raw_content:
Narrative:
Confidential interviews reveal there have not been any major injuries for Child #1 and staff are treating old wounds. Staff reported that daily body checks are conducted on the resident to see if any injuries. Staff deny that they would refuse to provide first aid to resident. Due to inconsistent statements LPA Phillips was not able to determine if the above said allegation occurred, therefore the allegation is found to be Unsubstantiated meaning that although the allegation may have happened or are valid there is not a preponderance of evidence to prove that the alleged incident occurred. Based on the observations made during today's inspection, no deficiencies were cited. Exit interview was conducted, and a copy of this report will be emailed to Administrator.

Investigation Findings:
13On 12/06/2022 @ 8: AM Licensing Program Analyst (LPA) ZenaPhillips conducted a follow up visit to ANGELES VISTA CHILDREN'S HOME and met with Brittney Jumper /Case Manager who provided the census. The purpose of the visit was to deliver findings for the complaint allegation listed above. During the course of the investigation five (5) confidential interviews were conducted, reviewed the following documentarty evidence:, Needs and Services Plan, medical appointments, medication log, SIR reports, staff and client files. It was reported to LPA that if resident is injured the nurse is called and if severe the resident will be transported to the hospital. First aid kit is available on site and injuries that go beyond first aid are reported on Special Inicident Report. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Zena Phillips 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 34-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. Continental Blvd. #290B FACILITY NAME: ANGELES VISTA CHILDREN'S HOMEFACILITY NUMBER: VISIT DATE: 12/06/2022

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

met_with: Brittney Jumper /Case Manager


state: CA

facility_name: ANGELES VISTA CHILDREN'S HOME

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
LPA received conflicting testimonies regarding the operational status of the facility phone. Witness interviews shared that the phone was not working during a specific visit. Witness interviews could not testify to why the phone was not working, for how long the phone was not working, or what the facility's response was. Staff testified that the facility phone was non-operational for a time, the facility's response was to try and fix the issue with the provider Spectrum, and then when the issue could not be fixed the facility just replaced the phone. LPA also observed the new phone to be in working order. Based on the available information LPA gathered from interviews, and observation evidence, the preponderance of the evidence standard has not been met; therefore, the allegation that the "Staff did not ensure telephone was working properly" is found to be unsubstantiated. Exit interview conducted. A copy of this report and appeal rights was given to Administrator.

Investigation Findings:
13On7/22/25 at 1: PM, Licensing Program Analyst (LPA) Reagan Cohen arrived at the above facility and met with Administrator Larrina Maloy for the purpose of delivering complaint findings regarding the above allegation. During the course of the investigation, LPA interviewed involved staff and witnesses. LPA was unable to interview clients due to them being non-verbal. Witness testimony alleged that during a visit, staff shared that the facility phone was not working at the moment and would hopefully be fixed soon. Staff interviews admitted that there was an issue with the phones for a short period of time from 3/29-4/1 2025. During that time, the facility's response was to call Spectrum, the phone provider. Spectrum tried to do some resets and reboots remotely, which did not work. Staff explained that neither they nor Spectrum could figure out the phone problem. Spectrum shared that they could not come out to service the phone until 4/3/25. The facility did not want to wait, so they just replaced the phone, which is now in working order. Staff state that they were not able to receive a work order from Spectrum because Spectrum never came out physically to work on the phone. During LPA's visit, LPA called and tested the new phone and observed it to be in working order. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Reagan Cohen 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 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: ANGELES VISTA CHILDREN'S HOMEFACILITY NUMBER: VISIT DATE: 07/22/2025

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

report_type: Complaint Investigation

met_with: Larrina Maloy Administrator

complaint_status: unsubstantiated


summary: Facility Evaluation

raw_content:
Narrative:
On 10/07/2021 at 9: AM Licensing Program Analyst (LPA) Zena Phillips made an unannounced to Angeles Vista Children's Home to conduct Annual Inspection. LPA met with Linda Hudson/ who granted access to the facility. The entire physical plant was inspected. The Group Home is to provide care and supervision for six (6) children, ages 11-21 years Ambulatory Only. The Administrator confirmed that there are no guns or weapons on the premises. This is a 1-story three (3) bedrooms; 2 1/2 bathrooms. There is a fully furnished living room, dining room and Central Air conditioning unit. The outdoor perimeter front yard, side yard and backyard were inspected and found cleared of debris and hazards materials. LPA observed all windows, screens and blinds from the inside and outside of the facility were observed to be in good condition. The windows are double hung style with no bars on the windows in the event of an emergency evacuation. The passageways and porches are unobstructed. All posting requirements were met, (food menu, regulations, licenses, emergency disaster plan and personal rights). Posting are in the common area accessible to clients (clients are nonverbal). The cleaning supplies solutions, disinfectants are stored under the kitchen sink locked; sharp knives are also inaccessible in separate locked cabinet opposite of the kitchen sink. All the children prescribed medications are in locked rolling cabinet. LPA observed 5 hard wired connected and 3 battery operated combined Smoke detectors and Carbon Monoxide; tested to be operable. Report continues on LIC-809-C The garage has been converted in 2 offices; Administrator & Social Worker office and other portion used for extra supplies stacked neatly on metal shelving. One additional office for Staff is just behind laundry are to the left of rear exit of the house. The facility has a working telephone and clients can use the telephone unless restricted by court order. The staff accompanies clients to local recreational facilities based on the rules of the COVID-19. Clients are accorded dignity in personal relationships with staff and others The Facility operates within license conditions and limitations including capacity limitations. Facility has a current, written plan of operation. Facility personnel are instructed to report violations of personal rights. Licensee will report changes in the plan of operation affecting service to clients. Licensee will report client injuries requiring medical treatment. LPA will return to the facility at later date to complete Annual Inspection Clients records, Staff Records review, Staff interviews/ clients are nonverbal). There were no deficiencies cited at this time. Exit Interview was conducted and a copy of this report was left at the facility.

report_type: Facility Evaluation

visit_type: Annual

met_with: Linda Hudson/Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 10/08/2021 at 10: AM Licensing Program Analyst (LPA') Zena Phillips, made an announced visit to Angeles Vista Children's Home for Annual/Required licensing Inspection. LPA' met with Linda Hudson/ Administrator & Jasmine Hernandez/Case Manager who granted access to the facility. LPA reviewed the following during the inspection: Staff records review; the information regarding the Emergency Preparedness. LPA reviewed Criminal Records and confirmed that all current and former staff were also cleared. LPA reviewed The Administrator and Direct Care staff records. LPA reviewed the facility binder that included specific training: Specific Trainings include the following: Policies & Procedures; Health & Safety: Covid Training, Emergency Procedures: Medication;Trauma-Informed Care; Defensive Driving; Job Duties; and information about the Stakeholders. LPA was not able to interview residents all are are nonverbal. LPA observed the Board of Directors Meeting Notes and confirmed that meetings are held quarterly. LPA inspected facility vehicle and confirmed current registration and valid insurance in place. There were no deficiencies cited at this time. Exit Interview was conducted and a copy of this report was left at facility

visit_type: Case Management

met_with: Linda Hudson/Administrator & Jasmine Hernandez/ Case Manager


facility_name: ANGELFIELD SERVICES

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPA) Alyssa Ng and Licensing Program Manager (LPM) Helga Wong met with applicant Mary Jane Cagadas via Microsoft Team Meeting to conduct a component II of the orientation process. The following items were discussed: - Physical Plant and the use of the facility - Facility will provide care for DD clients, Level 4I with Regional Center -Administrator will be working at the facility minium 20 hours weekly -Training for staff including topics on Medication, DSP 1 & 2, and Emergency Intervention -Reviewing and understanding of Title 22 regulations and Health and Safety Codes -Personal Rights -Supportive Services Component III and Pre-Licensing inspection will be scheduled by LPA Alyssa Ng when she received fire clearance. An exit interview was conducted and a copy of this report was given to applicant Cagadas.

met_with: Mary Jane Cagadas


summary: Facility Evaluation

raw_content:
Narrative:
On 7/20/22 at 1: PM, Licensing Program Analyst Alyssa Ng met with applicant Mary Jane Cagadas via Microsoft Teams Meeting. The purpose of this meeting was to discuss the facilities Program Statement and Plan of Operation. The following items were discussed: - Goal/Purpose of the Group Home -Training for staff (CPI, DSP, etc.) -Intake/Admission Process for future clients -Needs & Service Plan & how to incorporate the goals into the clients lives -Planned Social Activities -Emergency Intervention Procedures (COVID plan, ON-Call staff, Fire, etc.) -AWOL/Runaway Procedure -Incident Reports -Special Services offered -Fingerprinting/Guardian process -Behavior management -Visitation Procedure/Policy Component III and Pre-Licensing date is set for August 8th at 10: AM. LPA advised Mary Jane to have forms available (Staff, Client, Medication) when LPA conducts the Pre-Licensing visit. An exit interview was conducted and a copy of this report was sent to Applicant Mary Jane Cagadas.


