summary: Facility Evaluation

raw_content:
Narrative:
On March 1, 2024, at 9: AM, Licensing Program Analyst (LPA) Shalisa Stiger made an unannounced required Annual Inspection to the above facility. LPA Stiger met with the Administrator who assisted with this inspection. This facility is licensed for six (6) clients and currently has four (4) clients in care. LPA Stiger observed all required postings posted. LPA Stiger observed and tested smoke detector and carbon monoxide detector. LPA Stiger observed one (1) staff office with locked files, desks, lockers, and extra belongings. LPA Stiger observed two (2) client bedrooms with appropriate bedding and furniture. All bathrooms were tested and working. The hallway cabinet contained extra linens, towels, blankets and hygiene products. All cleaning chemicals were locked and inaccessible to clients. LPA Stiger observed medications and sharps to be locked. There is one (1) fire extinguisher on site tested and working. LPA Stiger reviewed four (4) staff files and four (4) youth files. LPA Stiger issued a Technical Assistant (TA) given for missing an Individualized Program Plan (IPP) for one (1) youth file. LPA Stiger interviewed one (1) staff. No clients were available to interview during this inspection. LPA Stiger observed the kitchen refrigerator, freezer, and pantry to be filled with perishable and non-perishable food items for four (4) clients. LPA Stiger observed an adequate supply of utensils, dishes and a menu. A trash bin with a lid is located in the kitchen. LPA Stiger observed the living room to have adequate furniture and lamps. Washer and dryer is located in the garage and accessible to clients. LPA Stiger observed the outdoor area to be clear of clutter and debris. The locked garage contained holiday decorations, tools, canned goods and client's inventories. LPA Stiger conducted an exit interview with Administrator and provided a copy of the report to facility.


state: CA

facility_name: ELK GROVE RANCH-VALLEY OAK

summary: Facility Evaluation

raw_content:
Narrative:
On November 7, 2024 at 11: AM Licensing Program Analyst (LPA) Sarina Buchannan conducted an unannounced Case Management inspection to the above Group Home for the purpose of addressing the age range not being followed at the facility. LPA was greeted by Priscilla Salvador, Licensee, who granted LPA access. The census at the facility is 3. On September 5, LPA Buchannan was notified that the census of the facility was 4 clients between the ages of 17 to 22. LPA was informed that the 22 year old client would be leaving the facility by October 18, 2024. LPA Buchannan was also informed that an age exception request was going to be submitted to the department for a 19 year old client in care who exceeded the age range on the License. Currently the facility is Licensed to provide care and supervision to 6 clients ages 12-17 years old, Ambulatory and 2 non-Ambulatory. File review showed that as of 10/15/2024 the 22 year old client left the facility, LPA also confirmed this upon inspection. As of today, LPA Buchannan has not received the required documentation from the facility to review the age exception request for approval or denial. LPA is issuing a Technical Advisory for the following: One 19 year old client in care is living in the facility and has not been granted an age exception (See LIC TV) LPA conducted a tour of the inside and outside of facility and no deficiencies were cited. Exit interview conducted and a copy of this report and appeal rights were provided to Licensee, Priscilla Salvador.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Priscilla Salvador, Licensee


summary: Facility Evaluation

raw_content:
Narrative:
On 04/02/ Licensing Program Analyst (LPA) Chad Cabigon conducted an unannounced Annual inspection of this Group Home and met with Administrator Priscilla Salvador. A tour of the interior and exterior areas of the Home's physical plant was done and no Building & Grounds deficiencies were observed. Facility staff were interviewed; client and staff records were reviewed. No citations are being issued as of this time. A subsequent onsite inspection is needed to complete this Annual inspection. A copy of this report is being provided to the facility.

visit_type: Annual

met_with: Priscilla Salvador


summary: Facility Evaluation

raw_content:
Narrative:
On 04/04/ Licensing Program Analyst (LPA) Chad Cabigon continued and completed the Annual Inspection of this Group Home; LPA was met by Administrator Priscilla Salvador with whom the findings were discussed and are as follows: The facility has three client bedrooms each of which furnished with the necessary beddings and personal storage space that sufficiently meet the requirements. The clients' bathroom was found to be in good working condition and provided hot water metered within the acceptable temperature range (105.0 degrees F out of the vanity sink; 106.3 degrees F out of the shower/bathtub fixture). Waste bins had covers and there was no indication of any pest infestations. The facility had on hand at least a week's worth of perishable and dried goods for its current census; no inspected food items were beyond expiration dates. An inspection of the physical plant's backyard was also done: the Home has no bodies of water on premises; no potentially hazardous items or areas were left accessible to clients. Passageways were unobstructed and the facility's building and grounds were found to be in good repair. A review of the facility's records was conducted: four client files and five personnel files were reviewed and found to contain required documentation. Interviews were conducted with three direct-care facility staffers; no interviews with clients were possible due to the population's developmental levels. This Group Home was found to be in substantial compliance with Regulations; no deficiencies are being cited. Exit interview was done, and a copy of this report is being provided to Elk Grove Ranch-Valley Oak.


summary: Facility Evaluation

raw_content:
Narrative:
An annual required inspection was conducted by Licensing Program Analyst (LPA) Tana Kinder on 6/28/2021. Criminal record clearances were reviewed, and the facility is in compliance. Community Care Licensing file, incident reports, facility roster, facility profile and complaint history were reviewed prior to visit to the facility. The licensing fees are current. The Group Home has a capacity of 6 and currently has 4 youth. There are 10 staff members associated to the license and 2 currently working at the Group Home today. LPA Kinder reviewed 5 staff files; all those reviewed were complete and up to date. Staff files reviewed have required training hours, education, and fingerprint clearances. 4 child files were reviewed. C2 needs a copy of their needs and services plan/Individual Program Plan in their file. C1 needs a current physical as the last one occurred over a year ago. Immunization records were current for all youth. Medical consent forms were signed by authorized representatives. Medication Sheets were accurate for each client. Additionally, the children's files had a record of personal property. The facility was inspected jointly with Priscilla Castellanes, Administrator of the Group Home. LPA attempted to interview 4 clients, but due to their diagnoses of intellectual disabilities and Autism, the clients were not able to communicate verbally. There are 5 bedrooms and 3 bathrooms. The facilities are in good repair, but the client bathroom and 1 client bedroom (next to the client bathroom) need to be painted and 1 mattress needs to be replaced as it is concaved in the middle and has 5, finger sized holes all the way through. There is a hall closet with additional linen if needed for the bedrooms and the bathroom. Client and staff files are in locked cabinets. The passageways from the front to the back of the home are unobstructed. LPA observed 2 locked sheds in the backyard with yard supplies and client belongings. LPA observed enough perishable/non-perishable food for 4 clients for 4 days/5 weeks. Smoke detectors are in working order. There is a carbon monoxide monitor and 1 fully charged fire extinguisher. An exit interview conducted and discussed with Priscilla Castellanes, Administrator, deficiencies were cited on an 809D page and a copy of the annual inspection report was emailed to the Group Home.

met_with: Administrator


facility_name: ELKHORN HOUSE

summary: Complaint Investigation - Substantiated - 1 deficiency - 1 allegation

raw_content:
Narrative:
Based on interviews and record review, the preponderance of evidence standard has been met and the Department has determined that S1 pushed C1. Therefore, the allegation is substantiated. The facility is being cited for violating California Code of Regulations, Title 22, Division 6, Chapter 5, Article 6, regulation 84072(c)(15) Personal Rights (see 9099-D page). An exit interview was conducted, and a copy of this report and appeal rights were left with the Administrator Vice President Residential Services Fred J. Lindahl III

Investigation Findings:
13On July 12,2024, at 10:00AM, Licensing Program Analyst (LPA) Carol Anderson met with of Assistant Vice President of Residential Services Fred Lindahl III and Vice President of Residential Services Laurie J. Purcell at Home of Guiding Hands, Incorporation, to deliver finding of the above allegation. On 9/28/23, Licensing Program Analyst (LPA) Lucero Jauregui initiated the complaint allegation and interviewed one staff. Furthermore, LPA Anderson interviewed two of three clients, two of three staff and reviewed Individual Program Plan (IPP), San Diego County Health and Human Services Report, San Diego County Sheriff's Department report as well as Special Incident Report. The Department received a complaint on September 21, 2023, alleging staff pushed child. Confidential interviews revealed that C1 wanted to go to the store, C1 got upset bite and kicked S1. Confidential interviews revealed that S1 admitted C1 came towards S1 and in self-defense S1 pushed C1 away and C1 fell and hit C1's back. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Carol Anderson LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: ELKHORN HOUSEFACILITY NUMBER: 374603372

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

Deficiencies:
84072: Personal Rights. Personal rights include the right to be free from physical, sexual, emotional, or other abuse, and corporal punishment.

