summary: Facility Evaluation

raw_content:
Narrative:
On March 04, 2024 at 11: A.M. Licensing Program Analyst (LPA) Stephannie Verna made an announced pre-licensing inspection at the facility and met with Esther Wambui Kiiru, Licensee, who assisted LPA with the inspection. LPA inspected the facility's interior and exterior building and grounds. The facility is comprised of four bedrooms and three bathrooms. There are three client bedrooms, and the licensee has the ability to provide bedroom accommodations to meet the requirements related to the license capacity and client special health needs. At this time, there are no clients in care, however pending placement of a client into the facility, the licensee is prepared to provide care and has the following maintained at the facility: a locked and secure location for cash resources to be entrusted to Licensee; a secure location and process for locking and maintaining medication in a centrally stored location; and maintaining a separate client records for each client to ensure the confidentiality of the records maintained. The facility has no swimming pool or bodies of water on the property, and no use of security recording cameras in private areas. A few fence posts were observed to be missing from the backyard fence, due to a storm. The licensee filed a claim with their home insurance company and is in the process of repairing the backyard fence. The facility was observed to be clean, sanitary, and in good repair; and no deficiencies were observed. continued on 809-c LPA reviewed the Licensee's personnel record, and observed all required documentation present, and filed, including documentation pertaining to criminal record clearance, mandated reporter statement, and current (RN) Nursing License and CPR and First Aid Certification. LPA completed Component Three of the licensing process with the Licensee. LPA conducted an interview with the licensee and provided the following information and resources pertaining to: Fingerprint clearances/Guardian, LPA inspections, citation/advisory note process, civil penalty types, CARE tools, CDSS forms and how to find them, exceptions and waivers, PINs, reporting requirements, inspection authority, POCs, extensions on POC due dates, personal rights, updates to the Program Statement, and Small Family Home specific regulations; Technical Support Program, and the following websites:https://www.cdss.ca.gov/inforesources/childrens-residential/resources-for-provider, https://cdss.ca.gov/inforesources/community-care-licensing/subscribe, https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian and https://www.cdss.ca.gov/inforesources/forms-brochures/forms-alphabetic-list/i-l On this date, the facility is ready to be licensed and LPA will issue the license to the Licensee. The Licensee will keep in communication about placement of clients into the facility, and will submit required documentation to the Department as required, including Incident Reports and LIC 500, Employee Rosters. An exit interview was conducted with Esther Wambui Kiiru, Licensee, and a copy of this report was provided to them.

met_with: Esther Wambui Kiiru, Licensee


state: CA

facility_name: ESTHER WAMBUI SMALL FAMILY HOME

summary: Facility Evaluation - 3 deficiencies

raw_content:
Narrative:
On 10/14/2024 at 10:00 a.m. Licensing Program Analysts (LPAs) Elena Gonzalez-Soto and Jean Stidman arrived at the above facility and conducted an unannounced Post-Licensing Inspection. LPAs were greeted by Licensee, Esther Kiiru who assisted with the inspection and file review. LPAs observed the facility is a four-bedroom, three-bathroom two story home. When LPAs arrived two staff and three children were present. During the inspection one child arrived. LPAs inspected the facility inside and outside. LPAs inspected and/or reviewed the following: Client Records: LPA Stidman reviewed three children's files and observed all three were missing written consent forms, an account of cash resources and personal property/valuables, and needs and services plans. Two children's files were missing authorization for psychotropic medications. Two Centrally Stored Medication Logs were incomplete. Staff Records: LPA Gonzalez-Soto reviewed six out six staff files and observed six out of six staff did not have documentation of training requirements. The following items were reviewed for compliance: Guardian Roster, LIC500, copy of LIC400 and original LIC402. Facility Citation Violation of California Code of Regulations, Title 22, Division 6, 83064(a)(2), 83064(h),83064(j)(1) Licensee Duties and Responsibilities, 80070(b) Clients Records, 83070(b)Child's Records, 80075(k)Health-Related Services, 83068.2(a)Needs and Services Plan. An exit interview was conducted and a copy of this report and appeal rights were left with Licensee, Esther Kiiru.

Deficiencies:
80070(b): Client Records

(b) Each record must contain information including, but not limited to, the following
83070(b): Child's Records

(b) For each child in the home, the licensee shall maintain a separate, complete, and most up to date record or file that includes the following
80075(k): Health-Related Services

(k) The following requirements shall apply to medications which are centrally stored

report_type: Facility Evaluation

met_with: Licensee, Esther Kiiru


summary: Facility Evaluation

raw_content:
Narrative:
On 10/15/2024 at Licensing Program Analyst (LPA) Elena Gonzalez-Soto arrived at the above facility and conducted an unannounced continuation Post-Licensing Inspection. LPA was greeted by Mamadou Bah (S6) and notified LPA that Licensee, Esther Kiiru was on her way home. LPA thanked S6 and waited for Licensee to arrive. Licensee arrived shortly after and assisted LPA with the inspection. When LPA arrived two staff and no children were present. LPA observed the facility is a four bedroom, three bathroom two story home. LPA inspected the facility inside and outside. LPA inspected and/or reviewed the following: Physical Plant: Posting of license, Personal Rights, Disinfectants/Cleaning solutions inaccessible, Refrigerator Temperature at or below 45 degrees F, 36 degrees, Freezer Temperature at or below 0 degrees, 0 degrees F, Nonperishable Foods one week and fresh perishable foods for three days, menu present and posted, working telephone, First Aid Kit fully stocked, Common Room available, Dining area (enough seating, furniture good condition, not broke or damaged), Medication centrally stored, locked/inaccessible, Hot Water between 105-120 degree F, 122 degrees, Fire Extinguishers purchased September 2024. Toilets wash basin, bath and shower fixtures in good repair/no leaks/hot water temperature 122 degrees, soap and enough washing rags, Laundry Facilities available, Bedrooms-required linen and furnishings in good repair, Facility free of vermin. Disaster Preparedness: Disaster and mass casualty plan updated and available, quarterly drills conducted and documented, Disaster preparedness supplies verified. LPA interviewed one staff member. One Technical Violation was issued related to CCR 83070.1(d)(4) Children's Records. An exit interview was conducted and a copy of this report was left with Licensee, Esther Kiiru.

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
On 11/26/2024 at 12:35 p.m. Licensing Program Analysts (LPAs) Elena Gonzalez-Soto and Maie Soliman arrived unannounced at the Small Family Home (SFH) for the purpose of a Plan of Correction Inspection. LPAs were greeted by Mamadou Bah (S2). S2 called an adult downstairs and LPA introduced themselves. LPA Gonzalez-Soto asked their name and if they are staff. The individual provided their name and said they are staff but later said they are not staff but visiting the SFH. The individual called Mabel Strasser-King, Facility Designee (FD) and notified FD LPAs arrived. LPA Gonzalez-Soto spoke with FD at 12:50 p.m. and asked FD their estimated time of arrival. FD said 20 to 30 minutes. At 1:21 p.m. FD arrived to the SFH and assisted LPAs with the Inspection. LPAs reviewed three children's files for: Needs and Services Plans (NSP), Cash Resources and Valuables Logs, Medication and Administration Logs, and Psychotropic Medication Logs. LPAs observed C1 and C2 have NSPs signed on 11/25/2024. C3 did not have a signed NSP by his discharge date of 11/19/2024. LPAs observed C3 has a signed Consent Form dated 09/19/2024, C1 and C2 have signed Consent Forms dated 10-18-2024. LPAs observed C1, C2, C3 had an account of cash resources and personal property with no dates. LPAs observed C1 and C2 have separate logs for psychotropic medication, but was missing the quantity prescribed, prescription filled, prescription number and number of refills. LPAs observed C1 and C2 did not have court approved JV-220 forms. LPAs reviewed six staff files for: documentation of training on psychotropic medications and administration, Foster Youth Bill of Rights, Reasonable Prudent Parent Standard, Children's right to sexual reproductive health information, Supporting LGBTQ+ Youth in Care and cultural competency. LPAs observed S1, S2, S3, S4, S5, S6 have certificates of completion for Foster Youth Bill of Rights and Reasonable Prudent Parent Standard Training issued on 11/7/2024. Cont. on 809-C. LPAs observed S4 has certificate of completion for Supporting LGBTQ+ Youth in Care issued on 11/13/2024. LPAs observed S1, S2, S3, S5, and S6 did not have certificates of completion for Supporting LGBTQ+ Youth in Care. LPAs observed S5 did not have a certificate of completion for First Aid. S5 is registered for the course to complete first aid on 11/30/2024. LPAs observed S1, S2, S3, S4, S5, and S6 did not have documentation of completed training in psychotropic medication and administration. LPAs observed S1 did not have documentation of training in children's right to receive sexual and reproductive health care and information. LPAs conducted one confidential interview. Due to provider not meeting POC deadline, the SFH is receiving a civil penalty for failure to correct deficiencies of Title 22, Division 6, CCR 83064(h) and (j)(1) Licensee Duties and Responsibilities, 83070(b) Child's Records, 80075(k) Health-Related Services in the amount of 1,200 dollars for the period of 11/15/2024 to 11/26/2024. An exit interview was conducted and a copy of this report, civil penalty, and appeal rights was issued to Mable Strasser-King, Facility Designee.

