summary: Facility Evaluation

raw_content:
Narrative:
On June 6, 2023 at 10:30AM Licensing Program Analyst (LPA) Yuvi Diaz made an unannounced visit to the above facility. LPA Diaz met with Eric Mahan, Facility Manger. LPA Diaz conducted an interview with one of the youths from this facility. This report has been created to document this visit. A copy of this report was provided.

met_with: Eric Mahan, Facilty Manager


state: CA

facility_name: CIRCLE C RANCH INC.

summary: Facility Evaluation

raw_content:
Narrative:
On July 03, 2023 at 11: AM Licensing Program Analyst (LPA) Stephannie Verna arrived unannounced at the facility for the purpose of a case management inspection related to the facility's closure as of June 29, 2023. The licensee withdrew the facility's STRTP application on June 29, 2023 and the facility is closed as of June 29, 2023. LPA Verna met with Michelle Smith, Facility Manager. Sammie Archangel-Johnson, Office Manager/Trainer and Lashey Sanford, Facility Staff, were also present. During the course of the physical inspection of the facility, LPA Verna observed there were four clients present (S2, S3, S5, S7). LPA Verna observed there were four client bedrooms and one non-client bedroom, all had an individual bed and storage space for personal belongings. The non-client bedroom was observed to be locked at the time of the inspection and was unlocked for inspection. Michelle Smith, Facility Manager, confirmed there are seven youth residing in the facility, S1-S7. LPA requested and gathered all of the facilities posted and/or printed provisional licenses. A signed copy of this LIC-809 report provided to Michelle Smith, Facility Manager and an exit interview was conducted.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Michelle Smith, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Shoua Xiong conducted an unannounced Case Management to the facility on 4/2/2021. Due to COVID-19 restrictions, this Case Management was conducted telephonically. LPA met with the Administrator, Raynisha McDonald, and explained the purpose of today's call was to discuss the background clearances of Staff members as a follow up to the Case Management conducted on 3/23/21. LPA had received an LIC500 in which two staff members (S1 and S2) did not have Criminal Record Clearances to work at the facility. Administrator sent a clearance document for Staff S2 for LPA to review. Upon review and further inquiry with representatives from Guardian, it was determined that Staff S2 did not have their Child Abuse Central Index (CACI) clearance. S1 at the time of the Case Management inspection on 3/23/21, did not have clearance and there was no proof that the Live Scan process was started. Administrator was recommended to contact and create an account with Guardian, the new electronic data system designed to give facilities access to check eligibility statuses of applicants, view and print rosters. The facility is being cited for violations of California Code of Regulations, Title 22, Division 6, Chapter 1, Section section 80019(e)(1) Criminal Record Clearance: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. The facility is also being assessed an Immediate Civil Penalty Fee (LIC421BG) of $100 per day per person, with a maximum of five days per person. Exit interview was conducted an a copy of this report, LIC421BG, and appeal rights was emailed to the facility Administrator, Raynisha McDonald. LPA is requesting that all documents be signed and returned electronically via email.

met_with: Administrator, Raynisha McDonald


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
Licensing Program Analyst (LPA) Shoua Xiong conducted an unannounced visit to the facility on 11/18/21 at 12: PM. LPA met with Derek Thompson, Facility House Manager. The Administrator, Raynisha McDonald joined in and spoke with LPA via telephone. LPA explained that the purpose of the visit was to conduct a Case Management. During the course of a complaint investigation, it was evident that the facility had failed to report and submit an Incident Report in which the facility had filed a Suspected Child Abuse Report (SCAR) to their local county. During this investigation, facility Administrator stated they believe they had sent in the report to the Department. However, there is no such record of the report and facility was unable to provide proof that the incident had been reported and sent in. The facility is being cited for violation of the California Code of Regulations, Title 22, Division 6, Chapter 1, Section 80061(b) Reporting Requirements: Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. Exit interview conducted and a copy of this report, along with appeal rights, was given to the facility.

Deficiencies:
80061(b): Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.

met_with: Derek Thompson, Facility House Manager

title:
1
2
3
4
5
6
780061(b) Reporting Requirements


summary: Facility Evaluation

raw_content:
Narrative:
On 12/9/22, Licensing Program Analyst (LPA), Jessica Caplinger, conducted an unannounced inspection for the purpose of a Case Management. During review of background checks, it was found that two direct care staff did not have a complete background check on file through the Guardian system. The facility was cited for CCR Section 80066(a)(12)(B) Personnel Records: For employees that are required to be fingerprinted pursuant to Section 80019: Documentation of either a criminal record clearance or exemption as required by Section 80019(e). This will be assessed a civil penalty for posing an immediate personal rights, health and safety risk to clients in care by failing to obtain the clearance prior to the staff's presence in the facility. Please see LIC 809-D for the deficiency and LIC 421-BG for the civil penalty. During inspection, the indoor pool was also observed accessible to youth in care as the audible alarm to alert staff when the pool area is be accessed was not working and the door was unlocked. Refer to LIC 809-D for the deficiency. This will be assessed a civil penalty for being an immediate health and safety risk to clients in care. An exit interview was conducted with the above administrator and a plan of correction was completed. A copy of this report and Appeal Rights were given during the inspection.

met_with: Raynisha McDonald; Administrator


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Jean Stidman on 3/8/23 at 10:30am. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Stidman met with Raynisha McDonald, Administrator and inspected the facility inside and out. LPA reviewed four child's records and three staff personnel files on site at the facility. LPA reviewed four child's psychotropic medications and medication records. LPA interviewed three staff on site to discuss the facilities policies and procedures of operation. LPA interviewed four children currently prescribed psychotropic medication. During the inspection the LPA observed deficiencies (see attached 809D), plan of corrections were discussed and appeal rights were provided. LPA provided a copy of this licensing report to Raynisha McDonald, Administrator. Facility cited Interim Licensing Standards for STRTP Articles 1-10, Regulation 87068.2(f) Needs and Services Plan and 87068.3(a) Modification to the Needs and Services Plan, and 87070(b)(12) and 87070(b)(13) Children's Records, 87065.1(d)(3)(M) Supervision, Evaluation and Training Requirements, 80075(k)(7) Health Related Services and California Code of Regulations Title 22, Division 6, Chapter 1 regulation 80087(a) Buildings and Grounds. LPA observed four client files are missing the client's signature for the initial NSP and on all modifications from July 2022 - March 2023. LPA observed four client's NSP for July 2022-February 2023 are missing the authorized representative signatures from between 1-3 months.. LPA observed four client's file are missing updated NSP from 1-3 months from July 2022-February 2023. LPA observed one client file has staff initials for one medication that will be given on 3/9/23, 3/10/23 and 3/13/23. LPA observed one client file is missing the current JV220 forms. LPA observed two staff files are missing documentation of initial training on oversight and monitoring of psychotropic medications. LPA observed client files were missing documentation of centrally stored medications. LPA observed three bedrooms were missing a door. LPA reviewed and provided a copy of this report to Raynisha McDonald, Administrator.

