summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) T. Davis went to San Gabriel Children's Center, Inc./Enid Home on December 02, 2021 at 11:15am for the purposes of conducting an unannounced Required Annual inspection. LPA met with Renae Williams, House Manager (HM), and discussed the purpose of today's inspection. LPA and the HM toured the facility and discussed the inspection in detail. The Short Term Residential Therapeutic Program (STRTP) is located in a residential neighborhood and has three bedrooms, two bathrooms, kitchen, staff office, game room, dining area, and a garage Presently, there are four clients in placement at the facility. LPA observed the facility's kitchen to be clean and well stocked with several food items (perishable and nonperishable). Sharp knives, chemicals, cleaning supplies, and medications are kept locked in areas inaccessible to clients. LPA observed two bathrooms to be in good repair and working order. All three bedrooms contained twin beds, dressers, and closet space. Smoke alarms were operable throughout the facility. Exit signs were visible throughout the facility as well. The First Aid Kit was fully stocked with bandages, scissors, band-aids, tweezers, and a thermometer. There is adequate seating in the dining area and the living room. There is also a screened inoperable fireplace in the living room. LPA observed a fully charged fire extinguisher in the dining area. The HM stated that there were no guns or weapons on the premises. The last fire drill was held on November 17, 2021 at 6:02p.m. The last earthquake drill was held on November 17, 2021 at 6:23pm. The outdoor areas were observed to be free of debris and hazards. LPA reviewed three staff files and all four client files and found the reviewed files to be in order. LPA obtained an updated LIC500 (Personnel Report) and a client roster. Licensee will scan/email LPA copy of their most recent Board of Director's meeting minutes. LPA found no Title 22 deficiencies on this date. Exit interview done


state: CA

facility_name: SAN GABRIEL CHILDREN'S CENTER, INC./ENID HOME

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) T. Davis went to San Gabriel Children's Center/Enid Home on December 15, 2023 at 1:58pm for the purposes of conducting an unannounced Random Annual inspection. The facility is licensed to serve six male clients ages 12-17 years old. LPA met with Sylvester Johnson, Site Administrator (SM), and together they toured the facility. The facility is a Short Term Residential Therapeutic Program (STRTP) and is located in a residential neighborhood. It is a single story home with three bedrooms, two bathrooms, living room, dining area, game room, staff office, and a backyard. Presently, there are three clients in placement at the facility. The backyard was observed to be free of debris and hazards. LPA observed two bathrooms to be in good repair and working order. There is adequate perishable and nonperishable food supply at the facility. All three bedrooms contained two twin beds, two dressers, and closet space. There are no guns or weapons at the facility. Smoke alarms were operable in each bedroom. LPA observed a fully stocked linen closet in the hallway. There is no swimming pool or other bodies of water on the premises. Sharp knives, cleaning supplies, and medications are kept locked in areas inaccessible to clients. There is adequate seating in the living room and dining area. The last fire drill was held on November 30, 2023 at 4:35pm. All rules and regulations were posted at the facility. Exit signs were visible throughout the facility. Files were reviewed and found to be in order. SM provided LPA an updated LIC500 (Personnel Report) and a client roster. Licensee also provided LPA a copy of their most recent Board of Director's meeting minutes dated December 05, 2023. LPA found no Title 22 deficiencies on this date. Exit interview conducted

report_type: Facility Evaluation

visit_type: Annual

met_with: Sylvester Johnson, Site Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) T. Davis went to San Gabriel Children's Center/Enid Home on October 03, 2024 at 11:42am for the purposes of conducting an unannounced Random Annual inspection. The facility is licensed to serve six male clients ages 12-17 years old. LPA met with Sylvester Johnson, Site Administrator, and together they toured the facility. The facility is a Short Term Residential Therapeutic Program (STRTP) and is located in a residential neighborhood. It is a single story home with three bedrooms, two bathrooms, dining area, kitchen, staff office, game room, living room, and a backyard. Also, there is a screened inoperable fireplace in the dining area. Currently, there are four clients in placement at the facility. LPA observed two bathrooms to be in good repair and working order. There is adequate perishable and nonperishable food supply at the facility. All three bedrooms contained two twin beds, two dressers, and closet space. The backyard and front yard were observed to be free of debris and hazards. There are no guns or weapons at the facility. LPA observed a fully stocked linen closet in the hallway. There is no swimming pool or other bodies of water on the premises. The First Aid Kit was fully stocked. There was one client present at the facility during the inspection and LPA interviewed the client. There is adequate seating in the living room and dining area. Smoke alarms were operable in each bedroom. Sharp knives, cleaning supplies, and medications are kept locked in areas inaccessible to clients. Exit signs were visible throughout the facility. The last fire drill occurred on September 11, 2024 at 4:00pm. Staff and client files were reviewed and found to be in order. All rules and regulations were posted at the facility. The Site Administrator provided LPA an updated LIC500 (Personnel Report) and a client roster. Licensee will send LPA a copy of their most recent Board of Director's meeting minutes. LPA found no Title 22 deficiencies on this date. Exit interview conducted.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPAs) Timika Martin and Pamela Silva 10/30/24 at 9: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs met with Administrator, Sylvester Johnson and inspected the facility inside and out. LPAs reviewed one (1) child record and three (3) of staff personnel files on site at the facility. LPAs reviewed one (1) child psychotropic medications and medication records. LPAs interviewed two (2) staff on site to discuss the facility's policies and procedures of operation. LPAs were unable to interview one (1) child currently prescribed psychotropic medication due to the child being unavailable. LPAs will attempt to conduct an interview at a later time. LPAs provided a copy of this licensing report to Administrator, Sylvester Johnson. No deficiencies are being cited at this time. LPA conducted exit interview with Administrator, Sylvester Johnson.

visit_type: Case Management

met_with: Administrator, Sylvester Johnson


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
There was a total of five clients residing in the facility. During investigation, all the clients were interviewed. During the incident, all five clients witnessed the physical altercation between C1 and C2. Based on the interview, on the day when the incident happened, an argument escalated, leading to C2 hitting C1. Both C1 and C2 engaged in a physical fight. Following the altercation, S3 called 911 for assistance. Three staff members were present during the incident, and all three were interviewed as part of the investigation. C1 sustained injuries during the altercation and was transported to the local hospital for medical attention. The interviews conducted with the youth placed in the facility revealed consistent statements. According to the accounts provided by C1(interviewed on 05/03/23), C2 (interviewed on 05/17/23), C3 and C4 (interviewed on 05/05/23), , and C5 (interviewed on 05/17/23), the staff members attempted to prevent the youth from engaging in a physical altercation during the incident. Statements from the youth also revealed that the staff members made efforts to intervene physically but also employed verbal redirection techniques to prevent the youth in care from engaging in a physical altercation. The client interviews indicated that the staff used communication strategies to redirect and de-escalate the situation. LPA Martinez also interviewed three staff during the investigation. S1 was interviewed on 04/28/23, S2 and S3 were interviewed on 07/06/23.The interviews revealed that the staff members were consistent in their presence during the altercation and made efforts to intervene. Staff members utilized both verbal de-escalation techniques and physical intervention to address the incident. Based on interviews conducted with five clients and three staff members, in addition to reviewing the needs and services plan obtained during the investigation, the allegation against license #197804961 is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. No deficiencies were identified during the inspection. An exit interview was conducted, and a copy of this report was provided to the director.

