summary: Facility Evaluation - 2 deficiencies

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced annual continuation inspection at the facility's Administrative Office located at Georgia Street, Vallejo, CA 94590. LPA met with Administrator Steve Dogan, who assisted with the inspection. LPA reviewed two of two client files and found: one client refused all medical and dental appointment efforts. The clients have all identifying information completed. Both clients are receiving mental health services as required. Both clients have Needs and Services Plans as required, however both were out of date by more than one month, and in one case, more than two months. One NSP is missing the signature of one client. Both NSPs are missing information about money management, crisis management plans, including any known limitations of the use of emergency interventions, and behavior interventions, and the anticipated duration of placement, including the transfer plan. Neither NSP includes how the clients' family members are integrated in the treatment process, including post-discharge, and how sibling connections are maintained to the extent clinically appropriate and consistent with any applicable court orders, and in accordance with the client's best interest. Neither client file documented when the client's case plan was received by the County. The facility did not receive one case plan and there was no documentation of efforts by the facility to obtain it. During this inspection, Administrator reached out to the County and obtained the case plan for that client. Additionally, there was no documentation in either client's file of the steps taken to facilitate outreach to the family members of the child, including siblings. All other requirements were met. LPA reviewed the facility's Continuous Quality Improvement (CQI) plan and found: The facility is compiling their CQI data during their Accreditation period, and they include all required elements, except for peer-review amongst other STRTPs with a similar population. LPA reviewed 5 staff files which included the Administrator, Social Worker/Head of Service, Facility Manager, and Staff. LPA found: all staff were fingerprinted and associated to the facility as required. All staff reviewed met training, education, and experience requirements. All staff had a valid Driver's License. All staff files had required identification information. One staff's CPR/First Aid was expired by just over a month. This staff is an on-call part-time staff. All other staff reviewed had valid CPR/First Aid certificates. The Administrator's Administrator Certificate expired on 12/17/2023. Administrator sent in his renewal by certified mail on 12/16/2023 and is waiting for his certificate. LPA observed that the Department is currently processing renewals received on 7/24/2023, as they are back-logged. LPA observed signed Board of Director statements from five out of seven of the members of the Board. All chair-holding members have signed. On this date, the facility is being cited for violations of the Short Term Residential Therapeutic Program Interim Licensing Standards, Version 5, Sections: 87070(b)(18), 87068.2(b), 87068.2(f), and 87068.3(a). LPA also issued Technical Violation Advisory Notes, which are not citations. LPA will return on another date to interview two clients and one more staff. An exit interview was conducted with Administrator and a copy of this report and appeal rights were provided to him.

Deficiencies:
87068.2(b): Needs and Services Plan

(b) The needs and services plan shall be trauma informed, culturally relevant, and age and developmentally appropriate and shall identify the child's needs in the following areas
87068.3(a): Modifications to The Needs And Services Plan

(a) The needs and services plan as described Sections 87068.2 and 87068.22, shall be updated at least every 30 days to determine the following


state: CA

facility_name: MILE HIGH MOUNTAIN TOP

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced annual continuation inspection at the facility and met with Facility Manager Jamilliah Cabunoc, who assisted with the inspection. There was a newly placed client as of today present, Facility Manager, and one staff. One client was at school, and the other client was on an unauthorized absence. One client returned to the facility during this inspection after school. LPA interviewed Facility Manager. LPA found Facility Manager to be knowledgeable about the clients and the facility. LPA recommends the Facility Manager receive refresher Mandated Reporter/SCAR training. LPA interviewed one client and found that the facility is meeting the client's needs and treats the client with respect. An exit interview was conducted with Facility Manager and a copy of this report was sent to Administrator.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Jamilliah Cabunoc


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced case management inspection at the facility and met with Facility Manager Steven Anderson, who assisted with the inspection. CCL received an incident report dated 4/1/2024 which LPA is gathering more information about. LPA spoke to FM about the incident. LPA reviewed client records and found: the client received a prescription for a medication they needed related to this incident, on 4/1/2024. The client's Centrally Stored Medication and Destruction Record shows that the client was not placed with that medication. The client was placed on 3/23/2024. LPA took photos of the CSMDR and the current month's Medication Administration Record. LPA is requesting the following be sent to LPA: 1. C1's MAR from March 2024 and April 2024. 2. Any placement background information which would state what conditions the client has and any medication the client is currently on. 3. Records of the hospital visits on 3/31/2024 and 4/1/2024. 4. Referral from the County for placement of C1. An exit interview was conducted with FM and a copy of this report was provided to FM and Administrator.

met_with: Steven Anderson


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced case management inspection at the facility and met with Administrator Steve Dogan who assisted with the inspection. This inspection is to close the case management opened on 5/6/2024. The incident was in regard to a client (C1 - See Confidential Names List dated 7/10/2024) having to go to the emergency room due to asthma symptoms, and did not have an inhaler. LPA reviewed medical records, medication records, and emails. The client was placed on 3/23/2024, and on 3/25/ Administrator emailed the County Social Worker, informing her that the client stated they need an inhaler. The County Social Worker was not aware that the client needed an inhaler, and the client did not come to the facility with one. On 3/31/2024, as stated in the incident report dated 4/1/2024, the client went to the ER for shortness of breath, but did not want to stay to be seen. On 4/1/2024, the client was again taken to the ER by the facility to be treated for asthma symptoms and was prescribed medication to assist with them. On 4/19/2024 the client had a doctor's appointment and the doctor did not prescribe an inhaler, but assessed the client to have allergies. Since then, the client has had no other symptoms. LPA found the facility took the client to be treated for symptoms as required, and the facility was not informed prior to placement that the client needed an inhaler as the County Social Worker was not aware, and the client did not come to the facility with one. This case management is now closed, no further action necessary. An exit interview was conducted with Administrator and a copy of this report was provided to him.

met_with: Steve Dogan


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced Plan of Correction inspection at the facility and met with Administrator Steve Dogan, who assisted with the inspection. On 7/10/2024, the facility was cited: 87072(c)(11). The plan of correction that was agreed upon by LPA and Administrator was, "By POC due date of 7/11/2024 the ED and FM will have been refreshed on de-escalation techniques, observed by Admin, and will submit a document acknowledging the different steps that could have been taken prior to restraint." LPA advised Administrator on 7/10/2024 that even if the citation and finding was disagreed with, the POC still needs to be completed as required. On 7/11/2024, Administrator emailed LPA informing her that they would not be completing the POC as they will be appealing, which is their right to do so. However, the POC was still required to be completed. LPA and Admin further discussed the citation-->POC-->appeal process. On this date, the facility is being assessed a Failure to Correct Civil Penalty in the amount of $700, which is $100 per day that the citation was not corrected after the POC due date of 7/11/2024. Further failure to complete the POC will result in a continuation of $100 being assessed for every day the POC is not submitted. An exit interview was conducted with Administrator and a copy of this report and appeal rights were provided to him.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced case management inspection at the facility and met with Facility Manager Tom Hermann, who assisted with the inspection. CCL received an incident report from the facility dated 10/5/2024 regarding client C1 (See Confidential Names List dated 11/6/2024). LPA is conducting this case management to attain more information regarding the incident. LPA spoke with staff Tom who was not aware of the incident. LPA collected client information. No clients or other staff present. Further information is needed to resolve this case management. An exit interview was conducted with staff Tom and a copy of this report was provided to him.

met_with: Tom Hermann


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess and Regional (RM) Manager Margo Castaneda made an announced case management inspection at a separate location and met with Tegre Miles, Executive Director (ED), and Reyes Bonilla Program Director (PR) who assisted with the inspection. LPA and RM are conducting this case management to gather more information in regard to MSK Solutions' fiscal accountability. On November 14, 2024, the Community Care Licensing Division received a letter via Child and Family Services Division in regard to Solano County Behavioral Health Services Division terminating their contract with MSK Solutions, Inc.. The Sacramento Regional Office requested the last 12 months of bank statements, November 1, 2023, through November 1, 2024, for all their accounts pertaining to Mile High Legend Home Facility #487005982, Mile High Mountain Top Facility # 487005059, and any other accounts associated with MSK Solutions, Inc. This will be provided to CCL by 12/10/2024. LPA and RM interviewed ED and PD. An exit interview was conducted with ED and PD and a copy of this report was provided to them.