met_with: Raynisha McDonald, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On March 17, 2023 at 10: AM Licensing Program Analyst (LPA) Stephannie Verna and Licensing Program Manager (LPM) Dara Campos arrived unannounced at the facility for the purpose of a case management inspection. A case management inspection was determined to be needed due to during prior review of Incident Reports received from the facility LPA Verna observed missing information, untimely reports, and was informed of an Incident which was not reported by the facility. Upon arrival there were two cars in the driveway, LPA knocked several times and there was no answer. LPA called and texted Administrator Raynisha and she arrived at the facility at 10: AM. LPA Verna met with Raynisha McDonald, Administrator. LPA Verna and LPM Campos completed an inspection of the facility with Raynisha McDonald, Administrator. During the inspection it was noted that one of the facility vehicles was out of registration and was not in good repair (due to the tires needing repair/replacement). Additionally, the home was observed to be deficient in regards to cleanliness, safety, and the facility being in good repair. LPA Verna discussed the incident reporting process for the facility with Raynisha McDonald, Administrator, and gathered further information related to Incidents and Incident Reports completed by the facility staff. LPA Verna reviewed the deficiencies related to the physical inspection of the home with the Administrator. LPA completed 1 interview. The Case Management was completed on today's date. The facility is being issued two citations regarding deficiencies to CCR Title 22 regulations section 80061(b) and section 80074(c). Additionally the facility is being issued a Technical Advisory related to CCR Title 22 regulations section 80087(a). A signed copy of this LIC-809 and LIC-809D, Technical Advisory and appeal rights were provided to the facility and an exit interview was conducted with Raynisha McDonald, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On 4/17/ Licensing Program Analyst (LPA) Jean Stidman met with Raynisha McDonald, Administrator, for the purpose of a Plan of Correction (POC) Inspection. Facility cited violation of Interim Licensing Standards for STRTP Articles 1-10, Regulation 87061(a) Reporting Requirements; 87070(b)(13) Children's Records; 87076(c)(1) Food Service; and 87087(a) Buildings and Grounds. Facility cited for violation of Title 22, Division 6, Chapter 1, Article 06, regulation 80075(k)(7) Health Related Services. LPA client files were missing documentation of centrally stored medications containing current information for two clients. LPA observed facility missing documentation of three clients psychotropic medication logs LPA observed one bedroom dresser was broken, the upstairs bathroom is missing a corner baseboard/tile, the two downstairs bathrooms have what appears to be mold growing in the bottom of the shower, the downstairs bathroom at the end of the hall has a broken/missing tile in the right hand bottom corner of the counter, the kitchen cabinet door below the kitchen sink does not latch closed, the pool pump room door is partially dented/kicked in, the facility does not have a minimum of two days supply of milk. LPA reviewed and provided a copy of this report to Raynisha McDonald, Administrator.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On June 29, 2023 at 1: PM Licensing Program Analyst (LPA) Stephannie Verna arrived unannounced at the facility for the purpose of a case management inspection. A case management inspection was conducted to follow-up on a March 16, Incident that occurred and was not reported to the Department by facility staff. Additionally, the Department had other concerns to address with the licensee including their current and proposed allowance policy, staff and Board of Director changes and requirements to notify the Department of these changes, Outstanding Building and Grounds repairs and safety concerns, and Administrator Qualifications and Duties. Upon arrival LPA arrived and was greeted by staff Derek Thompson. There were a total of two staff and six client present. LPA Verna met with Michelle Smith, facility Manager, and with Licensee, Raynisha McDonald, by phone. Sammie Archangel-Johnson, Office Manager/Trainer arrived at the facility and was present as well. LPA Verna discussed and gathered current information from the licensee regarding the findings for the case management inspection concerning allowance policy, staff and Board of Director changes, Outstanding Plan of Correction for Building and Grounds repairs and Administrator Qualifications and Duties. LPA Verna completed an inspection of the facility for outstanding building and ground plan of corrections or other deficiencies. During a facility inspection on 06/29/ LPA Verna noticed staff and youth in care had access to the outdoor staircase which was observed to be in need of major repair of the railings and posts and was a notable safety concern. Additionally, there were outstanding building and grounds repairs observed in the facility bathroom and kitchen as of today's date. The Case Management was completed on today's date. The facility is being issued six citations due to deficiencies related to STRTP ILS Regulations sections 87072.1(c), Discipline Policies and Procedures; 87061(g), Reporting Requirements; 87064(b), Administrator Qualifications and Duties; 87074(e), Transportation; and CCR Title Regulations, sections 80026(h), Safeguards for Cash Resources, Personal Property, and Valuables of Residents; and 80087(a), Building and Grounds. A signed copy of this LIC-809 and appeal rights were provided to the facility and an exit interview was conducted with and via phone with Raynisha McDonald, Licensee.

Deficiencies:
80026(h): 1
2
3
4
5
6
780026(h)
Safeguards for Cash Resources, Personal Property, and Valuables of Residents
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following


facility_name: CIRCLE OF FRIENDS

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Confidential interviews revealed they do smoke marijuana outside the home. Other confidential interviews revealed they do smoke and when staff sees the clients smoking, staff tells them not to smoke, "but can't touch them." Confidential interviews stated that staff do room searches when they smell marijuana but never find their "stash." Confidential interviews revealed C5 did pull out a knife and threatened other residents. Confidential interviews revealed that staff were not aware C5 was in possession of a weapon and they had conducted room searches and never found the knife. In addition, confidential interviews disclosed C5 purchased the weapon when C5 was living in another foster home. Confidential interviews revealed that when C5 pulled out the knife S1 got in the middle of the altercation and used a piece of a vacuum to create space amongst the clients while S2 called law enforcement. Confidential interviews detailed that C5 had hidden the knife in their guitar which was in C5's possession at the beginning of C5's placement with Circle of Friends and staff did not think to check C5's guitar case for a weapon. Confidential interviews could not confirm or dispute that facility staff did not provide adequate supervision to minors in care. Based on confidential interviews and record review, although the allegations of C1, C2, C3, and C4 are smoking marijuana while in care, C1, C2, C3, and C4 threatened C5 while in care, C5 had access to a weapon while in care and staff do not provide adequate supervision to the minors while in care, may or may not 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, and a copy of this report was provided along with appeal rights to Circle of Friends Program Director, Yoshita Conrad.

Investigation Findings:
13On October 8, 2021 at 2: PM, Licensing Program Analyst (LPA), Danielle Garcia, met with Facility Manager, Kai Pelaez, to deliver the findings for the above stated allegations. The investigation was conducted by Licensing Program Analyst (LPA) Danielle Garcia and LPA Marisol Lopez. During the investigation, LPA Garcia and LPA Lopez included interviews with Client 1(C1), Client 2 (C2), Client 3 (C3), Client 4 (C4), Client 5 (C5) refused interview, Staff 1 (S1), Staff 2 (S2) and Program Director (D1). In addition, Special Incident Reports, client records and facility records were reviewed. On August 18, Community Care Licensing received allegations of minors (C1, C2, C3, C4) are smoking marijuana while in care, (C1, C2, C3, C4) threatened C5 while in care, C5 had access to a weapon while in care and staff do not provide adequate supervision to the minors while in care. R- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, METROPOLITAN DR. # FACILITY NAME: CIRCLE OF FRIENDSFACILITY NUMBER: VISIT DATE: 10/08/2021

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

report_type: Complaint Investigation

met_with: Kai Pelaez

complaint_status: unsubstantiated


raw_content:
Narrative:
of this alleged incident makes residents in the facility feel uncomfortable and unable to trust staff. Confidential interviews were unable to confirm or dispute the abuse of former resident. Confidential interviews reported that there was a former staff member that was overly friendly with residents but denied that any inappropriate interactions were observed or occurred. Confidential interviews further reported current residents feel comfortable and safe in the facility and have at least one staff member they feel they can trust. Based on record review and confidential interviews the allegation of staff (unknown) sexually assaulted a minor (Child #2 [C2]) in care, may or may not have occurred, however it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of the report was provided along with appeal rights to Circle of Friends Administrator (ADM), Yoshita Conrad.

Investigation Findings:
13On December 16, 2021 at 9:05am Licensing Program Analyst (LPA), Nicole Strickland, met with Circle of Friends Administrator (ADM), Yoshita Conrad, to deliver the finding for the above stated allegation. LPA conducted an inspection of the facility on June 24, 2021 at approximately 1:50pm and no immediate deficiencies were observed. The investigation was conducted by Special Investigator Nikki Vo and LPA Strickland and included interviews with ADM, Staff #2 (S2), Staff #3 (S3), four of four foster children (Child #1 [C1], Child #2 [C2], Child #3 [C3], and Child #4 [C4]), and two County Social Workers (CSW#1, and CSW#2). One confidential witness did not respond to LPA's request for an interview and therefore was not interviewed. In addition, county records and facility records were reviewed. On June 18, 2021, Community Care Licensing (CCL) received an allegation alleging that staff (unknown) sexually assaulted a minor (Child #2 [C2]) in care. Specifically it was reported an unknown staff member abused a former resident prior to the resident leaving the facility. It was also reported that the knowledge UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Nicole Strickland 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: CIRCLE OF FRIENDSFACILITY NUMBER: VISIT DATE: 12/16/2021

