raw_content:
Narrative:
The investigation revealed that the facility reported that Ref. #4 and #5 would come to the facility with different bicycles. It revealed that the facility reported that on one occasion Ref. #4 and #5 threw rocks at cars and were chased by a driver while away from the facility without permission. The investigation revealed that the facility reported while Ref. #5 left the facility without permission, Ref. #5 was hit by a train while intoxicated causing a small injury. It revealed that the facility provided first aid, but Ref. #5 refused to go to Urgent Care. A review of the reports indicating law enforcement involvement indicates that the facility followed their Runaway (AWOL) Plan as it relates to Procedures for Responding to a Runaway Youth. The reports indicated that according to the Procedures staff talked to Ref. #5 and offered alternatives, such as accompanying the staff to the park or swimming, instead of leaving without permission. An interview with the Probation Officer (PO) revealed that the PO had no concerns about the facility. The PO indicated that Ref. #5 was a chronic runaway, and constantly used drugs and alcohol. Interviews with the other witnesses and Ref. #5, revealed that Ref. #5 was intoxicated by liquor or high on drugs on more than one occasion. It revealed that when staff attempted to engage Ref. #5 or confiscate liquor bottles in Ref. #5's possession, Ref. #5 would leave without permission. The investigation revealed that the facility provided Ref. # Core Services and Trauma-Informed Care Services with their mental health personnel, but Ref. #5 would not engage with the therapists. The investigation revealed that on one occasion the facility requested that the Probation Department search Ref. #5's physical person, but nothing was found. It revealed that on one occasion staff searched Ref. #5's bedroom and found one empty liquor bottle. The LPA was unable to corroborate the allegations. Based upon the above, it is determined that there is no preponderance of evidence to substantiate that the facility did not properly supervise Ref. #5; did not prevent Ref. #5 from bringing alcohol into the facility; nor report incidents that occur at the facility to the appropriate parties. So, although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the allegations are unsubstantiated. There are no deficiencies to be cited regarding this complaint. A copy of this report was emailed to the facility representative.

Investigation Findings:
On December 15, 2022 at 12:45 p.m., Licensing Program Analyst (LPA), Karen McGee, delivered the findings of the complaint investigation to the facility. The LPA met with Administrator, Marci Madison. On August 22, 2022, the Monterey Park Children's Residential Program (MPCRP), received a complaint with the above-mentioned allegations. Confidential interviews were conducted that included, but were not limited to: four staff - one staff, Ref. #1 on August 26, 2022, the Administrator on December 6, 2022 and two staff, Ref. #2 and #3 on December 14, 2022 via telephone; two clients, Ref. #4, on December 8, 2022 and Ref. #5 on December 14, 2022 face-to-face; and one Probation Officer via telephone on December 12, 2022. The LPA reviewed Special Incident Reports and Ref. #5's Needs and Services Plan. Following is the evidence that was revealed in the investigation: The investigation revealed that Ref. #5 was placed at the facility from July 28, 2022 and discharged on August 16, 2022, which indicates that the client resided at the facility for 20 days. A review of records indicates that the facility submitted incident reports to MPCRP involving Ref. #5 on the following dates: 7/29/22, 7/31/22, 8/4/22, 8/5/22, two on 8/6/22, two on 8/7/22, and 8/12/22, as required by Title Regulations, Reporting Requirements. The LPA observed incident reports for the incidents that were stated to have not been reported (cont'd). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Karen McGee 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 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: STOCKDALE BOYS CENTER IIFACILITY NUMBER: VISIT DATE: 12/15/2022

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

met_with: Marci Madison


state: CA

facility_name: STOCKDALE BOYS CENTER II

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
The facility provides wi-fi to clients. However, the clients need to earn their privilege to use wi-fi. The clients have to be in level three and attend school in order for them to use the wi-fi. The wi-fi is turned off at PM to prevent the clients to be up all night using their devices connected to the internet. Staff do not turn off the wi-fi as discipline. Statements obtained from the confidential interviews did not provide sufficient information to corroborate the allegations. Based on the information gathered, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that alleged violation occurred, therefore the allegation is unsubstantiated. There were no deficiencies cited during this inspection. An exit interview was conducted. Appeal rights explained and a copy of this report, and Appeal Rights were provided to the facility representative.

Investigation Findings:
13On April 26, 2023, at 11: AM, Licensing Program Analyst (LPA) Karen Suh conducted a follow-up complaint inspection to deliver the findings of an investigation concerning to the allegations above. The LPA met with the representative named above and discussed the findings. The investigation included confidential interviews that consisted of but were not limited to: Administrator and three staff on April 14, 2022; one client on December 27, 2022. The LPA was unable to interview the C1 as they refused to be interviewed. The LPA was unable to contact the County Social Worker (CSW) after several attempts. The LPA reviewed C1's Daily Logs for August 2022, Needs and Services Plan and Personnel Record. It was alleged that a staff threatened to fight client and staff turn off wi-fi at the facility as discipline. Staff denied the allegations stating that they did not threaten the client to fight; staff never threatened any clients to fight. Staff are trained and received trainings in personal rights; staff are trained to manage situations. Staff do not fight with clients. (cont'd) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Yan Yeung LICENSING EVALUATOR NAME: Karen Suh 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 32-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, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: STOCKDALE BOYS CENTER IIFACILITY NUMBER: VISIT DATE: 04/26/2023

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

report_type: Complaint Investigation

met_with: Iraina Holliday, Facility Manager Supervisor

complaint_status: unsubstantiated


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
When staff become aware of clients using or smoking marijuana in the facility either by observance or smell, staff request the clients to surrender the contraband. in the facility when staff a. Clients are informed house rules of drugs during intake process. It was alleged that staff do not notify authorized representative of doctors appointments and staff are not returning authorized representatives calls in a timely manner. Staff denied the allegations. Staff stated social workers or authorized representatives, are provided with clients' medical appointment dates when they inquire. A copy of examinations and reports are provided to social workers or authorized representatives after services are completed. Staff stated call are always returned as soon as possible. The call is returned immediately or next business day if there is a voicemail left. However, social workers or authorized representatives have Administrator and facility manager supervisor's cell phone number to contact if they need to contact someone immediately. It was also alleged that staff are not ensuring minor attends school. Staff denied the allegation. Staff encourage clients to attend school. Staff stated since staff cannot force clients to go to school if they refuse, clients are provided incentives of $5.00 a day when they go to school. The LPA was unable to obtain any statements from clients as they declined to be interviewed. The statements obtained from the confidential interviews did not provide sufficient information to corroborate the allegations. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that alleged violations occurred, therefore the allegations are unsubstantiated. There were no deficiencies cited during this inspection. An exit interview was conducted. Appeal rights explained and a copy of this report, and Appeal Rights were provided to the facility representative.

