summary: Facility Evaluation

raw_content:
Narrative:
On 05/17/2023 at 10:00 am, Licensing Program Analyst (LPA) Charmaine Linley arrived at the facility for an unannounced post-licensing visit. The facility was inspected inside and out with Dana Rexrode, National Clinical Director of Operations. The facility is located on a campus with Multi-buildings for use. The campus site includes a private high school, administrative offices, wellness center, gym, and cafe. Each dorm is an autonomous, independent living environment with a living/dining room, kitchen, four bedrooms, two bathrooms, and attached private living areas for house parents' and/or staff. Each of these dorms has a separate entrance and does not connect internally with any other residence. The facility will be temporarily operating with the capacity of 60 and once renovations are completed and inspected by CCL, they will have a capacity of 80. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. Each dorm includes the living room, recreational area, and kitchen. There is adequate indoor and outdoor activity space. Medication and the first aid kit are locked in the staff office. Medication room has a locking door and a locking medication cabinet. The facility also has a refrigerator that locks to store medications that require refrigeration. The facility's smoke detectors and carbon monoxide detectors are on a signal system. Fire extinguishers are properly charged and serviced. The facility has a fully equipped first aid kit and first aid manual. There are no guns or weapons in the facility as stated by Program Director. Disinfectants and cleaning solutions are stored and locked in a closet next to the laundry rooms. Sharp knives will be made inaccessible and stored in a locked cabinet in the kitchen. The staff and client files are maintained in the Administrative Building in locked file cabinets. The following required posted items were observed accessible to clients: Facility License, Grievance Procedures, Personal Rights, Emergency Disaster Plan and current menu. *** Areas of the facility were evaluated: Residential dorms consist of eight female and eight male houses in the lower level. Two male houses and two female houses were furnished. Each home has four bedrooms with two twin beds in each bedroom, all required linens were provided, and mattresses were in good condition. Additional mattresses have been requested from the County Warehouse. Each bedroom is equipped with dresser drawers and adequate closet space. Total capacity is eight. There are two bathrooms that include two sinks, one toilet, and one bath/shower stall. Each home is attached to a house parent's living area. The other homes in the dorms are not furnished as they are going to be renovated prior to placing additional children. On the upper campus area there are three attached houses that house females and additional three attached houses that house males. The second floor of each of the homes have an apartment for house parents. Each home has four bedrooms with two twin beds in each bedroom, all required linens are provided, and mattresses were in good condition. Each bedroom is equipped with dresser drawers and adequate closet space. Total capacity is eight. There are two bathrooms that include two sinks, one toilet, and one bath/shower stall. All bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. The bathrooms were clean and in good repair. Each dorm has a living/dining rooms that is equipped with a TV, radio, CD player, cards, games, books, and art supplies. Each dorm has a kitchen that includes a refrigerator, stove/oven, microwave, dishwasher, dining room table and chairs. Student Residence Hall: There are two and they are located between each set of the dorm buildings. Each is equipped with a TV/Media center, ping pong/pool tables, games, art supplies, and inside recreational items. Wellness Center: There are two examination rooms, a medication room, one small meeting room, and one office for a medical practitioner. *** Pool: The facility has a pool that has a fence measured at six feet with a locked gate. The pool has a cover. Designated staff will receive Water Safety training. Campus Cyber Café: The Cyber Café includes an industrial sized kitchen, which includes one industrial sized refrigerator and one industrial sized freezer. There is a storage room for dry goods and additional food. There is an industrial sized dishwasher and sink system. Gym: There is a Full sized basketball court, bleachers, weight room, two locker rooms, and bathrooms. LPA Linley reviewed two client files (C1-2) and the files were in compliance. LPA Linley conducted a record review of the staff list and noted that there were five staff that did not have a criminal record clearance prior to working at the facility. LPA reviewed the dates the staff members worked and reviewed Guardian to ensure that staff did not have a criminal record clearance and they did not. S1-5 were working at the facility and left the facility during LPA's visit. LPA Linley is administering one civil penalty during this visit. The facility is being cited for the violation of California Code of Regulations, Title 22, Division Six, regulation 80019(e) Criminal Record Clearance. Record review confirms S1, S2, S3, S4 and S5 have worked in the facility without a criminal record clearance. An immediate civil penalty is being issued for $500. Based on the facility post-licensing inspection review, no additional deficiencies were noted at the time of inspection. The facility is reminded to send LPA an updated LIC 500 when staff are hired. The facility is to send LPA paperwork for review of the new Administrator. The facility will submit the paperwork to LPA within 10 days, per regulations. An exit interview was conducted with Dana Centanni. Due to printer malfunction, a copy of this report will be emailed to the Facility Administrator.

met_with: Dana Centanni


state: CA

facility_name: SAN PASQUAL ACADEMY

summary: Facility Evaluation

raw_content:
Narrative:
On June 6, 2023 at 11:00 am, Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced visit at the facility listed above. The purpose of the visit was to interview two clients regarding an incident that is not related to this facility's license. No other information needed at this time. No deficiencies were cited. Exit interview was conducted and a copy of this report was reviewed with Wayne Ferguson, Deputy Director. Due to printer malfunction, this report will be emailed to Wayne Ferguson, Deputy Director.

report_type: Facility Evaluation


summary: Facility Evaluation

raw_content:
Narrative:
On June 6, 2023 at 10:25 am, Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced visit at the facility listed above The purpose of the visit was to interview two clients and two staff to complete the Post-Licensing inspection for the facility. No deficiencies were cited. Exit interview was conducted and a copy of this report was reviewed with Wayne Ferguson, Deputy Director. Due to printer malfunction, this report will be emailed to Wayne Ferguson, Deputy Director.

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
On June 29, 2023 at 10:40 am, Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced visit at the facility listed above. The purpose of the visit was to interview clients and staff regarding an incident that is not related to this facility's license. No other information needed at this time. No deficiencies were cited. Due to printer malfunction, this report will be emailed to the Facility Administrator.

met_with: Rich Boyer


summary: Facility Evaluation

raw_content:
Narrative:
On 07/08/2023 at 3:00 pm, Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced visit at the facility listed above. The purpose of the visit was to interview staff regarding an incident that is not related to this facility's license. No other information needed at this time. No deficiencies were cited. Due to printer malfunction, this report will be emailed to the Facility Administrator.

met_with: Josh Munderloh


summary: Facility Evaluation

raw_content:
Narrative:
On November 2, 2023 at 12: 00pm, Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced visit at the facility listed above. LPA Linley met with RIch Boyer, Program Director. The purpose of the inspection is to conduct a case management on a Serious Incident Report (SIR) dated 10/27/2023. No deficiencies were cited. Exit interview was conducted and a copy of this report was reviewed with Rich Boyer, Program Director. Due to printer malfunction, this report will be emailed to Rich Boyer, Deputy Director.


summary: Facility Evaluation

raw_content:
Narrative:
On 12/19/2023 at 8:30 pm, Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced visit at the facility listed above. LPA Linley met with Wayne Ferguson, Deputy Director. The purpose of the inspection is to conduct interviews on a case management regarding a Serious Incident Report (SIR) dated 10/27/2023. No deficiencies were cited. LPA conducted one client interview with one client and two interviews with two staff. Exit interview was conducted and a copy of this report was reviewed with Wayne Ferguson. Due to printer malfunction, this report will be emailed to the Facility Administrator.

met_with: Wayne Ferguson


summary: Facility Evaluation

raw_content:
Narrative:
On February 12, 2024, at 10: AM, Licensing Program Analyst (LPA) Carol Anderson conducted an unannounced inspection to the above facility and met with Compliance Coordinator Belinda Contreras. The purpose of the inspection was to interview clients regarding an incident that occurred at a previous placement. LPA interviewed two clients. An exit interview was conducted, and a signed copy of this report was provided to Compliance Coordinator Belinda Contreras.

met_with: Belinda Contreras


summary: Facility Evaluation

raw_content:
Narrative:
On March 1, 2024, at 11:00AM, Licensing Program Analyst (LPA) Carol Anderson conducted an unannounced case management Inspection at the above facility. LPA Anderson and Christina Bradley, Senior Protective Service Worker, County of San Diego Health, and Human Services Agency met with Richard Boyer, Program Director. The purpose of the inspection is to conduct a case management on a Special Incident Report (SIR) dated 2/20/24. No deficiencies were cited. Exit interview was conducted and a copy of this report was given to Richard Boyer, Program Director.

