summary: Facility Evaluation

raw_content:
Narrative:
On December 03, 2021 at 12: PM, Licensing Program Analyst (LPA) Jean Herring conducted an unannounced Post-Licensing inspection at the above named Transitional Housing Placement Program (THPP) for non-minor dependents (NMDs). LPA met with Petra Gil-Vigie, Administrator. Currently, the THPP office is staffed by two(2) Social Work Personnel, one(1) Social Work Supervisor, two(2) Peer Life Skills, one (1) Office Manager and an Administrator. BUILDINGS AND GROUNDS A tour of the THPP administrative office was conducted with the administrator. The THPP administrative office shares the same suite with Victory Family Services- Foster Family Agency and Adoption Agency. The office is conveniently located for the public and less than two hours' travel by automobile from the THPP participant units as required. The office has a reception area, file room, copy area, conference room, break room, cubicles and individual offices. THPP participant records and personnel records are kept locked at all times in file cabinets. The administrative office has telephone service at all times. The program has 11 remote sites and 20 participants in placement. Per Administrator, the program has no non-ambulatory participants in placement. OPERATIONS The THPP maintains on file a current, written, definitive Plan of Operation. The THPP's governing body is active and functioning in order to ensure accountability. The THPP maintains a listing of all participants and living units. DISASTER PREPAREDNESS The THPP has a current Emergency and Disaster Preparedness Plan which includes emergency information, instructions and phone numbers including a 24-hour emergency number for the licensee and the participant's responsible party. The facility provides training on the plan to each staff member. (cont...) STAFFING During this inspection, LPA reviewed two(2) Social Worker Personnel files, one(1) Social Work Supervisor's file and Administrator's file. All personnel have obtained criminal record clearances and child abuse index checks. All personnel are associated to the THPP's facility number. During this inspection, the THPP was cited for violation of: Title 22, Division 6, Chapter 7, THPP regulation, Section 86030.5(e) - Record review reveals THPP does not maintain a Certificate of Compliance for each THPP living unit. Title 22, Division 6, Chapter 7, THPP regulation, Section 86071(a)(1)(A) - Record review reveals current participant roster does not contain information on the following: participant's ambulatory status; name, address and phone number of attending physician; authorized representative information. Title 22, Division 6, Chapter 7, THPP regulation, Section 86071(a)(1)(B) - Record review reveals current participant roster does not contain information on the following: participant's ambulatory status; name, address and phone number of attending physician; authorized representative information. Title 22, Division 6, Chapter 7, THPP regulation, Section 86071(a)(1)(C) -THPP's register of participants does not contain authorized representative information as specified in Section 86170(b)(7). A Case Management - Post-licensing Continuation inspection is required to complete the inspection. A signed copy of this report was provided to the THPP representative along with LIC 809C, LIC 809Ds, LIC 9102TV (Advisory Notes-Technical Violation), LIC 811 (Confidential Names list) and Appeal Rights.

met_with: Petra Gil-Vigie, Administrator


state: CA

facility_name: VICTORY FAMILY SERVICES

summary: Facility Evaluation

raw_content:
Narrative:
On December 9, Licensing Program Analysts (LPA) Jean Herring conducted an unannounced inspection of the facility at 4: PM. LPA met with Petra Gil-Vigie, Administrator. The purpose of the inspection was to verify proof of correction to the deficiency cited on December 3. 2021. During today's inspection, the following documents were observed: - Register of Participants which contains information specified in Section 86071 (a)(1)(A) thru (C) - Certificate of Compliance for each THPP living unit as specified in Section 86030.5(e) The deficiencies are cleared. Plan of Correction (POC) Clearance letters were provided to the facility representative along with this report.

report_type: Facility Evaluation


summary: Facility Evaluation

raw_content:
Narrative:
On May 9, 2022 at 12: PM, Licensing Program Analyst (LPA) Jean Herring conducted an unannounced Case Management - Post-Licensing Continuation inspection at the above named Transitional Housing Placement Program (THPP) for non-minor dependents (NMDs). LPA met with Gregorio Aguinaldo, During this inspection, LPA reviewed four(4) participant records, including but not limited to: Admission Agreement; ID and Emergency Information; Health and Education Passports including mental health information and immunization record; education and/or work documents; Needs and Services Plan (NSP) and Transitional Independent Living Plan (TILP); modifications to NSP; Removal/Discharge Policy; and medical assessment. There are no deficiencies cited during this inspection. LPA provided one(1) Advisory Note - Technical Violation regarding medical assessment. No additional Post-licensing continuation inspection is required. An exit interview was conducted and a signed copy of this report was provided to the facility representative along with LIC TV (Advisory Notes) and LIC 811 (Confidential Name/s list).

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
On May 9, 2022 at 4: PM, Licensing Program Analyst (LPA) Jean Herring conducted an unannounced Case Management at the above named Transitional Housing Placement Program (THPP) for non-minor dependents (NMDs). LPA met with Gregorio Aguinaldo, Social Work Supervisor. The purpose of the inspection was to follow up on an incident report received by the Department on 2/9/22 involving NMD1 and NMD2. During today's inspection, LPA reviewed participant records and obtained copies of pertinent documents. Additional time is needed to resolve this case. A signed copy of this report was provided to the THPP representative along with LIC 811 (Confidential Names list).

met_with: Petra Gil-Vigie, Administrator and Gregorio Aguinaldo, Social Work Supervisor


summary: Facility Evaluation

raw_content:
Narrative:
On December 16, 2022 at 10:45 a.m., Licensing Program Analyst (LPA) Demetris Teal conducted an unannounced case management at the above named Transitional Housing Placement Program (THPP) for non-minor dependents (NMD's). LPA met with Raymond Martinez, FFA Social Worker Supervisor. Supervisor said he has knowledge for both the FFA and THPP. Purpose of the visit was to follow up on an incident report received by Community Care Licensing on 11/09/22 involving NMD1 and NMD2. During todays inspection, LPA reviewed participant records, staff record and obtained copies of pertinent documents. Interviews will be conducted as necessary Additional time is needed to resolve this case. A signed copy of this report was provided to the THPP representative along with LIC 811 (Confidential Names)

met_with: Raymond Martinez-FFA Social Worker Supervisor


summary: Facility Evaluation

raw_content:
Narrative:
On 12/30/22 at 11: A.M. Licensing Program Analyst (LPA) Demetris Teal conducted an unannounced case management inspection at the THPP administrative office. LPA met with Petra Gil-Vigie- Administrator, to deliver the Conclusion of the Case Management from an in-person case management inspection performed on 12/16/22, by the LPA Demetris Teal. Interviews were conducted with Staff associated with Victory Family Services, Ronald (Ron) Hernandez, Petra Gil-Vigie, Jasmeet Aujla and Dept.of Social Services with Kern County, Social Worker Somphou Siripane. Interviews were conducted with NMD 1 and an attempt to interview NMD 2 was made, without success. Based on review of files, interviews conducted and all available information, LPA did not find any personal rights or Interim Licensing Standards violated regarding Victory Family Services, where it involves a weapon produced by NMD 2 with intent to use said weapon against NMD 1. No injuries were reported by NMD 1. NMD 1 did feel threatened and called the police. Incident appears to have been isolated between two participants who lived together. NMD 2 is no longer a part of the THPP program. No further follow up is needed at this time. Exit Interview. A signed copy of this report was provided to the THPP representative along with LIC 811 (Confidential Names list).

met_with: Petra Gil-Vigie-Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On March 26, 2024 at 11: A.M, Licensing Program Analysts (LPA) Demetris Teal and Ashley Ruacho conducted an unannounced Annual Inspection at the above named Transitional Housing Placement Program (THPP) for non-minor dependents (NMDs). LPA's met with Petra Gil-Vigie, Administrator. Currently, the THPP office is staffed by three (3) Social Work Personnel, one (1) Acting Administrator, three (3) Peer Life Coach's, one (1) Support Staff Manager, three (3) Support Service Aide's, one (1) Office Manager and an Administrator. PHYSICAL PLANT A tour of the THPP administrative office was conducted with the administrator. The THPP administrative office shares the same suite with Victory Family Services- Foster Family Agency and Adoption Agency. The office is conveniently located for the public and less than two hours travel by automobile from the THPP participant units as required. The office has a reception area, file room, copy area, conference room, break room, cubicles and individual offices. THPP participant records and personnel records are kept locked at all times in file cabinets. The administrative office has telephone service at all times. The program has 26 remote sites and 32 participants in placement. Per Administrator, the program has no non-ambulatory participants in placement. OPERATIONS The THPP maintains on file a current, written, definitive Plan of Operation. The THPP's governing body is active and functioning in order to ensure accountability. The THPP maintains a listing of all participants and living units. Continued.... ......Continued DISASTER PREPAREDNESS The THPP has a current Emergency and Disaster Preparedness Plan which includes emergency information, instructions and phone numbers including a 24-hour emergency number for the licensee and the participant's responsible party. The facility provides training on the plan to each staff member. STAFF RECORDS Staff records are available upon request. LPA reviewed two (5) personnel records (refer to Confidential Names form LIC 811 dated March 26, 2024 and interviewed five (5) staff. All individuals who work, or have contact with clients, have a current criminal record clearance or exemption and Child Abuse Index Check clearance/Live-Scan fingerprints and/or request for association have been submitted for that purpose. The Administrator meets required education and experience. Social workers have the required education and experience. Personnel records contain documentation of staff training. CLIENT RECORDS LPA reviewed five (5) client records. Client records are maintained onsite in the administrative THPP office. Client record are in a locked cabinet. Administrative office is locked. Client record contained the name, address, telephone numbers of physicians, pertinent client information including ambulatory/non-ambulatory status. Client records were made accessible when requested. A deficiency citation was issued at the time of the inspection. An exit interviewed was conducted and a copy of the LIC 809, LIC 809C, LIC 809D and appeal rights were provided to Administrator.