report_type: Complaint Investigation

met_with: Fred J.LIndahl III

complaint_status: SUBSTANTIATED

title: (c)(15) Section D


summary: Facility Evaluation

raw_content:
Narrative:
On 11/8/2021 at 10: AM, Licensing Program Analyst (LPA) Gloria Meza-Gonzalez conducted an unannounced inspection of the facility. The purpose of the visit is conducted an annual required inspection. LPA Meza - Gonzalez met with Program Administrator (PA) Tracie Arellano. The facility is licensed for four developmentally delayed ambulatory clients. There are four clients in care. The home is a one-story residence with four bedrooms, two bathrooms, staff office, kitchen, dining room, living room, garage, laundry room, backyard and front yard. Bedroom #1 contains one twin size bed; all required linen, is present and mattresses are in good condition. Bedroom #2 contains one full size bed; all required linen is present and mattresses in good condition. Bedroom #3 contains one full size bed; all required linen is present, and mattresses are in good condition. Bedroom #4 contains one full size bed; all required linen is present, and mattresses are in good condition. The bedrooms are arranged so that no more than one client per room per bed. The facility has two bathrooms. The bathrooms is clean, sanitary and in good repair. The hot water in the client bathroom was measured to be 110 degrees F. The dining room has a dining table with four chairs and a bench. The dining room and kitchen are clean, sanitary and in good repair. LPA Meza-Gonzalez two-day perishable supply of food in the refrigerator. The menu is posted on the refrigerator. The pantry closet is next to the dining. LPA Meza - Gonzalez observed a minimum seven-day non-perishable in the pantry There was a variety of snacks available for clients as well. The sharp knives are locked in a cabinet in the pantry. There is an additional freezer and refrigerator in the garage for additional food. See LIC 809C page Cleansers/chemicals are locked a cabinet in the garage. The garage is set up as a workout room with four stations, punching bag, treadmill, bike and workout trampoline. The clients are able use the workout room under staff supervision. The garage also storage for seasonal decors, emergency disaster supplies, over follow first aid kit and over follow paper items. There is a washer and dryer for clients use with staff supervision. The overall clients' hygiene products are located in a locked cabinet in the laundry area. There is a first a kit and contains all required supplies in the laundry area. The staff office has first aid supplies in the medication cabinet. Clients medications were observed to be inaccessible and stored in a locked in a cabinet behind the staff desk in the staff office. The living room a space for art, a table for puzzles, two couches, a TV and an indoor basketball game. There are a variety of recreational activities such as board games for clients' use. There is an additional closet with additional recreational activity items. The facility outside grounds was also inspected and it was observed to be clean, well maintained. Emergency exits were free from obstruction. The facility has ten smoke detector and two carbon monoxide detector. The fire alarm and carbon monoxide were check and was operable. The following required posted items were observed accessible to clients: Grievance Procedures, Personal Rights, visitation policies, emergency disaster,(LIC 610C) and license is posted. There are no clients or staff were present at time of inspection. Due to time constraints, the annual inspection is being extended for staff files reviews, clients file review, staff and clients interviews. Based on observations made during the inspection, no deficiencies observed during today's visit. An exit interview was conducted, and this report was reviewed with PA Arellano and a copy of this report was provided.

met_with: Tracie Arellano


summary: Facility Evaluation

raw_content:
Narrative:
On 11/17/2021 at 9: AM, Licensing Program Analyst (LPA) Gloria Meza-Gonzalez conducted unannounced inspection to the facility. The purpose of the inspection is to conducted an annual continuation. LPA Meza-Gonzalez met with Program Administrator (PA) Tracie Arellano. The facility services four developmentally disabled ambulatory clients. LPA Meza-Gonzalez reviewed four clients' files (see confidential list, dated: 11/17/2021) and seven staff files. LPA observed the clients' files appeared to be complete and in order. Six out of seven staff files appeared to be completed and in order. LPA Meza-Gonzalez observed that the current Administrator's license expired 11/16/2019. Based on observations made during the inspection, the Facility is being cited for violation Title 22, Division 6, 80066(a)(12)(B)(1) Personnel Records which poses a potential Health, Safety or Personal Rights risk to children in care. Please see attached LIC809-D. Exit interview conducted and appeal rights discussed with PA Arellano. A copy of this report and LIC811 was left with was given to PA Arellano


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA), Val Wilson, on June 2, 2022 at 1:00PM. During the inspection, LPA Wilson met with Tracie Arellano, Administrator, and inspected the facility inside and out. The medications are kept in the office double locked and the door locks automatically. There is a keypad safe for the narcotic medications that is also kept in the locked staff office. LPA reviewed two of two child's records on site at the facility at 1:15PM. LPA reviewed two of two staff personnel files on site at the facility at 3:30PM. LPA reviewed two of two child's psychotropic medications and medication records at 2:00PM. LPA interviewed two of two staff on site at 2:30PM. LPA interviewed two of two children currently taking psychotropic medication at 3:00PM. LPA provided the Summary Report to Tracie Arellano, Administrator, upon completion. No deficiencies are being cited at this time. LPA conducted exit interview with Tracie Arellano, Administrator, at 4:30PM.

met_with: Tracie Arellano, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On October 26, 2022 at 9: AM, Licensing Program Analyst (LPA) Gloria Meza-Gonzalez conducted an unannounced inspection of the facility. The purpose of the visit is conducted an annual required inspection. LPA Meza - Gonzalez met with Program Administrator (PA) Tracie Arellano. The facility is licensed for four developmentally delayed ambulatory clients. There were two clients present at the time of inspection. The home is a one-story residence with four bedrooms, two bathrooms, staff office, kitchen, dining room, living room, garage, laundry room, backyard and front yard. Bedroom #1 contains one twin size bed; all required linen, is present and mattresses are in good condition. Bedroom #2 contains one full size bed; all required linen is present and mattresses in good condition. Bedroom #3 contains one full size bed; all required linen is present, and mattresses are in good condition. Bedroom #4 contains one full size bed; all required linen is present, and mattresses are in good condition. The bedrooms are arranged so that no more than one client per room per bed. The facility has two bathrooms. The bathrooms is clean, sanitary and in good repair. The hot water in the client bathroom was measured to be 111 degrees F which is within Community Care Licensing Regulation. The dining room has a dining table with four chairs and a bench. The dining room and kitchen are clean, sanitary and in good repair. LPA Meza-Gonzalez two-day perishable supply of food in the refrigerator. The menu is posted on the refrigerator. The pantry closet is next to the dining. LPA Meza - Gonzalez observed a minimum seven-day non-perishable in the pantry There was a variety of snacks available for clients as well. The sharp knives are locked in a cabinet in the pantry. There is an additional freezer and refrigerator in the garage for additional food. See LIC809c page Cleansers/chemicals are locked a cabinet in the garage. The garage is set up as a workout room with four stations, punching bag, treadmill, bike and workout trampoline. The clients are able use the workout room under staff supervision. The garage also storage for seasonal decors, emergency disaster supplies, over follow first aid kit and over follow paper items. There is a washer and dryer for clients use with staff supervision. The overall clients' hygiene products are located in a locked cabinet in the laundry area. There is a first a kit and contains all required supplies in the laundry area. The staff office has first aid supplies in the medication cabinet. Clients medications were observed to be inaccessible and stored in a locked in a cabinet behind the staff desk in the staff office. The living room a space for art, a table for puzzles, two couches, a TV and an indoor basketball game. There are a variety of recreational activities such as board games for clients' use. There is an additional closet with additional recreational activity items. The facility outside grounds was also inspected and it was observed to be clean, well maintained. Emergency exits were free from obstruction. The facility has ten smoke detector and two carbon monoxide detector. The fire alarm and carbon monoxide were check and was operable. The last emergency disaster drill was held on October 20, 2022. LPA Meza-Gonzalez reviewed four clients' files (see confidential list, dated: October 26,2022) and seven staff files. LPA observed the staff and clients' files appeared to be complete and in order. LPA Meza-Gonzalez conducted on staff interview. LPA Meza-Gonzalez observed that the current Administrator's license expired November 16, 2023. The following required posted items were observed accessible to clients: Grievance Procedures, Personal Rights, visitation policies, emergency disaster,(LIC 610C) and license is posted. There are no clients or staff were present at time of inspection. Based on observations made during the inspection, no deficiencies observed during today's visit. An exit interview was conducted, and this report was reviewed with PA Arellano and a copy of this report was email due to printer difficulties.