met_with: Richard Boyer


summary: Facility Evaluation

raw_content:
Narrative:
On March 27, 2024, at 10:42AM, Licensing Program Analyst (LPA) Carol Anderson conducted an unannounced annual/required inspection at the facility. LPA met with Program Director Rich Boyer. LPA reviewed 10 client files and 10 staff file and clients,and they had the necessary forms in the files. Due to time constraints, the annual/required inspection is being extended to conduct an inspection of the physical plant and staff and client interviews. A review of Guardian on March 27, 2024, indicates that all facility staff associated to the facility had DOJ, FBI, and child abuse index checks clearances. Based on file review this date, no deficiencies cited at this time. An exit interview was conducted, and this report was given to Program Director Rich Boyer

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
On April 10, 2024, at 1:20PM, Licensing Program Analyst (LPA) Carol Anderson conducted a case management Inspection at the above facility. LPA Anderson and Christina Bradley, Senior Protective Service Worker, County of San Diego Health, and Human Services Agency met with Rich Boyer, Program ,Director. The purpose of the inspection is to conduct a case management a Special Incident Report (SIR) dated April 10, 2024. LPA interviewed Client 1 (C1) and Client 2 (C2). No deficiencies were cited. Exit interview was conducted and a copy of this report was given to Rich Boyer, Program Director.


summary: Facility Evaluation

raw_content:
Narrative:
On June 19, 2024, at 10:45AM, Licensing Program Analyst (LPA) Carol Anderson conducted an unannounced Case Management inspection at the facility. LPA Anderson met with Rich Boyer; Program Director regarding a Special Incident Report (SIR) dated 6/15/2024 . During the case management inspection, LPA Anderson reviewed Staff 1 (S1)'s personnel file and training file. LPA obtained documentation from S1's personnel file and training file. No deficiencies were cited. An exit interview was conducted, and a copy of this report was given to Rich Boyer, Program Director.


summary: Facility Evaluation

raw_content:
Narrative:
On September 27, 2024, at 3: PM, Licensing Program Analyst (LPA) Jacob Salem made an unannounced visit to the above facility and met with Belinda Contreras, Compliance Manager. The purpose of the visit was to conduct a collateral investigation regarding a previous placement. LPA conducted one confidential interview with a client. An exit interview was conducted and a signed copy of this report was provided to Belinda Contreras, Compliance Manager.

met_with: Belinda Contreras, Compliance Manager


summary: Facility Evaluation

raw_content:
Narrative:
On December 02, 2024, at 2: PM, Licensing Program Analyst (LPA) Jacob Salem conducted an unannounced inspection. LPA Salem met with Richard Boyer, Program Director. The purpose of the inspection was to conduct a case management on a Serious Incident Report (SIR) dated 11/15/24. LPA conducted one confidential interview, attempted one interview, and received copies of pertinent records. Based on information gathered, there were no deficiencies cited at this time. An exit interview was conducted and a signed copy of this report was provided to Richard Boyer, Program Director.

met_with: Richard Boyer, Program Director


summary: Facility Evaluation

raw_content:
Narrative:
On May 23, 2025, at 11:15AM, Licensing Program Analysts (LPAs) Joon Choi and Cynthia Ramos made an unannounced visit to the facility and met with Supervisor Chau Tonnu. The purpose of the visit was to conduct a case management regarding a Special Incident Report (SIR) follow up date 4/26/25 involving Client (C1) Client 2 and (C2). (Please see confidential names LIC 811) LPAs Choi and Ramos interviewed one client and three staff. Confidential interviews report that C1 and C2 were in each others room during an overnight shift without permission. Confidential interviews indicated that clients in the living units are supervised overnight by an overnight staff. Confidential interviews reported that overnight staff conduct routine checks. Other confidential interviews reported that some overnight staff do not conduct routine checks. LPAs still need to interview additional staff and clients associated to this case management that were not present during this visit. Due to the need to gather more information this case management will be concluded at a later date. An exit interview was conducted and a copy of this report was provided to Deputy Director Wayne Ferguson.

met_with: Deputy Director Wayne Ferguson


summary: Facility Evaluation

raw_content:
Narrative:
On June 26, 2025, at 1: PM, Licensing Program Analyst (LPA) Jacob Salem conducted an unannounced case management inspection at the facility. LPA Salem met with Chau Tonnu, Shift Supervisor. The purpose of the inspection was to follow up on a case management visit on 5/23/25. While at the facility, LPA Salem conducted five confidential interviews and received copies or pertinent records. Based on information gathered, there were no deficiencies cited at this time. An exit interview was conducted and a signed copy of this report was provided to Chau Tonnu, Shift Supervisor

met_with: Chau Tonnu, Shift Supervisor


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
to relieve them before they left the house. Confidential interviews indicated that on August 16, 2025, S1 contacted S6 to let them know they needed to leave their shift and S1 left the house keys at another house and left the house without another staff in the house. Confidential interviews and records reviewed indicated that S6 worked between both houses during the overnight shift and walked between both houses to check on the clients until the morning staff arrived for their shift. Regarding the allegation that staff did not administer medication to clients as prescribed, it was reported that staff did not administer C1, C5, and C6's medication. Some confidential interviews denied that staff did not administer medication, while other confidential interviews indicated some staff did not give out medication or sign off that they gave medication to C5 and C6, as prescribed to the clients. Records reviewed indicated that on the following dates, staff did not administer or sign off for C5's prescribed medication #1 on 07/10-11/2025, 07/18/2025, 07/25/2025, and 07/31/2025, and staff did not administer or sign off for C5's prescribed medication #2 on 07/18/2025 and 07/25/2025, and staff did not administer or sign off for C5's prescribed medication #3 on 07/18/2025 and 07/25/2025 and staff did not administer or sign off for C6's prescribed medication #1 on 07/05/2025, 07/09/2025, 07/11/2025, 07/18-07/19/2025, 07/30/2025, 08/01/2025, 08/02/2025, 08/15/2025, 08/16/2025, 08/29/2025, and 08/31/2025 and staff did not administer or sign off for C6's prescribed medication #2 on 07/15/2025, 07/18/2025, 08/16/2025, 08/18/2025, 08/22/2025, and staff did not administer or sign off for C6's prescribed medication #3 on 07/01-07/02/2025, 07/04/2025, 07/08/2025, and 07/11/2025. Based on confidential interviews and records reviewed the allegations that S1 left minors unsupervised for an extended period of time and staff did not administer medication to clients as prescribed is substantiated. The preponderance of evidence standard has been met. The facility is cited for violation of the California Code of Regulations, Title Division Six, regulation 84065.2(b)(1) Personnel Duties and California Code of Regulations, Title Division Six, regulation 84070(b)(16)(H) Children's Records. An exit interview was conducted, appeal rights explained, and a copy of this report, LIC 811, and appeal rights were provided to Lidia Hockley. A copy of this report will be placed in the facility file. indicated conflicting information. Some interviews indicated that S1 does not cook dinners on the weekends when the campus café is closed. Regarding the allegation that staff slept during shift, some interviews indicated they have observed S1 asleep while sitting at the dining room table while S1 is working alone in the house. There were no witnesses to this allegation. LPA was unable to interview all individuals, although multiple attempts were made, thus, confidential interviews could not confirm or deny the allegations. Based on confidential interviews and records reviewed the allegations that S1 did not provide adequate food service to clients in care and S1 slept during shift, which may have occurred, however, they are not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report and appeal rights were provided to Lidia Hockley. A copy of this report will be placed in the facility file.

Investigation Findings:
13On December 22, 2025, at 11:55 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility and met with Lidia Hockley, Compliance Manager, to discuss the investigative finding for the allegations noted above. LPA Jacob Salem conducted an inspection of the facility on August 26, 2025, at 2:40 pm. No deficiencies were observed. LPA Salem interviewed one Client (C5), and one Staff (AD). LPA Linley interviewed five Clients (C1-4, C7) and interviewed eight Staff (S1-3, S6, S8, S12-14), LPA was unable to interview one Client (C6) who declined to be interviewed and seven Staff (S4, S5, S7, S9, S10, S11, S15), despite multiple attempts to contact them. LPA reviewed the facility documents. On August 21, 2025, Community Care Licensing (CCL) received allegations that staff left minors unsupervised for an extended period of time and staff did not administer medication to clients as prescribed. It was reported that S1 left at the end of their shift and did not ensure another staff was present in the house 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: SAN PASQUAL ACADEMYFACILITY NUMBER: VISIT DATE: 12/22/2025

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:

report_type: Complaint Investigation

met_with: Lidia Hockley

complaint_status: unsubstantiated


summary: Facility Evaluation

raw_content:
Narrative:
On January 8, 2026, at 3: PM, Licensing Program Analyst (LPA) Jacob Salem conducted an unannounced case management inspection at the facility. LPA Salem met with Dana Centanni, Administrator. The purpose of the inspection was to follow up on a special incident report dated 12/02/25. While at the facility, LPA Salem conducted confidential interviews and requested copies or pertinent records. Based on information gathered, there were no deficiencies cited at this time. An exit interview was conducted and a signed copy of this report was provided to Dana Centanni, Administrator.