met_with: Tegre Miles & Reyes Bonilla


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced case management inspection at the facility and met with Facility Manager Steven Anderson, who assisted with the inspection. This Case Management was opened at the facility on 11/6/2024. CCL received an incident report from the facility dated 10/5/2024 regarding client C1 (See Confidential Names List dated 11/6/2024). LPA reviewed this incident report by conducting confidential interviews with five clients and the Administrator from 11/6/2024 - 1/7/2025, and reviewing the facility investigation into the subject of the incident report. Based on interviews and all information, LPA found the accusation in the incident was not true, as confirmed by the client. This case management is now closed. No further action necessary. An exit interview was conducted with FM and a copy of this report was provided to him.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPA) Alyssa Burgess and Orlando Areizaga, and Licensing Program Manager (LPM) Jodean Hall met with Administrator Steven Anderson via Microsoft Teams. The purpose of this visit was to provide any technical assistance needed regarding the facility's Program Statement and Plan of Operation updates, detailed in the revisions letter provided to the facility on 4/7/2025. During the review it was agreed upon that the letter is understood, and Administrator will reach out if any additional guidance is needed. The revisions are due to CCL by 5/21/2025. An exit interview was conducted with Administrator and a copy of this report was provided to him. Administrator will send a signed copy back to CCL.


summary: Facility Evaluation - 2 deficiencies

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Tamara Hill and Orlando Areizaga made an unannounced case management inspection at the facility and met with Steven Anderson, Administrator to discuss the inspection. On 2/3/ The Licensee, MSK Solutions, was informed by the Department's Audit Section that they will be receiving a solvency audit for both of their licensed STRTPs: Mile High Legend Home #487005982 and Mile High Mountain Top #487005059. The Department informed the Licensee of the reason for the audit, and all required information needed to perform the audit. The due date for submission of the required information was 3/3/2025. On 3/7/2025, the Department followed up with the Executive Director (ED) Tegre Miles regarding not having received the required documents to conduct the audit, nor a request for an extension of time. On 3/12/ ED responded with their concerns, and that they intended to finish everything by the coming Friday (3/14/2025). The Department responded to ED addressing their concerns and granting an extension until 3/14/2025. Failure to submit the required documents would result in the completion of the audit, documenting noncompliance with the Department's Inspection Authority. On 3/17/2025, ED responded to the Department with their concerns, however no documentation was provided. On this date the facility is being cited for violations of the California Code of Regulations, Title 22, Division Chapter 1, Section 80044(c) Inspection Authority of the Licensing Agency, Section 80062(a) Finances, Section 80063(a) Accountability, and Section 80064(a) Administrator Qualifications and Duties. A repeat civil penalty in the amount of $250 is assessed for violation of Section 80044(c). Civil penalties in the amount of $100 per day will continue to accrue until the POC is met. LPA Hill did advise the administrator, Mr. Anderson, that while they have a plan of correction date of 5/15/25, civil penalties will continue to accrue on the citation related to Inspection Authority until the documents have been provided to the Audit Section per the request. LPA Hill advised the agency that they need to provide the requested documents as soon as possible to prevent further accrual of the civil penalties. LPA Hill advised that the civil penalties include an initial penalty of $250 plus $100 per day until the document(s) have been provided per the audit request. An exit interview was conducted with Mr. Anderson and a copy of this report and appeal rights was provided

Deficiencies:
80062(a): 1
2
3
4
5
6
7Finances. The licensee shall meet the following financial requirements
80063(a): 1
2
3
4
5
6
7Accountability. The licensee, whether an individual or other entity, is accountable for the general supervision of the licensed facility, and for the establishment of policies concerning its operation.1
2
3
4
5
6
7By 5/15/25, the Licensee will submit evidence of their accountability in operating the facilities.
8
9
10
11
12
13
14Based on records review, the Licensee did not provide evidence that they are accountable for their facilities which poses a potential Health, Safety, or Personal Rights risk to clients in care.8
9
10
11
12
13
14Proof of correction can be in the form of a letter, board resolution, or other documentation indicating the required accountability in operating the facilities.
Type B
05/15/2025
Section Cited
CCR80064(a)

1
2
3
4
5
6
7Administrator Qualifications and Duties. The administrator shall have the following qualifications

met_with: Steven Anderson, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Hill on 9/9/21 at 11: AM. During the inspection, LPA Hill met with Steven Dogan, Administrator and inspected the facility inside and out. During the facility tour of the facility, LPA Hill observed the medication storage location is currently in a restroom on the first floor as the normal medication storage location is on the second floor but there is currently a youth in isolation in that room. LPA observed that the medications are currently in a locked location in the facility. LPA reviewed two youth files on site at the facility during the inspection at 3: PM. LPA was unable to interview one youth during the site inspection as the youth is currently in school. LPA set up for one youth to be interviewed at a later date. LPA did interview one youth during the inspection at 3: PM. LPA reviewed two staff personnel files on site at the facility at 2: PM. LPA interviewed two staff on site at the facility during the inspection at 12: PM. LPA observed that of the two youth taking psychotropic medications one has authorization by a parent/guardian and another has a current JV223 that expires in November 2021. Facility was cited for Facility cited for violation of Short Term Residential Therapeutic Program Interim Licensing Standards, Regulation 87070(b)(12)(H) and (E) Children's Records. LPA observed that the Psychotropic Medication Administration Record (PMAR) document was not signed upon administration of psychotropic medications for C1 (see LIC811 dated 9/9/21) on 9/8/21, 9/9/21 and C2 on 9/3/21. In addition, one of C1's documents had the incorrect dosage noted on the PMAR. LPA conducted an exit interview with Steven Dogan, Administrator upon completion of the inspection.

met_with: Steven Dogan, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPA) Alyssa Burgess and Monica Roberts made an unannounced case management inspection at the facility and met with staff Tom Hermann, Program Director (PD) Reyes Bonilla, and Administrator Steve Dogan, who assisted with the inspection. LPAs, staff, and PD conducted a walk-through of the facility and LPAs observed the following: a missing door handle on the first section of the upstairs bathroom, a broken window screen in the living room, three broken rolling chairs in the media room missing backs and arms with frame exposed, one ripped up couch cushion in the media room, broken outside table/bench with missing bench part - exposing the metal frame, broken thin metal beam in trash pile in corner of back yard, accessible poison rodent trap on the ground in the backyard, the kitchen table was in disrepair, and LPAs had no access to the staff office as neither staff nor PD had access to it. PD stated that they are planning on replacing the chairs and having the couch repaired. PD called Executive Director Tegre Miles to request to get rid of the broken outside table and connected seating, which he stated he can do today. PD threw away the poison trap and stated that it was an old one. PD also threw away the thin metal beam during this inspection. PD messaged the maintenance workers about the bathroom door handle and the broken window screen during this inspection. Due to the facility's recent renovations and door lock changes, the PD did not have the new key, but it is at the Administration Office. Later in the inspection at around 12: PM Administrator Steve Dogan arrived, and he has access to the staff office. On this date, the facility is being cited for a violation of the California Code of Regulations (CCR) Title 22, Division 6, Section 80087(a), Buildings and Grounds. An Advisory Note for a Technical Violation was also issued, which is not a citation, for the office door being inaccessible during this inspection. An exit interview was conducted with Administrator and a copy of this report and appeal rights was provided to him.

met_with: Reyes Bonilla and Steve Dogan


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Jean Stidman and Connie Goldie on 5/10/23 at 5:00pm.. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Stidman and Goldie met with Steve Dogan, Administrator, and inspected the facility LPAs observed the facility had three staff present with five clients present. LPA reviewed five child's records and three staff personnel files on site at the facility. LPA reviewed five child's psychotropic medications and medication records. LPA interviewed three staff on site to discuss the facilities policies and procedures of operation. LPA interviewed five children currently prescribed psychotropic medication. During the inspection the LPAs observed deficiencies (see attached 809D), plan of corrections were discussed and appeal rights were provided. LPAs provided a copy of this licensing report to Steve Dogan, Administrator. Facility cited Interim Licensing Standards for STRTP Articles 1-10, Regulation 87068.2(f) Needs and Services Plan (NSP) and 87068.3(a) Modification to the Needs and Services Plan, and 87070(b)(13) Children's Records. LPAs observed one client file is missing the client's authorized representative's signature on the initial NSP and two client's initial NSP's were not completed within 30 days of placement. LPAs observed two client's NSP were not updated every 30 days. Facility cited Interim Licensing Standards for STRTP Articles 1-10, Regulation 87070(b)12) Children's Records. LPAs observed four out of five clients Psychotropic Medication Administration Records (PMAR) have inaccurate information such as prescription fill date, number of refills. Facility cited Interim Licensing Standards for STRTP Articles 1-10, Regulation 87068.2(c) Needs and Services Plan for five out of five clients files reviewed were missing a description of the services to be provided or arranged to meet the short- and long-term needs and goals of the child as assessed by the Qualified Individual... LPA provided a copy of this licensing report and appeal rights to Steve Dogan Administrator

