks, youth inappropriately hitting other youth on the buttocks, in the chest area, etc. While some of these incidents were reported to Licensing, LPA Hill did find incidents regarding C3 and C4 that were not reported to Licensing as required. As a result of these incident(s) not being reported as required, the facility was cited for not reporting per per California Code of Regulations, Title 22, General Licensing Standards, Section 80061(b) Reporting Requirements. Exit interview conducted with Ms. Edwards and documentation provided, along with appeal rights.

met_with: Tracy Edwards, Program Director


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
While S1's termination documentation indicated S1 was not holding youth in care accountable and that the job was "overwhelming" and that they were "unable to fulfill the responsibilities" of the job. Additional investigation by the agency indicated that S1 was providing at least one youth in care with contraband including an unauthorized cell phone, nicotine and marijuana vaping device(s). LPA Hill attempted to contact S1 several times for interview during the course of this investigation, but S1 did not respond to the LPA's requests for interview. LPA Hill did observe that the facility did not report this incident to the placing county, local Child Protective Services, or Community Care Licensing. Investigation showed that S1 provided a youth in care with a cell phone to assist the youth in directly contacting an individual, not associated with Rite of Passage, to provide nicotine and marijuana vaping device(s) for purchase. Confidential interviews determined that these devices were delivered to this youth in care by S1. Based on review of the documentation obtained, the allegation that staff provided nicotine and nicotine vaping devices to youth in care and that staff's behavior poses a risk to minors is SUBSTANTIATED meaning the "preponderance of the evidence standard" has been met. The facility was cited for violation of Title 22, Division 6, Article 6, General Regulation 80078(a) Responsibility for Providing Care and Supervision as S1 did not provide the services necessary to meet the needs of youth when providing youth in care with nicotine and marijuana vaping devices. In addition, LPA Hill cited the agency for failure to report the incident per Title Regulations Section 80061(b)(1)(E) as the agency did not provide the 24 hour report or the seven day written report as required by this regulation. Exit interview was conducted and documents were provided to Ms. Edwards along with appeal rights. End of documentation.

Investigation Findings:
13This document was amended on 4/17/26 at 2: PM by LPM Tamara Hill. Licensing Program Analyst (LPA) Tamara Hill conducted an unannounced complaint inspection on 7/23/25 at 9: AM and met with Tracy Edwards, Administrator. LPA Hill conducted an initial complaint investigation on 6/26/25 and a subsequent inspection was conducted on 7/17/25 to interview staff and 7/21/25 and 7/23/25 to interview youth. The allegations that staff are providing access to marijuana and vaping devices to youth in care and staff behavior poses a risk to minors is related to a disclosure made by a youth in care that S1 (see LIC811 dated 7/23/25) provided nicotine and marijuana vaping device(s) to youth in the facility. LPA Hill obtained documentation related to S1's termination of employment indicating S1 was terminated on 6/19/25. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Danielle Walker-Flores LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE FREELFACILITY NUMBER: VISIT DATE: 07/23/2025

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

report_type: Complaint Investigation

complaint_status: SUBSTANTIATED


facility_name: ROP QUALIFYING HOUSE MT. RUBY

raw_content:
Narrative:
The allegation that staff gave a foster child non-prescribed medication for illicit use is related to C1 obtaining pills from S1. While S1 denied giving the medication to C1, S1 did tell law enforcement that C1 might have "helped themselves to S1's medications". Without information from S1, there is no plausible explanation for C1 to have knowledge of S1 taking any medication, of C1 knowing that S1 had medication in the facility or knowing what medication(s) S1 was taking. As a result of the investigation and interviews conducted, the allegations that staff sexually abused a foster child and that staff gave a foster child non-prescribed medication for illicit use are SUBSTANTIATED at this time meaning that the allegation is valid because the preponderance of the evidence standard has been met. Facility was cited for Interim Licensing Standards 87072(d)(11) Personal Rights. The facility has a responsibility to accord personal rights to all children in care including the right to be free of physical, sexual, emotional, or other abuse... investigation showed that S1 sexually abuse C1 in the facility. Facility was cited for Interim Licensing Standards 87065.2(b)(1) Personnel Duties. The facility did not employ staff to appropriately supervise, protect, and care for children living in the facility at all times in that S1 provided non-prescribed medication(s) for illicit use to C1 while at the facility. Exit interview was conducted with Ms. Edwards and documents provided at the conclusion of the inspection.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 10/20/21 at 9: AM and met with Tracy Edwards, Administrator to discuss the findings for the complaint allegations as stated. LPA informed Ms. Edwards that the investigation included an initial complaint inspection on 7/8/21 by Investigator Juan Barajas. All interviews with staff, clients, law enforcement, social workers, reporting party and other personnel was conducted by the Investigations Branch for the Department from 7/8/21 to 9/30/21. The allegation that staff sexually abused a foster child is related to a disclosure made on 6/30/21, by C1 (see LIC811 dated DATE) that C1 had engaged in sexual intercourse with S1 in the staff room at the facility. When interviewed by law enforcement, S1 admitted to investigating officers on 6/26/21, that this allegation was true. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., Ste Sacramento, CA Facility Name: Rop Qualifying House Mt. RUBYFACILITY NUMBER: VISIT DATE: 10/20/2021