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

met_with: Yoshita Conrad


raw_content:
Narrative:
On 06/03/2021, the Department received an allegation that due to a lack of staff supervision minor ingested pills resulting in death, client has access to weapons, client caused injury to another client in care, staff are not providing adequate supervision to clients, staff did not provide a safe environment to clients in care and staff did not report incidents. Confidential interviews stated the facility is limited to conducting searches and putting hands on the clients however the facility has taken measures to prevent the clients from entering the facility with alcohol and contraband by conducting routine checks. Confidential interviews stated staff were unaware that minor #1(M1) ingested street drugs prior to M1's shower and staff was unable to provide immediate first aide because it is underdetermined how long M1 was unresponsive prior to Paramedics and Fire Department arriving. Confidential interviews stated the facility has recently added additional staff to maintain continuous supervision of clients. Confidential interviews stated staff conduct room searches when it is suspected the individual client is in possession of an illegal substance, cigarettes, weapons, or belonging of others. Confidential interviews stated clients have been involved in physical altercations with each other however staff follow the emergency intervention plan and intervene to the best of their ability by placing their bodies between clients to de-escalate clients and law enforcement is contacted as a last resort however, the clients have rights and it would be a violation on the facility staff to search or place hands on clients or their personal belongings without the clients consent. Confidential interviews stated staff actively supervise and conduct 10-15 minute random night checks however when a client is AWOL, staff are unaware of clients behaviors or actions until they are reported by law enforcement or other. Confidential interviews stated all incidents that occur at the facility are reported to the appropriate parties including AWOL's. Confidential interviews stated during an AWOL attempt, staff follow the emergency intervention plan, staff follow client until staff lose sight of client, staff drive around looking for client, staff contact law enforcement and staff report AWOL's to appropriate parties. Confidential interviews stated staff meet with social workers and work with client to come up with behavioral contracts or incentives. Confidential interviews stated staff are limited to verbal interventions to stop an AWOL and bad behaviors and cannot physically restrain clients. Confidential interviews stated the facility provides a safe environment to clients in care however other witnesses allege otherwise. Confidential interviews contradicted the information provided and denied the allegations occurred however; other information provided alleged the incidents occurred. Based on confidential interviews, the allegations that due to a lack of staff supervision minor ingested pills resulting in death, client has access to weapons, client caused injury to another client in care, staff are not providing adequate supervision to clients, staff did not provide a safe environment to clients in care and staff did not report incidents may have occurred, however are not supported or proven by evidence. Therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this signed report was provided to Program Administrator, Yoshita Conrad.

Investigation Findings:
13On 12/21/2021, at 9:40 a.m. Licensing Program Analyst (LPA) Marisol Lopez arrived at the facility unannounced and met with Program Administrator Yoshita Conrad, of Circle of Friends to discuss the investigative findings for the allegation noted above. On June 08, 2021, Community Care Licensing's (CCL) Investigations Branch Bureau, Investigator Ernestina Bellucco, conducted the initial complaint investigation at the facility. The investigation for neglect/lack of care and supervision included interviews with one administrator, two staff, one sergeant, review of records and incidents. On June 21, 2021 at 3:30 p.m., Licensing Program Analyst (LPA) Marisol Lopez met with Program Administrator Yoshita Conrad to conduct an unannounced complaint investigation for the above stated allegations. LPA conducted a safety inspection and no deficiencies were observed at that time. During the investigation, LPA Lopez and Danielle Garcia conducted confidential interviews with Client #1-5 (C1-C5), Staff #1-2 (S1-S2), one social worker (SW) and Program Administrator (P1). LPA Lopez conducted additional confidential interviews with Client #6-8 (C6-C8), one program manager (P2), Staff #3-4 (S3-S4) and reviewed incident reports. (see continuation form LIC9099-C dated 12/21/2021) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Marisol Lopez 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, METROPOLITAN DR. # FACILITY NAME: CIRCLE OF FRIENDSFACILITY NUMBER: VISIT DATE: 12/21/2021

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


raw_content:
Narrative:
Based on interviews and record reviews the allegations that staff engaged in substance and alcohol with C1, C2 and C3 and staff was communicating with the minors on social media., may have occurred, however is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Yoshita Conrad.

Investigation Findings:
13Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera conducted an unannounced inspection to the facility to deliver the findings of the above allegations. LPA met with Yoshita Conrad. On May 27, 2021 at 12:00pm LPA Marisol Lopez conducted a safety inspection at the facility and no deficiencies were observed at that time. LPA Lopez reviewed all of the client files. Five of Six of children (C1, C2, C3, C4, C5), county social workers, facility staff and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that staff ( name unknown) engaged in substance and alcohol with minors and that the staff was communicating with the minors on social media. Confidential staff interviews reported that on several occasions C1, C2 and C3 went absent without leave (awol) from the facility. Once the minors returned from being awol the minors would return intoxicated. Confidential interviews revealed that C1, C2 and C3 were consuming the alcohol and substance while out on awol and not at the facility. Confidential interviews reported that staff followed all awol protocols and notified all appropriate parties. LPA did not receive any further information regarding what staff member was allegedly engaging in alcohol, substance and communicating with the minors on social media. The interviews that were provided to the LPA were not consistent regarding the allegations. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Darlene Almaraz 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: CIRCLE OF FRIENDSFACILITY NUMBER: VISIT DATE: 01/14/2022

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


raw_content:
Narrative:
Confidential interviews stated clients (C1-C4) were messing around, C1 was restrained and hand sanitizer was set on fire on C1's chest however, other versions of how the incident occurred were provided. Confidential interviews stated staff were unable to enter the room due to (C1-C4) barricading the door for a few minutes. Confidential interviews indicated that while S1 was attempting to open the door, S2 ran outside to the window attempting to gain sight of the clients, at which time C1 opened the bedroom door and indicated that C1 obtained a "rug burn" injury. Confidential interviews stated C4 was not supposed to be at the facility, staff asked C4 to leave and staff contacted law enforcement however law enforcement did not remove C4 from the facility. Confidential interviews stated staff are limited in how they can intervene and followed the facility emergency intervention plan by calling law enforcement. Records obtained indicted law enforcement was contacted and arrived at the facility. Although, C1 sustained a 2nd degree burn while in care, there were inconsistent statements from the suspects, witnesses, and victim as to what occurred and how staff responded to the incident. Based on confidential interviews, the allegations that Client #1 (C1) was injured while in care due to neglect or lack of supervision may have occurred, however are not supported or proven by evidence. Therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this signed report was provided to Program Representative, Jeannette Villarreal.

Investigation Findings:
13On 1/14/2022, at 11:30 a.m. Licensing Program Analyst (LPA) Marisol Lopez arrived at the facility unannounced and met with Program Representative Jeannette Villarreal, of Circle of Friends to discuss the investigative findings for the allegation noted above. On 09/09/2021, Community Care Licensing's (CCL) Investigations Branch Bureau (IB), Investigator Nikki Vo was assigned the investigation. On 09/13/2021 at 11: A.M., LPA conducted an initial complaint investigation and met with Facility Manager Freddy Macias. LPA conducted a safety inspection and no deficiencies were observed at that time. The investigation, consisted of confidential interviews with Client #1-4 (C1-C4), Staff #1-3 (S1-S3), three social workers (SW1- SW3), Program Administrator (P1) and review of documents: Incident reports and law enforcement documents. On 09/08/2021, the Department received an allegation that Client #1 (C1) was injured while in care due to neglect or lack of supervision. The report disclosed that C1's roommate and some of the other minors in the home attacked C1 in a room and put hand sanitizer on C1's chest and set C1 on fire. (see continuation form LIC9099-C dated 01/14/22) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Marisol Lopez 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, METROPOLITAN DR. # FACILITY NAME: CIRCLE OF FRIENDSFACILITY NUMBER: VISIT DATE: 01/14/2022

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

met_with: Jeannette Villarreal


raw_content:
Narrative:
Other confidential interviews revealed that S1 specifically asked about adopting C1. Confidential interviews did not indicate that any boundaries were crossed between S1 and C1; however S1 was unable to be interviewed. S1 is no longer employed by the facility and S1's contact number is no longer in service. Based on confidential interviews, the allegation that Staff #1 (S1) had an inappropriate relationship with Client #1(C1) may have occurred, however are not supported or proven by evidence. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this signed report was provided to Program Representative Jeannette Villarreal.

