summary: Facility Evaluation

raw_content:
Narrative:
On 12/11/24, Licensing Program Analyst (LPA) Kellie McKinley arrived unannounced at the facility and met with Amanda Shelton - Clinical Program Manager. The purpose of the visit was to conduct a Required, Two year Annual Inspection of the facility. This is the facility's first inspection. LPA utilized the CARE Tool to complete the Annual 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. The facility is a home like setting, with five client bedrooms, two which are used as offices, one is a recreation room and the other two are client bedrooms. There is a large open kitchen with an attached dining area, and living room with a fire place made inaccessible to clients in care. Each client had a closet and dresser in good repair. Mattresses and bedding were observed to be clean. Clients were able to decorate their rooms with their personal belongings. There is no backyard, but does have a fenced side yard with a punching bag and grass area for a badminton set which is not out all the time. A variety of games can be found in a locked closet inside the facility for use. LPA observed the proper postings including: facility license, complaint hotline, client personal rights, and emergency disaster plan. The facility has one client bathroom and two staff bathroom. All were observed to be clean and fully functioning. Smoke alarms were in working order, fire extinguishers were current, and a first aid kit was fully stocked. LPA observed the kitchen to have at least 2 days of perishable food and 7 days of non-perishable food on hand, with additional food stored in the office refrigerator. The garage is used for storage of needed supplies and equipment. LPA observed client files and client medications were stored in a locked cabinet in the locked staff office back room. The facility has no outstanding fees. The facility currently has 2 clients, with a licensed maximum capacity of 2. Staff to client ratio is 3 staff to two clients. LPA reviewed 3 staff files. Staff files had completed criminal record clearances and all required initial and annual training. All First Aid and CPR certifications were up to date for staff. LPA interviewed 3 staff on site. continued on 809-C page LPA reviewed 2 client files. All clients had signed Admission Agreements on file. Client files had completed initial Needs and Service Treatment Plans and updated Needs and Service plans every 30 days. The facility had evidence of attempting to obtain signatures from placing agencies. Needs and Service Plans detailed adequate supportive services the facility offers to the clients. Clients were current on CHDP physical exams and dental exams. 1 of 2 clients were taking court ordered psychotropic medications and had current JV-220's on file. A signed copy of this LIC-809 an additional documents of the report was provided to Amanda Shelton Clinical Program manager. An exit interview was conducted.


state: CA

summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Continued from It was alleged one staff member took a youth's belongings on one occasion. Interviews and records reviewed were inconsistent. Seven of 9 interviews reported that they had never witnessed or heard of any youth's personal belongings being taken. One staff reported seeing one other staff take one item that had been confiscated from the youths belongings. One interview out of nine reported they had heard of staff making inappropriate comments to and around youth, but no staff reported hearing inappropriate comments directly. Support Services Manager denied having knowledge of the allegations prior to the investigation but subsequently held a team meeting to review policies and procedures on safeguarding client's belongings and maintaining boundaries in conversation with youth. Based on LPA's interviews which were conducted, and records reviewed, although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove the violations did, or did not, occur. Therefore, the allegations are UNSUBSTANTIATED. A signed copy of this LIC-9099 report, the LIC-9099C, and appeal rights were provided to the facility. An exit interview was conducted.

Investigation Findings:
13Licensing Program Manager (LPM) Hillary Hall arrived unannounced at the facility on this date for the purpose of delivering findings for the complaint investigation. LPM met with Steven Stewart, Therapeutic Skills Coach. LPA Vue conducted the complaint investigation and initiated the investigation with the facility on 11/03/25 and met with Chris Jeffrey, Program Supervisor (PS). LPA also conducted a Health and Safety Inspection. During the course of the investigation, LPA interviewed the Reporting Party, seven (7) facility staff, and one (1) youth. LPA reviewed records including Staff Schedule, Staff Personnel Report-LIC500, Staff Contact List, and Staff Training Log. LPA also reviewed Client Roster, Need and Services Plan, Child and Family Team Meeting notes, Case Notes for one youth, Facility's Team Meeting notes, Client Personal Property, Serious Incident Reports, and Hiring interview questions. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Margo Castaneda 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 CHICO - RESIDENTIAL, COHASSET RD., STE. FACILITY NAME: REDWOOD COMMUNITY SERVICES, INC - SEQUOIA HOUSEFACILITY NUMBER: VISIT DATE: 12/18/2025

report_type: Complaint Investigation

met_with: Steven Stewart, Therapeutic Skills Coach IV

complaint_status: unsubstantiated


facility_name: REDWOOD COMMUNITY SERVICES, INC - SEQUOIA HOUSE

summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
Licensing Program Analyst (LPA) Lyta Vue arrived unannounced at the facility for the purpose of a Case Management following the review of Serious Incident Reports submitted by the facility to the Department. LPA met with Program Manager, Amanda Shelton. On March 4, 2025, Licensing Program Manager (LPM) Hillary Hall conducted a review of the Serious Incident Reports (IRs) which were submitted to the Department between December 2024 and February 2025. LPM determined eleven (11), 24-hour IR's were submitted late, and 15 full IR's were submitted late. Three of the full IR's submitted late, were not preceded by a 24-hour report. Four of the 24-hour IR's did not have a corresponding full report submitted to the Department at the time of the review. Five IR's involving law enforcement did not have a corresponding LIC Law Enforcement contact form as required. The requirement of the facility is that 24-hour IR's are submitted to the Department within 24 hours of the incident. Full reports are to be submitted within 7 days. Facility is issued a citation per Title 22, Division 6, Section 80061(b): Reporting Requirements: (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. A signed copy of this LIC 809 and 809D were provided to the facility along with appeal rights. Exit interview conducted.

Deficiencies:
80061(b): Reporting Requirements: (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business ...............1
2
3
4
5
6
7Staff (supervisor-SV) did IR training on 03/11, will submitt training; Facility plan a time frame for SV to be available and dedicated to IRs and emials; 03/19- Program Coordinator schduled training with all Sequoia house staff, will submit training w/ content, sign-in sheet, date, time, hours
8
9
10
11
12
13
14

report_type: Facility Evaluation

visit_type: Case Management

met_with: Program Manager, Amanda Shelton

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


facility_name: REDWOOD COMMUNITY SERVICES, INC MCCC

summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Brian Bertoli met with Program Manager Paulita Peredia regarding a complaint investigation at the Short-Term Residential Therapeutic Program. The purpose of the inspection was to deliver the findings for the above allegation. During the course of the investigation, LPA Bertoli inspected the Facility, interviewed youth and staff, and reviewed documentation. LPA confirmed through confidential interviews and incident reports that a staff person engaged in intentional physical contact with youth by pushing or hitting youth with a laptop computer. Based on the information obtained, there is a preponderance of the evidence to prove that the staff violated personal rights of client. Therefore, the above allegation is substantiated. Title 22 deficiencies were cited regarding the physical abuse. Appeal Rights were provided and discussed with the facility. An exit interview was conducted and a copy of the report was left with the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Mendoza LICENSING EVALUATOR NAME: Brian Bertoli 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 21-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, NEOTOMAS AVENUE, STE. FACILITY NAME: REDWOOD COMMUNITY SERVICES, INC MCCCFACILITY NUMBER: 236890071

met_with: Paulita Peredia

complaint_status: SUBSTANTIATED


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Brian Bertoli conducted an unannounced inspection for the purposes of completing an Annual/Required Inspection and met with Program Supervisor. A pre-screening call was done prior to arrival, and Supervisor Peredia indicated that no one was Covid positive, symptomatic, or had known exposure. The Physical Plant was toured inside and out by LPA Bertoli at 10:30am. Water temperatures were measured at 111 degrees. Seven-day Non-perishable food supply was inspected and was found to be adequate. Two-day perishable food supply was inspected and were found to be adequate and consistent with the menu. LPA inspected bedrooms and found that there were adequate linens and each bed had mattress pads. The home is clean and in good repair. There are no firearms in the facility. There are no open bodies of water on the property. Medications are locked in the office. Toxics and cleaning solutions are locked in the laundry closet. Required documents are posted. There are charged operable fire extinguishers. Carbon monoxide and smoke detectors are in the facility. Five staff and three clients were interviewed. Three client files were reviewed and staff files will be reviewed on another date. Per Title Regulations, no deficiencies were cited during this inspection. An exit interview was conducted and a copy of the report was left at the facility.