summary: Facility Evaluation

raw_content:
Narrative:
On September 21, 2022 at 9:45am, Licensing Program Analyst (LPA) Monica Pavia conducted an announced pre-licensing inspection of the facility. LPA met and toured the facility with Mary Jane Cagadas, Licensee. This Group Home is a one story facility located in a residential area. The facility consists of 3 client bedrooms and 2 client bathrooms, living and dining areas, kitchen, and laundry room. There are two locked sheds in the backyard and it was discussed with the Licensee that Community Care Licensing (CCL) would need access at all times. The facility is clean, safe, sanitary, and in good repair. All passageways are unobstructed and all doors open freely. There is no pool on the premises. Fire arms are not allowed on the facility premises. At the time of visit, the following was observed: Fire extinguishers are throughout the house. Smoke detectors are throughout the house and operational. Carbon monoxide detectors are located in the hallway, outside of the client bedrooms. Each bedroom has a bed, clean linens, and adequate drawer/cabinet space. Facility has a fire clearance. First aid kit was observed. Hot water temperature measured at 108 degrees Fahrenheit. Staff and client files will be locked in the filing cabinet in the dining room. Medications will be centrally stored and locked in the filing cabinet in the dining room. Disinfectants and other toxic materials will be locked in the laundry room. Extra bedding and towels are kept unlocked, in the hallway closet. Sharp knives are kept locked in a tool box in the kitchen. Site location has a live in staff bedroom and bathroom that is kept locked, and meets prelicensing requirements. Site location has ring cameras at the front door and on the outside perimeter of the house. Per Licensee, they belong to the homeowner and are not hooked up. Licensee will provide a sworn affidavit from homeowner stating the ring cameras are not in use and will not be activated as long as this site location is a Community Care Licensing facility. Licensee agrees to meet current County safety COVID guidelines. Items to complete prior to licensure/placement. Send photos once complete. - remove or hang pictures that are currently in client bedroom closets - replace missing electric plate in dining room - lock toxins in laundry room and staff bathroom - child lock on mini-fridge in dining room (secure lock if meds are inside) - swing outside to be set up This facility will be ready for licensure once above is completed, Licensee submits Nonprofit Articles of Incorporation and Licensing Program Manager (LPM) has reviewed the application file. Component II: LPA Pavia discussed with the following, with Administrator: - Administrator on site required hours - discipline policies & house rules - facility emergency intervention plan

visit_type: Prelicensing


summary: Facility Evaluation

raw_content:
Narrative:
On 10/24/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a required annual inspection. LPA met with Administrator Mary Jane Cagadas and informed of the purpose of the visit. The facility has had no placements (clients), as the vendorization is still pending with Regional Center. Administrator agreed to update LPA when the vendor certificate is acquired. LPA inspected the facility site and grounds and reviewed facility records with Administrator. LPA observed the facility to be clean and organized, kitchen and bathroom spaces to be maintained in sanitary condition, and bedrooms to be tidy and ready for clients. Using the CARE Inspection Tool, no deficiencies were found. An exit interview was conducted, and a copy of this report was left with Administrator Mary Jane Cagadas, whose signature on this form confirms receipt.

met_with: Administrator Mary Jane Cagadas


summary: Facility Evaluation

raw_content:
Narrative:
On 10/07/24, Licensing Program Analysts (LPAs) Celeste Aparicio and Jonathan Medina conducted a unannounced required annual inspection. LPAs met with Administrator Mary Jane Cagadas and informed of the purpose of the visit. During the inspection the resident in care was present in the facility due to being on a Fall break from school. The resident was engaged in daily activities during the inspection. Administrator indicated that the resident is nonverbal. LPAs observed resident to be dressed in clean, well-fitting clothes, and to be closely supervised by present personnel. Facility Administrator indicated that the present personnel helping with the resident in care were the Administrators parents who would be residing at the facility for a six month period. The CARE Inspection Tool was used to conduct the inspection. At the start of the inspection LPAs conducted a walk through of the facility, inside and out. LPAs observed centrally stored medications maintained in a locked cabinet, three client bedrooms, two bathrooms , living room, kitchen, dining area, washroom, and garage that had been converted into a staff office/ bedroom. LPA's observed at least one-week supply of nonperishable and a two-day supply of perishable food. In the backyard LPA's observed two sheds. The larger shed was used as a storage space as the other smaller shed was used for gardening materials. Both sheds were locked. The facility is maintained at 77 degrees. Hot water temperature measures at 112 degrees. LPA observed the facility to be clean, organized, and to be maintained in sanitary condition. During the walk through LPA's observed two cleaning materials left out in unlocked spaces. LPAs asked licensee to keep these materials in locked cabinets, the facility Administrator placed these cleaning materials in the appropriate locations. LPAs reviewed one client file and three staff files. After documentation review and interview with Administrator, LPA advised the facility converting into a Small Family Home to better satisfy facility licensing standards. LPAs identified areas in which the licensee could improve documentation regarding staff training logs, disaster preparedness, licensing forms, and complaint procedures. LPA is issuing six technical assistance advisory notes and one Technical Violation relating to the discussed topics. Additionally, LPA is issuing a citation Health and Safety Code, Section 1565(c) regarding the two uncleared personnel present at the facility. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Mary Jane Cagadas, whose signature on this form confirms receipt.

met_with: Mary Jane


summary: Facility Evaluation

raw_content:
Narrative:
On October 15, 2025 at 2pm, Licensing Program Analyst (LPA) Celeste Aparicio conducted an unannounced case management inspection. The purpose of the inspection is to amend report from October 7, 2025.

met_with: Administrator , Mary Jane Cagadas


summary: Facility Evaluation

raw_content:
Narrative:
On October 30, 2025 at 10:50am, Licensing Program Analyst (LPA) Celeste Aparicio conducted an unannounced visit to the facility for the purpose of conducting Angelfield Services Annual inspection. LPA Aparicio met with facility Administrator, Mary Jane Cagadas who helped facilitate the inspection. At the beginning of the visit, there were zero (0) clients and two (2) staff members present in the facility. By the conclusion of the inspection, there were 3 clients and 4 staff members present. During the inspection, LPA Aparicio utilized the CARE Tool to complete a comprehensive walkthrough of the facility, review four (4) client files, and examine the Centrally Stored Medication and Medication Administration Records (MARs). The walkthrough revealed that the facility was clean, organized, safe, sanitary, and in good repair. The home is a single-story residence consisting of three (3) client bedrooms, each arranged for double occupancy with single beds, and two (2) bathrooms. Two of the clients share a bedroom. The facility administrator resides in a separate bedroom located in the converted garage area of the home. The property also features a spacious backyard with artificial turf and two large storage sheds, both used for facility storage purposes. During the review of client files, LPA found no documentation showing that the health, safety, and compatibility of the two clients sharing a bedroom had been assessed. There was also no documentation showing that the licensee talked with the children about their sexual orientation and gender identity. Additionally, LPA observed no standard appraisal forms upon intake for each client in care. {See LIC809-C for continued report} LPA is issuing citation of California Code of Regulations (CCR),Title 22, Division 6, Chapter Section 84087(e)Building and Grounds and 84068.1(b)(1)(C) Intake Procedures. LPA also identified three areas in which technical assistances could be beneficial. Reference related LIC9102. The annual inspection is not complete at this time. A continuation visit will be conducted at a later date to complete this inspection. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to Administrator, Mary Jane Cagadas whose signature on this form confirms receipt.


summary: Facility Evaluation - 2 deficiencies

raw_content:
Narrative:
On November 4, 2025 at 10:06am, Licensing Program Analyst (LPA) Celeste Aparicio conducted an unannounced visit to the facility for the purpose of completing the Angelfield Services Annual inspection. LPA Aparicio met with facility Administrator, Mary Jane Cagadas who helped facilitate the inspection. At the beginning of the visit, there was (1) client and (1) staff member present in the facility. By the conclusion of the inspection, there were (3) clients and (4) staff members present. LPA observed the clients in care to be well groomed, fed, and comfortable in the facility. During the inspection, LPA Aparicio utilized the CARE Tool to complete a comprehensive review of the facility's Disaster Preparedness, Operations, Emergency Intervention protocol, and (5) staff files. During the review of the facility's operations, LPA observed that the facility did not have documentation to support that board members are active. In addition, the facility could not show board minutes to LPA upon request. Regarding operations, LPA observed that the facility has not developed, maintained and implemented written complaint procedures by which children or their authorized representatives are permitted to file complaints. Additionally upon the review of facility operations, LPA Aparicio learned that the corporation of the facility is on suspended status. At this time further investigation into the status of the corporation is needed. LPA will follow up with facility at a later date. Upon the review of the Disaster Preparedness, LPA observed that emergency drills were not being conducted on a quarterly basis and the facility did not have all of the following readily available in case of an emergency: roster of individuals served by facility, copies of Needs and Services Plans, medication lists for individuals severed, or contact information for the responsible party and physician. {See LIC809-C for continued report}. During the review of (5) staff files, LPA observed that (5) staff had no documentation of training received of the facility's approved Emergency Intervention Plan(EIP) regarding CPI Nonviolent Crisis Intervention training. LPA only observed ProACT certifications for EIP which have not been approved by the department at this time. Additionally upon the review of staff training files, LPA did not observe any staff to have received training regarding the reasonable and prudent parent standard. Based on documentation review of the LIC Personnel Report and interview with the Administrator it was found that the facility has no designated facility manager. {Reference related LIC9102 and LIC809-D pages}. Based on LPA observations, LPA is issuing (6) Technical Violations, (2) Technical Assistances and (7) Citations for the regulation sections stated below. The Technical Violations include: CCR Sections 84072.2(a)(3), 80066(a)(8),84066(b)(1), 84066(b)(6),84065(i)(2), and 84065(k). The Technical Assistances include: CCR Sections 80071(a)(1)(D) and 84065(i)(3)(X) Citation sections of California Code of Regulations (CCR),Title 22, Division 6, Chapter 5, Section 84063(a)Accountability, 84072.2(a)Complaint Procedures, 84365(d)(1)(C)Emergency Intervention Staff Training, 84065(b)(1)Personnel Requirements, and 84065(d)Personnel Requirements. Citations of Health and Safety Code (HSC) Sections 1565(c) and 1565(e) Other Provisions. The annual inspection is not complete at this time. A continuation visit will be conducted at a later date to complete one more section in the CARE Tool and conduct staff/client interviews. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to Administrator, Mary Jane Cagadas whose signature on this form confirms receipt.