met_with: Dana Centanni, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On May 6, 2025, at 11: AM, Licensing Program Analyst (LPA) Jacob Salem made an unannounced visit to the facility and met with Dana Centanni, Administrator. The purpose of the visit was to discuss a case management inspection. LPA Salem reviewed five staff files (S1-S5) and observed the annual training requirement for three staff had not been met in the year of 2024 and/or within the last twelve months. Confidential interviews indicated that training requirements were not met due to staff being unable to find coverage during scheduled training. The facility is being issued a citation, LIC 809D, for violating California Code of Regulations, Title 22, Division Six, Chapter 5, regulation 84065(j)(1) Personnel Requirements. An exit interview was conducted and a copy of this report and appeal rights were provided to Dana Centanni, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On December 22, 2025, at 12:30 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Lidia Hockley, Compliance Manager, to discuss information that was reported to Community Care Licensing and records reviewed by LPA Linley on December 19, 2025. LPA Jacob Salem interviewed one Client (C5), and one Staff (AD). LPA Linley interviewed five Clients (C1-4, C7) and interviewed eight Staff (S1-3, S6, S8, S12-14), LPA was unable to interview one Client (C6) who declined to be interviewed and seven Staff (S4, S5, S7, S9, S10, S11, S15), despite multiple attempts to contact them. LPA reviewed facility documents. On December 19, 2025, while reviewing C5's Psychotropic Medication Administration Record or equivalent (PMAR), LPA observed C5's PMAR that indicated there were "Rs" (R = client refusal) recorded in the boxes for the following dates of 08/10/2025, 08/12/2025, 08/18/2025, 08/25-08/31/2025 for medication #1, 08/12/2025, 08/18/2025, 08/22/2025, 08/28-08/30/2025, for medication #2 and medication #3 on the following dates of 07/18/2025 and 07/25/2025, 08/12/2025, 08/18/2025, 08/22/2025, 08/28-08/30/2025. LPA observed that there was no additional documentation of the medication refusal as required, such as date and time of the refusal, the reason for the refusal, who was notified of the refusal, and any observed results of the refusal. Based on confidential interviews and records reviewed, the facility is being cited for violating California Code of Regulations, Title Division Six, regulation 84070(b)(16)(G) Children's Records (refer to LIC 809D). An exit interview was conducted, appeal rights explained, and a copy of this report, LIC 811, and appeal rights were provided to Lidia Hockley. A copy of this report will be placed in the facility file.


summary: Facility Evaluation

raw_content:
Narrative:
On February 27, 2024, at 11:40 am, Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced inspection at the facility and met with Rich Boyer, Program Director.. This inspection was a follow-up to the case management inspection completed on 11/02/2023. Refer to Confidential Names (LIC 811) dated 02/27/2024. Community Care Licensing received information that C1 was involved in a physical altercation and called 911. When the ambulance arrived, C1 was transported to the Emergency Room, staff did not accompany C1 to the emergency room and staff was not present to sign the medical paperwork, which resulted in C1 calling a family member to the emergency room to sign the medical paperwork and wait with C1 until a staff member arrived at the emergency room. Community Care Licensing received information that after being discharged from the Emergency Room, C1 returned to the facility and requested to spend the night at their brother's house. Confidential interviews and records reviewed, indicated that C1 was not approved for overnight visits with their brother and was only approved for unsupervised day passes. Confidential interviews indicated that C1 spent two nights at their brother's house, along with their mother, who was only approved for supervised visits before C1's County Social Worker picked them up. Community Care Licensing received a Special Incident Report from the facility, dated 10/27/2023, that C3 was not feeling well and requested to be taken to the Emergency Room. It was reported that once a staff member became available, they would transport C3 to the Emergency Room, however, C3's family called 911 for an ambulance to respond to the facility. Confidential interviews and records reviewed indicated that staff did not accompany C3 to the Emergency Room and handed C3's paperwork to the paramedics. The facility is cited for violation of the California Code of Regulations, Title Division Six, regulation *** An exit interview was conducted, and appeal rights were reviewed with Rich Boyer. Due to printer malfunction, a copy of this report, along with the LIC 811, and appeal rights will be emailed to the Facility Administrator. A signed copy of this report will be kept in the Facility file.


summary: Facility Evaluation

raw_content:
Narrative:
On January 23, 2026 at 9: AM, Licensing Program Analysts (LPAs) Lisa Bernabe and Stephanie Arreola made an unannounced visit to the above facility and met with Chau Tonnu, Shift Supervisor. The purpose of the visit was to conduct an interview regarding a complaint lodged against a different facility. LPA Bernabe conducted one client interview. An exit interview was conducted and a signed copy of this report was provided to Chau Tonnu, Shift Supervisor.


summary: Complaint Investigation - Unsubstantiated - 3 allegations

raw_content:
Narrative:
...CONTINUED Based on conflicting confidential interviews, the allegations that staff pushed a minor in care and staff threatened a minor in care are unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted with Wayne Ferguson, Deputy Director and a copy of this report and appeal rights were provided.

Investigation Findings:
13On March 17, 2026 at 11: AM, Licensing Program Analyst (LPA) Jacob Salem met with Wayne Ferguson, Deputy Director of San Pasqual Academy to deliver the findings for the above-stated allegations. LPA Salem initiated a complaint inspection at the facility on 12/02/2025 at 11: AM and no immediate deficiencies were observed. During the investigation, LPA Salem interviewed Clients (C1), Staff (S1-S3), and a county social worker. Pertinent records were obtained and reviewed. On November 26, 2025, Community Care Licensing (CCL) received the allegations that staff (S1) pushed a minor (C1) in care and staff (S1) threatened a minor (C1) in care. It was reported that S1 pushed C1 with the door while entering the cottage, and that S1 had made threats toward C1. A confidential interview indicated that when C1 opened the door for S1, S1 pushed the door into C1's chest and challenged C1 to fight; however, this was not corroborated by named witnesses. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem 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. # San Diego, CA Facility Name: San Pasqual Academyfacility Number: Visit Date: 03/17/ Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32...CONTINUED Based on conflicting confidential interviews, the allegations that staff pushed a minor in care and staff threatened a minor in care are unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted with Wayne Ferguson, Deputy Director and a copy of this report and appeal rights were provided. SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 2 of 2

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0

met_with: Wayne Ferguson, Deputy Director


raw_content:
Narrative:
In regard to the allegation that facility staff did not protect minors from other resident at the facility, confidential interviews revealed S1 and S2 were on overnight duty and immediately arrived to attempt to separate C1 and C2 during an altercation. Additional confidential interviews revealed that C1 and C2 were separated by other clients at the facility. Based on confidential interviews and information gathered during the investigation, the allegations that due to lack of supervision, C1 sustained injuries while in care and facility staff did not protect C1 and C2 from other resident at the facility, may have occurred, however, are not supported or proven by evidence. Therefore, the allegations are unsubstantiated. An exit interview was conducted, appeal rights discussed, and a copy of this report was provided to Program Director Tia Moore.

Investigation Findings:
13On April 29, 2021 at 10:30AM, Licensing Program Analyst (LPAs) Carol Anderson and Daniella Garcia met with Program Director Tia Moore to deliver findings of the above allegations. The investigation was conducted by Senior Special Investigator Ernestina Bellucco of the Community Care Licensing (CCL) Investigation Branch. Special Investigator Ernestina Bellucco interviewed seven staff and four clients. The investigation included a review of San Diego Sheriff's investigative report. On January 29, 2021, the Department received an allegation that resident sustained injuries while in care and facility staff did not protect minors from other residents at the facility. In regard to the allegation that resident sustained injuries while in care, confidential interviews revealed that C1 entered into C2's bedroom through a shared bathroom and assaulted C2 while C2 was sleeping. Confidential interviews revealed that C1 sustained minor cuts and bruising caused by a broken mirror. Confidential interviews revealed that the altercation was videotaped between C1 and C2 by another client in the facility. Law enforcement reviewed the video recording and it did not show how C1 sustained the injuries. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Stephanie Hudak 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: SAN PASQUAL ACADEMYFACILITY NUMBER: VISIT DATE: 04/29/2021

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

met_with: Tia Moore


raw_content:
Narrative:
participated in a mediation conducted by the facility regarding the alleged incident, during which time S1 stated S1 did not recall placing S1's hands on C1 but did apologize for making C1 feel uncomfortable. Based on confidential interviews and record review, although the allegation of minor (Child #1 (C1) was inappropriately touched by staff (Staff #1 (S1), 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, and a copy of this report was provided along with appeal rights San Pasqual Academy Residential Director, Beth Hyde.