visit_type: Annual


facility_name: WALDEN FAMILY SERVICES

summary: Facility Evaluation

raw_content:
Narrative:
On 11/10/2021 at 10: AM, Licensing Program Analyst (LPA) Marisol Lopez conducted an unannounced required annual inspection at the facility above. LPA met with Program Representative (P1) Stephanie Wahl. The Agency utilizes apartment buildings and housing model throughout San Diego County. Currently, there are 36 participants in the program. Participants residences are inspected by agency social worker once a week. Staffing: The agency employee's the following assigned staff under the THP program. Chief Operating Officer/Administrator, Social Worker Supervisor, Social Worker, Housing Specialist; Case manager, Enhanced Services Support Worker, and Employment Specialist. All employees have the required experience, and training for their current job employment. LPA reviewed 10 of 10 staff files (S1-S10) and interviewed 2 of 10 staff (S1, S2). All staff files met the minimum qualifications for training requirements. The facility provided a list of clients and certified apartment information, current Personnel Report (LIC 500), Designation of Facility Responsibility (LIC 308) and all staff have current CPR certificates on file. (see continuation form LIC 9099-C dated 11/10/21) Staff and client files are available for review and maintained online password protected. Due to time constraints, the annual inspection is being extended for 10 of 10 client (C1-C10) file reviews and 8 of 10 staff (S3-S10) interviews. An exit interview was conducted, and this report, and LIC 811 was reviewed with Program Representative Stephanie Wahl and a copy of this report was provided.

met_with: Stephanie Wahl


summary: Facility Evaluation

raw_content:
Narrative:
On 11/12/2021 at 9: AM, Licensing Program Analyst (LPA) Marisol Lopez conducted an unannounced required annual continuation inspection at the facility above. LPA met with Program Representative (P1) Stephanie Wahl. The Agency utilizes apartment buildings and housing model throughout San Diego County. Currently, there are 36 participants in the program. Participants residences are inspected by agency social worker once a week. LPA reviewed ten of ten client files (C1-C10) and interviewed six of six staff (S3-S8). Two staff (S9-S10) were unavailable to be interviewed. (see confidential name list, LIC811, dated 11/12/2021) Based on records review, the licensee did not comply as four (C2, C3, C4, C6) out of ten clients (C1-C10) did not have a medical assessment in the client file which poses a potential health, safety or personal rights risk to persons in care. The facility is being issued a citation in accordance with the Title 22, section 86069(a) Participant Medical Assessments. (See LIC809-D dated 11/12/21 for the cited deficiency.) An exit interview was conducted, and this report, appeal rights and LIC 811 was reviewed with Program Representative Stephanie Wahl and a copy was provided.


summary: Facility Evaluation

raw_content:
Narrative:
On December 18, 2023 at 10: AM, Licensing Program Analyst (LPA) Jacob Salem arrived at the above facility's corporate office for the purpose of conducting an annual inspection. LPA met with Edith Pedroza, Program Director and explained the purpose of the visit. LPA began by conducting an inspection of the office's physical plant. The office consists of a lobby, several office spaces, and a conference room that can be used for confidential interviews. LPA observed the facility license to be prominently posted near the entrance. Client files are kept in a secure online system called Extended Reach. LPA conducted a review of five client files (C1-C5), which were provided upon request. All five client files reviewed contained the required demographic information, health and educational records, signed discharge policies, and signed and up-to-date Needs and Services Plans. All five client files reviewed did not contain a written medical assessment prior to entering the program, but documentation of the clients decision to opt-out of the assessment was documented in their files. Due to time constraints, the annual is being extended to conduct an inspection of the staff files and emergency disaster plan. Based on observations made during the inspection, there were no deficiencies cited at this time. An exit interview was conducted with Edith Pedroza, Program Director, Administrator and a signed copy of this report was provided.

met_with: Edith Pedroza, Program Director


summary: Facility Evaluation

raw_content:
Narrative:
On December 21, 2023 at 8: AM, Licensing Program Analyst (LPA) Jacob Salem arrived at the above facility and met with Edith Pedroza, Program Director. The purpose of this Case Management inspection is to conduct an annual continuation from 12/18/2023. LPA reviewed five staff files (S1-5), all of which were provided to LPA upon request. The files contained the required personnel information, criminal record clearances, health screening, and documented training from the online system Relias. Records for S1 and S2's training upon hire in the previous online training system will be sent to LPA after the human resources supervisor returns to the office on 1/8/2024.. LPA also conducted a review of the facility's written disaster preparedness plan, which was updated and signed this year. The written disaster preparedness plan includes the signed LIC 610C and signed training log for disaster drills. Additionally, the emergency plan includes a 24-hour number for clients to contact and an alterative location for clients to go in the case of emergencies. Based on observations made during the inspection, there were no deficiencies cited at this time. An exit interview was conducted with Edith Pedroza and a signed copy of this report was provided.


summary: Facility Evaluation

raw_content:
Narrative:
On December 11, 2025, at 1:30 pm, Licensing Program Analyst (LPA) Cynthia Velasquez arrived unannounced at the facility to initiate a required inspection. LPA explained the purpose of the visit to Teresa Stivers, CEO. Staff roster and client roster were supplied to LPA, and a total of 5 staff and 5 client files were requested for viewing. The files are kept electronically via Extended Reach and ETO. LPA visually viewed C1-C5 files. All client files contained Intake/Placement documentation, County Social Worker Provider Agreements, Needs and Services Plans, Health and Education Passports, Walden Social Worker case notes, and personal Identifying information. Due to time constraints, staff files and inspection of premises will be conducted at a later time.


summary: Facility Evaluation

raw_content:
Narrative:
On December 12, 2025, at 9:00 am, Licensing Program Analyst (LPA) Cynthia Velasquez arrived unannounced at the facility to continue required inspection. Staff files were made available for viewing by Edith Pedroza, Program Director. The files are kept electronically via Extended Reach. LPA visually viewed staff files (S1-S5) All staff files contained current training transcripts, Child Abuse reporting forms, Resume, Educational Transcripts and/or copies of degrees, current CPR cards, Health Screenings and TB screenings, Identification, and Background Clearances. The agency contains 15 individual offices which are for CFO, CEO, Accounting Officers, Development workers, Payroll officer, FFA Supervisor,and social workers. There are postings of Foster Youth Bill of Rights, Foster Youth Mental Health Bill of Rights, Foster Youth Sexual and Reproductive Rights, Ombudsman poster, Cal-FURS, Grievance procedures, Community Care Licenses, Legal Assistance, and Emergency Disaster Plan, Preparedness, and binders available for viewing. The reception area has emergency kit and binders, as well as copy machine/fax equipment. There is an Information Technology (IT) room, supply area, and break room. There is a large conference room available with three long desks, chairs, and several tables that join to make a large seating area. The capacity of the room is approximately 20 persons. Continued from LIC There were no blocked passageways, and hallways were free flowing. There were posters of encouragement throughout the facility. Based on the facility inspection and file reviews , there are no deficiencies found at this time. A copy of this report was reviewed and given to the Program Director, Edith Pedroza, along with a Confidential Names List (LIC 811).