Deficiencies:
84063(a): Accountability

(a) The board of directors shall be active in ensuring accountability, and shall perform, at a minimum, the following duties
84065(d): 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


facility_name: APOLLO GROUP HOME

summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Based on today's visit, Children's Residential Title Community Care Regulations, Section 80022(k)); Plan of Operation; deficiency was cited. However, due to the staff being forthcoming about the injury, the injury not intentionally being caused to the client in care, and the Administrator still deciding to terminate the staff, there will not be a plan of correction, as the staff has already been terminated. An exit interview was conducted at 11: AM, and a copy of the report was mailed to Ms. Ayala.

Investigation Findings:
13On 6/23/2023, at 10: AM, Licensing Program Analyst (LPA) Vaishali SIngh-Sood conducted an unannounced visit to the facility. The purpose of this visit was to deliver the findings on the listed allegations. LPA met with Juanita Ayala, Caregiver. At the time of the visit, there were four youth and four staff in the facility. Over the course of the investigation, confidential interviews, a file review, and evidence were obtained regarding the aforementioned allegation. Based on the staff involved admitting he had been playing with the client in which he unintentionally caused injury, there is a preponderance of evidence. As a result of the injury/bruising, the Administrator immediately terminated the staff. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Vaishali Singh-Sood 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: APOLLO GROUP HOMEFACILITY NUMBER: 435202522

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

met_with: Eleanor Asia Rall

complaint_status: SUBSTANTIATED


summary: Facility Evaluation

raw_content:
Narrative:
On August 6, 2021, at 9: AM Licensing Program Analyst (LPA) Sam Raissi conducted an unannounced inspection to the facility for the purpose of conducting an Annual/Required inspection. LPA Raissi met with Administrator, Juanita P. Ayala of Apollo Group Home and both toured the facility, inside and out. The Group Home is licensed to serve six clients, ages 6-17 years. Currently in placement are six clients. All six of the clients were present during the inspection. LPA Raissi observed at the time of this inspection, the facility to be clean, safe, and sanitary. All fire alarms, and carbon monoxide detectors were in good working condition, and the fire extinguisher is current. This LPA reviewed the staff and client files, medication logs, and they had the necessary forms. The following documents are posted in the facility: facility license, emergency disaster plan, facility sketch, menu, activity calendar and personal rights. The hot water temperature was at (Kitchen Sink - 105.1, Hall Bathroom 105.3, and Bedroom Bathroom 105.3 degrees). A review of Licensing Information System on August 4, 2021 indicates that all facility staff are associated to the facility had DOJ, FBI, and child abuse index check clearances. According to the Administrator, there are no weapons, and/or bodies of water at the facility which meets title 22 regulations. There are currently no exceptions on file, and there have not been any deficiencies cited in the past year. There were no deficiencies noted at today's inspection. The agency listed above this report was issued Advisory Notes -Technical Assistance (LIC 9102TA). Exit interview conducted and a copy of the report was left with the Administrator.

met_with: Juanita P. Ayala


summary: Facility Evaluation

raw_content:
Narrative:
On August 31, 2022, at 10: AM Licensing Program Analyst (LPA) Vaishali Singh-Sood conducted an unannounced inspection to the facility for the purpose of conducting an Annual/Required inspection. LPA Singh-Sood met with Administrator, Jaclyn Tan of Apollo Group Home and both toured the facility, inside and out. The Group Home is licensed to serve six clients, ages 6-17 years. Currently in placement are six clients. All six of the clients were present during the inspection. LPA Singh-Sood observed at the time of this inspection, the facility to be clean, safe, and sanitary. All fire alarms, and carbon monoxide detectors were in good working condition, and the fire extinguisher is current. This LPA reviewed the staff and client files, medication logs, and they had the necessary forms. The following documents are posted in the facility: facility license, emergency disaster plan, facility sketch, menu, activity calendar and personal rights. The hot water temperature was at (Kitchen Sink - 107.1, Hall Bathroom 109.3, and Bedroom Bathroom 108.3 degrees). A review of Licensing Information System on August 31, 2022 indicates that all facility staff are associated to the facility had DOJ, FBI, and child abuse index check clearances. According to the Administrator, there are no weapons, and/or bodies of water at the facility which meets title 22 regulations. There are currently no exceptions on file, and there have not been any deficiencies cited in the past year. There were no deficiencies noted at today's inspection. The agency listed above this report was issued Advisory Notes -Technical Assistance (LIC 9102TA). Exit interview conducted and a copy of the report was left with the Administrator at 4: PM.

met_with: Jaclyn Tan


summary: Facility Evaluation

raw_content:
Narrative:
On August 23, 2023, at 9: AM Licensing Program Analyst (LPA) Vaishali Singh-Sood conducted an unannounced inspection to the facility for the purpose of conducting an Annual/Required inspection. LPA Singh-Sood met with Lead Staff, Zandy Aycardo of Apollo Group Home and both toured the facility, inside and out. The Group Home is licensed to serve six clients, ages 6-17 years. Currently in placement are five clients. Only one of the client was present during the inspection, but all the clients are non-verbal. LPA Singh-Sood observed at the time of this inspection, the facility to be clean, safe, and sanitary. All fire alarms, and carbon monoxide detectors were in good working condition, and the fire extinguisher is current and was serviced on February 2023. This LPA reviewed the staff and client files, medication logs, and they had the necessary forms. The following documents are posted in the facility: facility license, emergency disaster plan, facility sketch, menu, activity calendar and personal rights. The hot water temperature was at (Kitchen Sink - 111.3, Hall Bathroom 112.4, and Bedroom Bathroom 111.1 degrees). A review of Guardian/LIS on August 23, 2023 indicates that all facility staff are associated to the facility had DOJ, FBI, and child abuse index check clearances. According to the Administrator, there are no weapons, and/or bodies of water at the facility which meets title 22 regulations. There are currently no exceptions on file, and there have not been any deficiencies cited in the past year. There were no deficiencies noted at today's inspection. The agency listed above this report was issued Advisory Notes -Technical Assistance (LIC 9102TA). Exit interview conducted and a copy of the report was left with the Administrator at 3: PM.

met_with: Zandy Aycardo


summary: Facility Evaluation

raw_content:
Narrative:
On August 29, 2024, at 10: AM Licensing Program Analyst (LPA) Vaishali Singh-Sood conducted an unannounced inspection to the facility for the purpose of conducting an Annual/Required inspection. LPA Singh-Sood met with Administrator, Juanita Ayala, of Apollo Group Home and both toured the facility, inside and out. The Group Home is licensed to serve six clients, ages 6-17 years. Currently in placement are six clients. During the inspection, only one client was present, but all the clients are non-verbal. LPA Singh-Sood observed at the time of this inspection, the facility to be clean, safe, and sanitary. All fire alarms, and carbon monoxide detectors were in good working condition, and the fire extinguisher is current and was serviced on March 20, 2024. This LPA reviewed the staff and client files, medication logs, P&I, and the facility had the necessary forms. The following documents are posted in the facility: facility license, emergency disaster plan, facility sketch, menu, activity calendar and personal rights. The hot water temperature was at (Kitchen Sink - 113, Hall Bathroom 114, and Bedroom Bathroom 112.2 degrees). A review of Guardian/LIS on August 29, 2024 indicates that all facility staff are associated to the facility had DOJ, FBI, and child abuse index check clearances. According to the Administrator, there are no weapons, and/or bodies of water at the facility which meets title 22 regulations. There are currently no exceptions on file, and there have not been any deficiencies cited in the past year. On August 20, 2024, San Andreas Regional Center did a quarterly inspection for the facility. There were no deficiencies noted at today's inspection. Exit interview conducted and a copy of the report was provided to Ms. Ayala at 3: PM.