Investigation Findings:
13On June 3, 2021 at 2:26pm, Licensing Program Analyst (LPA), Nicole Strickland, met with San Pasqual Academy Residential Director, Beth Hyde, to deliver the finding for the above stated allegation. The investigation was conducted by Special Investigator, Ernestina Bellucco with Community Care Licensing's (CCL) Investigations Branch Bureau. The investigation included interviews with Resident Director, Child #1 (C1), Child #2 (C2), Child #3 (C3), Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), C1's Court Appointed Advocate (CASA). In addition, county records and facility records were reviewed. On May 5, CCL received an allegation of Minor (Child #1 (C1) inappropriately touched by staff (Staff #1 (S1). Specifically, it was reported C1 disclosed C1 was "sexually assaulted" by C1's boss. Confidential interviews revealed details of the "sexual assault" to be an incident where S1 allegedly placed S1's hands on C1's waist for an extended period of time. Confidential interviews could not confirm or dispute that S1 put S1's hands on C1 for any period of time. Confidential interviews and record review revealed C1 and S UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Nicole Strickland LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 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: SAN PASQUAL ACADEMYFACILITY NUMBER: VISIT DATE: 06/03/2021

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

met_with: Residential Director, Beth Hyde


raw_content:
Narrative:
Specifically, it was reported that C1 was "sexually assaulted" by S1. Confidential interviews revealed details of the "sexual assault" to be an incident where S1 allegedly touched C1's buttocks in the kitchen. Confidential interviews could not confirm or dispute that S1 touched C1's buttocks or that S1 touched C1's buttocks purposely as the spacing in the kitchen is tight. There were no witnesses to the alleged incident. Based on confidential interviews and record review, although the allegation of Child #1 (C1) was inappropriately touched by staff (S1), 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, and a copy of this report was provided along with appeal rights San Pasqual Academy Campus Director, Tia Moore

Investigation Findings:
13On August 17, 2021 at 10:20 am, Licensing Program Analyst (LPA), Danielle Garcia and LPA Carol Anderson, met with San Pasqual Academy Campus Director, Tia Moore, to deliver the finding for the above stated allegation. The investigation was conducted by Special Investigator, Hector Quintanar with Community Care Licensing's (CCL) Investigations Branch Bureau. The investigation included interviews with Clients Social Worker (SW1), San Diego County Sheriff Department (SD1), San Pasqual Academy School Counselor (SC1), Social Worker #2 (SW2), San Diego County Children's Welfare Services Protective Services Supervisor (CWS1), and San Pasqual Academy staff (S1). In addition, county reports and facility records were reviewed. On March 22, 2021, CCL received an allegation of Minor Child #1 (C1) was inappropriately touched by staff (S1). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Danielle Garcia 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: SAN PASQUAL ACADEMYFACILITY NUMBER: VISIT DATE: 08/17/2021

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


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Based on confidential interviews and information gathered during the investigation the allegation that S1 is making inappropriate comments to C1 is substantiated. The preponderance of evidence has been met. This poses an immediate Health and Safety, or personal rights violation. The facility is being cited for California Code of Regulations, Title 22, Division Six, regulation 84072(d)(10) Personal Rights. An exit interview was conducted, appeal rights discussed, and a copy of this report was provided to Program Director Tia Moore.

Investigation Findings:
13On March 21, 2023, at 2:10PM, Licensing Program Analyst (LPA) Carol Anderson completed the investigation on the above allegation. During the complaint investigation, LPA reviewed Client 1 (C1) file. LPA interviewed four of four Staff (S1 - S4), and one of three Clients (C1 - C3). One client (C4) was unavailable to be interviewed. LPA reviewed FC1's Appraisal Needs, and Services Plans, County of San Diego Health and Human Services report as well as Special Incident Report. The Department received a complaint on April 27,2022, that staff are making inappropriate comments towards minor. Confidential interviews reported that S1 admitted using the word prostitution towards C1 instead of the trauma inform approach Commercial Sexual Exploitation Children (CSEC) during a meeting with County Social Worker. Confidential interviews revealed that S1 was directed to use more appropriate trauma inform language. SubstantiatedEstimated 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: SAN PASQUAL ACADEMYFACILITY NUMBER: VISIT DATE: 03/21/2023

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

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
Based on confidential interviews and documents reviewed during the investigation, the allegation that staff did not safeguard C1's personal belongings, 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 Program Director Tia Moore.

Investigation Findings:
13On March 21, 2023, at 2:52PM, Licensing Program Analyst (LPA) Carol Anderson completed the investigation on the above allegation. During the complaint investigation, LPA reviewed Client 1 (C1) file. LPA interviewed four of four Staff (S1 - S4), and three of four Clients (C1 - C3). One client (C4) wase unavailable to be interviewed. LPA reviewed FC1's Appraisal Needs, and Services Plans, County of San Diego Health and Human Services report as well as Special Incident Report. The Department received a complaint on April 27,2022, that staff did not safeguard minor's personal belongings. Confidential interviews revealed that when C AWOLed from the facility, C1's full-length mirror was missing, one full-length mirror broken, and C1'strip lights were missing. However, confidential interviews revealed when C Awoled staff packed up C1's personal belongings, and staff observed C1's full-length mirror was cracked, and C1's strip lights were not attached to the wall and had been broken. There were conflicting statements to weather the items were previously broken and if they were replaced when C1 returned to the facility. 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: SAN PASQUAL ACADEMYFACILITY NUMBER: VISIT DATE: 03/21/2023

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


raw_content:
Narrative:
sitting outside the door. It is unknown how long C1 and C2 were alone and if any sexual acts occurred. Based on confidential interviews and records reviewed that C1 was sexually abused by C2 while at the facility, due to lack of supervision, 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 reviewed with Beth Hyde. Due to printer malfunction, a copy of this report will be emailed to the Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On May 5, 2023, at 11:05 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at W Valley Pkwy, Escondido, California and met with Beth Hyde, Residential Director, to discuss the investigative finding for the allegation noted above. LPA Charmaine Linley and LPM Ann Valenzuela conducted an inspection of the facility on 02/23/2023 at 8:00 am and no deficiencies were observed. LPM Valenzuela interviewed two clients (C1, S2), one staff (S1) and LPA Linley interviewed one staff (S2). LPA reviewed the following documents during the investigation: Special Incident Reports. On 02/14/2023, Community Care Licensing (CCL) received an allegation that a Minor was sexually abused by another minor at the facility due to lack of supervision. It was reported that C2 asked C1 to give them oral sex and C1 agreed. Confidential interviews revealed conflicting statements to whether the act occurred. Furthermore, confidential interviews indicated that the C2 and C1 were being supervised by staff that was 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: SAN PASQUAL ACADEMYFACILITY NUMBER: VISIT DATE: 05/05/2023

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

met_with: Beth Hyde


raw_content:
Narrative:
fighting, and called for additional staff. Conflicting interviews reported that staff stood by the doorway and called for additional staff to intervene. Confidential interviews did not corroborate the allegation with a preponderance of evidence. Based on confidential interviews and records reviewed that staff did not intervene in an altercation between C1 and C2, 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 reviewed with Tia Moore. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights will be emailed to the Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On September 26, 2023, at 9:55 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility's FFA Office and met with Tia Moore, Facility Administrator, to deliver the investigative finding for the allegation noted above. LPA Meza-Gonzalez conducted an inspection of the facility on 03/02/2023 at 9:45 am and no deficiencies were observed. LPA Linley interviewed two clients (C1, C2) and four staff (S1-4). LPA reviewed the following documents during the investigation: Special Incident Report, House Roster, C1 and C2's Emergency and Identification forms, and C1 and C2's Needs and Services Plan. On February 24, 2023, Community Care Licensing (CCL) received an allegation that staff did not intervene in an altercation between minors. It was reported that C1 and C2 were involved in a physical altercation and staff told the minors "they did not get paid enough to intervene." Confidential interviews revealed conflicting statements. Some interviews reported that staff stood in between C1 and C2, redirected them to stop 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: SAN PASQUAL ACADEMYFACILITY NUMBER: VISIT DATE: 09/26/2023

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


raw_content:
Narrative:
Confidential interviews revealed conflicting statements. Confidential interviews did not corroborate the allegation with a preponderance of evidence. Based on confidential interviews and records reviewed that staff did not prevent C1 from having access to a lighter while in care and staff did not prevent C1 from causing harm to C2, which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Beth Hyde. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights will be emailed to the Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On 10/12/2023, at 10: AM, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the organization's FFA Office and met with Beth Hyde, Student and Alumni Success Coordinator, to discuss the investigative finding for the allegations noted above. LPA Carol Anderson conducted an inspection of the facility on 02/14/2023 at 10: AM and no deficiencies were observed. LPA Linley interviewed four clients (C1-4), and eight staff (S1-2, 4-9), and was unable to interview one staff (S4), despite multiple attempts to contact them. LPA reviewed the following documents during the investigation: Special Incident Reports, San Marcos Sheriff's Department Incident Report, Overnight Supervision Logs, Communication Logs, Housing Roster, and C1 and C2's Needs and Services Plan. On 02/09/2023, Community Care Licensing (CCL) received allegations that staff did not prevent a minor from having access to a lighter while in care and staff did not prevent a minor from causing harm to another minor. It was reported that C2 set C1's bed on fire while C1 was sleeping in the bed on two separate occasions. 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: SAN PASQUAL ACADEMYFACILITY NUMBER: VISIT DATE: 10/12/2023