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


raw_content:
Narrative:
Confidential interviews revealed that S1 told numerous youth that upon completion of their program, they could return to Nevada to live with S1. Interviews revealed that there was no discussion of anything sexual but that they didn't know S1's intentions, making them feel uncomfortable at the mention of this. When staff were interviewed, they informed LPA that there was a company policy prohibiting contact with youth following their exit from the program without notification and written approval by management. Interviews revealed that S1 has not disclosed this offer to management nor had there been any written permission allowing S1 to discuss this with youth in the program. Another incident of youth not feeling comfortable was when one youth was taken into the staff room to do a hair cut and being one on one with S1 in the staff room. While youth reported that nothing happened in the staff room, company policy states the staff room as an "off limits" area for youth. Youth know this which made the youth feel uncomfortable since the other hair cuts being done in the home were done in the dining area. The next allegation is about S1 "spatting water" in youth's face during a walrus impression joke. This incident had no direct witnesses and S1 failed to provide a statement related to this incident. The final allegation that S1 threatened youth, is related to S1 telling youth that if they misbehaved or didn't do as S1 asked, S1 would get their friends in law enforcement in the area to come over and taze them. Youth also reported that S1 asked them to help S1 get information on other staff to get them fired. S1 allegedly told youth that they planted contraband in youth's possessions and took photos to provide to management to sabotage youths' program. There is no evidence any of this happened and S1 failed to provide a statement. During the course of the investigation, a youth alleged that S1 hit them with a belt one evening while in their own room and out of sight of cameras at the facility. The youth claimed to have not disclosed this happening because S1 told youth that they would not be believed. Youth also stated they were not a snitch and could handle it themselves. During interviews, another youth in the home disclosed hearing the belt strike the youth and heard the youth get upset and scream at S1 for striking them with the belt immediately after it happened. A staff also alleged that S1 bragged about striking another youth in the stomach. While there is not a significant amount of evidence in all of these allegations, the totality of the allegations and the number of recounts of the same or like information that came out as a result of the investigation demonstrates the overall character of S1. In addition to S1 not making themselves available to provide input despite the multiple attempts by LPA Hill, give preponderance to the allegations against S1. As a result of the information disclosed and the lack of response from S1, the allegations that S1 violated youth's rights, spat in a youth's face, and threatened or intimidated youth are SUBSTANTIATED meaning that the "preponderance of the evidence" standard has been met. The facility was cited for Personal Rights 87072(a)(11) as children have the right to be free physical abuse, intimidation, threat, ridicule, and coercion. On at least one occasion, S1 struck a youth in care with a belt. S1 also disclosed to a staff that they had punched a youth in the stomach. S1 intimidated and threatened youth in care to have friends in law enforcement come to the facility to taze youth to get youth to comply and behave. S1 also intimidated and threatened youth to plant contraband in their possessions to get them into trouble or to fail their program. Exit interview was conducted and documentation was provided to the facility.

Investigation Findings:
13Licensing Program Analyat (LPA) Tamara Hill made an unannounced complaint visit to Business Park Drive, Minden, NV on 3/2/22 at 12: PM and met with Tracy Edwards, Administrator to discuss the findings. LPA informed Ms. Edwards that the initial investigation of the allegations occurred on 11/23/21. LPA interviewed children and staff at the school site on 11/23/21. LPA interviewed additional staff via phone on 2/10/22 and attempted to contact S1 eight times from 2/11/22 to 2/23/22, using email, text messages and phone messages. LPA did speak with S1 on 2/18/22 and S1 stated that they were sick with COVID since 2/11/22. LPA asked staff to please contact LPA on 2/22/22 to discuss a time and date to conduct an interview to allow S1 to give input about the allegations. LPA then contacted S1 via text message and phone message on 2/23/22, but S1 did not respond to the multiple requests for interview. The first allegation is related to S1 violating personal rights of youth in care. Youth reported feeling uncomfortable around S1 due to some of the following issues. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., Ste Sacramento, CA Facility Name: Rop Qualifying House Mt. RUBYFACILITY NUMBER: VISIT DATE: 03/02/2022

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


raw_content:
Narrative:
C1 was observed to be red in the face and have a swollen or bloody lip following the incident. It was also alleged that this incident was not reported to Licensing as required. LPA obtained a copy of a draft incident while at the agency on 5/16/2022. This report was not sent to Licensing. When staff reviewed the cameras at the facility, it was disclosed that there were no staff supervising the youth in the living area at the time of the incident which allowed the youth the opportunity to step outside, outside of view of any cameras at the facility, and engage in the altercation. As a result of the interviews conducted and review of the cameras, the allegations that there was a lack of supervision allowing the youth to engage in a physical altercation and that the facility failed to report the incident to Licensing as required are SUBSTANTIATED at this time meaning that the "preponderance of the evidence" standard has been met. The allegation that a lack of supervision resulted in a youth to leave the facility undetected is related to an incident that happened on 4/26/22 in which C2 was able to leave the facility and be gone for multiple hours without staff knowing. When interviewed, C2 admits to leaving the facility around midnight on 4/26/22 but S1 failed to notice that C2 was gone until AM. When the administrator reviewed the cameras for the evening of 4/25/22 to the early morning of 4/26/22, S1 failed to conduct the nightly checks according to the agency policy which requires youth to be checked on every 15 minutes and for staff to verify that they see skin when checking on youth. As a result of the information obtained and interviews conducted, the allegation that a lack of supervision resulted in a youth leaving the facility undetected and being gone for hours is SUBSTANTIATED at this time meaning that the "preponderance of the evidence" standard has been met. As a result of the allegations substantiated, the facility was cited for Title 22, California Code of Regulations, General Regulations, 80078(a) Responsibility for Providing Care and Supervision as staff failed to supervise youth appropriately to prevent an altercation that took place on 5/5/2022 between C1 and C2, out of camera view and with no staff present. In addition, staff failed to appropriately supervise youth on 4/26/22 leading to C2 being able to leave the facility undetected and being gone for approximately two hours prior to staff knowing. The facility was also cited for Title 22, California Code of Regulations, General Regulations, 80061(a) Reporting Requirements as the agency failed to report the altercation between C1 and C2 that happened on 5/5/2022. The incident was not provided to Licensing until LPA Hill obtained a copy while initiating the complaint investigation on 5/16/2022. Exit interview was conducted with Ms. Edwards and documents were provided via email along with appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 9/1/22 at 11: AM and met with Tracy Edwards, Administrator to discuss the findings of the allegations. LPA Hill informed Ms. Edwards that the complaint investigation included an initial inspection at the facility on 5/16/2022 and collateral inspection at the administrative offices in Minden, NV, to interview staff and clients involved in the incidents. LPA interviewed C1, C2, and C3 (see LIC811 dated 9/1/22) and staff while at the administrative offices and obtained documentation related to the clients and incidents under investigation. LPA informed Ms. Edwards that the allegation regarding lack of supervision resulting in a serious altercation between clients happened on 5/5/2022 while at the facility in which two clients stepped out on the back patio of the facility and engaged in a physical altercation without staff detection. When interviewed, the clients refused to disclose that anything had happened but there was evidence that something had happened as SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., Ste Sacramento, CA Facility Name: Rop Qualifying House Mt. RUBYFACILITY NUMBER: VISIT DATE: 09/01/2022