Deficiencies:
87068.2(f): 1
2
3
4
5
6
7

met_with: Steve Dogan, Administrator

title:
1
2
3
4
5
6
7 87068.2(f) Needs and Services Plan (NSP). The licensee shall obtain written approval from the child, if age and developmentally appropriate, and the child's authorized representative prior to implementing the child's needs and services plan (NSP). This requirement is not met as evidenced by

description:
1
2
3
4
5
6
7


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced inspection at the facility and met with staff Thomas Hermann, who assisted with the inspection. Present at the facility was one client and one staff. Another staff arrived not long after. There were no facility managers at the facility. Administrator Steve Dogan arrived a little bit later. On this date, the facility is being cited for a violation of the Short Term Residential Therapeutic Program Interim Licensing Standards, Version 5, Section 87065(f), Personnel Requirements. An exit interview was conducted with Administrator Steve Dogan and a copy of this report and appeal rights were given to him.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced case management inspection at the facility and met with Facility Manager Steven Anderson, who assisted with the inspection. On 1/4/2024, LPA received allowance records for a client for the months of February 2023 through December 2023. LPA observed some unclear and incorrect entries. When LPA visited the facility again on 3/6/2024 for an annual inspection, LPA observed a random sample of a client's allowance sheet in which LPA again observed errors. LPA addressed this with the Administrator during that inspection. LPA also later brought this to the attention of the Executive Director, reviewing the records together, who then also discussed this with Administrator. LPA conducted an investigation into a complaint allegation in which it was alleged that the facility staff do not safeguard minor's personal belongings. LPA found this allegation to be unsubstantiated (see LIC9099 dated 5/6/2024 for the full report), however during LPA's investigation she reviewed clients' cash resources/allowance records, which due to these errors made the records unreliable. On this date the facility is being cited for a violation of the California Code of Regulations, Title 22, Division 6, Chapter 1, Section 80070(b)(14). An exit interview was conducted with FM, and a copy of this report and appeal rights were provided to him.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced case management inspection at the facility and met with Facility Manager Steven Anderson, who assisted with the inspection. The purpose of this case management inspection is to deliver the findings to the case management which was investigated by the Department's Investigations Branch Investigator (IB) Nathan Gonzalez, regarding an incident report received by the Department on 4/15/2024 by the facility. The reported incident stated that one client (C1) had been sexually assaulted when C1 was forced by a client (C2) to perform oral sex on C2 on the night of 4/15/2024. See confidential names list dated 8/9/2024. IB conducted this investigation by reviewing police reports, facility file information, and by conducting confidential interviews with one County Social Worker, three clients, three staff, the facility Administrator, and the facility Program Director, on 5/1/2024, 5/21/2024, 5/23/2024, 6/20/2024, 7/13/2024, 7/17/2024, and 7/23/2024. IB had also requested staff and Administrator write-ups relating to the incident from the Program Director on 7/17/2024, 7/26/2024, and 7/30/2024, which IB never received. IB found through their investigation that on 4/16/2024 a staff informed the Program Director that a non-consensual sexual encounter had occurred between clients. Clients were interviewed by Law Enforcement (LE) and informed LE that they were forced to smoke marijuana with C2 and play truth or dare. During truth or dare, C2 forced C1 to perform oral sex on them, under threat of physical violence. One staff (S1) was present at the facility during this incident and had called the Administrator of the facility, who was the on-call staff that night, three times for assistance with other escalated client behaviors with no response. S1 admitted to feeling that she, "neglected," some of the clients who were upstairs during her shift. Staff reported to IB that they are directed to supervise clients from the upstairs media room during overnight shifts, and S1 acknowledged that she should have more effectively supervised the clients from the media room. Administrator confirmed to IB that he missed three calls from S1. Administrator informed IB that he and S1 were both reprimanded for this incident. The Program Director informed IB that staff are to follow the emergency phone call procedures when needing management assistance, however S1 did not think to do that in the moment. Based on information obtained by IB, IB found that S1 and Administrator failed to provide adequate supervision to clients during the early morning of 4/15/2024, which resulted in C2 sexually assaulting C1 while in care. On this date the facility is being cited for violations of the California Code of Regulations, Title 22, Division 6, Chapter 1, Section 80078(a), Responsibility for Providing Care and Supervision, and Section 80044(c), Inspection Authority. See attached LIC809-D. An exit interview was conducted with FM, and a copy of this report, confidential names list, advisory note, and appeal rights were provided to him.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On February 11, 2026, at approximately 9: AM, Licensing Program Analyst (LPA) Orlando Areizaga and Licensing Program Manager (LPM) Connie Goldie made an unannounced case management inspection to the above Short-Term Residential Therapeutic Program (STRTP). LPA and LPM met with Office Manager, Corri Collins who granted LPA and LPM access to the facility. LPA and LPM conducted a walk through of the interior and exterior of the facility. The following items were observed. Kitchen blinds were broken Staff bathroom had an electrical hazard Missing blinds on the door leading out to the backyard Client bathroom was observed to have dried toilet paper on the floors, yellowing in the shower basin and shower walls, under client sink had dark spots Windows did not have screens Per the following observations, the STRTP is being sited for California Code of Regulations (CCR) Buildings and Grounds 80087(a) and Furniture, Fixtures, Equipment, and Supplies 80088(b) on the LIC809-D page. An exit interview was conducted, and appeal rights were discussed. A copy of this report along with the appeal rights were given to Office Manager, Corri Collins.

Deficiencies:
80088(b): All window screens shall be in good repair and be free of insects, dirt and other debris.

met_with: Office Manager, Corri Collins

title:
1
2
3
4
5
6
7Furniture, Fixtures, Equipment, and Supplies


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On February 11, 2026, at approximately 9: AM, Licensing Program Analyst (LPA) Orlando Areizaga and Licensing Program Manager (LPM) Connie Goldie made an unannounced case management inspection to the above Short-Term Residential Therapeutic Program (STRTP). LPA and LPM met with Office Manager, Corri Collins who granted LPA and LPM access to the facility. LPA and LPM conducted a walk through of the interior and exterior of the facility. It was noted during the inspection, that there was an uncleared staff working at the facility. The facility staff has a criminal clearance but was not associated to the above facility. Per the following observations and records review, the facility is being cited for California Code Regulation (CCR) Criminal Record Clearance 80019(e)on the LIC809-D An exit interview was conducted, and appeal rights were discussed. A copy of this report along with the appeal rights were given to Office Manager, Corri Collins.

Deficiencies:
80019(e): All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

title:
1
2
3
4
5
6
7Criminal Record Clearance


facility_name: MILESTONE GROUP HOME

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Confidential interviews revealed that staff conducted room checks and did not witness C1 and C2 engaging in any inappropriate behavior. However, when staff was made aware of the alleged allegation C1's room was changed, and staff were directed to increase supervision on both C1 and C2 to ensure proper supervision was carried out. Documents reviewed indicated that there was no indication that C2 needed extra supervision. Based on confidential interviews and documents reviewed during the investigation, the allegation that C1 was inappropriate touched by C2 at the facility, may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated. An exit interview was conducted, appeal rights discussed, and a copy of this report was provided to Licensee Beverly Boone.