Investigation Findings:
13On 07/06/23, Licensing Program Analyst (LPA) Joe Martinez conducted a follow-up complaint investigation at the facility mentioned above and met with Director Lynette Hanna .The purpose of the inspection was to deliver the findings of the investigation. The investigation included interviews with five clients placed in the facility, three staff members, and a social worker. LPA Martinez requested and reviewed the needs and services plans for C1 and C2. Staff and client rosters were also inspected as part of the investigation. On 04/24/23, the Department received a complaint alleging staff's failure to prevent a physical altercation between youth in care. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Yan Yeung LICENSING EVALUATOR NAME: Joe Martinez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: SAN GABRIEL CHILDREN'S CENTER/HOMEREST HOMEFACILITY NUMBER: VISIT DATE: 07/06/2023

report_type: Complaint Investigation

met_with: Lynette Hanna- Director

complaint_status: unsubstantiated


raw_content:
Narrative:
On 04/16/25, the Department received a complaint alleging staff engaged in an altercation with youth resulting in injury. S1 denied the allegation and stated the C1 was becoming upset because S1 did not want to give him allowance money which is only to be given to his mother as C1 has a tendency to use money for drugs. S1 stated C1 became agitated and grabbed S1 by his necklace/shirt and began to punch him. S1 stated he tried to separate from C1 and both ended on the ground. S1 stated that he did not throw any punches and just tried to pull away from C1. C1 stated he was not punched by S1 and stated he threw punches at S1 and did not know how many times he struck S1. C1 stated he had a scratch on his hand and his foot when they fell to the ground. S1 had a knot on his head and a mouse on his eye a scratch on his face. In confidential interviews, three staff workers provided statements to support S1 saying that he gets along with the clients and the clients pick on S1 do to his age. In confidential interviews with clients, they revealed inconsistent statements and could not corroborate the reported allegation. Based on the information gathered during confidential interviews, and records reviewed, it cannot be determined whether the allegation occurred resulting in staff engaged in an altercation with youth resulting in injury. Therefore, the above allegations are determined unsubstantiated at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged abuse occurred. The resolution to this complaint was discussed with the agency representative and copies of all licensing reports were provided at the conclusion of the inspection. An exit interview was conducted and the Appeal rights were given and explained. No deficiencies were cited at this time.

Investigation Findings:
13On September 26, 2025 at 8:30AM, Licensing Program Analyst (LPA) Pedro Ramos conducted a follow-up inspection to provide findings for the above complaint investigation. LPA met with the representative above. During this investigation, LPA conducted in-person interviews with two clients, four facility staff on 4/23/25, ER CSW on 5/13/25 and attempted to contact county social worker. Reference Confidential names list LIC811 dated 9/26/ During the inspection, LPA requested for review and obtained a copy of the staff and client facility roster reports, clients' needs and services (NSP), intake documents and Special Incident Report associated with this complaint investigation. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Pedro Ramos LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: SAN GABRIEL CHILDREN'S CENTER/HOMEREST HOMEFACILITY NUMBER: VISIT DATE: 09/26/2025

met_with: Ray Leon, Residential Counselor


raw_content:
Narrative:
On 09/13/2024, the Department received a complaint alleging that a staff worker (S1) applied a chokehold to a client (client to be identified only as C1 for this report), including making inappropriate comments about his overall status being placed in a facility, and that his family doesn't love him. S1 denied the allegations that he applied a chokehold to a client. S1 denied telling a client his family does not love him, which is why he is in a facility. S1 disclosed that on 09/01/24., a client got upset for impatiently waiting to be served more food, aside from just finished eating a large meal. S1 reported that C1 got upset, grabbed S1's food, and threw it at him, including smearing fries on his face. S1 reported that C1 became combative and was attempting to hit him. S1 only held his wrists or hands to prevent being injured by the client. S1 reported that other staff workers assisted and escorted the client to his bedroom without further incident. In confidential interviews, two staff workers who witnessed the incident denied the allegations, other staff workers provided statements to support S1 saying that he is not the type of person who would do and say things inappropriately to a client. In confidential interviews with five clients, they revealed inconsistent statements and could not corroborate the reported allegations against the staff identified in the report. Based on the information gathered during confidential interviews, and records reviewed, it cannot be determined whether the allegations occurred resulting in staff applying a chokehold to a client, and staff making inappropriate comments to a client. Therefore, the above allegations are determined unsubstantiated at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged abuse occurred. The resolution to this complaint was discussed with the agency representative and copies of all licensing reports were provided at the conclusion of the inspection. An exit interview was conducted and the Appeal rights were given and explained. No deficiencies were cited at this time.

Investigation Findings:
13On 09/13/2024 at 1: AM, Licensing Program Analyst (LPA) Joseph Vargas conducted a follow-up inspection to provide findings for the above complaint. LPA met with Mr. Johnson. During this investigation, LPA conducted in-person visits, and telephone interviews with five clients, Facility Administrator, four facility staffs, individual identified as other on 09/16/24, two facility staffs on 09/17/2024, county social worker on 10/09/24. Reference Confidential names list LIC811 dated 10/11/ During the inspection, LPA requested for review and obtained a copy of the staff and client facility roster reports, clients' needs and services (NSP), intake documents and Special Incident Report associated with this complaint investigation. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Joseph Vargas LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: SAN GABRIEL CHILDREN'S CENTER/HOMEREST HOMEFACILITY NUMBER: VISIT DATE: 10/15/2024

met_with: Mr. Johnson, Administrator


facility_name: SAN GABRIEL CHILDREN'S CENTER/HOMEREST HOME

summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Claudia Portillo and Gilbert Gutierrez, at San Gabriel Children's Center, Inc./Homerest Short Term Residential Therapeutic Program (STRTP) on 8/6/21 at 9: AM. During the inspection, LPAs Portillo and Gutierrez met with Sylvia Quintana, House Manager. All clients at this facility are Probation placements. Therefore, no files were inspected. LPA Gutierrez conducted a tour of the facility at 9: AM. The facility is clean, safe, sanitary and in good repair. All medications are centrally stored, locked and accessible only to employees responsible for stored medications. There is adequate staffing in the facility to provide care and supervision for the clients per facility's Plan of Operation/Program Statement. A review of the program statement was conducted at 10: AM. LPA Portillo reviewed four (4) staff files on site at 11: AM. Employees received training on psychotropic medications as specified in Section 16501.4(d) of the Welfare and Institutions Code (WIC). LPA Gutierrez interviewed three (3) staff members administering psychotropic medication on site. A copy of this report, and LIC811 was provided to the STRTP representative upon completion. No deficiency was found. LPAs conducted exit interview with STRTP representative.