met_with: Mable Strasser-King, Facility Designee


summary: Facility Evaluation

raw_content:
Narrative:
On 04/02/2025 at 11:00 a.m. Licensing Program Analyst (LPA) Elena Gonzalez-Soto arrived at the facility to conduct a required annual inspection. LPA knocked on the door and there was no answer. LPA called Esther Kiiru, Licensee to determine when licensee will be at the facility. Licensee informed LPA they would be at the home soon. Licensee arrived at the facility at 11:20 a.m. Licensee assisted LPA with the inspection. LPAs inspected and/or reviewed the following: Physical Plant: LPA observed the facility is a two-story home with five bedrooms a front yard and a backyard. LPA observed posting of personal rights, working carbon monoxide and smoke detectors, first aid kit, fire extinguisher purchased 9/19/2024, inaccessible cleaning solutions, food menu, appropriate amount of fresh perishable and non-perishable foods, hot water temperature of 120F, Fridge Temperature of 53F, and freezer temperature of 0.7F. Operations: LPA observed register of clients, posting of license, safeguards for client resources and valuables, Disaster plan and drill log, and plan of operation. LPA observed fire clearance but new fire clearance is needed for new addition of a partition in master bedroom. Client Records: LPA reviewed two children's files and observed written consent forms, an account of cash resources and personal property/valuables, immunization records, signed personal rights, and individual education plans. Cont. on 809-C Staff Records: LPA reviewed six staff files and observed six out of six staff had a first aid certificate, criminal record clearance, personnel record, signed employee rights, health clearance, and applicable training. LPA conducted interviews with staff. The following items were reviewed for compliance: Guardian Roster, LIC500, copy of LIC400 and original LIC402. No citations or advisories were issued related to this inspection. An exit interview was conducted and a copy of this report was issued to Ester Kiiru, Licensee.

visit_type: Annual

met_with: Esther Kiiru, Licensee


summary: Facility Evaluation

raw_content:
Narrative:
On 04/18/2025 at 09:15 a.m. Licensing Program Analyst (LPA) Elena Gonzalez-Soto arrived at the facility to continue a required annual inspection. LPA was greeted by RighteousEsther Njogu, Staff Member (S2) and Catherine Mwangi, Facility Designee (FD).FD assisted LPA with the inspection. LPA observed two children in care and how facility staff facilitate their care. LPA conducted interviews. No citations or advisories were issued related to this inspection. An exit interview was conducted and a copy of this report was issued to Catherine Mwangi, Facility Designee (FD).

met_with: Catherine Mwangi, Facility Designee


summary: Facility Evaluation - 2 deficiencies

raw_content:
Narrative:
On 09/09/ Licensing Program Analysts (LPAs) Elena Gonzalez-Soto and Jean Stidman arrived at the facility for a case management inspection. LPAs met with Licensee, Esther Wambui. At the beginning of the inspection, LPAs observed two staff and two children present in the facility. At the of the inspection LPAs observed one more child arrive. LPAs conducted an inspection of the home and observed two fire extinguishers with no dates of purchase or service, one dresser in one child's room with exposed screws, a camera placed in one child's bedroom, one staff's personal items in a child's bedroom, LPAs observed one staff was present and working in the facility without a criminal record clearance. LPAs observed a wading pool filled with water and exposed extension cords throughout the backyard. LPAs conducted a file review of three staff and four children's records. Facility Citation Violation of California Code of Regulations, Title 22, Division 6, Buildings and Grounds, 83010.1(a) Limitations on Capacity for Specialized Small Family Homes, and 80019(e) Criminal Record Clearance on the attached D. Exit interview conducted and a copy of this report and appeal rights was left with Licensee, Esther Wambui.

Deficiencies:
80019(e): 1
2
3
4
5
6
7LPAs observed the licensee had S2 leave the premises during the inspection.
80087: 1
2
3
4
5
6
7

met_with: Licensee, Esther Wambui

title:
1
2
3
4
5
6
780019 (e) Criminal Record Clearance
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility. This requirement was not met as evidenced by

title:
1
2
3
4
5
6
780087(a) and (e) Buildings and Grounds
The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
All licensees serving children or serving clients who have physical handicaps, mental disorders, or developmental disabilities shall ensure the inaccessibility of pools, including swimming pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds or similar bodies of water through a pool cover or by surrounding the pool with a fence. This requirement was not met as evidenced by

description:
1
2
3
4
5
6
7


summary: Facility Evaluation

raw_content:
Narrative:
On 03/02/2026 at 10:20 a.m. Licensing Program Analyst (LPA), Elena Gonzalez-Soto, arrived at the facility unannounced to conduct a required annual inspection. LPA met with Esther Kirru, Licensee who assisted with the inspection. LPAs inspected and/or reviewed the following: Operations: LPA observed register of clients, posting of license, safeguards for client resources and valuables, Disaster plan and drill log, and plan of operation. Client Records: LPA reviewed three children's files and observed written consent forms, an account of cash resources and personal property/valuables, immunization records, signed personal rights, and individual education plans. Staff Records: LPA reviewed six staff files and observed six out of six staff had a first aid certificate, criminal record clearance, signed employee rights, health clearance, and applicable training. Further inspection is needed to complete annual inspection requirement. The following items were reviewed for compliance: Guardian Roster, LIC500. No deficiencies were observed during today's inspection. An exit interview was conducted and a copy of this report was issued to Esther Kiiru, Licensee.


summary: Facility Evaluation

raw_content:
Narrative:
On 03/03/2026 at 08:55 a.m. Licensing Program Analyst (LPA), Elena Gonzalez-Soto, arrived at the facility unannounced to conduct a required annual inspection. LPA met with Esther Kirru, Licensee who assisted with the inspection. Physical Plant: LPA observed the facility is a two-story home with five bedrooms a front yard and a backyard. LPA observed posting of personal rights, working carbon monoxide and smoke detectors, first aid kit, fire extinguisher inspected on 11/2025, inaccessible cleaning solutions, food menu, appropriate amount of fresh perishable and non-perishable foods, hot water temperature of 120F, Kitchen fridge Temperature of 46F, and freezer temperature of 0F, Freezer temperature in the garage is 0F, Fridge temperature in garage is 46F LPA conducted staff interviews. Further inspection is needed to complete required to complete annual inspection. An exit interview was conducted and a copy of this report was issued to Esther Kiiru, Licensee.


summary: Facility Evaluation

raw_content:
Narrative:
On 03/10/2026 at 1: P.M. Licensing Program Analyst (LPA), Elena Gonzalez-Soto, arrived at the facility unannounced to conduct a case management inspection related to proposed construction on the facility grounds. LPA met with Esther Kiiru, Licensee. During the visit, LPA discussed California Code of Regulations, Title 22, Section 83010. Limitations on Capacity for Specialized Family Homes with Licensee. Technical Assistance was provided regarding regulatory requirements related to capacity limitations for Specialized Family Homes and supervision requirements within the home during construction. No citations were issued related to this inspection. An exit interview was conducted and a copy of this report was issued to Esther Kiiru, Licensee.