summary: Facility Evaluation

raw_content:
Narrative:
On December 19, 2023, at 10:30AM, Licensing Program Analyst (LPA) Carol Anderson conducted an unannounced inspection of the facility. The purpose of the visit is conducted an annual required inspection. LPA met with Facility Group Home Administrator Tracie Arellano. The facility is licensed for four developmentally delayed ambulatory clients. There are currently three clients residing at this facility, no clients were available to be interviewed. LPA will return to interview clients. LPA interviewed two staff. The home is a one story residence with four bedrooms, two bathrooms, staff office, kitchen, dining room, living room, garage, laundry room, backyard, and front yard. Bedroom #1 contains one twin size bed; all required linen, is present and mattresses are in good condition. Bedroom #2 contains one full size bed; all required linen is present and mattresses in good condition. Bedroom #3 contains one full size bed; all required linen is present, and mattresses are in good condition. Bedroom #4 contains one full size bed; all required linen is present, and mattresses are in good condition. The bedrooms are arranged so that no more than one client per room per bed. The facility has two bathrooms. The bathrooms are clean, sanitary and in good repair. The dining room has a dining table with four chairs and a bench. The dining room and kitchen are clean, sanitary and in good repair. LPA two day perishable supply of food in the refrigerator. The menu is posted on the refrigerator. The pantry closet is next to the dining. LPA observed a minimum seven day non-perishable in the pantry. There was a variety of snacks available for clients as well. The sharp knives are locked in a cabinet in the pantry. There is an additional freezer and refrigerator in the garage for additional food. Cleansers/chemicals are locked a cabinet in the garage. The garage is set up as a workout room with four stations, punching bag, treadmill, bike, and workout trampoline. The clients are able use the workout room under staff supervision. The garage also storage for seasonal decors, emergency disaster supplies, over follow first aid kit and over follow paper items. There is a washer and dryer for clients use with staff supervision. The overall clients' hygiene products are in a locked cabinet in the laundry area. There is a first a kit and contains all required supplies in the laundry area. The staff office has first aid supplies in the medication cabinet. Clients' medications were observed to be inaccessible and stored in a locked in a cabinet behind the staff desk in the staff office. The living room a space for art, a table for puzzles, two couches, a TV, and an indoor basketball game. There are a variety of recreational activities such as board games for clients' use. There is an additional closet with additional recreational activity items. The facility outside grounds was also inspected and it was observed to be clean, well maintained. Emergency exits were free from obstruction. The facility has ten smoke detector and two carbon monoxide detectors. The fire alarm and carbon monoxide were check and was operable. Hot water temperature reading at 107 degrees. LPA Anderson reviewed three clients' files and five staff files, and they had the necessary forms. The following required posted items were observed accessible to clients: Grievance Procedures, Personal Rights, visitation policies, emergency disaster, (LIC 610C) and license is posted. A review of Guardian on December 19, 2023, indicated that all facility staff associated to the facility had DOJ, FBI, and child abuse index check clearances. Based on observations made during the inspection, no deficiencies observed during today's visit. An exit interview was conducted, a copy of this report was given to Facility Group Home Administrator Tracie Arellano.


summary: Facility Evaluation

raw_content:
Narrative:
On November 13, 2025, Licensing Program Analyst (LPA) Cynthia Velasquez, began an annual inspection of the facility. The facility was toured inside with Renee Robinson, House Manager. The home is a one-story residence with 4 bedrooms, and 2 full bathrooms for staff, and clients. There are two clients placed currently. Facility was maintained and there were no blockages to walkways or entryways. The walkway from the parking location to the front door was clean and in good repair. The facility has concrete outside, including the driveway. It is situated on a street with other homes surrounding it which have higher elevations surrounding the backyard. The entrance to the facility has a current Fire Inspection Clearance certificate, Licensing Certification, Grievance Procedures, Client Rights, Emergency Disaster Plan, Child Abuse Reporting flyer, and Ombudsman poster. The kitchen area had fresh fruit options, perishable items in refrigerator and frozen items available for meals and snacks. The dining room is adjacent to the kitchen with seating for 4. The TV room is connected to kitchen area, and has two love seats, two chairs and TV with gaming console and controllers. There is a stand-up basketball hoop indoors. In the living room, there is a fireplace that has been filled with materials which allow no access. There are two locked cabinets that contain staff files and client files. Due to time constraints, this inspection will be continued at a later time. An exit interview was conducted and a copy of this report was given to Tracie Arellano, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On December 2, 2025, Licensing Program Analyst (LPA) Cynthia Velasquez, continued an annual inspection of the facility which was initiated on November 13, 2025. The facility was previously toured inside with Renee Robinson, House Manager. The home is a one-story residence with 4 bedrooms, and 2 full bathrooms for staff, and clients. There are two clients placed currently. Due to time constraints, this annual inspection is being resumed today. Staff files and client files were reviewed. All staff that work at the facility have Department of Justice and Child Abuse Clearance Index clearances, CPR/First aid and training hours in addition to education, identification, job description information, and child abuse reporting requirement forms. All client files contained Individual Service Plan (ISP) information, Individual Placement Program (IPP) information and/or addendums, placement and admission agreements, personal rights, and prescription information. The hot water in the kitchen was deemed to be at the safe temperature of 107 degrees Fahrenheit. Per facility staff, there are no firearms or weapons in the facility. Chemicals are locked the hallway closet housed in the garage. First Aid Kits are also stored in various locations within the facility. All First Aid Kits have required bandages, thermometers, tweezers, and manuals. Medications were stored in a locked box in the office area. Based on the facility inspection and file reviews this date, there are no deficiencies found at this time. Interviews were conducted with available staff, and client interviews will be conducted via telephone within 1 day. An exit interview was conducted with Tracie Arellano, Administrator and copies of report were reviewed and issued.


facility_name: ELLA'S HOME, INC

summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Investigation Findings:
13On 2/24/2023 at 10: AM, Licensing Program Analyst (LPA) Alyssa Ng conducted a complaint inspection at Ella's Home and spoke with Dioneil Noriega, Facility Manager. The purpose of the inspection was to deliver the findings for the above complaint allegation. During investigation, LPA Ng did a search of the active/pending Administrator certification list, and it was determined that the listed Administrator on file did not have an active certificate. Based on record review(s), the preponderance of evidence standard has been met, therefore the above allegation, Facility does not have a certified Administrator on the premises is found to be SUBSTANTIATED. Facility is being cited for violation of California Code of Regulations (CCR), Title 22, Division 6 & Chapter 1: 80066(a)(12)(B)(1) Personnel Records. Please refer to attached 9099D. At this time, one deficiency was given. An exit interview was conducted, appeal rights provided and discussed, and a copy of this report was given to Dioneil Noriega, Facility Manager. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Alyssa Ng LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, TRAEGER AVE., SUITE FACILITY NAME: ELLA'S HOME, INCFACILITY NUMBER: 075650134

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

met_with: Dioneil Noriega


summary: Facility Evaluation

raw_content:
Narrative:
On Wednesday 9/1/21 at 10AM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility for a required annual inspection. LPA met with Facility Manager Dioneil Noriega and informed of the purpose of the visit. Safety precautions were taken, including screening call and mask-wearing. LPA used the Inspection Tool to conduct the inspection. There are five children in care, and four children were at school. There are three staff. LPA toured the facility site and observed: -- The facility site and grounds are clean, free of debris and hazards, and is well-maintained. -- Food is properly stored, is fresh and within date, and meets the 7-day nonperishable, 2-day perishable mandate to meet the needs of residents in care. The kitchen is stocked with utensils and dishware. -- Medications, sharps, and chemicals are all locked and inaccessible to residents in care. -- The smoke detectors were tested and are functioning. -- The first aid kit is missing tweezers and scissors. LPA advises, per California Code of Regulations (CCR), Title 22, Section 80075, that the facility ensure the first aid kit is stocked with all required items. LPA inspected the facility files and observed: -- The client files are complete and contain all required documentation. Medication records are complete and indicate consistent and proper administration of medications. LPA advises, per CCR, Title 22, Section 84070, that the facility begin logging all psychotropic medications on a separate log, using the LIC 622B Psychotropic Medication Administration Record (PMAR) or variation of this form. -- The staff files are complete and contain all required documentation. All staff are cleared and associated to the facility. LPA advises, per CCR, Title 22, Section 84065, that the facility update the training records, as it does not currently reflect that the 20 hour annual requirement was met. The records do reflect that 13 hours have been completed for 2021 so far, and LPA advises that the facility ensure they meet the 20 hours by the end of the year. LPA conducted resident observation and staff interviews: -- Resident present during visit appeared happy and comfortable and was being engaged by attentive staff. -- Staff are knowledgeable about the needs of residents in care and program procedures. An exit interview was conducted, and a copy of this report was left with Facility Manager Dioneil Noriega, whose signature on this form confirms receipt.