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Brian Bertoli conducted an unannounced inspection for the purposes of completing an Annual/Required Continuation Inspection and met with Program Supervisor Paulita Peredia. A pre-screening call was done prior to arrival, and there were no changes since last visit. The staff records were reviewed at the administrative office on South Orchard St in Ukiah and were acceptable. The Emergency Intervention and Disaster Preparedness were reviewed at the facility. The Annual/Required inspection is complete. Per Title Regulations, no deficiencies were cited during this inspection. An exit interview was conducted and a copy of the report was left at the facility.


facility_name: REDWOOD COMMUNITY SERVICES, INC.-BIRCH HOUSE

raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Brian Bertoli met with Program Manager Paulita Peredia regarding a complaint investigation at the Short-Term Residential Therapeutic Program. The purpose of the inspection was to deliver the findings for the above allegation. During the course of the investigation, LPA Bertoli inspected the facility, attempted to interview youth, interviewed staff and Authorized Representatives, and reviewed documentation. While youth in the home stated to others that the staff had verbally and physically abused them, the youth declined to be interviewed, and both staff and authorized representatives indicated they had no knowledge of any such occurrences, and they all stated that the youth has a history of making unfounded accusations. Based on interviews conducted, LPA was unable to determine if foster youth was physically assaulted or if staff spoke inappropriately to the youth. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that foster youth was either physically assaulted or suffered verbal abuse; therefore, the above allegation is unsubstantiated. Appeal Rights were provided and discussed and no deficiencies were cited. An exit interview was conducted and a copy of the report was left with the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Mendoza LICENSING EVALUATOR NAME: Brian Bertoli LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3


raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Cheyenne McCambridge met with Theraputic skills coach Zach Crossman regarding a complaint investigation at the Short-Term Residential Therapeutic Program. The purpose of the inspection was to deliver the findings for the above allegation. During the investigation, LPA Brian Bertoli inspected the facility, interviewed youth, staff and Authorized Representatives, and reviewed documentation. The youth in the home stated that staff had not been physically abusive or rough with her, and both staff and authorized representatives indicated they had no knowledge of any such occurrences, and they all stated that the youth has a history of making unfounded accusations. Based on interviews conducted, LPA was unable to determine if foster youth was handled in a rough manner. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that foster youth was handled in a rough manner; therefore, the above allegation is unsubstantiated. Appeal Rights were provided and discussed, and no deficiencies were cited. An exit interview was conducted, and a copy of the report was left with the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Cheyenne McCambridge LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

met_with: Zach Crossman


raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Brian Bertoli met with STRTP Coordinator Rebecca Diaz regarding a complaint investigation at the Short-Term Residential Therapeutic Program. The purpose of the inspection was to deliver the findings for the above allegation. During the investigation, LPA Bertoli inspected the facility, interviewed youth, staff, and Authorized Representatives, and reviewed documentation. All parties interviewed indicated that the youth had received mental health services and was supported by the facility staff in engaging in those services. Youth was known to engage in self-harm and staff was alert to the issue and made efforts to reduce the behavior. Youth was documented as attending mental health services regularly. Based on interviews conducted and documents reviewed, LPA did not observe any indication that the youth was not receiving appropriate mental health services. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that Staff are not ensuring minor's mental health needs are met; therefore, the above allegation is Unsubstantiated. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Brian Bertoli LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Rebecca Diaz


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Brian Bertoli conducted an unannounced inspection for the purposes of completing an Annual/Required Inspection and met with administrator Lorraine Montano. A pre-screening call was done prior to arrival, and Program Supervisor Paulita Peredia indicated that no one was Covid positive, symptomatic, or had known exposure. The Physical Plant was toured inside and out by LPA Bertoli. Water temperatures were measured at 114 degrees. Seven-day Non-perishable food supply was inspected and was found to be adequate. Two-day perishable food supply was inspected and were found to be adequate and consistent with the menu. LPA inspected bedrooms and found that there were adequate linens and each bed had mattress pads. The home is clean and in good repair. There are no firearms in the facility. There are no open bodies of water on the property. Medications and sharps are locked in the office. Toxics and cleaning solutions are locked in the laundry room. Required documents are posted. There are charged operable fire extinguishers, carbon monoxide and smoke detectors are in the facility. Four staff were interviewed. Client files and staff files were requested and will be reviewed on another date. Per Title Regulations, no deficiencies were cited during this inspection. An exit interview was conducted and a copy of the report was left at the facility.

met_with: Lorraine Montano


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Brian Bertoli conducted an unannounced inspection for the purposes of completing an Annual/Required Continuation Inspection and met with Program Supervisor Paulita Peredia. A pre-screening call was done with Administrator Lorraine Montano prior to arrival, and there were no changes since last visit. The staff records were reviewed at the administrative office on South Orchard St in Ukiah and were acceptable. The client records were reviewed at the facility and found to be acceptable. A Technical Advisory was issued for Title 22 80023(d)(2) and Health and Safety Code 1565(a)(6) and 1565(a)(7)(A) Regarding the Disaster Plan. The Annual/Required inspection is complete. Per Title Regulations, no deficiencies were cited during this inspection. An exit interview was conducted and a copy of the report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Carolyn Flynn on 9/17/2021 at 10: AM. During the inspection, LPA Flynn met with Kate Napp, Program Administrator at the main office to review staff files and facility file. LPA then moved to the facility at 11: AM and was met by Zobeyda Borjorquez, Lead Therapeutic Skills Coach III and inspected the facility inside and out. LPA reviewed three of staff personnel files and the facility program statement on site at the main office at 10: AM. LPA reviewed one of child's psychotropic medications and medication records at 12: PM LPA attempted to interviewed one of children currently taking psychotropic medication at 1: PM LPA reviewed one of child's records on site at the facility at 12: PM LPA interviewed three of staff on site. The first at 1: PM, the second at 1: PM, and the third at 2: PM LPA provided the Summary Report to Kate Napp, Program Administrator upon completion No deficiencies are being cited at this time, but one Advisory Note (Technical Violation see LIC9102 dated 09/17/2021) was issued by LPA Flynn who conducted exit interview with Kate Napp, Program Administrator at 23: PM.

met_with: Kate Napp


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Brian Bertoli on 8/2/22 at 10:10am. During the inspection, LPA Bertoli met with Zobeyda Bojorquez, TSC V and inspected the facility inside and out. A COVID pre-screening call was completed prior to arrival with Program Supervisor Paulita Peredia, and she confirmed that there are no COVID positives, know exposures, or symptomatic persons present at the facility. LPA reviewed 1 child's records on site at the facility at 10:30am. LPA reviewed 5 of staff personnel files on site at the facility at 2:40pm. LPA reviewed 1 child's psychotropic medications and medication records at 1:30pm. LPA interviewed 2 of staff on site at 11:15am. LPA attempted interview of 1 child currently taking psychotropic medication at 11:45am. LPA provided the Summary Report to Supervisor Peredia upon completion. No deficiencies are being cited at this time. LPA conducted an exit interview with TSC V Bojorquez at 2:30pm.

met_with: Zobeyda Bojorquez


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Brian Bertoli on September 1, 2023 at 10:15am. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Bertoli met with Rebecca Diaz, STRTP Coordinator, and inspected the facility inside and out. LPA did not review any children's records due to no current placements. Three staff personnel files were reviewed at the administrative office on S Orchard St in Ukiah. LPA did not review any children's psychotropic medications and medication records. LPA interviewed three staff on site to discuss the facilities policies and procedures of operation. LPA did not interview children. LPA provided a copy of this licensing report to Rebecca Diaz, STRTP Coordinator. No deficiencies are being cited at this time. LPA conducted an exit interview with Rebecca Diaz, STRTP Coordinator.