facility_name: EUNICE AND NELSON BORU SFH

summary: Facility Evaluation

raw_content:
Narrative:
On January 15, 2026, at 09:30AM, Licensing Program Analysts (LPAs) Rachel Vanegas and Valerie Wilson met with Eunice Boru and Nelson Bolly Small Family Home (SFH) Applicants for Eunice and Nelson SFH, at the Riverside Children's Residential Program Regional Office for the purpose of conducting a Component II meeting. LPAs discussed corrections and revisions needed for the Program Statement. The following is a summary of the corrections and revisions discussed and requested. These revisions are due by close of business on January 30, 2026. A1. Application (LIC 200) Update Facility and Applicant mailing address A2. Applicant Information (LIC 215) Please provide an updated document to reflect current employment for Eunice. A9. Budget Information (LIC 420) Please update this document to reflect current income and income source for Eunice. A11. Personnel Record (LIC 501) Please provide an updated document to reflect current employment for Eunice. Please provide a letter of reference from the current employer for Eunice. *Continued on the next page* A12. Health Screening Report (LIC 503) Please provide health screening and tuberculosis screening results for Eunice and Nelson, the one provided is not stamped or authenticated by a medical practitioner. Results provided are over one year old. A14. Emergency Disaster Plan (LIC 610C) Section IV: Please provide updated signed authorization letters for the use of both relocation sites to also acknowledge that they are not licensed facilities. A15. Facility Sketch (LIC 999) Indicate exit routes by number as shown on the LIC 610C Emergency Disaster Plan and identify camera locations as applicable. Section B Documents Please review and revise your table of contents as the page numbers do not align with the document Please clearly identify placement source(s) for clients intended for your program Please provide detailed information regarding regulations sections that you cite throughout the Program Statement (Ex: Section 83017 on Page 3). Please review and revise reference to Regional Center OR provide documentation for vendorization in-process. Please remove medically fragile population as you are not becoming licensed for a Specialized Health Care home. Please remove all references to "Foster Children" Program Purpose, Target Population: Please clarify the role of "therapies" as you are not the medical professional providing these services (Page 3) Please elaborate on the difference between a "Case Worker" and a "Social Worker" as the titles appear to be used interchangeably (Page 4) Ages to be admitted Please review and revise ages listed for clients to be admitted as the ages currently listed do not match your application (Page 5) *Continued on the next page* Incident Reports Please include reporting requirements to Community Care Licensing AND Authorized Representatives (Page 5) Bedroom Sharing Please review and revise this section. No more than 2 clients can share one room, not 4 clients per bedroom as stated here (Page 5) Staffing Please provide clarity regarding 2:1 staff to client ratio. (Page 5) Overnight or Friends' Visits Please clarify which agency you are referring to in this section regarding guidelines for these visits. (Page 5) Please review and revise references to connections with Birth Families to ensure accordance and compliance with court orders (Page 5) Residents' Complaints Please provide the Hotline Phone Number in this section (Page 5) Please identify how you will notify clients and authorized representatives of complaints received/submitted by clients, timeframes including how to submit a grievance/complaint, who responds, the timeframe, how the outcome is documented, where is the procedures documented. Admission Policies and Procedures Please review and revise reference to LIC 604 as the admission agreement. This form is only a guide, but can not be used as the admission agreement. (Page 7) Please review and revise the age ranges that are identified to match your LIC 200 (Page 7) Please remove references to medically fragile and physical needs (Page 7) Please review and revise "Person's Responsible for Admitting Clients" as the information stated contradicts information on "Pre-Admission Process" (Page 7) Procedures for Accepting Emergency Placements Please clarify what "Cleared Up" means (Page 7) Admission Process Please clarify that the Needs and Services Plan must be completed by the Licensee(s) utilizing the LIC 625 if it is not received by the placing agency. The time frame is within 30 days of placement (Page 8) *Continued on the next page* Monthly Rate Please revise the statement regarding 1:1 or 1:2 rates to match statement regarding staffing (Page 8) Please revise statement to client responsibility for payment of services, it is the placement agency, etc. responsible for payment, not the client. (Page 8) Discharge/Removal at age Please remove this section, it does not apply (Page 9) Clothing and Dressing Accessories Policy Please provide more information regarding the specified budget discussed in this section (Page 11) Financial Management Please provide more information regarding how you will document or track money management for residents (page 13) Optional Services Please review and revise referrals for services to clearly state that the residents Primary Care Physician will be the one to make referrals for services, etc. not you as the Licensees. (Page 13) Please clarify what "FERPA" means. (Page 13) Rules of Discipline/Personal Rights Please include information regarding how the residents and authorized representatives will be notified of this information and specify if they will be provided with documentation for signed acknowledgement, etc. (Page 16) House Rules for our Home Please clarify what CFTM Guidelines means in reference to bedtime (Page 16) Please remove reference to residents/clients in care as "foster children" (Page 16) #12: Please identify the frequency for training discussed and for who the training will be (Page 17) Please ensure that all reference to family visit/connection is by court authorization and court compliance (Page 17) Emergency Intervention Plan for Aggressive Behavior Please review and revise reference to (51/50) for a trauma informed focus. (Page 19) Runaway Plan Please revise Child Care Licensing reference to accurately identify Community Care Licensing (CCL) (Page 19) *Continued on the next page* Please include reporting requirements for instances involving runaway youth (Page 19) Handling Complaints from Children Please include the complaint hotline in this section (Page 19) Child's Personal Rights Please review and indicate acknowledgment of client and authorized representative signatures required for the LIC 613B. (Page 20) Activities Please review identified times for meals (breakfast) is listed differently on Menu, Page 21. (Page 27) Please review and revise "Mental/Physical/Occupational Therapy" and "Physical Therapy" as an identified event to provide clarification that these events are provided by licensed professionals. (Page 27) Transportation Please review and specify the frequency of vehicle maintenance (Page 30) Medical and Dental Care Please review and identify where documentation will take place for medication refusal or missed dose (Ex: Incident Reporting requirements) (Page 31) Missing Court Orders/Authorization Please review and identify the appropriate court documentation required for psychotropic medication administration (Psychotropic Medication/JV-220/Parental Consent/PMAR) (Page 33) Please remove reference to Foster Agency as this does not apply (Page 33) Please include a statement that there can be temporary administration of psychotropic medication authorized on the JV220(A) Physician's Statement while the JV223 is pending Describe how the facility will obtain a copy of the current court order, or written authorization of the child's parent or guardian, for each psychotropic medication, as defined in Section 84001(p)(4). Describe the use of Psychotropic Medication Administration Records (PMAR LIC 622B). A separate log for each psychotropic medication prescribed to the child documenting all the following in Title 22 83070(12). Medical Emergencies Describe where first aid supplies and a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency will be stored. (Page 34) Needs and Services Plan (NSP) Please identify the frequency for "regularly" regarding NSP updates (Page 36) *Continued on the next page* Please provide more information regarding the use of the LIC 625 for the Licensee to complete a Needs and Services Plan within 30 days of placement for clients in care if it is not provided by the placing agency (Page 36) Cash Resources and Personal Property Please review and revise this section to align with compliance of your surety bond. (Page 38) Please provide more information regarding the allowance that will be provided to youth in care. You discuss examples of teenagers receiving an allowance but do not discuss the plan for younger youth to receive an allowance (Page 38) Staff Training Please review and revise this section. There is a lot of repetition that makes this section unclear of the expectations (Page 39) Reporting Requirements Please review and revise the email address identified on the reporting requirements notifications. Correct email for the program and regional office is: cclpaccr@dss.ca.gov (Page 42) Video Cameras Please identify camera locations to match on the LIC 999 (Facility Sketch) Please review Provider Information Notification 24-09-CRP for information needed in the Program Statement for use of cameras in congregate care facilities LPA Vanegas conducted an exit interview and a copy of this report along with the signed LIC 281C, Care Tools Pre-licensing form, and Children's Residential Program Provider Information Notice 24-09 were reviewed and provided to the applicants, Eunice Boru and Nelson Bolly.

met_with: Applicants - Eunice Boru and Nelson Bolly


facility_name: EVANGELINE HOME CARE

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
the County Social Services Agency (OCSSA). Confidential interviews revealed that S1 was in contact with OCSSA and that OCSSA was going to handle the situation involving C1. Confidential interviews also revealed that S1 was in contact with the hospital. Confidential interviews revealed that S1 did not receive clear information from OCSSA on how to proceed with the situation. Confidential interviews also revealed that S1 will unplug S1's landline phone. Confidential interviews also revealed that S1 does not unplug S1's landline phone. Confidential interviews resulted in conflicting statements as to whether or not S1 responded to telephone calls from the hospital and OCSSA, or whether or not S1 attended the discharge meeting. Based on confidential interviews, the allegations that S1 did not respond to telephone calls from hospital or from social services during child's hospitalization, and S1 did not attend scheduled discharge meeting for child, may have occurred, however are not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report, along with appeal rights were explained and provided to Administrator Pamela Salaguinto.

Investigation Findings:
13On September 30, 2021 at 10: AM, Licensing Program Analyst's (LPA) Adrian Mendez and Jesus Cervantes conducted an unannounced inspection with the facility and met with Administrator Pamela Salaguinto of Evangeline Home Care to discuss the investigative findings for the allegations noted above. LPA conducted an unannounced tele-inspection with the Small Family Home (SFH) on May 4, 2021, at 10:46am. No safety concerns were observed. During the investigation, LPA Mendez interviewed one County Social Worker (CSW), and one Facility Staff (S1). On April 27, 2021, the Department received allegations that licensee did not respond to telephone calls from hospital or from social services during child's hospitalization, and licensee did not attend scheduled discharge meeting for child. It was reported that on or about April 16, 2021, C1 was transported to Children's Hospital of Orange County (CHOC) by Irvine Police Department due to exhibiting self-injurious behaviors while at the placement with the facility. It was also reported that S1 did not attend the discharge meeting at the hospital and was not responding to several calls from CHOC and ..... See Page Two UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Jesus Cervantes 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: EVANGELINE HOME CAREFACILITY NUMBER: VISIT DATE: 09/30/2021

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

report_type: Complaint Investigation

met_with: Pamela Salaguinto

complaint_status: unsubstantiated


summary: Facility Evaluation

raw_content:
Narrative:
On June 23, 2021, at 10:27am Licensing Program Analyst (LPA) Adrian Mendez conducted an unannounced Post Licensing/Annual Required Inspection of the small family home. LPA met with Licensee Pamela Salaguinto. The facility was toured inside and out. The home is a four bedroom and three bathroom home. Bedrooms were arranged so that no more than two children share a room, and there was one child per bed. There was adequate drawer and closet space for children's belongings. The First Aid Kit contained all required supplies and is stored in the kitchen and bathrooms of the facility. The clients' medications were observed to be inaccessible and stored in a lockbox in the kitchen of the home. The small family home's smoke and carbon monoxide detector was checked and were operable. The bathrooms were clean and in good repair. The hot water in the client bathroom sink was measured at 10:43am to be 115.3, which is within regulatory requirements. The facility outside grounds was also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. There is no swimming pool/bodies of water located on the premises. The facility currently has no clients placed. One staff/licensee file was reviewed during the inspection. The file appeared to be completed and in order. All staff that work at the facility have Department of Justice and Child Abuse Clearance Index clearances. A review of administrative records indicate that the facility has paid their current licensing fees. Based on the facility inspection and file reviews on this date, there are no deficiencies found at this time. A copy of this report was reviewed and provided to Licensee Pamela Salaguinto.


summary: Facility Evaluation

raw_content:
Narrative:
On November 8, 2022 at 10:30 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility for a required annual inspection of the small family home. LPA met with Licensee's sister, Melody Quijano. Upon arrival, LPA was informed by Ms. Quijano the facility would not be interested in continuing with their license. LPA advised Ms. Quijano if the facility did not want to continue with the annual inspection, the facility could surrender their license, and send an email to LPA. Ms. Quijano consulted with the licensee and decided to continue with the annual inspection at this time. At 11:15am, LPA entered the facility. The facility was toured inside and out. The home is a four bedroom and three bathroom home. Bedrooms were arranged so that no more than two children share a room, and there were no beds in the bedroom. There were no clients placed at this time. There was adequate drawer and closet space for children's belongings. The First Aid Kit contained all required supplies and is stored in the kitchen of the facility. The small family home's smoke and carbon monoxide detector was checked and were not operable, as they are chirping. The bathrooms were clean and in good repair. The hot water in the client bathroom sink was measured at 109.4 at 11:30 am, which is within regulatory requirements. The hot water in the kitchen sink was measured at 109.7 at 11:31 am which is within regulatory requirements. The facility outside grounds was also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. There is no swimming pool/bodies of water located on the premises. The facility currently has no clients placed. The licensee has all of the staff files and fire clearance with them and are not in the facility LPA could not review staff files in the facility at this time. A review of administrative records indicate that the facility has paid their current licensing fees. Ms. Quijano was advised LPA will need to return to check the bedroom, staff files, and smoke detectors before the facility accepts any children into the facility. Based on the facility inspection , there are no deficiencies found at this time. A copy of this report was reviewed and provided to Licensee Pamela Salaguinto.