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


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
neighbors, with the youth present, telling the neighbor to "take [their] racist ass back home" as they thought the youth walking were being racially targeted by the neighbors. Staff admitted to making the inappropriate comment out of anger toward the neighbors due to the perceived racial targeting. During confidential interviews, it was confirmed that S1 did make the inappropriate statements to the neighbors instead of attempting to intervene in an appropriate manner or attempting redirect the youth back to the facility without a confrontation. As a result of the confidential interviews and information received, the allegation that staff shouted racial epithets at the neighbors, is SUBSTANTIATED meaning that the "preponderance of the evidence" standard has been met. Facility was cited for violation of Short Term Residential Therapeutic Program, Interim Licensing Standards, Section 87072(c)(10) Personal Rights as youth are to be accorded the right to dignity in their personal relationships with staff and other persons. This did not happen as the youth were subjected to an inappropriate interaction between the staff and the neighbors. Exit interview was conducted and documentation was provided to the facility. The allegation about the staff not supervising the youth is related to whether or not staff were supervising youth while they were walking on the street and playing ball in front of the facility. Confidential interviews were not consistent about where staff were at to supervise the youth while the youth were on the street walking and playing ball. Some of the interviews stated that the staff were not present but other interviews stated that the staff were supervising the youth from the facility driveway as they walked approximately 300 yards down the street as part of their exercise program and played ball in front of the facility. The allegation that the facility is not adhering to the good neighbor policy relates to two separate issues wherein the community members feel that the youth and staff working in the facility are not being friendly to the neighbors, not respecting the right to privacy, and being respectful of local ordinances where the facility is located. While the good neighbor policy is not addressed in Title Regulations and thereby not a violation of the regulations that govern the facility, these incidents could have been addressed within the facility's Neighborhood Complaint Policy, the community members could have contacted a facility representative when these issues surfaced. Community members have expressed concern that they have brought issues to the attention of staff at the facility but the information reportedly is not being provided to the administrative staff. The facility shall provide Neighborhood Complaint Policy to neighbors/community members for future reference. As a result of the investigation conducted, confidential interviews, and other documentation received, the allegations that youth were wandering unaccompanied by staff and that the facility was not adhering to a good neighbor policy are UNSUBSTANTIATED at this time meaning that the allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview was conducted and documentation was provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 6/27/23 at 2: PM and met with Tracy Edwards, Program Director/Administrator to discuss the findings of the allegation as stated. LPA Hill informed Ms. Edwards that the investigation included an initial inspection on 4/26/23, where three youth and three staff persons were interviewed. LPA Hill requested a copy of the police report from Alpine County Sheriff's Office on 4/26/23, for an incident that occurred on 4/11/23. The police report was received 4/27/23. A subsequent inspection was conducted on 6/6/23, where personnel records were reviewed. LPA Hill informed Ms. Edwards that the allegation that staff shouted racial epithets at the neighbors is related to an incident that took place in front of the facility on 4/11/23, where the youth were stopped by the neighbors while walking on the street. S1 (see LIC811 dated 6/27/23) subsequently confronted the SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., Ste Sacramento, CA Facility Name: Rop Qualifying House Mt. RUBYFACILITY NUMBER: VISIT DATE: 06/27/2023

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:

complaint_status: unsubstantiated


raw_content:
Narrative:
current psychiatrist was terminating their contracted psychiatry services as of August 2023. In July 2023, the agency found and began the process of on-boarding a new psychiatrist, but the process was lengthy, and the agency did not have the new psychiatrist on board until November 2023, meaning the youth did not have the required monthly psychiatry consultations for the months of September 2023 and October 2023 but the agency continued to accept youth, specifically, C1 (see LIC811 dated 3/25/24) was admitted 10/23/23. The agency was able to provide documentation including emails and correspondence between the agency's HOS, Placer County, the new contracted provider, Health Link Now, and the psychiatrist from July 2023 through November 2023, indicating that the agency was actively trying to get the new psychiatrist through the contract and on boarding process to provide services to youth in care. In addition, in anticipation of not having the psychiatrist on board in time, Head of Service (HOS) did reach out to Barton Psychiatry in South Lake Tahoe on 8/5/23 but were informed that the wait time would be until January 2024, and Washoe County (Nevada) Behavioral Health informed the agency that they could not provide services to the agency's youth. HOS presumed this was due to the youth being California youth and not from Nevada. The new psychiatrist was providing psychiatry services to youth in care as of November 14, 2023. LPA Hill was informed that during the time with no psychiatry services, the agency had prepared in advanced and did have prescription refills for all youths' medications and no youth went without medications or had lapses in medications during the months of September 2023 or October 2023. The allegation that the facility did not ensure client's medical and/or mental health needs were met is related to the same allegation as stated regarding youth having the required psychiatry consultations prescribed in regulation. When reviewing C2 and C3's paperwork, it was indicated that all medical and mental health services were provided except for the psychiatry consultations as described. C1 was admitted in the facility and did have the required psychiatry appointments as required as they were part of C1's negotiated services with the placement agency. Interviews indicate that the facility did ensure all youth had consultations with doctor, dentist, and optometry as needed while at the facility and that the agency did ensure that therapy, and other mental health services were being provided during youths' time at the facility. As a result of the investigation, documentation received, interviews conducted, the allegations that the facility did not provide clients in care with consultation from a psychiatrist as required and that the facility did not ensure medical and/or mental health needs were met is UNSUBSTANTIATED at this time as the facility did employ active efforts in locating and on boarding the new psychiatrist and were providing other mental health services to youth in care. Unsubstantiated means that the allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. Exit interview conducted with Ms. Scott and documentation provided, including appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 3/25/24 at 3: PM and met with Alina Scott, Head of Service to discuss the complaint findings as stated. LPA Hill informed Ms. Scott that investigation included an initial inspection at the facility on 10/27/23 and subsequent inspection 2/15/24. Two youth were interviewed 11/17/23 and the placing agency Public Health Nurse was interviewed 1/11/24. The facility administrator and Head of Service were interviewed 2/15/24. Documentation received including placement documents, Needs and Services Plans, and documentation related to the agency's efforts to onboard a psychiatrist dating from July 2023 to November 2023. The allegation the facility did not provide clients in care with consultation from a psychiatrist as needed is related to the facility not having a contract with a psychiatrist and youth not being provided the psychiatry appointments for the months of September 2023 and October 2023 as required by regulation. Confidential interviews conducted demonstrated that the agency was given a 60-day notice in June 2023 that their UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE MT. RUBYFACILITY NUMBER: VISIT DATE: 03/25/2024