met_with: Juanita Ayala


summary: Facility Evaluation

raw_content:
Narrative:
On September, 25 2025, at 09: AM Licensing Program Analyst (LPA) Omar Sawyer and LPA, Shikya Belfield conducted an unannounced inspection of the above facility for the purpose of conducting an Annual/Required inspection. LPA Sawyer and LPA Belfield met with Administrator, Juanita Ayala, of Apollo Group Home and toured the facility, inside and grounds. The Group Home is licensed to serve six clients, ages 6-17 years. Currently in placement are four clients. No clients were present during this inspection. All clients are non-verbal. LPA Sawyer observed at the time of this inspection, the facility to be clean and in safe condition. All fire alarms, and carbon monoxide detectors were in good working condition, and the fire extinguisher is current and was serviced on March 12, 2025. Based on the review of Staff files, five out of nine Staff files reviewed did not have Criminal Record Clearance. Facility is being cited for violation of California Code of Regulations, Title 22, Division 6, Section 80019(e)(2), as described on the following page LIC809D. The following documents are posted in the facility: facility license, emergency disaster plan, facility sketch, menu, activity calendar and personal rights. The hot water temperature was at (Kitchen Sink - 104, Hall Bathroom 103, and Bedroom Bathroom 104 degrees Fahrenheit). Based on LPA observations there are no bodies of water at the facility. At this time the inspection is incomplete and will be concluded at a later date. An exit interview was conducted and a copy of the report was provided to Administrator, Juanita Ayala, whose signature confirms receipt.

met_with: Juanita Ayala, Administrator


summary: Facility Evaluation

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Narrative:
On September, 26 2025, at 10: AM Licensing Program Analyst (LPA) Omar Sawyer and LPA, Shikya Belfield conducted an unannounced inspection of the above facility for the purpose of conducting an Annual/Required inspection continuation. LPA Sawyer and LPA Belfield met with Administrator, Juanita Ayala, of Apollo Group Home. The Group Home is licensed to serve six clients, ages 6-17 years. Currently in placement are four clients. No clients were present during this inspection. All clients are non-verbal. LPA Sawyer requested the Four Client files, P&I reports, and consultant logs for review. Based on a review of of clients P&I reports, LPA asked Adminstrator questions regarding the transactions on the accounts of two clients. LPA obtained copies of these files for further review. There were no Violations of California Code of Regulations, Title 22, Division Six cited during this inspection. An exit interview was conducted and a copy of this report was left with Administrator Juanita Ayala whose signature confirms receipt.


facility_name: AR & EM HOME CARE, INC

summary: Facility Evaluation

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Narrative:
On August 19, 2025, at 9:05 am, Licensing Program Analysts (LPAs) Charmaine Linley, Stefanie Mutialu, and Gilbert Marquez arrived at the facility to conduct a pre-licensing inspection of the facility. The facility was inspected inside and out with Marie Noel, Facility Administrator, Monica Daniel, Chief Financial Officer, and Roxanne Spencer, Chief Executive Officer. The home is a single-story residence with a swimming pool in the backyard. There are no camera located inside or outside of the facility. The facility consists of one living room, one family room, two restrooms, one dining room and one kitchen. The garage is located next to the kitchen and leads to the driveway. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. The living room is furnished with one couch, one love seat, and one chair with enough seating for four people. The living rooms has board games and arts and crafts activities available for the client's use. The family room is equipped with two desks, two computers and locked file cabinet and two telephones that were tested and were observed to be in working order. The kitchen is equipped with operable appliances, kitchen utensils, pot, pans and dishes. The facility had a two day supply of perishable food and a seven day supply of non-perishable food. The hot water in the kitchen was measured at 117 degrees, which is within regulatory requirements. The kitchen's appliances were tested and were observed to be in working order. The facility's smoke detectors were tested and observed to be in working order. There are six smoke *** detectors, one in the dining room, one in the hallway, and one in each individual bedroom. There are two carbon monoxide detectors that are located in the hallway and in the dining room. The carbon monoxide detectors were tested and observed to be in working order. Fire extinguishers are properly charged and serviced. There are a total of four fire extinguishers located in the laundry room, garage, under the kitchen sink, and in the hallway. The facility has a fully equipped first aid kit and first aid manual stored on top of the file cabinet in the family room. There are no guns or weapons in the facility as stated by the Administrator. Medications are locked and centrally stored in a medication cabinet in the family room. Disinfectants and cleaning solutions were stored locked in a locked cabinet in the garage. Sharp knives were made inaccessible and stored in a locked drawer in the kitchen. The staff and client files will be maintained in a locked file cabinet in the family room. The following required posted items were observed accessible to clients: Fire Clearance, Grievance Procedures, Personal Rights, Visitation policies, Emergency Disaster Plan and current menu. The bedrooms are set up as follows: Bedroom #1 will be occupied by one resident; has one twin bed, all required linen, mattress is in good condition. Bedroom #2 will be occupied by one resident; has one twin bed, all required linen, mattress is in good condition. Bedroom #3 will be occupied by one resident; has one twin bed, all required linen, mattress is in good condition. Bedroom #4 will be occupied by one resident; has one twin bed, all required linen, mattress is in good condition. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. The bathrooms were clean and in good repair. The facility outside grounds were also inspected and it was observed to be clean and well maintained. *** Emergency exits were free from obstruction. There is an in-ground swimming pool located in the backyard of the facility which is made inaccessible with a fence and two pool gates that swing away from the pool, self-close and have a self-latching device located no more than six inches from the top of the gate. The fence is constructed so that the fence does not obscure the pool from view. The fire clearance has been approved. Based on the facility pre-licensing inspection review, no deficiencies were noted at the time of inspection. Upon Licensing Program Manager's final review, the license will be provided. An exit interview was conducted, and a copy of this report was given to the facility.

met_with: Marie Noel


summary: Facility Evaluation

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Narrative:
On January 15, 2026, at 9:05 am, Licensing Program Analyst (LPA) Gilbert Marquez arrived unannounced at the facility to conduct a post-licensing inspection of the facility. The facility was inspected inside and out with Marie Noel, Facility Administrator. The home is a single-story residence with a swimming pool in the backyard. There are no cameras located inside or outside of the facility. A physical plant inspection was completed and included the following checks: one living room, one family room, two restrooms, one dining room, one kitchen and three bedrooms. The garage is located next to the kitchen and leads to the driveway. Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. The living room is furnished with one couch, one love seat, and one chair with enough seating for four people. The living rooms has board games and arts and crafts activities available for the client's use. The family room is equipped with two desks, two computers and locked file cabinet and two telephones that were tested and were observed to be in working order. The kitchen is equipped with operable appliances, kitchen utensils, pot, pans and dishes. The facility had a two day supply of perishable food and a seven day supply of non-perishable food. The hot water in the kitchen was measured at 115.3 degrees Fahrenheit, which is within regulatory requirements. The kitchen's appliances were tested and were observed to be in working order. The facility's smoke detectors were tested and observed to be in working order. There are six smoke detectors, one in the dining room, one in the hallway, and one in each individual bedroom. There are two carbon monoxide detectors that are located in the hallway and in the dining room. The carbon monoxide detectors were tested and observed to be in working order. Fire extinguishers are properly charged and ***CONTINUED ON LIC809C*** **Continued from LIC809** serviced. There are a total of four fire extinguishers located in the laundry room, garage, under the kitchen sink, and in the hallway. The facility has a fully equipped first aid kit and first aid manual stored on top of the file cabinet in the family room. There are no guns or weapons in the facility as stated by the Administrator. Medications are locked and centrally stored in a medication cabinet in the family room. Disinfectants and cleaning solutions were stored locked in a locked cabinet in the garage. Sharp knives were made inaccessible and stored in a locked drawer in the kitchen. The staff and client files are maintained in a locked file cabinet in the family room. The following required posted items were observed accessible to clients: Fire Clearance, Grievance Procedures, Personal Rights, Visitation policies, Emergency Disaster Plan and current menu. The bedrooms are set up as follows: Bedroom #1 will be occupied by one resident; has one twin bed, all required linen, mattress is in good condition; Bedroom #2 will be occupied by one resident; has one twin bed, all required linen, mattress is in good condition; Bedroom #3 has one resident C2; has one twin bed, all required linen, mattress is in good condition, and there was one dresser and one TV; Bedroom #4 is occupied by one resident; has one twin bed, all required linen, mattress is in good condition, one dresser, and one tv, and personal desktop computer. Bedrooms are arranged so that no more than one client is in a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. The bathrooms were clean and in good repair. All bedrooms have a wall air-conditioning unit installed and in working condition. The facility outside grounds were also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. There is an in-ground swimming pool located in the backyard of the facility which is made inaccessible with a fence and two pool gates that swing away from the pool, self-close and have a self-latching device located no more than six inches from the top of the gate. The fence is constructed so that the fence does not obscure the pool from view. **Continued on LIC809C page 2** **Continued from LIC809C** LPA reviewed two of two client files. Two out of two client files did not contain the medical authorization form and admission agreement in the facility current name. LPA did not find an activities calendar posted in the dining room that was current, and both clients did not have a educational activities plan. Interviews revealed that staff support the clients to go to school, but that there is no official facility plan that described how the staff support clients with educational activities after school. Due to time restraints LPA was unable to review staff files. LPA will return at a later unannounced date to complete the inspection. Based on the facility inspection review, the facility is being given a technical violation for California Code of Regulations (CCR), Title 22, Chapter 5, Section 84079(a), due to not having activity calendar posted, and CCR, Title 22, Chapter 5, Section 84079(a)(4) for not having a written plan to support educational activities. Finally, a technical violation for CCR Title 22, Chapter 5, Section 84068.1(b)(4)(A) for clients not having an admission agreement under the new facility name. An exit interview was conducted, and a copy of this report with the appeals rights was given to Facility Administrator Marie Noel.

met_with: Marie Noel, Administrator


facility_name: ARROW HOUSE, THE

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Narrative:
educational qualifications for the therapist position. Confidential interviews reported S2 was the therapist for C2. Conflicting statements reported S2 was listed as the mentor/coach for C2 while waiting for another therapist to start working at the facility. Due to C2 not being able to verify in what capacity S2 was working with C2, it is unknown if S2 was working as a therapist or a mentor. Confidential interviews and records reviewed did not provide a preponderance of evidence to prove or disprove the allegation that unqualified staff is performing therapy for the minors while in care. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and appeal rights were reviewed with Brittany Schoeneck. Due to printer malfunction, a copy of this report, along with the LIC 811, and appeal rights will be emailed to the Facility Administrator. A signed copy of this report will be kept in the Facility file.