met_with: Melody Quijano


facility_name: EVELYN'S NURSERY

summary: Facility Evaluation

raw_content:
Narrative:
On 10/8/2021 at 10 am, Licensing Program Analysts (LPAs) Cynthia Galindo, Lidia Tinoco and Vanessa Galvan conducted an unannounced required annual inspection of the small family home (Bates Home) located in Porterville, California. LPA was met at the facility by Licensees, Beverly Day and Katherine McDonell. LPA inspected the home, inside and out. The home is licensed to serve six clients. Currently in placement are two clients. LPA observed the facility license, the menu, client's personal rights, and other forms posted on the walls throughout the facility. LPA reviewed two client and three staff files. All three staff member's files and four client files were reviewed with the Licensee. Clients were not interviewed due to being nonverbal. Two staff were interviewed. A review of staff records indicate that all facility staff associated to the facility received fingerprint and child abuse index check clearances. There is at minimum one week supply of nonperishable, and a two day supply of perishable foods. The facility is maintained at 71 degrees. There are no weapons or pets at the facility. There are no deficiencies to cited during this inspection. Exit interview conducted and a copy of the report was left at the facility.

met_with: Katherine McDonell


summary: Facility Evaluation

raw_content:
Narrative:
On 10/8/2021 at 10 am, Licensing Program Analysts (LPAs) Cynthia Galindo and Reyna Martinez conducted an unannounced required annual inspection of the small family home (Bates Home) located in Porterville, California. LPA was met at the facility by Licensees, Beverly Day and Katherine McDonell. LPAs inspected the home, inside and out. The home is licensed to serve six clients. Currently in placement are two clients. LPAs observed the facility license, the menu, client's personal rights, and other forms posted on the walls throughout the facility. LPAs reviewed two client and three staff files. All three staff member's files and two client files were reviewed with the Licensee. Clients were not interviewed due to being nonverbal. Two staff were interviewed. A review of staff records indicate that all facility staff associated to the facility received fingerprint and child abuse index check clearances. There is at minimum one week supply of nonperishable, and a two day supply of perishable foods. The facility is maintained at 71 degrees. There are no weapons or pets at the facility. There are no deficiencies to cited during this inspection. Exit interview conducted and a copy of the report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On this date, Licensing Program Analyst (LPA) Cynthia Galindo conducted a Case Management inspection at Evenlyn's Nursery and met with Katherine McDonell. The purpose of the inspection was ensure there were no more children in the home. Licensee is retiring and surrendering the license as of 02/09/2023. LPA inspected the home and everything looked good. LPA picked up the licensed which is signed by the licensee. A copy of this report was left at the facility.


facility_name: EVELYNA'S SMALL FAMILY HOME

summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
FM stated that the foster children could use any part of the house and she never told children to stay in their room. Regarding the physical altercation allegation, a confidential interview indicated that the altercation occurred suddenly between two roommates' due to arguments. Staff and FM both stated that the altercation has occurred suddenly, and staff intervened immediately. For the inappropriate comment towards a foster child allegation, S1 and FM denied the allegation of inappropriate comments were made towards any foster child while in care. Confidential interviews confirmed foster children were treated well and felt safe in the home. County Social Worker (CSW) stated that she had conducted facility visits and observed FC1, FC2, FC3, FC4 coming out of their rooms to the living room and backyard areas. CSW felt the facility was safe and appropriate for all children in care. Based on confidential interviews, the Department determined there was not sufficient information to determine lack of supervision resulting in FC1 and FC2 engaging in a physical altercation, foster children (FC1, FC2, FC3, FC4) were kept in bedroom for a long period of time, adult in home made an inappropriate comment towards FC1. Although the allegations may have happened or may be valid, there was not a preponderance of evidence to support or deny the allegations, therefore, these allegations were unsubstantiated at this time. A copy of this report and appeal rights were reviewed and provided to the licensee.

Investigation Findings:
13On October 29, 2021, at 1: PM, Licensing Program Analyst (LPA), Babatunde Aborchie arrived at Evelyna's Small Family Home (SFH) to deliver the finding of the investigation involving the small family home and a foster child (FC1). LPA met with a staff (S1) who granted LPA access into the home. On July 20, 2021 a complaint report was referred to Community Care Licensing (CCL) alleging that lack of supervision resulting in foster children engaging in a physical altercation, foster child is kept in bedroom for a long period of time and adult in home made an inappropriate comment towards a foster child. On July 26, 2021 at 1: PM, LPA conducted a safety inspection with S1. There were no immediate safety hazards observed at the time of inspection. LPA reviewed the children's file and obtained copies. During the investigation, LPA conducted interviews with the foster mother (FM), foster children (FC1, FC2, FC3, FC4) and S1. All confidential interviews denied being kept in the bedroom for a long period of time, staff or FM conduct room visit hourly on the average. Four of four foster children stated that they preferred to be in their rooms and come out whenever they wanted. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Babatunde Aborchie LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: EVELYNA'S SMALL FAMILY HOMEFACILITY NUMBER: VISIT DATE: 10/29/2021

met_with: Evelyn Oyembera


summary: Facility Evaluation

raw_content:
Narrative:
On February 10, 2022 at 9: AM Licensing Program Analyst (LPA) Babatunde Aborchie, met with staff Sarah Arungah, who led a tour of the home. The purpose of the visit was to conduct an annual inspection of the Evelyna's Small Family Home. The facility was toured inside and out with the staff. Currently, there were four foster children in the home. FC1, FC2, FC3 and FC The home is set up as follows: · Bedroom #1 has a queen size bed, used as a guest room. It sleeps currently one live in staff. · Bedroom #2 has two full beds, sleeps one client (FC2). · Bedroom #3 has one full and one twin beds, sleeps one clients (FC3) · Bedroom #4 has one twin bed; sleeps one client (FC1) · Bedroom #5 has a king-sized bed, sleeps licensee and one client on a crib, a month-old baby (FC4) . Bedrooms were arranged so that no more than two children share a room and there is one child per bed. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. There were adequate drawers and closet space for children's belongings. The fireplace was properly screened. All hazardous items have been properly made inaccessible to areas where children will have access. Cleansers/chemicals were stored and locked in the laundry room cabinet. Sharp knives were inaccessible and stored in locked kitchen cabinet. The first aid kit was in the locked closet between the hallway and the living room. There were no guns or weapons as stated by staff at this time. The hot water temperature was tested and noted to be within regulatory requirements. Proper storage of all food was noted. Trash cans for storage of solid wastes had tight fitting lids. The smoke detectors located in the hallways were tested and were in good working order. The carbon monoxide detector located downstairs was operable. The Emergency Disaster Plan with exit map, Title Personal Rights, and visitation policies are posted at this time. The backyard where children will have access to play is completely fenced and free of hazards. There were no bodies of water on the premises. A review of staff records on this date indicated that all facility staff had received criminal record and child abuse index check clearances. In accordance with Title 22, Division 6, Chapters 1 & 4 there were no deficiencies being cited at this time. Exit interview was conducted and a copy of this report along with a Confidential Names List (LIC 811) was provided to facility staff.

met_with: Staff


summary: Facility Evaluation

raw_content:
Narrative:
On April 26, 2023 at 10: AM Licensing Program Analyst (LPA) Babatunde Aborchie, met with licensee Sarah Arungah, who led a tour of the home. The purpose of the visit was to conduct an annual inspection of the Evelyna's Small Family Home. The facility was toured inside and out with the licensee. Currently, there were five foster children in the home. FC1, FC2, FC3, FC4 and FC The home is set up as follows: · Bedroom #1 has a queen size bed, used as a guest room. It currently sleeps one live in staff. · Bedroom #2 has two full beds, sleeps two clients (FC1 and FC2). · Bedroom #3 has two full beds, sleeps two clients (FC3 and FC4) · Bedroom #4 has two twin beds and a crib; sleeps one client (FC5) · Bedroom #5 has a king-sized bed, sleeps licensee. Bedrooms were arranged so that no more than two children share a room and there is one child per bed. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. There were adequate drawers and closet space for children's belongings. The fireplace was properly screened. All hazardous items have been properly made inaccessible to areas where children will have access. Cleansers/chemicals were stored and locked in the laundry room cabinet. Sharp knives were inaccessible and stored in locked kitchen cabinet. The first aid kit was in the locked closet between the hallway and the living room. There were no guns or weapons as stated by licensee at this time. The hot water temperature was tested and noted to be within regulatory requirements of 111 degrees. Proper storage of all food was noted. Trash cans for storage of solid wastes had tight fitting lids. The smoke detectors located in the hallways were tested and were in good working order. The carbon monoxide detector located in the living room was operable. The Emergency Disaster Plan with exit map, Title Personal Rights, and visitation policies are posted at this time. The backyard where children will have access to play is completely fenced and free of hazards. There were no bodies of water on the premises. A review of staff records on this date indicated that all facility staff had received criminal record and child abuse index check clearances. In accordance with Title 22, Division 6, Chapters 1 & 4 there were no deficiencies being cited at this time. Exit interview was conducted and a copy of this report along with a Confidential Names List (LIC 811) was provided to licensee.

met_with: Licensee


raw_content:
Narrative:
***Continued from LIC 9099-C*** . A confidential interview denied the incident occurred. Another confidential interview stated children are not allowed in each other's rooms, and the foster children are always monitored. A confidential interview said, "Nothing is happening in this home." A confidential interview disclosed that no relative of the Licensee lives in the home. During another confidential interview, it was stated that none of the foster children in the house ever reported being touched or spoken to inappropriately. Based on confidential interviews, the allegation that facility staff did not provide adequate supervision resulting in inappropriate interaction between minors (unknown and FC1) in care, resulting in a foster child (FC1) being touched and spoken to inappropriately, is unsubstantiated. The allegations may have happened or be valid, but there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted. A copy of this report and appeal rights were explained and given to Licensee Sarah Bland.