met_with: Sylvester Johnson, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) T. Davis went to San Gabriel Children's Center/Homerest Home on December 06, 2021 at 12:30pm for the purposes of conducting an unannounced Required Annual inspection. The facility is licensed to serve six male clients ages 12-17 years old. The facility also provides services to non-minor dependents. LPA met with Sylvia Quintana, House Manager (HM), and together they toured the facility. The facility is a Short Term Residential Therapeutic Program (STRTP) and is located in a residential neighborhood. It is a single story home with three bedrooms, two bathrooms, living room, dining area, staff office, and a backyard. Presently, there are four residents in placement at the facility. The backyard was observed to be free of debris and hazards. Smoke alarms were operable in each bedroom. LPA observed two bathrooms to be in good repair and working order. Sharp knives, cleaning supplies, and medications are kept locked in areas inaccessible to clients. There is adequate perishable and nonperishable food supply at the facility. LPA observed a fully stocked linen closet in the hallway. All three bedrooms contained two twin beds, two dressers, and closet space. There is adequate seating in the living room and dining area. The HM stated that there were no guns or weapons at the facility. There is no swimming pool or other bodies of water on the premises. All rules and regulations were posted at the facility. LPA observed several disaster kits, board games, and reference materials. LPA also observed a fully charged fire extinguisher in the dining area. The last fire drill was held on December 05, 2021 at 10:30am. The last earthquake drill was held on December 05, 2021 at 10:35am. LPA reviewed three staff files and all four client files and found the reviewed files to be in order. LPA also interviewed staff as well as clients during today's inspection. LPA obtained an updated LIC500 (Personnel Report) and a client roster. Licensee will scan/email LPA a copy of their most recent Board of Director's meeting minutes. LPA found no Title 22 deficiencies on this date. Exit interview conducted

met_with: Sylvia Quintana, House Manager


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Timika Martin and Pamela Silva on October 26, 2023, at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs Martin and Silva met with Administrator, Sylvester Johnson and inspected the facility inside and out. All clients at this facility are Probation placement's and none of the clients are currently prescribed psychotropic medication. Therefore, no files were inspected, and no interviews were conducted with clients. LPAs reviewed 0 of child's records and 2 of staff personnel files on site at the facility. LPAs reviewed 0 of child's psychotropic medications and medication records. LPAs interviewed 1 of the staff on site to discuss the facilities policies and procedures of operation. LPAs interviewed 0 of children currently prescribed psychotropic medication. LPAs provided a copy of this licensing report to Administrator, Sylvester Johnson No deficiencies are being cited at this time. LPAs conducted exit interview with Administrator,Sylvester Johnson.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) T. Davis went to San Gabriel Children's Center/Homerest Home on December 15, 2023 at 11:10am for the purposes of conducting an unannounced Random Annual inspection. The facility is licensed to serve six male clients ages 12-17 years old. LPA met with Sylvester Johnson, Site Administrator (SM), and together they toured the facility. The facility is a Short Term Residential Therapeutic Program (STRTP) and is located in a residential neighborhood. It is a single story home with three bedrooms, two bathrooms, living room, dining area, staff office, and a backyard. Presently, there are four clients in placement at the facility. The backyard was observed to be free of debris and hazards. LPA observed two bathrooms to be in good repair and working order. Sharp knives, cleaning supplies, and medications are kept locked in areas inaccessible to clients. There is adequate perishable and nonperishable food supply at the facility. All three bedrooms contained two twin beds, two dressers, and closet space. There is adequate seating in the living room and dining area. There are no guns or weapons at the facility. Smoke alarms were operable in each bedroom. LPA observed a fully stocked linen closet in the hallway. There is no swimming pool or other bodies of water on the premises. All rules and regulations were posted at the facility. LPA observed two fully charged fire extinguishers at the facility. The last fire drill was held on November 21, 2023 at 3:20pm. Files were reviewed and found to be in order. SM provided LPA an LIC500 (Personnel Report). Licensee will scan/email LPA a copy of their most recent Board of Director's meeting minutes and a client roster. LPA found no Title 22 deficiencies on this date. Exit interview conducted


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) T. Davis went to San Gabriel Children's Center/Homerest Home on October 03, 2024 at 2:38pm for the purposes of conducting an unannounced Random Annual inspection. The facility is licensed to serve six male clients ages 12-17 years old. LPA met with Sylvester Johnson, Site Administrator, and together they toured the facility. The facility is a Short Term Residential Therapeutic Program (STRTP) and is located in a residential neighborhood. It is a single story home with three bedrooms, two bathrooms, staff office, kitchen, living room, dining area, and a backyard. Currently, there are five clients in placement at the facility. There is adequate perishable and nonperishable food supply at the facility. The backyard and front yard were observed to be free of debris and hazards. LPA observed two bathrooms to be in good repair and working order. All three bedrooms contained two twin beds, two dressers, and closet space. Smoke alarms were operable in each bedroom. There is adequate seating in the living room and dining area. LPA observed a fully stocked refrigerator in the kitchen. There are no guns or weapons at the facility. Sharp knives, cleaning supplies, and medications are kept locked in areas inaccessible to clients. LPA observed a fully stocked linen closet in the hallway. There is no swimming pool or other bodies of water on the premises. Fire and earthquake drills were conducted on September 06, 2024 at 4:45pm. All rules and regulations were posted at the facility. Staff and client files were reviewed and found to be in order. All fire extinguishers at the facility were fully charged. There were three clients present at the facility during the inspection. LPA interviewed two of the three clients. The third client did not want to be interviewed. The Site Administrator provided LPA an updated LIC500 (Personnel Report) as well a client roster. Licensee will scan/email LPA a copy of their most recent Board of Director's meeting minutes. LPA found no Title 22 deficiencies on this date. Exit interview conducted


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Regarding the allegation that staff did not prevent bullying among children resulting in an altercation; it was specifically reported that C2 and C3 were bullying C1 which ultimately led to an incident where C1 was chasing C2 and C3 with a large rock, and at one point, C2 tripped and fell sustaining a knee injury when trying to get away from C1. In addition, it was reported that C1 didn't make contact with either C2 or C3 with the rock, but law enforcement called in a violation of assault with a deadly weapon. During investigation, multiple confidential interviews disclosed that C1 and C2 were involved in a verbal altercation that escalated to a physical altercation outside, although staff attempted to prevent C1 from going outside. However, C1 was able to get outside by escaping the house through the back door. In addition, multiple confidential interviews corroborated that staff attempted to de-escalate the altercation, however, C1 exited the area and pursued C2 and C3 with a rock. During the pursuit, C2 tripped and sustained a knee injury. LPAs received conflicting information. Based on interviews, the allegation that staff did not prevent bullying among children resulting in an altercation may have occurred, however, there was not a preponderance of evidence to support the alleged violations, therefore, this allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Regional Director, Dana Centanni.