Investigation Findings:
13On April 18, 2023, at 11:35 am , Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Brittany Schoeneck, Program Director of The Arrow House, to discuss the investigative finding for the allegation noted above. LPA Charmaine Linley conducted an inspection of the facility on 02/13/2023 at 10:59 am and no deficiencies were observed. LPA Linley interviewed two staff (S1, S2) and was unable to interview one client (C2) despite multiple attempts to contact them. LPA reviewed the following documents during the investigation: (C2) Master Treatment Plan, (C2) Biopsychosocial assessment, and group therapy notes. On 02/07/2023, Community Care Licensing received an allegation that unqualified staff are performing therapy for the minors while in care. It was reported that S2 and S4 were performing individual therapy sessions with the residents. Based on confidential records, S4 has a CADAC degree and meets the qualifications. Based on records reviewed, S2 was listed as the therapist for C2 and does not have the UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: ARROW HOUSE, THEFACILITY NUMBER: VISIT DATE: 04/18/2023

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

met_with: Brittany Schoeneck, Program Director


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Narrative:
have private phone calls, staff open minors mail, staff are administering medications without a physician's order, staff take away family visits as punishment, unqualified staff working with minors, due to staff stealing medications, minors are missing medication, and staff do not seek timely medical care for minors. Confidential interviews revealed conflicting statements. Due to not having specific dates and details regarding the allegations, confidential interviews and records reviewed did not corroborate the allegations with a preponderance of evidence. Based on confidential interviews and records reviewed the allegations that staff do not allow minors to have private phone calls, staff open minors mail, staff are administering medications without a physician's order, staff take away family visits as punishment, unqualified staff working with minors, due to staff stealing medications, minors are missing medication, and staff do not seek timely medical care for minors, which may have occurred, however, they not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Ehsan Ebrahim. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights was emailed to the Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On July 17, 2024, at 1:55 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Ehsan Ebrahim, Program Director, to discuss the investigative finding for the allegations noted above. LPA conducted an inspection of the facility on May 7, 2024, and no deficiencies were observed. LPA Linley interviewed three clients (C2, C4, C5), nine staff (S1-9), two clients declined to interview (C1, C3), and LPA attempted to interview three staff (S10-12), however, LPA was unable to contact them despite multiple attempts to contact them. The following documents were reviewed during the investigation: Personnel Roster, Client Roster, Admission Agreements, Medication Logs, Centrally Stored Medication Records, Physician Reports, Nursing Notes, Master Treatment Plans, Needs and Services Plans, Degrees/Licenses, Timesheets, and employee schedules. On May 3, 2024, Community Care Licensing (CCL) received allegations that staff do not allow minors to UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: ARROW HOUSE, THEFACILITY NUMBER: VISIT DATE: 07/17/2024

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

met_with: Ehsan Ebrahim


summary: Facility Evaluation

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Narrative:
On April 21, 2022 at 2:00pm, Licensing Program Analyst (LPA) Charmaine Linley and Licensing Program Manager (LPM) Ann Valenzuela arrived at the facility to conduct a pre-licensing inspection of the facility. The facility was inspected inside and out with Administrator John Lieberman, and Operations Director, Emily Cohen. The home is a single-story residence with a front house and back house/main house, separated by the garage and driveway. There are cameras in the common areas and outside areas. The cameras are video only, no audio. This home provides awake night staff. The facility will be operating with the capacity of 20. The front house consists of one living room, three offices, two storage rooms, one restroom, one kitchen, and one dining area. The garage is located next to the storage area and leads to the driveway and the back house/main house. The front house will mainly be used for offices and for the intake area for clients. The back house/main house has a school room, recreation room, kitchen, dining room, staff room, two offices, medication room/Nurse's station, group room, laundry room, pantry, supply closet, four bathrooms, and ten -bedrooms. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. Living room, dining room, group home, recreation room, and school room are for clients to use. There is adequate indoor and outdoor activity space. Medication and the first aid kit will be kept locked in the medication room/Nurses' station, located in the "Main House." Medication room has a locking door, locking window, and a locking medication cabinet. The facility also has a refrigerator that locks to store medications that require refrigeration. *** The facility's smoke detectors and carbon monoxide detectors were tested and observed to be in working order. Fire extinguishers are properly charged and services. The facility has a fully equipped first aid kit and first aid manual. There are no guns or weapons in the facility as stated by Administrator. Disinfectants and cleaning solutions were stored locked in a supply room next to the laundry room. Sharp knives were made inaccessible and stored in a locked cabinet in the supply closet. The staff and client files will be maintained electronically stored. LPM advised Administrator that staff and client files are to be accessible to Community Care Licensing (CCL) at any time. The following required posted items were observed accessible to clients: Facility License, Grievance Procedures, Personal Rights, Visitation policies, Emergency Disaster Plan and current menu. The bedrooms are set up as follows: Bedroom #1 will be occupied by two residents; two twin beds, all required linen, mattresses in good condition. Bedroom #2 will be occupied by two residents; two twin beds, all required linen, mattresses in good condition. Bedroom #3 will be occupied by two residents; two twin beds, all required linen, mattresses in good condition. Bedroom #4 will be occupied by two residents, as needed; two twin beds,, all required linen, mattresses in good condition. Bedroom #5 will be occupied by two residents, as needed; two twin beds,, all required linen, mattresses in good condition. Bedroom #6 will be occupied by two residents, as needed; two twin beds,, all required linen, mattresses in good condition. Bedroom #7 will be occupied by two residents, as needed; two twin beds,, all required linen, mattresses in good condition. Bedroom #8 will be occupied by two residents, as needed; two twin beds,, all required linen, mattresses in good condition. Cont. on 809-C Bedroom #9 will be occupied by two residents, as needed; two twin beds,, all required linen, mattresses in good condition. Bedroom #10 will be occupied by two residents, as needed; two twin beds,, all required linen, mattresses in good condition. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. The bathrooms were clean and in good repair. The hot water in one of the client bathrooms was measured at 118 degrees, which is within regulatory requirements. The fire clearance has been approved. Based on the facility pre-licensing inspection review, no deficiencies were noted at the time of inspection. Upon Licensing Program Manager's final review, the license will be provided. An exit interview was conducted, due to printer failure. LPA emailed the Administrator and COO, John Lieberman, the LIC 9099's.

met_with: John Lieberman, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On July 20, 2022, at 9:30 am, Licensing Program Analyst (LPA) Charmaine Linley arrived at the facility to conduct a Comprehensive Annual Post-Licensing Inspection visit. LPA and Facility Administrator Ehsan Ebrahim, and Operations Manager, Westley Cruz, inspected the facility inside and outside. The facility was licensed as a group home on April 22, 2022. The facility is a single-story residence with a front house and a back house/main house, separated by the garage and driveway. There is at least one week's supply of nonperishable, and two days' supply of perishable foods. There is a variety of snacks available for the clients. There are cameras in the common areas and outside areas. The cameras are video only, with no audio. This home provides awake night staff. The facility has a capacity of 20. The group home serves clients between the ages of 12-17 years old, both female and male. There were four clients at the facility during LPA's visit. The front house consists of one living room, three offices, two storage rooms, one restroom, one kitchen, and one dining area. The garage is located next to the storage area and leads to the driveway and the back house/main house. The front house will mainly be used for offices and the intake area for clients. The back house/main house has a school room, recreation room, kitchen, dining room, staff room, two offices, medication room/Nurse's station, group room, laundry room, pantry, supply closet, four bathrooms, and ten bedrooms. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris and observable hazards. The living room, dining room, group home, recreation room, and school room are for clients to use. There is adequate indoor and outdoor activity space. Medication and the first aid kit is kept locked in the medication room/Nurses' station, located in the "Main House." The *** medication room has a locking door, a locking window, and a locking medication cabinet. The facility also has a refrigerator that locks to store medications that require refrigeration. The facility has a fully equipped first aid kit and first aid manual. The facility's smoke detectors and carbon monoxide detectors were tested and observed to be in working order. Fire extinguishers are properly charged and services. There are no guns or weapons in the facility as stated by the Administrator. Disinfectants and cleaning solutions were stored locked in a supply room next to the laundry room. Sharp knives were made inaccessible and stored in a locked cabinet in the kitchen. The staff and client files are maintained and electronically stored. LPM advised the Administrator that staff and client files are to be accessible to Community Care Licensing (CCL) at any time. The following required posted items were observed accessible to clients: Facility License, Grievance Procedures, Personal Rights, Visitation policies, Emergency Disaster Plan, and current menu. All hazardous items have been properly made inaccessible. There are a total of ten bedrooms in the facility and two clients are assigned to each bedroom. There is one client per bed. All bedrooms in the units had adequate beds, lighting, shelf, dressers, and closet space for clients' belongings. There are sufficient linens, blankets, towels, and pillows. The bathrooms were clean and in good repair. The kitchen's water temperature was inspected and measured 125 degrees. Bathroom one's water temperature was inspected and measured 125 degrees. Bathroom two's water temperature was inspected and measured 110 degrees. LPA partially reviewed four out of four client files (C1-C4) (see confidential names list, LIC 811, dated 07/20/2022). Due to time constraints, LPA will return at a later date to review the remaining client files, staff files, and conduct interviews with clients and staff. An exit interview was conducted, and a copy of this report was discussed with Ehsan Ebrahim, Facility Administrator. Due to printer malfunction, LPA emailed the LIC 809, LIC 811, to John Lieberman. A copy of the report will be placed in the facility file.