summary: Facility Evaluation

raw_content:
Narrative:
On 05/31/2022 at 9:00AM Licensing Program Analyst (LPA) Olivia made an unannounced to Walden Family Services Transitional Housing Placement plus Foster Care (THP + FC) and Non-Minor Dependents (NMD) Administrative Office for the purpose to conduct the Required 2 year licensing Inspection. LPA Rosas met with Staff#1(S1) who granted access to the Administrative Office and an inspection was conducted together. Individuals mention in this report are identify on the Confidential Names List (LIC811) dated 05/31/22. LPA Rosas inspected following during the inspection: The facility is licensed to provide Transitional Housing Placement plus Foster Care (THP + FC) and Non-Minor Dependents (NMD) to hundred and fifty (150) participants ages eighteen (18) through twenty one (21). There are currently fifty-nine (59) participants in placement at different remote sites in the Los Angeles County (sites are located in Conoga Park, Santa Clarita, Van Nuys, Mission Hills, Tarzana, Lancaster, Pasadena and Pomona). Facility has six (6) Social Workers (1 per 12 participants) and one (1) Social Worker Supervisor (1 per Social Workers). The facility is currently operating within staff ratio. The administrative office is located at Balboa Blvd. # Encino, CA 91316. The business office building and is set up as follows: Temperature and health checks are conducted at the entrance in the sign-in area in Suite #130. The administrative office consists of Suite #130, and Suite #134. Suite #134, which accommodates THP+FC staff. Suite#130 consists of offices and desks primarily for the Walden FFA program, and Adoption program. There is a visitors room (for the FFA children), a conference room, a kitchen, and desks/offices for the Program Director, Adoptions Supervisor, Recruiter/Housing Specialists, Grant Manager, Office Assistant, and THP/FFA/Adoptions Social Workers. Suite#134 is directly adjacent to Suite#130, and consists of the following: three (3) offices where six (6) THP Social Workers, one (1) THP/FFA Social Worker, and one (1) THP Social Worker & Intake Coordinator have desks. Staff and Client records are store digitally in Extended Reach. All posting requirements were met. Report continues on LIC 809-C Page 1 of LPA Rosas reviewed following during the inspection: LPA Rosas requested the following forms for review, Current Census, Personnel Report (LIC 500), Emergency Disaster Plan Protocols, Emergency Disaster Plan for Children's Residential Facilities (LIC 610C). The certification/decertification list of participants living units. Staff Records Review: LPA reviewed three (3) staff records stored in individual personnel file provided by S1. LPA ensured to thoroughly review the records of the primary active staff (i.e The Program Administrator, Supervising Case Manger, Social Worker). LPA reviewed the Personnel Report (LIC 500) and confirmed that facility has six (6) Social Workers (1 per 12 participants) and one (1) Social Worker Supervisor (1 per Social Workers) who carries social worker caseload. The facility is currently operating within staff ratio. LPA review of Facility's Personnel Report Summary on 05/31/2022 that indicates that all personnel have criminal record clearance has obtain the necessary clearances with DOJ, FBI, and Child Abuse Response. LPA reviewed staff qualifications and training hours. The facility has social worker personnel available on a 24-hour basis to respond to any emergency. Clients Records Review: LPA reviewed three (3) clients records which meet requirement. LPA reviewed the Admission Agreements, date of placement in unit, Emergency Contact information, and Needs and Services Plan, Cash Records. Staff Interviews: LPA Rosas conducted a confidential interview with three (3) staff. LPA Rosas together with Housing Specialist conducted a collateral visit to the following remote site located in Tarzana, CA. No deficiencies observed or cited during the inspection. LPA Rosas by email send the following PINS to S PIN 20-17-CRP: New Background Check Requirements, Assembly Bill 819 (Chapter 777, Statutes of 2019), PIN 21-20-CRP: Statewide Launch of New Inspection Tools for Children's Residential Licensees, PIN 21-05-CRP: The Family Urgent Response System (FURS). There were no deficiencies observed or cited at this time. Exit interview was conducted with Sq and a copy of this report was left at the facility.

met_with: Staff#1 (S1)


summary: Facility Evaluation

raw_content:
Narrative:
On 10/15/2024 at 9:12AM Licensing Program Analyst (LPA) Christine Wilson made an unannounced visit to Walden Family Services Transitional Housing Placement plus Foster Care (THP + FC) and Non-Minor Dependents (NMD) Administrative Office for the purpose to conduct the Required 2 year licensing Inspection. LPA Wilson met with Staff#1(S1) who granted access to the Administrative Office. At 9:48am, LPA Wilson met with staff #2 (S2) and conducted an inspection together. Individuals mentioedn in this report are identified on the Confidential Names List (LIC811) dated 10/15/24. The facility is licensed to provide Transitional Housing Placement plus Foster Care (THP + FC) and Non-Minor Dependents (NMD) to hundred and fifty (150) participants ages eighteen (18) through twenty one (21). There are currently fifty-one (51) participants in placement at different remote sites in the Los Angeles County (sites are located in Conoga Park, Santa Clarita, Van Nuys, Mission Hills, Reseda, Tarzana, Lancaster, Pasadena and Pomona). Facility has two (2) Social Workers (1 per 12 participants max) and two (2) Social Worker Supervisors (1 per Social Workers max) and eight (8) Case Managers (1 per 12 participants max). The facility is currently operating within staff ratio. LPA Wilson inspected following during the inspection: The administrative office is located at Balboa Blvd. # Encino, CA 91316. The business office building is set up as follows: Temperature and health checks are conducted at the entrance in the sign-in area in Suite #130. Suite #130, which accommodates THP+FC staff. Suite#130 consists of offices and desks primarily for the Walden THP Plus FFA program, and Adoption program. There is a conference room used as the visitors room (for the NMD participants), there is a kitchen, and desks/offices for the Program Director, Adoptions Supervisor, Recruiter/Housing Specialists, Grant Manager, Office Assistant, and THP/FFA/Adoptions Social Workers, Housing Specialist, THP Plus Supervisor and Intake Coordinator. The previous suite #134 has not been in use since June 28 2022. Staff and Client records are storde digitally in Extended Reach. All posting requirements were met. Report continues on LIC 809-C Page 1 of LPA Wilson reviewed following during the inspection: Current Census, Personnel Report (LIC 500), Emergency Disaster Plan Protocols, Emergency Disaster Plan for Children's Residential Facilities (LIC 610C). The certification/decertification list of participants living units. Staff Records Review: LPA reviewed three (3) staff records stored in individual personnel file. LPA ensured to thoroughly review the records of the primary active staff (i.e The Program Director, THP Plus Supervisor, and Case Manager). LPA review of Facility's Personnel Report Summary on Guardian 10/14/2024 that indicates that all personnel have criminal record clearance and have obtained the necessary clearances with DOJ, FBI, and Child Abuse Response. LPA reviewed staff qualifications and training hours, Identification and Physical Health Screening with TB clearance. The facility has three (3) social worker personnel available on a 24-hour basis to respond to any emergency. Clients Records Review: LPA reviewed three (3) clients records (NMD1, NMD2, NMD3) which meet requirement. LPA reviewed the Admission Agreements, date of placement in unit, Emergency Contact information, Cash Records. Staff Interviews: LPA Wilson conducted a confidential interview with two (2) staff (S1, S2). LPA Wilson together with THP Housing Specialist (S4) conducted a collateral visit to remote site (C4 and C6) located in Tarzana, CA. No deficiencies observed or cited during the inspection. LPA Wilson together with THP Housing Specialist (S4) conducted a collateral visit to remote site (C5) located in Van Nuys, CA. No deficiencies observed or cited during the inspection. There are no deficiencies at this time. A copy of report was reviewed by LPA and THP Pus Supervisor (S2) and a copy provided.

met_with: THP Case Manager


facility_name: WALDEN FAMILY SERVICES THP+FC

summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
The THPP is being issued a citation for violations of the Interim Licensing Standards, Chapter 7, Version 2, Sections 86272 (a)(12) Personal Rights. See attached LIC 9099D for cited deficiency. An exit interview was conducted, appeal rights explained and a copy of this report was provided to Patrick Taylor, along with the LIC 811.

Investigation Findings:
13On December 29, 2022 at 2:25pm, Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera conducted an unannounced inspection to the facility to deliver the findings of the above allegation. LPA met with Patrick Taylor. LPA conducted an inspection of the facility on August 19, 2022 at 10:20 am and no immediate deficiencies were observed. One of one client (C1), three staff and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that staff #1 (S1) interacted inappropriately with C1. Confidential staff interviews reported that on June 23, 2022, the facility became aware that S1 told C1 confidential information about another client. Confidential interviews reported that S1 had been inappropriately interacting with C1 and not in a professional manner. All of the persons interviewed including S1 corroborated this information. Based on record review and interviews S1 interacted inappropriately with C1. The preponderance of evidence standard has been met, therefore the allegation S1 interacted inappropriately with C1 is found to be Substantiated. This poses a potential Health, Safety or Personal Rights risk to the children in care. SubstantiatedEstimated 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 19-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, MAIN ST., SUITE FACILITY NAME: WALDEN FAMILY SERVICES THP+FCFACILITY NUMBER: VISIT DATE: 12/29/2022

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

report_type: Complaint Investigation

met_with: Patrick Taylor

complaint_status: SUBSTANTIATED


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Confidential interviews and documentation reported that NMD2 had stolen a package worth over $100 from NMD1's front porch on 03/08/2024. This stealing was caught on camera and reported to the facility, and NMD1 filed a police report. Confidential interviews reported that NMD2 did not receive any discipline for this action. Confidential interviews reported that NMD1 had to call the cops due to NMD2 harassing NMD1 multiple times by standing at the front door of NMD1 and not leaving, causing NMD1 to feel harassed. Confidential interviews reported that NMD1 had requested to move, but the facility was not accommodating the request. Additional confidential interviews reported that the facility had asked NMD1 if they wanted to move, and NMD1 requested to stay in their current apartments because they were close to school and work. Additional confidential interviews reported that NMD1 was asked if they felt safe to continue living at the apartment, and NMD1 stated that they felt safe. Confidential interviews reported that NMD2 was not reprimanded for the stealing due to the mental health background and felt keeping NMD2 was in the best interest of NMD2. Confidential interviews also reported that the facility encouraged NMD1 and NMD2 to leave and avoid each other. Confidential interviews reported that NMD1 moved apartments at the end of July 2024. Based on inconsistent confidential interviews, the allegation that Facility staff did not ensure that the participant (NMD1) was accorded a safe and healthful home accommodation is unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted, and a copy of this report LIC 9099 and the appeal rights were discussed and provided to Patrick Taylor, Program Director.