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


summary: Facility Evaluation

raw_content:
Narrative:
On June 24, 2021 at 4:03pm Licensing Program Analyst (LPA) Nicole Strickland returned to the facility to follow-up on a Plan of Correction (POC) that has not been received by Community Care Licensing (CCL). LPA Strickland met with San Pasqual Academy Supervisor, Tia Moore. The facility was cited on June 3, 2021 at 3:01pm for a type B Personal Rights violation, FFA Interim Licensing Standards (ILS) 84072(d). CCL requested a POC that the Residential Director acknowledged and signed be submitted to CCL by June 18, 2021. The POC was to include a signed memorandum of understanding (MOU) by Staff #1 (S1) regarding appropriate trauma informed communication between all staff and residents and S1 will participate in a individual training regarding appropriate trauma informed communications. Residential Director will provided LPA proof of completion of training and a copy of the MOU by POC date 6/18/2021. As of today's date CCL has not received the POC. Academy Supervisor informed LPA that S1 has been out sick and therefore they were unable to complete the POC. LPA issued a Technical Advisory LIC 9102. A copy of this report along with the LIC 9102 were provided to San Pasqual Academy Supervisor, Tia Moore

met_with: Academy Supervisor, Tia Moore


summary: Facility Evaluation

raw_content:
Narrative:
.On January 27,2022 at 10:15AM, Licensing Program Analyst (LPA) Carol Anderson conducted an unannounced required 2-year annual inspection. LPA met with Program Director Tia Moore. The facility is licensed to serve up to 184 clients, ages 12-17 including non-minor dependents. There are currently 42 clients in placement. LPA inspected the administrative building during today's required 2-year annual inspection. The administrative building is in the front of the facility, the administrative building consists of a lobby/reception area, administrative staff offices, conference rooms, and several private rooms that could be used as therapy or visitation rooms, LPA reviewed 10 staff and 10 clients' files during today's visit. All staff met the minimum qualifications and training requirements. A review of the records on January 27,2022 indicates that all facility staff associated to the facility had FBI, DOJ and child abuse index check clearances. All files reviewed were complete and had the requirement documents. LPA observed client's files to be complete and in order. Due to time constraints, LPA will return to complete the required 2-year annual inspection. No deficiencies were cited during today's required 2-year annual inspection. An exit interview was conducted and a copy of this report and was given to Program Director Tia Moore.


summary: Facility Evaluation

raw_content:
Narrative:
On June 3, 2021 at 3:01pm, Licensing Program Analyst (LPA), Nicole Strickland, met with San Pasqual Academy Residential Director, Beth Hyde, to deliver a Case Management - Deficiencies report. Information received by Community Care Licensing (CCL) revealed Staff #1 (S1) utilized the term "baby girl" when referring to female residents at the facility. Confidential interviews and record review revealed S1 had been written up and provided with sexual harassment training on March 22, 2021 for a separate incident. Confidential interviews revealed although S1 had been provided sexual harassment training, S1 continued to use the term "baby girl" which created an environment where residents are made to feel uncomfortable and not respected. Based on confidential interviews and record review of facility documentation the facility is cited for violation of Title 22, Division 6, Chapter 5, Article Continuing Requirements Personal Rights regulation 84072(d) The licensee shall ensure that each child, regardless of whether the child is in foster care is accorded the personal rights specified in Welfare and Institutions Code section 16001.9, as applicable. An exit interview was conducted, and a copy of this report was provided along with appeal rights San Pasqual Academy Residential Director, Beth Hyde.


facility_name: SANWAL GROUP HOMES INC.

summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Based on interviews conducted throughout the investigation process, 5 out of 8 interviews stated that no one has observed any form of aggression from any staff towards any clients in care at the facility. However, 2 out of 8 people of interest could not be interviewed due to a disability diagnosis. LPA conducted facility visits on 7/31/2025 and 8/28/2025, LPA did not observe any marks or bruises on any youths placed at the facility; LPA also observed youth to remain in close proximity of staff without signs of fear. Although the allegation may have happened or is valid there is not a preponderance of evidence to prove the alleged violation did occur therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted, and Appeal Rights were discussed with Gurjit Dhaliwal, Facility Manager. A copy of this report and Appeal Rights were left at the facility.

Investigation Findings:
13On 10/30/ Licensing Program Analyst (LPA) Sara Luman-Gonzalez conducted an unannounced visit to the above agency to deliver the findings of a complaint investigation. LPA met with Gurjit Dhaliwal, Facility Manager and was granted entry. During the investigation, LPA conducted the 10-day inspection of the facility on 7/31/2025. LPA obtained Incident Reports for last month, Needs and Services Plan for 1 client, 3 months of Case Notes for 1 client, Staff Roster, Staff Contact information, Client Roster, and Staff Schedule for June and July. Eight confidential interviews were conducted between July 2025 and October 2025 by LPA Luman-Gonzalez. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Connie Goldie LICENSING EVALUATOR NAME: Sara Luman-Gonzalez 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: SANWAL GROUP HOMES INC.FACILITY NUMBER: VISIT DATE: 10/30/2025

met_with: Gurjit Dhaliwal, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 04/03/2024 ,at 02: PM, Licensing Program Analyst (LPA) Connie Goldie made an announced pre-licensing inspection at the facility and met with Administrator, Gaganjit Sandhu and Licensee, Harvir Dhaliwal, who assisted LPA with the inspection. During the pre-licensing inspection, LPA Goldie toured the facility inside and out and observed that the facility was clean inside and safe. The outside of the facility is free of debris and has adequate space for client use. The home was a comfortable 71 degrees. LPA Goldie observed four single occupancy client rooms equipped with appropriate furniture, bedding and supplies. LPA observed light blankets for beds currently not in place. Licensee agreed to place a blanket on each resident's bed. LPA observed three bathrooms in the facility that are accessible to client use and equipped with soap and towels. LPA observed that the medication cabinet is located in the kitchen/dining area and is locked and inaccessible to clients in care. LPA observed that the kitchen area is equipped with an adequate number of utensils, dining supplies, and cups for clients. LPA observed that the dishwasher is working. LPA advised licensee that non-perishable foods need to be obtained. LPA observed that there is office space as required that is locked and inaccessible to clients in care. LPA observed nine smoke/carbon monoxide detectors which were tested and functional during the inspection. LPA observed one fire extinguisher located in the pantry that were last inspected on 10/12/2023. LPA observed a first aid kit in the kitchen area as required. Licensee advised to obtain a first aid guide per regulation. The water temperature initially measured 131 degrees. The water heater was adjusted and measured 109 degrees within acceptable compliance range. The laundry room has an operating washer and dryer and secured cabinets for chemicals. The garage is organized and has storage space. . LPA completed Component Three of the licensing process with Ms. Sandhu and Ms. Dhaliwal by reviewing regulation and processes with them. LPA reminded licensees that CCL needs to be notified within five days of a client being placed in the facility and that LIC forms LIC500, LIC308 and LIC610 will need to be updated. An unannounced post licensing inspection will follow within 90 days. LPA explained that any changes to the Board of Directors need to be communicated to the Department within 10 days and board meetings need to occur quarterly. The following topics were discussed: Fingerprint clearances, Guardian, LPA inspections, citation/advisory note process, civil penalty types, CARE tools, CDSS forms and how to find them, exceptions and waivers, ACLs, ACINs, PINs, reporting requirements, inspection authority, POCs, extensions on POC due dates, client access to telephones, and personal rights. LPA Goldie recommends that the facility be licensed upon completion of technical advisories.

visit_type: Prelicensing

met_with: Gaganjit Sandhu Harvir Dhaliwal


summary: Facility Evaluation

raw_content:
Narrative:
On 03/20/2025, Licensing Program Analyst (LPA) Connie Goldie made an unannounced visit to the above facility for the purpose of conducting a Post Licensing Inspection. LPA met with Gaganjit Sandhu. Program Administrator and Harvir Dhaliwal, Licensee who provided LPA with a tour of the interior and exterior of the facility. LPA observed the following: This facility has 4 bedrooms, 2 living rooms, kitchen, backyard and 3 bathrooms. LPA observed fixtures and furniture, equipment, and supplies necessary for this operation. LPA observed locked cabinets personnel files to ensure confidentiality. LPA tested nine combination smoke detectors and carbon monoxide detectors. LPA observed chemicals and sharps to be locked. A first aid kit and fire extinguishers were on site. The water temperature was tested and found to be above a safe temperature in bathroom #2 121.6 degrees. Administrator immediately lowered hot water heater to bring into compliance.. LPA Goldie observed the agency's license posted near the front door, the emergency disaster plan, personal rights poster, menu and activity calendar posted in the dining area. The agency currently employs one Administrator, one Licensee, and Direct Support Professionals. The agency currently has two clients in care. LPA reviewed two client's files with all required documents and four staff files.. During today's inspection two Tittle 22 type B deficiencies are being sited. An exit interview was conducted, and a copy of this report was provided to the Administrator at the conclusion of the inspection.