Investigation Findings:
13On 1/14/2022, at 12:35 p.m. Licensing Program Analyst (LPA) Marisol Lopez arrived at the facility unannounced and met with Program Representative Jeannette Villarreal, of Circle of Friends to discuss the investigative findings for the allegation noted above. On September 13, 2021 at 12: P.M., LPA conducted an initial complaint investigation and met with Facility Manager Freddy Macias. LPA conducted a safety inspection and no deficiencies were observed at that time. During the investigation, LPA conducted confidential interviews with four clients (C1, C2, C3, C4), two social workers, three staff (S1, S2, P1, P2), one agency worker, and reviewed incident reports. On 09/09/2021, the Department received an allegation that Staff #1 (S1) had an inappropriate relationship with Client #1(C1). It was reported C1 had S1's personal phone number and S1 had asked about adopting C1. Confidential interviews revealed conflicting statements: C1 did not have possession of S1's phone number. Also, C1 had S1's phone number and requested to call S1 when C1 was placed in juvenile hall. Confidential interviews stated S1 had asked about adopting foster children. (see continuation form LIC9099-C dated 01/14/22) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Marisol Lopez 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, METROPOLITAN DR. # FACILITY NAME: CIRCLE OF FRIENDSFACILITY NUMBER: VISIT DATE: 01/14/2022

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


raw_content:
Narrative:
It was also reported that C1 and Client #2 (C2) rubbed a dirty plunger on each other's' bed however conflicting interviews disclosed C1 and C2 threw feces in the bathroom, staff intervened and staff cleaned the area. Confidential interviews did not have any knowledge of two former clients physically assaulting C1 and/or stealing C1's personal belongings. Confidential interviews stated C1 has not reported any missing items however, it is unknown when the allegation may have occurred. Confidential interviews had conflicting statements on whether clients' needs were being met due to client's behaviors/allegations while in placement. Confidential interviews stated the facility follows the emergency intervention plan, intervenes between clients during any altercation/behavior and law enforcement is contacted as support when needed. Confidential interviews contradicted the information provided and denied the allegations occurred however; other information provided alleged the incidents occurred. Based on confidential interviews, the allegations that due to lack of supervision clients engaged in a physical altercation, staff failed to safeguard client's personal belongings, and staff failed to meet clients' needs may have occurred, however are not supported or proven by evidence. Therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this signed report was provided to Program Administrator, Yoshita Conrad.

Investigation Findings:
13On 2/07/2022, at 10:20 a.m. Licensing Program Analyst (LPA) Marisol Lopez arrived at the facility unannounced and met with Program Administrator Yoshita Conrad, of Circle of Friends to discuss the investigative findings for the allegation noted above. On December 21, 2021 at 11: A.M., LPA conducted an initial complaint investigation and met with Facility Administrator Yoshita Conrad. LPA conducted a safety inspection and no deficiencies were observed at that time. During the investigation, LPA conducted confidential interviews with two staff (S1,S2), one program administrator (P1), three of four social workers (SW1-SW4), three of four clients (C1-C4) and reviewed incident report. On 12/16/2021, the Department received an allegation that due to lack of supervision clients engaged in a physical altercation, staff failed to safeguard client's personal belongings, and staff failed to meet clients' needs. The report disclosed that an unknown staff, on an unknown date, allowed two former clients to physically assault Client #1(C1) and stole C1' personal belongings. (see continuation form LIC9099C dated 02/07/2022) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Marisol Lopez 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, METROPOLITAN DR. # FACILITY NAME: CIRCLE OF FRIENDSFACILITY NUMBER: VISIT DATE: 02/07/2022

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


raw_content:
Investigation Findings:
13On November 29, 2022 at 1: PM, Licensing Program Analyst (LPA) Lucero Jauregui arrived unannounced to deliver an amendment to the report dated 10/20/2022, due to the document being delegated confidential and should be available for public view; no other changes were made to the document. LPA met with Jermaine Williams and provided a copy of this document. On October 20, 2022 at 09:35, Licensing Program Analyst (LPA) Lucero Jauregui arrived unannounced to the facility and met with Administrator Yoshita Conrad of Circle of Friends to discuss the investigative findings for the allegation noted above. LPA conducted an inspection with Licensing Program Analyst Eduardo Barragan with the facility on September 23, 2022 at 11: AM, no deficiencies were noted. During the investigation LPA's interviewed one staff (S3) and one of four clients (C1), C2 and C4 declined to interview, C3 was not involved in the incident. LPA reviewed C1's Needs and Services Plan and Special Incident Report. On September 19, 2022, the Department received an allegation of minor ingesting unknown medications while in care. It was reported C1 was found unresponsive and taken to Rady Children's Hospital. It was also reported the urine screen of C1 was presumptive positive for THC and benozodiazepine. Confidential interviews revealed that C1 consumed Xanax with C3 and C4. Confidential interviews revealed that C1, C3, C AWOLED two times that night. Confidential interviews revealed clients often break into the garage from the outside of the home including the night of this allegation. Confidential interviews revealed there are no clients in the home prescribed Xanax and there is no medication stored in the garage. Confidential interviews indicated that there were two staff present at the facility within ratio and conducted room checks. Confidential interviews entailed conflicting statements to whether the staff witnessed C1, C2, C4 ingest any substances. It is unknown where the clients obtained Xanax. Based on confidential interviews, the allegation of C1 ingesting unknown medications while in care due to lack of supervision, may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. Exit interview was conducted and copy of this report, along with appeal rights were explained and provided to Administrator Yoshita Conrad. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Yoshita Conrad, Administrator


raw_content:
Investigation Findings:
13On November 29, 2022 at 1: PM, Licensing Program Analyst (LPA) Lucero Jauregui arrived unannounced to deliver an amendment to the report dated 10/20/2022, due to the document being delegated confidential and should be available for public view; no other changes were made to the document. LPA met with Jermaine Williams and provided a copy of this document. On October 21, 2022 at 09:30, Licensing Program Analyst (LPA) Lucero Jauregui arrived unannounced to the facility and met with Administrator Yoshita Conrad of Circle of Friends to discuss the investigative findings for the allegation noted above. LPA conducted an inspection with Licensing Program Analyst Eduardo Barragan with the facility on September 13, 2022 at 10: AM, no deficiencies were noted. During the investigation LPA's interviewed two of two staff (S1, S2), the administrator, and six of six clients (C1 - C6) at the facility. LPA reviewed C1's Needs and Services Plan, Special Incident Report and Staff Schedule. On September 6, 2022, the Department received an allegation of staff not preventing youth in care from physically assaulting another youth in care. It was reported C1 was attacked by C4 at C1's group home. It was reported C4 hit C1 on C1's head, neck, clavicle and back with a pole and it is unknown if staff intervened. Confidential interviews revealed C4 did physically assault C1 while they were on the patio roof of the facility. Confidential interviews indicate that the staff told C1 to come down from the roof and told C4 not to go onto the roof. Confidential interviews revealed that the clients on the ground handed a broom stick to C4 while on the roof. Confidential interviews reveal staff were unable to intervene due to the interfering with the clients safety and their own as the clients were on the roof. There were no witnesses to whether the staff could have prevented the physical altercation. Based on confidential interviews, the allegation of C1 being physically assaulted by C4 in care due to staff not utilizing the facility emergency intervention plan, may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. Exit interview was conducted and copy of this report, along with appeal rights were explained and provided to Administrator Yoshita Conrad. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: LUCERO JAUREGUI 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 3

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


raw_content:
Narrative:
Confidential interviews stated the facility follows the supervision plan and maintains active supervision at all times however clients personal rights are respected. Confidential interviews contradicted the information however specific details about the incident were not provided. Based on confidential interviews, the allegations that lack of supervision resulted in residents (C1-C2) engaging in sexual interactions while in care may have occurred, however are not supported or proven by evidence. Therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this signed report was emailed to Program Representative Jermaine Williams.

Investigation Findings:
13On 2/23/2023, at 11:30 a.m. Licensing Program Analyst (LPA) Marisol Lopez arrived at the facility unannounced and met with Program Representative Jermaine Williams, of Circle of Friends to discuss the investigative findings for the allegation noted above. On April 19, 2022, at 9: AM, LPA Gloria Meza-Gonzalez conducted an initial complaint investigation and met with Program Representative Jermaine Williams. LPA conducted a safety inspection and no deficiencies were observed at that time. During the investigation, LPA Lopez conducted confidential interviews with one program administrator (P1), three facility staff (S1- S3), two service workers, two of two clients (C1-C2) and reviewed incident report. On 04/15/2022, the Department received an allegation that lack of supervision resulted in residents (C1-C2) engaging in sexual interactions while in care. Confidential interviews denied that lack of supervision resulted in residents (C1-C2) engaging in sexual interactions while in care however it was reported residents (C1-C2) engaged in sexual activity without staff being aware by sneaking around on two occasions. (see continuation form LIC9099-C dated 02/23/23) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Marisol Lopez 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, METROPOLITAN DR. # FACILITY NAME: CIRCLE OF FRIENDSFACILITY NUMBER: VISIT DATE: 02/23/2023

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

met_with: Jermaine Williams


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Based on confidential interviews, the allegations that S2 disclosed personal information about a minor while in care and A1 did not enroll a minor into school while in care are SUBSTANTIATED because the preponderance of evidence has been met. This posed an immediate Health, Safety, or Personal Rights risk to C1 in care, the facility will be cited for violating Interim Licensing Standards, STRTP, Article 06. Continuing Requirements, 87072(c)(1) Personal Rights and violating Interim Licensing Standards, STRTP, Article 06. Continuing Requirements, 87072(c)(27) Personal Rights . An exit interview was conducted and plan of corrections was developed with Yoshita Conrad, Administrator. A copy of this report and appeal rights were provided to Yoshita Conrad, Administrator.