Investigation Findings:
13On November 15, 2024, at 9: AM, Licensing Program Analyst (LPA), Karen Suh, conducted a follow-up complaint inspection to the facility above to deliver the findings of a complaint investigation. LPA met with the representative named above and discussed the findings. The investigation included confidential interviews that consisted of but were not limited to: Head of Services, four staff on May 5, 2024, and rehabilitation specialist on September 25, 2024. The LPA was unable to interview three clients (see Confidential Names LIC 811, dated November 15, 2024) as they declined to be interviewed. The LPA reviewed House Rules of substance use, school, and the plan of operations regards to medical/dental services. It was alleged minors are using illegal substances in the facility. Staff stated clients are not allowed to smoke or have possession of any drugs in the facility. Staff encourage clients not to smoke marijuana and remind them about dangers and long-term effects of substance use. (cont.) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Yan Yeung LICENSING EVALUATOR NAME: Karen Suh 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 32-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, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: STOCKDALE BOYS CENTER IIFACILITY NUMBER: VISIT DATE: 11/15/2024


raw_content:
Narrative:
On January 9, 2025, as C1 was preparing for school, he was walking around with his phone, speaking softly to himself. At that moment, he encountered S1 and S3, informing them that they had been sexually assaulted earlier that morning while they were asleep. C1 was unable to provide any information regarding the alleged assailant and declined medical assistance. S1 reported that the Bakersfield Police had been informed, and soon after, Officer Nelson arrived at the STRTP to converse with C1; however, the information given by C1 was inconsistent, as C1 claimed that the sexual assault had been happening for the last eight months yet had only been living in the STRTP for two weeks. Because C1 provided conflicting details and declined to pursue medical assistance, Officer Nelson consulted with the staff and then left the STRTP. The staff members (S1, S2, and S3) refuted the allegation, asserting that all personnel are trained in trauma-informed care and recognize the significance of upholding a secure and healthy atmosphere for every client. S3 stated that on the night of the alleged incident, they were the only staff member on duty. They described the night as calm and confirmed that no one entered or exited the facility during that time. S3 expressed surprise at what C1 had reported the following morning. S2, the Head of Service, indicated that they have tried to arrange meetings with C1 three to four times weekly; however, C1 often rejected these meeting requests. Furthermore, S2 mentioned that they provided both individual and group therapy sessions and had enrolled C1 in a substance abuse program, due to C1's history of substance abuse, yet C1 has declined to participate in these sessions. S2 also disclosed that C1 frequently suffered from hallucinations triggered by this substance use, which intensified as C1 increasingly went AWOL. Information gathered from the PO indicated that C1 has a background of substance abuse and may exhibit delusional behavior at times. Before C1's absence without leave from the STRTP on January 21, 2025, they had made allegations of sexual abuse. These allegations were communicated to the relevant authorities, and C1 was referred for a medical evaluation at Urgent Care, where no irregularities were detected. Additionally, confidential statements obtained from facility clients refuted the allegation, asserting that they have never witnessed or heard of any staff behaving inappropriately with clients and that they are consistently monitored by staff. Clients also reported having access to mental health services and programs, and stated that they have no concerns regarding the care and supervision they receive. Therefore, based on the information received, the above allegation(s) are determined to be unsubstantiated. Although the allegation(s) may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred, therefore, the allegation(s) are found to be unsubstantiated. Appeal Rights were provided and discussed with the STRTP Facility Manager. There are no deficiencies to be cited at this time. An exit interview was conducted, and a copy of the report along with the (LIC 811) was left with the STRTP Facility Manager.

Investigation Findings:
13On June 19, 2025, at 11: AM, Licensing Program Analyst (LPA) John Bonilla on behalf of LPA Winston Moroney carried out an unannounced inspection of the aforementioned Short Term Residential Therapeutic Program (STRTP) to present the findings related to the stated complaint. LPA engaged with the Facility Manager of the STRTP and reviewed the results concerning the identified allegation(s). On January 9, 2025, the California Department of Social Services Community Care Licensing Division received a complaint from Centralized Complaint and Information Bureau (CCIB) with the following allegation(s): Minor was sexually assaulted UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: John Bonilla 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 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: STOCKDALE BOYS CENTER IIFACILITY NUMBER: VISIT DATE: 06/19/2025

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

met_with: Kiauna Dixon, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 10/26/2020 at 2: PM, Licensing Program Analyst (LPA) Janeth Chavez conducted a post-licensing virtual inspection of the Short Term Residential Therapeutic Program (STRTP) and met with the Administrator Marcy Madison. The LPA along with the facility staff conducted a virtual tour of the facility inside and outside. There are 5 clients currently residing in the home. At 2:35PM the following was observed during the virtual inspection. The facility is a single-family home in a residential neighborhood. The facility consists of 4 bedrooms (one of which is being utilized as an office), 2 bathrooms, living room, game room, kitchen, dining room, laundry, 2-car garage, covered patio and backyard. All areas are appropriately furnished. The facility is clean, safe, and sanitary. There is adequate supply of perishable and non-perishable food. Kitchen utensils, dishes, glasses were found clean adequate and in good condition. There is a refrigerator and freezer in the garage. The facility provides nutritious snacks between meals and the weekly menu is posted by the kitchen area. Medications, first aid kit, all cleaning supplies and laundry detergent, sharp knives, client files are stored and secured out of the reach of clients. The facility license, emergency disaster plan, activity calendar, ombudsman complaint procedure and personal rights were observed to be posted on the wall. The smoke alarm, fire extinguishers and carbon monoxide monitor are in good working condition. There are no bodies of water on the property. The Administrator stated that there are no firearms or any other item that may be considered as weapon in the Facility. Fire/earthquake drills are conducted once a month and kept in a log. There were no physical plant deficiencies noted at the time of this inspection. Report Continues on Next Page At 02: PM LPA interviewed two staff. A file review was conducted at 3:30PM and included 2 staff files and 2 clients files. There is currently one client taking medication. Client files contained an original admission agreement. Files for clients currently taking prescribed medication contained all the required documentation such as the medical consent forms and authorizations. Overall, clients are provided adequate services in accordance with their needs and services plan and are being updated. Staff files contained criminal record clearances or exemptions and child abuse index check, job descriptions, required training and work evaluations. All documents were complete and signed by employee. All staff requiring training, including Mandated Reporter, Emergency Intervention, initial and annual training, was current. All adult individuals who require caregiver background checks have received criminal record and child abuse index check clearances or exemption. In accordance with California Code of Regulation, Title 22, Division 6. Exit interview was conducted. A copy of the LIC 809, LIC 809C, LIC 858, and LIC859 were provided to the facility representative.