met_with: Gaganjit Sandhu. Program Administrator Harvir Dhaliwal, Licensee


summary: Facility Evaluation

raw_content:
Narrative:
On 05/09/2025, at 08: AM, Licensing Program Analyst (LPA) Connie Goldie made an unannounced visit to conduct an Annual/Required inspection. LPA Goldie was greeted at the door by Gurjit Dhaliwal, Direct Support Professional, (S1). S1 stated Program Administrator, Gagangit Sandhu was on her way. S1 stated he is the only staff present. The clients are at school. LPA Goldie provided Administrator the Entrance Checklist and obtained the following documents: LIC500, LIC308, LIC610C,and LIC400. LPA toured facility with Administrator and S1 and observed a 4 bedroom, 3 bath single story home with a large living room that has adequate seating for clients/staff. The temperature was observed to be a comfortable 72 degrees farenheight. Bedrooms had appropriate furnishings and youth's preferred decor. LPA tested combined smoke/carbon monoxide detectors and found them to be in working order, LPA observed kitchen to have a pantry with 5 days of non-perishables and refrigerator/freezer with 2 days of perishables. Refrigerator temperature read 39 degrees Fahrenheit. Dining area has adequate seating for clients. Family room has additional area for activities. LPA observed soap and towels in all bathrooms. The water temperature was observed to be compliant in kitchen and bathrooms. LPA observed hygiene projects to be available to clients. Backyard was clear of debris. LPA observed facility van to be in safe driving condition, headlights working, tire tread appropriate, first aid kit present and all seat belts working. Maintenance log was also reviewed. LPA informed Administrator that annual fees are current. LPA verified that all staff are background cleared. Care Tool domains Staff Records and Client Records were completed during today's inspection. Continued on LIC809C. LPA Goldie conducted 2 client interviews C1, C2 and 3 staff interviews S1, S2, and S3. Client interviews were observations. LPA reviewed 2 client files, medication administration records and 5 staff files. No deficiencies were cited during inspection. Annual inspection is complete.


facility_name: SAVING ANOTHER MANCHILD SERVICE'S SAM'S

raw_content:
Narrative:
Confidential witnesses stated that when the clients returned to the facility, they knocked on the door but staff #1 (S1) did not open the door. Furthermore, it was disclosed that when C1 and C2 were seen at a park by facility staff only C2 was allowed to return to the facility and C1 was not. Other confidential witnesses stated that they did not hear staff tell C1 that he could not return to the facility. Also, it was disclosed in confidential interviews that C1 decided on his own to not return to the facility. LPA received inconsistent information during interviews. Based on confidential interviews and record reviews, the allegation that S2 kicked C1 out of the facility and did not let C1 get C1's belongings may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. A copy of this report and appeal rights were explained and provided to Trina Sanford.

Investigation Findings:
13On February 1, 2023, at 9: AM Licensing Program Analyst (LPA) Michael Almaraz arrived at the facility and met with administrator, Trina Sanford, to issue the finding for the above stated allegation. On April 6, 2022, at 11: AM LPA Almaraz arrived at the facility to initiate the investigation and conducted a safety inspection. During the safety inspection, LPA interviewed one facility staff and reviewed four client records. Additionally, LPA conducted interviews with four of four clients (C1, C2, C3, and C4) listed on the confidential names list (LIC 811) dated February 1, 2023, and one staff. On March 30, 2022, the Department received a complaint that alleged staff kicked minor out of the facility. More specifically, it was alleged that after C1 went absent without leave (AWOL) facility staff #2 (S2) did not allow C1 to return to the facility. Confidential witness stated that on the evening March 27, 2022, C1 and C2 went absent without leave (AWOL) from the facility and when they returned to the facility later that evening, they could not gain access and staff was not opening the door. (continued on page 2...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Michael 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 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: SAVING ANOTHER MANCHILD SERVICE'S SAM'SFACILITY NUMBER: VISIT DATE: 02/01/2023

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

met_with: Trina Sanford


raw_content:
Narrative:
In regard to the allegation of wrongful eviction, it was specified that Program Administrator wanted client to be removed immediately due to behaviors and refused to keep the client in the home any longer and did not want to give C1 a 14- day notice. During investigation, Staff indicated that client AWOLed and didn't return to the office. Staff continued stating that C1 was bring illegal drugs to the facility which poses a risk to the other clients. Staff also disclosed that the facility was attempting to give a 14-day notice, but client didn't return. Other interview confirmed that C1 was under the influence of marijuana whenever C1 returned from AWOL, but they were not aware of eviction. One interview stated that it was heard from the facility staff that C1 was going to be evicted. Regarding the allegation of facility did not prevent minor from AWOLING, a confidential interview stated that the facility can't prevent a client from AWOL, however, staff would try to convince clients to stay. Another confidential witness reported C1 would AWOL and return under the influence of marijuana. It was added that staff would talk to C1, but C1 never listen and AWOL anyway. LPAs received consistent information regarding AWOL protocols. Based on interviews and record reviews the allegation that C1 was wrongful evicted and staff didn't prevent C AWOLing may have happened or may be valid, there was not a preponderance of evidence to support or deny the allegations. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report and appeal rights was provided to Administrator Trina Sanford

Investigation Findings:
13On March 9, 2023 at 1: PM licensing Program Analyst (LPA) Karen Beal and Licensing Program Manager (LPM) Abdoulaye Traore arrived at Saving Another Manchild Service's Short-Term Residential Therapeutic Program (STRTP) and me with STRTP's Administrator Trina Sanford to deliver the investigative finding regarding the above stated allegations involving the STRTP and a client (C1) as listed in the confidential names (LIC 811). On September 23,2022, Community Care Licensing (CCL) received a complaint alleging a wrongful eviction and facility did not prevent minor from AWOL (Absence without leave) On September 28, 2022, at 11: AM, Licensing Program Analyst (LPA) Almaraz initiated met with facility Administrator Trina Sanford and initiate the allegation. In addition, LPA Almaraz conducted a safety inspection, interviewed one staff, and reviewed four clients' files. There no safety concerns observed. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Karen Beal LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: SAVING ANOTHER MANCHILD SERVICE'S SAM'SFACILITY NUMBER: VISIT DATE: 03/09/2023

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

met_with: Trina Sanford, Administrator


raw_content:
Narrative:
On February 27, LPA K. Beal conducted collateral interview with two clients. LPA wasn't unable to interview two clients due to being in AWOL. During investigation, the Program Administrator stated that she was not aware of a staff threatening a client or staff inciting clients to fight. She added that she comes to the facility daily and she was not told about anything like that. Additionally, the administrator stated that she didn't believe the staff would touch themselves front of you inappropriately. A confidential interview denied using profanity, threatening clients or yelling at clients. It was disclosed that staff will always separate clients and follow protocols. Other confidential interviews disclosed that staff were always nice to clients, and they didn't witness staff threatening clients or using dirty words. Confidential interviews stated that clients didn't hear staff yelling at clients, however, staff will use a stern tone to get the clients' attention. Confidential witness stated when clients get into altercation, staff would redirect them. In the regards to allegation that facility did not prevent minor from AWOLING, a confidential stated that the facility can't prevent a client from AWOL, however, staff would try to convince clients to stay. Other confidential witness reported that they would not AWOL to be out of trouble, however, clients will always AWOL and return under the influence of marijuana. It was added that staff would talk to clients, but clients never listen. LPAs received consistent information regarding AWOL protocols. Based on interviews and record reviews the allegations that staff threatened to hit clients in care with a chair; staff encouraged clients in care to fight; staff touched himself inappropriately in front of clients in care; staff spoke inappropriately in front of clients in care; staff yelled at clients in care; staff spoke inappropriately to clients in care; and staff did not prevent clients in care from AWOLing may have happened or may be valid, there was not a preponderance of evidence to support or deny the allegations. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report and appeal rights was provided to Administrator Trina Sanford