Investigation Findings:
13On April 7, 2023, at 10: AM, Licensing Program Analyst (LPA) Lucero Jauregui conducted an unannounced complaint inspection. The purpose of the inspection is to deliver the findings for the above allegation. LPA Jauregui met with Yoshita Conrad, Administrator. LPA Jauregui conducted an inspection of the facility on March 6, 2023, and no deficiencies were noted. During the investigation, LPA Jauregui requested staff schedule for 2/13/23-3/3/23, staff contact information, SIR medication refusal for C1, and February MARS for C1. During the investigation LPA Jauregui conducted record review, one client interview (C1), four staff interviews (S1-S3, A1). On February 28 2023, Community Care Licensing (CCL) received the allegation that staff disclosed personal information about a minor while in care and staff did not enroll a minor into school while in care. Confidential interviews revealed that S2 commented on the medication with another staff member and A1 submitted enrollment paperwork nine days after C1's admission. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: LUCERO JAUREGUI 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 SO. Cal Sc/res, Metropolitan Dr. # FACILITY NAME: CIRCLE OF FRIENDSFACILITY NUMBER: VISIT DATE: 04/07/2023

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

complaint_status: SUBSTANTIATED


summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA), Tamara Melikian met with the Short Term Residential Therapeutic Program (STRTP) administrator and Facility Manager to discuss the investigative findings for the above stated allegation. LPAs Tamara Melikian and Marisol Lopez interviewed seven of nine staff members(S1-S7) and one of four former clients(C1) as well as reviewed client and facility records and obtained records from law enforcement. Attempts were made to interview C2, C3, and C4 who have been reunified or whereabouts are unknown at this time. LPA did not receive a response to attempted interviews. On October 20, 2022, Community Care Licensing received information alleging that the staff (unknown which staff) was not properly supervising the minors. Confidential interviews state that the staff is following the emergency intervention plan, however there are conflicting reports stating the staff is not intervening during supervision. Confidential interviews did not corroborate the allegation with a preponderance of evidence. Based on interviews and confidential information obtained during the course of this investigation, the allegation that the staff do not properly supervise the minors may have occurred, however is not supported or proven by evidence. Therefore, the above allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report was provided. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Melanie Krage LICENSING EVALUATOR NAME: Tamara Melikian 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 3

met_with: Tammy Hudson


summary: Complaint Investigation - Substantiated - 3 allegations

raw_content:
Narrative:
Confidential interviews revealed C1-C5 were drinking alcohol in the same bedroom. Confidential interviews revealed C1 began inappropriately touching C2 in their private area, as a result C2 became upset and punched C1 in the chest area. Confidential interviews revealed that staff was sitting outside of the bedroom while the drinking took place and had left the area to follow C5 while C1, C2, C3, and C4 were still in the bedroom. Based on confidential interviews, the allegation that staff (S3 and S4) did not prevent C2 in care from physically assaulting another minor in care (C1), staff (S3 and S4) did not prevent minor in care (C1) from inappropriately touching another minor in care (C2), and minors are drinking alcohol while in care are SUBSTANTIATED because the preponderance of evidence has been met. This posed an immediate Health, Safety, or Personal Rights risk to children in care, the facility will be cited for violating Title 22, Division 6, Chapter 1, Article 06. Responsibility for Providing Care and Supervision 80078(a) The licensee shall provide care and supervision as necessary to meet the client's needs. An exit interview was conducted, and plan of corrections was developed with Yoshita Conrad, Administrator. A copy of this report and appeal rights were provided to Yoshita Conrad, Administrator.

Investigation Findings:
13On May 15, 2023, at 9: AM, Licensing Program Analyst (LPA) Lucero Jauregui conducted an unannounced complaint inspection. The purpose of the inspection is to deliver the findings for the above allegation. LPA Jauregui met with Yoshita Conrad, Administrator. LPA Charmaine Linley conducted an inspection of the facility on December 21, 2022, and no deficiencies were noted. During the investigation, LPA Linley obtained C1 and C NSP, staff schedule for 12/09/22, shift notes from 12/09/22, client roster, and staff roster with contact Information. During the investigation LPA Jauregui conducted record review, two client interviews (C2, C3), and three staff interviews (S1, S3, S4). LPA attempted to interview one staff (S2) and one client (C1). However, after numerous attempts LPA was unsuccessful. On December 15, 2022, Community Care Licensing (CCL) received the allegation that staff did not prevent minor in care from physically assaulting another minor in care, staff did not prevent minor in care from inappropriately touching another minor in care, and minors are drinking alcohol while in care. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: LUCERO JAUREGUI 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 SO. Cal Sc/res, Metropolitan Dr. # FACILITY NAME: CIRCLE OF FRIENDSFACILITY NUMBER: VISIT DATE: 05/15/2023

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Estimated Days of Completion: 0


summary: Complaint Investigation - Unsubstantiated - 3 allegations

raw_content:
Narrative:
On April 18, 2023, the Department received an allegation that staff (P1) sexually touched a minor (C1) in care. It was reported that P1 touched C1's breasts. Confidential interviews stated P1 touched C1 on the shoulder to wake them up for school. Confidential interviews with clients stated they feel safe at the facility with no concerns of physical and sexual abuse from the staff members. Confidential interviews did not provide consistent statements and there were no witnesses to the event. Based on confidential interviews, the allegation that staff (P1) sexually touched a minor (C1) in care may have occurred, however is not supported, or proven by evidence. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this signed report was provided to Freddy Macias, Facility Manager.

Investigation Findings:
13On June 28, 2023, at 9: AM, Licensing Program Analyst (LPA) Lucero Jaureugui arrived at the facility unannounced and met with Freddy Macias, Facility Manager of Circle of Friends to discuss the investigative findings for the allegation noted above. On April 19, 2023, Community Care Licensing's (CCL) Investigations Branch Bureau (IB), Investigator Ge Sun was assigned the investigation. On April 21, 2023 at 09: AM, LPA conducted an initial complaint investigation and met with Administrator Yoshita Conrad. LPA conducted a safety inspection and no deficiencies were observed at that time. The investigation, consisted of confidential interviews with five Clients (C1-C5), seven staff (S1-7), Program Administrator (P1), Child Protective Service Social Worker (SW1), Escondido Police Detective (W1), and review of documents: incident report, police report, and facility wake up policy. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: LUCERO JAUREGUI 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 SO. Cal Sc/res, Metropolitan Dr. # FACILITY NAME: CIRCLE OF FRIENDSFACILITY NUMBER: VISIT DATE: 06/28/2023

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

met_with: Freddy Macias, Facility Manager


raw_content:
Narrative:
Based on confidential interviews, the allegation that S6 sexually abused C1 in care may have occurred, however is not supported, or proven by evidence. Therefore, the allegation is unsubstantiated. An exit interview was conducted, a copy of this signed report along with appeal rights was provided to Robert Brevick, Facility Representative.

Investigation Findings:
13On November 16, 2023, at 9: AM, Licensing Program Analyst (LPA) Lucero Jaureugui arrived at the facility unannounced and met with Robert Brevick, Facility Representative of Circle of Friends to discuss the investigative findings for the allegation noted above. On July 26, 2023, Community Care Licensing's (CCL) Investigations Branch Bureau (IB), Investigator Thoams Smith was assigned the investigation. On July 28, 2023, at 12: PM, LPA conducted an initial complaint investigation and met with Head of Services Sofia Alvarez. LPA conducted a safety inspection and no deficiencies were observed at that time. The investigation, consisted of confidential interviews with two clients (C1-C2), six staff (S1-6), and Protective Service Social Worker Investigator (W1). On July 25, 2023, the Department received an allegation that staff sexually abused minor(s) in care. It was reported that S6 groped C1. Confidential interviews did not provide consistent statements whether S6 groped C1 and there were no witnesses to the event. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: LUCERO JAUREGUI 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 SO. Cal Sc/res, Metropolitan Dr. # FACILITY NAME: CIRCLE OF FRIENDSFACILITY NUMBER: VISIT DATE: 11/16/2023

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

met_with: Robert Brevick, Facility Representative


raw_content:
Narrative:
Information received by the Licensing Office stated that these allegations had occurred. Based on interviews and confidential information obtained during the course of this investigation, the allegation that Child # 2 (C2) was threatened and/or assaulted by Child # 1 (C1), due to a lack of supervision, may have occurred, however is not supported or proven by evidence. Therefore, the above allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report and appeal rights were provided.