met_with: Facility Manager Dioneil Noriega


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 9/2/22 at 11: AM, Licensing Program Analyst (LPA) Alyssa Ng made an unannounced annual/required inspection to listed facility. The facility is licensed for six residents, and currently in placement are 5 clients. During this inspection, 2 clients and 1 staff were present in the home. The staff present was a direct care staff. At 12: PM, another direct care staff and client arrived at the facility. There were no facility manager or Administrator present. Safety precautions were taken, including screening call, hand hygiene, and mask-wearing. Two clients are non-verbal and one client is was verbal at the time of the inspection. LPA Ng observed the clients and staff interacting during play time. Staff were responsive to the clients needs and able to provide care and supervision to the clients in care. Clients were smiling and clapping when staff played to music. LPA conducted one client interview and two staff interviews. LPA Ng toured the facility inside and out. The home is single storied, and has two double occupancy bedroom and 1 single occupancy bedroom. There are two staff bedrooms. All client bedrooms were equipped with comfortable furnishings which included ample storage space for clients' belongings, desks and chairs, and twin sized beds. Each bedroom has a closet with sliding doors for extra storage space. Client bathroom was clean and furnished with hygiene supplies for each client. The water temperature measured 115 degrees F. The thermostat measured 71 degrees. The facility is clean, safe and sanitary. The kitchen was observed to be clean and free of hazards or chemicals. Sharps were located in a locked cabinet. The weekly menu was in the kitchen. LPA observed at least 2 days of perishable foods and 7 days of nonperishable foods. The smoke detectors are in working order. No bodies of water on the premises. All walkways were free from debris or hazards. -----------Cont. ON 809C----- At 11: AM LPA toured the backyard and observed it to be free from hazards. There is a basketball hoop and a sitting area in the backyard. The backyard is surrounded by a wooden fence with locked gates. The facility has a centralized AC unit in the side yard All client records complete with all of the required documentation. Each client has their own separate binder of all required documents. Each psychotropic medication was observed to have its own Psychotropic Medication Administration Record (PMAR), as well as individual Centrally Stored Medication Destruction Records (CSMDR). All medications were consistent with these records. Facility is in compliance, with only the following exceptions: Due to Facility Manager and Administrator not being present at the time of the inspection, staff files were not reviewed. Facility cited for California Code of Regulations 80044(a) Inspection Authority of the Licensing Agency. Please see 809D. LPA Ng will come back at a later time to review staff files/training. There was no Facility Manager and Administrator present. Facility cited for California Code of Regulation 84065(a) Personnel Requirements. Please see attached 809D. After reviewing client files, records reveal that all clients are over the age of 18. Clients ages are 23, 22, 22, 21, and 20. Facility had one age exception for a client until the age of 22. That clients' current age is 23. During the last annual dated 9/1/2021, it was discussed that the clients who were turning over 18, were going to be moved to an Adult Residential Facility. However since that visit, no application was submitted and clients are still in care. Facility cited per CCR regulation, 80010(a), Limitations on Capacity and Ambulatory Status. Please see 809D. At this time, three deficiencies were cited today. Appeal Rights were provided, an exit interview was conducted, and a copy of this report was left at listed facility.

Deficiencies:
84065(d): 84065	Personnel Requirements	 (d)The licensee shall designate at least one facility manager to be present at the facility at all times when children are present

met_with: Rosalinda Santa Maria


summary: Facility Evaluation

raw_content:
Narrative:
On 2/24/2023 at 10: AM, Licensing Program Analyst (LPA) Alyssa Ng conducted a cas management inspection at Ella's Home and spoke with Dioneil Noriega, Facility Manager. The purpose of the inspection was to discuss the conversion to Adult Residential Facility (ARF). On 9/2/2022, LPA Ng went to listed facility to conduct an Annual Inspection. During the file review, it was revealed that clients residing in the home are over the age of 18. LPA Ng cited per CCR regulation, 80010(a), Limitations on Capacity and Ambulatory Status. LPA wrote age exceptions for two clients. Currently, there are 5 clients in the home. They are ages 22, 20, 22, 24, and 22. Facility Manager Dioneil stated that their Program Design is done. The Application for the Adult Residential Facility is almost completed. The listed facility already has an ARF so they have been in contact with their LPA at Adult and Senior in the Oakland Office. Regional Center is aware of their application. Their estimated time for completion/submission is a month. LPA will contact Facility Manager Dioneil monthly for updates. At this time, no citations were given. An exit interview was conducted and copy of this report was left with Dioneil Noriega, Facility Manager.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 07/19/23 at 10: AM, Licensing Program Analyst (LPA) Alyssa Ng made an unannounced annual/required inspection to listed facility. The facility is licensed for six residents, and currently in placement are 5 clients. During this inspection, 3 clients and 3 staff were present in the home. Safety precautions were taken, including screening call, hand hygiene, and mask-wearing. Three clients are non-verbal and one client is was verbal at the time of the inspection. LPA Ng observed the clients and staff interacting during play time. Staff were responsive to the clients needs and able to provide care and supervision to the clients in care. Clients were smiling and clapping when staff played to music. LPA conducted 3 client interview and 2 staff interviews. At 11: AM, LPA Ng toured the facility inside and out. The home is single storied, and has two double occupancy bedroom and 1 single occupancy bedroom. There are two staff bedrooms. All client bedrooms were equipped with comfortable furnishings which included ample storage space for clients' belongings, desks and chairs, and twin sized beds. Each bedroom has a closet with sliding doors for extra storage space. Client bathroom was clean and furnished with hygiene supplies for each client. The water temperature measured 115 degrees F. The thermostat measured 68.5 degrees. The facility is clean, safe and sanitary. The kitchen was observed to be clean and free of hazards or chemicals. Sharps and chemicals were located in the garage in a locked cabinet. The weekly menu was in the kitchen. LPA observed at least 2 days of perishable foods and 7 days of nonperishable foods. The smoke detectors are in working order. No bodies of water on the premises. All walkways were free from debris or hazards. At 11: AM LPA toured the backyard and observed it to be free from hazards. There is a basketball hoop and a sitting area in the backyard. The backyard is surrounded by a wooden fence with locked gates. The facility has a centralized AC unit in the side yard along with two storage sheds. All staff and client records complete with all of the required documentation. Each staff and client has their own separate binder of all required documents. Each psychotropic medication was observed to have its own Psychotropic Medication Administration Record (PMAR), as well as individual Centrally Stored Medication Destruction Records (CSMDR). All medications were consistent with these records. -------------cont. on 809C------------------------- Resident and staff records were observed to be complete and the facility in compliance, with only the following exceptions: During inspection, LPA requested a updated copy of the LIC Personnel Report to maintain their file current. A review of the facility's Guardian roster on July 19th, 2023 indicates that all but one staff to the facility had DOJ, FBI and child abuse index check clearances. Facility is being cited 80019(e) Criminal Background Clearance. During a review of the staff files, the listed Administrator did not have a current/active Group Home Administrator certificate. The Administrator has a current Adult Residential Facility certificate. LPA Ng stated that the Administrator would still need a Group Home Administrator certificate since the facility is still under a Children's Residential license. Complaint procedures were not posted in the facility and was not accessible for staff and clients and their authorized representatives. LPA advises per CCR regulation, 84072.2(a)(3), complaint procedures must be posted in the facility within clear view of clients and their authorized representatives. At this time, 3 deficiencies were cited. An exit interview was conducted, and a copy of this report was given to Facility Manager, Rosalinda Maria, whose signature on this form confirms receipt.

Deficiencies:
80019(e): Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility

met_with: Rosalinda Maria


summary: Facility Evaluation

raw_content:
Narrative:
On 09/11/2024 at 11:00 a.m., Licensing Program Analyst (LPA) Brenda Rodriguez and Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced Annual Inspection and met with Dioneil Noriega, Administrator. LPA Rodriguez disclosed the purpose of the inspection and was granted entry into the facility. LPA Rodriguez and LPA Medina used the CARE Inspection Tool. There were three (3) staff members, and four (4) clients were present at the time of inspection. One client present was verbal, and the rest of the clients present were non-verbal. The facility currently has a census of five clients. All clients are non-minor dependents ages twenty-one and up. LPA Rodriguez and LPA Medina reviewed four (4) staff files and five (5) client files. LPA Rodriguez and LPA Medina also reviewed the personnel binder and the emergency disaster plan. LPA Medina conducted two confidential staff interviews and one confidential client interview. During the physical plant inspection, no deficiencies were found. The facility was clean, sanitary, free of obstructions, and an adequate amount of food for all clients in care was present. Client bedrooms were clean and had space for belongings and client necessities. LPA Rodriguez and LPA Medina observed the locked cabinet where all facility files and medication is stored and kept. Administrator informed LPA's that the Group Home is currently in the process of turning into an Adult Residential Facility. The required Annual Inspection is complete. No deficiencies were cited. An exit interview was conducted at 3:20 p.m., and a copy of this report was emailed to Administrator Dioneil Noriega, whose signature on this form confirms receipt.