report_type: Facility Evaluation

met_with: Marcy Madison


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Janeth Chavez conducted a case management virtual inspection for the purpose of addressing an Exemption Denial for Ref-1 received on 10/05/2020. LPA reviewed with Administrator the Exemption Denial letter stating that the request for a criminal record exemption for Ref- ID # 7512118225 has been denied. A denied exemption means that this individual may not work or be present in a facility licensed by the Department. This individual is also prohibited from having contact with clients of any facility licensed by the Department. If this individual was allowed to work or be present in your facility because he/she had a previous clearance, this individual must be immediately removed from your facility. Per Administrator, subject individual was a previous employee of the facility during the exemption process. However, the subject individual is no longer employed at this facility as of 10/12/2020. Administrator provided a signed copy of the Confirmation of Removal (LIC 300B) for Ref-1 signed and dated 10/12/2020. LPA interviewed Staff 1 & 2 and both staff stated that Ref-1 is no longer employed at this facility since 10/12/2020. Exit interview was conducted and a copy of LIC 809 & LIC 811 was provided to the facility representative.

visit_type: Case Management

met_with: Marcheletta Madison, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 09/08/21 at 12:27PM, Licensing Program Analysts (LPAs) Janeth Chavez and Raymond Wu conducted an unannounced Annual/Required, onsite inspection, at the Facility to evaluate compliance with rules and regulations, and to assess the Facility's continuing ability to meet regulatory requirements. The LPAs met with Facility Manager Supervisor, Iraina Holiday and stated the purpose for the inspection. The Facility Administrator was not present during the inspection. At 12:40PM, LPAs along with Staff 1 conducted a walk through of the entire grounds and observed the overall maintenance and operation of the Facility. The Facility is licensed to provide 24-hour services and supervision to male clients ages 12 to 17 and non minor dependents. LPAs did not observe any bodies of water. At the time of this inspection, the LPAs observed the clients being supervised by two staff members and the staff appeared to be providing proper care and supervision. At the time of this inspection, the facility physical plant level of maintenance meets regulatory requirements and is in good repair. Passageways are unobstructed. No disinfectants/cleaning materials were accessible to clients. There are plenty non-perishable foods for one week and perishable food for more than two days, and there were plenty meal snacks. The medications are locked and only accessible to staff capable of administering the medications. Facility operates within license conditions and limitations including capacity limitations. The Facility license is posted in a prominent place. The fire extinguisher and smoke alarms including the carbon monoxide monitor are operational. The first aid kit is available and complete. An exit interview was conducted and Copy of this report was provided to the Facility Manager. An Annual Continuation will be conducted to complete the inspection tool and review clients and staff files. The are no deficiencies cited on today's inspection.