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

met_with: Alina Scott, Head of Service


raw_content:
Narrative:
August 2024, not all youth were immediately assigned to the new therapist, S2. When it was finally decided to assign all youth to S2 and begin their transition, S2 noted that there were three to four weeks' of missing or undone therapy documentation to facilitate this change in therapists. S2 noted that in discussing this with the agency's management, S2 was directed to "start new" with all of the youth being added to S2's caseload, which was about half of all the youth they had in care at that time. S2 indicates that this meant going back and completing documents for all youth as if they were brand new, even if they had been in care for some time, as there were incomplete and/or undone documented therapy notes. Subsequent interviews with other agency personnel indicates that the agency will not be returning S1 to their employment position within the agency. As a result of interviews conducted and documentation reviewed, the allegation that staff did not ensure that youth are provided mental health services is SUBSTANTIATED at this time meaning the "preponderance of the evidence" standard has been met. The facility cited for Interim Licensing Standards for Short Term Residential Therapeutic Programs, regulation 87072(d): Personal Rights. Youth have the right to access and receive medical...mental health, and substance use disorder services...with reasonable promptness that meets the needs of the child...Confidential interviews conducted with staff and youth in care indicate that youth were without mental health services, specifically therapy sessions, for three to four weeks. Further interviews indicate when therapy sessions did resume for youth in care, there were therapy session notes not documented as required by the previous therapist for a reported period of up to four weeks. Exit interview was conducted and documentation was provided to Ms. Edwards.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 1/7/25 at 10: AM and met with Tracy Edwards, Administrator, to discuss the findings of this complaint investigation. LPA Hill informed Ms. Edwards that the complaint investigation included an initial inspection of the facility on 9/5/24, with subsequent collateral inspections to the administrative offices on 9/20/24, 10/25/24, and 11/26/24, where interviews were conducted with administrator, therapist, and youth in care. During the course of the investigation, LPA Hill also interviewed youths' social workers. The allegation that staff did not ensure that youth are provided mental health services is related to the youth in care not being provided therapy as dictated in the agency's program statement. While the documentation provided indicates that some youth were seeing the previous therapist, S1, who went out on leave in SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE MT. RUBYFACILITY NUMBER: VISIT DATE: 01/07/2025

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


raw_content:
Narrative:
Facility staff acknowledge that they knew about C1's desire to exit the program as soon as possible but had not communicated directly with a responsible party to arrange for exit or transportation. C1 had a visitation scheduled at the school site with another family member on 8/31/24, where C1 was going to ask that family member for a ride back to the family's home. The agency made tentative alternate plans to provide the transportation for the youth to the family's home on 9/3/24, if the family member did not agree to provide that transportation. During the investigation, it was discovered that staff did not communicate discharge plans, including the family member transporting C1 from the program, with C1's parent/guardian to ensure that C1 had a place to stay upon arrival. Further confidential interviews indicate that the relationship between C1 and their parent/guardian was "difficult", and staff did not verify that this was an appropriate plan for C1 at the time of their discharge. As a result of the lack of an appropriate discharge plan, C1 left the facility on an unauthorized absence and when law enforcement was called and subsequently arrived, they provided transportation to C1 to a public location where C1 was left. As a result of the investigation and documentation provided, the allegation that staff did not assist C1 with their transportation needs while in care is SUBSTANTIATED meaning the "preponderance of the evidence" standard has been met. Facility was cited for Interim Licensing Standards, regulation 87068.4(c) Removal and/or Transfer Procedures as the short-term residential therapeutic program shall provide trauma-informed support and transition services including the alignment and coordination of transportation and other foster youth services as required. The facility identified that C1 was going to exit the program but did not arrange the transportation services needed for that transition. Exit interview conducted with Ms. Edwards and documentation was provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 1/7/25 at 10: AM and met with Tracy Edwards, Administrator, to discuss the findings of this complaint investigation. LPA Hill informed Ms. Edwards that the complaint investigation included an initial inspection of the facility on 9/5/24, with subsequent collateral inspections to the administrative offices on 10/25/24, and 11/26/24, where interviews were conducted with administrator and therapist, and documents were obtained. During the course of the investigation, LPA Hill attempted contact with C1 (see LIC811 dated 1/7/25) and C1's parent but they did not respond to LPA Hill's calls. The allegation that staff did not adequately assist C1 in their transportation needs while in care is related to the facility not arranging for C1 to exit the program despite knowing that C1 had expressed their desire and intent to leave the program once they became of age to make that decision. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE MT. RUBYFACILITY NUMBER: VISIT DATE: 01/07/2025