Investigation Findings:
13On 08/21/2025, at 1:00PM, Licensing Program Analyst (LPA) Maya Chavez met with Regional Director, Dana Centanni of San Pasqual Academy (SPA) to deliver the investigative finding for the allegation listed above involving staff and clients (C1-C3) as listed on the Confidential Names List (LIC811). On 04/22/2025, Community Care Licensing (CCL) received a complaint that staff did not prevent bullying among children resulting in an altercation. On 05/01/2025, LPA J. Salem initiated the complaint at the facility and completed health and safety inspection. During the inspection, LPAs interviewed clients (C2 and C3), staff (S1, S3, and S4), and C1's County Social Worker (CSW). LPAs were unable to interview client 1 (C1) and staff (S2). Pertinent records were obtained and reviewed. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Maya Chavez 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: SAN PASQUAL TREATMENT CENTER - FEMALE PROGRAMFACILITY NUMBER: VISIT DATE: 08/21/2025

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

met_with: Regional Director, Dana Centanni


facility_name: SAN PASQUAL TREATMENT CENTER - FEMALE PROGRAM

summary: Facility Evaluation

raw_content:
Narrative:
On February 10, 2025, at 2: PM, Licensing Program Analyst (LPA) Jacob Salem conducted an announced visit to the above facility and met with San Pasqual Treatment Center Frank Simmons Program Manager, Keary Mason Head of Service, Dana Centanni Regional Director for the purpose of conducting a pre-licensing inspection. Currently there are no clients placed in the home. The applicant is applying to serve six ambulatory clients ages 12 to 17 and Non-Minor Dependents. LPA conducted component III of the orientation process and reviewed with the applicants Licensing requirements. The home is a one-story building with three client bedrooms and two client bathrooms which are set up as follows: · Bedroom #1 (Client) has two twin beds and will sleep two clients. · Bedroom #2 (Client) has two twin beds and will sleep two clients. · Bedroom #3 (Client) has two twin bed and will sleep two client and attached bathroom · Kitchen, dining area, and family room area, locked storage and laundry room, hallway and storage closets, backyard/patio area, and attached two car garage for set up for visitation and mental health services. The Emergency Disaster Plan, Personal Rights, and complaint procedures are posted in the hallway of the home. The license will be posted as soon as it is issued. LPA and the applicants toured the facility inside and out and conducted a full inspection of the facilities physical plant, including building and grounds, food service, furniture fixtures and supplies, telephone service, health-related services, personal services, and activity space. The facility has demonstrated compliance with Title 22, Division 6 of the California Code of Regulations and Interim Lincensing Standards. An exit interview was conducted and a copy of this report was provided to Frank Simmons, Program Manager.