Investigation Findings:
13On March 9, 2023 at 12: PM Licensing Program Analyst (LPA) Karen Beal arrived at Saving Another Manchild Service's Short-Term Residential Therapeutic Program (STRTP) and me with STRTP's Administrator Trina Sanford to deliver the investigative finding regarding the above stated allegations.. On October 24.2022, Community Care Licensing (CCL) received a complaint alleging that staff threatened to hit a client in care with a chair; staff encouraged clients in care to fight; staff touched himself inappropriately in front of clients in care; staff spoke inappropriately in front of clients in care; staff yelled at clients in care; staff spoke inappropriately to clients in care; and staff did not prevent a client in care from AWOLing. On November 1, 2022, at 1: PM, Licensing Program Analyst (LPA), Michael Almaraz initiated the complaint allegations, conducted a safety inspection and interviewed one staff. On February 1, 2023, Licensing Program Analysts (LPAs), Karen Beal and Michael Almaraz arrived at the STRTP to conducted interviews. LPAs interviewed one staff and reviewed two clients' files. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Karen Beal LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: SAVING ANOTHER MANCHILD SERVICE'S SAM'SFACILITY NUMBER: VISIT DATE: 03/09/2023

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

met_with: Trina Sanford, Adminnistrator


raw_content:
Narrative:
During the investigation, confidential witnesses stated that C1 would go AWOL often from the facility. Additionally, it was reported that staffing was always appropriate and staff would attempt to convince C1 not to go AWOL. LPA received other information that the facility may not be following their emergency intervention plan to prevent youth in care from AWOLing. Regarding the allegation that C1's needs could not be met at the facility. Confidential witnesses stated that C1 used drugs and obtained drugs away from the facility. Additionally, LPA was informed that staff did not provide drugs to C1 and he would obtain drugs elsewhere. Another confidential witness stated that they did not feel that the facility was adequate to meet C1's needs. Based on confidential interviews and record reviews, the allegations that C1 went AWOL from the facility due to staffing levels and that C1's needs could not be adequately met at the facility may have occurred, however, they are not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Ashley Sanford.

Investigation Findings:
13***This is an amended report*** On April 19, 2024, Licensing Program Analyst (LPA) Michael Almaraz met with facility staff, Ashley Sanford, to issue the finding for the above stated allegations. On April 10, 2023, at 1: PM, LPA Almaraz initiated the investigation and conducted a safety inspection, no deficiencies were noted. During the inspection LPA interviewed one facility staff and reviewed three of three client's records (see confidential names list LIC 811 dated April 19, 2024). Additionally, LPA conducted interviews with one additional staff. Two of three clients were unavailable to interview due to one being absent without leave (AWOL) and LPA being unable to locate the other client. On April 10, 2023, the Department received a complaint that staff did not follow their emergency intervention plan to prevent youth in care from AWOLing and minor's needs are not being met while in care. It was specified that client #1 (C1) went AWOL from the facility due to staffing level and that C1's needs could not be adequately met at the facility. (continued on page 2...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Michael 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 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: SAVING ANOTHER MANCHILD SERVICE'S SAM'SFACILITY NUMBER: VISIT DATE: 04/19/2024

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

met_with: Ashley Sanford


raw_content:
Narrative:
Based on the lack of information, the allegation that staff threatened a minor with a knife while in care may have occurred or valid, however, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated at this time. An exit interview was not conducted as LPA M. Perez could not contact the facility due to it being closed. A copy of this report and appeal rights will be placed in the facility closed file.

Investigation Findings:
13Licensing Program Analyst (LPA) Maryjane Perez attempted to contact Saving Another Manchild Services Group Home using the last known phone number to deliver the finding of the stated allegation. On November 26, 2024, Community Care Licensing (CCL) received a complaint alleging that staff threatened a minor with a knife while in care. On December 6, 2025, LPA arrived at the closed facility location in attempt to initiate a 10-day visit. LPA did not receive an answer at home; therefore, LPA called the last known telephone number associated with the facility administrator (AD). LPA was unable to contact them or receive responses. The facility has been closed since April 10, 2024. In addition, LPA attempted to locate client 1 (C1) and was unsuccessful. LPA contacted C1's last known placement and spoke to former resource parent (RP) who stated that they had not seen C1 since the beginning of the year 2025 as C1 left the home on an unauthorized absence. LPA attempted to speak with C1's social worker (SW) via phone call but it was unsuccessful. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: MaryJane Perez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: SAVING ANOTHER MANCHILD SERVICE'S SAM'SFACILITY NUMBER: VISIT DATE: 10/17/2025


summary: Facility Evaluation - 6 deficiencies

raw_content:
Narrative:
On August 20, 2021 at 9: AM, Licensing Program Analysts (LPAs) Michael Almaraz, Adaleyci Caballero and Licensing Program Manager (LPM) Abdoulaye Traore conducted an annual inspection. The facility converted from a Group Home to STRTP (Short Term Therapeutic Program) on August 28, 2020. Facility manager Sharon Mayberry granted LPAs and LPM access into the facility. There were one out five clients present during the inspection. A physical plant inspection was completed at 10: AM and included the following checks: Facility grounds were clean and free of debris and observable hazards. There was adequate indoor and outdoor activity space. All facility smoke detectors and carbon monoxide detectors were in appropriate working order; however, one smoke detector was beeping due to a possible low battery. The fire extinguishers were properly charged and serviced. LPA's and LPM observed adequate supply of perishable and non-perishable foods and appears to be following the posted menu. All required forms are posted including the Grievance Procedures, visitation policies, personal rights, and Foster Care Ombudsman posters. Medications were locked and centrally stored in a locked closet downstairs. Two Individual beds were missing appropriate clean linens. The hot water temperature was measured, and it was within the range. Facility had cameras in common areas of the facility. The facility has an exception on file to use the cameras and are meeting the terms and conditions. Per facility staff, no firearms or weapons are allowed in the facility. Five of five clients' file reviews were completed. Based on observation and file review, the facility is being cited on the following areas: children record and physical plant. In addition, the facility was unable to provide copies of the Board of Director's meeting minutes. Other deficiencies were observed and cited on 809Ds. (...) A case management inspection will be conducted at a later date to complete the annual inspection. Exit interview was conducted and deficiencies were advised.

Deficiencies:
80088(d): Deficient Practice Statement
1
2
3
4Based on observation, the facility did not comply with the section cited above in three out of three cleint rooms which poses a potential health, safety or personal rights risk to persons in care .
POC Due Date: 09/03/2021
Plan of Correction
1
2
3
4
80026(e): Deficient Practice Statement
1
2
3
4Based on record review, the licensee did not comply with the section cited above in six of six clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2021
Plan of Correction
1
2
3
4
80026(j): Deficient Practice Statement
1
2
3
4Based on observation, the licensee did not comply with the section cited above in five out of five clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2021
Plan of Correction
1
2
3
4
80026(h): Safeguards for Cash Resources, Personal Property, and Valuables

(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following
87068.3(a): Modifications to The Needs And Services Plan

(a) The needs and services plan specified in Section 87068.2 shall be updated at least every 30 days to determine the following
87068.2: (2)

met_with: Sharon Mayberry

title:
Fixtures, Furniture, Equipment and Supplies

(d) The licensee shall provide lamps or lights as necessary in all rooms and other areas to ensure the comfort and safety of all persons in the facility.

This requirement is not met as evidenced by

title:
Safeguards for Cash Resources, Personal Property, and Valuables

(e) Cash resources, personal property, and valuables of clients shall be separate and intact, and shall not be commingled with facility funds or petty cash.

This requirement is not met as evidenced by

title:
Safeguards for Cash Resources, Personal Property, and Valuables

(j) Cash resources entrusted to the licensee and kept on the facility premises, shall be kept in a locked and secure location.