Investigation Findings:
13Licensing Program Analyst (LPA), Daniel Mena met with Administrator, Yoshita Conrad to discuss the investigative findings for the above stated allegation. Licensing Program Analysts (LPAs) Lucero Jauregui and Daniel Mena conducted an inspections of the Short Term Residential Therapeutic Program (STRTP). No immediate hazards were observed. The investigation was jointly conducted by LPAs Jauregui and Mena. The investigation included interviews with five staff (Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), Staff #4 (S4) & Staff # 5 (S5), two clients (Child # 1 (C1) & Child # 3 (C3), as well as a review of client and facility records. LPA Mena was unable to interview Client # 2 (C2) due to C2's refusal to speak to LPA regarding complaint allegations. Community Care Licensing received information on February 02, 2023, alleging that due to a lack of supervision Child # 2 (C2) was threatened and/or assaulted by Child # 1 (C1). Information obtained in confidential interviews did not corroborate the allegation with a preponderance of evidence. LPAs obtained conflicting information during interviews. Confidential interviews denied allegations of a lack of supervision resulting in altercation between Child # 1 (C1) and Child # 2 (C2). According to confidential information, staff immediately intervened and separated C1 and C2 when altercation began. While other confidential UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Daniel Mena 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 RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: CIRCLE OF FRIENDSFACILITY NUMBER: VISIT DATE: 05/01/2024


raw_content:
Narrative:
Regarding the above allegations, it was specifically reported that the facility was refusing to pick up C1 from the hospital because the facility closed C1's bed due to C1's unsafe behavior. During investigation, confidential interviews stated that C1 was having bizarre behavior and engaging in property damage. Confidential interviews continued stating that C1 would be aggressive towards staff and engaged in property damage including physical altercation. Confidential interviews reported that law enforcement placed C1 on an emergency hold (5150). Confidential interviews stated that it was not safe for C1 to return back to the facility and the facility closed C1's bed. Confidential interviews denied a client exposing themselves to each other and there were no witnesses to the allegation. Based on confidential interviews and record review, the allegations that facility staff refused to pick up C1 after hospitalization; facility staff did not allow C1 to return to the placement; and facility staff did not provide adequate supervision, resulting in a youth exposing themselves to another youth, may have occurred, however, there was not a preponderance of evidence to support or deny the allegations. Therefore, the above allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this signed report was provided to Yoshita Conrad.

Investigation Findings:
13On June 28, 2024, at 10: AM, Licensing Program Analyst (LPA) Lucero Jauregui conducted an announced visit and met with Yoshita Conrad. The purpose of the visit is to deliver the finding for the above allegations. LPA conducted an inspection of Circle of Friends on January 10, 2024, and no deficiencies were noted. During the investigation, LPA conducted four staff interviews (S1-S2, S5-S6), three client interviews (C1-C3) and obtained pertaining documents. LPA attempted to interview numerous occasions two staff (S3-S4) and one County Social Worker interview, however, the attempts were unsuccessful. On January 8, 2024, Community Care Licensing (CCL) received the allegation that facility staff refused to pick up a youth after hospitalization; facility staff did not allow a youth to return to the placement; and facility staff did not provide adequate supervision, resulting in a youth exposing themselves to another youth. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI 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: CIRCLE OF FRIENDSFACILITY NUMBER: VISIT DATE: 06/28/2024

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

met_with: Yoshita Conrad, Facility Representative


raw_content:
Narrative:
It was reported that staff provided clients with drugs and provided clients with money to buy the drugs. During the investigation, confidential interviews stated that staff would confiscate contraband about once a week. Confidential interviews continued stating that staff conducted room checks and searches to prevent drug use at the facility. The confidential interviews added that clients got drugs during outings or AWOL. Other confidential interviews indicated clients smoked marijuana and denied staff provided clients with drugs. The investigators received conflicting information. Based on confidential interviews, the allegation that staff provided drugs to minors in care and staff are allowing drug activities on the premises, may have occurred, however, there was not a preponderance of evidence to support or deny the allegations. Therefore, the above allegation are unsubstantiated at this time. An exit interview was conducted, and a copy of this signed report was provided to Yoshita Conrad.

Investigation Findings:
13On June 28, 2024, at 11: AM, Licensing Program Analyst (LPA) Lucero Jauregui conducted an announced visit and met with Yoshita Conrad. The purpose of the visit is to deliver the finding for the above allegation. On December 2023, Community Care Licensing's (CCL) Investigations Branch Bureau (IB), Investigator Ge Sun was assigned the investigation. On December 28, 2023, LPA Jacqueline Garcia conducted an initial complaint investigation and met with Facility Representative Robert Brevick. LPA Garcia conducted a safety inspection, and no deficiencies were observed at that time. The investigation consisted of confidential interviews with four clients (C1-C4), six staff (S1-S2,S4-S7) . LPA Jauregui attempted to interview two staff (S3, S8) and Investigator Sun attempted one Protective Services Worker interview, however, the attempts were unsuccessful. On December 22, 2023, Community Care Licensing (CCL) received the allegation that staff provided drugs to minors in care and staff are allowing drug activities on the premises. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI 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: CIRCLE OF FRIENDSFACILITY NUMBER: VISIT DATE: 06/28/2024

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


raw_content:
Narrative:
Confidential interviews reported that S3 offered C2 help to find them before blaming other clients. Confidential interviews disclosed that C2 began asking clients and when C2 asked C1, C1 did not respond. Another confidential interview indicated C3 slammed C2's cell phone on the kitchen floor and C1 making a comment provoking C2. Confidential interviews indicated C2 began banging on C1's bedroom door. Confidential interviews continued stating that C2's banging on the door causing it to break down. Confidential interviews indicated S2 was standing in the doorway of C1's bedroom and S2 was preventing C2 from getting in the bedroom of C1 and a staff was inside the bedroom with C1. However, confidential interviews indicate C2 grabbed a curtain rod from their own bedroom and began swinging it; C2 got through into C1's bedroom and struck C1 once; C1 was hit on the cheek and C2 chased C1 around in the kitchen. Confidential interviews indicated C2 ran outside the facility and S3 followed. Confidential interviews reported that law enforcement was outside and the C1 got arrested. LPA viewed a video footage of the incident. Based on confidential interviews, the allegation that lack of supervision resulting in C1 and C2 engaging in a physical altercation, may have occurred, however, there was not a preponderance of evidence to support or deny the allegation. Therefore, the above allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this signed report was provided to Yoshita Conrad.

Investigation Findings:
13On June 28, 2024, at 11: AM, Licensing Program Analyst (LPA) Lucero Jauregui conducted an announced visit and met with Yoshita Conrad. The purpose of the visit is to deliver the finding for the above allegation. LPA conducted an inspection of Circle of Friends on December 4, 2023, and no deficiencies were noted. During the investigation, LPA conducted two staff interviews (S2-S3), three client interviews (C2-C4) and obtained pertaining documents. LPA attempted to interview one staff (S1) on multiple occasions, however, LPA was unsuccessful. On November 27, 2023, Community Care Licensing (CCL) received the allegation that lack of supervision resulting in minors engaging in a physical altercation. It was specifically reported that C2 chased C1 around the facility with a curtain rod and C2 hit C1 in the face with it. Confidential interviews indicated the facility had gone out on an outing to the movie theater where C2 was going in and out of the movie. Confidential interviews added that C2 reported to S3 their headphones were missing. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI 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: CIRCLE OF FRIENDSFACILITY NUMBER: VISIT DATE: 06/28/2024

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


raw_content:
Narrative:
Confidential interviews denied staff making physical contact with C1. Confidential interviews indicated C1 was very touchy with male staff. Confidential interviews denied staff making inappropriate comments to C1. Confidential interviews indicated that C1 would make sexual comments and C1 would try to touch staff. Based on confidential interviews, the allegation that staff made inappropriate comments towards C1 may have occurred, however, there was not a preponderance of evidence to support or deny the allegation. Therefore, the above allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this signed report was provided to Yoshita Conrad.