Investigation Findings:
13On November 11, 2024, Licensing Program Analyst (LPA) Cynthia Robinson conducted an unannounced visit to Walden Family Services THP + FC and met with Patrick Taylor, Program Director to deliver the investigative findings for the allegation listed above. On 07/22/2024, LPA Cynthia Robinson conducted an inspection of the facility, and no immediate health and safety hazards were observed at the time. LPA Robinson obtained documents pertinent to the investigation. LPA Robinson interviewed the Non-Minor Dependent 1 (NMD1), Staff 1 (S1), Staff 2 (S2), County Social Worker (CSW) and Agency Social Worker (ASW). LPA Robinson was unsuccessful and made multiple attempts to interview Non-Minor Dependent (NMD2) and Staff 3 (S3). On 07/22/2024, Community Care Licensing received an allegation that facility staff did not ensure that participant (NMD1) was accorded a safe and healthful home accommodation. It was alleged that NMD1 was being stalked, harassed, and threatened by NMD2. The facility was aware of the issues, but no accommodations or actions were being taken to ensure NMD1's safety. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Cynthia Robinson 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 19-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: WALDEN FAMILY SERVICES THP+FCFACILITY NUMBER: VISIT DATE: 11/22/2024

met_with: Patrick Taylor, Program Director

complaint_status: unsubstantiated


raw_content:
Narrative:
During the inspection of the apartment damages, it was discovered that NMD1 would owe $4,200.00 that would come out of their savings. Confidential interviews reported that S1 was threatening NMD1 with the money owed. Confidential interviews reported that S1 only relayed the information that NMD1's savings would be depleted due to the property damages. Confidential interviews denied threatening NMD1. Based on inconsistent confidential interviews, the allegation that staff (S1) is threatening client (NMD1) is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted, and a copy of this report LIC 9099 and 9099C, LIC811 with the appeal rights were discussed and provided to Tiffani Brownlee, Supervisor.

Investigation Findings:
13On April 25, 2025, Licensing Program Analyst (LPA) Cynthia Robinson conducted an unannounced visit to Walden Family Services THP + FC and met with Tiffani Brownlee, Supervisor to deliver the investigative findings for the allegation listed above. On 02/12/2025, LPA Cynthia Robinson conducted a health and safety inspection of the facility, and no immediate hazards were observed at the time. LPA Robinson obtained documents pertinent to the investigation. LPA Robinson interviewed the Non-Minor Dependent 1 (NMD1), Staff 1 (S1), Staff 2 (S2), and County Social Worker (CSW). On 02/06/2024, Community Care Licensing received an allegation that staff (S1) was threatening the client (NMD1). It was alleged that NMD1 was threatened by S1 to pay damages to an apartment, or they would be "put out". Confidential interviews and documentation reported that NMD1 had done significant damage to the apartment and was being moved to another apartment for safety reasons. (Continued on LIC 9099C...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Cynthia Robinson 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 19-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: WALDEN FAMILY SERVICES THP+FCFACILITY NUMBER: VISIT DATE: 04/25/2025

met_with: Tiffani Brownlee, Supervisor


summary: Facility Evaluation

raw_content:
Narrative:
On 02/10/2022, Licensing Program Analyst's (LPAs) Lorena Valenzuela and Jessica Rubio, arrived at the agency for the purpose of conducting an annual inspection for the agency's Transitional Housing Program (THPP +NMD). LPAs met and toured the facility with Chief Operations Officer, Sue Evans. The facility is licensed to provide Transitional Housing Placement for Non-Minor Dependents (NMD). Facility utilizes apartment complex housing model. The agency currently has Apartment Complexes utilized for NMD. The facility provides care for 200 participants ages eighteen (18) through twenty-one (21). There are currently 113 participants residing in the program, which includes remote sites throughout San Bernardino, Riverside, Orange counties. Administrative Office is located at Arlington Avenue, Suite 106, Riverside CA, 92506. The office is located on the first floor of a retail business establishment. The office consists of a lobby/reception area, a play room/computer for the participants, furnished with chairs and tables. Cubicles/offices for the Program Director, Social Worker Supervisor, Case Managers and Social Workers. There is a kitchen area for the staff, and an additional conference room. There are working telephones and office equipment, furniture, and supplies located throughout the office space. The facility has all client records in an online database. Personnel files are also in the online database with some documents being physical files being kept at the facility. LPA reviewed 10 personnel records. All staff have Criminal Background and Child Abuse Clearances which are complete and current for all employees. Currently the facility is staffed with four Case Managers, eight Social Workers, one Housing Specialist, and one Social Worker Supervisor. All employees have the required experience, and training for their current job employment, or exceptions on file. LPA's reviewed NMD records with the assistance of Program Director Meghan Anderson. During the inspection, LPA's observed three of ten client files (C5, C7, C8) did not contain a signed Needs and Service Plan by either the authorized representative, non-minor dependent and/or social worker. Based on the record review and interviews, the agency did not ensure the participants needs and service plans were signed, the facility is being cited under Interim Licensing Standards the Nonminor Dependents regulations (AB 12), Section 86268.3 (d) Needs and Services Plan. LPA's observed 10 of 10 client records did not have a written medical assessment on file which is required within 30 days to determine the agency's ability to provide necessary health related services to the participant. Based on record review and interview, the agency did not ensure a medical assessment was obtained and kept in client records. The facility is cited under Title 22, Division 6, Section 86069 (a) Participant Medical Assessments. At 2:25 pm, Program Director Meghan Anderson assisted LPA's with the inspection at two remote sites. A smoke alarm and carbon monoxide detector were observed. Apartments were clean and organized. An exit interview was conducted, a copy of the LIC 809, LIC 809D, LIC 9102 (TA) Technical Assistance and Appeal Rights was provided to Program Director, Meghan Anderson

met_with: Meghan Anderson, Sue Evans


summary: Facility Evaluation

raw_content:
Narrative:
On August 23, 2023, Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera, arrived at the agency for the purpose of conducting an annual inspection for the agency's Transitional Housing Program (THPP +NMD). LPA met and toured the facility with Program Director, Patrick Taylor. The facility is licensed to provide Transitional Housing Placement for Non-Minor Dependents (NMD). Facility utilizes apartment complex housing model. The agency currently has twenty two apartment complexes utilized for NMD. The facility provides care for 200 participants ages eighteen (18) through twenty-one (21). There are currently 107 participants residing in the program, which includes remote sites throughout San Bernardino, Riverside, Orange counties. Administrative Office is located at Arlington Avenue, Suite 106, Riverside CA, 92506. The office is located on the first floor of a retail business establishment. The office consists of a lobby/reception area, a play room/computer for the participants, furnished with chairs and tables. Cubicles/offices for the Program Director, Social Worker Supervisor, Case Managers and Social Workers. There is a kitchen area for the staff, and an additional conference room. There are working telephones and office equipment, furniture, and supplies located throughout the office space. The facility has all client records in an online database. Personnel files are also in the online database with some documents being physical files being kept at the facility. LPA reviewed 16 personnel records. All staff have Criminal Background and Child Abuse Clearances which are complete and current for all employees. Currently the facility is staffed with four Case Managers, eight Social Workers, one Housing Specialist, and two Social Worker Supervisor. All employees have the required experience, and training for their current job employment, or exceptions on file. Continued on page LPA reviewed ten NMD records with the assistance of Program Director Patrick Taylor. All files reviewed were complete and had the required documents. The facility provided a copy of the drill log of the emergency disaster and mass casualty plan. The facility is in compliance no deficiency were notes at this time. Exit interview was conducted with Patrick Taylor, a copy of this report was provided to the facility representative.


summary: Facility Evaluation

raw_content:
Narrative:
On October 24, 2025, at 9: AM, Licensing Program Analyst (LPA) Cynthia Robinson arrived at the agency for the purpose of conducting an annual inspection for the agency's Transitional Housing Program (THPP +NMD). LPA met and toured the facility with Program Director, Patrick Taylor. The facility is licensed to provide Transitional Housing Placement for Non-Minor Dependents (NMD). Facility utilizes apartment complex housing models and some remote housing. The agency currently has ninety-four apartment complexes and four remote homes utilized for NMD. The facility provides care for two hundred participants aged eighteen (18) through twenty-one (21). There are currently eighty-eight participants residing in the program, which includes remote sites throughout San Bernardino, Riverside and Orange county. Administrative Office is located at Arlington Avenue, Suite 106, Riverside CA, 92506. The office is located on the first floor of a retail business establishment. The office consists of a lobby/reception area, and a playroom/computer for the participants, furnished with chairs and tables. Cubicles/offices for the Program Director, Social Worker Supervisor, Case Managers and Social Workers. There is a kitchen area for the staff, and an additional conference room. There are working telephones and office equipment, furniture, and supplies located throughout the office space. (Continued on LIC 809C...) The facility has all client records in an online database. Personnel files are also in the online database for the facility. LPA was assisted by Jenny Bolen, Human Resources for review of personnel files. LPA reviewed five personnel records, one Administrator file, one Supervisor Social Worker, and three Social Workers files. All staff have Criminal Background and Child Abuse Clearances which are complete and current for all employees. The facility is within ratio for social workers. All employees have the required experience and training for their current job employment. LPA reviewed five NMD records with the assistance of Program Director Patrick Taylor. All files reviewed were complete and had the required documents. The facility provided a copy of the drill log of the emergency disaster and mass casualty plan. The THPP facility is in compliance no deficiency were noted at this time. Exit interview was conducted with Patrick Taylor, and a copy of this report was provided to the facility representative.