facility_name: REFUGE SUNSET

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Angelique Hill conducted an announced Pre-licensing inspection on 2/25/2026 at 10: AM at the facility, as required for the Short-Term Residential Therapeutic Program (STRTP) license. LPA met with Jennifer Crosetti, Administrator (A1) who helped with the inspection. During the pre-licensing visit, LPA conducted a Health and Safety inspection using the CARE tool. LPA observed the facility was clean inside and outside and safe. LPA observed the facility is a one story house. LPA observed two bedrooms with bedding, three bathrooms and one office equipped with appropriate furniture. Sufficient storage space for client's personal belongings was observed in the prospective bedrooms. The STRTP is requesting to be licensed for four youths ranging in age from 12 to 17 years old. LPA Hill observed a medication Lock box in the office space which was empty, but locked, and has a lock code. The kitchen area was equipped with perishable foods in the refrigerator and non-perishable foods in the pantry. The STRTP has an attached garage space which houses one empty fridge and a facility vehicle. LPA observed a wood burner fireplace in the living room with a glass barrier. No serious concerns were observed.

visit_type: Prelicensing

met_with: Jennifer Crosetti, Administrator


facility_name: REFUGE WALNUT

summary: Facility Evaluation

raw_content:
Narrative:
On January 2, 2026 at approximately 10: AM, Licensing Program Analysts (LPA) Zaria Turner an made an announced visit with the purpose of conducting a pre-licensing inspection to the above Short Residential Therapeutic Program (STRTP). LPA met with Facility Administrator, Jennifer Crosetti, and a walk through of the interior and exterior was completed. LPA conducted a walk though of the interior and exterior of the facility. The facility was clean, safe and kept free of obstruction. LPA observed the posting of License, Personal Rights, and Emergency Disaster Plan. The facility consists of 3 bedrooms, 2 bathrooms, kitchen, dining room, living room, and a office/garage. Bedroom #1 is equipped with 2 twin size beds, bedding, 2 bedside tables, 2 dressers, and closet space for clothing and personal belongings. Bedroom #2 and #3 are equipped with 1 twin size bed, bedding, 1 bedside table, 1 dresser, and closet space for clothing and personal belongings. The 2 bathrooms in the facility are equipped with working toilets, shower/tub, and running water. Upon entry, the living room is equipped with a desk and chair, a fireplace with wood cover, 2 sofas, 3 chairs, 2 side tables, and a coffee table. The dining room is equipped with a table and 6 chairs, a side table, a cube storage organizer, and a side cart. The office/garage is equipped with 2 desks, 4 chairs, a side table, a cube storage organizer, and a stackable washer and dryer. Continue summary of inspection on 809-C Disinfectants/cleaning solutions are inaccessible to clients in care and locked in the office/garage. The refrigerator temperature is at or below 45 degrees F. There is nonperishable food for one week and fresh perishable food for three days minimum. There are containers to place leftover food. Carbon monoxide and smoke detectors are in working order. Hot water between 105-120 degrees F. Fire Extinguishers are up to date and in working order. The toilets, bathtubs, and shower fixtures are in good repair. Soap and paper towels are available to clients in care. The facility is free of vermin. The backyard contains a covered patio, side patio, grassy area, gravel area, and concrete area with a basketball hoop. There is a standalone structure in the back of the property that is not a part of the facility. There is no pool on the premises. The following adjustments need to be made: · Facility Telephone · Disaster and Mass Casualty Plan of Action on file An exit interview was conducted with Facility Administrator, Jennifer Crosetti, and a copy of this report was discussed and provided during today's inspection.

met_with: Jennifer Crosseti, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 11.4.25 1:00pm LPA Jennifer Baca met with Jason Henderson CEO and Jennifer Crosetti Program Administrator for the purpose of a Component 2. LPA disussed the Licensing process and took copies of ID's. LPA discussed the revisions that were submitted via email which included Plan of operation, Program statement, Personnel Requirements and children's records. LPA also discussed Personal Rights requirements and Discipline Policies. LPA also discussed Health related services, Manual Restraints. LPA also discussed the state of the old facility binder at the old location, and the status of the new property and if the facility has a deed or a lease as of today. CEO stated they have acquired a property and will be turning in the new binder for the new facility on Sunset blvd on 11.5.2025. LPA discussed the scheduling of COMP 3.

met_with: Jason Henderson


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On April 23, 2026 at 09:54AM Licensing Program Analyst (LPA) Angelique Hill, arrived unannounced at the facility for the purpose of a Post Licensing inspection. During the inspection, LPA Hill met with Cheryl Gutierrez, Administrator (A1). There were two clients present in the facility upon arrival. LPA Hill conducted a walk-through of the facility inside and out. Number of staff interviewed _3_. LPA observed # _3_ bedrooms, # _2_ bathrooms and a ADU home that consisted of two bedrooms and two bathrooms. LPA Hill inspected and/or reviewed the following: I. Physical Plant Posting of license__x_ Personal Rights__x_ Disinfectants/Cleaning solutions inaccessible _x_ Refrigerator Temperature at or below 45 degrees F __x__ Freezer Temperature at or below 0 degrees __x__ Nonperishable Foods one week and fresh perishable foods two days minimum __x__ Menu present and posted __x__ Working telephone __x_ Carbon monoxide detectors __x_ Smoke Detector __x__ First Aid Kit fully stocked _x__ Common Room available __x__ Dining area (enough seating, furniture good condition, not broke or damaged) ___x___ Medication centrally stored, locked/inaccessible __x___ Hot Water between 105-120 degree F (Properly labeled if over 125 degree F_x__ Fire Extinguisher dated August Toilets wash basin, bath and shower fixtures in good repair/no leaks/hot water temperature __x__ Soap and Paper towels _x__ Laundry Facilities(available and work)__x__. Bedroom required linen and furnishings __x_ Locked Facilities (open locked storage area/building/sheds) __yes__ Bedroom (required bedding/furniture, furniture in good repair) yes Disaster and mass casualty plan updated and available _no Quarterly Drills conducted and documented no Disaster preparedness supplies verified _no__. SCHN not required/not applicable.

Deficiencies:
87087(c): Deficient Practice Statement
1
2
3
4Based on LPA's observation and staff interviews, the licensee did not comply with the section cited above in one out of three persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2026
Plan of Correction
1
2
3
4

met_with: Cheryl Gutierrez, Administrator

title:
(c) The licensee shall prohibit smoking in the facility and on the grounds of the facility

This requirement is not met as evidenced by


summary: Facility Evaluation - 4 deficiencies

raw_content:
Narrative:
On 04/30/2026 at 9:00AM Licensing Program Analyst (LPA) Angelique Hill conducted an unannounced Post-Licensing inspection continuation and met with Misty Jackson, Administrator. LPA inspected the facility inside and outside and observed the home is a one story home with three bedrooms and two bathrooms. The property has a one story ADU with two bedrooms and two bathrooms. There were two children and six staff present during the inspection. LPA reviewed the following: Staffing/Volunteers Number of Staff files reviewed __five__ Criminal record clearances verified _five__ First Aid Certificate __five__ Certified Administrators certificate valid and current _one_ Job title/qualification verified ___five__ Continuation of the inspection still needed.

Deficiencies:
87089.2(a): Deficient Practice Statement
1
2
3
4Based on LPA's interviews and record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2026
Plan of Correction
1
2
3
4
87068.2(c): Needs and Services Plan

(c) The needs and services plan shall include a description of the services to be provided or arranged to meet the short- and long-term needs and goals of the child as assessed by the Qualified Individual, pursuant to Sections 4096 and 11462.01 of the Welfare and Institutions Code. The needs and services plan shall also include the following information regarding services necessary to meet the child's needs, consistent with the case plan prepared by the placing agency, if provided, and consistent with the Qualified Individual's assessment
87068.3(a): Modifications to The Needs And Services Plan

(a) The needs and services plan as described Sections 87068.2 and 87068.22, shall be updated at least every 30 days to determine the following
80087(a): Deficient Practice Statement
1
2
3
4Based on LPA's observation, there are holes in the hallway walls, C1 and C2 had holes in their bedrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2026
Plan of Correction
1
2
3
4

met_with: Misty Jackson, Administrator

title:
Nursing Services

(a) On and after October 1, 2021, a short-term residential therapeutic program shall ensure the availability of licensed nursing staff as specified in subdivision (n) of Section 1562.01 of the Health and Safety Code.