met_with: Ehsan Ebrahim, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On July 21, 2022, at 11: AM, Licensing Program Analyst (LPA) Charmaine Linley arrived at the facility to continue a Comprehensive Annual Post-Licensing Inspection visit that began on 07/20/2022. LPA met with John Lieberman, Facility Administrator. During the inspection, LPA reviewed staff files and client files. All the staff files are stored and secured electronically at the corporate office. LPA reviewed ten out of twenty staff files (see confidential name list, LIC811, dated 07/21/2022) via Zoom with Human Resources Director, Jennifer Richardson from 9:00 am-10:15 am. All staff that works at the facility have Department of Justice, FBI, and Child Abuse Index Clearances. LPA reviewed staff training records. During the inspection, LPA interviewed three out of five staff. LPA reviewed four out of five client files (C1-C4) (see confidential names list, LIC 811, dated 07/20/2022). LPA was unable to conduct interviews, due to clients attending group sessions. The client files are maintained in a locked cabinet in the medication room. LPA completed the component III Orientation and discussed Incident reporting, including incidents related to Assembly Bill 388 law enforcement contacts as well as incidents involving emergency interventions. The facility was informed that the address to this facility is available to the public. All special incident reports (SIRs) will be sent via e-mail to: cclpaccr@dss.ca.gov. The reporting requirements were reviewed with the Facility Administrator on this date. Please complete the LIC 500 and send it to LPA Linley within 30 days. Based on the facility's post-licensing inspection review, two deficiencies were issued for CCR 84070(b)(13) and CCR 80075(k)(7)(B) An exit interview was conducted, and a copy of this report and appeals were discussed with John Lieberman, Facility Administrator. Due to printer malfunction, LPA will email a copy of the the LIC 809, LIC 809D, LIC 811, and appeals form, to John Lieberman, Facility Administrator. A copy of the report will be placed in the facility file.

met_with: John Lieberman, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On April 11, 2024, at 9:45 am Licensing Program Analyst (LPA) Charmaine Linley arrived at the facility to conduct a Comprehensive Annual Inspection visit. LPA and Ehsan Ebrahim, Facility Administrator, inspected the facility inside and outside. The facility was licensed as a group home on April 22, 2022. The facility is a single-story residence with a front house and a back house/main house, separated by the garage and driveway. There is at least one week's supply of nonperishable, and two days' supply of perishable foods. There is a variety of snacks available for the clients. There are cameras in the common areas and outside areas. The cameras are video only, with no audio. This home provides awake night staff. The facility has a capacity of 20. The group home serves clients between the ages of 12-17 years old, both female and male. There were five clients at the facility during LPA's visit. The front house consists of one living room, three offices, two storage rooms, one restroom, one kitchen, and one dining area. The garage is located next to the storage area and leads to the driveway and the back house/main house. The front house is mainly used for offices and the intake area for clients. The back house/main house has a school room, recreation room, kitchen, dining room, staff room, two offices, medication room/Nurse's station, group room, laundry room, pantry, supply closet, four bathrooms, and ten bedrooms. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris and observable hazards. The living room, dining room, group room, recreation room, and school room are for clients to use. There is adequate indoor and outdoor activity space. Medication and the *** first aid kit is kept locked in the medication room/Nurses' station, located in the "Main House." The medication room has a locking door, a locking window, and a locking medication cabinet. The facility also has a refrigerator that locks to store medications that require refrigeration. The facility has a fully equipped first aid kit and first aid manual. The facility's smoke detectors and carbon monoxide detectors were tested and observed to be in working order. Fire extinguishers are properly charged and serviced. There are no guns or weapons in the facility as stated by the Administrator. Disinfectants and cleaning solutions were stored locked in a supply room next to the laundry room. Sharp knives were made inaccessible and stored in a locked cabinet in the supply closet. The staff and client files are maintained and electronically stored, as well physical files. The following required posted items were observed accessible to clients: Facility License, Grievance Procedures, Personal Rights, Visitation policies, Emergency Disaster Plan, and current menu. All hazardous items have been properly made inaccessible. There are a total of ten bedrooms in the facility and two clients are assigned to each bedroom. There is one client per bed. All bedrooms in the units had adequate beds, lighting, shelves, dressers, and closet space for clients' belongings. There are sufficient linens, blankets, towels, and pillows. The bathrooms were clean and in good repair. The kitchen's water temperature was inspected and measured 105 degrees. Bathroom one's water temperature was inspected and measured 108 degrees. Bathroom two's water temperature was inspected and measured 106 degrees. LPA reviewed five out of five client files (C1-C5) (see confidential names list, LIC 811, dated 04/11/2024). LPA conducted three out of five interviews (C1-C3). The client files are maintained in a locked office. LPA reviewed five out of five staff files (S1-5) (see confidential names list, LIC 811, dated 04/11/2024). LPA interviewed two staff. All staff that work at the facility have Department of Justice, Federal Bureau of Investigation and Child Abuse Index Check clearances. A review of administrative records indicates that the facility has paid their current licensing fees. No deficiencies were cited during today's visit. An exit interview was conducted, and a copy of this report was discussed with Ehsan Ebrahim. Due to printer malfunction, LPA emailed the LIC 809, LIC 811, and appeal rights to Ehsan Ebrahim. A copy of the report will be placed in the facility file.


summary: Facility Evaluation

raw_content:
Narrative:
On this date at 5:00 pm, Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced case management inspection to this facility. LPA Linley met with Ehsan Ebrahim, Program Director. LPA conducted a walk through of the facility and no deficiencies were observed. A case management has been opened regarding information reported to the Department. LPA interviewed one staff. Further information and interviews are required, therefore this case management is being extended. The outcome of the investigation will be provided to the Facility Administrator. The facility is reminded not to discuss the ongoing investigation with any interested parties. An exit interview was conducted and due to printer malfunction, a copy of this report will be emailed to the Facility Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On June 12, 2025, at 09: AM , Licensing Program Analyst (LPA) Stefanie Mutialu made an unannounced visit for the for the purpose of conducting an annual inspection of the facility. LPA met with Executive Director, Jackie Hoagland and Administrator, Ehsan Ebrahim . The Facility is licensed to serve twenty (20) ambulatory children ages 12-17 years old. The current census is nine (9) children. The facility is a one story ten-bedroom, four-bathroom home with a front house and a back house/main house, separated by the garage and driveway. A physical plant inspection was completed with Executive Director, Jackie Hoagland and included the following checks: The front house, one living room, three offices, two storage rooms, one restroom, one kitchen, and one dining area. The back house/main house, school room, recreation room, kitchen, pantry, dining room, staff room, two offices, medication room/nurse's station, group room, laundry room, pantry, supply closet, ten client bedrooms, three client bathrooms, one staff bathroom, kitchen, living room, dining room, Administrator office, outdoor garden, and laundry room. All required forms are posted including Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster, the Emergency Disaster ****Continued on Page 2**** Plan was also posted. Clients' medications were observed to be inaccessible and stored in the medication room. LPA observed eighteen (18) interior and nine (9) exterior cameras placed around the facility. No cameras are positioned in direct line of bedrooms, ,bathrooms, or any direction that would violate personal rights. Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. Fre extinguishers are properly charged and serviced on 05/18/2025. Fire inspection was completed on 01/14/2025 and LPA received a copy of the approved Fire Inspection to place in facility file. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. LPA observed a minimum seven-day non-perishable and two-day perishable supply of food. On staff chef prepares three meals a day tailored to each client. Individual beds were observed with clean linens, pillows, comforters, and mattress in good repair. All ten bedrooms contain two twin beds. The facility has three client bathrooms and five showers. The water temperature was tested in one bathroom and met the appropriate range of 105 degrees to 120 degrees Fahrenheit. LPA reviewed five client files to ensure client records had all required documents per Title 22 regulations. Client records are stored in a secured office. LPA reviewed nine client medication records. LPA conducted two staff interviews and two client interviews. No deficiencies cited. Per facility staff, no firearms or weapons are allowed in the facility. The licensing fee payments are current. An exit interview was conducted, and a copy of this report, confidential names (LIC811), and appeal rights were discussed and provided to Ehsan Ebrahim. A copy of this report will be placed in the facility file.