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
It was alleged that NMD was requesting mental health assistance and did not receive it. Confidential interviews reported that NMD was offered mental health assistance through the THP, but could not provide long-term assistance. Confidential interviews reported that staff attempted to help NMD with setting up mental health appointments, but were unsuccessful and limited due to NMD being an adult. On 08/22/2025, Community Care Licensing (CCL) received an allegation that staff (S1) illegally evicted non-minor. It was alleged that NMD did not receive proper notice of the program's termination. Documentation reviewed and collected revealed that the THP facility communicated the discharge notice to the CSW and provided written notice to NMD and the CSW. Based on inconsistent confidential interviews and documentation review, the allegations that Staff did not ensure non-minor's mental health needs were met and the allegation that staff illegally evicted non-minor are unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of evidence to prove that the alleged violations occurred. A copy of this report and appeal rights were provided to Patrick Taylor, Administrator.

Investigation Findings:
13On February 27, 2026, at 11:30 am, Licensing Program Analyst (LPA) Cynthia Robinson conducted an unannounced visit to Walden Family Services THP+FC, Transitional Housing Placement Program (THPP), and met with Patrick Taylor, Administrator to deliver the investigative findings for the allegations listed above. On 08/28/2025, LPA Jose Gonzalez conducted a health and safety inspection and observed no immediate health and safety hazards. LPA Gonzalez obtained documents pertinent to the investigation. LPA Robinson interviewed the Agency Social Worker (ASW) and the Staff (S1 and S2). LPA Robinson attempted to interview the Non-Minor Dependent (NMD) and the County Social Worker (CSW), but was unable to do so after multiple attempts. On 08/22/2025, Community Care Licensing (CCL) received an allegation that staff (S1) did not ensure the non-minor's mental health needs were met. (Continued on LIC 9099C..) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Cynthia Robinson 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 19-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: WALDEN FAMILY SERVICES THP+FCFACILITY NUMBER: VISIT DATE: 02/27/2026

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

met_with: Patrick Taylor, Administrator


facility_name: YMCA YOUTH & FAMILY SERVICES

summary: Facility Evaluation

raw_content:
Narrative:
On November 15,2021 at 10:18AM, Licensing Program Analyst (LPA) Carol Anderson arrived at the address above. The purpose of the visit was to conduct an annual/ required inspection. LPA met with Program Administrator Amanda Mizer. The facility utilizes Remote Site Model, with one remote unit located in Escondido; there are Participants currently in the program. LPA reviewed staff files: three supervising social worker, five social workers, and two Housing Specialist and all the required documents were in the files. LPA Anderson and LPA Nicole Strickland will interview one participant during today's inspection. LPA interviewed five staff. LPA reviewed Participant files and all the required documents were in the files. Also, the facility utilizes, the Effort to Outcome (ETO) database a San Diego County computerized electronic system that update participants records. A review of Licensing Information System on November 15, 2021 indicates that all facility staff are associated to the facility had DOJ, FBI and child abuse index check clearances. The facility has demonstrated compliance with Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was given to Program Administrator Amanda Mizer.

met_with: Amanda Sanchez


summary: Facility Evaluation

raw_content:
Narrative:
On December 8, 2023 at 10:19AM, Licensing Program Analyst (LPA) Carol Anderson arrived at the facility, no one was at the facility. LPA Anderson contacted the program administrator via cellphone. At 11: AM, Amy Gonzales, Program Director and Sarah Tiscareno, Housing Operations Manager arrived to assist LPA Anderson with annual/random inspection. The facility utilizes Remote Site Model, with one remote unit (Apartment Building) located in Escondido, CA. There are Participants currently in the program. LPA interviewed two staff during today's inspection. LPA reviewed staff files: three social worker files and all the required documents were in the files. LPA reviewed five participants files and all the required documents were in the files. Also, the facility utilizes, the Effort to Outcome (ETO) database a San Diego County computerized electronic system to update participants records. A review of Guardian on December 8, 2023, indicates that all facility staff are associated to the facility had DOJ, FBI, and child abuse index check clearances. Based on observations made during the inspection, no deficiencies observed during today's inspection. The facility has demonstrated compliance with Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was given to Amy Gonzales, Program Administrator.

met_with: Amy Gonzales


summary: Facility Evaluation

raw_content:
Narrative:
On December 12, 2025, Licensing Program Analyst (LPA) Cynthia Velasquez, initiated an annual inspection of the facility. LPA was greeted by Amy Gonzales, Senior Housing Program Manager. Copies of Staff and Client Rosters were supplied to LPA. A perimeter walk of the facility was conducted and there were no obstructions in entry ways or sidewalk paths. There are currently 16 clients in care. San Diego County Client records were available via ETO, and additional client records were on hand at facility. Due to time constraints, this required inspection will be conducted at a later date. An exit interview was conducted with Amy Gonzales, Senior Housing Program Manager, and a copy of report was issued.


summary: Facility Evaluation

raw_content:
Narrative:
On December 16, 2025, Licensing Program Analyst (LPA) Cynthia Velasquez, arrived unannounced to continue and complete annual inspection of the facility. LPA was greeted by Amy Gonzales, Senior Housing Program Manager. Human Resources staff assisted LPA electronically through Microsoft Teams call in viewing documents pertaining to staff. Documents included: Identification, Job Description and Resume, Health Assessments and TB test results, trainings, CPR certifications, Educational Transcripts and degrees, Background Checks and clearances, Child Abuse reporting documentation, and childrens personal rights. Client files were reviewed and also had Intake/Placement documents, Needs and Service Plan, and current case manager notes. Additional perimeter walk of the facility was conducted and there were no obstructions in entry ways or sidewalk paths. There are currently 17 clients in care. Based on the facility inspection and file reviews this date, there are no deficiencies found at this time. Exit interview was conducted and a copy of this report was reviewed and given to Senior Housing Program Manager, Amy Gonzales.


raw_content:
Narrative:
Confidential interview reported that S4 yelled at C1 while in the common area due to them grabbing too many food items when they should only take one at a time. This caused C1 to feel singled-out. Confidential interview disclosed that information pertaining to C1's behaviors is shared among staff and may negatively impact their housing, which is a form of abuse and misuse of authority. Additional confidential interviews reported that there have been arguments between C1 and S4 which cause anxiety for C1. However, confidential interviews could not provide dates or witnesses to those arguments. Therefore, there was no evidence that supported the allegation that staff spoke to non-minor dependent in an inappropriate manner. Another confidential interview disclosed that C1 has aggressive behaviors and that staff should do what is necessary in interacting with them. Additionally, S6 proclaimed that C1 does not have any issues with overnight staff and there is mutual respect between them. Based on conflicting confidential interviews the allegation that staff spoke to non-minor dependent in an inappropriate manner may have occurred or is true, however there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated. A copy of this report and appeal rights were discussed and provided to YMCA Youth & Family Services representative Amy Gonzales, Program Administrator Designee.

Investigation Findings:
13On March 20, 2026, Licensing Program Analyst (LPA) Cynthia Velasquez met with YMCA Youth & Family Services, Amy Gonzales, Program Administrator Designee, to deliver findings for the above complaint allegation. On December 12, 2025, an inspection of the facility was conducted; there were no immediate health and safety hazards observed. The investigation included interviews with Staff 1 - Staff 4 (S1-S4), Staff 6 (S6) Client 1 (C1), and county social worker (CSW). Pertinent documents were gathered. On December 8, 2025, the department received an allegation that staff spoke to a non-minor dependent in an inappropriate manner. Specifically, it was reported that staff spoke inappropriately to C1 and threatened to report their behavior to the program administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Cynthia Ann Velasquez 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: YMCA YOUTH & FAMILY SERVICESFACILITY NUMBER: VISIT DATE: 03/20/2026

met_with: Amy Gonzales,


facility_name: YOUTH FOR CHANGE - THPP

raw_content:
Narrative:
Continued from Interviews with two youth and Social worker confirmed the mentor did misuse the youth's funds, as documentation revealed. The payment documentation received from THP office determined a payment for the THP participants, which were made out in the mentor's name, was not received by the THP participant. The documentation determined the THP Program reimbursed THP participant what the mentor owed the participant. The mentor never submitted documents, determining THP participant had spent the money and was not owed it, to the THP office. The mentor stopped communications with the THP Program following their request for the documentation of expense by THP participant. The THP Program decertified mentor on 7/12/2021. Based on interviews and documentation the preponderance of evidence has been met, therefore the allegations are substantiated, meaning the allegations are valid because the preponderance of evidence standard has been met. Regulatory Statute Facility cited for violation of California Code of Regulations, Title 22, Division and Chapter Six, regulation 80026(h)(1)(A): 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: Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order. Receipts for cash provided to any client from his/her account(s) shall include the client's full signature or mark, or authorized representative's full signature or mark, and a statement acknowledging receipt of the amount and date received. Conclusion An exit interview was conducted with CEO. This report was given to the facility office at the time of the delivery of findings. Appeal Rights were emailed with a copy of this report.