visit_type: Annual

met_with: Iraina Holiday


summary: Facility Evaluation

raw_content:
Narrative:
On 09/09/21 at 10: AM, Licensing Program Analysts (LPAs) Janeth Chavez and Raymond Wu conducted an unannounced Annual Continuation to complete the facility inspection. The LPAs met with the Administrator, Marcheletta Madison and stated the purpose of the inspection. During today's inspection there are 3 staff present and there are no clients present. During the inspection process the Administrator provided the following: Staff Training Handbook; Emergency Disaster plan, and facility file indicating emergency drills have been conducted, and their Disaster and Mass Casualty Plan; Facility Sketch and fire escape plan; Planned Activity Schedule; Meals Menu for past three months; Current Personal Rights Listing and reporting requirements; Neighborhood complaint procedures; Biannual review of Emergency Intervention Plan; Monthly Log of Restraints; Medication Log; List of staff certified (in writing) to use or participate in emergency intervention (restraints). At 11:10AM, the LPAs reviewed a random sample of staff/personnel and minor/non-minor dependents records. Client and staff records were complete and up to date. The Administrator provided the Client's Roster, Personnel LIC 500, and staff schedule. All individuals who work at the facility, or have contact with clients, have a current criminal record clearance or exemption, Child Abuse Index Check clearance/Live-Scan fingerprints and/or association. LPAs inspected the facility operational requirements, planned activities, register of clients, safeguards for children/youth's cash allowances, emergency procedures, emergency intervention plan, and emergency intervention staff training, documentation and reporting requirements. The facility staff ratio meets regulatory requirements. The Administrator and staff are fully qualified to perform their assign duties of their individual position.Report Continues on Next Page As per administrator, Staff are instructed to report personal rights violations and to provide a safe, healthy and comfortable environment to clients in care. All clients in placement attend school, extracurricular, cultural, and personal enrichment activities. Clients can contact CCLD or Foster Care Ombudsman in confidence without threats, punishment or retaliation. The facility uses a Toyota Sienna as a means for transporting clients to and from school, extracurricular activities and medical appointments. The van seats 7 passengers. The facility maintains a mileage and maintenance log of the vehicle and have current vehicle insurance. LPAs inspected the van and contains all safety fixtures required by law. The Facility Administrator ensures that Title 22 along with the Facility Program Statement, Staff Training Handbook and other Group Home requirements are followed and understood. Also, that reporting requirements are followed and enforced. At the time of this inspection, LPAs observed no specific reason for concern and did not observe hazards, and/or obvious health and safety issues in the Facility premises. At the time of this inspection the Facility is operating within Title 22 requirements. An exit interview was conducted and Copy of this report, Clients Record/Resident's Records Review (LIC 858), Staff Of Staff/Volunteer Records Review (LIC 859) were provided to the Facility Administrator.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On November 15, 2024 at 10:30 a.m., Licensing Program Analyst (LPA) John Bonilla arrived unannounced at Stockdale Boys II Short Term Residential Therapeutic Program (STRTP) for the purpose of conducting a Required - Year inspection. LPA met with Iraina Holliday, Facility Manager Supervisor. A tour of the facility was conducted, and LPA reviewed the following domains in the Compliance And Regulation Enforcement (CARE) Tool: Physical Plant, Operational Requirements, Disaster Preparedness, Emergency Intervention Plan, Staffing Records, Client Records, and Core/Therapeutic Services. LPA also interviewed two (2) staff and attempted to interview one (1) client. Physical Plant: The license is posted in a prominent, publicly accessible location in the facility. Disinfectants, cleaning solutions and sharps are locked in the office. Facility has non-perishable foods for at least one week and perishable foods for at least two days. Facility provides at least three(3) meals per day. Medications are centrally stored and locked in office. All kitchen, food preparation, and storage areas are kept clean and free of rodents and other vermin. Facility has one or more carbon monoxide detectors in the facility. Facility provides basic laundry services. Room temperatures are maintained at 69 degrees F. The hot water temperature was within the required range. All toilets, hand washing and bathing facilities are maintained in safe and sanitary operating condition and meet the requirements. No more than 2 clients share a bedroom. All beds are in good repair; equipped with good springs and a clean mattress; and supplied with pillows which are clean and in good repair. Facility provides age-appropriate clothing items and hygiene products. Overall, facility is clean, safe sanitary and in good repair. Operational Requirements: Facility maintains a current, written plan of operation that meets licensing standards. Facility maintains a register of clients and the register is available upon request. Facility maintains and implements written complaint procedures and the procedures are posted in a publicly accessible location in the facility. The board of directors regularly conducts meetings to review and discuss the STRTP's operation. Cash resources are kept on the facility premises in a locked and secure location. (Continued...) Disaster Preparedness Plan: Facility maintains a current, written disaster and mass casualty plan of action. Facility conducts disaster drill at least every month for each shift. The drills are documented, and the documentation is maintained in the facility for at least a year. Facility maintains an emergency and disaster plan, register of clients, Needs and Services Plan for each client, medication records, and contact information for each client's responsible party and physician. Emergency Intervention Plan: Facility maintains a monthly log of each use of manual restraints that contains all required information. The log is available for review by the Department upon request. LPA observed documentation of Emergency Intervention Training and on-going training. Staff Records: LPA reviewed four (4) staff records. Staff records contain documentation of the required education and experience requirements and training. All staff subject to criminal records review are fingerprint cleared and associated to the facility at the time of the inspection. Client Records: LPA reviewed four (4) client records. All client records are available to the licensing agency to inspect, audit and copy upon demand. Client records reviewed include, but not limited to, consent forms, court orders, appraisal/needs and services plan, removal/discipline/complaint procedures; medical assessment; safeguards for cash resources, personal property and valuables; education records; personal rights forms; and medication administration records. Core/Therapeutic Services: Facility provides core services and supports to children and non-minor dependents as appropriate or necessary that are trauma informed, culturally relevant, age and developmentally appropriate and include the following: Medi-Cal specialty mental health services; transition support services; educational and physical, behavioral, and mental health supports; activities to support children and non-minor dependents and services to achieve permanency. During today's inspection, the STRTP was issued two (2) Type B deficiencies and provided thirteen (13) Advisory Notes/Technical Violations (LIC9102TVs). An exit interview was conducted. A signed copy of this report, LIC809-D, LIC Confidential names list dated 11/15/24, LIC9102TVs, and appeal rights were provided to Ms. Holliday. Inspection complete.

Deficiencies:
87068.3(a): Modifications to The Needs And Services Plan

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


summary: Facility Evaluation

raw_content:
Narrative:
On September 11, 2025, at 01:45 p.m., Licensing Program Analyst (LPA) John Bonilla conducted an unannounced Case Management - Incident inspection at Stockdale Boys Center II, a Short-Term Residential Therapeutic Program (STRTP). The purpose of the inspection was to follow up on an incident report (IR) received by the Department. LPA met with Iraina Holliday, Facility Manager Supervisor. On September 9, 2025, the Department received an IR stating that on September 7, 2025, a client (C1) (See LIC Confidential Names list dated 09/11/25) had a behavioral episode which resulted in the client acquiring a bottle of bleach, and drinking from the bottle, spitting the liquid out immediately thereafter. During this inspection, LPA obtained LIC Client Roster, clients' school information, and Needs and Service Plan for C1. LPA also interviewed two (2) facility staff No deficiencies were issued at this time. Exit interview conducted. Signed copies of this report and LIC811 were provided to Iraina Holliday. Further action required before completing the Case Management.


summary: Facility Evaluation

raw_content:
Narrative:
On September 23, 2025, at 11:15 a.m., Licensing Program Analyst (LPA) John Bonilla conducted an unannounced Case Management - Incident follow-up inspection at Stockdale Boys Center II, a Short-Term Residential Therapeutic Program (STRTP). The purpose of the inspection was to follow up on a previous inspection conducted September 11, 2025 regarding an incident report (IR) received by the Department. LPA met with Marcheletta Madison, Administrator. On September 9, 2025, the Department received an IR stating that on September 7, 2025, a client (C1) (See LIC Confidential Names list dated 09/11/25) had a behavioral episode which resulted in the client acquiring a bottle of bleach, and drinking from the bottle, spitting the liquid out immediately thereafter. Throughout the Case Management, LPA interviewed three clients, three staff, and one professional contact. Staff denied that a lack of supervision allowed a client to retrieve a bottle of bleach, stating supervision was present, that client grabbed the bottle unexpectedly while another client was doing laundry, and that efforts were made to confiscate bottle from client. The professional contact stated having no concerns with the facility's ability to provide supervision. Client interviews returned conflicting statements regarding the incident. Based on the information provided during the inspection, there are no violations of Title 22, Division 6 of the California Code of Regulations. No deficiencies were issued at this time. Exit interview conducted. Signed copies of this report and LIC811 were provided to Marcheletta Madison. No further action required.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Pamela Silva and Timika Martin on November 16, 2023 at 9: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs Silva and Martin met with Administrator, Marcy Madison, and inspected the facility inside and out. LPAs reviewed 1 of child's records and 3 of staff personnel files on site at the facility. LPAs reviewed 1 of child's psychotropic medications and medication records. LPAs interviewed 2 of staff on site to discuss the facility's policies and procedures of operation. LPAs interviewed 1 child currently prescribed psychotropic medication. During the inspection, LPAs observed deficiencies (see attached 809-D). Plan of corrections were discussed and appeal rights were provided. LPAs provided a copy of this licensing report to Marcy Madison, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Juliet Robles on 01/28/25 at 9:35AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Robles met with Iraina Holiday, Facility Manager Supervisor and inspected the facility inside and out. LPA reviewed 2 of child's records and 3 of staff personnel files on site at the facility. LPA reviewed 2 of child's psychotropic medications and medication records. LPA interviewed 1 of staff on site to discuss the facilities policies and procedures of operation. LPA interviewed 0 of children currently prescribed psychotropic medication due to children being unavailable. LPA will interview at a later time. During the inspection the LPA observed deficiencies (see attached 809D), and LIC 9102 plan of corrections was discussed, and appeal rights were provided. LPA provided a copy of this licensing report to Iraina Holiday, Facility Manager Supervisor.