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


raw_content:
Narrative:
The allegations that staff did not prevent clients from having access to medicine is related to reports from clients in care that C3, C6, and C7 (see LIC811 dated 2/6/25) brought in over the counter medications without authorization or knowledge of the facility staff and administration. Confidential interviews revealed that clients found it "easy" to steal the over the counter medication when going into stores during outings. Some clients brought the over the counter medication from home visits or were accessing the over the counter medication from the facility's medication box when administering medication for clients. The allegation that staff smoke with clients in care is related to the allegation that staff member(s) have provided vape pens containing nicotine products and wax pens (also called weed pens, dap pens, or vapes containing cannabis products) to clients in the facility. Confidential interviews indicated that clients were being provided these items to smoke or ingest by staff working at the facility. While the named staff person(s) declined to be interviewed, the confidential client interviews revealed that more than one client received or used these devices as offered or provided by the staff person(s) while working at the facility. The allegation that staff make inappropriate comments towards clients is related to remarks made by staff person(s) that are not trauma informed. Confidential interviews indicated that while most staff are interacting with clients in a trauma informed manner, not all staff are using trauma informed language when interacting with clients. Confidential interviews with clients indicate that some staff do make remarks to clients when frustrated or overwhelmed. Confidential interviews indicate some of the remarks made to clients include that clients need to "stop bitching", threats to "beat [client's] ass", making disparaging remarks about client's biological families, "catch their fade" (meaning to fight them or be prepared to get beat up), to name a few. The allegation that staff are disclosing personal information about client(s) is related to an allegation that S7 disclosed personal and sensitive information about client(s) either in conversations with staff where clients were present to hear or directly to other clients in care. Confidential interviews with clients revealed certain information was only disclosed to S7 during confidential therapy sessions but revealed to other clients during their confidential sessions. Confidential interviews with staff indicated that information disclosed during confidential therapy sessions was also disclosed to staff working directly with clients in care. The allegation that staff did not prevent a client from contaminating another client's food is related to an allegation previously investigated on April 10, 2024. This investigation resulted in a citation for not providing supervision during food preparation. As a result of the investigation conducted and citation issued, this allegation was not investigated again as there was no new evidence provided. As a result of the investigation conducted by the Department's Investigation Branch and by LPA Hill, including an investigation by the Investigation Branch, confidential interviews of staff and clients, and review of the documents obtained, the allegations that staff did not prevent minors from accessing a drug, from having access to medication, staff smoking with minors in care, staff making inappropriate comments towards minors, and staff not preventing a client from contaminating another client's food are SUBSTANTIATED meaning the "preponderance of the evidence" standard has been met. The facility was cited for violation of Title General Regulations, Section 80087(g) Buildings and Grounds as the facility shall store items inaccessible to clients that could pose a danger if readily available. This was not done as evidenced by clients having access to ingest or "snort" a drug and/or medication. The facility was cited for violation of Title General Regulations, Section 80078(a) Responsibility for Providing Care and Supervision as the licensee did not provide care and supervision as necessary to meet the client's needs including an environment free of substances or other unauthorized items, including but not limited to vape pens and/or wax pens. The facility was cited for violation of the Interim Licensing Standards, Section 87072(c)(1) Personal Rights including the right to live in a safe, healthy, and comfortable home where they are treated with respect. The licensee did not provide a safe environment where comments and remarks made by staff interacting with clients are trauma informed and culturally relevant. Exit interview was conducted with Ms. Edwards and documentation was provided. wish to speak to probation officers, social workers, attorneys, or other similar individuals, they are given access to make phone calls while at school. While clients may be directed to wait to use the phone for a period of time, they are not denied access to phone use. The allegation that staff threaten client(s) is related to allegations that staff make threats to clients if they tell supervisors or administrative staff about things that happen in the facility. Some of the identified remarks included but were not limited to being in possession of unauthorized items while working at the facility including vapes, clients being disobedient when given direction by staff, or other staff experiencing frustration towards clients during situations happening. While confidential interviews of the clients in care indicate that staff can get "snippy", are short, and make remarks to youth, there were other confidential interviews indicating that staff are kind, gentle, and trauma informed. The allegation that staff did not prevent clients from accessing drugs is related to an allegation that one client brought an illegal substance into the facility that was later ingested by that client and another client while in the facility. Confidential interviews with both clients provided conflicting stories about being in possession of or ingestion of the illegal substance. Staff interviewed indicated they had no knowledge of an alleged illegal substance in the facility until it was alleged by another client in crisis. There was no evidence or additional interviews that could corroborate this allegation. As a result of the investigation, including interviews conducted with staff and clients, the allegations that staff denied client(s) access to a telephone, staff threatened client(s), and staff do not prevent clients from accessing an illegal substance (drug) are UNSUBSTANTIATED at this time meaning the allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview was conducted with Ms. Edwards and documents provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 2/6/25 at 9: AM and met with Tracy Edwards, Administrator, to discuss the complaint allegations as stated. LPA Hill informed Ms. Edwards that the complaint investigation included an initial inspection at the facility on 9/5/24 and collateral inspections were conducted on 10/25/24 and 11/26/24. The complaint was referred to the Department's Investigation Branch, Investigator Austin Blatnick completed a partial investigation while LPA Hill conducted the remaining investigation. In total, seven youth and nine staff were interviewed. Investigator Blatnick investigated allegations including staff not preventing clients from having unauthorized access to medication and staff smoking with clients. LPA Hill investigated allegations including inappropriate comments being made to clients, personal information being disclosed to unauthorized staff or youth in care, and staff not preventing a client from contaminating another client's food. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE MT. RUBYFACILITY NUMBER: VISIT DATE: 02/06/2025