met_with: Dioneil Noriega, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 08/05/2025 at 10:00 a.m., Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced annual inspection and met with Dioneil Noriega, Administrator. LPA Medina disclosed the purpose of the inspection and was granted entry into the facility. The CARE Inspection Tool was used to guide the inspection. At the time of the visit, there were three staff members and two clients present. One of the clients is verbal and the others are non-verbal. Administrator Noriega stated that the Group Home is currently in the process of converting to an Adult Residential Facility. Due to personal family matters, there have been delays in submitting the required documentation for the conversion process. At approximately 10:30 a.m., LPA Medina reviewed five client files under the client records section of the CARE tool. All clients were confirmed to be non-minors. Clients are enrolled in day programs and regularly participate in weekend outings. An area of improvement was noted in this section: several clients' Needs and Services Plans were overdue for updates. Per regulation, Needs and Services Plans must be reviewed and updated at least every six months. Please refer to LIC9102 for more information. At 12:00 p.m., LPA Medina reviewed four staff files belonging to staff who actively work in the day-to-day operation of the facility. Each file contained current CPR certifications, health screenings, criminal record statements, personnel records, and documentation of completed training. No deficiencies were observed in the staff records section. Continues on LIC809-C At 1:15 p.m., LPA Medina began the physical plant inspection. The facility was observed to be clean, sanitary, and free of hazards or obstructions. Client bedrooms were well-maintained, with appropriate furnishings, clean linens, and adequate storage space. Medications and facility records were stored in a locked cabinet. All bedrooms are double-occupancy. Food observed on-site was of good quality, properly stored, within expiration dates, and sufficient to meet regulatory requirements. The water temperature measured 108°F, and the thermostat reading was 69°F-both within regulatory limits. No deficiencies were observed in the physical plant section. At 2:00 p.m., LPA Medina reviewed the operational requirements section of the CARE tool. Upon review of the facility's license, it was determined that the home is operating outside the conditions authorized by its license. The facility is licensed to serve clients ages 6 to 17; however, all current clients are over the age of 18. Please refer to LIC809-D for details regarding this deficiency. At 2:15 p.m., LPA Medina reviewed the disaster preparedness section. The most recent emergency drill was conducted on July 21, 2024. As required by regulation, emergency drills must be conducted quarterly. However, the facility maintains an up-to-date client roster, medication log, and current Needs and Services Plans for all clients to ensure preparedness in the event of an emergency. Please refer to LIC809-D for additional information on the deficiency. At 2:30 p.m., LPA Medina reviewed the emergency intervention plan. The Administrator reported that staff are trained in Pro-Act, and the home operates as a hands-off facility. No restraints are used. No deficiencies were observed in this section. During the inspection, LPA Medina conducted two confidential staff interviews and one confidential client interview. The required annual inspection has been completed. Two deficiencies were cited during today's visit: one under California Code of Regulations, Title 22, Section 80010(a), and one under Health and Safety Code, Section 1565(c). An exit interview was conducted with Administrator Dioneil Noriega at 3:30 p.m. During the meeting, the findings, including appeal rights, were reviewed and a copy of the report was provided via email. Administrator's signature on this form acknowledges receipt of the report and understanding of the information discussed.


summary: Facility Evaluation

raw_content:
Narrative:
On 08/20/2025 at 12:30p.m., Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced inspection at the facility and met with Dioneil Noriega, Administrator, to follow up on outstanding Plans of Correction (POCs). LPA Medina disclosed the purpose of the visit and was granted entry. At the time of the inspection, there were two staff members and three clients present. On 08/05/2025, LPA Medina conducted the facility's annual inspection. As a result of that inspection, the facility was cited for two deficiencies: California Code of Regulations, Title 22, Section 80010(a) - Operating beyond the limitations of the license. Health and Safety Code, Section 1565(c) - Failure to conduct required emergency drills. During today's visit, LPA Medina reviewed the POCs with the Administrator. It was determined that both deficiencies were not corrected by the agreed due date. Consequently, the facility was assessed two civil penalties totaling $200 for failure to correct, and will continue to accrue $100 per day until the deficiencies are cleared. Additionally LPA conducted a quick walk through of the home and observed the home was clean and in good repair. An exit interview was conducted, and the report along with appeal rights was reviewed with and provided to Dioneil Noriega, Administrator.

met_with: Dioneil Noriega - Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 09/16/2025 at 1:15 p.m., Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced inspection at the facility and met with Gray Cabuco, Lead Caregiver and spoke to Dioneil Noriega, Administrator over the phone to follow up on outstanding Plans of Correction (POCs). LPA Medina disclosed the purpose of the visit and was granted entry. At the time of the inspection, there were two staff members and two clients present. On 08/05/2025, LPA Medina conducted the facility's annual inspection. As a result, the facility was cited for the following deficiencies: California Code of Regulations, Title 22, Section 80010(a) - Operating beyond the limitations of the license. Health and Safety Code, Section 1565(c) - Failure to conduct required emergency drills. During today's visit, LPA Medina reviewed the POCs with Lead Caregiver and Administrator. Both POCs were due on August 19, 2025. Proof of completed emergency drills was submitted to LPA on August 21, 2025; however, documentation for the conversion to an Adult Home has not yet been submitted to Licensing. LPA checked in with the Administrator regarding the status of the conversion process and provided an update on accrued civil penalties. For violation of Section 80010(a) - Operating beyond the limitations of the license, the civil penalty has accrued to $2,800. The penalty was initially assessed on 08/20/2025 at a rate of $100 per day and will continue to accrue until the required documentation is submitted. An exit interview was conducted. The report, along with appeal rights, was reviewed with and provided to Gray Cabuco, Lead Caregiver and discussed with Administrator over the phone. LPA also attempted to contact Licensee Estrella Noriega by phone but was unable to reach her.

met_with: Gray Cabuco - Lead Caregiver


summary: Facility Evaluation

raw_content:
Narrative:
On 10/15/2025 at 10:20 a.m., Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced visit to the facility and met with Gray Cabuco, Lead Caregiver. LPA also spoke with Administrator Dioneil Noriega via telephone to follow up on previously issued Plans of Correction (POCs). LPA disclosed the purpose of the visit, which was to verify compliance and clear last cited deficiency, and was granted entry. At the time of the visit, two staff members and two clients were present. Other clients were attending their respective day programs. On 08/05/2025, LPA Medina conducted the facility's annual inspection. As a result, the facility was cited for the following deficiencies: California Code of Regulations, Title 22, Section 80010(a) - Operating beyond the limitations of the license. Health and Safety Code, Section 1565(c) - Failure to conduct required emergency drills. During today's visit, LPA reviewed the POCs with the Lead Caregiver and Administrator. Both POCs were due on August 19, 2025. Proof of completed emergency drills was submitted to LPA on August 21, 2025. Proof of submission of the facility's application to convert to an adult home was received by LPA on September 25, 2025; therefore, the POC for Section 80010(a) has been cleared. As a result of the violation of Section 80010(a) - Operating beyond the limitations of the license, a civil penalty in the amount of $3,700 has accrued. The penalty was initially assessed on August 20, 2025, at a rate of $100 per day and concluded on September 25, 2025. An exit interview was conducted. The report, along with appeal rights, was reviewed with and provided to Gray Cabuco, Lead Caregiver, and discussed with Administrator Dioneil Noriega via telephone.


summary: Facility Evaluation

raw_content:
Narrative:
On February 3, 2026, at 11:00 a.m., Licensing Program Manager (LPM) Joel Segura and Licensing Program Analyst (LPA) Jonathan Medina conducted an in-person informal meeting with the facility regarding the conversion process. In attendance were the facility Administrator, Dioneil Noriega; Adult and Senior Care Analyst, Celia Phomphachanh; and Regional Center of the East Bay (RCEB) Case Worker, Ashanta Royal. The Department has been aware of the facility's urgent need to complete the conversion process; however, the home has not yet converted. On February 24, 2023, a case management inspection was conducted with the facility regarding conversion to an Adult Residential Facility (ARF). At that time, the Department was provided with a one-month timeframe for the conversion to be completed; however, the conversion did not occur. On July 12, 2023, LPA Alyssa Ng contacted the facility and was informed that financial matters would be completed within the following week. On November 9, 2023, there was a change in LPAs assigned to the facility. On September 11, 2024, the Department conducted the facility's annual inspection. During the visit, LPAs Brenda Rodriguez and Jonathan Medina reviewed facility files and confirmed that all clients were age 21 and older. LPA Brenda Rodriguez contacted the facility and was informed that the facility would be ready for conversion no later than December 2024. On May 6, 2025, LPA Rodriguez contacted the facility again regarding the status of the conversion process. The facility stated that the process was delayed due to the administrator's mother traveling to the Philippines because of a family emergency. Continues on LIC809-C On August 5, 2025, LPA Medina conducted the facility's following annual inspection. The facility was cited in accordance with California Code of Regulations(CCR), Title 22, Division 6, Chapter 1, Section 80010(a), Operating Beyond the Limitations of the License. The Plan of Correction (POC) required the facility to apply for an Adult Residential Facility (ARF) license, with a due date of August 19, 2025. Proof of submission of the ARF application was not received by August 19, 2025. A Proof of Correction inspection was conducted on August 20, 2025, at which time LPA Medina confirmed the facility had not submitted an application for conversion to an ARF; therefore, civil penalties of $100 per day were initiated for failure to correct. On September 16, 2025, LPA Medina conducted a follow-up POC inspection and informed the facility that $2,800 in civil penalties had accrued. Proof of submission of the facility's application to convert to an Adult Residential Facility was not received until September 25, 2025. As a result of the failure to correct, civil penalties totaling $3,700 accrued, assessed at $100 per day from August 20, 2025, through September 25, 2025. Upon review of the initial application submission, several required sections were missing. On January 30, 2026 the department was notified that the facility was put on sanction by RCEB. Furthermore, no Administrator Certificate for ARF was located. During this meeting, a plan for compliance was discussed: · Facility turned in missing application documents to department. · Administrator, Dioneil Noriega will continue working toward obtaining an Administrator Certificate for ARF. · Updates of Administrator Certificate recertification unit receipts will be sent to LPA.