raw_content:
Narrative:
The investigation revealed that the Administrator observed C6 in crisis when C6 was returned to the facility after a 24 hour hold at the hospital. It revealed that the Administrator requested C6 be re-admitted to the hospital. It revealed that C6 exhibited behavioral issues in the transportation vehicle that he was returned in. The Administrator indicated observing C6 in a rage, punching and kicking the vehicle's windows as the vehicle was parked in the facility's drive way. The Administrator indicated that C6 needed to be re-admitted to the hospital, because C6's behavior presented a safety issue for the other clients and staff at the facility. The Administrator indicated that she conducted a telephone conversation with the hospital staff that released C6 and requested to speak with a doctor. The Administrator indicated that they informed hospital staff that C6 can resume placement after receiving the proper treatment. The investigation revealed that C6 returned to the facility the next day. The investigation revealed that the Administrator was in the driveway with C6 and the vehicle transporter, so at no time was C6 left abandoned outside or alone outside the facility. An interview with the PO revealed that they had no concerns with the facility's care for C6. Interviews with other clients at the facility revealed that C6 engaged in self-harm on more than one occasion. The LPA reviewed at least five Law Enforcement Contact Reports in which C6 threatened self-harm and at least two in which C6 threatened to harm others. It is determined that since C6 returned to the facility. The allegations cannot be corroborated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the allegation is unsubstantiated. There are no deficiencies to be cited regarding this allegation. A copy of this complaint was provided to the facility representative at the signing.

Investigation Findings:
13On February 13, 2026 at 4:30 p.m., Licensing Program Analyst (LPA), Karen McGee, delivered the finding of the complaint investigation to the facility. The LPA met with Mental Health Rehabilitation Specialist, Rachelle Randall. On September 10, 2025, Monterey Park Children's Residential Program (MPCRP), received a complaint with the above mentioned allegation. Confidential interviews were conducted that included, but were not limited to: the Facility Manager Supervisor, Iraina Holliday, at the facility on September 12, 2025; the Probation Officer on January 22, 2026 via telephone; Client (C6) at the new placement on January 29, 2026; C3 at school on January 30, 2026; and C2 via telephone on February 3, 2026; the Administrator, Marcy Madison, via telephone on The LPA reviewed the following documents: Daily Log dated September 8, 2025, Appraisal Needs & Services Plan, Law Enforcement Contact Reports. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Karen McGee 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 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: STOCKDALE BOYS CENTER IIFACILITY NUMBER: VISIT DATE: 02/13/2026

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

met_with: Rachelle Randall


facility_name: ST. ANNE'S MATERNITY HOME

raw_content:
Narrative:
Due to lack of evidence, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or disprove that a violation occurred; therefore, the above allegation is Unsubstantiated. There were no deficiencies cited at this time. Exit interview was conducted, and a copy of this report was emailed to Tony Weaver to sign and return.

Investigation Findings:
13On April 12, 2020 at 1:30 p.m. Licensing Program Analyst (LPA) Cameo Banks conducted a follow-up complaint inspection via telephone to St. Anne's Maternity Home and spoke with Tony Weaver, Vice President of Housing Programs & STRTP Administrator. The purpose of the inspection was to deliver findings for the above complaint allegations. During investigation process, LPA conducted interviews and reviewed documents. Based on interviews, there were no statements collected to determine that staff failed to adequately supervise clients. Interviews with facility staff revealed that staff were present for the entirety of the incident. Staff gave verbal commands to de-escalate and redirect clients as well as seperating clients who were involved in the physical altercation. Interviews with clients revealed that staff were present and intervened as well. Clients who were involved in the alcercationed remained seperated for the evening without further incident. Facility was in ratio on the evening of the incident and had an adequate number of staff on duty. There was no documentary evidence or witnesses to corroborate allegation. Continued on LIC 9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Cameo Banks LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290b El Segundo, CA Facility Name: St. ANNE'S MATERNITY HOMEFACILITY NUMBER: VISIT DATE: 04/12/2021

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

met_with: Tony Weaver Vice President of Housing Programs & Administrator


raw_content:
Narrative:
Food Service: LPA Martin's observations of facility's dinning and kitchen areas including, but not limited to, food storage, preparation, menus, and temperature controls of refrigerator and freezer storage produced no damaged containers, expired or food spoilage during this investigation period. Food was observed stored, prepared and served free from contamination and spoilage. Accommodations are made for those with special diets and/or allergies. Food quantities are observed ample for facility capacity. Interviews revealed that Clients believe that the food overall is "okay" but, believes the food could be seasoned better. Neglect/Lack of Supervision: A review of client file/records revealed Client #1 (C1) was first placed in the facility on 05/13/2020. At the beginning of placement through current date, the facility has and continues to provide C1 with Spanish translator/interpreter on demand for client's communication needs. C1 disclosed no concerns with the need for Spanish interpreter while in placement. LPA confirmed facility currently has assigned Spanish interpreters employed on each shift. There is at least one Spanish speaking Therapist available for Client's needs. Records reviewed revealed Client #2 (C2) was first placed in the facility on 05/15/2020 through 02/16/2021. During that stint of time C2 left the facility without permission(AWOL) on numerous occasions. A review of records and interviews indicate facility followed appropriate procedures including reporting appropriate parties for each occurrence. Records further indicates suitable measures were taken by facility to address C2's needs including, but not limited to, mental health services and the acknowledgment of the eventual need for a more appropriate placement to meet C2's need for a higher level of care. C2 was not interviewed after unsuccessful attempts during the investigation process due to AWOL status. Although the above allegations may have happened or is valid, there is not a preponderance of evidence to prove that a violation occurred. Based on the gathered evidence the allegations of neglect/ lack of supervision and food service is Unsubstantiated. There were no deficiencies cited per California Code of Regulations, Title 22. Exit interview was conducted; a copy of appeals rights and this report was emailed to Mr. Weaver.