visit_type: Prelicensing

met_with: Frank Simmons, Program Manager


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On February 24, 2025, at 11: AM, Licensing Program Analyst (LPA) Jacob Salem and Licensing Program Manager (LPM) Dawn Segura conducted a technical assistance meeting virtually, via Teams, with San Pasqual Treatment Center (STRTP) Executive Director (ED) Lawrence Howell, Regional Director (RD) Dana Centanni, and Business Manager (BM) Jennifer Stoops. Also present at the meeting were System of Care Branch Analyst, Ansar Mohammed, System of Care Branch Manager, Marjana Jackson, and San Diego County Representatives Eileen Marshall, Jimabeth Ramsey, and Christina Bradley. The Purpose of the meeting was to discuss and review the following pending Licensing forms, Plan of Operation (POO), and Program Statement (PS) revisions: Application and Supporting Documentation (LIC 281E) 1. Application for a Community Care Facility (LIC 200) - Meets Standards 2. Orientation Certificate (Reference CCR § 80018(b) - Proof of attendance on file/Meets Standards 3. County Letter of Recommendation (Reference HSC § 1562.01(f) ILS § 87018(c)(6)) - Pending 4. Applicant information (LIC 215) - Does Not Meet Standards 1. Photocopied signature was provided. Please provide the original wet signature or new forms with electronic signature (using Adobe). 4. Designation of Facility Responsibility (LIC 308) (Reference CCR § 80064) - Meets Standards 5. Affidavit Regarding Client Cash Resources (LIC 400) (Reference HSC § CCR § 80018) - Does Not Meet Standards 1. Wrong bond amount listed on the form. Based on the amount stated the facility will hold at one time, a surety bond of $5000 is required. Please correct. 2. Photocopied signature was provided. Please provide the original wet signature or new form with electronic signature (using Adobe). 6. Surety Bond (LIC 402) (Reference CCR § 80018(d)) - Pending CONTINUED... ...Continued 2 7. Monthly Operating Statement (LIC 401) (Reference HSC § 1520(c) CCR § 80018 - Does Not Meet Standards 1. Wrong number of clients listed under program revenue section at top of form. 2. Salary and wages is too low given the number of employees listed on the LIC Personnel Report. Please correct or provide break down of employee salary/wages. 3. Photocopied signature was provided. Please provide the original wet signature or new forms with electronic signature (using Adobe). 8. Supplemental Financial Information (LIC 401A) (Reference HSC § 1520(c) CCR § 80018) - Does Not Meet Standards 1. Please complete Part II of the form. 2. Photocopied signature was provided. Please provide the original wet signature or new forms with electronic signature (using Adobe). 9. Balance Sheet (LIC 403) (Reference HSC § 1520(c), CCR § 80018) - Does Not Meet Standards 1. Numbers not transferred over correctly from LIC 403a forms, specifically lines 8 & 13. Please correct or provide explanation of discrepancy. 2. Photocopied signature was provided. Please provide the original wet signature or new forms with electronic signature (Adobe). 10. Balance Sheet supplemental Schedule (LIC 403A) (Reference HSC § 1520(c), CCR § 80018) - Does Not Meet Standards 1. Numbers not transferred over correctly to LIC 403 forms, specifically lines 23 & 29. Please correct or provide explanation of discrepancy. 2. Photocopied signature was provided. Please provide the original wet signature or new forms with electronic signature (using Adobe). 11. Financial Information Release and Verification (LIC 404) (Reference HSC § 1520(c), CCR § 80018) - Pending 12. Personnel Report (LIC 500) (Reference HSC § 1522, CCR § 80018) - Does not Meet Standards 1. Staff are currently scheduled to work at the same time in both facilities. Please correct. 13. Health Screening Personnel (LIC 503) (Reference CCR § 80018(d)) - Meets Standards 14. Emergency Disaster Plan (LIC 610C) (Reference CCR § 80023) - Does not Meet Standards 1. Form is not signed by administrator. Please ensure wet or electronic signature is provided. Continued... ...Continued 3 2. Letters of approval from relocation sites are missing. Please include. 15. Fire Inspection Authority (LIC 9054) (Reference CCR § 80018(d)), CCR § 87018(d)) - Meets Standards 16. Board of Directors Statement (LIC 9165) contained in PUB 326) (Reference CCR § 87018(d)) - Meets Standards 17. Control of Property (Reference CCR § 80018(c) - Meets Standards 18. Bacterial Analysis of Water (Reference CCR § 80021) - Meets Standards 19. Application or Documentation of Accreditation (Reference ILS § 87089) - Does not Meet Standards 1. See below notes for Section 20 of Program Statement Plan of Operation Section A, Purpose and Goals - Meets Standards Section B, Administrative Organization - Does Not Meet Standards 1. Organizational chart on page 220 is outdated. Please update. 2. Administrator certificate pending. Section C, Facility Sketch - Meets Standards Section D, Staff Plan - Does Not Meet Standards 1. At a minimum, the following course should be included in the 16 minimum training plans: Health issues in foster care-missing (87065.1 (d)(3)(Z)). 2. Facility Manager training missing the following training: - Implementation of the assessment by the Qualified Individual, as specified in section 87022.1(b)(8)(A), and information about the Qualified Individual's assessment process pursuant to Sections 4096 and 11462.01 of the Welfare and Institutions Code. - Facilitation of participation of family members in child's treatment program and documentation of integration of family members into the treatment process, as specified in section 87022.1(b)(13)(A). - Facilitation of outreach to family members and documentation of outreach, as specified in section 87022.1(b)(13)(A). - A child's right to receive gender affirming sexual and reproductive health care and information. - A child's right to have their health information kept confidential. - The duties and responsibilities of the assigned case management worker and the licensee to ensure that children can obtain sexual and reproductive health services and information. Continued... ...CONTINUED 4 - Guidance about how to engage and talk with children about healthy sexual development and reproductive and sexual health in a manner that is medically accurate, gender affirming, age or developmentally appropriate, and trauma informed. - Information about current contraception methods and how to select and provide appropriate referral resources and materials for information and service delivery. 3. Please ensure required training below has been included in their training: - Prior to working with children, a peer partner shall be certified in cardiopulmonary resuscitation (CPR) and first aid and are required 16 of training prior to working with children and those training are required at minimum to include (87065.1(g)(1) and 87065.1 (f)(1)). i. The confidentiality of information and records relating to children in the short term residential therapeutic program. ii. Teamwork and interpersonal communication among facility personnel and children, children's family members, and the child and family team members. iii. The children's personal rights as specified in Welfare and Institutions Code section 16001.9 and section 87072, including, but not limited to, the right to have fair and equal access to all available services, placement, care, treatment, and benefits, and to not be subjected to discrimination or harassment on the basis of actual or perceived race, ethnic group identification, ancestry, national origin, color, religion, sex, sexual orientation, gender identity and expression, mental or physical disability, or HIV status. iv. Physical and psychosocial needs of children, including behavior management, de-escalation techniques, and trauma-informed crisis management planning, including the use of emergency interventions. v. Child and adolescent development, including sexual orientation, gender identity and gender expression. Section E, Policies Regarding Child Abuse Reporting - Meets Standards Section F, Administrative Policies and Procedures - Meets Standards Section G, Admission Determination Procedures - Does Not Meet Standards 1. Please also include how the licensee defines these characteristics (CSEC, fire starting) for the purposes of assessing appropriateness of fit (87068.05 (C)(3)). 2. Please clearly detail the timeframes for initial and final response to the county placing agency regarding referrals for placement. 87068.05(c)(4)(A). Continued... ...CONTINUED 5 - The established timeframes must include, but are not limited to, an initial response period in which the facility accepts, denies, or requires more information for the consideration of the referral for placement. The facility's initial response period shall not exceed 5 days following the receipt of referral for placement and-meets standards. - A final response period in which the facility accepts or denies the referral for placement. 3. Elevated review procedures: If the licensee determines that the program is not capable of meeting the child's needs without additional services and/or supports, the licensee shall request such assistance from the placing agency, Community Based Organization, or any other resource, and shall document this request. 87068.05 (g) please ensure to document this request. Recommend adding this on page 284, after "the Head of Service will make the support request." Section H, Intake Policies and Procedures - Does Not Meet Standards 1. Please mention that a needs and services plan will be completed within 30 days of intake. Page 289 mentions Needs and Services Plans for Non-minor dependents, but a Needs and Services Plan should be completed for all youth. 2. Please update procedures for child/youth emergency placement to include 87068.1(e): No later than 7 days after emergency placement, the administrator or social work staff shall review the intake documents to determine whether the facility can continue to provide the services necessary to meet the needs of the nonminor dependent. Section I, Admission Agreement - Meets Standards Section J, Removal or Transfer Policies and Procedures - Does Not Meet Standards 1. Please detail policies and procedures for removal or transfer of children and nonminor dependents during the following times (87022 (c)): After program goals have been reached. 2. Please include a description of how the licensee will mitigate against potential impacts to a child as a result of removal or transfer, including but not limited to 87068.4 (a): - how licensee will assist in preventing delays or gaps in delivery of services(please describe on page 302). - The program statement states "Maintain contact and provide aftercare support to the child after transfer (if applicable and not the responsibility of another STRTP)." Please describe the types of trauma-informed support and transition services to be provided. Continued... ...CONTINUED 6 - The program statement states, "San Pasqual Treatment Center will incorporate best practices for staff communication with the child and family prior to their transition." Please explain these best practices. As a reminder, the facility shall provide trauma-informed support and transition services to children/foster youth as part of a planned or unplanned removal or transfer, as specified in Subdivision (l) of Section 1562.01 of the Health and Safety Code (87068.4 (c)(1)). 3. If it is determined that the facility cannot meet the needs of the child, the licensee shall notify the authorized representative(s) of the determination and request that the child be placed elsewhere. The Requests shall be submitted to the county placing agency and shall contain the following information: 87068.4 (e)(2) - on page 304, please ensure the letter is submitted to the county placing agency and includes a request for the child to be placed somewhere else. Please ensure the following as well: - Date the county placing agency was informed of the concern pursuant to Section 87068.4 (e)(1)(B). - date the Child and Family Team meeting was held pursuant to Section 87068.4 (e)(1)(D). - Please ensure requests that the child be placed somewhere else shall be accompanied by a statement, signed by the facility's Mental Health Head of Service, providing an explanation of why the facility was unable to meet the needs of the child, including the following information: 4. Please include the procedures for an NMD to transfer from an STRTP in accordance 87068.4 (h): - Written notice to the NMD and placement agency; - Transfer shall state the reason for the transfer and request the NMD be placed elsewhere; and - Procedures for appropriately distributing the NMD's records. Section K, Rate Setting and Refunds - Meets Standards Section L, Handling Money, Personal Property, and or Valuables - Meets Standards Section M, Consultants and Community Resources to be Utilized - Meets Standards Section N, Trauma-informed Intervention and De-Escalation Techniques - Meets Standards Section O, Plan or Use of Delayed Egress Devices - Meets Standards Section P, Conflict of Interest Mitigation Plan - Meets Standards Section Q, Continuous Quality Improvement (CQI) - Does Not Meet Standards 1. Please detail how the CQI plan is developed based on the mission, vision, and values. (87081) 2. Please describe how direct input is used to inform program development and improvement. (87081 (b)(1)) CONTINUED... ...Continued 7 3. Please include a description of how outcome measures will inform Dignity of its program being trauma-informed and culturally relevant. 87081(c)(2) 4. Include collecting data on the numbers and types of complaints received and, if applicable, the resolution of each complaint. 87081(c)(7) 5. How the facility will take the data to inform and improve policies, practices, and programs. 6. After the facility has analyzed and interpreted the data, how does the facility use that data to improve polices, practices and programs? 