met_with: Administrator, Ehsan Ebrahim


facility_name: ASCEND BEHAVIORAL HEALTH

summary: Complaint Investigation - Substantiated

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Investigation Findings:
13On March 8, 2023, Licensing Program Analyst (LPA) Wayne Aoki was met by Program Manager, Aaron Vargas for the purpose of closing the investigation and providing the agency with the findings for the above-mentioned allegation. Based on confidential interviews and other documents obtained during the investigation, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. The agency is being cited in Group Home, Title 22, Division 6, Chapter 5, Article Continuing Requirements, Section 84072 (d)(10) Personal Rights. An exit interview was conducted, and a copy of the report and appeal rights were provided to the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Wayne Aoki 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 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SIERRA CASCADE AC/SC, E SHAW AVE FACILITY NAME: ASCEND BEHAVIORAL HEALTHFACILITY NUMBER: 107207217

met_with: Aaron Vargas


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13On June 22, 2023, Licensing Program Analyst (LPA) Wayne Aoki was met by Program Manager, Aaron Vargas for the purpose of closing the investigation and providing the agency with the findings for the above-mentioned allegations. Based on confidential interviews and other documents obtained during the investigation, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. The agency is being cited in Group Home, Title 22, Division 6, Chapter 5, Article Continuing Requirements, Section 84072 (d)(10) Personal Rights and Chapter 1, Article 6. Continuing Requirements, section 80075(b)(5)(B) Health Related Services An exit interview was conducted, and a copy of the report and appeal rights were provided to the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Wayne Aoki 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 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SIERRA CASCADE AC/SC, E SHAW AVE FACILITY NAME: ASCEND BEHAVIORAL HEALTHFACILITY NUMBER: 107207217


summary: Complaint Investigation - Substantiated

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Investigation Findings:
13Licensing Program Analyst (LPA) Daiquiri Boyd conducted a follow up complaint inspection at the Short Term Residential Therapeutic Program (STRTP) and met with Aaron Vargas . The purpose of the inspection was to deliver the findings for the above complaint allegation. During the course of the investigation, LPA conducted interviews and reviewed documentation. Based on confidential interviews and documentation the allegation is SUBSTANTIATED. Citation was issued for lack of supervision. A copy of this report was left at the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Daiquiri Boyd 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 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FRESNO RO, E SHAW AVE FACILITY NAME: ASCEND BEHAVIORAL HEALTHFACILITY NUMBER: 107207217


summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Daiquiri Boyd conducted an unannounced visit to the Short Term Residential Therapeutic Program (STRTP) to deliver the findings of the above allegations and met with Program Manager, Aaron Vargas. The above allegations were referred to Community Care Licensing for investigation. The investigation included interviews and a review of facility and client records. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegations occurred. Therefore, the allegations are UNSUBSTANTIATED at this time. A copy of this report was discussed and provided along with appeal rights. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Daiquiri Boyd 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


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Investigation Findings:
13On August 29, Licensing Program Analysts (LPA) Angelica Borja conducted a complaint inspection at Ascend Behavioral Health and met with Aaron Vargas. The purpose of the inspection was to deliver the findings for the above complaint allegation. During the investigation, LPA conducted interviews, a records review and reviewed supporting documents provided by the facility. Based on confidential interviews and other information obtained, the department has made the following determination. Although the allegation may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Melikian LICENSING EVALUATOR NAME: Angelica Borja LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Aaron Vargas, Program Manager


raw_content:
Investigation Findings:
13On May 13, Licensing Program Analyst (LPA) Angelica Borja conducted a complaint inspection at Ascend Behavioral Health and met with Aaron Vargas. The purpose of the inspection was to deliver the findings for the above complaint allegation. During the investigation, LPA conducted interviews, a records review and reviewed supporting documents provided by the facility. Based on confidential interviews and other information obtained, the department has made the following determination. Although the allegation may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Melikian LICENSING EVALUATOR NAME: Angelica Borja LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Program Manager, Aaron Vargas


summary: Facility Evaluation

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Narrative:
On the above date a scheduled component II orientation was held virtually via the Microsoft teams platform. Present for the Department was Lisa Slusher, Licensing Program Analyst. Representing the Applicant were: Jason Christopherson, Alicia Alva, Devon Wayt, Jazmin Galvan and Christina Kiesselbach. Discussed review letter dated 7/1/22 and outstanding program items as well as status of the organization. LPA also discussed licensing environment and expectations. LPA stated that component III and pre-licensing inspection would be scheduled following program approval.

met_with: Matthew Tatum, Alicia Alva


summary: Facility Evaluation

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Narrative:
On the above date, Licensing Program Analyst (LPA) Lisa Slusher travelled to the facility listed above to conduct a pre-licensing inspection. The applicant submitted an application on 2/4/2022. The Program Statement has been reviewed and approved as meeting regulatory requirements. LPA met with Jason Christopherson, Brittany Farrell, Alicia Alva, Devon Wayt, Jazmin Galvan and Christina Kiesselbach 1. Facility grounds inspected. Grounds are clean and free from observable hazard. No bodies of water observed on the property. 2. Adequate indoor activity space and materials observed, and outdoor activity space was observed. 3. Chemicals were appropriately locked 4. Procedures for Locked and centrally stored medications observed. 6. Adequate storage space observed. 7. Individual beds in good repair observed. A supply of extra linens available for bed changes. 8. The house has 4 bedrooms, a mixture of single double occupancy, located on two levels. Bedrooms are accommodating of all required furnishings. 9. Adequate food storage space observed. Facility will add appropriate supply of foods upon placement of youth in the home. A supply of nonperishable foods were observed on this date. 10. Sample menu posted. 11. All appropriate forms posted within client view. 12. Dining room equipped with large table and chairs accommodating of all clients. 13.Facility has three full restrooms, two for client use, one for staff use, all are operable. Hot water measured within 105-120 on this date. Applicant does not have personnel associated through Guardian. Prior to initial license approval, the licensee (corporation owner) and Administrator must be fingerprint cleared and associated to the facility. Prior to accepting clients for care, the facility shall ensure that all personnel who will have client contact are cleared and associated. Discussed Guardian process with the facility. Discussed with the facility the process for changing the facility Administrator. The following documents are required: 1. LIC 308 (Designation of Facility Responsibility) designating new administrator. 2. Current Personnel Record for new Administrator. 3. Verification of Education and/or experience for new administrator. 4. Copy of current administrator certificate. 5. Current (within one year) health screening and TB test. 6. Board Resolution granting administrative responsibility to the new administrator. 7. Fingerprint association transfer request (if the Administrator is not already associated to the facility) 8. Exception request (if the Administrator does not specifically meet regulatory requirements, i.e. experience is in a facility with a capacity of six or fewer). Discussed Incident reporting. An initial report for all reportable incidents is to be made by the next working day to CCLFresnoIncidents@dss.ca.gov. A full report is to be remitted within 7 days and may also be made to the incident reporting email. The currently assigned analyst for the facility will be Wayne Aoki. Wayne.Aoki@dss.ca.gov or at (559) 978-9486. On this date, the facility will be approved for initial licensure, pending verification of guardian clearance and association for the Licensee and Administrator. Initial license will be issued on a provisional basis, expiring one year from effective date. License will be valid for up to 6 male and/or female youth ages 12 through 17.

met_with: Alicia Alva, Jason Christopherson


summary: Facility Evaluation

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Narrative:
On October 6, 2025, Licensing Program Analysts (LPAs) Angelica Borja and Briana Placencia traveled to Ascend Behavioral Health located in Clovis CA. LPAs were met by Administrator Alicia Alva and Program Director Aaron Vargas, for the purpose of a scheduled pre-licensing inspection for the Group Home. A general overview of their program and a tour of the facility was provided. The facility is a single story residence with five bedrooms, the bedrooms have all required furnishings, the facility has three and a half restrooms, one bedroom serves as the therapy room and the master bedroom serves as the office. Facility is to ensure water temperature is maintained between 105 and 120 degrees or post warning signs as today the hot water read 145 degrees. LPAs observed fixtures and furniture, equipment and supplies necessary for this operation. LPAs observed locked cabinets for client and staff files in order to ensure confidentiality. The facility does have a pool on site that meets regulatory standards. The agency employs one administrator and program director. The facility is equipped with a first aid kit and a fire extinguisher. All required LIC forms and personal rights are posted in a common area. Items discussed were the hot water temperature and outside debris. The Group Home has requested to submit a waiver to associate all staff to one facility number. The licensee is being cited two Technical Advisories (TA), please see attached LIC 9102s. Upon completion of the two TA's the facility will be ready for licensure. A copy of this report was provided to the Licensee.