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

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

met_with: Tony Weaver Vice President of Housing Programs


raw_content:
Narrative:
Evidence obtained revealed that Staff did intervene to prevent and stop altercation between residents. Staff immediately secured residents infant safely away from the altercation. Also, confidential interviews with Child 1 & Child 2 reveal during altercation food was thrown, hitting and biting due to Child 1 put Child 2 in headlock. Child 2 bite Child 1 to get released from headlock. Staff revealed all steps were taken to de escalate the residents prior to altercation and continued during altercation.. Child 2 admitted throwing food due to mad at Child 1 for smart comments. Also staff are providing healthy foods for resident and adequate personal products are available for resident use. Based on the gathered evidence the allegations are Unsubstantiated. There were no deficiencies cited per California Code of Regulations, Title 22. Exit interview was conducted; a copy of appeals rights and this report was emailed to Mr. Weaver

Investigation Findings:
13On January 6, 2022 at 10:12AM PM Licensing Program Analyst (LPA), Zena Phillips conducted a follow-up complaint investigation visit to ST. ANNE'S STRTP and met with Tony Weaver, Vice President of Housing Programs. The purpose of the visit was to deliver findings for the above complaint allegations. During the course of investigating the allegations: LPA Phillips conducted confidential interviews with related parties, reviewed facility records and Incident Reports. Based on the interviews conducted and statements obtained during the investigation the above allegations cannot be substantiated because LPA Phillips obtained inconsistent statements from staff and residents in care. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Zena Phillips LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290b El Segundo, CA Facility Name: St. ANNE'S STRTPFACILITY NUMBER: VISIT DATE: 01/06/2022

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


raw_content:
Narrative:
Residents confirmed Staff are taking them to Laundromat multiple times weekly at no cost. Staff 1 stated two (2) washers and two (2) dryers are operational on the 2nd floor. Staff provided schedule for laundering residents clothes. Based on the interviews conducted and documentary evidence obtained the information did not produce corroborating evidence to support the above said allegation. Based on information gathered the facility provides adequate laundry service on and off site for the residents. Due to inconsistent statements LPA Phillips was not able to determine if the above said allegations occurred, therefore the allegations are found to be Unsubstantiated meaning that although the allegations may have happened or is valid there is not a preponderance of evidence to prove that the alleged allegation occurred. No deficiencies cited at the time of this investigation. Exit interview was conducted and copy of report will be emailed to Tony Weaver/Vice President of Housing Programs

Investigation Findings:
13On January 28, 2022 at 12: PM Licensing Program Analyst (LPA), Zena Phillips conducted a follow-up complaint investigation visit to ST. ANNE'S STRTP and met with Veronica Nande, Assistant Director. The purpose of the visit was to deliver findings for the above complaint allegation. During the course of investigating the allegation: LPA Phillips conducted confidential interviews with related parties,toured the facility, reviewed facility records,email correspondence and Incident Reports. Based on the interviews conducted and statements obtained during the investigation the above allegation cannot be substantiated. LPA Phillips obtained inconsistent statements from staff and residents in care. Evidence obtained revealed Staff are taking residents to the laundromat multiple times per week. at no cost to residents. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Zena Phillips LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290b El Segundo, CA Facility Name: St. ANNE'S STRTPFACILITY NUMBER: VISIT DATE: 01/28/2022

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

met_with: Vernica Nande/ Assistant Director


raw_content:
Narrative:
Also, confidential interview with Child 1 in care revealed crib was being exchanged by maintenance staff. Staff 1 stated crib was being cleaned and changed out with maintenance bolting crib down. LPA observed crib had been exchanged and appeared and clean and sanitary for infant. Child 1 confirmed cancels appointment due to not wanting to attend no reason provided. Staff revealed residents sometimes cancel appointments. Child 1 stated not involved in fight with other residents just witness fights. Child 1 confirmed staff try to stop fights and intervene when residents fight. Based on the interviews conducted and documentary evidence obtained the information did not produce corroborating evidence to support the above said allegations. Due to inconsistent statements LPA Phillips was not able to determine if the above said allegations occurred, therefore the allegations are found to be Unsubstantiated meaning that although the allegations may have happened or is valid there is not a preponderance of evidence to prove that the alleged incidents occurred. There were no deficiencies cited per California Code of Regulations, Title 22. Exit interview was conducted; a copy of appeals rights and this report will be emailed to Tony. Weaver.

Investigation Findings:
13On March 3, 2022 at 9: AM PM Licensing Program Analyst (LPA), Zena Phillips conducted a follow-up complaint investigation visit to ST. ANNE'S STRTP and met with Tony Weaver, Vice President of Housing Programs. The purpose of the visit was to deliver findings for the above complaint allegations. During the course of investigating the allegations: LPA Phillips conducted confidential interviews with related parties, reviewed facility records and Incident Reports. Based on the interviews conducted and statements obtained during the investigation the above allegations cannot be substantiated because LPA Phillips obtained inconsistent statements from staff and residents in care. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Zena Phillips LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290b El Segundo, CA Facility Name: St. ANNE'S STRTPFACILITY NUMBER: VISIT DATE: 03/03/2022

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


raw_content:
Narrative:
that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or disprove that a violation occurred. No deficiencies cited at the time of this investigation. Exit interview was conducted, and copy of the report will be emailed to Tony Weaver VP of Housing Services.