Investigation Findings:
13On August 27, 2021 at 1:13PM, Licensing Program Analyst (LPA) Carol Anderson met with Licensee Beverly Boone to deliver the findings for the above stated allegation regarding the minor engaged in inappropriate touching of another minor in the home as listed on the Confidential Names List, LIC 811. The investigation was initiated on April 15, 2021 at the facility. There were no deficiencies noted at that time. During the investigation, LPA interviewed five of five clients (C1 through C5), five of three staff (S1 through S3). LPA reviewed C1 and C2's Appraisal Needs and Services Plans as well as Special Incident Reports. The Department received a complaint on April 8, 2021, alleging minor engaged in inappropriate touching of another minor in the home. Confidential interviews revealed conflicting statements; C2 has been licking C1's face and touching C1's chest every night during bedtime since first placed at the facility, and C2 did not touch C1. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Carol Anderson LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, METROPOLITAN DR. # FACILITY NAME: MILESTONE GROUP HOMEFACILITY NUMBER: VISIT DATE: 08/27/2021

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

report_type: Complaint Investigation

met_with: Beverly Boone

complaint_status: unsubstantiated


raw_content:
Narrative:
S4 was removed from the schedule immediately and the agency terminated the employee's employment, as of 10/30/2021. Based on confidential interviews, the preponderance of evidence standard has been met regarding the allegation that S4 made inappropriate comments towards a client, therefore the complaint allegation is substantiated. The facility is cited for violation of Interim Licensing Standards (ILS) v. Personal Rights 87072(c)(10). This posed a potential Health, Safety, or Personal Rights risk to children in care. A copy of this report was provided to and reviewed with Beverly Boone, Executive Director, along with the appeal rights and the LIC 811. A signed copy of the report will be kept in the Facility file. resulted in C1 and C4 being unsupervised in a bedroom and had sex. The interviews that were provided to the LPA were not consistent regarding the allegation that staff were not properly supervising minors and did not provide any further specific details regarding staff supervision. Based on interviews the staff did not properly supervise minors while in care, resulting in minors having inappropriate interactions, which may or may not have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Beverly Boone, Executive Director. A copy of this report will be placed in the Facility file.

Investigation Findings:
13On April 29, 2022, at 12:55 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility and met with Beverly Boone, Executive Director, of Milestone to discuss the investigative findings for the allegation noted above. LPA Carol Anderson conducted an inspection with the facility on June 7, 2021, at 10: AM. No deficiencies were observed. During the investigation, LPA Carol Anderson and LPA Charmaine Linley interviewed four clients (C1, C2, C3, C5) and two staff (S1, S2). LPA Anderson and LPA Linley reviewed the following documents C1's Appraisal Needs and Services Plan, C1's Child-Family-Team Meeting notes, staff scheduled for January-February 2021, and staff contact information On May 28, 2021, Community Care Licensing (CCL) received an allegation that staff members had made inappropriate comments toward the minor. It was alleged that two staff members had told clients "you will never amount to anything and you'll end up in jail or on the streets." Based on confidential interviews, S4 made inappropriate comments towards several clients, and S5 overheard S4 telling C2 to "shut up." SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-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, FACILITY NAME: MILESTONE GROUP HOMEFACILITY NUMBER: VISIT DATE: 04/29/2022

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

met_with: Beverly Boone, Executive Director


raw_content:
Narrative:
placed a Facetime call to the staff inside of the facility. Regarding the allegation that the facility has pests. Confidential interviews report that the facility has slugs, roaches, and mice. Confidential interviews reveal they have seen roaches in the bathroom and hallways. Confidential interviews reveal that they have seen mice in the house at night. Confidential interviews and documents revealed that there were monthly pest control services at the facility, however, the dates of the services were after the facility was made aware of the allegation roaches, slugs, and mice were present in the facility. Based on confidential interviews and record review of facility documentation, the allegations that the staff is not properly supervising the minors and the facility has pests. are substantiated which poses a potential health, safety, and personal rights risk to clients in care. The preponderance of evidence standard has been met. The facility is cited for violation of the California Code of Regulations, Title 22, Division 6, Chapter 1, Article 6, 80078(a) Responsibility for Providing Care and Supervision. The facility is cited for violation of the California Title 22, Division 6, Chapter 1, Article 07, regulation 80076(a)(17) Food Service. A copy of this report was provided to and reviewed with Beverly Boone, Executive DIrector, along with the appeal right and the LIC 811. A signed copy of the report will be kept in the Facility file. or paraphernalia. Confidential interviews revealed that staff increases their supervision level if they suspect clients are using drugs. Other confidential interviews revealed that clients have smoked in the bathroom and outside of their bedroom doors and covered it up with perfume. Other confidential interviews revealed that staff have smelled smoke in the facility and had not asked the clients if someone was using drugs. Regarding the allegation that the facility vehicle is not in proper driving condition. Confidential interviews and reports revealed that the facility van was replaced in July 2021 and has not had any issues since the transmission was replaced. Other confidential interviews revealed the vehicle struggles and makes sounds while driving up hills. Confidential interviews revealed that clients are offered the opportunity to clean the vehicles once a month and earn an extra allowance. Other confidential interviews revealed that staff will take the vehicle to an automatic car wash and pay for it themselves. Based on interviews and information obtained, the allegations that minors are using drugs on the facility premises, and the facility vehicle is not in proper driving condition, may or may not have occurred, however, it is not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. A copy of this report was provided to and reviewed with Beverly Boone, Executive DIrector , along with the appeal right and the LIC 811. A signed copy of the report will be kept in the Facility file

Investigation Findings:
13On April 29, 2022, at 12:21 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility and met with Beverly Boone, Executive DIrector of Milestone to discuss the investigative findings for the allegations noted above. LPA Carol Anderson conducted an inspection of the facility on July 19, 2021, at 11: AM. No deficiencies were observed. During the investigation, LPA Carol Anderson and LPA Charmaine Linley interviewed three clients (C1, C2, C3) and two staff (S1, S2). LPA Anderson and LPA Linley reviewed the following documents C1's Appraisal Needs and Services Plan, Staff Schedule, Pest Control Invoices from 2020-2021, and notes from the communication log about C1's incidents. On July 9, 2021, Community Care Licensing (CCL) received allegations that the staff is not properly supervising the minors and the facility has pests. Confidential interviews and documents reviewed indicated that two clients were left unsupervised outside to go on a walk together, which resulted in one minor placing another minor in a grocery cart and pushing them down a hill. Confidential interviews revealed that staff was not aware the clients were going down the hill in a cart until one of the clients SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-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, FACILITY NAME: MILESTONE GROUP HOMEFACILITY NUMBER: VISIT DATE: 04/29/2022

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

met_with: Beverly Boone, Executive DIrector


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
substantiated. This posed a potential Health, Safety, or Personal Rights risk to C3 in care, the facility will be cited for violating Interim Licensing Standards, STRTP, Article 06, 87070(g) Client Records. A copy of this report was provided to and reviewed with Beverly Boone, Executive DIrector, along with the appeal rights and the LIC 811. A signed copy of the report will be kept in the Facility file.

Investigation Findings:
13On April 29, 2022, at 12:01 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility and met with Beverly Boone, Executive DIrector, of Milestone to discuss the investigative findings for the allegation noted above. LPA Carol Anderson conducted an inspection with the facility on September 9, 2021, at 11: AM. No deficiencies were observed. During the investigation, LPA Carol Anderson and LPA Charmaine Linley interviewed one client (C1) and two staff (S1, S2). On August 31, 2021, Community Care Licensing (CCL) received an allegation that staff did not safeguard the minor's personal information. The staff is alleged to have used C1's name and date of birth at an Independent Living Program Event for C2 to obtain a gift card. Confidential interviews revealed that S4 did use C1's name and date of birth since they were eligible to receive a gift card, while C2 was not eligible. During this incident, C2 was able to obtain C1's confidential birth name. Based on confidential interviews, the preponderance of evidence standard has been met regarding the allegation that S4 did not safeguard C1's personal information, therefore the complaint allegation is SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-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, FACILITY NAME: MILESTONE GROUP HOMEFACILITY NUMBER: VISIT DATE: 04/29/2022

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

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
access to them. Regarding the stove is in disrepair. Reports alleged that the stovetop has caught fire and the burners are loose. Based on confidential reports, all the stovetop burners do not work, and they must be adjusted multiple times before they work. Confidential interviews revealed the maintenance people have worked on the stovetop, despite the repairs, it was revealed the burners do not all consistently work. Based on LPA's observation, the back-left burner of the facility does not work. Based on confidential interviews, the preponderance of evidence standard has been met regarding the allegations that hazard tools are left accessible to clients, and the stove is in disrepair therefore the complaint allegations are substantiated. This posed a potential Health, Safety, or Personal Rights risk to clients in care, the facility will be cited for violating California Title 22, Division 6, Chapter 1, Article 07, Regulation 80087(g) Building and Grounds and Regulation 80076(a)(19) Food Service. A copy of this report was provided to and reviewed with Beverly Boone, Executive DIrector, along with the appeal rights and the LIC 811. A signed copy of the report will be kept in the Facility file. residents. Other confidential interviews revealed maintenance staff called residents "princesses" and made them feel uncomfortable. There were no witnesses of the maintenance staff speaking inappropriately to the residents. Based on confidential interviews, although the allegation that staff called residents inappropriate names may or may not have occurred, however, it is not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. A copy of this report was provided to and reviewed with Beverly Boone, Executive DIrector , along with the appeal right and the LIC 811. A signed copy of the report will be kept in the Facility file.