This requirement is not met as evidenced by

title:
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by


facility_name: REMI VISTA PORTA DEGO HOME

raw_content:
Narrative:
...Continued from LIC Based on the corroborating interviews of the clients and staff members explaining acceptable disciplinary methods are used, that the staff do not put their hands on clients, and the incapability to interview the victim, the allegation, "Client received inappropriate discipline from staff," cannot be proven true. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove that alleged violation(s) did or did not occur, therefore the allegation(s) is unsubstantiated. Exit interview was completed with Chris Magera and appeal rights explained, on 3/22/22 at 1: PM. LPA provided a signed copy of LIC 9099 and appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA), Stefanie Whitlow, conducted complaint investigation for the allegation stating, "Client received inappropriate discipline from staff." LPA, Kellie McKinley, conducted initial complaint opening inspection. LPA McKinely conducted interviews with the facility program manager and one staff member. LPA, Stefanie Whitlow conducted two staff interviews and two client interviews. The victim moved placements two days after the incident and LPA was unable to interview them, after three attempts. Three out of three staff stated restriction or removal of privileges are used for discipline and that staff do not put hands on clients. Three out of three staff stated the day of the incident, food was not refused to the victim; they did not receive ice cream due to the ice cream being a reward to other clients for good behavior. Two out of two clients interviewed stated staff do not put their hands on clients and that restriction is used as discipline. Continued on LIC 9099-C... UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Daniel Allmon LICENSING EVALUATOR NAME: Stefanie Whitlow 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., Suite Chico, CA Facility Name: Remi Vista Porta Dego Homefacility Number: Visit Date: 03/22/ Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32...Continued from LIC Based on the corroborating interviews of the clients and staff members explaining acceptable disciplinary methods are used, that the staff do not put their hands on clients, and the incapability to interview the victim, the allegation, "Client received inappropriate discipline from staff," cannot be proven true. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove that alleged violation(s) did or did not occur, therefore the allegation(s) is unsubstantiated. Exit interview was completed with Chris Magera and appeal rights explained, on 3/22/22 at 1: PM. LPA provided a signed copy of LIC 9099 and appeal rights. SUPERVISORS NAME: Daniel Allmon LICENSING EVALUATOR NAME: Stefanie Whitlow LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 2 of 2

met_with: Chris Magera


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
...Continued from LIC Based on the corroborating interviews of the clients and staff members explaining acceptable disciplinary methods are used and that the staff do not put their hands on clients, the incident was a momentary lapse in judgement and an isolated event. The allegation, "Staff touched client in care inappropriately," is found to be substantiated, but LPA is not citing. A technical violation will be provided. The allegation, "Client received inappropriate discipline from staff," cannot be proven true. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove that alleged violation(s) did or did not occur, therefore the allegation(s) is unsubstantiated. Exit interview was completed with administrator, Chris Magera, and appeal rights explained, on 3/22/22 at 2: PM. LPA provided a signed copy of LIC 9099 and appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA), Stefanie Whitlow, conducted complaint investigation for the allegation stating, "Client received inappropriate discipline from staff," and "Staff touched client in care inappropriately." LPA, Kellie McKinley, conducted initial complaint opening inspection. LPA McKinely conducted interviews with the facility program manager and one staff member. LPA, Stefanie Whitlow conducted two staff interviews and two client interviews. The victim moved placements two days after the incident and LPA was unable to interview them, after three attempts. Four out of four staff stated restriction is used as discipline and that staff do not put hands on clients. When trying to confiscate objects, four out of four staff stated they use verbal prompts. Two out of two clients interviewed stated staff do restrain clients if they are in danger, that staff do not touch them inappropriately, and that staff use removal of privileges as discipline. Continued on LIC 9099-C... SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Daniel Allmon LICENSING EVALUATOR NAME: Stefanie Whitlow 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., Suite Chico, CA Facility Name: Remi Vista Porta Dego Homefacility Number: Visit Date: 03/22/ Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32...Continued from LIC Based on the corroborating interviews of the clients and staff members explaining acceptable disciplinary methods are used and that the staff do not put their hands on clients, the incident was a momentary lapse in judgement and an isolated event. The allegation, "Staff touched client in care inappropriately," is found to be substantiated, but LPA is not citing. A technical violation will be provided. The allegation, "Client received inappropriate discipline from staff," cannot be proven true. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove that alleged violation(s) did or did not occur, therefore the allegation(s) is unsubstantiated. Exit interview was completed with administrator, Chris Magera, and appeal rights explained, on 3/22/22 at 2: PM. LPA provided a signed copy of LIC 9099 and appeal rights. SUPERVISORS NAME: Daniel Allmon LICENSING EVALUATOR NAME: Stefanie Whitlow LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 2 of 2


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Katherine Deaton emailed a copy of this report to the facility in accordance with COVID-19 precautions. The LPA met with Chris Magera, Acting Administrator, and Chad Medlin, Head of Mental Health Services, at the facility administrative office. The facility meets all Core Services, Specialty Mental Health Services, and Trauma Informed Care requirements. The facility is in the process of updating their Administrator information. Two staff members have probationary Administrator Certificates as Administrator Certification Testing is currently suspended (see PIN 20-04-CRP). Clients are advised of their personal rights & house rules. There are several posters/resources/notices posted at the facility including: Mental Health Resources, CCLD contact information, and Ombudsman contact information. Clients gender identity, expression and orientation are respected and kept confidential. Clients receive information about their own healthy sexual development. The LPA conducted an on-site file review following all COVID-19 precautions. The LPA reviewed three staff files and three client files. Staff are meeting all training requirements. The facility has scheduled outstanding PCMA training and employee evaluations. No citations were issued at the time of this inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On 5/26/ Licensing Program Analyst Kellie McKinley met with Derek Hodsdon and Rondoe Taylor Facility Manager conduct a Case Management inspection for the purpose of delivering an exclusion notice. Based on the evidence obtained during today's inspection, this LPA has verified the individual is not present, employed or residing at a resource Group home. No deficiencies observed or cited during this inspection. Copy of this report left with the agency at the conclusion of the inspection. The exclusion notice was given at the time of the inspection.

met_with: Derek Hodsdon - Program Facilitator and Rondoe Taylor- Facitly Manager


summary: Facility Evaluation

raw_content:
Narrative:
An announced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Stefanie Whitlow at STRTP Remi Vista, Porta Dego located at address above on 9/14/21 at 12: PM. During the inspection, LPA met with facility administrator, Derek Hodsdon, and inspected the facility inside and out. There were no deficiencies noted. A medication count was also conducted. LPA interviewed three staff on site during the inspection at 12: PM. LPA conducted exit interview with program manager, Chris Magera, who signed the LIC 809. Appeal rights were not explained, as no citations are being given. LPA provided the Summary Report to Chris Magera, program manager, upon completion by email.

met_with: Derek Hodsdon


summary: Facility Evaluation

raw_content:
Narrative:
An announced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Stefanie Whitlow at administrative office located at address above on 9/14/21 at 2: PM. During the inspection, LPA met with Chris Magera, program manager. There were no deficiencies noted. LPA reviewed four children's records. LPA interviewed four children currently taking psychotropic medication at 2: PM LPA reviewed three staff personnel files. LPA conducted exit interview with Chris Magera, program manager, who signed the LIC 809. Appeal rights were not explained, as no citations are being given. LPA provided the Summary Report upon completion by email.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Katherine Deaton conducted an annual required inspection at the facility in accordance with COVID-19 precautions. The LPA met with Garrett Vargas, Administrator (AD) and toured the facility; the facility is clean, safe, and sanitary. The LPA used the CARE Inspection Tool and initiated a review of the Physical Plant, Operations, Disaster Preparedness, and Emergency Interventions. The LPA conducted two staff interviews; there were no clients at the facility at this time. The LPA then traveled to the Administrative office located at Churn Creek Rd, Redding, CA and met with Chris Magera, Administrator. The LPA initiated review of Core Therapeutic Services, staff and client file reviews No citations were issued. Due to time constraints, this inspection will be completed at a later date.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Katherine Deaton continued the annual required inspection at the Administrative office located at Churn Creek Rd, Redding, CA in accordance with COVID-19 precautions. The LPA met with Chris Magera, Administrator and completed review of the Physical Plant, Operations, Disaster Preparedness, Emergency Interventions, Core Therapeutic Services, and Staff File components of the CARE Inspection Tool. The LPA interviewed one client. The LPA then traveled to the facility location and met with Garrett Vargas, Administrator. The LPA completed review of Client Files. Advisory Note Technical Violations were issued regarding Personnel Duties, Disaster Preparedness, and Emergency Intervention Staff Training. No citations were issued throughout the course of this investigation.