facility_name: EMBARK AT SAN MARTIN

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility to inform them that a new complaint had been filed with Licensing and that LPA Simien was opening an investigation for the above listed allegations. LPA discussed this with Dawn Halliburton-Rudy, Administrator (ADM) at 10: AM on 7/1/22. Based on confidential interviews conducted on 7/1/22. There was evidence of above allegations occurring. The complaint allegations, facility did not provide supervision resulting inappropriate interaction between clients, is valid because the preponderance of the evidence standard has been met, therefore the allegation is substantiated. As a result of this visit, there is one title Regulation and General Licensing Standards Responsibility for Providing Care and Supervision (a) violation observed. The facility will be cited (see LIC 9099-D for details). Appeal rights were discussed and provided. Exit interview was conducted and a copy of this report was provided to Jael Debora, Residential Dirctor whose signature on this form confirm receipt of these documents SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien 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 26-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, N. First Street, Ste. FACILITY NAME: EMBARK AT SAN MARTINFACILITY NUMBER: 435390032

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

met_with: Dawn Halliburton-Rudy, Administrator


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility to inform them of the findings for the above listed allegation. LPA met with Daniel Padron Garcia, Site superviser (SS) at 1: PM on 6/7/23. LPA conducted confidential interviews and reviewed documents during this investigation. During interviews with individuals invovled it was determined that the facility at times was operating out of ratio due to a staff shortage. There were times where there was only one staff member watching six clients. This lead to some of the individuals' needs not being met.Things individuals could do were limited due to not having enough staff to provide supervision for everyone. Based on interviews and documents review, the preponderance of evidence standard has been met, therefore the above listed allegations are found to be SUBSTANTIATED. As a result of this visit, there is one General Licensing Standards Personnel Requirements violation (80065(a)) an one General Licensing Standards Plan of Operation (80022(k)).The facility will be cited. Appeal rights were discussed and provided to ED. Exit interview was conducted and a copy of this report was provided to Daniel Padron Garcia, SS whose signature on this form confirm receipt of these documents (POC will be made on a different day due to Admin being ill). SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien 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 26-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, N. First Street, Ste. FACILITY NAME: EMBARK AT SAN MARTINFACILITY NUMBER: 435390032

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

Deficiencies:
80065: Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

title: Personnel Requirements (a)


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with Maira Sanchez, Residential Program Director (RPD), at 1: PM on 11/29/23. Based on confidential interviews conducted it was determined that the allegations listed above are Unsubstantiated. Witnesses interviewed stated the facility conducted AWOL protocols within regulations. The facility had an Administrator in place at the start of this investigation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was emailed to Maira Sanchez, RPD. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien 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 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN JOSE RO, N. First Street, Ste. This is an official report of an unannounced visit/investigation of a complaint received in our office on 04/04/2023 and conducted by Evaluator Paul Simien PUBLICCOMPLAINT CONTROL NUMBER: 26-CR- FACILITY NAME:EMBARK AT SAN MARTINFACILITY NUMBER: ADMINISTRATOR:DAWN HALIBURTON-RUDYFACILITY TYPE: ADDRESS: EAST MIDDLE AVENUETELEPHONE: (408) 838- CITY:SAN MARTINSTATE: CAZIP CODE: CAPACITY:6CENSUS: 3DATE: 11/29/ UNANNOUNCEDTIME BEGAN: 01: PM MET WITH:Maira Sanchez, Residential Program DirectorTIME COMPLETED:03: PM 9Staff did not notify minors parent that minor wasn't eating Minor loss an excessive amount of weight INVESTIGATION FINDINGS: 13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with Maira Sanchez, Residential Program Director, at 1: PM on 11/29/23. Based on confidential interviews conducted and documents reviewed it was determined that the allegations listed above are Substantiated. The facility was aware of minor restricting food intake and skipping weigh-ins and failed to inform minor's parent. This was despite the minor's parent expressing concerns with minor's poor eating habits and issues with having eating disorders at previous treatment facilities at the time of admission. Documents provided showed that minor had a huge fluctuation of weight between 3/2/23 and 3/27/23. From 3/9 to 3/27 the minor lost aproximitly12 pounds. The preponderance of evidence standard has been met, therefore the above allegations, are found to be SUBSTANTIATED. As a result of this visit, there is one Interim Licensing Standards Personal Rights violation (84072(d)(3)) and one General Licensing Requirement violation Responsibility for Providing Care and Supervision (80078(a)). The facility will be cited (see 809-D for details). Appeal rights were discussed and provided. Exit interview was conducted and a copy of this report was emailed to RPD. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien 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: 2 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN JOSE RO, N. First Street, Ste. FACILITY NAME: EMBARK AT SAN MARTINFACILITY NUMBER: 435390032

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

complaint_status: unsubstantiated


summary: Complaint Investigation - Substantiated - 3 allegations

raw_content:
Narrative:
Based on a review of facility training records, staff did not receive training in the required training topics as outlined in the regulations and were not trained to handle or in preparations for situations in the facility. Therefore, these allegations are Substantiated. Facility cited for violations of the California Code of Regulations, Title 22, Division Six, Section 80022(k) Plan of Operation, 80022(k) Plan of Operation, 84065(i) Personnel Requirements, and an advisory is being issued for section 80087(a) Buildings and Grounds as described on the following page LIC 9099D. An exit interview was conducted a copy of this report along with appeal rights was left with Alyssa Avila.

Investigation Findings:
13On 3/19/2024 at 9: AM, Licensing Program Analyst (LPA) Shikya Belfield and LPA Mona Lam, conducted an unannounced inspection to the above facility. The purpose of this visit was to inform the facility representative of the findings for the allegations above. LPA met with Alyssa Avila who assisted with the inspection. Based on confidential interviews conducted and supportive documentation to include but not limit repair receipts. The facility grounds has a septic tank that became backed up and the plumbing in the facility was not able to be used. Clients needed to use the restrooms in the main office next door. Facility also has a broken dryer and the dryer used to dry clients clothing is in the office next door. Facility maintenance person responded and the septic tank was worked on for at least two days. Technical advisory issued. Based on confidential interviews and a review of supportive documentation to include but not limit staff schedule and program plan of operation, the facility was operating outside of the required operating ratio according to plan of operation. Based on confidential interviews administrator and supervisors did not respond to crisis situations when called on for support as outlined in the plan of operation emergency intervention plan. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Shikya Belfield 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 26-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, N. First Street, Ste. FACILITY NAME: EMBARK AT SAN MARTINFACILITY NUMBER: VISIT DATE: 03/19/2024

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Estimated Days of Completion: 90

met_with: Alyssa Avila


raw_content:
Narrative:
Therefore, these allegations are Substantiated. Facility cited for violations of the California Code of Regulations, Title 22, Division Six, Section 84072(d)(14)(a)(1) Personal Rights, 80022(k) Plan of Operation, and 84065(i) Personnel Requirements as described on the following page LIC D.

Investigation Findings:
13On 3/19/2024 at 9: AM, Licensing Program Analyst (LPA) Shikya Belfield and LPA Mona Lam, conducted an unannounced inspection to the above facility. The purpose of this visit was to inform the facility representative of the findings for the allegations above. LPA met with Alyssa Avila who assisted with the inspection. Based on confidential interviews conducted and a review of supportive documentation to include but not limit, incident reports and video surveillance. Facility did not prevent client from assaulting other staff and client in care. It was also confirmed that the client who committed the assaults was in placement outside of the compliance of the facility's plan of operation as C1 (see lic811 dated 3/19/2024) was 18 years old. No exception was requested before their birthday to allow them to remain in the facility. Based on confidential interviews and observations of video surveillance, the placement of C1 in the facility was not compatible with other clients who were placed in the facility. Based on a review of facility training records, staff did not receive training in the required training topics as outlined in the regulations and were not trained to handle or in preparations for situations in the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Shikya Belfield 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 26-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, N. First Street, Ste. FACILITY NAME: EMBARK AT SAN MARTINFACILITY NUMBER: VISIT DATE: 03/19/2024

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Estimated Days of Completion: 90


summary: Complaint Investigation - Unsubstantiated - 5 allegations

raw_content:
Narrative:
Facility has also been cited for reporting requirements and currently have a plan of correction in place Facility is cited for violations of the California Code of Regulations, Title 22, Division Six, Section 84075(e) Health Related services. Facility is issued a Technical Violation Advisory for section 84070(b)(16) - (B)(C)(D)(G) medication. An exit interview was conducted a copy of this report along with appeal rights was left with Facility Manager Arianna Mandoza.