Investigation Findings:
13On April 29, 2022, at 11:31 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility and met with Beverly Boone, Executive DIrector, of Milestone to discuss the investigative findings for the allegations noted above. LPA Carol Anderson conducted an inspection of the facility on December 6, 2021, at 11: AM. No deficiencies were observed. During the investigation, LPA Carol Anderson and LPA Charmaine Linley interviewed five clients (C1, C2, C3, C4, C5) and three staff (S1, S2, S3). LPA Anderson and LPA Linley reviewed the following documents client roster, C1's food log, C1's monthly weight records, facility maintenance log, and staff roster. On December 6, 2021, Community Care Licensing (CCL) received an allegation that hazard tools are left accessible to residents, and that the stove is in disrepair. Reports alleged that while the maintenance people are working at the facility, they have left out tools, including a saw, and nails on the ground. Based on confidential interviews, the maintenance people have left out tools and supplies and have been told on several occasions to secure and lock up their tools and supplies, so the clients do not have SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-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, FACILITY NAME: MILESTONE GROUP HOMEFACILITY NUMBER: VISIT DATE: 04/29/2022

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


raw_content:
Narrative:
property. Other confidential interviews entail that the staff did smoke in the facility and on the grounds. Confidential interviews revealed two staff members smoke, and they have been observed smoking while in their personal vehicles away from the facility. There are no witnesses to this allegation. Regarding the allegation that staff did not protect minors' belongings. The allegation entailed that teddy bears and an I-pad were stolen from a C3's bedroom and money from various clients. Confidential interviews reported that the I-pad was returned to the client one week later. Confidential interviews revealed that clients would misplace their money and accuse others of stealing their money and later the clients would find their money. Confidential interviews entailed that there were no reports of stolen money or belongings to the staff. Other confidential interviews entailed that clients never found their belongings that were allegedly stolen. Regarding the allegation that staff shows favoritism to clients. Confidential interviews revealed that staff shows favoritism to certain clients not getting consequences after using drugs, taking them on a one-on-one outing in the community, and treating them nicer than the other clients. Confidential interviews revealed conflicting reports; clients are not given consequences and clients are placed on restrictions for using drugs. Confidential interviews revealed that S5 took C5 to cultural events in the community, as both persons are of similar cultural backgrounds. Confidential interviews revealed that certain clients are more talkative and engage with staff that clients perceive as favoritism. Confidential interviews revealed that there was no specific client that was given preferential treatment. Based on interviews, the allegations that staff smoked inside of the facility and outside of the facility next to the client's exit doors, staff did not protect minors' belongings, and staff shows favoritism to clients may or may not have occurred, however, it is not supported or proven by the evidence. Therefore, the allegations are unsubstantiated currently. A copy of this report was provided to and reviewed with Beverly Boone, Executive Director, along with the appeal right and the LIC 811. A signed copy of the report will be kept in the Facility file.

Investigation Findings:
13On April 29, 2022, at 10:50am, Licensing Program Analyst (LPA) Charmaine Linley made an unannounced complaint inspection at the facility. LPA Linley met with Beverly Boone, Executive Director, to discuss and deliver the investigative findings for the allegations noted above. LPA Linley conducted an unannounced inspection of the facility on April 19, 2022. No deficiencies were observed. During the investigation, LPA Linley interviewed four clients (C1, C3, C4, C5) and four staff (S1, S2, S3, S4) C2 was ill in bed and unable to be interviewed (see confidential name list, LIC 811, dated 04/29/22). LPA Linley reviewed the following documentation: C Needs and Services Plan, dated 09/30/2021, C Discharge Report, dated 10/04/2021, Copy of the House Rules, C Discharge Inventory signed 10/01/2021. On April 19, 2022, the Department received an allegation that staff smoked inside of the facility and outside of the facility next to the client's exit doors, staff did not protect minors' belongings, and staff shows favoritism to clients. Confidential interviews revealed conflicting statements: Confidential interviews revealed that staff has never been observed smoking inside of the facility or on the facility UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-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, FACILITY NAME: MILESTONE GROUP HOMEFACILITY NUMBER: VISIT DATE: 04/29/2022

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

met_with: Beverly Boone, Executive director


raw_content:
Narrative:
An exit interview was conducted, appeal rights explained and a copy of this report was provided to Beverly Boone, along with the LIC 811.

Investigation Findings:
13On November 4, 2022 at 10:40am, Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera conducted an unannounced inspection to the facility to deliver the findings of the above allegation. LPA met with Beverly Boone. LPA Daniel Garcia conducted an inspection of the facility on November 09, 2021 at 11:20 am and no immediate deficiencies were observed. Four of four children (C1, C2, C3, C4), four staff and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that staff #1 (S1) made an inappropriate comment to C1. Confidential interviews reported that on October 29, C1 and S1 were engaging in a conversation about another staff member. Confidential interviews reported that S1 then made an inappropriate comment, " screw you" to C1. All of the persons interviewed corroborated this information. Based on record review and interviews S1 did make an inappropriate comment C1. The preponderance of evidence standard has been met, therefore the allegation S1 pushed C1 is found to be Substantiated. This poses an Potential Health, Safety or Personal Rights risk to the children in care. The STRTP is being issued a citation for violations of the Interim Licensing Standards, Chapter 7.5, Version 3.1, Section 87072(d)(10) Personal Rights. See attached LIC 9099D for cited deficiency. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Darlene Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-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, FACILITY NAME: MILESTONE GROUP HOMEFACILITY NUMBER: VISIT DATE: 11/04/2022

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


raw_content:
Narrative:
Based on record reviews and confidential interviews, C1 sexually exploiting themselves on November 3, 2022. The details gathered from police report did not provide sufficient evidence to prove or disprove the allegations that facility staff are not preventing C1 from sexually exploiting themselves online and in person while in care. Therefore, the allegations are unsubstantiated. LPA conducted an exit interview and provided a copy of this report along with appeal rights to Beverly Boone, Executive Director.

Investigation Findings:
13On January 6, 2023 at 2: PM, Licensing Program Analysts (LPA's) Lucero Jauregui and Eduardo Barragan conducted a complaint inspection at Milestone and met with Beverly Boone, Executive Director and Desiree West, Clinical Director. The purpose of the inspection was to deliver the findings for the above complaint allegations. LPA Jauregui conducted an inspection of the facility on November 29, 2022, and no deficiencies were noted. During the investigation, LPA Jauregui reviewed needs and services, shift notes, incident reports and interviewed one client (C1), five staff (S1-S4,S6), and one county social worker (A1). LPA attempted to interview one staff (S5). However, after attempts LPA was unsuccessful. On November 21, 2022, the Department received a complaint report, with allegations that facility staff are not preventing minor from sexually exploiting themselves online and in person while in care. Confidential interviews revealed conflicting statements as to staff intervening prior to C AWOLing from the facility. In addition, there was no safety plan documented in C1's file. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SO. Cal Sc/res, Metropolitan Dr. # FACILITY NAME: MILESTONE GROUP HOMEFACILITY NUMBER: VISIT DATE: 01/06/2023

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


summary: Complaint Investigation - Substantiated - 3 allegations

raw_content:
Narrative:
Confidential interviews indicated that C1 had texted S3 to request a ride home from school, while S3 was in a meeting and did not see the text for an extended period. LPA observed C1's phone which showed that the staff was aware that C1 needed a ride and had been responding to C1's texts. The staff made C1 wait at least two hours before picking C1 up from school. Confidential interviews revealed that C1 was not getting along with roommate C2 and staff placed C1's mattress on the floor next to the front door which gave C1 no privacy. C1 had to sleep there for three nights. LPA observed pictures of the mattress placed on the floor of the room next to the front door. Confidential Interviews indicated that C1 left the facility without permission and staff packed up C1's belongings for safeguarding. Confidential interviews revealed that when C1 returned to the facility C1 did not receive all their belongings. Based on confidential interviews, and LPA's observations the allegations that staff did not pick up C1 in a timely manner, the staff made C1 sleep by the facility entrance/exit door, and the staff confiscated C1's belongings are SUBSTANTIATED because the preponderance of evidence standard has been met. This posed a potential Health, Safety, or Personal Rights risk to C1 in care, the facility will be cited for violating Interim Licensing Standards, STRTP, Article 06, 87072(c)(11) Personal Rights, and 87072(c)(6)(C) Personal Rights. An exit interview was conducted, and appeal rights were discussed with Beverly Boone, Executive Director. A copy of the report, LIC 811, and appeal rights were provided to the facility administrator.