met_with: Garrett Vargas


facility_name: RICHMOND

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
It was specifically reported to CCL that S1, who is not assigned a role over client care and supervision at the facility is providing clients with drug paraphernalia in care. During the investigation there was no corroborating evidence to support the allegation. Although the department received information that S1 was providing drugs to clients in care the information received is inconsistent. Confidential interviews reported that clients obtain drugs from school and deny that S1 provides drugs to clients in care. Other confidential interviews stated that clients have been observed under the influence of substances and in possession of nicotine, and marijuana, however it is not known where clients obtain the drugs. A confidential interview revealed an incident in which smoke was observed as S1 was exiting an area of the facility where clients were congregating. It was further revealed that S1(non-childcare staff) was socializing with clients in care when S1 was directed not to socialize with clients. There were no other known witnesses to the allegation or to the incident involving S1 and clients in care. Based on confidential interviews, the allegation that staff provides drugs to youths while in care, may have happened or is valid but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Administrator, Stacey Rougely

Investigation Findings:
13On March 14, 2024, at 11: AM, Licensing Program Analyst (LPA), Cynthia Urena met with Richmond Short Term Residential Therapeutic Program (STRTP) Administrator, Stacey Rougely to deliver the investigative finding for the above stated allegation. On November 8, 2023, at 2: PM, LPA Cynthia Urena initiated the investigation at the STRTP and collected pertinent documents from the STRTP staff and client files. A health and safety inspection was conducted with a Residential Manager, and no immediate deficiencies were observed. LPA advised the Residential Manager that Charlotte Jackson with the Community Care Licensing Division (CCLD) Investigations Branch (IB) would be leading the investigation. Interviews were completed with four staff members (S1, S2, S3, S4,), four clients (C1, C2, C3, C4), a Probation Officer and a witness. On November 8, 2023, Community Care Licensing (CCL) received a complaint alleging that staff provides drugs to youths while in care. (**Continued on LIC C**) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Cynthia Urena 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 PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: RICHMONDFACILITY NUMBER: VISIT DATE: 03/14/2024

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

met_with: Administrator, Stacey Rougely


raw_content:
Narrative:
Confidential interviews revealed that S1 never made any inappropriate comments to C1 or any clients. Confidential interviews revealed that C1 dislikes S1 and C1 would make false allegation towards to S1 in hopes to get S1 fired. Confidential interview revealed that there are no concerns with S1 violating C1's personal rights. Based on confidential interviews, the allegation that S1 made inappropriate comments to C1 in care may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this report along with appeal rights was provided to Olive Crest - Richmond Short Term Residential Therapeutic Program (STRTP), Mwape Nchima Chongwe, Residential Coordinator.

Investigation Findings:
13On 05/09/24 at 09: AM, Licensing Program Analyst (LPA) Sarah Lo met with Mwape Nchima Chongwe, Residential Coordinator, to deliver the finding for the above complaint allegation at Olive Crest - Richmond Short Term Residential Therapeutic Program (STRTP). On 08/11/23, LPA Emina Preciado inspected the facility's physical plant, and no immediate health and safety hazards were observed. The investigation included interviews with one staff (S1), Residential Manager (RM), and two clients (C1 and C3). Clients' Needs and Services Plans and case notes were reviewed. On August 01, 2023, Community Care Licensing received an allegation that staff (S1) made inappropriate comments to a client (C1) in care. Specifically, it was reported that S1 made an inappropriate comment to C1 on an outing. The investigation resulted in conflicting statements: Confidential interview revealed that S1 made a sexual innuendo regarding a toy to C1. (Continued on LIC 9099c) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Sarah Lo 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: RICHMONDFACILITY NUMBER: VISIT DATE: 05/09/2024

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


raw_content:
Narrative:
Confidential interviews reported that C1 received pictures of C2 on their (C1) personal cell phone and showed the pictures to staff and clients. Confidential interviews reported that the STRTP does not monitor personal cell phones due to personal rights. Confidential interviews reported that C1 showed pictures of C2 to staff and that they (C1) were directed to delete the photos immediately. Confidential interviews reported that C1 was not told to delete the photos immediately but two or three days after staff was made aware. LPA received inconsistent information on the timeline from when staff was made aware of the photos and when staff directed C1 to delete the photos. Based on inconsistent confidential interviews, the allegation that due to a lack of supervision, the minor (C1) engaged in inappropriate interactions is unsubstantiated. The allegation 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. A copy of this report and appeal rights were explained and given to Stacy Rougely, Adminstrator.

Investigation Findings:
13On October 15, 2024, at 9: AM, Licensing Program Analyst (LPA) Cynthia Robinson conducted an unannounced visit to Richmond- Olive Crest STRTP to deliver the investigative findings for the allegation listed above. On 06/24/2024, LPA Robinson conducted a health and safety inspection at the STRTP. LPA obtained documents pertinent to the investigation. LPA interviewed Clients (C1, C4, and C5), and Staff (S1, S3, S4, and S5). LPA attempted to interview C2 but was unsuccessful because C2 was apprehended. LPA attempted to interview C3 and C6 but was unsuccessful because both clients refused to be interviewed. LPA made several attempts to interview S2 and the Probation Officer (PO) but was unsuccessful. On 06/19/2024, Community Care Licensing received an allegation that, due to a lack of supervision, a minor (C1) engaged in inappropriate interactions. It was alleged that C1 was sharing inappropriate pictures of C2. 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: RICHMONDFACILITY NUMBER: VISIT DATE: 10/15/2024

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

met_with: Stacy Rougely, Administrator


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
Confidential interviews revealed that the staff position of House Supervisor oversees notifying the mental health team of the prescription refills, but S1 did not notify the mental health team in a timely manner. Additional confidential interviews reported that the House Supervisor does not oversee medication and that the staff position, the Residential Coordinator, oversees medication refills. LPA obtained pertinent documentation of job descriptions and confirmed that the Residential Coordinator job description states this position is responsible for ensuring there is a sufficient supply of prescribed and over-the-counter medication on hand. As a result of the STRTP staff blaming each other, the STRTP did not meet the needs of C1, causing C1 not to receive their (C1) medication according to the physician's order. In addition, LPA observed that C1 was missing medication, and there was no more medication for C1 to take due to a missed refill in a timely manner. Based on consistent confidential interviews and pertinent documentation, the allegation that staff did not refill minors (C1) prescriptions is substantiated.The facility is cited with a violation of the Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS), Section 87075(c) Health Related Services (c) Psychotropic medications shall be used only in accordance with the written directions of the physician prescribing the medication.... The STRTP did not meet the needs of C1, causing C1 not to receive their (C1) medication according to the physician's order. LPA observed the missing medication, and confidential interviews revealed that C1 did not receive their medication due to a missed refill. This posed an immediate risk to the Health, Safety, and Personal Rights of children in care. An exit interview was conducted. A copy of this report and appeal rights were explained and given to Stacey Rougely, Administrator.