887071(c)(5) 7. Describe how CQI program will be culturally relevant, trauma-informed, and age and developmentally appropriate. For example, input is received from all levels of staff, children and CQI objectives and plan is directly tied to trauma informed principles of safety, permanency, and trauma informed services/supports. Program Statement Section 1, Population Served - Does Not Meet Standards 1. Please describe the treatment modalities aimed at addressing the needs of youth in the population served by your facility (probation youth/ survivors of commercial sexual exploitation/various diversities/LGBTQ/probation/substance abuse). ILS 87022.1 (b)(2)(A) - page 349 "all interventions will be evidence based and trauma informed", integrated core practice. 2. Can you describe programs and services specific to assisting an NMD in preparing for the transition to independent living? 3. Does the facility plan to serve youth with special heath care needs? Section 2, Emergency Disaster Response Procedures - Meets Standards Section 3, Transportation Arrangements - Meets Standards Section 4, Core Services and Supports - Does Not Meet Standards 1. Please describe the core services and supports offered to youth at the facility to include the following 87078.1 (a)(1-5): Services to achieve permanency, including supporting efforts to reunify or achieve adoption or guardianship and efforts to maintain or establish relationships with parents, siblings, extended family members, tribes, or others important to the child or nonminor dependent, as appropriate. Please describe in depth what the services/supports to achieve permanency look like, for example family therapy sessions, transportation to visits. Continued... ...Continued 8 2. Does the facility plan to contract (or hold any current contracts) with any community-based providers/agencies/organizations to provide core services and supports? If so, please attach the agreements and ensure documentation of agreements with other agencies shall be maintained by a short-term residential therapeutic program and be available upon request by the licensing agency. 87078.1(b)(2) 3. Please provide the names of any existing relationships with community and county-based providers and describe the core services secured through agreements (87078.1(b)(2)). This may include local parks and recreation to support extracurricular activities, LGBTQ centers to support clients, colleges for NMD support in academic continuation, linkages to TAY programs, American Indian centers/programs, regional centers. Section 5, Culturally Relevant Interventions, Practices, Services, and Supports - Meets Standards 1. Recommend describing any specific services for CSEC, African American, Latino. Does the facility work with any specific culturally relevant community-based organizations or agencies? In addition to discussion of services and supports pg. 390, recommend describing how these services are implemented. Section 6, Trauma Informed Interventions and Treatment Practices - Does Not Meet Standards 1. The trauma-informed prevention services, interventions, practices, services and supports must demonstrate the following: maximization of physical and psychological safety for the child or nonminor dependent; recommend describing examples. 2. Please provide the procedures for how the provider will access and make referrals for evidence-based and/or promising services and practices that are trauma informed. 3. Please provide the procedures for maintaining consistency with TILPS (when applicable). Section 7, Development, Implementation, and Modification of Needs and Services Plan - Meets Standards Section 8, Planned Activities - Meets Standards 1. Please include a written plan for indoor and outdoor activities including, but not limited to, the following: - Activities which meet the training, money management, and personal care, grooming needs, and any other independent living skills identified in the children's needs and services plans, as specified in Section 87068.2(b)(3) through (5) and Section 87068.22(c)(1); recommend describing the money management planned activities: credit recovery, how to open a bank account, etc. Fake monopoly is a great way to help learn financial management, but since you already have classes to teach these things, could it be more age appropriate to allow the "younger" youth access to the classes instead? Continued... ...CONTINUED 9 - As a reminder, a schedule of the planned activities shall be posted on at least a weekly basis in a central facility location readily accessible to children, relatives, and representatives of placement. 87079(e) Section 9, Services During Placement and After Discharge - Does Not Meet Standards 1. Please use this section to list any agencies or community-based organizations that the facility has identified or commonly uses to provide additional services during care and after care. Please add the name, location, and the services. You can also include a statement that references another section where this information can be found. Section 10, Plan of Participation in the Child and Family Team - Does Not Meet Standards 1. How often will CFTM be held after the initial CFTM? Please see ILS § 87022.1(b)(11); ILS § 87001(c)(4). 2. Repetitive language. Recommend condensing. Section 11, Identification of Home-Based Care - Meets Standards Section 12, Participation of Family Members in Treatment & Outreach to Family - Meets Standards Section 13, Complaints and Grievances - Meets Standards Section 14, Participation and Assistance in Initiatives to Improve the Child Welfare System - Meets Standards Section 15, Family Visitation - Meets Standards Section 16, Children and Non-minor Dependents Personal Rights - Meets Standards Section 17, House Rules for Children and Non-minor Dependents - Does Not Meet Standards 1. What is the actual curfew time? 2. Please detail house rules on alcohol, drugs, weapons, smoking, room search/search of personal belongings. Section 18, Positive Discipline Policies - Does Not Meet Standards 1. Please include a copy of the code of conduct. 2. Please include a description on how discipline policies are trauma informed and include a description on how discipline policies account for specialized populations (CSEC youth). 3. Please ensure Staff, children, and authorized representatives shall sign and receive copies of discipline policies and procedures and the Signed copies shall be maintained in the child's record 87072.1(a)(3-4) Section 19, Storage of Medication - Meets Standards Section 20, Documentation of Accreditation - Does Not Meet Standards CONTINUED... ...Continued 10 1. The facility has included a copy of an accreditation. Please demonstrate that this is the accreditation for this specific facility's location. 2. New applicants should submit a declaration of accreditation status including what accrediting entity was chosen and a description of steps the applicant has taken to acquire accreditation. 87089 (c)(1). The applicant shall submit documentation of accreditation/a copy of its application for accreditation (87089(c)). 3. Please include a statement that the facility will provide documentation to the Department reporting its accreditation status at 12 months and 18 months after the date of provisional licensure (87089 (d)). 4. Please include a statement that the facility will provide a copy of final accreditation summary report to the licensing agency within 30 days of its release date (87089 (f)) 5. Please include a statement that if a corrective action is required by the accrediting entity in response to the final accreditation summary report, or at any other time following accreditation, a short-term residential therapeutic program shall provide documentation of its corrective action to the ..licensing agency Department within 30 days of its completion date (87089(g)) Section 21, Mental Health Program Approval - Meets Standards 1. Please update section if Mental Health approval has been received since submitting application. Section 22, Nursing Services - Does Not Meet Standards 1. Page 547 states "The ROP Nurse oversees multiple STRTP homes and is not based solely at one home." Is this nurse employed/hired by ROP or contracted? If so, please detail and include any MOU/contracts. Section 23, Food and Nutritional Plan/Sample Menus/Schedule - Meets Standards Section 24, Emergency Intervention Plan - Does Not Meet Standards 1. Please include the following in runaway plan: - Procedure for complying with Reporting Requirements specified in Section 87061(i). - Procedures for management review of incident reports, policies, and practices to determine the cause of, and to develop strategies to address, runaway children, both on an individual and facility-wide level. Procedures must include regular management reviews to be conducted at least once a year.*n - How staff respond to runaway child(ren) and child(ren) outside of the facility property without permission, but who are within view of the staff. Continued... ...CONTINUED 11 i. The section stated "If a client is outside the facility without permission in view of staff, they will be immediately informed they must ask to return to the facility," is this what was intended to have been said? When reporting incidents, please ensure all report requirements specified in Section 87061(I) are also maintained Incident Reports documenting a runaway situation must include the following: - (A) When, how, and by whom was the child's absence first noted. (B) The child's last known activities. (C) What were the circumstances surrounding the child's absence. (D) What action did the facility personnel take to discourage the child from leaving and what interventions were utilized. (E) What action was taken by facility personnel to locate the child. If a manual restraint was used, and if it is determined by the post incident review, as required in Section 87095.68, that facility personnel did not attempt to prevent the manual restraint, a description of what action should have been taken by facility personnel to prevent the manual restraint incident. (F) Describe what corrective action that will be taken or will not be taken against thefacility personnel and why. (G) If law enforcement was involved in the incident, a detailed description of the events involving the law enforcement contact, including a - police report number if available. (H) Documentation that the child's authorized representative has been notified of the incident. 2. Please specify whether the youth are being supervised during the 15 min cool down. 3. Please describe the procedures for determining and using age and size appropriate emergency intervention techniques. 4. Please include criteria for assessing when an emergency intervention plan needs to be modified or terminated, along with the procedures for terminating the plan or making any necessary modifications. 5. The section stated, "Manual restraints shall not be longer than 15 minutes." Please describe in-depth what the facilities' intervention process is after 15 minutes. If the youth is unable to remain calm, what are the facilities' policies? If the facility will use restraints longer than 15 mins, please describe the procedures. Recommend detailing these procedures if the facility plans to use restraints past 15 mins. 6. The following required detail in the descriptions of the monthly restraint log was left out: result of licensee review. Please include. 7. Please include if facility will use separation rooms. Continued... ...Continued 12 8. Please state that the admissions agreement will include a written statement regarding the types of emergency interventions the licensee has been approved to use and must be reviewed with the child/NMD and authorized representative at the time of admission, and that a copy of the interventions used will be provided to the authorized rep upon request. (87095.22(i)(1)(A)) 9. Please state that the facility will follow the reporting requirements for each use of manual restraints of a child/NMD (87061(i)(7), which are: - Date and time of other manual restraints involving the same child in the past 24 hours. - A description of the child's behavior that required the use of manual restraints, and description of the precipitating factors which led to the intervention. - Description of what manual restraints were used and how long the child was restrained. - Description of what non-physical interventions, trauma-informed practices, or de-escalation techniques were utilized prior to the restraint and an explanation of why more restrictive interventions were necessary. - Description of any injuries sustained by the child or facility personnel, including what type of medical treatment was sought and where the child was taken. Provide an explanation if medical treatment was not sought for injuries. - Name(s) of facility personnel who conducted the manual restraint. - Name(s) of facility personnel who witnessed the child's behavior and the restraint. - The child's verbal response and physical appearance, including a description of any injuries at the completion of the restraint. - If it is determined by the post incident review, as required in Section 87095.68, that facility personnel did not attempt to prevent the manual restraint, provide a description of what action should have been taken by facility personnel to prevent the manual restraint incident. Describe the corrective action that will be taken or will not be taken against the facility personnel and why. - If law enforcement was involved, a detailed description of the events involving the law enforcement contact, including a police report number if available. - Documentation that the child's authorized representative has been notified of the incident. General Notes: -Correction of "The Southern California Treatment Programs" used on page 564. A copy of this report was sent to Lawrence Howell, Executive Director for signature. The original signed copy will be maintained in the facility file in the San Diego Regional Office.