Investigation Findings:
13On January 6, 2023, at 3: PM, Licensing Program Analyst (LPA) Lucero Jauregui arrived unannounced to the facility and met with Beverly Boone, Executive Director of Milestone to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on September 28, 2022, at 11: AM. No deficiencies were observed. During the investigation, LPA interviewed three of three clients (C1, C2, C3) and four of four staff (S1, S2, S3, S4). LPA reviewed staffs monthly schedule, staff contact list, C1's day pass, C1's progress notes (9/15-9/19) and C1's needs and services plan. On September 20, 2022, Community Care Licensing (CCL) received allegations that staff did not pick up C1 in a timely manner, the staff made C1 sleep by the facility entrance/exit door, and the staff confiscated C1's belongings. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SO. Cal Sc/res, Metropolitan Dr. # FACILITY NAME: MILESTONE GROUP HOMEFACILITY NUMBER: 372008440

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Estimated Days of Completion: 0


raw_content:
Narrative:
Based on confidential interviews and record review, the preponderance of evidence standard has been met regarding the allegation that the staff did not ensure that C1 had fair and equal access to placement at the facility, therefore the allegation is substantiated. This poses an immediate Health, Safety, or Personal Rights risk to the children in care. The facility will be cited for violating the California Code of Regulations, Short Term Residential Treatment Program ILS 87068. Admission Determination Procedures. An exit interview was conducted and plan of corrections was developed with Beverly Boone, Executive Director. A copy of this report and appeal rights was provided to Beverly Boone, Executive Director,

Investigation Findings:
13On May 18, 2023, at 3: PM, Licensing Program Analyst (LPA) Lucero Jauregui arrived unannounced at the facility and met with Beverly Boone, Director and Maria Horton, Facility Manager to discuss the investigative finding for the allegation noted above. LPA Eduardo Barragan conducted an inspection of the facility on 01/31/2023 at 10:15 am. No deficiencies were observed. LPA Barragan interviewed five staff (S1-S5) and one of one Client (C1). LPA Barragan reviewed the facility's program statement. On 01/24/2023, Community Care Licensing (CCL) received an allegation that the staff did not ensure that the minor had fair and equal access to placement at the facility.Confidential interviews and record reviews indicated that the facility declined placement for (C1) due to the minor being transgender. Confidential interviews confirmed that the facility did not accept C1 for placement due to being born of a specific gender. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SO. Cal Sc/res, Metropolitan Dr. # FACILITY NAME: MILESTONE GROUP HOMEFACILITY NUMBER: VISIT DATE: 05/18/2023

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Estimated Days of Completion: 0


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Confidential interviews also denied allegations that C1 had missed any medical follow-up appointments or failed to pick up C1's medication in a timely manner. According to confidential information obtained C1 absconded several times from the facility during this period of time. While other confidential information received by Licensing Office stated that these allegations had occurred. There were no other know witnesses to these allegations. Based on interviews and confidential information obtained during the course of this investigation, the allegations that staff did not seek timely medical attentions for Client # 1 (C1), ensure that C1 attended a scheduled medical appointment, as well as mishandled C1's medication, may have occurred, however is not supported or proven by evidence. Therefore, the above allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report and appeal rights were provided.

Investigation Findings:
13Licensing Program Analyst (LPA), Daniel Mena met with Director, Beverly Boone to discuss the investigative findings for the above stated allegations. Licensing Program Analyst (LPA) Lucero Jauregui conducted inspection of the Short Term Residential Therapeutic Program (STRTP). No immediate hazards were observed. The investigation was jointly conducted by LPAs Jauregui and Mena. The investigation included interviews with five staff (Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), Staff #4 (S4) & Staff # 5 (S5), as well as a review of client and facility records. LPA Mena was unable to interview Client # 1 (C1) due to C1's current whereabouts being unknown and C1 not being responsive to LPA Mena's requests for an interview. Community Care Licensing received information on May 09, 2023, alleging that staff did not seek timely medical attention for Client # 1 (C1), ensure that C1 attended a scheduled medical appointment, as well as mishandled C1's medication. Information obtained in confidential interviews did not corroborate the allegation with a preponderance of evidence. LPAs obtained conflicting information during interviews. According to confidential information, facility staff was not initially aware of C1 needing medical attention since it was C1's Social Worker who was initially made aware and not facility staff. According to confidential interviews, once aware facility staff made a medical appointment for C1 the following day. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Daniel Mena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: MILESTONE GROUP HOMEFACILITY NUMBER: VISIT DATE: 05/10/2024


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Narrative:
However, confidential interviews disclosed that facility never followed the posted menu to be served for the clients and staff told clients to cook their own food. Additional confidential interviews reported that some clients required some special diet and do not eat seafood or pork, but the facility would not provide food for them or accommodate client's choices. Staff interviews disclosed that staff allowed clients to cook their own meals as an independent living skill. LPA was unable to obtain documentation supporting cooking as independent living skills for clients. Based on confidential interviews and records review, the preponderance of evidence standard has been met, therefore, the allegation that staff are not serving an adequate amount of meals to clients in care is substantiated. The facility is being cited for the violation of Interim Licensing Standards Article 06. Continuing Requirements for Food Service 87076 (c)(C) (See LIC 9099D) An exit interview was conducted, and plan of corrections was developed with Jordyn Murphy Assistant Program Operations Coordinator and Beverly Boone, Director. A copy of this report and appeal rights were provided to Beverly Boone, Executive Director. Regarding clients are not receiving 30 minutes to an hour-long therapeutic session allegation, confidential interviews disclosed that clients met with their therapist twice a week for 20-30 minutes and 50 minutes. Confidential interviews denied that clients didn't receive adequate therapeutic sessions. Concerning the allegation that staff did not complete required training, it was reported the facility is falsifying staff training. A confidential interview stated that S5 was completing training for S2 on behalf of S2. Other confidential interviews indicated that clinical staff receive ongoing clinical training. LPA received conflicting statement. Based on confidential interviews and record review, the allegations that that staff did not ensure that medications are inaccessible to clients in care, staff did not provide adequate therapeutic sessions to clients in care and staff did not complete required training may have occurred, however, there was not a preponderance of evidence to support or deny the allegations. Therefore, the above allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this signed report was provided to Beverly Boone, Executive Director.

Investigation Findings:
13On June 5, 2024, at 9: AM, Licensing Program Analyst (LPA) Lucero Jauregui conducted an unannounced complaint inspection. The purpose of the inspection is to deliver the finding for the above allegation. LPA Jauregui met with Desiree West, Clinical Director, Jordyn Murphy Assistant Program Operations Coordinator and Bevery Boone, Executive Director. LPA Jauregui conducted an inspection of the facility on September 11, 2023, and no deficiencies were noted. During the inspection, LPA Jauregui interviewed five staff (S1, S3-S6), four clients (C1-C3, C5) and obtained pertaining documents to the allegation. On September 6, 2023, Community Care Licensing (CCL) received the allegation that staff are not serving an adequate amount of meals to clients in care. It was specifically reported that dinner is not being prepared for the clients and they are not receiving meals. During investigation, confidential interviews stated that the afternoon staff cook meals for the clients every day unless the facility orders outside food. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: MILESTONE GROUP HOMEFACILITY NUMBER: VISIT DATE: 06/05/2024

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

met_with: Desiree West, Clinical Director, Jordyn Murphy Assistant Program Operations Coordinator & Beverly Boone, Executive Director


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Narrative:
Confidential interviews stated that when C2, C3 and C4 engaged in the physical altercation, facility staff intervened. Confidential interviews added that after the altercation C2 became upset and punched a hole in the wall causing in C2 obtaining a sprain. Regarding the allegation that staff discriminate against C1, it was reported that C1 was being discriminated because of C1's race. Confidential interviews stated that C1 was always placed on restrictions and given a 30-day notice for C1's behavior while other clients would not be placed on restrictions. LPA didn't receive additional information. It was also alleged that staff did not provide C1 with adequate personal hygiene products. Confidential information disclosed that staff do not know how to meet C1's hair curl needs and did not provide C1 with the adequate hair products. Confidential interviews stated that the hair products provided to C1 did not help C1's hair. Additionally, C1 requested to get braids or a wig and C1 was told by staff to purchase those items on their own. Documents reviewed indicated a wig was purchased along with the required accessories. LPA received conflicting statements. Based on confidential interviews and record review, the allegations that staff did not prevent C2 from being injured by other minor/non-minor dependent (C3 and C4); staff discriminate against C1, and staff did not provide C1 with adequate personal hygiene products may have occurred, however, there was not a preponderance of evidence to support or deny the allegations. Therefore, the above allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this signed report was provided to Beverly Boone, Executive Director.