Investigation Findings:
13On January 7, 2025, at 10AM, Licensing Program Analyst (LPA) Cynthia Robinson conducted an unannounced visit to Richmond- Olive Crest Short-Term Residential Therapeutic Program (STRTP) to deliver the investigative findings for the allegation listed above. On 10/24/2024, LPA Robinson conducted a health and safety inspection at the STRTP, and no immediate health and safety hazards were observed. LPA obtained documents pertinent to the investigation. LPA interviewed Clients (C1 and C2), and Staff (S1, S2, S3, and S4). LPA attempted to interview Clients (C3, C4, C5, and C6) but was unsuccessful because clients refused to be interviewed. On 10/23/2024, Community Care Licensing received an allegation that staff did not refill minors (C1) prescriptions. It was alleged that C1 did not get a refill promptly, resulting in missed medication for C1. Confidential interviews revealed that C1 did not receive their medication due to not having a filled prescription. (Continued on LIC 9099C...) SubstantiatedEstimated 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: RICHMONDFACILITY NUMBER: VISIT DATE: 01/07/2025

met_with: Stacey Rougely, Administrator


raw_content:
Narrative:
Confidential interviews reported that S1 hit C1 with a closed-hand fist to the back of the head three times because C1 had stopped S1 from trying to touch them (C1). Other confidential interviews denied hitting C1 in the back of C1's head. Additional confidential interviews reported that S1 had pointed to C1's new nose ring and this caused C1 to think S1 was trying to take it out and raised their (C1) hands to "block" S1's hand. Confidential interviews reported that S1 then raised their (S1) hands to "block C1's hands" with an open palm. Confidential interviews reported that C1 was under the influence during the incident causing C1 to become defensive. Confidential interviews denied hitting C1 with closed fists or any physical abuse toward C1. Regarding the allegation that staff (S1) inappropriately spoke to youth (C1) in care, confidential interviews reported that S1 called C1 inappropriate words after the alleged incident between C1 and S1. In addition, confidential interviews reported that S1 did not say any inappropriate words toward C1. LPA was unable to determine if the allegations occurred or did not occur. Based on inconsistent confidential interviews, the allegations that staff (S1) hit youth (C1) in care and staff (S1) inappropriately spoke to youth (C1) in care are unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted. A copy of this report and appeal rights were explained and given to Stacy Rougely, Administrator.

Investigation Findings:
13On February 7, 2025, at 10: AM, Licensing Program Analyst (LPA) Cynthia Robinson conducted an unannounced visit to Richmond- Olive Crest STRTP to deliver the investigative findings for the above-stated allegations. On 12/17/2024, LPA Robinson conducted a health and safety inspection at the STRTP. LPA obtained documents pertinent to the investigation. LPA interviewed Client (C1), and Staff (S1, S2, S3, S4, and S5). LPA attempted to interview clients (C2, C3, C4, C5, and C6) but was unsuccessful because clients refused to be interviewed. On 12/16/2024, Community Care Licensing received allegations that staff (S1) hit youth (C1) in care and staff (S1) inappropriately spoke to youth (C1) in care. Confidential interviews reported that S1 had reached their hand out to point out C1's new nose ring and tried to reach out to pull it out. Confidential interviews reported that C1 raised their hands to stop S1 from touching them (C1). (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: RICHMONDFACILITY NUMBER: VISIT DATE: 02/07/2025

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


summary: Facility Evaluation

raw_content:
Narrative:
On October 26, 2021, at 9: AM Licensing Program Analysts (LPAs) Leslie Covarrubias and Carmen Escobar arrived at Richmond, Short Term Residential Program (STRTP). LPAs met with Residential Manager, Tyresha Calhoun. The purpose of the visit is to conduct an annual inspection of the facility. At 9: AM, Residential Manager, Tyresha Calhoun, led the physical inspection of the facility. The home is set up as follows: Bedroom #1- Was furnished with one twin bed and sleeps one client. Bedroom #2- Was furnished with one twin bed and sleeps one client. Bedroom #3- Was furnished with one twin bed and sleeps one client. Bedroom #4- Was furnished with one twin bed and sleeps one client. Bedroom #5- Was furnished with one twin bed and sleeps one client. Bedroom #6- Was furnished with one twin bed and sleeps one client. Bedrooms are arranged so that only one child is placed per room. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. There is adequate drawer and closet space for children's belongings. Bedroom #2 was observed to be missing a screen on the window, and therefore is being given a technical violation of Section: Physical Plant 80088(b). A physical plant inspection was completed and included the facility's kitchen area, four refrigerators/freezers, food storage areas, client rooms, two bathroom/showers, and community gathering area and dining area. Facility grounds are clean and free of debris and observable hazards. Sports equipment/toys/books/games/musical instruments were observed for client's recreation time. There is adequate indoor and outdoor activity space. Facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods and the menus were posted. At the time of inspection the facility license was observed to be posted by the front door. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsperson poster. Medications are locked and centrally stored inside staff office. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The hot water in the client's bathrooms was measured to be 107.6 degrees Fahrenheit for bathroom #1 and bathroom #2 was 106.8 degrees Fahrenheit. Per the Residential Manager, no firearms or weapons are allowed in the facility. LPAs inspected the facility vehicle to be in good repair. LPAs conducted a client record review of six of six client files. Client #1 did not have a TB test on file and therefore is being cited for violation of Section: Client Medical Assessment 80069(c)(1). Licensee has Mental Health Program Approval that is valid through 12/13/2021. Licensee has obtained National Accreditation that is valid through 10/31/2021. Licensing fee payments have been paid and there is currently a balance of $0. An exit interview was conducted and a copy of this report, LIC 809D, LIC9102, LIC 811 and appeal rights were provided to Residential Manager, Tyresha Calhoun.

met_with: Tyresha Calhoun


summary: Facility Evaluation

raw_content:
Narrative:
On November 10, 2021, at 8:35am, Licensing Program Analyst (LPAs) Ronnesha Fountain and Leslie Corvurriabias conducted an announced inspection. The purpose of the inspection was to complete the continuation inspection for STRTP annual inspection that was initiated on October 05, 2021. LPA's already completed the physical plant inspection, client records and three client interviews of the facility. During this annual inspection continuation LPAs interviewed three of the six clients to ensure the STRTP are meeting the Title Regulations and Interim Licensing Standards (ILS), see LIC 811 dated 11/10/21. The client interviews are located under the LIC 809 dated 10/05/21. Based on the interview with clients, there was some confusion over the "point system" used that determines the amount of cash a client can keep on them physically, but the amount that is deposited into their savings does not change. The STRTP appears to be meeting Core Services/Supports requirements. Based on the need to conduct staff interviews and a review staff records, this inspection will be continued at a later date. No deficiencies were found during this inspection. An exit interview was conducted and a copy of this report was provided to the residential manager Anne Lacy.

met_with: Anne Lacy


summary: Facility Evaluation

raw_content:
Narrative:
On Friday, November 19, 2021, at 9:30 am, Licensing Program Analyst (LPA) Ronnesha Fountain conducted an announced inspection. The purpose of the inspection was to complete the continuation inspection for the Richmond STRTP annual inspection initiated on October 26, 2021. LPA Fountain has already completed the physical plant inspection, client records, client and staff interviews. During the time of the inspection, there were no clients on site. During this annual inspection, LPA Fountain interviewed one staff, reviewed staff records and Operational Requirements, Disaster Preparedness, Emergency Intervention Plan, and Core/Therapeutic Services to ensure the STRTP meets the Title Regulations and Interim Licensing Standards (ILS), see LIC 811 dated 11/10/21. The client interviews are located under the LIC 809 dated 10/26/21 and 11/19/21. Based on the interview with the staff, the STRTP appears to be meeting Core Services/Supports requirements. With the facility's inspection, interviews with clients and staff, and a review of their records, CCL does not recognize any violation of regulations and/or ILS. This will conclude the annual inspection for the Richmond STRTP's last visit. No deficiencies were found during this inspection. An exit interview was conducted, and a copy of this report was provided to the residential manager Anne Lacy.


facility_name: ROP ATCS BAKER HOUSE

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Narrative:
Confidential interviews revealed conflicting statements. Some interviews indicated that it was requested for staff to stay with C1 while at the Hospital while other interviews indicated the Hospital contacted the facility and told the facility they did not need to stay at the Hospital with C1. Therefore, confidential interviews did not corroborate the allegation with a preponderance of evidence. Based on confidential interviews and records reviewed the allegation that staff left C1 unaccompanied while receiving medical attention, which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, and appeal rights explained. A copy of this report and appeal rights were provided to Erika Merales. A copy of this report will be placed in the facility file.