Investigation Findings:
13Introduction On 1/7//2021 at 2:30pm Licensing Program Analyst (LPA) Hillary Hall met with Beth Parsons, CEO at the facility, for the purpose of delivering the complaint findings into the allegation listed above. LPA delivered findings in person. Relevant Facts and Findings: On 7/12/ Licensing Program Analyst (LPA) Whitlow conducted an unannounced complaint investigation and met with Nancy Jorth- Director of Social Services Programs. LPA stated the investigation allegation and requested the following documents: Placement logs, copy of text messages from THP participant, and mentor pre - placement training review. LPA McKinley further requested payment logs for both THP participants and decertification documentation. LPA Word made attempts to open the complaint with the mentor and was refused inspection and an interview. LPA McKinley conducted interviews with two Transitional Housing Placement (THP) youth (one THP participant interviewed by LPA Rosas), an agency social worker, an agency supervisor, the THP participant's boyfriend, a county social worker and the reporting party. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Daniel Allmon LICENSING EVALUATOR NAME: Hillary Hall 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 25-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, COHASSET RD., STE. FACILITY NAME: YOUTH FOR CHANGE - THPPFACILITY NUMBER: VISIT DATE: 01/07/2022

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

met_with: Beth Parsons, CEO


raw_content:
Narrative:
Continued from LPA McKinley conducted interviews with two Transitional Housing Placement (THP) youth (one THP participant interviewed by LPA Rosas), an agency social worker, an agency supervisor, the THP participants boyfriend, a county social worker and the reporting party. The Interview with second THP youth contradicted information given by the first THP youth. Interviews did not determine if mentor ever hit anyone in the home, as no bruises were seen on THP participant. As the second THP participant left a few months prior to the first THP participant, it could not be confirmed or denied. Based on interviews and documentation the preponderance of evidence has not been met, therefore the allegations are unsubstantiated, Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Regulatory Statute No Interim Licensing Standards or Title Regulations were cited as a result of this complaint investigation. Conclusion An exit interview was conducted with the CEO. This report was given to the Facility at the time of the delivery of findings. A copy of the Appeal Rights was emailed with the findings at the time of the delivery.

Investigation Findings:
On 1/7/2021 at 3pm Licensing Program Analyst (LPA) Hillary Hall met with Beth Parson, CEO at the facility for the purpose of delivering the complaint findings into the allegation listed above. LPA delivered findings in person. Relevant Facts and Findings: On 7/12/ Licensing Program Analyst (LPA) Whitlow conducted an unannounced complaint investigation and met with Nancy Jorth- Director of Social Services Programs. LPA stated that the investigation allegation and requested the following documents: Placement logs, copy of text messages from THP participant, and mentor pre - placement training review. LPA McKinley further requested additional documentation from the Foster Family Agency. LPA Word made attempts to open the complaint with the mentor and was refused inspection and an interview. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Daniel Allmon LICENSING EVALUATOR NAME: Hillary Hall 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 25-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, COHASSET RD., STE. FACILITY NAME: YOUTH FOR CHANGE - THPPFACILITY NUMBER: VISIT DATE: 01/07/2022

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


summary: Facility Evaluation

raw_content:
Narrative:
On 11/29/ Licensing Program Analyst (LPA) Wendy Brown and Licensing Program Analyst (LPA1) Melinda Pope arrived unannounced at the facility for the purpose of conducting the Required Two-Year Inspection. LPA and LPA1 met with Brooke Wells, Program Manager, and conducted a facility inspection, reviewed five personnel files and five client files.The inspection was not completed on this date. LPA will follow up on a later date. No citations were issued at this time.

met_with: Brooke Wells, Program Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 12/01/ Licensing Program Analyst (LPA) Wendy Brown arrived unannounced at the facility to complete the Required Two-Year Inspection. LPA completed file review and interviewed one agency social worker and the program manager. No other staff were onsite/available for an interview. The last Annual inspection for the facility was on 12/17/2020. LPA utilized the CARE Tool to complete the inspection. LPA conducted an inspection of the physical plant and checked for all necessary requirements. The facility was clean and organized and maintained an acceptable room temperature. LPA observed the proper postings including: facility license, complaint hotline, and emergency disaster plan. The restrooms for clients and staff were clean. Smoke alarms were in working order, fire extinguishers were current, and a first aid kit was fully stocked. Evacuation drills for the facility were completed quarterly. LPA observed client files were stored in locked cabinets. The facility has no outstanding fees. The facility currently has no minor clients and ten Non-Minor Dependent clients. Clients live in remote site apartments. No client resides more than two hours from the facility. The facility employs two Social Worker(s) and one Case Manager, and one Supervisor/Program Manager. LPA reviewed five employee personnel files. Social work personnel had completed criminal record clearances and met minimum education and experience qualifications. All First Aid and CPR certifications were up to date for personnel. LPA reviewed five client files. All clients had signed Admission Agreements. Client files had current Needs and Service Plans. Needs and Services Plan detailed adequate supportive services the facility offers to the clients. No citations were issued. An exit interview was conducted.


summary: Facility Evaluation

raw_content:
Narrative:
On 12/07/ Licensing Program Analyst (LPA) Wendy Brown met with Brooke Wells, Program Manager (PM) to discuss and review progress on the Facility's Program Statement for their Transitional Housing Placement Program. An updated Program Statement was provided by PM on 11/13/23. LPA provided direction and PM will made adjustments and resubmit the Program Statement to LPA by 01/15/24.

met_with: Brooke Wells Program Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 02/025/ Licensing Program Analyst (LPA) Wendy Brown met with Program Manager/Administrator (PM) Brooke Wells at the Chico office of Community Care Licensing, to review the Program Statement information submitted to date and briefly review additional documentation provided during our meeting. The original submittal was short and not comprehensive and included some Plan of Operation information. Discussion to move the process forward included -layout (specifically section headings); -specific required and sometimes repetitive wording; -the need to address discharge policies and procedures and retaining the signed discharge plan in client files; -wording to indicate how the agency can and will request information, such as medical records, but cannot require it of THP participants; and -clarity when addressing some policies and procedures (i.e. "we will encourage staff" versus "staff will"). LPA advised PM to discontinue efforts on revamping the Plan of Operation, but to focus on the Program Statement at this time. It was established that the Agency will submit three new sections of the Program Statement to LPA by email each week for review. Sections to be provided as follows: 02/16/2024: Sections 1 - 3 02/23/2024: Sections 4 - 6 03/01/2024: Sections 7 - 9 03/08/2024: Sections 10 - 12 03/15/2024: Sections 13 - 15 03/22/2024: Sections 16 - 18


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 10/30/2024, Licensing Program Analysts (LPAs) Wendy Brown and Bianca Mendez arrived unannounced at the facility and met with Brooke Wells, Program Manager. The purpose of the visit was to conduct a random inspection of the facility. The last inspection for the facility was on 11/28/2023. LPA utilized the CARE Tool to complete the inspection. LPA conducted an inspection of the physical plant, and checked for all necessary requirements. The facility was clean and organized and maintained an acceptable room temperature. LPA observed the proper postings including: facility license, complaint hotline, and emergency disaster plan. The restrooms were clean. Smoke detectors are wired throughout and the fire extinguishers were current. The first aid kit was fully stocked, except for scissors which are prohibited due to a behavioral health contract agreement. Evacuation drills for the facility were completed quarterly. LPA observed client files were stored electronically and paper files are in a locked file cabinet. The facility provided verification of payment and has no outstanding fees. The facility has Non-Minor Dependent clients. Clients live in remote site apartments. No client resides more than two hours from the facility. The facility employs four Social Workers, one Case Manager, and one of Supervisor/Program Manager. LPAs reviewed five Social Worker personnel files and the Program Manager file. Social work personnel had completed criminal record clearances and met minimum education and experience qualifications. There is one social worker exception on file. LPA interviewed five social worker personnel. Social work personnel indicated they did not have more than 12 clients on their individual caseloads. LPAs reviewed five client files. All clients had signed Admission Agreements. Client files had current Needs and Service Plans, signed by the client and placing agency. Needs and Services Plan detailed adequate supportive services the facility offers to the clients. Facility is issued a citation per 86056(f)(3) and (4) and (h)(1) through (5). A signed copy of these LIC-809, LIC-809C, and LIC 809D reports were provided to the Program Manager. An exit interview was conducted. Appeal rights were provided.

Deficiencies:
86065(f): Reporting Requirements

(f) All THPP personnel shall, at a minimum, receive training that provides knowledge of and skill in the following areas, as evidenced by safe and effective job performance


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
Licensing Program Analyst (LPA) Hillary Hall arrived unannounced at the facility for the purpose of delivering a case management investigation. LPA met with Brooke Wells, Administrator. LPA determined through record review that two staff persons listed on the LIC- Personnel Report did not have criminal background clearances. One staff had been employed since May 2020 and the other staff had been employed since December 2021. Per Title 22 regulations, Division 6, Chapter 2, Article 03. Application Procedures, Section 88019(e) 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 being assessed a citation and immediate civil penalty of $100 per day, for a maximum of 5 days, resulting in a $500 civil penalty, for each of two employees. A signed copy of this report, the LIC 809D and LIC 421BG were provided to the facility. Exit interview was conducted and Appeal rights were provided.