Investigation Findings:
13On June 28, 2024, at 11: AM, Licensing Program Analyst (LPA) Lucero Jauregui conducted an announced visit and met with Yoshita Conrad. The purpose of the visit is to deliver the finding for the above allegation. LPA conducted an inspection of Circle of Friends on October 10, 2023, and no deficiencies were noted. During the investigation, LPA conducted five staff interviews (S1-S5), three client interviews (C2-C4) and obtained pertaining documents. LPA attempted to interview client (C1) and staff on multiple occasions. On October 9, 2023, Community Care Licensing (CCL) received the allegation that staff made inappropriate comments towards a minor. It was reported that staff demonstrated "sexually aggressive" behavior towards C1, specifically "rubbing against C1" and stating, "I will beat that ass up" to C1. Confidential interviews indicated C1 would outburst aggressive comments and make threats to staff. Confidential interviews continued stating that C1 would make threats against staff. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI 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: CIRCLE OF FRIENDSFACILITY NUMBER: VISIT DATE: 06/28/2024

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


raw_content:
Narrative:
S1 conducted a routine check of C1 upon return from AWOL. Confidential interview disclosed that S1 began knocking on the restroom door. Staff were unaware that C1 ingested street drugs prior to C1's shower and staff was unable to provide immediate first aide because it is undetermined how long C1 was unresponsive prior to Paramedics and Fire Department arriving. The interviews that were provided to the LPA were not consistent regarding the allegations. Based on interviews and record reviews the allegations that due to lack of supervision minors had engaged in a physical altercation and C1 was found unresponsive, may have occurred, however is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Yoshita Conrad.

Investigation Findings:
13Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera conducted an unannounced inspection to the facility to deliver the findings of the above allegations. LPA met with Yoshita Conrad. Special Investigator (SI) Ernestina Bellucco of the Community Care Licensing Investigative Bureau completed the investigation. LPA Marisol Lopez inspected the facility on May 27, 2021 at 11:00 am no immediate deficiencies were observed at that time. LPA Lopez reviewed all of the client files. Five of Six of children (C1, C2, C3, C4, C5), county social workers, facility staff (S1,S2,S3,S4) and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that due to lack of supervision minors had engaged in a physical altercation and C1 was found unresponsive. Confidential staff interviews reported that on May 19, 2021, C2 and C3 went absent without leave (awol) from the facility. When C2 and C3 returned to the facility both C2 and C3 were intoxicated and ignoring staff directives to go inside the facility. Confidential interviews disclosed that C1 and C2 were outside being "loud" and verbally arguing with each other. Additional confidential staff interviews stated that on May 20, 2021, C1 had returned from an awol. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Darlene Almaraz 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: CIRCLE OF FRIENDSFACILITY NUMBER: VISIT DATE: 01/14/2022

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


summary: Facility Evaluation

raw_content:
Narrative:
On April 29, 2021 at 11:00 am, Associate Governmental Program Analyst (AGPA) Kim Robinson met with the Short Term Residential Therapeutic Program (STRTP) administrator, Yoshita Conrad, to assess an Enhanced Civil Penalty (ECP). On March 23, 2021, the Department concluded a complaint investigation alleging that Staff #1 (S1) (See the Confidential Names List, LIC 811, dated April 29 2021) engaged in sexual acts with fourteen-year-old client #1 (C1). S1 acknowledged performing lewd and lascivious sexual acts with C1 during multiple encounters, inside and outside the STRTP. The allegations were substantiated and the STRTP was cited under the Interim Licensing Standards, Section 87072(d)(11) Personal Rights. S1 willfully participated in multiple lewd acts with C1 by use of S1's employment with the STRTP Based on the analysis of the interviews, the Department has determined that an enhanced civil penalty is warranted for the physical abuse. The Penal Code section 288a (b)(1) and 288a(b)(2) define sexual conduct with a minor as physical abuse. This section describes a number of more or less direct and (always) willful acts that constitute sexual assault. Pursuant to the Enhanced Civil Penalty law, Health and Safety (H&S) code section 1548 (f)(1)(c), the Department will be issuing an immediate civil penalty of $2,500.00. An exit interview was completed, and appeal rights discussed. A copy of this report, the Confidential Names List, Appeal Rights, and a Civil Penalty Assessment - Serious Bodily Injury/Physical Abuse (Form 421-D) were provided to the administrator.

met_with: Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 5/04/2021 at 12: PM, Licensing Program Analyst (LPA) Marisol Lopez conducted an unannounced inspection with Facility Manager Freddie Macias and Program Administrator Yoshita Conrad. The purpose of the inspection is to conduct a case management to follow up on a preliminary report dated 5/04/2021 regarding the death of Client #1 (C1) at the above agency. The agency reported that on 05/03/2021, Client #1 (C1) was taking a shower and Staff #1(S1) checked on C1 and C1 did not respond to S1. S1 contacted 911 and was directed to open the door and found C1 unconscious. Emergency Responders arrived in approximately eight minutes. Program Administrator contacted the hospital and C1 was pronounced dead due to cardiac arrest. The facility contacted the Child Welfare Services for the County of San Diego, and C1's social worker. The facility has identified therapy and counseling services that are being provided to both clients and staff. LPA Lopez conducted confidential staff interviews. LPA Lopez requested the police report and incident report to be submitted to Community Care Licensing (CCL). An exit interview was conducted, and a copy of this report was provided to Program Administrator Yoshita Conrad.

met_with: Freddie Macias


summary: Facility Evaluation

raw_content:
Narrative:
On 06/21/2021 at 9: AM Licensing Program Analyst (LPA) Marisol Lopez arrived at the above facility for the purpose of conducting an Annual Inspection. LPA met with Program Manager Freddy Mancias and inspected the facility inside and out. The facility consists of a one story four-bedroom, two bathroom building with a staff sitting room/office, living room two hallways, laundry room, kitchen, dining area and two car garage. Bedroom #1 is occupied by one client; it contains one twin bed, all required linen, mattress, closet space and dresser with enough space for clients belongings. Bedroom #2 is not occupied; it contains two twin beds, all required linen, closet space and two dressers with enough space for two clients belongings. Bedroom #3 is occupied by one client; it contains two twin beds, all required linen, closet space and two dressers with enough space for two clients belongings. Bedroom #4 has an attached bathroom and is occupied by one client; it contains two twin beds, all required linen, closet space and two dressers with enough space for two clients belongings. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment/books/games were observed for client's recreation time. LPA observed sufficient perishable food for six clients for two days and seven days of non-perishable foods and appears to be following the posted menu. LPA tested the water temperature which measured 117.0 degrees Fahrenheit(F) which is within the acceptable range of 105 degrees and 120 degrees F. The living room hallway contains a locked closet which contains sharp knives, medications are locked and centrally stored in the locked closet inside a locked tool box. Licensee has provisions for contraceptives to be held in individually locked containers by clients. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The laundry room contains a washer and dryer with built-in cabinets and a utility sink. The living room contains a large screen TV, two couches and a dining area with seven chairs. LPA observed the bathrooms were clean and in good repair. In the garage LPA observed a second fridge, a locked medications refrigerator, locked cabinets with tools, chemicals and poisons, and storage area. All hazardous items were made inaccessible to residents. Cleansers and chemicals were stored in a locked garage cabinet. The facility's smoke detectors located in each of the bedrooms and the living room and hallway were checked and were operable. The carbon monoxide detector located in the hallway area was tested and is in operable condition. The single fire extinguisher housing is located next to staff office and has a current inspection tag. The following required posted items were observed and accessible to children: Ombudsman Poster, Foster Youth Bill of Rights, Grievance Procedures, Personal Rights, and current menu. LPA observed that the personal rights was updated to meet the current Interim Licensing Standards (ILS). Per facility staff, no firearms or weapons are allowed in the facility. Facility appears to be meeting the terms and conditions of their license. Licensee has obtained National Accreditation through CARF and the Accreditation is valid through November 2021. LPA discussed the following with the Program Manager: Incident reporting, including incidents related to Assembly Bill 388 law enforcement contacts as well as incidents involving emergency interventions. Personnel Files are maintained off-site and transported to LPA within reasonable time. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. A review of client records was also completed on this date including the Medication Administration Record (See Confidential Name List- LIC 811 dated on June 21, 2021). Personnel files were reviewed to ensure they contained all required documentation. Children and staff records are organized. Staff's CPR and First Aid card were current. Child's records contain original needs and services plan signed by the child and their authorized rep. Child's records contain authorization for emergency medical care signed by each child's authorized rep. Licensee has a current needs and services plan for each resident on file. Facility personnel meet staff training requirements Program Administrator is present at the facility a minimum of 20 hours a week, as verified by staff schedule. Appropriate staff/client ratios were verified during this inspection. Based on observations made during the inspection, no deficiencies observed during today's visit. An exit interview was conducted and this report was reviewed with Program Manager Freddy Mancias and a copy of this report was provided.