Investigation Findings:
13On March 6, 2025, at 1:20 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Erika Merales, Senior Coach, and Facility Administrator, Brittnie Peluso, was on the telephone, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on December 16, 2024, at 10:25 am and no deficiencies were observed. LPA Linley interviewed one of five Clients (C1), and five Staff (S1-5), LPA was unable to interview one Adult (A1) and one County Social Worker (CSW), despite multiple attempts to contact them. LPA reviewed facility documents during the investigation. On December 20, 2024, Community Care Licensing (CCL) received an allegation that staff left a minor unaccompanied while receiving medical attention. It was reported that C1 was transported to the Hospital via ambulance and staff did not accompany C1 to the Hospital, which resulted in A1 responding to the Hospital to stay with C1. It was reported that the Hospital attempted to contact the facility and could not reach anyone. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: ROP ATCS BAKER HOUSEFACILITY NUMBER: VISIT DATE: 03/06/2025

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

met_with: Erika Merales


raw_content:
Narrative:
staff bathroom located inside of the staff office. Confidential interviews further revealed that there were no staff nor clients that have witnessed staff smoking in any facility bathrooms however no specific bathroom was identified in the complaint. Confidential interviews also indicated there were no witnesses to support that staff are transporting minors while under the influence in addition staff files were reviewed and had all required documents for staff providing transportation protocols. Therefore, the allegations could not be confirmed. Based on confidential interviews, that staff are smoking inside of the facility and that staff are transporting minors while under the influence, may have occurred, however, it is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained. A copy of this report, LIC 811, and appeal rights was provided to the Administrator.

Investigation Findings:
13On March 10, 2025, at 2: PM, Licensing Program Analyst (LPA) Guadalupe Munoz arrived unannounced at the STRTP facility and met Senior Coach, Erka Merales and on the phone with Administrator, Brittnie Peluso, to discuss the investigative finding for the allegations noted above. LPA conducted an inspection of the facility on 05/23/24 at 1: PM and no deficiencies were observed at this time. LPA Interviewed four Staff (S1-4), LPA interviewed four out of six Clients (C1-4), LPA attempted to interview two Clients (C5-6), however clients declined. During the investigation, the following documents were reviewed: staff schedule, special incident reports, staff file review. On 05/16/2024, Community Care Licensing (CCL) received an allegation that staff are smoking inside of the facility and that staff are transporting minors while under the influence. Specifically, it was reported that staff "smokes inside of the bathroom" and that "staff member transported minors while under the influence". Confidential interviews revealed that there are two bathrooms in the facility. A shared client bathroom and a UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz 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 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: ROP ATCS BAKER HOUSEFACILITY NUMBER: VISIT DATE: 03/10/2025

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

met_with: Brittnie Peluso on phone and Erika Merales


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Narrative:
Interviews revealed conflicting statements regarding the reason C1 wanted to change rooms and conflicting statements on whether or not C2 was hitting C1 in the bedroom. Confidential interviews further revealed that the staff counseled both clients on conflict resolution however they did not move either client at that time. Furthermore, interviews confirmed that clients are redirected if observed having any type of negative interactions with each other. In addition, there are no witnesses that observed clients hitting each other, therefore, the allegations could not be confirmed. Based on confidential interviews the allegation that due to lack of supervision, minor is hitting another minor in care, may have occurred, however, it is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained. A copy of this report, LIC 811, and appeal rights was provided to Senior Coach, Ashley Wilson.

Investigation Findings:
13On March 28, 2025, at 11: AM, Licensing Program Analyst (LPA) Guadalupe Munoz arrived unannounced at the STRTP facility and met with Ashely Wilson, Senior Coach,to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 10/09/24 at 10: AM and no deficiencies were observed at this time. LPA Interviewed two staff (S1-2), LPA interviewed three out of six clients (C1-3), LPA attempted to interview two clients (C4-6), however clients declined. During the investigation, the following documents were reviewed: Staff Schedule, Special Incident Reports, and Clients' Needs and Services Plans. On 10/04/2024, Community Care Licensing (CCL) received an allegation that due to lack of supervision, minor is hitting another minor in care. Specifically, it was reported that clients "hit each other". Confidential interviews revealed that C1 and C2 were roommates and that C1 had requested to change rooms. ***Continued on 9099C*** UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz 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 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: ROP ATCS BAKER HOUSEFACILITY NUMBER: VISIT DATE: 03/28/2025

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

met_with: Ashely Wilson


summary: Facility Evaluation

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Narrative:
On December 20, 2023 at 9: AM, Licensing Program Analysts (LPAs) Guadalupe Munoz and Jacqueline Garcia conducted an announced pre-licensing inspection and completed Component III. LPAs met with Facility Administrator, Dana Butler. The facility is a three client bedroom one client bathroom single-family, single-story home. The applicant is applying for a Short Term Residential Treatment Program (STRTP) with the capacity of six ambulatory clients aged between 9-17 years old. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. Clients will use a cordless telephone to make and receive confidential telephone calls. The water temperature in bathroom #1 located in the hallway measured to be Degrees Fahrenheit. The facility smoke detectors and carbon monoxide detectors tested and were observed to be in working order; the fire extinguishers are properly charged and serviced. The facility has a fully equipped first aid kit and first aid manual. The applicants stated there were no weapons in the facility. Disinfectants and cleaning solutions will be stored and locked. Sharp knives will be stored in a locked kitchen cabinet. Medication will be locked in the locked cabinet in the attached garage used as a staff office. The staff and client files will be maintained on a digital database. LPA's advised Facility Administrator, that staff and client files to be accessible to Community Care Licensing (CCL) at any time. ****** The following required forms were posted in the facility: Personal Rights form, Foster Care Ombudsmen Poster and Disaster plans were posted. The facility is set up as follows There is adequate indoor and outdoor activity space.The entry hallway has an attached garage that is designated as a staff office. It has locked cabinets for facility logs, client files and medications. The hallway leads to an open living room that flows into the dining area and attached kitchen. There are three client bedrooms with two clients per room with twin sized beds dresser and closet space for each client. Bedroom #1 is designated for two clients, two twin beds, one dresser with four drawers, and closet space. . Bedroom #2 is: designated for two clients, two twin beds, one dresser with four drawers, and closet space. Bedroom #3 is designated for two clients, two twin beds, one dresser with four drawers and closet space. Each room has adequate clean linens, pillows, blankets, comforters, mattress pads, and mattresses. Next to the client bedrooms is a room that is used as a clinical office and for therapy sessions. The Backyard is set up as follows: The facility dining room has a sliding glass door that leads into the backyard. The backyard has seating area for visits and large yard that is free of debris. ****** Facility Vehicles: The facility has two vehicles for client needs, a facility van and a sedan. LPA Garcia observed vehicle logs that were not updated. Vehicles had current with valid registration and proof of insurance. Vehicles contained emergency backpack with required items. All special incident reports (SIR's) will be sent via e-mail to: cclpaccr@dss.ca.gov. The reporting requirements were reviewed with the Applicant/CEO on this date. LPA explained that once the license is approved, all employees shall have an approved criminal record clearance for CCL and be associated to this facility. LPAs observed the following areas that need to be corrected: Vehicle logs for monthly inspections. Blinds are missing slider stick to open the blinds Disaster Logs that need to be updated monthly. Monthly Manual Restraint log is needed. Based on the facility pre-licensing inspection, the facility will make the corrections and once completed submit proof of correction to LPA

met_with: Dana Butler


summary: Facility Evaluation

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Narrative:
On 03/11/24 at 1: PM, Licensing Program Analyst (LPA) Guadalupe Munoz met with Brittnie Peluso, ffor the purpose of conducting a post licensing inspection of the facility. A physical plant inspection was completed and included the facility's building and grounds, kitchen area, refrigerator/freezers, food storage areas, client bedrooms, bathroom/showers and facility vehicles used to transport clients. The facility grounds were clean and free of debris and observable hazards. Sports equipment, toys, books, games, computers were observed for children's schooling and recreation time. There is adequate indoor and outdoor activity space. Facility smoke detectors and carbon monoxide detectors are in appropriate working order. Licensee maintains an adequate supply of perishable and non-perishable foods and the menu was posted. All other required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights, Emergency Disaster Plan and Foster Care Ombudsperson poster. Medications are locked and centrally stored inside staff's office. The facility ensures that there is one client per bed with appropriate linens, pillows, comforters, and mattresses in good repair. All bedrooms have individual beds and drawer space for each client. The hot water in the client's bathrooms was measured to be between 103 and 116 degrees. Per designee, no firearms or weapons are allowed in the facility. Chemicals and/or poisons are locked in the hallway closet. The LPA reviewed LIC 610C Emergency Disaster Plan, completed disaster training for staff and clients and completed emergency drills. LPA interviewed 2 clients and 2 staff during visit. Staff files are located at corporate office and therefore inspection will need to be continued at a later date. An exit interview and a copy of this report was provided to Brittnie Peluso, facility representative.