Investigation Findings:
UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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

met_with: Sarrah Bland, Licensee


summary: Facility Evaluation

raw_content:
Narrative:
On December 15, 2023 at 03: AM Licensing Program Analyst (LPA) Babatunde Aborchie began a Pre-Licensing inspection for a Small Family Home relocation license. LPA met with applicant Sarah Arunga Bland who led a tour of the home. The facility was toured both inside and out with the applicant. The applicant is applying for a relocation and to serve 6 ambulatory clients. The home consists of: Downstairs: Bedroom #1, It was furnished with a full-sized bed and a crib. It was vacant. There were also an office, a visitor lounge, a family room, a living room, two dining areas, a pantry, a kitchen and one bathroom. Upstairs: Bedroom #2, The room was furnished with two full-sized beds. It was vacant. Bedroom #3, The room was furnished with two twin sized beds. It was vacant. Bedroom #4, The room was furnished with two twin sized beds. It was vacant. Bedroom #5, Master bedroom. The room consisted of one king sized bed. It sleeps the applicant/Licensee. Bedrooms were arranged so that no more than two children share a room, and there was one child per bed. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. There was adequate drawer and closet space for children's belongings. The smoke detectors were checked and were working properly. Inside the facility the fireplace was properly screened. Telephone service and appliances were in a working order. All hazardous items have been properly made inaccessible to areas where children will have access. The medication will be locked in the kitchen cabinet area by the pantry. Cleansers/chemicals were locked and stored in the laundry room cabinet. Sharp knives were inaccessible and stored in a locked kitchen cabinet under the sink. There were no guns or weapons as stated by the applicant at this time. The hot water temperature was tested and noted to be 111 degrees. Proper storage of all food was discussed. Trash cans for storage of solid waste have tight fitting lids. First Aid kit was accessible with all required items, and it was in the hallway closet. A Fire extinguisher was observed and properly charged. The Facility Sketch, Emergency Disaster Plan, visitation policy and Personal Rights were posted. The backyard where children will have access to play was completely fenced and free of hazards. There are no deficiencies to be cited at this time. The request for relocation will be forwarded to the Licensing Program Manager for final approval. An exit interview was conducted. A copy of this report was provided to Applicant/Licensee.

visit_type: Prelicensing

met_with: Sarah Arunga Bland


summary: Facility Evaluation

raw_content:
Narrative:
On November 6, 2025, Licensing Program Analyst (LPA) Babatunde Aborchie arrived at Evelyna's Small Family Home (SFH) required 2-year inspection. Currently, there are five clients in placement. The home was licensed for a capacity of six clients (all ambulatory). The Facility was toured both inside and out with the licensee. The home is a two-story building with five bedrooms and four bathrooms. During the inspection, LPA observed that downstairs consisted of a lounge, an office, a dining area, the kitchen, living room and one bedroom. Bedroom #1 was furnished with a crib and a queen-sized bed, it sleeps a three-year-old client, and a care giver. There was an additional toddler training bed in the living room for the three-year-old client. The three-year-old client had a doctor's order to sleep in the crib due to frequent falling from bed. Sharp knives were inaccessible and stored in a locked cabinet under the kitchen sink, cleansers/chemicals were locked in the cabinet under the kitchen sink. The First Aid Kit was in the hall-way closet and contained all required items. Medications were stored in a locked cabinet opposite the pantry. The garage was inspected and used for cars and storage. The water temperature was tested and measured at 114 degrees F. LPA observed a minimum of seven-day non-perishable and a three-day perishable supply of food. There was a variety of snacks available for clients. In addition to the downstairs space, there was also one full bathroom fully functioning. A trash can was observed to have tight fitting cover. The following required posted items were observed accessible to clients: personal rights, visitation policy, and current menu. The clients' medication log records were kept updated with no discrepancy. One fire extinguisher was observed and operable. Upstairs was bedroom #2, it was fully furnished with two full size beds; it sleeps two clients. Bedroom #3, it was fully furnished with two twin size beds; it sleeps one client. Bedroom #4 was fully furnished with full sized bed, a closet and plenty of storage space. It sleeps one client. Bedroom #5, it was fully furnished with a king-sized bed, and a walk-in closet. It sleeps licensee. The licensee's bedroom is not accessible to the clients. All bedrooms were arranged for one child per bed. No room was commonly used for other purposes other than a bedroom, and no bedroom serves as a passageway to another room. There was adequate drawer and closet space for each child's belongings. The smoke and carbon monoxide detectors were checked and working. Additional cleansers and chemicals were locked in the laundry room. The upstairs space includes additional storage, a loft - fully furnished and an additional bathroom used by the clients. All hazardous items have been properly made inaccessible to areas where clients have access. All windows and screens were in good repair. Licensee states that there were no guns/weapons in the home at this time. There was a total of five cameras, two located outdoors, and three indoors which met the title 22 camera policy. The facility outside grounds were also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. Clients' files and staff files were reviewed and found to comply. Based on today's inspection and observations, there are no deficiencies being cited at this time. A copy of this report will be provided to the licensing program manager for final approval. An exit interview was conducted, and a copy of this report was discussed and provided to Licensee.


facility_name: EVELYNAS SMALL FAMILY HOME 2

raw_content:
Narrative:
Confidential interviews consistently reported that C1 would refuse their (C1) insulin. A Special Incident Report submitted to the Department documented an incident that occurred on January 15, 2025 which C1 had trouble managing their (C1) insulin. Confidential interviews also disclose that staff adhered to the small family home's emergency protocols to intervene and respond to situations safely. Furthermore, there were no disclosures that staff failed to manage minors' (C1) medical needs adequately. Confidential statements deny the allegation. . Based on confidential interviews and records review, the allegation that the licensee is not adequately managing the minor's (C1) medical needs is unsubstantiated. The allegation may have happened or be valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted. A copy of this report and appeal rights were explained and given to Administrator Evelyn Oyiera Oyomb.

Investigation Findings:
13This is an amended report from the original report created on 05/29/2025. On May 29, 2025, at 12: PM, Licensing Program Analyst (LPA) Julian Lucas conducted an unannounced visit to Evalynas Small Family Home 2 to deliver the investigative findings for the allegation listed above. LPA Julian Lucas initiated the complaint investigation at the small family home on 04/18/2025. The investigation included interviews with client (C1) and staff (S1, S2, and S3). LPA attempted to interview C2 and C3, but both were unavailable to interview. On January 15, 2025, Community Care Licensing received an allegation that the licensee was not adequately managing the minor's (C1) medical needs. Multiple confidential interviews including documentation reported a history of C1 refusing medication and unsafe behaviors. Continued on LIC 9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Julian Lucas LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: EVELYNAS SMALL FAMILY HOME 2FACILITY NUMBER: VISIT DATE: 05/29/2025

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

met_with: Evelyn Oyiera Oyomb Administrator


raw_content:
Narrative:
C1's age but no one has ever called C1 any inappropriate name because of it. Other confidential interviews corroborated that they've never heard LS speak inappropriately about C1. Regarding the allegation that licensee does not ensure a minor is fed, confidential interviews stated that all clients will have breakfast, lunch and dinner with snacks in-between on a daily basis. Another confidential interview stated that staff make the same food for everybody but sometimes a client may refuse to eat. Other confidential interviews stated that some clients can be picky eaters, but they are able to request any food they'd like. LPA was unable to obtain additional information. Based on confidential interviews and a review of pertinent documents, the allegation that that licensee speaks inappropriately about C1 and licensee does not ensure C1 is fed may have happened or is valid there was not a preponderance of evidence to support the alleged violation. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, a copy of this report, LIC811 and appeal rights were explained and given to direct care staff Sarah Bland.