Deficiencies:
90087: 02/24/2025 Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32...Continued 10 1.

met_with: Lawrence Howell, Executive Director

title: Visit Date


summary: Facility Evaluation

raw_content:
Narrative:
On May 6, 2025 at 3: PM, Licensing Program Analyst (LPA) Jacob Salem conducted an unannounced visit to the above facility for the purpose of conducting a post-licensing inspection and met with Frank Simmons, Administrator. LPA conducted two staff interviews (S1 and S2) and one client interview (C1). LPA initiated an inspection the facility's physical plant. Due to time constraints, the annual is being extended to complete the physical inspection, as well as conduct files reviews and client interview. An exit interview was conducted and a signed copy of this report was provided to Frank Simmons, Administrator.

met_with: Frank Simmons, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On May 15, 2025 at 10: AM, Licensing Program Analyst (LPA) Jacob Salem conducted an announced visit to the above facility and met with Frank Simmons, Administrator. The purpose of this Case Management inspection is to conduct an annual continuation from 5/06/2025. LPA inspected the facility's physical plant, including personal rights postings, health-related services, buildings and grounds, food services, telephones, indoor and outdoor activity space, and furniture, fixtures, equipment and supplies. The home is clean, in good repair, and free from observable risks to clients' health, safety, and personal rights. The home is a one story building with three client bedrooms and two client bathrooms which are set up as follows: Bedroom #1 has two twin beds and sleeps two clients, bedroom #2 has two twin beds and sleeps two clients, and bedroom #3 has two twin beds and sleeps two clients. There is a kitchen and living room, separate office garage for client visitation and therapy, laundry room and locked storage closets, and backyard/patio area. LPA reviewed two client files (C1 and C2), which are on kept locked in the staff office garage. The client files reviewed contain required information and records, including demographic information, needs and services plans, personal rights and facility policy acknowledgements, and medication logs. LPA reviewed staff files (S1-S5), which are kept in the human resource building on campus. The files reviewed contain the required background clearance and demographic information, educational and professional background information, and job description and duties. The annual is being extended to conduct a review of staff training records and conduct one client interview. An exit interview was conducted and a signed copy of this report was provided to Frank Simmons, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On May 21, 2025 at 10: AM, Licensing Program Analyst (LPA) Jacob Salem conducted an unannounced visit to the above facility and met with Frank Simmons. The purpose of this Case Management inspection is to conduct an annual continuation from 3/15/2025. LPA reviewed staff (S1-S5) training records, which are kept in a separate human resource building on campus. LPA observed initial and ongoing training to be documented in staff files, including training on personal rights, reporting requirements, emergency intervention plan, disaster preparedness plan, and trauma informed care. LPA conducted one client interview. Based on observations made during the inspection, there were no deficiencies cited at this time. An exit interview was conducted with Frank Simmons, Administrator and a signed copy of this report was provided.


raw_content:
Narrative:
conflicting statements. Some interviews indicated that C1 was not allowed use a cell phone and was required to have their phone calls supervised by staff. Some interviews indicated that staff supervised C1 closely and checked on C1 while C1 was in their bedroom every fifteen minutes up to every hour. Some interviews indicated that C1 asked to use C3 and C5's cell phones and C5 allowed C1 to use their phone. Some interviews indicated that when staff checked on C1 in their bedroom, C1 hid the phone from staff. Other interviews indicated that staff observed C1 hiding under a blanket using the cell phone and C1 was told not to use the cell phone and staff observed C1 at the Hospital with C5's cell phone in their possession. Regarding the allegation that staff slapped minor, it was also reported that C1 was arguing with the other clients at the facility and then the clients walked out of the facility and S2 walked into the facility and told C1 to "shut up," and S2 hit C1 on the mouth with the back of their hand. Some confidential interviews denied that S2 hit C1 or told C1 to "shut up." Records reviewed indicated that C1 stated they lied about the incident in which S2 allegedly told them to "shut up," and hit C1. Conflicting interviews indicated C1 was persuaded to admit they lied about the allegations to remain placed at the facility. LPA was unable to interview all individuals, although multiple attempts were made, thus, confidential interviews could not confirm or deny the allegations. Based on confidential interviews and records reviewed the allegations that staff are not providing adequate supervision to minors engaging in inappropriate activities and staff slapped a minor, which may have occurred, however, they are not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report and appeal rights were provided to Frank Simmons. A copy of this report will be placed in the facility file.