Investigation Findings:
13On April 15, 2022 at 8: AM Licensing Program Analyst (LPA), Zena Phillips conducted a follow-up complaint investigation visit to ST. ANNE'S STRTP and met with Mitzuky Orellana/Assistant Director @ 9: AM. The purpose of the visit was to deliver findings for the above complaint allegations. During the investigation of the allegations listed above: LPA Phillips reviewed facility file, Special Incident Reports and conducted confidential interviews with relevant parties. After conducting the confidential interviews and reviewing the following documentation: Client files, Special Incident Reports and Needs and Service Plan. The Department has determined that the allegations above are unsubstantiated, meaning UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Zena Phillips LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290b El Segundo, CA Facility Name: St. ANNE'S STRTPFACILITY NUMBER: VISIT DATE: 04/15/2022

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

met_with: Mitzuky Orellana/Assistant Director


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13This report is being Amended from the original report dated 04/13/2023 to correct the violation Type and section code. On April 13, 2023, Licensing Program Analyst (LPA) C. White conducted an unannounced visit to St. Anne's STRTP for the purpose of concluding the investigation and deliver findings on the above allegation. LPA met with Administrator, Talesha Payne and discussed the findings. During the course of this investigation, LPA interviewed pertinent parties and reviewed records. Staff interviews revealed the food served to the clients in the STRTP is different from what is served in the cafeteria; that they follow the National School Lunch Program guidelines to provide meals to the STRTP clients; and that food purchased for the STRTP kitchen is separate from food purchased for the main cafeteria. Client interviews revealed meals were not fresh, and that they have started using their own allowance to purchase food. Based on information obtained and documentary evidence, the preponderance of standard has been met, therefore the above allegation is found to be substantiated. Facility cited on the attached LIC D for violation of California Code of Regulations, Title 22, Division 6, regulation 80076(a)(1) FOOD SERVICE. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Charmetha White LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290b El Segundo, CA Facility Name: St. ANNE'S STRTPFACILITY NUMBER: 191802087

met_with: Administrator - Talesha Payne

complaint_status: SUBSTANTIATED


raw_content:
Investigation Findings:
13On April 13, 2023, Licensing Program Analyst (LPA) C. White conducted an unannounced visit to St. Anne's STRTP for the purpose of concluding the investigation and deliver findings on the above allegation. LPA met with Administrator, Talesha Payne and discussed the findings. During the course of this investigation, LPA interviewed pertinent parties and reviewed records. Confidential interviews and records did not produce corroborating evidence to support the allegation. Staff denied that clients in care are treated differently and stated inadequate and unfair treatment towards clients is prohibited. Client interviews were inconsistant. Based on information obtained, the allegation is found to be unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation did or did not occur. Exit interview completed and a copy of this report was left with the Administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Charmetha White 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 3


raw_content:
Investigation Findings:
13On April 27, 2023 at 1: PM, Licensing Program Analyst (LPA) C. White conducted an unannounced visit to St. Anne's STRTP for the purpose of concluding the investigation and deliver findings on the above allegation. LPA met with STRTP Director, Milena Melkonyan and discussed the findings. During the course of this investigation, LPA interviewed pertinent parties and reviewed records. Confidential interviews and records did not produce corroborating evidence to support the allegation. Staff denied the allegation and stated during the AM and PM shift they maintain a staff/client ratio of 1 staff to 4 clients and during the overnight shift it is 1 staff to 6 clients in addition to a facility manager. Client statements were inconsistent and did not produce corroborating evidence facility staff are out of ratio. Additionally, there were no specific dates or times provided to corroborate the allegation. Based on information obtained, the allegation is found to be unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation did or did not occur. Exit interview completed and a copy of this report was left with STRTP Director. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Charmetha White 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 3

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

met_with: Milena Melkonyan - STRTP Director


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Investigation Findings:
13On April 27, 2023 at 2: PM, Licensing Program Analyst (LPA) C. White conducted an unannounced visit to St. Anne's STRTP for the purpose of concluding the investigation and deliver findings on the above allegation. LPA met with STRTP Director, Milena Melkonyan and discussed the findings. During the course of this investigation, LPA interviewed pertinent parties and reviewed records. Confidential interviews and records produced corroborating evidence to support the allegation. Staff interviews revealed cafeteria staff were not present at the facility to prepare breakfast and that direct care staff present at the facility did not prepare breakfast which resulting in clients in care not being served a meal. Client statements revealed that staff did not provide breakfast in a timely manner. Based on information obtained and documentary evidence, the preponderance of standard has been met, therefore the above allegation is found to be substantiated. Facility cited on the attached LIC D for violation of California Code of Regulations, Title 22, Division 6, regulation 87072 (c) PERSONAL RIGHTS. 87022.1. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Charmetha White LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290b El Segundo, CA Facility Name: St. ANNE'S STRTPFACILITY NUMBER: 191802087

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


raw_content:
Investigation Findings:
13On July 12, 2023 at 11: AM Licensing Program Analyst (LPA), Zena Phillips conducted a follow-up complaint investigation visit to ST. ANNE'S STRTP and met with Milena Melkonyan/STRTP Director. The purpose of the visit was to deliver findings for the above complaint allegation. During the investigation of the allegation listed above: LPA Phillips reviewed facility file, Special Incident Reports and conducted confidential interviews with relevant parties. After conducting the confidential interviews and reviewing the following documentation: Grocery receipts and menu for three months and LPA observed kitchen and food storage. The Department has determined that the allegations above are unsubstantiated, meaning: that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove or disprove that a violation occurred. No deficiencies cited at the time of this investigation. Exit interview was conducted, and copy of the report will be emailed to Milena Melkonyan/STRTP Director. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Zena Phillips LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

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

met_with: Milena Melkonyan/STRTP Director


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13This report is being amended from previous report dated 07/12/ On July 12, 2023, Licensing Program Analyst (LPA) Zena Phillips conducted an unannounced visit to St. Anne's STRTP for the purpose of concluding the investigation and deliver findings on the above allegation. LPA met with Carlos Tobar/Quality Assurance Director and discussed the findings. During the investigation LPA Phillips interviewed and accounted for all available relevant parties; and gathered pertinent information regarding the allegation. Evidence revealed food served to the clients was undercooked, burnt and dry, there was insufficient juice brought up for the clients and their babies, the food didn't look appealing, clients and staff would not eat the food and food served was different from the menu. Based on the preponderance of the evidence, the allegation is being substantiated. A deficiency will not be issued due to the facility being cited on 4/13/23 regarding food concerns and the facility putting a policy in place to inspect the food. This amended report supersedes the prior report dated 07/12/2023. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Zena Phillips LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290b El Segundo, CA Facility Name: St. ANNE'S STRTPFACILITY NUMBER: 191802087

met_with: Carlos Tobar/Quality Assurance Director


raw_content:
Narrative:
Due to inconsistency in statements obtained during the investigation LPA Phillips was unable to determine if the above said allegation occurred, therefore the allegation are determined to be unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. There are no deficiencies cited at this time. Exit interview completed. A copy of this report will be provided to Facility Representative Carlos Tobar