Investigation Findings:
13On June 5, 2024, at 10: AM, Licensing Program Analyst (LPA) Lucero Jauregui conducted an unannounced complaint inspection and met with Desiree West, Clinical Director, Jordyn Murphy Assistant Program Operations Coordinator and Beverly Boone, Executive Director. The purpose of the inspection is to deliver the finding for the above allegations. LPA conducted an inspection of the facility on December 8, 2023, and no deficiencies were noted. During the investigation, LPA interviewed four staff (S1-S3, S6), three clients (C1-C3) and obtained pertinent documents. On December 7, 2023, Community Care Licensing (CCL) received a complaint alleging staff did not prevent minor from being injured by other minor/non-minor dependent; staff discriminate against minor; and staff did not provide minor with adequate personal hygiene products. Regarding the allegation that staff didn't prevent a minor from being injured, it was specifically reported that a minor (C3) and non- dependent (C4) jumped a minor (C2) and staff didn't stop the fight or help de-escalate it resulting the minor being injured on their hand. Continued..... UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: MILESTONE GROUP HOMEFACILITY NUMBER: VISIT DATE: 06/05/2024

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

met_with: Desiree West, Clinical Director, Jordyn Murphy Assistant Program Operations Coordinator, Beverly Boone, Executive Director


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Narrative:
On 01/14/2025, Community Care Licensing (CCL) received an allegation that the licensee does not ensure adequate hygiene care items are provided to children in care. Regarding the allegation that the licensee does not ensure adequate hygiene care items are provided to children in care, it was specifically reported that the facility does not provide hygiene products that accommodate clients' special needs and that the facility provides the least expensive brand-name products to clients. During the investigation, multiple confidential interviews disclosed that the facility provides adequate hygiene products and that there are extra hygiene products stored in the facility. In addition, multiple confidential interviews disclosed that the facility did not provide special hygiene products to accommodate curly hair, heavy menstrual flow, and sensitive skin. A confidential interview disclosed that clients may get preferred hygiene products with their allowance. Confidential interviews stated that the staff purchase hygiene products to accommodate a variety of hair types such as curly hair, heavy menstrual flow, and sensitive skin. LPA received conflicting information and couldn't determine if the allegation occurred. Community Care Licensing also received an allegation that the licensee does not ensure a comfortable temperature for children is maintained in the facility. Regarding the allegation that the licensee does not ensure a comfortable temperature for children is maintained in the facility, it was specifically reported that during the summer months, the facility gets very hot and during the winter it gets very cold. During the investigation, multiple confidential interviews disclosed that the client's bedrooms can get very hot during summer and very cold during winter. Confidential interviews stated that the house temperatures are adjusted during the summer and winter time. Per confidential interviews, during the summer, the fans are turned on and during the cold months, the heat is turned on for the clients. In addition, multiple confidential interviews disclosed that clients have fans in their bedrooms and there are heaters available. Based on inconsistent confidential interviews, the allegations that the licensee does not ensure adequate hygiene care items are provided to children in care and the licensee does not ensure a comfortable temperature for children is maintained in the facility are 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, appeal rights explained, and a copy of this report was provided to Desiree West, Clinical Director. On 01/14/2025, Community Care Licensing (CCL) received an allegation that the licensee does not ensure facility is kept free of pests and the licensee does not ensure the facility is kept in clean sanitary conditions. It was specifically reported that the facility has a rodent infestation and has roaches as well. During the investigation, multiple confidential interviews disclosed that there are mice at the facility. In addition, multiple confidential interviews disclosed that there have been roaches at the facility. Multiple confidential interviews disclosed that mice have been in multiple areas of the facility, including but not limited to the clients' bedrooms. Confidential interviews stated that mouse droppings have been observed in bedrooms, the kitchen, and other areas of the facility. It was specially reported that there is rodent feces in numerous areas of the facility. During the investigation, multiple confidential interviews disclosed that there were mice droppings in various parts of the facility including but not limited to the client's bedrooms and drawers. In addition, multiple confidential interviews disclosed that staff do not deep clean the facility. During the inspection, LPAs observed mice droppings at the facility. Community Care Licensing also received an allegation that staff does not ensure children are spoken to in an appropriate manner. It was specifically reported that S1 was verbally aggressive and created a hostile environment. During the investigation, multiple confidential interviews disclosed that S1 has yelled at clients resulting in clients becoming upset and crying. In addition, a confidential interview disclosed that S1 would speak aggressively towards clients. Multiple confidential interviews disclosed that clients did not like how S1 spoke to them and clients expressed this to staff/administration numerous times and nothing was done. Confidential interviews stated that S1 was observed yelling at the clients on serval occasions. Based on confidential interviews and record review, the preponderance of evidence standard has been met and the Department has determined that the licensee did not ensure facility was kept free of pests, the staff did not ensure children were spoken to in an appropriate manner, and licensee did not ensure the facility was kept in clean sanitary conditions. Therefore, the allegations are substantiated. The facility is being cited for the violation of Title 22, Division 6, Chapter Article 07, Physical Environment, Buildings and Grounds 80087(a) and Title 22, Division 6, Chapter Article 06, Continuing Requirements, Personal Rights 80072(a)(1). (See LIC 9099D) An exit interview was conducted. A copy of this report and appeal rights were explained and given to Desiree West, Clinical Director.

Investigation Findings:
13On 06/30/2025, at 1:30PM, Licensing Program Analyst (LPA) Maya Chavez conducted an unannounced visit to Milestone Group Home (GH) and met with Desiree West, Clinical Director to deliver the investigative findings for the allegations listed above involving the GH staff (S2, S3, S4, S5, & S10) and clients (C1, C2, C3, C4, & C5). On 01/17/2025, LPA L. Jauregui conducted a health and safety inspection at the STRTP, and no immediate health and safety hazards were observed. In addition, on 05/14/2025, LPA M. Chavez conducted an additional visit at the GH. LPAs interviewed clients (C1, C2, C3, & C4), staff (S2, S3, S4, S5, & S10), and attempted to conduct interviews with County Social Workers and client 5 (C5). LPAs were unable to interview S1 due to S1 being no longer employed at the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Maya Chavez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # This is an official report of an unannounced visit/investigation of a complaint received in our office on 01/14/2025 and conducted by Evaluator Maya Chavez PUBLICCOMPLAINT CONTROL NUMBER: 08-CR- FACILITY NAME:MILESTONE GROUP HOMEFACILITY NUMBER: ADMINISTRATOR:BOONE, BEVERLY A.FACILITY TYPE: ADDRESS: PORTOFINO DRIVETELEPHONE: (760) 433- CITY:OCEANSIDESTATE: CAZIP CODE: CAPACITY:6CENSUS: 5DATE: 06/30/ UNANNOUNCEDTIME BEGAN: 01: PM MET WITH:Desiree West, Clinical Director TIME COMPLETED:02: PM 9Licensee does not ensure adequate hygiene care items are provided to children in care. Licensee does not ensure a comfortable temperature for children is maintained in the facility. INVESTIGATION FINDINGS: 13On 06/30/2025, at 1:30PMPM, Licensing Program Analyst (LPA) Maya Chavez conducted an unannounced visit to Milestone Group Home (GH) and met with Desiree West, Clinical Director to deliver the investigative findings for the allegations listed above involving the GH staff and clients (C1, C2, C3, C4, & C5). On 01/17/2025, LPA L. Jauregui conducted a health and safety inspection at the GH, and no immediate health and safety hazards were observed. In addition, on 05/14/2025, LPA M. Chavez conducted an additional visit at the GH. LPAs interviewed clients (C1, C2, C3, & C4), and staff (S2, S3, S4, S5, & S10). LPA attempted to conduct interviews with County Social Workers and client 5 (C5). LPAs were unable to interview S1 due to S1 being no longer employed at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Maya Chavez 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: 3 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: MILESTONE GROUP HOMEFACILITY NUMBER: VISIT DATE: 06/30/2025