This requirement is not met as evidenced by


summary: Facility Evaluation

raw_content:
Narrative:
On August 26, 2021, at 09: AM, Licensing Program Analyst (LPA's) Michael Almaraz, Adalecyi Caballero and Darlene Almaraz conducted an unannounced inspection. The purpose of the inspection was to complete the continuation inspection for STRTP annual inspection that was initiated on August 20, 2021. LPA's already completed the physical inspection of the facility and reviewed facility client files. During this annual inspection continuation LPA's reviewed nine personnel files to ensure they contained all required documentation per Title Regulations and Interim Licensing Standards (ILS). All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Personnel files were locked in the staff office. LPA's reviewed the Personnel Report (LIC 500) and schedules to ensure appropriate staffing ratios. Based on observation and file review, the facility is being cited on the following areas: disaster preparedness and emergency intervention. LPA's observed that the training hours for 9 of 9 personnel files reviewed, for 2021 meet the training requirements, per STRTP Interim Licensing Standards (ILS) LPA M. Almaraz conducted interviews with one of one available staff. Staff was able to provide sufficient information in relation to the facility's STRTP Program Statement, Emergency Intervention Plan, clients' Needs and Services plan, and Reporting Requirements. Based on interview with staff, the facility appears to be meeting Core Services/Supports requirements. An exit interview was conducted and a copy of this report, LIC 809-d and appeal rights were provided to Director Trina Stanford.


summary: Facility Evaluation - 3 deficiencies

raw_content:
Narrative:
On August 31, 2021 at 10: AM, Licensing Program Analysts (LPA) Anne Visaya and Licensing Program Manager (LPM) Abdoulaye Traore conducted a required annual inspection at Saving Another's Man's Child Short-Term Residential Therapeutic Program (STRTP). LPM and LPA met with Director/Administrator Trina Stanford at the Facility entrance. Trina stated that she was leaving, and Staff Maria would grant access LPM and LPA into the home. There were one out of four clients present during the inspection. At 10: AM, LPA and LPM began the facility tour inside and out with the staff Maria. Facility grounds were clean and free of debris and observable hazards. A smoke detector/alarm located in the living room was not operable. LPA and LPM observed bleach under unlocked kitchen accessible to the clients. LPA and LPM observed two sharp objects in an unlocked kitchen drawer. LPA and LPM observed detergent and other chemicals were unlocked and accessible to the children in the laundry room located upstairs. Toilet in the staff bathroom was missing a flushing handle. Based on observation and testing, the fire alarm system of the facility was not operable. The facility is being cited for the violation of the Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) regulations...sections... An Immediate civil penalty of $500 is assessed. In addition, Sharp objects and chemical were accessible. The facility is cited for violation of the Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) sections 80087(g) and 87087(d). The facility maintained an adequate supply of perishable and non-perishable foods and appeared to be following the posted menu. All required forms were posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster. Medications were locked and centrally stored in downstairs closet. Individual beds were missing appropriate clean linens. The hot water in the client's bathroom was measured to be 115 degrees. Facility had cameras in common areas of the facility. Per facility staff, no firearms or weapons are allowed in the facility. A Review of staff fingerprint clearance showed that staff (S1, S2 and S3) didn't have a fingerprint clearance. Facility is being cited for a violation of California Code of Regulations Section 80019(e)(2). An immediate civil penalty of $1,500 is assessed for the day of 08/31/2022. Personnel files were reviewed to ensure they contained all required documentation per Title 22 and Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) regulations. Per record review, personnel files were missing the following information: All staff required orientation for new staff; 8 hours and 16 hours trainings; facility manager additional training; competency assessments; required training documentation; trauma informed care; emergency disaster trainings; staff evaluations; emergency intervention trainings; all required ILS training topics; Administrator designating a person responsible for activities; medication trainings and core therapeutic services. The facility is cited for violation of Title 22 and Interim Licensing Standards: ILS Sections Personnel requirements; ILS Sections 87065. Training Requirements. Citation sections and details on LIC 809D pages. The annual inspection to be continued in a later date. LPM contacted Administrator Trina to give an authorization to staff L. Perry to receive licensing reports including plan of corrections. An exit interview was conducted and a copy of this report, LIC along with the appeal rights were provided to Direct Care Staff.

Deficiencies:
87066(b): Personnel Records

(b) The licensee shall maintain the following personnel records
80066(a): Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information
87065.1(d): Supervision, Evaluation And Training Requirements

(d) Notwithstanding California Code of Regulations, Title 22, Section 80065(f)(1) through (6), new direct care staff shall complete a minimum of 24 hours of initial training comprised of the 8 and 16 hour training as specified in (1) and (2) below

met_with: MARIA LUIS JUAN & JIMMIE PAYTON


summary: Facility Evaluation

raw_content:
Narrative:
On February 1, 2023 at 10: AM, Licensing Program Analysts (LPA) Karen Beal and LPA Michael Almaraz conducted a continuation visit for an annual inspection at Saving Another's Man's Child Short-Term Residential Therapeutic Program (STRTP). LPAs met with Director/Administrator Trina Stanford. During the continuation of the annual LPAs reviewed the Client Record, Operational Requirements, Disaster Preparedness, and Core Therapeutic Services. Two clients files (C1, C2,) were reviewed on this date to ensure they contained all required documentation per Interim Licensing Standards. Two out of the two clients were in school at the time of the inspection. Facility appears to be meeting the terms and conditions of their license. Licensing fees have been paid and there is currently a balance of zero. The facility is being cited for violation of the Interim Licensing Standards, Chapter 7. Short Term Residential Therapeutic Program, Articles 1 through 10, Version Client Records 87070(c)(2) and Operational Requirements 87063(a)(9). LPAs provided a copy of these reports, along with appeal rights, to Trina Sanford.


summary: Facility Evaluation

raw_content:
Narrative:
On July 21, 2023, at 10: AM Licensing Program Analyst (LPA), Michael Almaraz , met with facility staff Ashley Sanford, via Microsoft Teams to conduct an interview. LPA went over revisions needed for the Application and Program Statement. Via EMAIL LPA provided Ashley Sanford a copy of this LIC 809, a LIC 184 and a Department letter of the revisions needed for the application. Signed LIC 809 will be placed in the facility file.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On June 23, 2022, at 11: AM Licensing Program Analyst (LPA), Michael Almaraz, met with facility staff, Jimmie Payton, to complete a Case Management inspection based off information received during a facility inspection on November 17, 2021. During LPA inspection of the facility on November 17, 2021, LPA observed client #1 (C1) see confidential names list (LIC 811) dated June 23, 2022, on the porch of the facility. It was discovered by LPA that C1 was locked out of the facility and there wasn't any staff coverage. Based on confidential interviews and record review the facility failed to meet direct care staff/child ratios. The facility is being cited for violation of the Interim Licensing Standards, Chapter 7. Short Term Residential Therapeutic Program, Articles 1 through 10, and Subchapter 7.5, Version 4 87065.5(a)(1). Direct Care Staff/Child Ratios. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Jimmie Payton.

Deficiencies:
87065.5: (1) During the hours of 7 am to 10 pm, there shall be one awake and on duty direct care staff for every three children, or fraction thereof,... 1
2
3
4
5
6
7Per facility representative, facility will retrain staff on 87065.5 Direct Care Staff/Child Ratios in its entirety provide proof to LPA by the POC due date.
8
9
10
11
12
13
14present, at a minimum.

met_with: Jimmie Payton

title:
1
2
3
4
5
6
787065.5 Direct Care Staff/child Ratios. (a) In a facility with a licensed capacity of six or fewer children, there shall be coverage by direct care staff as follows


facility_name: SECOND HOME, INC. - SAMPLE HOUSE

summary: Facility Evaluation

raw_content:
Narrative:
On November 16, 2021, Licensing Program Analyst (LPA) Les Inouye conducted an annual inspection of the facility indicated above. Met at the agency by Administrator Jennifer Fish. An inspection of the physical plant was conducted. LPA observed adequate food supply, appropriately maintained yard, adequate bedding, storage space, activity space, hot water that measured 118 degrees and lamps, toiletries and a facility that is safe, sanitary and in good repair. Staff files and training records were inspected on this date. At 3: PM, an interview of S1 (see LIC811 dated 11/16/2021) was conducted. The exit interview was conducted at 3:30PM and a copy of this report given to the Administrator.

met_with: Jennifer Fish


summary: Facility Evaluation

raw_content:
Narrative:
On the above date a Case Management evaluation was conducted to review physical plant and operations of the facility. The facility has had a census of 0 since approximately June 2020. The facility has requested to modify the gender accepted to accommodate new clients. A Board resolution and appropriate licensing forms have been submitted to the Fresno CCL office. Approval was given to the facility to accept females on 11/15/21. On inspection, the physical plant was reviewed and in compliance. Each bedroom was furnished appropriately, waiver was reviewed for captains bed and additional bedding and pillows were observed. The facility was stocked with toiletries, towels. Chemicals, laundry and cleaning supplies were secured. The kitchen was supplied with appropriate perishables and non-perishables. The back yard was free of observable hazards hazards. Hot water was measured at 118 degrees. Medication storage area was observed and is inaccessible to clients. 1st aide kit was observed and complete. Appropriate licensing signs was posted including personal rights, evacuation plans, menus.

met_with: Jennier Fish


summary: Facility Evaluation

raw_content:
Narrative:
On this date Licensing Program Analyst (LPA) Les Inouye met with Jennifer Fish at the office to discuss the status of the current application for Second Home Inc STRTP Sample House for a Component II.. The Department agreed to proceed with the application process and license Sample House during the review process due to two currently operating facilities San Jose House and Tenaya House. The current Sample House application was discussed including details of corrections needed for the Plan of Operation (POO) section. The Program Statement (PS) section was not reviewed at this time but a preliminary working copy of the PS review was provided. The hard copy of the application was returned, Due to conflicting schedules by both LPA and Jennifer Fish no return due date was scheduled. It was agreed that the review and corrections would be done in a timely manner.