met_with: Alicia Alva, Administrator and Aaron Vargas, Program Director


summary: Facility Evaluation

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Narrative:
On February 18, 2026, Licensing Program Analyst (LPA) Angelica Borja conducted a post-licensing inspection at Ascend Behavioral Health and met with Program Manager, Aaron Vargas. A inspection of the facility was conducted indoors and outdoors. The group home currently has two clients in care. The group home currently employs one Administrator, one Facility Manager, eight Direct Care staff, Program Director, Clinical VP, Clinical Lead, Clinicians/Therapists, one LVN, and two Case Managers/Counselors. LPA reviewed 5 staff files and two client files. LPA interviewed two staff and one client. LPA observed individual beds with appropriate clean linens and in good repair. Cleaning chemicals inaccessible to clients. The facility is maintained at 70 degrees. All facility smoke and carbon monoxide detectors appear to be in appropriate working order, fire extinguisher is properly charged and was last serviced in April 2025. The Group Home currently has no firearms and one swimming pool. Medications are centrally stored and locked. A review of the Licensing Information System on February 18, 2026, indicates that all facility staff are associated to the Group Home and have DOJ, FBI, and child abuse index check clearances. At this time the Group Home is in the process of accreditation. One Technical Advisory was cited during todays inspection A copy of this report and appeal rights was left at the facility at the conclusion of this inspection.


summary: Facility Evaluation

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Narrative:
On March 12, 2026, Licensing Program Analyst (LPA) Angelica Borja conducted a Case Management inspection at Ascend Behavioral Health and met with Ciara Armstead-Program Manager. The purpose of this inspection was to discuss concerns with an incident report that was sent into the Department on 2/10/26, the incident in question happened on 2/09/26. LPA conducted an interview and discussed medication administration procedures. The Department determined this to be an immediate risk to health and safety at this time, therefore the Group Home is being cited on the attached LIC809-D under CCR, Health Related Services 80075(b). A copy of this report and appeal rights was left at the facility.

met_with: Ciara Armstead, Program Manager


summary: Facility Evaluation

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Narrative:
Licensing Program Manager (LPM) Yan Yeung and Licensing Program Analyst (LPA) Caitlin Chambers conducted a meeting with the applicant, Mr. Matthew Tatum, via Microsoft Teams for the purpose of a Component II discussion of the application. The virtual meeting was held due to this regional office being under renovation. The following pending issues were discussed during the meeting: · Bank information with adequate funding-applicant needs to provide LIC 404 with appropriate bank account information. Current funding shown is inadequate. · Revised LIC 401 (monthly operating statement) showing rate for each client and wages for staff listed on LIC 500 · Copy of lease showing monthly rent which should be matching the rent listed on LIC 401 · Fingerprint association or live scan for all staff names on LIC 500 · Proof of qualification for all staff listed on LIC 500 · Current CPR/first Aid and Health screening for all staff listed on LIC 500 · Copy of Component I with clear information of attendees · Organization chart that shows all line of supervision, with agency titles matching GH staff according to Title 22 listed positions · Updated protocols for infectious diseases · Handling of Cash resources and inventory according to Title 22 regulations 80026. · Revision of meal services and menu of a week according to Title 22 regulation 80076 · Revision of House rules to avoid blanket statements which could be personal rights violations. · List all visitation hours for clients. · List all reporting requirement to the Department. · List details of Runaway plan showing time requirement for contacting law enforcement and reporting timeframe for the Department. · List the writer and the qualification that wrote the emergency intervention plan · List who are the internal/external trainers used for the training of staff · Reorganization of table of contents to comprise with all the content of LIC 9106 (Table of contents for Group home program statement) Some of the above topics need a revision of the program statement which will be due to the department by February 7, 2025. An exit interview was conducted, and a copy of this report was emailed to the applicant, Mr. Tatum for signature. Mr. Tatum will need to sign and mail back a hard copy and a e-copy of this report to LPA Chambers.

met_with: Matthew Tatum


summary: Facility Evaluation

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Narrative:
On 3/27/25, at 11: AM Licensing Program Analyst (LPA) Caitlin Chambers made an announced Prelicensing Inspection at the Ascend Behavioral Health Group Home. The LPA met with applicant Matthew Tatum and informed him that the purpose for the inspection was to assess the facility's physical environment prior to issuance of a license. LPA Chambers along with Mr. Tatum conducted an overall visual assessment of the inside and outside the Agency's physical plant. At the time of the inspection, LPA observed a one story home in a residential area. The facility is clean, safe, sanitary and in good repair. The Community Care Licensing Hotline complaint number and the Fresno Crisis Hotline number is framed on the wall where the client have a room to take there medication, located next to the classroom. The Emergency Disaster Plan for Children Residential Facilities (LIC 610C), Fire Evacuation/Escape plan and the Agency floor plan (sketch, with labeled rooms) is available near the front of the home. To the right of the home is a room for the therapist and clinicians to work. There is a menu of the fridge, and due to no clients being there, there is just snacks in the fridge. The facility has room for six clients. There are six beds for each of the clients in the bedrooms. Each bedroom has a dresser, night stand with drawers, a ceiling fan, and night lamps on the night stand. The bedrooms are as follows: Bedroom #1 has two beds, two dressers/ wardrobes. Bedroom #2 is a private bedroom meaning it has one full size bed, walk in closet, and a catty in the walk in closet. Bedroom #3 has two sinks, and a shower. Bedroom #4 has a private bedroom room meaning it has a full-size bed and shares a bathroom with Bedroom #2 and bedroom #3. The temperature of the water is in range in six sinks and 3 of the showers ranging from 111 degrees F to 119.3 degrees F. There is a full size bathroom outside Bedroom #2. There is a kitchen with 6 stools and a dining area for the clients to eat. There is a classroom/ multipurpose room where the Academic Case Manager will be. There are six large desks and six chairs with lighting for a classroom setting with windows. Next to the staff area is the medication room with all locked boxes and Medication folders to keep track of the medication checks. Outside of the classroom there is a closet for the clients to keep their personal items in security boxes. Next to the laundry room is locked closet full of colored coded towels of all sizes and well organized. There are two pairs of towels per client and two pairs of linens for each client. Also, inside the laundry room has the chemicals for cleaning clothes, and extra supplies for hygiene for the clients. Next to the classroom is for staff only area, with a shower, a sink, and a medication room. There is a garage that is turned into mobile workspace with new couches and new rugs and plenty of space. There are phones in the garage/mobile workspace to make phone calls. Outside there is a pool with a locked fence five feet tall. A ping pong table and space for clients to play in the grass, or cement. There are no firearms or ammunition in the facility. There is planned activities for the whole week. LPA Chambers checked the fire extinguisher next to the kitchen with current dates on the extinguisher and smoke detectors were checked in each bedroom. The home temperature is cool and comfortable at 70 degrees. Per applicant, written menus will be current and posted weekly in an area accessible to the staff and children, and the Planned Activity Schedule will be current and posted. An LIC 809 report was given to the Licensee. An exit interview was conducted


summary: Facility Evaluation - 1 deficiency

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Narrative:
On October 30, 2025, at 08:50 a.m., Licensing Program Analysts (LPAs) Amber Hunter and Brent Lockhart, and Licensing Program Manager (LPM) Jean Herring, conducted an unannounced Post Licensing inspection at Ascend Behavioral Health Group Home (GH). LPAs and LPM met with Leroy Rickard, Clinical Supervisor. The facility currently has a provisional Group Home license and is licensed to serve six (6) ambulatory clients age 12 to 17 years old. There are currently 3 clients (1 male and 2 females) placed at the facility. LPAs and LPM reviewed the following domains of the Compliance and Regulatory Enforcement (CARE) tool: Physical Plant, Disaster Preparedness, Operational and initial review of Client Records. Physical Plant The license, facility sketch, personal rights, emergency disaster form, complaints poster, emergency phone numbers and food menu are posted in a prominent, publicly accessible location in the facility. Disinfectants, cleaning solutions, sharps and knives are kept inaccessible and in a locked room located off the kitchen hallway. Facility has non-perishable food for at least one week and perishable food for at least two days except milk products. Medications are centrally stored in a locked cabinet in the office. Smoke and carbon monoxide detectors were tested and in proper working order. Fire extinguishers were fully charged. Room temperatures are maintained at around 66-71 degrees F. The hot water temperature was tested and measured at 103 degrees F. All sinks, showers and toilets are in working order. All beds are in good repair; equipped with good springs, clean mattresses and pillows. Adequate supply of beddings and linens were observed. Overall, facility is clean, safe, sanitary and in good repair. Operations Facility maintains a current, written plan of operation that meets licensing standards. Facility maintains and implements written complaint procedures and the procedures are posted in a publicly accessible location in the facility. Disaster Preparedness Plan Facility maintains a current LIC610C - Emergency Disaster Plan. Written disaster and mass casualty plan is available at the facility. LPAs and LPM also initiated review of client records. During today's inspection, the facility was issued one (1) Type B deficiency citation (see LIC809-D) and provided six (6) Advisory Notes-Technical Violations/Technical Assistance (LIC9102s). An exit interview was conducted. A signed copy of this report, LIC809-D, LIC 811, LIC9102TVs, LIC 9102TA and appeal rights were provided to Leroy Rickard, Clinical Supervisor. A continuation inspection is required.

Deficiencies:
80087(b): (b)	All clients shall be protected against hazards within the facility through provision of the following

met_with: Leroy Rickard - Clinical Supervisor