visit_type: Annual

met_with: Freddy Macias


summary: Facility Evaluation

raw_content:
Narrative:
On June 29, 2021, an office conference was held with Short Term Residential Therapeutic Program (STRTP) provider, Circle of Friends (COF) via Microsoft Teams, due to COVID-19 pandemic. In attendance were: Community Care Licensing representatives Regional Manager (RM) LaCresha Cook, Licensing Program Manager (LPM) Ann Valenzuela, LPM Stephanie Hudak, Licensing Program Analyst (LPA) Marisol Lopez, LPA Danielle Garcia; COF representatives- Program Administrator Yoshita Conrad; San Diego County Representatives included: Senior Deputy Probation Officer Maria Arreola, Supervising Probation Officer Yovana Cortez, Institutions Evaluation Unit (IEU) Child Welfare Protection Services Supervisor Eileen Marshall, IEU Manager Natasha Hood, IEU/Contracts Supervisor Lyn Worthington, and IEU Contract Monitor Susan Hayes. The following issues were discussed: Complaints Law Enforcement Contacts Extension for the Provisional STRTP license During the meeting, LPM Valenzuela addressed that this meeting is to support and discuss how CCL and San Diego County can assist the facility in avoiding health and safety issues and to discuss the provisional STRTP license. LPM Valenzuela discussed the recent increase in complaints and requested information on what the facility has changed; how the facility is incorporating resources to assist with difficult clients and how staff is being trained. (see continuation form LIC809-C dated 06/29/21) In response, the facility representative responded with an explanation of difficulties the facility had in obtaining assistance from the social worker when working with extremely difficult clients. The facility representative addressed that the majority of incidents occurred due to one client and it was not a common issue the facility faces. It was discussed how the facility will use their resources and elevate contacts when having a difficult time obtaining answers. The facility representative agreed to use the duty lines and supervisors as a source of obtaining information. LPM Valenzuela addressed the extension for the Provisional STRTP license and asked the facility representative where they are in the process. The facility representative stated the two components are complete, mental health has been approved and the site inspection is pending. The facility was made aware there is no further extensions after 24 months. RM Cook inquired about what the facility is doing to support staff's and clients wellbeing, including self-care and trauma informed training. The facility discussed having a therapist on site available for clients, having a recent additional trauma informed care training and providing staff time-off as needed. The facility highlighted the importance of staff wellness and the encouragement for self-care. All recommendations/suggestions and requirements given during the meeting by CCL were acknowledged by STRTP representatives. County and CCR representatives had no recommendations to add. In closing, all parties were satisfied with all information that was discussed during the meeting. Program Administrator Yoshita Conrad designated Program Representative Kathryn Rimington to sign receipt of the report and meet with LPA via tele-inspection to answer any questions. A copy of this report was emailed to Program Representative Kathryn Rimington with "read receipt" notification to verify that the licensee received the report. A copy of the signed reports will be placed in facility file.


summary: Facility Evaluation

raw_content:
Narrative:
On September 30, 2021 at 10: A.M, an office conference was held with Short Term Residential Therapeutic Program (STRTP) provider, Circle of Friends (COF) via Microsoft Teams, due to COVID-19 pandemic. In attendance were: Community Care Licensing representatives Regional Manager (RM) LaCresha Cook; Licensing Program Manager (LPM) Ann Valenzuela; LPM Angela King; Licensing Program Analyst (LPA) Marisol Lopez; LPA Danielle Garcia; LPA Margaret Lentner, COF representatives: Program Administrator Yoshita Conrad; Head of Service Desiree West; President of COF Board Mindey Morrison; Treasurer of COF Board Niki Shields, San Diego Behavioral Health Policy Analyst: Stacie Kinney, Department of Health Care Services: Sandi Snelgrove; David Gutierrez; Alexandria Andrews, San Diego County Representatives included: Senior Deputy Probation Officer Maria Arreola, Supervising Probation Officer Yovana Cortez, Escondido Police department, Sergeant Ryan Hicks, Institutions Evaluation Unit (IEU) Child Welfare Protection Services included: Supervisor Eileen Marshall, IEU Lillian Asoera, IEU/Contracts Supervisor Lyn Worthington, and IEU Contract Monitor Susan Hayes. The following issues were discussed: Health and Safety and Law Enforcement (LE) concerns Program Statement required updates Special Incident reports. During the meeting, RM Cook addressed that this meeting is to provide support and discuss how agencies can assist the facility in avoiding health and safety issues, address concerns and to discuss the STRTP program being provided. Additional topics discussed: 1. SIR's require additional information to indicate precursor to incidents, interventions used according to Emergency Intervention Plan (EIP), and staff follow up. (see continuation form LIC 809-C dated 09/30/2021) (continuation form page 2) 2. AWOL policy is to be more trauma informed 3. Specialty Mental Health Services & Presumptive Transfers 4. EIP needs to be more trauma informed. 5. Facility must ensure staff know and understand the EIP and Needs and Service Plans. 6. Law Enforcement's (LE) concern that staff are failing to intervene or report delinquent and illegal behavior. RM Cook requested a plan of correction and plan of action due on 10/30/2021 for the following: - An update to the Program Statement including: AWOL policy, SIR reporting, Emergency Intervention Plan focusing on Trauma informed Care, Mental Health Interventions after-hours/ weekends and Ratio. - Licensee will contact LE for additional staff training and a consultation for behavioral services and provide a plan on how the facility will ensure staff feel supported. - Licensee will address the lack of managerial oversight, lack of supervision, and complaints of lack of support by management for staff. All recommendations/suggestions and requirements given during the meeting by CCL were acknowledged by STRTP representatives. County, Law Enforcement and CCR representatives had no recommendations to add. In closing, all parties were satisfied with all information that was discussed during the meeting. A copy of this report was emailed to Program Administrator Yoshita Conrad with "read receipt" notification to verify that the licensee received the report. A copy of the signed reports will be placed in facility file.


summary: Facility Evaluation

raw_content:
Narrative:
On October 21, 2021 at 10: AM, Licensing Program Analysts (LPA) Marisol Lopez conducted an unannounced inspection at the above facility. During the inspection, LPA met with Program Representative (P1) Robert Brevick. LPA conducted telephone call with Program Administrator Yoshita Conrad who designated P1 to facilitate inspection and sign document (LIC-809 dated 10/21/21). LPA conducted a safety inspection of the facility, and no safety hazards were observed. The purpose of the case management inspection is to conduct a record review. Community Care Licensing (CCL) has requested the following documents to be submitted to LPA within 48 hours. LIC LIC Control of Property An exit interview was conducted and this report was reviewed with Program Representative Robert Brevick and a copy of this report was provided.

met_with: Robert Brevick


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Manager, Angela King, Licensing Program Analyst, Margaret Lentner conducted a case management inspection on November 2, 2021, at 11:11am, based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. 4 out of Direct Care Staff and 4 out of 4 youth files as identified on the LIC 811 confidential names dated 11/2/2021, were reviewed. 3 out of Direct Care Staff and 2 out of 4 youth were interviewed. The Plan of Operation including policies and procedure were reviewed. A copy of this report was discussed and provided to Freddy Macias, Facility Manager.

met_with: Yoshita Conrad Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Sethany Yem conducted a case management inspection on 7/27/22 based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 10 out of Direct Care Staff and 5 out of 5 youth files were reviewed. 3 out of Direct Care Staff and 3 out of 5 youth were interviewed. (See the Confidential Names List, LIC 811, dated July 27th, 2022). The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, youth case plans, quarterly assessments, and crisis intervention plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Yem observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Administrator Yoshita Conrad.

met_with: Administrator Yoshita Conrad