Investigation Findings:
13On October 22, 2025, Licensing Program Analyst (LPA) Maryjane Perez conducted an unannounced visit to Evelyna's Small Family Home 2 (SFH) and met with direct care staff Sarah Bland to deliver the finding for the above stated allegations. On July 8, 2025, community care licensing received a complaint alleging that licensee speaks inappropriately about a minor and licensee does not ensure a minor is fed. On July 9, 2025, LPA Maryjane Perez initiated the investigation and conducted a health and safety inspection of the facility, and no hazards were observed. Lpa M. Perez obtained pertinent documents and interviewed Licensee (LS), staff 1(S1), staff 2(S2) and client 2 (C2). In regard to the allegation that licensee speaks inappropriately about minor, it was reported that licensee told someone (unknown) that C1 is acting like a hoe and dressing a certain way to get attention. During confidential interviews, it was reported that LS has never called C1 a hoe or any other derogatory names. Another confidential interview stated that when it comes to clothing C1 will wear very revealing clothes for UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: MaryJane Perez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: EVELYNAS SMALL FAMILY HOME 2FACILITY NUMBER: VISIT DATE: 10/22/2025

met_with: Direct care staff- Sarah Bland


summary: Facility Evaluation

raw_content:
Narrative:
On April 19, 2024, Licensing Program Analyst (LPA) Rafael Enriquez met with applicant Evelyn Oyombera for a Component II. LPA went over revisions needed for the application prior to licensure. LPA gave a copy of the notification of incomplete application (LIC 184), Letter of Application Revisions, and additional correspondence to assist with the revisions needed to the application. Copy of this report was emailed to applicant and a signed copy will be placed in the facility file.

met_with: Applicant - Evelyn Oyombera


summary: Facility Evaluation

raw_content:
Narrative:
On May 09, 2024, at 10: AM, Licensing Program Analyst (LPA) Rafael Enriquez began a pre-licensing inspection and component III for Evelyna's Small Family Home 2 for an initial license. LPA met with applicant Evelyn Oyombera who led a tour of the home. The facility was toured both inside and out with the applicant. Currently there are no children placed in the home. The applicant was approved to serve six children ages 0 to 17. The home is a single-story building with five bedrooms and three bathrooms which is set up as follows: · Bedroom #1 sleeps a caregiver, has a bed and a crib. · Bedroom #2 will sleep two foster children, has two beds. It was vacant. · Bedroom #3 will sleep two foster children, has two beds. It was vacant. · Bedroom #4 will sleep two foster children, has two beds. It was vacant. · Bedroom #5 sleeps the applicant, has a California King bed, a crib, has a bathroom and a walk-in closet. · A formal living room, formal dining room, living room, kitchen with dining area, two storage rooms, three bathrooms, three car garage, backyard, and a laundry room. Bedrooms were arranged so that no more than two children share a room, and there was one child per bed. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. There was adequate drawer and closet space for children's belongings. The smoke detectors and carbon monoxide detectors were checked, and they were working properly. Telephone service and appliances were in working order. All hazardous items have been properly made inaccessible to areas where clients/children will have access. Sharp knives and sharp objects were locked in a cabinet in the kitchen. Cleansers/chemicals were inaccessible and stored in laundry room which has a lock on the door. There was adequate food storage space and a supply of three days of perishable foods and a week of non-perishable food. A proper storage of all food was discussed. Trash cans for storage of solid waste had tight fitting lids. The water temperature was observed to be at 112.6 degrees. First Aid kit was accessible with all required items, and it was in the hallway closet. A Fire extinguisher was observed and properly charged. The fireplace was in the living room area, and it was properly screened. All the appropriate forms were posted in view of facility clients. As stated by applicant, there were no weapons/firearms and there were no pools or other bodies of water. The backyard where children will have access to play was completely fenced and free of hazards. There are no deficiencies to be cited at this time. The request for licensure will be forwarded to Licensing Program Manager for final approval. An exit interview was conducted. A copy of this report was provided to applicant Evelyn Oyombera.

met_with: Applicant- Evelyn Oyombera


summary: Facility Evaluation

raw_content:
Narrative:
On June 21, 2024, at 09: AM, a post-licensing inspection was conducted by Licensing Program Analysts (LPAs) Rafael Enriquez and Maryjane Perez. LPAs met with licensee Evelyn Oyombera. During this inspection, LPAs and licensee inspected the facility inside and out. The home is a single-story building with five bedrooms and three bathrooms which is set up as follows: · Bedroom #1 sleeps a caregiver, has a twin sized bed and a crib. · Bedroom #2 will sleep two foster children, has two full sized beds. It was vacant. · Bedroom #3 will sleep two foster children, has two full sized beds. It sleeps one foster child. · Bedroom #4 will sleep two foster children, has two twin sized beds. It was vacant. · Bedroom #5 sleeps the applicant, has a California King bed, has a bathroom and a walk-in closet. · A formal living room, formal dining room, living room, kitchen with dining area, two storage rooms, three bathrooms, three car garage, backyard, and a laundry room. The Small Family Home (SFH) is operating within capacity/limitation, is clean, safe, sanitary and in good repair, the outdoor area is free of safety hazards, no pool, or other bodies of water on premise. The SFH has adequate supply of perishable and nonperishable foods, chemicals are locked in the laundry room in a locked cabinet. The knives are locked underneath the sink cabinet. The water temperature was measures at 113.9 degrees. Medications are stored in a locked hallway storage closet. The disaster plan, personal rights, and other documentation are properly posted, smoke detectors are operable/tested. There are no firearms or dangerous weapons per licensee. First aid kit is maintained, and complete First Aid certifications are current. All adults subject to background checks are cleared. There are no deficiencies to be cited at this time. An exit interview was conducted. A copy of this report was provided to licensee Evelyn Oyombera.

met_with: Licensee- Evelyn Oyombera


summary: Facility Evaluation

raw_content:
Narrative:
On January 23, Licensing Program Analyst (LPA) Maryjane Perez arrived at Evelynas Small Family Home 2 to initiate a complaint investigation. During the investigation licensee was not home but there were 2 staff members who greeted LPA into the home. LPA identified those 2 staff members to not be fingerprint cleared. Based on LPA's observation, the facility is cited for violation of the California Code of Regulations, Title Division Six, regulation 80054(b) Penalties: Notwithstanding Section 80054(a) above, an immediate penalty of $100 per cited violation per day for a maximum of five (5) days shall be assessed if any individual required to be fingerprinted under Health and Safety Code Section 1522(b) has not obtained a California clearance or a criminal record exemption, requested a transfer of a criminal record clearance or requested and be approved for a transfer of an exemption as specified in Section 80019(e) prior to working, residing or volunteering in the facility. SEE LIC809D Amended for signature on 1/24/2025.

met_with: Staff- Sarah Bland


summary: Facility Evaluation

raw_content:
Narrative:
On March 23, 2026, at 10:46AM, Licensing Program Analyst (LPA) Cynthia Ramos conducted a required biennial inspection at Evelyna's Small Family Home 2 (SFH). LPA was granted entry and met with caregiver Sarah Bland. A complete inspection of the interior and exterior of the facility was conducted. The facility is a single-story home consisting of five bedrooms and three bathrooms. Bedroom #1 contains a queen-size bed and is designated for caregiver use. Bedroom #2 is vacant and furnished with two full beds for future client placement. Bedroom #3 contains two twin beds and is occupied by a 13-year-old male client. Bedroom #4 contains a queen-size bed and is occupied by an 18-year-old female client. Bedroom #5 is occupied by the Licensee and includes a king bed, crib, private bathroom, and walk-in closet; per staff, this room remains locked at all times. LPA observed an additional small refrigerator located inside the locked licensee's bedroom containing extra diabetic medication (insulin). A separate locked medication box was observed inside the refrigerator located in the kitchen. The home includes a formal living room, formal dining room, family room, kitchen with dining area, two storage closets, three bathrooms, a three-car garage, backyard, and laundry room. Cleaning supplies and chemicals were observed locked under the kitchen sink, with additional supplies secured in the laundry room. All bedrooms contained adequate linens and storage space. No more than two clients shared a bedroom. No rooms used for other purposes served as bedrooms, and no bedrooms functioned as passageways. Smoke detectors were present in each bedroom. Carbon monoxide and smoke alarms were tested and found to be operational. Water temperature measured 108.1°F. The facility maintained at least seven days of nonperishable food and three days of perishable food. ... A fire extinguisher was located in the kitchen, observed to be fully charged, and had been inspected by the fire department. A first aid kit was located in the hallway closet and contained all required supplies. Per caregiver report, no firearms or weapons are present in the home. A total of three staff records and two client records were reviewed. Based on today's inspection, the facility is cited for a Type B deficiency under Interim Licensing Standards, AB Nonminor Dependents, Small Family Home, Article 06. Continuing Requirements: Health-Related Services 83175(f)(1) for failure to document the date, time, and dosage of all injections administered to a nonminor dependent, including those self-administered. Refer to LIC 809-D for additional details.

met_with: Staff, Sarah Bland


facility_name: EXTENDED FAMILY

raw_content:
Narrative:
a short time. Record review and confidential interview revealed C1 had been demonstrating a newer behavior that occurred when C1 would be attempting to sit on a chair, this behavior resembled a fear of the chair moving or fear of falling while attempting to sit. Confidential interviews could not confirm or dispute C1 being clingy or C1's demeanor being off. CCL received a second allegation alleging foster child (C1) had unexplained scratches. Specifically, it was reported that C1 had scratches on the back of C1's neck. Record review and confidential interviews confirm that C1 had been observed to have long fingernails on several occasions. Confidential interviews could not confirm or dispute C1 having scratches to the back of C1's neck. Confidential interviews reported assumptions as to how C1 would have received the scratches if he had had any. Record review was unable to provide any documentation of or explanation for how C1 obtained the scratches to the back of C1's neck. Based on record review and confidential interviews the allegations alleging foster child (Child #1 [C1]) who is non-verbal seemed unusually distressed and foster child (C1) had unexplained scratches, may or may not have occurred, however it is not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of the report was provided along with appeal rights to Extended Family Small Family Home licensee, Mona Skinner.