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


raw_content:
Narrative:
occurred as a result of trying to get youth out of the house to go to school in the morning. Staff reported that while C1 was challenging to get up and motivated, C1 was in the restroom with another youth getting ready with the door closed and locked. S1 knocked on the door of the restroom to request that the door be opened as the youth are prohibited to have more than one in the restroom at a time. When youth failed to open the door, S1 allegedly continued to knock and bang on the door to get youth out of the restroom. C1 opened the door swinging and struck S1 in the face. It was alleged that S1 hit C1 back and attempted to restrain C1 during this interaction. Immediately following the interaction, S1 called law enforcement and reported they had been assaulted in the facility. Confidential interviews of staff and youth in care revealed that while C1 was frequently a challenge both physically and verbally towards staff and other youth in care, C1 seemed to "bump heads" more with S1 than other staff in the facility. Staff indicated that S1 was typically sweet but S1 was unable to maintain their own composure at times making things harder in the facility with the youth. Staff indicated that when they observed that S1 was struggling with C1, they would step in to assist in diffusing situation(s). Staff admitted that while this didn't happen all the time, it was frequent enough that staff knew to watch for this during their shifts with S1 in the facility, and particularly when S1 worked with C1. Staff reported they did not feel that S1 was abusive but did feel that S1's inability to be trauma informed or with this population ultimately lead to S1 leaving the agency after this incident. As a result of the investigation, documentation received, and interviews conducted, the allegations that facility staff handle minors in a rough manner and that staff do not speak to minors with dignity and respect are SUBSTANTIATED at this time meaning the "preponderance of the evidence" standard has been met. The agency was cited for violation Interim Licensing Standards, Section 87072(c)(1) Personal Rights as the licensee is to ensure that youth are able to live in a safe, healthy, and comfortable home where they are treated with dignity and respect. As a result of this incident, C1 was not accorded their personal rights per this regulation as evidenced by the staff and administration at the facility knew that S1 struggled with interactive supervision and harm reduction while working with youth in care and did not provide additional training to ensure S1 was implementing training in a trauma informed manner with youth in care. Exit interview was conducted and documentation was provided, along with appeal right to Ms. Edwards.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill conducted an unannounced complaint inspection on 5/30/25 at 11: AM and met with Tracy Edwards, Administrator to discuss the findings of the allegations stated. LPA Hill informed Ms. Edwards that the complaint investigation included an initial inspection at the facility on 2/28/25 where four youth were interviewed. LPA Hill conducted interviews with staff, reporting party, and C1 (see LIC811 dated 5/30/25) from 2/26/25 to 5/21/25. LPA Hill attempted to contact S1 but was unable to obtain a statement. The allegation that facility staff handle minors in a rough manner and that staff do not speak to minors with dignity and respect is related to an incident that occurred on 11/22/24 in which C1 and S1 were involved in a physical altercation at the facility. Confidential interviews conducted revealed that the reported incident SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE MT. RUBYFACILITY NUMBER: VISIT DATE: 05/30/2025

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


raw_content:
Narrative:
it was reported that S1 did not supervise C1 and C2 while they were in or near the alcohol isle in the store. While unsupervised, youth were able to hide four bottles of alcohol on their persons and leave the store with the items undetected. Once back at the facility, C1 and C2 consumed the alcohol and left the facility without permission. Once youth returned to the facility with the assistance from law enforcement, one youth engaged in dangerous behaviors including injuring themselves and attempting to injure S2 and S3 and law enforcement already present at the facility. S1 was placed on immediate suspension and removed from the facility and later terminated as of 7/17/25. As a result of the investigation conducted including interviews with clients and staff, the allegation that staff allowed minors to drink alcohol resulting in inappropriate behavior is SUBSTANTIATED meaning that "preponderance of evidence standard" has been met. The facility was cited for violation of General Regulation Section 80078 as Responsibility for Providing Care and Supervision as S1 did not supervise youth while in a local store where alcohol was present which lead to youth absconding with four bottles of alcohol and later consuming them in the facility. Exit interview was conducted and documentation along with appeal rights were provided to the agency.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill conducted an unannounced complaint inspection on 7/18/25 at 10: AM and met with Tracy Edwards, Administrator. LPA Hill toured the facility inside and out and observed that one of the client bedroom windows was broken but has been temporarily boarded up until the replacement window can be delivered and installed this weekend. There appears to be no danger to youth in care at this time. The allegation that staff allowed minors to drink alcohol resulting in inappropriate behavior is related to S1 not supervising youth during an outing on 7/12/25 in which C1 and C2 were left unsupervised in a store where youth were then able to abscond with four bottles of alcohol. Confidential interviews were conducted with youth and staff where it was learned that S1 was authorized to take C1 and C2 on an outing but made an unauthorized stop during that outing, taking C1 and C2 to a local store. During the unauthorized stop SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE MT. RUBYFACILITY NUMBER: VISIT DATE: 07/18/2025

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


raw_content:
Narrative:
Confidential interviews were conducted with staff and clients in care. Youth admitted to going outside and while outside of staff view, smoked a nicotine device called a "puff bar". Prior to being found out of staff supervision, youth returned back inside the facility and hid the device. Youth reported that staff was not aware of them being outside and out of staff supervision until they were alerted via email by a neighbor later in the evening. This incident was not reported to Licensing per Title Regulations. Staff performed a search of the facility and found a device amongst one youth's possessions. The device was confiscated and disposed of. As a result of the investigation and interviews conducted, the allegation that staff did not provide adequate supervision to minors engaging in inappropriate activities is SUBSTANTIATED at this time meaning that a "preponderance of evidence" standard has been met. The facility was cited for violation of Title Regulation Section 80078(a) Responsibility for Providing Care and Supervision. The facility staff did not provide the supervision to two youth who were able to leave the facility and smoke a prohibited nicotine device on the side of the house. During the course of the investigation, it was noted that the agency did not provide the 24-hour notification to Licensing or the subsequent seven day written report to Licensing and a citation was issued for violation of Title Regulation Section 80061(b) Reporting Requirements. Exit interview was conducted and documents provided along with appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill conducted an unannounced complaint inspection on 8/5/25 at 11: AM and met with Peter Woods, Administrator, to discuss the findings of the complaint allegation. LPA Hill informed Mr. Woods that the complaint investigation included an initial inspection to the facility on 7/9/25 and collateral inspection conducted on 7/18/25 where youth and staff were interviewed. The allegation that staff are not providing adequate supervision to minors engaging in inappropriate activities is related to an incident involving two youth smoking while on the facility grounds on 6/21/25. The agency was alerted via email within the hour of the youth being seen smoking and conducted a search of the area where the youth were allegedly seen but found no cigarettes or evidence of other items being smoked. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE MT. RUBYFACILITY NUMBER: VISIT DATE: 08/05/2025