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

met_with: Desiree West, Clinical Director


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Narrative:
Regarding the allegation that staff made inappropriate comments in the presence of minors, it was specifically reported that S1 has been making political statements about the elected head of state and about the LGBTQIA+ community in front of minors, who have disclosed that S1 comments make them feel uncomfortable. In addition, multiple confidential interviews disclosed that S1 made negative remarks regarding C2's looks, it was specifically disclosed that S1 called C2 disgusting. Confidential interviews disclosed that they never witnessed S1 discussing any political topics, the LGBTQIA+ community, or the elected head of state in front of clients. LPA received conflicting statements and was unable to determine if any inappropriate comments were made in front of clients. Regarding the allegation that staff did not address minor by their preferred gender pronouns, it was specifically disclosed that S1 was angry that S1 had to refer to a client (C1) by their preferred pronoun. It was specifically disclosed that S1 disregards C1's preferred pronoun and purposely refuses to use C1's preferred pronoun. During the investigation, a confidential interview disclosed that C1 has been addressed by their "dead name" (birth name) several times and that S1, S2, and S3 purposely address C1 by their (C1) "dead name" which makes C1 uncomfortable. In addition, multiple confidential interviews disclosed that they never witnessed staff not referring to C1 by their pronoun and calling them by their "dead name". Regarding the allegation that staff touched minor in a physically inappropriate manner, it was specifically disclosed on 01/15/2025 that S1 touched C1 on the shoulder and arm in a non-sexual manner, but without consent, and called C1 "sweetie" and "honey." During the investigation, a confidential interview disclosed that S1 grabbed C1's elbow and shook it, and another time S1 tapped C1's knee. Another confidential interview disclosed that they witnessed S1 touching C1's knee which made C1 feel uncomfortable. Other confidential interviews stated that they did not witness S1 grabbing C1's elbow and shaking it, observed S1 tapping C1's knee, or calling C1 inappropriate names. Regarding the allegation that staff did not comply with reporting requirements, it was specifically disclosed that on 12/14/2024, S1 yelled at C2 which resulted in C2 crying, and that C2 filed a grievance the next day and left it on S4's desk but there has been no resolution, and the incident was not addressed. During the investigation, a confidential interview disclosed that C2 wrote a grievance, and the results are unknown. Other confidential interviews disclosed that when situations/incidents have been reported from staff/clients to the administration, the administration does not do anything about it nor follow up with those who make a report. Other confidential interviews stated that when a grievance is reported to the administration, a discussion occurs to come up with a solution. Multiple confidential interviews disclosed that the grievance protocol is posted on the wall. LPA observed the grievance protocol and complaint hotline number posted in the facility. Furthermore, confidential interviews disclosed that staff understand reporting requirements such as grievances and special incident reports. Regarding the allegation that staff did not provide minors with adequate food services, it was specifically reported that minors have complained there is not enough food in the house because S1 only shops on Fridays and the food that's bought is poor quality. During the investigation, multiple interviews disclosed that there was enough food at the GH. A confidential interview disclosed that a lot of the time there is rotten/expired food, however, LPAs did not observe any expired or rotten food during the inspection. In addition, multiple interviews disclosed that clients are not allowed to request specific groceries and clients don't like the groceries the GH provides. Other confidential interviews disclosed that staff at the facility cook dinner for the clients and there are other food options if clients do not like what the staff has prepared. LPA Lucero took pictures of food and LPA Chavez observed two days of perishable food and seven days of non-perishable food. Confidential interviews stated that the menu is posted but sometimes staff cooks something different from what's on the menu. Confidential interviews stated that when clients do not like the brands of food options, staff purchase the brands of food clients prefer. Furthermore, a confidential interview disclosed that staff takes into consideration the brands/groceries the clients prefer. Based on confidential interviews, the allegations that staff made inappropriate comments in the presence of minors, staff did not address minor by their preferred gender pronouns, staff touched minor in a physically inappropriate manner, staff did not comply with reporting requirements, and staff did not provide minors with adequate food services are 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, appeal rights explained, and a copy of this report was provided to Desiree West, Clinical Director .

Investigation Findings:
13On 06/30/2025, at 1:30PM, Licensing Program Analyst (LPA) Maya Chavez conducted an unannounced visit to Milestone Group Home (GH) and met with Desiree West, Clinical Director to deliver the investigative findings for the allegations listed above involving the GH staff and clients 1-5 (C1, C2, C3, C4, & C5). On 01/29/2025, Community Care Licensing (CCL) received a complaint that staff made inappropriate comments in the presence of minors, staff did not address minor by their preferred gender pronouns, staff touched minor in a physically inappropriate manner; staff did not comply with reporting requirements, and staff did not provide minors with adequate food services. On 02/05/2025, LPA L. Jauregui conducted a health and safety inspection at the GH, and no immediate health and safety hazards were observed. In addition, on 05/15/2025, LPA M. Chavez conducted an additional visit at the GH. LPAs interviewed clients (C1, C2, C3, & C4), and staff (S2, S3, & S6). LPA attempted to conduct interviews with County Social Workers and client #5 (C5). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Maya Chavez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: MILESTONE GROUP HOMEFACILITY NUMBER: VISIT DATE: 06/30/2025

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


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Narrative:
In addition, the children get 75 dollars a month to go shopping but the shopping trips were never planned, and some of the newer children do not have the standard number of outfits required and clothes are not being replaced when the children need new clothes. During investigations, confidential interviews stated that clients receive seventy-five dollars monthly to make clothing purchases. Confidential interviews stated that clients were taken shopping upon request. LPAs couldn't gather additional information. In regard to the allegation that facility staff handle children in a rough manner, it was specifically reported that previous staff grabbed a child on the elbow and shoulder even though the child doesn't like being touched, however, the staff grabbed the child with force. It was unknown if any injuries were sustained as a result of this grabbing. Confidential interviews state that staff utilize verbal de-escalation to diffuse situations. Confidential interviews stated there were no observations of staff grabbing clients by force. Other confidential interviews didn't observe the interaction between the child and the previous staff. Regarding the allegation that facility staff do not ensure the facility floor is in good repair, it was reported that the home has running water and electricity, but tiles are coming off the ground and they are being repaired with duct tape. Confidential interview denied the allegations, however, LPAs observed that the kitchen floor had minor damage where it was covered with a kitchen rug. The facility staff stated that they were actively collecting funds to replace the flooring of the facility. Based on confidential interviews, the allegations facility staff are not providing children with adequate clothing, facility staff handle children in a rough manner, and facility staff do not ensure facility floor is in good repair may have occurred, however, there was not a preponderance of evidence to support the alleged violations. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, a copy of this report along with appeal rights were explained and given to Beverly Boone.

Investigation Findings:
13On 08/14/2025 at 12: PM, Licensing Program Analyst (LPA) Claudia Aguilera arrived at Milestone Group Home and met with Beverly Boone, Program Director to deliver the finding for the above stated allegations. On 02/20/2025, Community Care Licensing received complaint allegations that facility staff are not providing children with adequate clothing, facility staff handle children in a rough manner, and facility staff do not ensure facility floor is in good repair. On 02/25/2025, LPA Lucero Jauregui conducted a health and safety inspection at the facility, and no immediate health and safety hazards were observed. Lpa L. Jauregui obtained documents pertinent to the investigation and conducted confidential interviews. In addition, LPA C. Aguilera conducted additional interviews and obtained pertinent information. In regard to the allegation that facility staff are not providing children with adequate clothing, it was reported that children in care were supposed to go clothes shopping once a month, but staff (previous staff) have not provided shopping in two months. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Claudia Aguilera LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: MILESTONE GROUP HOMEFACILITY NUMBER: VISIT DATE: 08/14/2025

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

met_with: Beverly Boone, Program Director