Investigation Findings:
13On October 29, 2021 2021 at 12:32pm Licensing Program Analyst (LPA), Nicole Strickland, met with Extended Family Small Family Home licensee, Mona Skinner to deliver findings for the above stated allegations. LPA conducted an inspection of the facility on July 30, 2021 at approximately 2:30 pm and no immediate health and safety deficiencies were observed. The investigation included interviews with Licensee, four of four children (Child #1 [C1], Child #2 [C2], Child #3 [C3], Child #4 [C4]), and San Bernardino County Social Worker (CSW). One confidential witness has not responded to the request for interview; therefore the confidential witness has not been interviewed at this time. In addition four of four children's records were reviewed along with county and facility records were reviewed. On July 22, 2021, Community Care Licensing (CCL) received an allegation alleging foster child (Child #1 [C1]) who is non-verbal seemed unusually distressed. Specifically it was reported that C1 appeared to be clingy and that C1's demeanor was off. Record review revealed that C1 had only been placed at the facility UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Nicole Strickland LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: EXTENDED FAMILYFACILITY NUMBER: VISIT DATE: 10/29/2021

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

met_with: Mona Skinner


raw_content:
Narrative:
Another confidential interview stated never observed any physical altercations between the minors. Additional confidential interview stated there was one incident when FC1 pushed C1 into a glass closet door and C1 punched FC1 in the face and FC1 was left with a bruise on the left cheek. Community Care Licensing received another allegation that stated minor (C1) speaks to resource child (FC1) in an inappropriate manner. Specifically, it was reported that C1 does not like FC1 and C1 would call FC1 names. A confidential interview stated C1 would call FC1 all sorts of names and FC1 does not know why. Another confidential interview stated never observed any minor speaking to FC1 in an inappropriate manner. Additional confidential interview stated never heard anyone in the home speaking inappropriately to FC1. Based on confidential interviews, the allegations that minor (C1) engages in physical altercations with resource child (FC1) while in care and minor (C1) speaks to resource child (FC1) in an inappropriate manner, may have occurred, however, they are not supported or proven by evidence. Therefore, the above allegation is unsubstantiated. An exit interview was conducted and a copy of this report, LIC 811, and appeal rights were provided to Licensee, Mona Skinner. **this is an amended 9099c that was signed on 12/19/23**

Investigation Findings:
13On December 19, 2023 at 09: AM, Licensing Program Analyst (LPA) Sarah Lo met with Extended Family Small Family Home Licensee, Mona Skinner, to issue the investigative findings for the above stated allegations. The investigate was jointly conducted by LPA Jessica Peete and LPA Sarah Lo, LPAs interviewed the Licensee (LI), Foster Children [Foster Child #1 (FC1) and Foster Child #2 (FC2)], Child #1 (C1) and County Social Worker (CSW). On December 22, 2022, the department received an allegation that stated minor (C1) engages in physical altercations with resource child (FC1) while in care. Specifically, it was reported that C1 physically abuses FC1 on a regular basis. A confidential interview stated that C1 would hit FC1 on the body often but did not leave any marks or bruises. (continued on LIC 9099c) **this is an amended LIC 9099c that was originally signed on 12/19/23** UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Sarah Lo LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: EXTENDED FAMILYFACILITY NUMBER: VISIT DATE: 12/19/2023

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

met_with: Mona Skinner, Licensee


summary: Facility Evaluation

raw_content:
Narrative:
On Thursday January 27 2022 at 08: AM Licensing Program Analyst (LPA) Linda Haynes conducted an annual inspection of the facility. At time of inspection LPA met with Licensee Mona Skinner. The facility was toured inside and out with Licensee Mona Skinner. The home is a one-story residence with five bedrooms and three bathrooms. No client was present at time of inspection. Bedrooms are arranged so that no more than two clients are in a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. The bathroom was clean and in good repair. The hot water in the clients bathroom was measured to be 115.6 degrees the clients do not have access to the other bathrooms in the home. All hazardous items have been properly made inaccessible to areas where clients will have access. The medications were stored and locked in a cabinet in the kitchen with a lock box in the refrigerator for refrigerated medications. Cleansers/chemicals are locked and stored in the cabinet under the kitchen sink. Sharp knives are inaccessible and stored in a cabinet above the stove which the clients cannot reach. The First Aid Kit is located in the kitchen and contained all required supplies. The facility's smoke detectors in each bedroom were checked and were operable. The carbon monoxide detector is located in the hall way and was operable. There are no guns or weapons in the facility as stated by Licensee Mona SKinner. LPA observed a minimum 7-day non-perishable and a 2-day perishable supply of food. There was a variety of snacks available for clients as well. The following required posted items were observed accessible to clients: Grievance Procedures, Personal Rights, Visitation policies, and current menu. The facility outside grounds was also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. The pool was surround by a five foot tall wrought iron fence with a gate that closes by it self and can be locked to make it inaccessible to clients. A sample of client files were reviewed during the inspection and noted to have documents required per regulations in file. There were no clients present at time of inspection to be interviewed. The Licensee does not have staff. The licensee needs to have her CPR and first aid card renewed as it is expired. Based on the facility inspection and file reviews this date, there was one deficiency found at this time. A copy of this report and LIC 809-D was reviewed and given to Licensee Mona Skinner.


summary: Facility Evaluation

raw_content:
Narrative:
On February 9, 2024 at 11: AM, Licensing Program Analyst (LPA) Linda Haynes began an annual inspection for Extended Family Small Family Home. LPA met with Licensee Mona Skinner who led a tour of the home. The facility was toured both inside and out with the Licensee. Currently there are no clients in placement. The home is a one story building with five bedrooms and three bathrooms which are set up as follows: · Bedroom #1 (Master) has one bed, it sleeps the licensee. · Bedroom #2 (Client's) has one twin bunk bed, it will sleep two clients. · Bedroom #3 (sons) had one bed, it sleeps the son. · Bedroom #4 (sons) had one bed, it sleeps the son. · Bedroom #5 (Client's) has one twin bunk bed it will sleep two client's. · A great room/living room, kitchen, dining area, three bathrooms, an office, an attached two car garage, and the backyard. The Client's bedrooms were arranged so that no more than two client's will be in a room. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. There was adequate closet space for the client's belongings. There was a smoke detector in every bedroom. The five smoke detectors were checked, and they were working properly. The Carbon Monoxide detector is located in the hallway it was checked and was working properly. The fire extinguisher is located on the wall by the kitchen it was properly charges and inspected by the fire department. LPA interviewed one of one staff. There were no deficiencies at this time. An exit interview was conducted. A copy of this report and appeal rights was provided to Licensee Mona Skinner.


summary: Facility Evaluation

raw_content:
Narrative:
On 02/16/2024, Licensing Program Analysts (LPAs) Sarah Lo and Cythnia Velasquez arrived at facility to conduct a amendment to LIC 9099 that was signed on 12/19/23. LPAs met with Licensee to sign the amended LIC 9099.

met_with: Licensee, Mona Skinner


summary: Facility Evaluation

raw_content:
Narrative:
On July 24, 2025, at 02: PM, Licensing Program Analysts (LPA) Raina Perez-Diaz and Matthew Dorantes, began an annual inspection for Extended Family Small Family Home. LPA met with Licensee Mona Skinner who led a tour of the home. The facility was toured both inside and out with the Licensee. Currently there are no clients in placement. The home is a one story building with five bedrooms and three bathrooms which are set up as follows: · Bedroom #1 (Master) has one bed, it sleeps the licensee and spouse. · Bedroom #2 (Client' and Son) has one twin bunk bed, it will sleep one client and licensee's son. · Bedroom #3 (Client) had one bed, it will sleep one client. · Bedroom #4 (sons) had one bed, it sleeps the licensee's son. · Bedroom #5 (Client' and Son) has one twin bunk bed it sleeps licensee's son and will sleep one client. · A great room/living room, kitchen, dining area, three bathrooms, an office, an attached two car garage, and the backyard. The Client's bedrooms were arranged so that no more than two client's will be in a room. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. There was adequate closet space for the client's belongings. Sharp knives are inaccessible and stored in a cabinet above the stove which the clients cannot reach. Any future medications and First Aid Kit, which contains all required items, will be stored and locked in a cabinet in the kitchen. LPA observed a minimum 7-day non-perishable and a 2-day perishable supply of food. There was a variety of snacks available for clients as well. The facility's utilizes a combo smoke/carbon monoxide detectors which are located in each bedroom and common areas. The detectors were checked and were operable. There are no guns or weapons in the facility as stated by licensee at this time. The fire extinguisher is located on the wall by the kitchen it was properly charges and inspected by the fire department. LPA interviewed one staff. The facility outside grounds was also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. The pool was surround by a five foot tall wrought iron fence with a gate that closes by it self and can be locked to make it inaccessible to clients. Based on the facility inspection and the current census being zero, LPA did not review any staffing or client files at the time of this inspections and there are no deficiencies cited at this time. LPA informed the Licensee to notify the Department at the time of receiving their first client in care. The Department will return to conduct staff and client file reviews at the facility. An exit interview was conducted. A copy of this report and appeal rights was provided to Licensee Mona Skinner.

met_with: Licensee- Mona Skinner


facility_name: FAMILY 4 LIFE

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward met with applicant Willie Harrison, Jr. and his assistant Janice Harrison for the purpose of conducting the Component II, face-to-face meeting. The following areas were discussed during the meeting: Licensee Duties and Responsibilities, Personnel Requirements, Needs and Services Plans, Buildings and Grounds, Fixture, Furniture, Equipment and Supplies, and Applicant Qualifications. An overview of the regulations was provided and Mr. Harrison was advised on how to locate and familiarize himself with both the Small Family Home Regulations and the General Regulation LPA Jones-Steward received from the applicant and reviewed with applicant the following updated documents: LIC, 200, LIC 215, LIC 503, LIC 402, LIC 500, House Rules and Sample Menu. The requirements for background clearances and health screenings for all staff were discussed.. LPA Jones-Steward advised applicant that additional follow-up is needed to verify the authority of the person who signed the LIC 503. The pre-licensing walk through was scheduled for August 24, 2023 at 1: PM. LPA Jones-Steward advised Mr. Harrison on how to prepare for the walk-through.