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

met_with: Peter Woods, Administrator


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
It was alleged that the Facility employed a Staff member (S1) who did not have a valid fingerprint clearance. The Agency stated they believed S1's criminal record clearance was finalized on 4/18/25, which was S1's official date of hire. Although S1 had a clearance for DOJ, FBI and CACI for California, there was a note in S1's file indicating they were waiting on the Out of State CACI clearance for S1, in order for them to be fully cleared. There was not an Out of State clearance in S1's file. Guardian revealed that S1 was associated to the Facility but was not cleared until 7/22/25. S1 was terminated by the Facility on 6/17/25 for other reasons, meaning that S1 worked at the Facility for two months without a valid criminal record clearance. This Department has investigated the allegation that Staff was allowed to work at the facility without a criminal record clearance. Based on records reviewed, we have found that the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A Type A citation of California Code of Regulations, Section 80019(e)(2) CRIMINAL RECORD CLEARANCE, is cited on the attached LIC 9099D page. An exit interview was conducted with Tracy Edwards. A copy of this report, and appeal rights were given.

Investigation Findings:
13On Friday, October 10th, 2025 at 12PM, Licensing Program Analyst (LPA) Brittany Crass, conducted an Unannounced complaint investigation inspection to deliver findings for the allegation listed above. This inspection was conducted at the Administrative offices. LPA met with Administrator Tracy Edwards, who assisted with the inspection. LPA Hill conducted the initial 10-day complaint investigation at the Facility's Administrative office on 7/18/2025. Between 7/18/25 and 10/7/25, LPA Hill interviewed the Administrator (A1) and one Staff Member (S2). LPA Crass also interviewed the Administrator (A1). (Continued on LIC 9099-C). SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Jensen-Hill LICENSING EVALUATOR NAME: Brittany Crass LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE MT. RUBYFACILITY NUMBER: VISIT DATE: 10/10/2025

announced_status: Unannounced

met_with: Administrator Tracy Edwards


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection to the administrative offices for Rite of Passage on 8/17/21 at 2: PM and met with Tracy Edwards, Administrator to discuss incident reports received for this facility. The first incident report discussed was an incident report dated 8/3/21 where C1 (see LIC811 dated 8/17/21) was on the phone and was asked to end their call but refused. As a result of the refusal, S1 unplugged the phone terminating C1's phone conversation. C1 in turn was escalated and caused damage to S1's vehicle. Law enforcement was called and C1 was arrested and removed from the program. LPA spoke with Ms. Edwards about the staff being trauma-informed and trained to de-escalate youth as this intervention was not trauma-informed. Ms. Edwards agreed to provide a reminder to all staff about being trauma-informed and how to de-escalate. This shall be sent to Licensing upon completion. The other two incidents, 7/2/21 and 7/3/21, were provided to Ms. Edwards as more informational in that additional informed was needed to be complete incidents. LPA explained that the incident reports should have a clear picture of the events leading up to, what happened during, and the resolution of/or the consequence(s) given to the youth/staff as a result of the incident(s). LPA also instructed Ms. Edwards that the incident reports should have all youth involved in the incident named in the report so as to have a clear picture of the events. No citations were issued and exit interview conducted with Ms. Edwards.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 10/20/21 at 11: AM and met with Tracy Edwards, Administrator to discuss an incident report. LPA informed Ms. Edwards that the incident report in question is dated 10/16/21 in which C1 (see LIC811 dated 10/20/21) was involved in a single person restraint with staff, S1. During the restraint, S1 lost their footing and fell to the floor while still in the restraint with C1. LPA asked Ms. Edwards for the staff training manual for the Emergency Interventions and did review an section of the manual during the visit. Ms. Edwards states that she is going to look further in the manual for information about what staff are to do when they lose control of a situation. LPA did advise the facility that when the staff engage in restraints with the youth in care, that the restraint should cease the moment that the staff "lose control" of the restraint so as to prevent injury to youth and staff involved in restraints. Ms. Edwards shall also follow up with S1 regarding the incident and the reporting and inform S1 that the incident itself needs additional information and clarity as the preliminary report provided during the visit today is missing relevant information. The final report is not yet due to Licensing as the final date is 10/23/21. As a result of this, there are no citations at this time. In addition, Ms. Edwards shall provide additional clarification on the Emergency Intervention Training Plan on what it states about how staff are to respond when they are no longer in control of the emergency intervention with the youth. Exit interview was conducted and document was provided at the conclusion of the visit.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA Tamara Hill made an unannounced annual inspection on 11/30/21 at 12: AM and met with Tracy Edwards, Program Manager, who assisted with the inspection. LPA Hill conducted a walk-through of the facility inside and out. There were no clients present during the inspection due to school. LPA observed two, dual occupancy client bedrooms, two single occupancy bedrooms, two bathrooms accessible to clients, and one staff room and staff bathroom during the inspection. LPA Hill inspected and/or reviewed the following: Postings of facility license, Personal Rights Poster Disinfectants/Cleaning solutions were inaccessible Refrigerator Temperature was at or below 45 degrees F and Freezer Temperature at or below 0 degrees Nonperishable Foods for one week and fresh perishable for foods two days minimum were present Menu was present and posted Working telephone was present Carbon monoxide detectors and Smoke Detectors were functioning First Aid Kit was present and had all required components Common Room (living room) was available as was a separate room for relaxing Dining area with enough seating was present and in good condition Medication was centrally stored, locked/inaccessible LPA observed a locked staff office/sleeping area. All documentation and equipment in the staff room is locked as is the staff room. Hot Water was between 105 -120 degree F Fire Extinguishers were observed to be last inspected on 2/8/21 and 4/1/21 (there were three present) Toilets, wash basin, bath and shower fixtures appeared to be in good repair, no leaks and delivering hot water. LPA observed there to be soap and paper towels available in the bathrooms. Laundry Facilities were available and LPA observed posted assigned washing days for clients. Bedrooms appeared to be clean and organized with required linen and furnishings Motor Vehicle was observed to have working seat belts, lights and adequate tires. Facility appeared to be free of vermin LPA observed no citations during the physical plant inspection. LPA arrived to the Minden, Nevada school site location to conduct interviews with staff and clients. LPA was not able to complete the staff and client file reviews during the inspection but will return on another date to complete the file reviews as required. Exit interview conducted and documentation provided to Ms. Edwards.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 5/16/22 at 11: AM and met with Tracy Edwards, Administrator. LPA Hill made this visit to the Administrative office location in Minden, Nevada as the youth were already on site at this location in attendance at school. LPA made the case management inspection visit today to discuss the following incidents: * 1/19/ C1 drank cleaning product in an act of self harm. C1 was hospitalized for three days as a result. C1 had asked for the cleaning product at a time when the youth were completing chores and there was no indication that C1 was going to drink the product. LPA found that staff acted appropriately and that all reports were made as required. The facility was not cited and there is no follow up for this incident. * 12/22/ C2 left the facility undetected and went to another facility. C2 was able to gain entry to the other facility, be in the other facility for an undisclosed amount of time, and return to this facility, without staff knowing that C2 was even gone. C2 left the facility again on 12/23/21 undetected and went to the other facility where C2 was inside the facility. C2 then heard staff discussing the situation of C2 being gone from this facility. C2 left the other facility through the other client's bedroom window and went to the front of the facility and knocked asking to be let in due to the snow and cold conditions. According to Administrator, S1 was given a progressive discipline for not conducting bed checks according to the facility policy. LPA requested a copy of the discipline for S1. LPA also discussed drug testing with the agency as there was a 24 hour incident report was received about drug testing youth. LPA advised Ms. Edwards that the 24 hour reports need to give enough detail which would include their cause for and consent received in order to conduct the drug testing on youth in the program. LPA advised Ms. Edwards that without a court order for weekly/random drug testing, they cannot perform drug testing without probable cause and without the consent of the placing agency and that this information needs to be in the 24 hour reports sent to Licensing. Exit interview conducted and document provided to the facility.