Investigation Findings:
13On 8/27/2024 at 1: PM, Licensing Program Analyst (LPA) Shikya Belfield and LPA Kristin Pierotti, conducted an unannounced inspection to the above facility. The purpose of this inspection is to inform the facility representative of the findings for the complaint investigation regarding the allegations above. Facility Manager Arianna Mendoza assisted with the inspection. Based on confidential interviews, obtained documentation to include but no limit, staff communication, a review of program statement, client files and staff schedules. It was observed that clients did not receive medications as required. Based on confidential interviews and a review of client files, it was confirmed that clients did not receive training or information regarding sexual reproductive health as outlined in the regulations. Based on a review of staff schedules it was observed that facility did not have sufficient staff in the facility to meet the required ratio outlined in the plan of operation. Based on a review of law enforcement logs and incident reports, it was observed that their were incidents that occurred and the department was not notified. Facility is currently addressing issues of ratio and currently have a plan of correction in place. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Shikya Belfield 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 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. This is an official report of an unannounced visit/investigation of a complaint received in our office on 05/08/2024 and conducted by Evaluator Shikya Belfield COMPLAINT CONTROL NUMBER: 26-CR- FACILITY NAME:EMBARK AT SAN MARTINFACILITY NUMBER: ADMINISTRATOR:AMIR RAFIEIFACILITY TYPE: ADDRESS: EAST MIDDLE AVENUETELEPHONE: (408) 838- CITY:SAN MARTINSTATE: CAZIP CODE: CAPACITY:6CENSUS: 4DATE: 08/27/ UNANNOUNCEDTIME BEGAN: 01: PM MET WITH:Arianna MendozaTIME COMPLETED:02: PM 9clients do not receive educational support. INVESTIGATION FINDINGS: 13On 8/27/2024 at 1: PM, Licensing Program Analyst (LPA) Shikya Belfield and LPA Kristin Pierotti, conducted an unannounced inspection to the above facility. The purpose of this inspection is to inform the facility representative of the findings for the complaint investigation regarding the allegations above. Facility Manager Arianna Mendoza assisted with the inspection. Based on confidential interviews and observations in the facility, although the above allegation may have happened or is valid, there is not enough of the evidence to support that the violation occurred. The preponderance of the evidence has not been met and this allegation is Unsubstantiated. An exit interview was conducted and a copy of this report was left with facility manager Arianna Mendoza. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Shikya Belfield 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: 2 of Control Number 26-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, N. First Street, Ste. FACILITY NAME: EMBARK AT SAN MARTINFACILITY NUMBER: 435390032

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 90

met_with: Arianna Mendoza


raw_content:
Investigation Findings:
13On 8/27/2024 at 1: PM, Licensing Program Analyst (LPA) Shikya Belfield and LPA Kristin Pierotti, conducted an unannounced inspection to the above facility. The purpose of this inspection is to inform the facility representative of the findings for the complaint investigation regarding the allegations above. Facility Manager Arianna Mendoza assisted with the inspection. On 8/27/2024 at 10: AM, Licensing Program Analyst (LPA) Shikya Belfield and LPA Kristin Pierotti, conducted an unannounced inspection to the above facility. The purpose of this inspection is to inform the facility representative of the findings for the complaint investigation regarding the allegations above. Facility manager Arianna Mendoza assisted with the inspection. Based on confidential interviews, obtained documentation to include but do not limit, staff communication, medication records, and staff schedules. There were at least four occasions where staff were operating out of ratio according to the plan of operation. Based on a review a of medication administration records, the medication logs were missing information or incomplete and medication logs did not list reasons for missed medication. Based on a review of client files it was observed that client documents were incomplete and missing information. The preponderance of the evidence has been met. Therefore, these allegations are Substantiated. Facility is issued a Technical Violation Advisory for California Code of Regulations, Title 22, Division Six, Section 84070(b)(16) Children's Records. Facility is cited for California Code of Regulations, Title 22, Division Six, Sections 80022(k) Plan of Operation as described on the following page LIC9099D. An exit interview was conducted on 8/27/2024,due to technical issues with equipment, LPA sent a copy of this report along with Appeal rights to Facility Manager Arianna Mendoza on 8/29/2024. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Shikya Belfield 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 26-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, N. First Street, Ste. FACILITY NAME: EMBARK AT SAN MARTINFACILITY NUMBER: 435390032

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Estimated Days of Completion: 90


raw_content:
Investigation Findings:
13On September 18, 2025 at 2: PM Licensing Program Analyst (LPA) Mona Lam made an unannounced inspection to the above listed facility. The purpose of this inspection is to deliver the finding for the above allegation. Micki Hankes assisted LPA with the inspection. Based on confidential interviews, statements indicated that staff responded accordingly to youth's actions when youth took items from the pantry from another facility. Multiple interviews stated youth was not touched when a blocking occurred. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation occurred. Therefore, the allegation is UNSUBSTANTIATED. A copy of this report was given to Micki Hankes prior to exiting the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Mona Lam LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Micki Hankes


summary: Facility Evaluation

raw_content:
Narrative:
On December 21, 2021, at 9:00am, Licensing Program Analyst (LPA) Monica Pavia conducted a pre-licensing inspection. Embark at San Martin has submitted an application for a Group Home license, for a capacity of 6 ambulatory children, ages 12-17. This inspection was conducted with Jessica Longoria and Genia Towner-Diaz and included observation of the following: The main living facility is a two story home. The first floor includes three client bedrooms; one and one half client bathrooms; kitchen and living room; area set up for school; and, a private space to meet with clients. The second floor is the staff area which includes an office and bathroom, and is locked and inaccessible to clients. The facility and grounds are in good repair, and free of obstructions; chemicals are stored and locked in the closet; locked and centrally stored medication room/cabinet observed; observed medication logs and discussed procedures for psychotropic medications; first aid kit complete; individual beds are in good repair; food storage space observed; emergency foods observed; perishable foods and nonperishable foods will be bought as soon as licensed; dining room equipped with tables and chairs accommodating all clients; all smoke detectors were tested by a fire inspector and appear to be in proper working order; carbon monoxide detector observed; fire extinguishers are properly charged; appropriate forms are posted in view of facility clients; facility has a swimming pool/hot tub with fencing (facility meets the regulation requirements for inaccessibility for their population); and, no firearms or weapons are allowed in the facility or on premises. The main living facility also has an isolation room which includes two beds and a bathroom, which is kept locked, and will only be used for COVID positive clients. Additional structures and buildings on the property: an outdoor BBQ area which includes one bathroom; locked and inaccessible barn which stores all maintenance tools; second home on the property is a staff only structure that consists of staff offices and where the staff files will be locked; and, grapevines on the extended property. All client files are electronic and available to Community Care Licensing (CCL). CCL is waiting for the fire clearance and a bank statement in lieu of financial verification. Once these items have been received and reviewed, Embark at San Martin will be ready for licensure on January 18, 2022.

met_with: Jessica Longoria


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Monica Pavia, LPA Paul Simien and LPA Lisette Valenzuela conducted an unannounced inspection on today's date at 9:00am, and met with Administrator, Noel Beaulieu. The facility is licensed for a capacity of 6 ambulatory children, ages 12 -17. There are currently 5 clients residing in the facility. During this inspection, the entire facility was toured. The facility and grounds are in good repair, and free of obstructions. There is adequate indoor activity space and materials. Chemicals are stored in a locked cabinet. Locked and centrally stored medications observed. Adequate storage space observed. Individual beds are in good repair, clean mattresses and pillows observed. Bedrooms are accommodating of all required furnishings. Adequate food storage space observed. Supply of two days of perishable foods and nonperishable foods observed upon inspection. Weekly menu is posted in the kitchen. Facility has a personal chef that buys and cooks all meals, daily. Several fire extinguishers were observed throughout the facility. LPA Pavia, LPA Simien and LPA Valenzuela reviewed 9 staff records. All current residents were placed within the last 2 weeks. All files are current and complete. Fingerprint clearances were reviewed using Guardian, on 4/28/22. All facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances and/or exemptions. There were no Title 22 deficiencies observed during this visit.

met_with: Noel Beaulieu


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility. The purpose of this visit was to conduct a office visit. LPA discussed this with Brandy Spindel, Clinical Director (CD) at 11: PM on 12/15/22. LPA Simien conducted a office visit to establish who was currently running the facility and met with CD and discussed the following: CCL's requirement that the facility must communicate a change of Administrator within 10 days, Embark's contingency plan to replace the previous Administrator, Administrator requirements, Employees needing fingerprint clearance, payment of licensing fee, and Incident reporting requirements. The facility informed LPA Simien that the previous administrator left on 12/5/22. The facility stated that they would email LPA Simien a contingency plan to replace the Administrator, which includes resumes for individuals who they plan to fill the Administrator role. LPA Simien conducted a walk through of the facility. There were six clients and seven staff members at the facility. LPA Simien emailed LIC PDF form (incident report) and the email address to send incident reports to facility. Exit interview was conducted and a copy of this report was provided to Brandy Spindel, CD whose signature on this form confirm receipt of these documents.