met_with: Willie Harrison, Jr., Applicant


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward met with Mr. Harrison to conduct the pre-licensing inspection. The following was observed. This is single family home located in the City of Gardena, CA. There are three bedrooms and two bathrooms. There are no bodies of water on the premises and no security bars on windows and windows are operational. There is a fully charged fire extinguisher in the kitchen area. There are smoke detectors in each bedroom and a combination smoke/carbon monoxide detector in the hallway. There is locked storage space for medications, knives and household chemicals. The kitchen and bathroom areas are in good condition. Stove and refrigerator are in good working condition. All trash cans are covered. Hot water tested at 115 degrees. There is a living room area/dining area with a dining table and 4 chairs, a sofa and love seat, coffee table and TV. There is a separate laundry room and an unused garage. Backyard area is free of visible hazards. Bedrooms are assigned as follows: Bedroom number 1 is reserved for two clients. It has two twin beds. It has closet and drawer space adequate for two. There is a smoke detector in the room There are no security bars on the windows. Bedroom number 2 is reserved for one client. It has a full size bed and drawer space. However there is no closet. There is a smoke detector in the room There are no security bars on the windows. Bedroom number 3 is used by the applicant. It has one queen sized bed and a master bathroom. There are no security bars on window. LPA observed two first aid kits in the home. LPA Jones-Steward observed that Mr. Harrison has an LIC 503 completed by a medical doctor and that he is in the process of revising the Program Statement and the LIC 500. LPA advised Mr. Harrison that the following actions are necessary: Submit revised Program Statement, LIC 500 and LIC 503 to the Department Obtain a set of tweezers and a first manual for the first aid kit Obtain a portable closet for bedroom # Mr. Harrison was advised that if he wishes to convert the unused garage to a play area, another fire clearance will be needed. Review of the application will continue when the above requested actions have been taken. Applicant may present photographic proof that tweezers and portable closet have been obtained.

met_with: Willie Harrison, Jr, Applicant


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward met with applicant Willie Harrison, Jr. to conduct the Component III meeting of the application process. LPA and applicant discussed the both general and category specific forms. Applicant was given copies of the forms that are necessary to run a Small Family Home. Progress on the corrections listed during the pre-licensing visit was also reviewed. LPA observed that applicant has obtained the tweezers, first aid manual and portable closet as required. Applicant is in the process of reformatting the program statement. Applicant submitted updated LIC 500 and LIC 503. Application review will continue when the re-formatted program statement is received. LPA collected orientation certificate to be returned to applicant upon application approval.

met_with: Willie Harrison, Jr.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward met with Mr. Harrison to conduct the post-licensing inspection. The following was observed. This is single family home located in the City of Gardena, CA. There are three bedrooms and two bathrooms. There are no bodies of water on the premises and no security bars on windows. Windows are operational. There is a fully charged fire extinguisher in the kitchen area. There are smoke detectors in each bedroom and a combination smoke/carbon monoxide detector in the hallway. There are currently no clients in placement and no working staff. There is locked storage space for medications, knives and household chemicals. The kitchen and bathroom areas are in good condition. Stove and refrigerator are in good working condition. All trash cans are covered. Hot water is within the safe temperature range. There is a living room area/dining area with a dining table and 4 chairs, a sofa and love seat, coffee table and TV. There is a separate laundry room and an unused garage that is securely locked. Backyard area is free of visible hazards. Bedrooms are assigned as follows: Bedroom number 1 is reserved for two clients. It has two twin beds. It has closet and drawer space adequate for two. There is a smoke detector in the room There are no security bars on the windows. Bedroom number 2 is reserved for one client. It has a full size bed, a chest of drawers and a portable closet. There is a smoke detector in the room There are no security bars on the windows. Bedroom number 3 is used by Mr. Harrison. It has one queen sized bed and a master bathroom. There are no security bars on window. LPA observed two first aid kits in the home. There were no deficiencies found as a result of the post-licensing inspection

met_with: Willie Harrison, Jr


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts Connie Jones-Steward and Reagan Cohen met with Mr. Harrison to conduct a case management inspection. The purpose was to verify that staff are being trained as required by Title 22 80065(f)(3) & 83065. LPAs reviewed the files of all employees and did not find proof of training. Mr. Harrison stated that he has certificated to prove that staff have taken DSP I & II training. He states that staff also have training from contracted behaviorist Mark Hurrell. LPA Jones-Steward requested that proof of trainings be emailed to the Department by November 4, 2024. There is a training in Crisis Intervention Essentials scheduled for November 13, 2024. The seminar was suggested by the WRAP team and will be conducted online by UMASS Global. Mr. Harrison will submit proof of the trainings to Regan Cohen via email. LPA Jones-Steward also reviewed employee schedule revisions with Mr. Harrison and asked that an updated LIC 500 be sent to Reagan Cohen by November 4th, 2024. Exit Interview was conducted.

met_with: Willie Harrison, Caregiver


summary: Facility Evaluation - 2 deficiencies

raw_content:
Narrative:
On 2/7/25 at 9: AM Licensing Program Analyst (LPA) Reagan Cohen and Licensing Program Manager (LPM) Lakescia Smith made an unannounced visit to Family Life Small Family Home for the purpose of an annual/Random inspection. LPA and LPM met with Albert and Administrator Willie Harrison arrived after. A tour of the home was conducted. The facility is licensed to provide care and supervision services for three (3) children, ages 3-17 years old, ambulatory only. The census today is two (2) and living in the home currently are the Licensee, Adult 1, and 2 clients ages 13 &11. The facility is set up as follows: There are three bedrooms and two bathrooms. There are no bodies of water on the premises and no security bars on windows and windows are operational. There is a fully charged fire extinguisher in the kitchen area. There are smoke detectors in each bedroom and a combination smoke/carbon monoxide detector in the hallway. Living Room/Dinning Area: There is a living room area/dining area with a dining table and 4 chairs, a sofa and love seat, coffee table and TV. Kitchen: has a four (4) burner gas stove/oven (all burners were operational during the inspection), and a refrigerator /freezer. Sharp knives are located under the sink in a locked cabinet. Cleaning supplies and disinfectants are kept under the kitchen sink in a locked cabinet and made inaccessible to children in care. The kitchen has an exit door leading to the backyard. Laundry area: is located off the house in the backyard and is equipped with a washer and a dryer. Backyard: a spacious area with a basketball hoop, clear of debris. LPM noticed a crawl space to beneath the house in the backyard that Licensee will ensure remains inaccessible to clients. Detached garage: remains locked at all times and LPA observed the garage to be used for storage. Bedroom #1: is reserved for two clients. It has two twin beds. It has closet and drawer space adequate for two. There is a smoke detector in the room. There are no security bars on the windows. There is a television, working lights, and two windows. Bedroom #2: is reserved for one client. It has a full size bed and drawer space, there is also a dresser. There is a smoke detector in the room There are no security bars on the windows. The room contains working lights and windows. Report continued on LIC 809C Bedroom #3: is occupied by Licensee and Adult 1. The room is furnished with a queen size bed, dresser, television, a working light, windows, and a closet. The closet contains personal belongings. (2) Bathrooms: one bathroom is located along the hallway, and the second bathroom is located inside bedroom #3. The bathrooms contain a toilet, sink, and a shower. The hot water was tested and found to be with 105-120 (F). The hallway has a cabinet which store extra linen. The smoke and carbon monoxide detectors were tested and found to be in working order. Medications are stored in a locked box inside a kitchen cabinet and made inaccessible to children in care. The home has a working telephone readily accessible to children in care. The First Aid Kit was checked and found to be complete. LPA observed the home to be clean, safe, and sanitary. Passageways, stairways, inclines, ramps and open porches are unobstructed. The front and backyard were clean and free of debris. There are no bodies of water located on the premises. Licensees ensure that children in placement are accorded personal rights and the corresponding form is in their file. Children are supported and encouraged to participate in extracurricular activities. Children are allowed and encouraged to contact the licensing agency, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. LPA reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. All posting requirements for Small Family Home Licensor and Emergency Plan were met. LPA reviewed the following records during the inspection: Client Records: The home currently has a total of two (2) clients. LPA reviewed the client's records and found the Needs and Services Plan and Pre Appraisal Plan missing for one client. LPA also found the Personal Rights incomplete for one client. LPA found the TB test missing for both clients. LPA instructed Licensee to contact the clients social workers to receive the required information and update the clients files ASAP. Emergency and Disaster Plan: LPA reviewed facility Emergency and Disaster Plan. LPA reviewd the disaster drills for the facility. LPA recived a copy of the facility staff and client rosters. An exit Interview was conducted, and a copy of this report was left with the Licensee, Willie Harrison.

Deficiencies:
83068.2(b): Needs and Services Plan

(b) The needs and services plan shall contain at a minimum the following information
80069(c): Client Medical Assessments

(c) The medical assessment shall include the following

met_with: Administrator Willie Harrison


summary: Facility Evaluation

raw_content:
Narrative:
On 3/6/25 at 11: AM Licensing Program Analyst (LPA) Reagan Cohen made an unannounced visit to Family Life Small Family Home for the purpose of an annual/Random inspection continuation. LPA and LPM met with Assistant Caregiver Myrna Douglas. LPA called and talked with Administrator Willie Harrison, who stated he just left and was out of town. Administrator shared that staff present at the facility will help LPA have access to all the staff files for LPA review. Staff Janice Harrison arrived and helped LPA with obtaining the files. The facility is licensed to provide care and supervision services for three (3) children, ages 3-17 years old, ambulatory only. The census today is two (2) and living in the home currently are the Licensee, Adult 1, and 2 clients ages 13 &11. LPA requested and received a copy of all staff files. LPA reviewed the files and completed the LIC Staff Records review wizard. LPA requested and recevied a copy of the clients files. LPA reviewed the files and completed the LIC Client Records review wizard. LPA completed the CARES Tools checklist. LPA conducted staff and client interviews. Exit interview conducted. LPA emailed a copy of this report to Administrator Harrison with Assistant Caregiver Janice Harrison verifying that the report was sent and received.

met_with: Janice Harrison