met_with: Tracey Edwards, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced annual inspection on 11/22/22 at 11: AM at the school site for the youth in Minden, NV. LPA initially attempted an inspection at the facility but there were no clients or staff present at 10: AM. During the annual inspection on 11/22/22, LPA interviewed clients as part of the annual and reviewed some client files. LPA informed the agency that an additional inspection date will be necessary at a later date. Exit interview conducted and documents were provided at the conclusion of the inspection today.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced annual inspection on 12/13/22 at 12: PM and met with Tracy Edwards, Administrator to continue the annual inspection at this location. LPA Hill toured the facility inside and out and did find that the facility was in substantial compliance with the regulations with the exception of one the kitchen and client bathroom needs deep cleaned. In addition, the wall in the laundry room area has some damage as a result of the child using the wall as leverage to move the washer. LPA advised Ms. Edwards that this needs to be fixed by as soon as possible.. Ms. Edwards states that it will be repaired by January 30, 2023 as they are currently hiring for a handy man. LPA found that the smoke detectors in the house work as required and that the carbon monoxide detector was tested and works as required. LPA observed that the fire extinguisher located right off the kitchen area was last inspected on 2/9/22. LPA observed that there are two bathrooms for client use and that there is one restroom for staff use but the door is locked to the staff room making it inaccessible to clients in care. LPA observed that the bathrooms were equipped with the required supplies as necessary for general hygiene, bathing and grooming. LPA observed that the restrooms had the required hot water as necessary. LPA observed that the kitchen and meal prep areas are tidy and all items are stored appropriately. LPA observed that the food in the facility is appropriate for the three clients in the facility. LPA did not issue any citations during the inspection but did advise the facility to conduct a cleaning of the kitchen and bathroom areas. An exit interview was conducted with Ms. Edwards at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced annual inspection on 12/13/22 at 2: PM and met with Tracy Edwards, Administrator to continue the annual inspection at the non-public school specifically for the review of files. LPA Hill reviewed three staff files during the inspection today, including the administrator. LPA observed that the required documentation is in the files as required. LPA reviewed client files during the inspection today and observed that the client files were in tact and required documentation is present as required. LPA did not cite the facility on this date for any violations related to client or staff files. Interviews were conducted and exit interview conducted with Ms. Edwards, administrator.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection 9/8/23 and met with Tracy Edwards, Administrator. The purpose of the inspection today was to review the temporary repairs made to the deck. LPA Hill observed that the deck railing has been secured and that the deck appears to be stable enough for the house to repopulate at this time. LPA Hill asked Ms. Edwards if the facility is still moving forward with the replacement of the deck and Ms. Edwards states that the three bids have to be submitted to the finance committee to be approved prior to commencing the work. Ms. Edwards estimates that the deck will be completed by the end of October 2023. LPA Hill requested that Ms. Edwards touch bases with LPA Hill when the work begins and again when the work is completed. End of interview.