met_with: Brittnie Peluso


summary: Facility Evaluation

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Narrative:
On 3/15/ LPA Munoz arrived at ROP ATCS Corporate office to complete post license inspection. LPA completed 5 staff file reviews and 5 client file reviews. An exit interview and a copy of this report was provided to Dana Centanni, facility representative.

met_with: Dana Centanni


summary: Facility Evaluation

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Narrative:
On 7/10/2024, at approximately 11:11 am, LPA Joon Choi arrived unannounced to the facility and met with Therapist Diana Guzman. LPA explained the reason for the visit was to interview a Client (C1) regarding a complaint (#19-CR-20240614124712) from a different facility (#33090238). During the visit, LPA interviewed C1 and provided a copy of this report.

met_with: Diana Guzman, Therapist


summary: Facility Evaluation

raw_content:
Narrative:
On January 23, 2025 at 10: AM, Licensing Program Analysts (LPAs) Sarah Lo and Gilbert Marquez conducted an unannounced Annual Inspection at ROP ATCS Baker House Short Term Residential Therapeutic Program (STRTP). LPAs were greeted by the Senior Coach Counselor, Erika Merales and was allowed entry into the facility; and later was joined by Facility Manager, Brittnie Peluso. At 10: AM, LPAs toured the facility and inspected inside and out with the Senior Coach Counselor, Erika Merales. The facility is a one-story home with (3) bedrooms, (1) client bathroom, living room and kitchen. There is a mental health office and a garage used as the staff office and one staff restroom. The Administrator stated current census is five. The facility is licensed to serve six ambulatory children ages between 12-17 years old and non-minor dependents. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. The beds and dressers in all the bedrooms are in good repair, and all window screens are attached. LPAs observed age-appropriate clothing in the closet of the clients. The bathroom is clean and in good repair. The temperature in rooms that clients occupy are registered at 70 degrees F. The hot water temperature was tested and noted to be 113.2 degrees F in the client bathroom. All hazardous items have been properly made inaccessible to areas where clients will have access. The medications were stored and locked in a cabinet in the staff office area. Cleaning supplies and chemicals are locked and stored in a locked cabinet in the staff office area. Sharp knives are inaccessible and stored in a locked cabinet in the kitchen. The First Aid Kit is located in a locked cabinet in the staff office and a locked kitchen cabinet and contains all required items. The facility's smoke detectors located in each bedroom and common areas were checked and were operable. The carbon monoxide detector located in the hallway was operable. There are no guns or weapons in the facility as stated by Administrator at this time. The following required posted items were observed accessible to clients: Grievance Procedures, Personal Rights, Ombudsman Poster, Visitation policies, and current menu. (continued on LIC 809c) LPAs observed a minimum 7-day non-perishable and a 2-day perishable supply of food. There was a variety of snacks available for clients as well. Refrigerators in the kitchen and garage are maintained in a good temperature. The facility outside grounds was also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. Facility has obtained Mental Health Certification which expires on March 23, 2025, and has been accredited by CARF which is valid through February 28, 2025. The facility annual licensing fees are paid to current. LPA Lo discussed the following with the Administrator: Core Services, Specialty Mental Health Service, Trauma Informed Care, Client Personal Rights, and Administrative Duties. LPA Marquez conducted two staff interviews and attempted to conduct interviews with the two clients that were present during the inspection and the two clients refused to be interviewed. Based on the facility inspection and file reviews on this date, there are no deficiencies found at this time. An exit interview was conducted and a copy of this report and LIC 811 was provided to the Administrator, Brittnie Peluso.

met_with: Brittnie Peluso, Administrator


facility_name: ROP ATCS JOANN HOUSE

summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Interviews revealed that C1 had reported this behavior to staff at facility and that as an intervention C4 would be under "heightened supervision". Interviews further revealed that "heightened supervision" was not maintained due to the number of staff scheduled to work during a shift and other residents who also needed increased supervision due to behavioral challenges. Based on confidential interviews, the preponderance of evidence standard has been met and the allegation that a minor inappropriately touched another minor in care due to lack of supervision is substantiated. The STRTP facility is being cited for violation of the Interim Licensing Standards Version 5, Article 06. Regulation 87065.5(g) Direct Care Staff/Child Ratios. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with XXX. A copy of this report, LIC 811, and appeal rights was provided to the Administrator.

Investigation Findings:
13On September 26, 2024, at 10: AM, Licensing Program Analyst (LPA) Guadalupe Munoz arrived unannounced at the facility and met with XXX, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 3/14/24 at 2:00 pm and no deficiencies were observed. LPA Interviewed three staff (S1-3), three clients (C1-3) and attempted to interview one client (C4). LPA obtained and reviewed the following documents: Needs and Service Plan, Staff Schedule, Client Roster and Incident Reports. On 03/8/2024, Community Care Licensing (CCL) received an allegation that a minor (C4) inappropriately touched another minor (C1) in care due to lack of supervision. Specifically, it was reported that C1 was touched on the thigh by a peer at the facility. Confidential interviews confirmed that C4 made sexually inappropriate comments and touched peers inappropriately during their time in placement at the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz 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 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: ROP ATCS JOANN HOUSEFACILITY NUMBER: VISIT DATE: 09/26/2024

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


raw_content:
Narrative:
Furthermore, interviews also revealed that other facility staff witnessed S1 speaking inappropriately to minors in care and that staff also reported this behavior to facility management. Interviews confirmed that S1 was addressed for this behavior by Program Director and supervisor and S1 underwent retraining. Based on confidential interviews, the preponderance of evidence standard has been met and the allegation that staff (S1) spoke inappropriately to minor (C1) in care is substantiated. The STRTP facility is being cited for violation of the Interim Licensing Standards Version 5, Article 06, Continuing Requirements regulation 87072(C)(1) Personal Rights. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Head of Service, Brittany Kelly on the phone and in person with Associate Social Worker, Sarah Hoover-Castorena. A copy of this report, LIC 811, and appeal rights was provided to the facility designee.

Investigation Findings:
13On November 1, 2024, at 11: AM, Licensing Program Analyst (LPA) Guadalupe Munoz arrived unannounced at the facility and met with Head of Service, Brittany Kelly on the phone and at facility with Associate Social Worker, Sarah Hoover-Castorena to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 3/25/24 at 10:45 am and no deficiencies were observed. LPA Interviewed three staff (S1-3), and two clients(C1-2). LPA obtained and reviewed the following documents: Needs and Service Plan for C1, Staff Schedule, Client Roster, Incident Reports and facility Training and Development Documentation for S1. On 03/18/2024, Community Care Licensing (CCL) received an allegation that staff spoke inappropriately to minor in care. Specifically, it was reported that S1 has been saying "F-you" and calling C1 the "B word." Confidential interviews confirmed that C1 and C2 had reported to facility supervisor and Program Director that S1 would speak to them in an inappropriate manner. Interviews further revealed that S1 spoke inappropriately to minor in care by telling C1 "likewise" whenever S1 was called names by C1. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz 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 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: ROP ATCS JOANN HOUSEFACILITY NUMBER: VISIT DATE: 11/01/2024

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

met_with: Sarah Hoover-Castorena