Investigation Findings:
13On December 22, 2025, at 11:10 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Frank Simmons, Program Director, to discuss the investigative finding for the allegations noted above. LPA Jacob Salem conducted an inspection of the facility on September 2, 2025, at 1:30 pm and no deficiencies were observed. LPA Salem interviewed two Clients (C1, C6) and two Staff (S1, S5) and one County Social Worker (CSW). LPA Linley interviewed one Client (C5), and four Staff (S2, S7-S9). LPA was unable to interview three Clients (C2-4) and four Staff (S3, S4, S6, S10), despite multiple attempts to contact them. LPA reviewed the facility documents during the investigation. On August 29, 2025, Community Care Licensing received allegations that staff are not providing adequate supervision to minors engaging in inappropriate activities and staff slapped a minor. It was reported that C1 sent partially nude images of themselves via Snapchat to unknown adults. Confidential interviews revealed UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley 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 08-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, FACILITY NAME: SAN PASQUAL TREATMENT CENTER - FEMALE PROGRAMFACILITY NUMBER: VISIT DATE: 12/22/2025

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

met_with: Frank Simmons


raw_content:
Narrative:
arguing with the other clients at the facility and then the clients walked out of the facility and S2 walked into the facility and told C1 to "shut up," and S2 hit C1 on the mouth with the back of their hand. Some confidential interviews denied that S2 hit C1 or told C1 to shut up. Conflicting interviews indicated that S2 told C1 to "shut up," and hit C1 on their face. Records reviewed indicated that C1 later denied that S2 told them to "shut up," or that S2 hit C1. Conflicting interviews indicated C1 was persuaded to admit they lied about the allegations to remain placed at the facility. There were no witnesses to this allegation. It was also reported that staff used unapproved restraint technique on client in care. Confidential interviews indicated that staff could not recall the specific restraint they used, however confidential interviews indicated S5 restrained C1 for a short period of time after C1 attempted to break the front door handle and S2 and S5 restrained C1 by C1's arms under one minute and then walked C1 to another area to get away from the broken glass and rock. Lastly, regarding the allegation staff did not prevent client from physically attacking another client in care it was reported that C1 was trying to break a window because C1 wanted to go to the bathroom and staff held C1 back so they would not break the window and clients came into the room and hit C1. Confidential interviews indicated conflicting statements. LPA was unable to interview all individuals, although multiple attempts were made, thus, confidential interviews could not confirm or deny the allegations. Based on confidential interviews and records reviewed the allegations that S2 spoke to C1 in an inappropriate manner, S2 hit C1 in care, staff used unapproved restraint technique on C2 in care, and staff did not prevent client from physically attacking C1 while in care, which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report and appeal rights were provided to Frank Simmons. A copy of this report will be placed in the facility file.

Investigation Findings:
13On December 22, 2025, at 11:30 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Frank Simmons, Program Director, to discuss the investigative finding for the allegations noted above. LPA Jacob Salem conducted an inspection of the facility on August 26, 2025, at 3:45 pm and no deficiencies were observed. LPA Salem interviewed two Clients (C1, C6) and two Staff (S1, S5) and one County Social Worker (CSW). LPA Linley interviewed one Client (C5), and four Staff (S2, S7-S9). LPA was unable to interview three Clients (C2-4) and four Staff (S3, S4, S6, S10), despite multiple attempts to contact them. LPA reviewed the facility documents during the investigation. On August 21, 2025, Community Care Licensing (CCL) received allegations that staff spoke to client in an inappropriate manner, staff hit client in care, staff used unapproved restraint technique on client in care, and staff did not prevent client from physically attacking another client in care. It was reported that C1 was UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley 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 08-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, FACILITY NAME: SAN PASQUAL TREATMENT CENTER - FEMALE PROGRAMFACILITY NUMBER: VISIT DATE: 12/22/2025

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


summary: Complaint Investigation - Unsubstantiated - 3 allegations

raw_content:
Narrative:
...CONTINUED Confidential interviews indicated that the only staff member present, S3, attempted verbal de-escalation before promptly contacting emergency services. Confidential interviews and a review of the facility's program statement indicated that staff are not permitted to physically intervene when only one staff member is present. Records reviewed indicated that S3 received training in emergency intervention prior to working alone with clients. Although it was confirmed during the investigation that the altercation occurred, the investigation did not yield sufficient evidence to conclude that the altercation occurred due to lack of supervision. Based on confidential interviews, the allegation that lack of supervision resulted in minors engaging in a physical altercation is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Frank Simmons, Administrator and a copy of this report and appeal rights were provided.

Investigation Findings:
13On May 7, 2026, at 3: PM, Licensing Program Analyst (LPA) Jacob Salem met with Frank Simmons, Administrator of San Pasqual Treatment Center - Female Program to deliver the findings for the above-stated allegation. LPA Salem initiated a complaint inspection at the facility on 01/15/2026 at 1: PM and no immediate deficiencies were observed. During the investigation, LPA Salem interviewed Clients (C1, C3, and C4) and Staff (S1-S3). LPA was unable to interview C2 despite multiple attempts. Pertinent records were obtained and reviewed. On January 5, 2026, Community Care Licensing (CCL) received the allegation that lack of supervision resulted in minors (C1 and C2) engaging in a physical altercation. It was reported that C1 and C2 engaged in a physical altercation at the facility, resulting in C1 being injured. Confidential interviews and reviewed records confirmed that the altercation occurred during the overnight shift and resulted in C1 receiving multiple injuries to their arm and face. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: San Pasqual Treatment Center - Female Programfacility Number: Visit Date: 05/07/ Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32...CONTINUED Confidential interviews indicated that the only staff member present, S3, attempted verbal de-escalation before promptly contacting emergency services. Confidential interviews and a review of the facility's program statement indicated that staff are not permitted to physically intervene when only one staff member is present. Records reviewed indicated that S3 received training in emergency intervention prior to working alone with clients. Although it was confirmed during the investigation that the altercation occurred, the investigation did not yield sufficient evidence to conclude that the altercation occurred due to lack of supervision. Based on confidential interviews, the allegation that lack of supervision resulted in minors engaging in a physical altercation is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Frank Simmons, Administrator and a copy of this report and appeal rights were provided. SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 2 of 2

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0


facility_name: SAN PASQUAL TREATMENT CENTER - MALE PROGRAM

summary: Facility Evaluation

raw_content:
Narrative:
On February 10, 2025, at 1: PM, Licensing Program Analyst (LPA) Jacob Salem conducted an announced visit to the above facility and met with San Pasqual Treatment Center Frank Simmons Program Manager, Keary Mason Head of Service, Dana Centanni Regional Director for the purpose of conducting a pre-licensing inspection. Currently there are no clients placed in the home. The applicant is applying to serve six ambulatory clients ages 12 to 17 and Non-Minor Dependents. LPA conducted component III of the orientation process and reviewed with the applicants Licensing requirements. The home is a one-story building with three client bedrooms and two client bathrooms which are set up as follows: · Bedroom #1 (Client) has two twin beds and will sleep two clients. · Bedroom #2 (Client) has two twin beds and will sleep two clients. · Bedroom #3 (Client) has two twin bed and will sleep two client and attached bathroom. · Kitchen, dining area, and family room area, locked storage and laundry room, hallway and storage closets, backyard/patio area, and attached two car garage which is set up for visitation and mental health services. The Emergency Disaster Plan, Personal Rights, and complaint procedures are posted in the hallway of the home. The license will be posted as soon as it is issued. LPA and the applicants toured the facility inside and out and conducted a full inspection of the facilities physical plant, including building and grounds, food service, furniture fixtures and supplies, telephone service, health-related services, personal services, and activity space. The facility has demonstrated compliance with Title 22, Division 6 of the California Code of Regulations and Interim Lincensing Standards. An exit interview was conducted and a copy of this report was provided to Frank Simmons, Program Manager.