Deficiencies:
88019(e): (1)Obtain a California clearance or a criminal record exemption as required by the Department.

met_with: Brooke Wells, Administrator


facility_name: ALAMEDA COUNTY ASSESSMENT CENTER

raw_content:
Narrative:
Six of thirteen individuals interviewed stated that they had no concerns about the de-escalation being used within the facility. Four of the thirteen individuals interviewed stated that they had concerns with the de-escalation from the staffed security guards at times, including three that had concerns about the incident on 12/12/2023. Based on confidential interviews, it was alleged that staff members had neglected to use verbal de-escalation, pulled client's clothes when unnecessary, and had used excessive force during physical intervention. Based on review of the security footage from body-worn cameras on 12/12/2023, LPA observed that staff members did not utilize verbal de-escalation with youth. LPA also observed that staff had pulled at client's clothes and had stood closely to clients after clients had asked for space. Based on review of the security footage, the staff members had used curse words and verbal threats towards the clients in care. Based on confidential interviews and review of the security footage, the allegation that facility staff had violated youth's personal rights during a restraint has met the preponderance of doubt and is therefore substantiated. This poses a potential risk to the health, safety, and person rights to the clients in care. LPA delivered a Type B citation for Operating Standards 84072(d)(12) Personal Rights. LPA delivered appeal rights and conducted an exit interview with Mia Buckner-Preston, Director at 2:53PM whose signature confirms the receipt of this document. Six of thirteen individuals interviewed stated that they had no concerns about the de-escalation being used within the facility. Four of the thirteen individuals interviewed stated that they had concerns with the de-escalation from the staffed security guards at times, including three that had concerns about the incident on 12/12/2023. Based on review of the security footage from body-worn cameras on 12/12/2023, LPA observed that the security guards had utilized physical intervention. Based on the review of camera footage, the intervention utilized had not reached the threshold of assaultive behaviors and were prompted due to the clients' aggressive behaviors. Based on confidential interviews and record review, no physical injuries were sustained from these incidents on 12/12/2023. Based on confidential interviews and review of the security footage, the allegation that facility staff had assaulted youth while in care has not met the preponderance of doubt and is therefore unsubstantiated. LPA conducted an exit interview with Mia Buckner-Preston, Director at 2:50PM whose signature confirms the receipt of this document.

Investigation Findings:
13On 3/27/2024 at 2:40PM, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the licensed facility. The purpose of this visit was to deliver the finding for the listed allegation. LPA met with Mia Buckner-Preston, Director. During the course of the investigation, LPA conducted thirteen confidential interviews between 12/14/2023 and 3/11/2024. LPA reviewed incident reports, staff schedule, internal investigation from partnered contractor, and security footage from the incident on 12/12/2023. LPA had requested the police report for this incident from the Hayward Police Department. LPA was informed that there was not a report in the system for this incident. Continued on LIC 9099C...... SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Selena Hood LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO ASC, TRAEGER AVE., SUITE FACILITY NAME: ALAMEDA COUNTY ASSESSMENT CENTERFACILITY NUMBER: VISIT DATE: 03/27/2024

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

met_with: Mia Buckner-Preston


summary: Facility Evaluation

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Narrative:
On Monday 1/24/22 at 10:28AM, Licensing Program Analysts (LPAs) Mariah Hawkins and Alyssa Ng made an unannounced visit to the facility for a required annual inspection. LPAs met with Social Service Agency Assistant Agency Director Michelle Love and informed of the purpose of visit. Safety precautions were taken, including mask-wearing and social distancing. Division Director/Administrator Mia Buckner-Preston arrived at noon. LPAs toured the facility site and observed it to be safe, sanitary, and free of obstructions. The facility kitchen and food storage was organized and sanitary. There were 4 staff and 1 county staff providing supervision and 9 residents in care. Confidential interviews were conducted with staff and residents. Room temperature and hot water measured within permitted ranges as F and 119. F, respectively. However, hot water was measured at multiple bathroom sinks, measuring 119. F at one bathroom, and 121.5 and 120. F at the sinks in the adjacent bathroom (B2). Licensee leases the property and will contact the landlord about scheduling a maintenance worker to come lower the temperature. LPAs issued an advisory of Operating Standards (OS) Section Fixtures, Furniture, Equipment and Supplies. There were no deficiencies cited at today's visit. An exit interview was conducted, appeal rights provided, and a copy of this report left with Administrator Mia Buckner-Preston, whose signature on this form

met_with: Service Agency Assistant Agency Director Michelle Love;


summary: Facility Evaluation

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Narrative:
On 4/22/22 at 3: PM, Community Care Licensing (CCL) representatives met with the facility above over Microsoft Teams for the purpose of conducting an Annual Review of the facility's program, needs, population, and overstay logs. In attendance in this meeting were: -CCL Regional Manager (RM) Nelson Martinez -Licensing Program Manager (LPM) Helga Wong -Licensing Program Analyst (LPA) Alyssa Ng -Adele Gray (Associate Government Program Analyst - Child Protection Policy Unit) -Julie Waters (Child Protection Policy Unit Manager) - Mia Buckner-Preston (ACAC Administrator) -Michelle Love (Alameda County SSA-CWS Child Welfare Director) -Andrea Ford ( Interim SSA) -Melissa Fegurgur (Program Manager) Background: The purpose of this meeting was to review the utilization of the receiving center, to evaluate and discuss the Population Reports and Overstay Logs provided monthly by the facility, and to collaborate with the facility on ways that CCL can support the facility going forward. (Continued on Lic809-c) Question #1: What activities has the County implemented that have increased capacity in home based care and in STRTP's? Website- Applicants can listen to testimonials, review our FAQ, sign up for orientations, and fill out an interest form if interested. Recruitment Efforts- We set up booths at our local community fairs and farmers markets in a limited capacity. A recruiter and volunteers are there to answer any questions and help interested applicants fill our forms. RFA Process- Able to work with their relatives to get them placed. Consultant Agencies- Hill and Associates Consulting and Experience Consultants. Their goal in working with these two agencies is to increase the number of home based resource family placement's for our older youth and teens, CSEC youth, LGBTQI+ youth, sibling groups, pregnant and parenting youth, and Non-minor Dependents. * This resulted in 5 additional homes that accept placement teens. (2 foster family agency homes and 3 county resource family approved homes!) Emergency/Guaranteed beds- planning to enter into contract with 2-3 more STRTP providers. (EX: Lighthouse Mentoring Center, Millie's Youth Services) We are still partnering with REFUGE STRTP as the preferred placement contract and will create a new contract to provide emergency/guaranteed beds (By July 2022). Attend Meetings: Resource Caregiver Association- goal is to seek interest in families providing emergency placements for older youth and teens. The County will provide training, funding, and wrap services to support the placements. The County began working with RFA families who are currently on the "Inactive" status list to determine their interest in continuing to provide care for children, youth, and NMDs Foster Family Agency Provider Meeting- offer training and recruitment strategies so that each FFA could recruit and train their own homes Placement Collaborative Meetings- to ensure that by the end of each meeting, the group has identified at least one possible placement for each youth discussed. Quarterly STRTP Providers meetings- By May, the consultant will be in Alameda County to help the County conduct in-person site visits with all Alameda County STRTP providers to observe the day-to-day operations and to survey each provider regarding supports they need to accept, stabilize, and preserve placements of Alameda County dependent youth. Question #2: What efforts has the County made in reducing the use of the Receiving Center? Have these efforts been effective in reducing the use of the Receiving Center? Why or why not? Explore all possible placement options- before bringing a child/youth to the AC. Options include approving visits with relatives or close family friends while placement is being located. Review the youth's electronic file in CWS/CMS- to understand the youth's needs. As a means of finding family the workers also reviews any information about the youth's Network of Support and previous placement providers for possible placement options. Hour Huddles- are conducted once a child, youth, NMD reaches the 48 hour time frame. Current placement options are explored and reviewed, barriers/challenges are identified, and next steps are created, including ways for managers to assist placement efforts. Monitor placement efforts for children ages 0-6 to identify placement timely and eliminate overstays. Support services -are provided and include transportation assistance to placements, taking youth to Medical Clearances and obtaining medication needed prior to placement, requesting funding and gift cards for items needed, including furniture, clothing, food, hygiene and hair supplies. Emergency RFA Placement time frames- to ensure that placement occurs within 72 hours. By 24 hours a relative/NREFM needs to respond and provide information needed to complete clearances on all adults. Within 48 hours the home inspection should be completed. Prior to the 72 hour time frame, the clearances, home inspection, and paperwork needs to be completed so placement can occur. If placement does not occur the child(ren) will be placed in a RFA home. Continue daily In-person meetings- with youth at the AC to engage them in their placement plan and support them during CFTs and placement interviews. Contact STRTPs to provide a response regarding acceptance of placement and assist in completing the STRTP Intake packets. CDSS Technical Assistance calls- for challenging to place youth/youth with special needs Barriers to Placement and Overstays: Question #3: In 2020 the County reported only 13 repeat overstays, but in 2021 the number increased to 43 repeat overstays. What would the County attribute to the significant increase in repeat overstays? ---------Cont. on 809-C-------------------- 2020 was an unprecedented year for us. As 2021, schools started to go back to school. We saw out intake at the center. In the last meeting, AC stated that they expected to return to pre-pandemic numbers (2019). If you look at previous years, 43 repeat overstays are lower than that. Many older youth "self presented" at the AC after returning from AWOL from previous placements. AC saw an increase in the number of children and youth brought by Law Enforcement, including courtesy holds from other counties.Due to the reduction of available STRTP beds, long STRTP intake processes that cannot be completed in the 72 hour time frame, and refusal of youth to be placed out-of-county our County may be unsuccessful in eliminating overstays for older youth and teens unless we discharge them once they reach 72 hours whether placement has been located or not. Community based organization MISSSEY now operates at the Assessment Center providing direct services to CSEC youth Monday - Saturday including evening hours. MISSSEY offers training and education to caregivers of CSEC youth to raise awareness of how to best care for and support these youth in their homes. Question #4: What steps will the County take to address these barriers regarding Placement and Overstays? -Please refer to Question 1 in regards to strategies and placement efforts to reduce overstays. Question #5: Has there been any trends in regards to overstays that County has observed and how have those trends been mitigated? What impact, if any, has COVID-19 had on the rate of overstays? The pandemic greatly affected all of our efforts towards reducing our reliance on the Assessment Center. It was difficult to recruit homes for our older youth and teens, as families were concerned for their own health and survival and did not have the capacity to care for foster youth. The County experienced a decrease in available placements, long facility waiting lists, longer STRTP intake process including an excessive amount of paperwork prior to placement, required medical clearances with COVID testing, no transportation support, technology limitations around educational and mental health supports, which led to placement disruptions. All of this contributed to an increase in the census at the AC and an increase in overstays. However, in review of the 2021 overstay reports what stood out was the majority of overstays were repeat clients, aged 13-17, requiring STRTP level of care, that have been described throughout this report. Several placement practice adjustments have been put in place to address this issue, however without more support from CDSS to hold STRTP's accountable, this will remain outside of our area of influence. Partnership Question #6: In what ways can the CDSS support the County to best meet the needs of children who are experiencing overstays? More available family based beds are needed- It would be a great support for CDSS to include the expectation of recruiting more homes. *CCL has clarified that we do not recruit homes* Technical Assistance (TA)- TA options to help clients find placements that were given 14 days notice. The County will notify their LPA when STRTPs are not responding after 5 days of a referral being submitted More oversight of STRTP's- CCL will let facilities know to contact their assigned LPA if Guardian was not working, finding placements for clients, collaborate between the county and STRTP's to ensure smooth transition for clients. Facilities in compliance with the 14-day notice removal of policy- Not following 14-day notice policies leave our County without the benefit of time to locate a new STRTP that can meet our youth's housing and therapeutic needs. Youth often return to the AC and often overstay while a new placement is located. Next Steps: Question #7: The CDSS recently extended the license for three months and will review for additional extensions every three months. What activities does the County plan to perform to reduce the need for/use of the Receiving Center for the next quarter? The County is in the process of contacting our Inactive RFA homes to support them in reinstating their RFA approval and resume accepting placements. The County has approximately Inactive homes on our list. These cases are being assigned to RFA Child Welfare Workers to re-engage the caregivers. AC is hoping approve at least one-third of the homes to care for older youth. Time frame: TBD. Engaged the family that are on the inactive applicants. Majority of the homes are for smaller kids. Certification, homes reassessed. Some cases are moving through really quickly and some might take time. Question #8: What is the County's plan in the event the license does not get extended at any quarterly review? The County's plan is to work towards our identified closure in September 2023. The County would work with CDSS to develop a transition plan, as it would be important to provide notice to those in the community who greatly depend on the AC for support and care of children/youth. The AC is a huge support to the community, Law enforcement, Probation, Hospitals, and other Child Welfare Jurisdictions to provide trauma informed care for children until placement is found. The County would hope that consideration is given to where children and youth will go if the AC is no longer in operation and to work with the County to facilitate the transition of care. This concluded CCL's Annual Review of the Alameda County Assessment Center. An exit interview was conducted, and a copy of this report was emailed to Administrator Mia Bucker-Preston with read receipt. Administrator Bucker-Preston will sign all documents and return to LPA Ng over email.