met_with: Brandy Spindel


summary: Facility Evaluation

raw_content:
Narrative:
An informal meeting is held on January 4, 2023 at 12: PM. The following are topics to be discussed are regarding the concerns the department has. Present in the meeting: Licensing Program Managers, (LPM) Carolyn Flynn, LPM Helga Wong, Licensing Program Analyst (LPA) Shikya Belfield, LPA Paul Simien, Brian Rogers, Princess Garcia, Christy Beaudin, Brian Beutin, Amir Rafiei, and Heather Schaffer. . The following topics are discussed due to concerns on recent non-compliance of the regulation and citations: - Reporting requirements: Facility had administrative changes to their board of directors and administrative organization; these changes were not reported to the Department. - Plan of Operation: Practices regarding food and snack supplies are not available to youths, staff training not meeting the requirements, staff are not trained on the regulations, the facility is not in compliance with applicable laws and regulations on personal rights of clients in care, criminal record clearance, and using restraint that was not part of their plan of operation. - Recent complaints and citations: Facility was cited for substantiated allegations for failing to report incidents to the Department. Facility was cited for not complying regarding pool safety, records not available for review by the Department, staffing being out of ratio, not providing notification to parents of crucial information (complaint regarding youth's health and not eating opened 4/12/2023), crisis response, and concerns with lack of supervision (complaint closed on 7/1/2023). Criminal Record Clearance: Concerns regarding lack of fingerprint clearance and having individuals working in the facilities. Concerns with restraint policies and procedures: Facility staff using restraint when not necessary, blocking clients, placing clients on 5150. (Complaint opened 11/8/2023). Crisis Response / protocol: Based on an investigated complaint opened on 10/24/2023, the facility did not have supervisor / manager / administrator or a person in charge to respond to police during a crisis. The response was handled by a staff member and the report of this incident was not reported to the Department. - Food service: Each facility must have the required amount of food per the regulations. The facility has been observed and cited for not having the proper amount of food in each home. Although the chef cooks at one home, each home must have proper food supply for the clients in care. Plan for compliance: · Reporting requirements: § Facility will submit a written plan to ensure changes to their board of directors and administrative organization will be reported to the Department within 7 days and designate multiple staff that are responsible to reporting requirements. · Plan of Operation: Facility will submit and update on their Plan of Operation to ensure snack are available for the youths in care; staff training on applicable laws and regulations on personal rights of clients in care, criminal record clearance, and using restraint, emergency intervention plan, and trauma informal; and update emergency intervention plan on restraint. All discussed the possibility of transitioning the group homes from co-ed to single sex. This was discussed but no decision was made regarding this. Recent complaints / citations: Facility will submit an update plan §Regarding pool safety and supervision when youths using the pool § Records available for review during the Department Inspection § New LIC 500 form to ensure staffing being in of ratio. § Contact with youth's responsible authority representative/parent when an incident happened to them. · Criminal Record Clearance: Facility will submit an update plan to ensure all individuals working at the facility have Criminal Record Clearance before starting work at the facility and management oversight on this hiring process. · Concerns with restraint policies and procedures: Facility will submit a new plan on restraint policies and procedures and ensuring staff received training · Crisis Response / protocol: Facility will submit a new plan to have additional managers on Crisis Response. LPA discussed the submission of the updated application with Christy Beautin and they stated they would submit during the week of January 8, 2024. The meeting was concluded.

met_with: Christy Boutin


summary: Facility Evaluation

raw_content:
Narrative:
On 1/31/ Licensing Program Analyst (LPA) Shikya Belfield attempted to conduct an annual inspection at the above facility. At this time the inspection was not able to be completed due to positive covid cases. LPA will conduct this inspection on a later date. A copy of this form will be sent to Administrator Garcia.

met_with: Princess Garcia


summary: Facility Evaluation

raw_content:
Narrative:
On January 27, 2025 at 10: AM, an unannounced annual inspection was conducted by Licensing Program Analysts (LPA's), Mona Lam and Hanako Primer at the above licensed facility. LPAs met with Michelle Hankes, William Han, Christopher VanNuLand and Zuzana Houbova. The facility has a capacity of six clients, ages twelve through seventeen and is currently holding a census of four. The home has three client bedrooms, each bedroom has two beds and the home has two client bathrooms for all the youth. There is a dining room, a living room, and a kitchen. LPAs inspected refrigerator and observed some foods without labeled dates. LPAs advised in labeling foods with dates for best practice. LPAs observed menu on fridge with listed lunch and dinner. LPA Lam asked if breakfast was served to youth in care. Michelle stated breakfast is served to youth. LPA Lam issued technical advisory 80076(a)(2) Food Services in listing breakfast on weekly menu. LPAs observed house phone was unplugged and located in closet. Facility removed house phone from closet and plugged house phone in the living room. A Type A citation was issued under 80073(a) Telephones. LPAs inspected a first aid kit. LPAs observed no thermometer in a first aid kit in a backpack brought for outings, but a thermometer within nurse's office. LPA Lam issued a technical advisory under 80075(g)(1)(G). All smoke detectors were were identified and are in working condition. The fire extinguisher were prominent and looked in good condition. LPA Primer measured bathroom hot water up to 94.6 degrees Fahrenheit. A Type A citation was issued under 80088(e)(1) Fixtures, Furniture, Equipment and Supplies. LPAs inspected the backyard of the facility. LPAs observed a pool without a pool cover. A Type B citation was issued under 80087(e)(1) Buildings and Grounds. (Continued on LIC809-C) LPAs inspected four client files. During the inspection, LPAs observed two files that did not list prescribing physician for current medications of clients. A technical violation was issued under 80070(b)(10) Client's Records. LPAs did not observe dental history within all of the client files. A Type B citation was issued under 84070(b)(7) Children's Records. LPAs observed all treatment plans, which did not contain child's or authorized representative's signatures. A Type A citation was issued under 84070(c)(1) Children's Records. LPA Lam asked any youth uses a Telecommunications Device. William Han identified one youth to use a telecommunications device. LPAs did not observe LIC9158 for youth. A Type B citation was issued under 80068(b) Admission Agreements. LPA Lam asked if youth sharing bedrooms have a documented compatibility agreement. No documentation was identified in the files for youth sharing bedrooms. A Type B citation was issued under 84087(e) Buildings and Grounds. LPA Lam inspected signed documentation of child's personal rights per client file. LPA Lam observed signatures for client's and authorized representative's. LPA Lam observed Alyssa Avila's name listed under licensee/designee in each of the client's personal rights, without their signature. LPA Lam asked who is delivering personal rights for clients due to being informed Alyssa Avila have been on leave with Embark for almost a year. Michelle informed that the enrollment director/therapist or direct care staff would deliver child's personal rights. A technical advisory was issued under 84070(b)(17) Children's Records. LPAs inspected photos of valve shut offs, fire clearance, board of directors' meeting minutes, and past licensing reports. LPA Primer conducted four confidential client interviews. At this time the inspection is not complete and it will be concluded at a later date. Seven (7) deficiencies were cited at the inspection (refer to LIC809-D). An exit interview was conducted a copy of this report and appeals rights page were discussed, printed, and delivered to Michelle Hankes prior to leaving the facility.

met_with: Michelle Hankes, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On February 5, 2025 at 10: AM, an unannounced annual inspection was conducted by Licensing Program Analysts (LPA's), Mona Lam and Hanako Primer at the above licensed facility. LPAs met with Michelle Hankes, who assisted with the inspection. The facility has a capacity of six clients, ages twelve through seventeen and is currently holding a census of five. During the inspection, LPAs reviewed five client files. LPAs issued three Type B citations: 84070(b)(15) Children's Records, 84070(b)(16)(G) Children's Records, and 84070(c)(2) Children's Records. LPAs issued a technical violation under 84068.3(b)(1) Modifications to Needs and Services Plan. LPA Primer conducted five confidential staff interviews. LPA Primer attempted one client interview. Youth denied interview. At this time the inspection is not complete and it will be concluded at a later date. Three (3) deficiencies were cited at the inspection (refer to LIC809-D) and one (1) technical violation was issued. Facility appealed 80087(e)(1) Building and Grounds, and the deficiency has been dismissed. An exit interview was conducted a copy of this report and appeals rights page were discussed, printed, and delivered to Michelle Hankes prior to leaving the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On February 11, 2025 at 10:30AM, Licensing Program Analysts (LPAs) Mona Lam and Hanako Primer conducted an unannounced annual continuation inspection to the above licensed facility. LPAs met with administrator Michelle Hankes and staff member Kelsy Pike. The facility has a capacity of six clients, ages twelve through seventeen and is currently holding a census of four. During the inspection, LPAs reviewed five client files and facility emergency disaster plan. LPAs issued two Technical Violations under 80075(l)(1)(B) Client Records, and 80023(a) Disaster Preparedness. LPAs issued two Technical Assistances under 1565(c) Disaster Preparedness, and 80075(l) Client Records. LPAs performed an inspection of the facility grounds, and inspected storage areas of clients' personal property. LPAs observed video camera surveillance located at the exterior of the property. LPAs were informed a camera is located in the medication room, which LPAs have not observed. In addition, LPAs received confirmation that video cameras are in use. LPA Lam emailed PIN 24-09-CRP to facility's management in regards to update the program statement accordingly. At this time the inspection is not complete and it will be concluded at a later date. Two (2) Technical Violations were issued and two (2) technical assistances were issued at the time of the inspection (refer to LIC9102). An exit interview was conducted and a copy of this report was printed, and delivered to Michelle Hankes prior to leaving the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On February 19th, 2025 at 10:25AM, Licensing Program Analysts (LPAs) Mona Lam and Hanako Primer conducted an unannounced annual continuation inspection to the above licensed facility. LPAs met with Administrator Michelle Hankes and Human Resources Director Zuzana Houbova. The facility has a capacity of six clients, ages twelve through seventeen and is currently holding a census of four. During the inspection, LPAs reviewed five staff files and facility emergency disaster plan. At this time the inspection is not complete and it will be concluded at a later date. No deficiencies were cited at this time. An exit interview was conducted and a copy of this report was printed, and delivered to Michelle Hankes prior to leaving the facility.