summary: Facility Evaluation

raw_content:
Narrative:
On 2/2/23 at 10: AM, Licensing Program Analyst (LPA) Alyssa Ng and Licensing Program Manager (LPM) Carolyn Flynn made an unannounced visit to the facility for a required annual inspection. LPA and LPM met with Program Manager Melissa Fegurgur and informed of the purpose of visit. Safety precautions were taken, including mask-wearing and social distancing. LPA and LPM toured the facility site and observed it to be safe, sanitary, and free of obstructions. The facility kitchen and food storage was organized and sanitary. There were sufficient 2 days of perishable and 7 days of non perishable food. There were 5 staff members that were contracted from the County providing supervision and 2 clients in care. At 10: AM, confidential interviews were conducted with 3 staff and 1 client. Room temperature and hot water measured within permitted ranges as 70F and 116.1F, respectively. The facility storage room contained extra linen, mattress pads, and plentiful hygiene supplies. At 11: AM, LPA Ng and LPM reviewed 2 client files. Please refer to attached LIC858. At the time of the inspection, the staff files were not on the premise, therefore LPA will come at a later time. The facility was observed to be in compliance except for the following exceptions: LPA Ng conducted confidential interviews and all stated that incident reports are being written within the 24 hour time-frame. CCL has not received an incident report since December of 2022. LPA advises per Operating Standards (OS) Section 84461(a)(1) Reporting Requirements. There were one deficiency cited at today's visit. An exit interview was conducted, appeal rights provided, and a copy of this report left with Program Manager Melissa Fegurgur, whose signature on this form

met_with: Melissa Fegurgur


summary: Facility Evaluation

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Narrative:
On Thursday February 9, 2022 at 10: AM Licensing Program Analyst (LPA) Alyssa Ng made an unannounced inspection to finish the annual required inspection. LPA met with Mia Buckner-Preston. The facility has a census of 4 clients. LPA Ng met with Emily Lathrop, Program Director for West Coast Children's Clinic. Emily showed LPA Ng 5 staff files and on-going training. All staff files and other documents are on their own system. Staff training hours meet the minimum requirements. No deficiencies were cited and a copy of this report has been left with the Mia Buckner-Preston, Administrator.


summary: Facility Evaluation

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Narrative:
On 5/31/22 at 3: PM, Community Care Licensing (CCL) representatives met with the facility above over Microsoft Teams. In attendance in this meeting were: -CCL Regional Manager (RM) Nelson Martinez -Licensing Program Manager (LPM) Carolyn Flynn -Licensing Program Analyst (LPA) Alyssa Ng -Adele Carlson (Associate Government Program Analyst - Child Protection Policy Unit) -Julie Waters (Child Protection Policy Unit Manager) - Mia Buckner-Preston (Administrator) -Michelle Love (Alameda County SSA-CWS Child Welfare Director) -Melissa Fegurgur (Program Manager) The purpose of the meeting was to discuss their current extension which is through October 30th of 2023. Back in April of last year, it was discussed that County's plan is to work towards their identified closure in September 2023. The County stated that if they decide to move forward with the extension, they anticipate on issuing a letter within the next 30 days stating why they need the extension, their transition plan, and what barriers they are currently facing. A solution that was discussed was to relocate out of Hayward and look for an alternative space. CCL stated that the license is not transferable and would need to submit a new application. CCL also stated that the County would need to prepare with the current Operating Standards (OS) and update their Program Statement to reflect the OS. CCL pointed out the Operating Standard is stating that all employees shall be fingerprint cleared and files will need to be accessible and that Alameda County would need to confer with their legal department regarding the new OS. Nothing was agreed upon, just discussed during this meeting. (Continued on Lic809-c) County introduced the idea of separating youth based on the age groups due to a concern regarding the connection that can occur between older youth with high level behavior and younger youth. CCL discussed the issue with sibling sets. Also, the County discussed the hardships between providers and not having enough placement's for youth resulting in Overstays. The providers are not accepting youth due to a variety of reasons. Some reasons discussed were that the staff in the facilities are not equipped with the proper training and that the behaviors have escalated. The County explained that the reason for the escalated behaviors can be from not seeking mental health treatments during COVID or youth just not having enough resources on hand. This concluded the discussion with Alameda County Assessment Center. An exit interview was conducted, and a copy of this report was emailed to Administrator Mia Bucker-Preston with read receipt. Administrator Bucker-Preston will sign all documents and return to LPA Ng over email.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Ng made an unannounced health and safety inspection on 6/26/2022 to the above listed facility and met with Melissa Fegurgur, Program Manager at 10: AM. This agency serves as a Transitional Shelter Care Facility (TSCF). Safety precautions were used such as social distancing and mask wearing. During the course of the inspection, LPA Ng requested for copies of all incident reports from February 2023 to present. At this time. LPA Ng received all AWOL reports from February 2023- present. LPA will work with Administrator Mia Buckner-Preston on the rest of the incident reports. LPA toured the facility site and observed it to be safe, sanitary, and free of obstructions. The facility kitchen and food storage was organized and sanitary. There were sufficient 2 days of perishable and 7 days of Non perishable food. There are currently no clients as the facility is on a diversion plan and not accepting any clients. LPA Ng asked what their procedure is for an incoming youth due to the diversion plan. For youth who have family, primary staff are arranging visits with family or are placed with an emergency RFA. Law enforcement is notified that the facility is currently on diversion. At this time, interviews were conducted and further investigation is required. No deficiencies were cited at this time. Exit interview was conducted and a copy of this report was given to Melissa Fegurgur, Program Manager.