Investigation Findings:
13On 02/01/2024 @ 10: Am Licensing Program Analyst (LPA) Zena Phillips made follow up visit to ST. ANNE'S STRTP for the purpose of delivering findings. LPA Phillips was met by Carlos Tobar/ Quality Assurance Director and provided todays census. During the investigation, Confidential interviews were conducted, facility file reviewed, special incident reports and documentary evidence did not substantiate the allegations that: Staff directed youth to engage in criminal activity while in care. Based on the interviews conducted, documentary evidence, the information gathered did not produce corroborating evidence to support the above said allegations. Staff denied the allegation that: Staff directed youth to engage in criminal activity while in care. Staff watch residents while shopping to ensure enough funds are available for purchase. It was reported to LPA Phillips that staff would not direct youth in criminal activity. Furthermore, it was reported to LPA Phillips that Staff watch youth while shopping and when completing the purchase to ensure all items are purchased. It was also reported to LPA Phillips all residents have funds when entering store for shopping. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Zena Phillips LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290b El Segundo, CA Facility Name: St. ANNE'S STRTPFACILITY NUMBER: VISIT DATE: 02/01/2024

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


summary: Complaint Investigation - Substantiated - 1 deficiency

raw_content:
Narrative:
Facility cited per California Code of Regulations, Title 22, Division 6, regulation 87072 (a)(10) PERSONAL RIGHTS. Statements and documentary evidence consistently indicated that minors in care are searched every time they return to the facility premises after an unauthorized absence, school, and community passes. Exit interview was conducted, and a copy of this report will be emailed to Daisy Delgado/ STRTP Director of Residential Services and Carlos Tobar/ Quality Assurance Director

Investigation Findings:
13On May 09, Licensing Program Analyst (LPA) Zena Phillips made a follow up complaint visit to St. Anne's STRTP for the purpose of delivering findings on the above complaint allegation. During the investigation, confidential interviews were conducted, facility file, Program Statement review, and Incident Reports were reviewed. Statements were consistent that safety checks were conducted each time clients returned from unauthorized absences, school, and community passes. Statements indicated that staff reminded minors in care that anytime they left facility premises without a staff, a search of their person and belongings would be conducted upon their return to the facility. Confidential statements revealed searches were conducted on each minor in care and minors in care were instructed to pull out bra and shake, empty pockets, checking their ponytails, taking off shoes, checking hoodies, bags, strollers, and baby seats for contraband. Based on information obtained from confidential interviews and documentary evidence, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Zena Phillips LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290b El Segundo, CA Facility Name: St. ANNE'S STRTPFACILITY NUMBER: VISIT DATE: 05/09/2024

Deficiencies:
87072: (a)(10) 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, and below, as applicable

met_with: Daisy Delgado/STRTP Director of Residential Services


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Investigation Findings:
13Licensing Program Analyst Connie Jones-Steward investigated the above allegations by interviewing staff and Client 1. Client #2 could not be reached to be interviewed. LPA also observed the "STRTP Kitchen", an area where girls can cook their own meals if they do not want what is offered. The STRTP kitchen was fully stocked with all food groups and snacks represented and all of the utensils needed to prepare food. The stove and refrigerator were in working order. Based on interviews and observations, LPA Jones-Steward was not able to obtain conclusive evidence that Client #1 was not fed adequately or that she received "left-over" food. Therefore both allegations were resolved as unsubstantiated. Unsubstantiated means that even though an allegation may have happened or is valid, there is not a preponderance of evidence that it did occur. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Connie Jones-Steward LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Mitzuki Orellana & Elizabeth Dennin


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Narrative:
LPA interviewed other involved staff who shared that the facility policy is for clients to ensure that their room is safe and clean before leaving on a pass C1 had not done this yet and we were trying to encourage them to do so. It is also facility policy to walk clients out of the facility when they leave, and to shadow them if clients AWOL. Since C1 was leaving and AWOLing without a pass S3 was sent to walk the client out and shadow. C1 and S3 soon returned, and S3 said C1 agreed to make their room safe first and go out on a pass. Then, when the elevator stopped, S3 stepped in between the doors to hold them open. C1 then hit S3 with an open hand. One staff member shared that "I saw the event happen live on the cameras. I think there was a mis-communication on whether S3 and C1 were returning to get a pass or clean the room. I don't think S3 was acting maliciously, and I think C1 just got overemotional and lost control of herself." LPA attempted to interview S3, but S3 declined and stated that they would only speak through their attorney. LPA was given the attorney's contact information and made multiple attempts to interview the attorney, but they never responded. LPA was shown the video interaction of the event in question. LPA observed, C1 and S3 enter the elevator. S3 pressed the buttons on the elevator. During the elevator ride C1 and S3 were talking with each other. The video did not have sound so their conversation was not heard. When the elevator reached its stop and opened the doors S3 stepped out and held the elevator door open for C1. C1 proceeded to step out and hit S3 with their left hand in an open palm. C1 and S3 continued talking and exited the elevator. LPA received conflicting testimonies regarding the incident in the elevator and staff's interaction with the client. The complaint alleges that S3 held C1 hostage and prevented C1 from leaving the elevator, resulting in an inappropriate interaction with the client. Staff testimonies stated that S3 was not acting maliciously and was following facility policies and procedures to shadow the client during AWOL's and to encourage room safety. LPA observed the video of the incident, and it did not appear as if S3 was trying to block or impede C1, though there was no audio available. LPA was also unable to gain facts from those involved due to the decline and refusal of interviews. . Based on the available information, LPA gathered from interview evidence from staff and clients, and from observations and video evidence review the preponderance of the evidence standard has not been met; therefore, the allegation that "Staff had inappropriate interaction with minor." is found to be unsubstantiated. Exit Interview conducted and a copy of this report was given to the administrator.

Investigation Findings:
13On 8/21/25 at 2: PM, Licensing Program Analyst (LPA) Reagan Cohen arrived at the above facility and met with Administrator Daisy Delgado for the purpose of delivering complaint findings regarding the above allegation. During the course of the investigation, LPA interviewed involved staff and client (C1). The complaint alleges that one day C1 was trying to leave the facility to pick up a check. C1 was not authorized to leave due to an "unsafe" room. C1 was asked to sign a pass paperwork before leaving and took an elevator with S3 to do so. S3 then used their body to block the elevator and stop C1 from leaving. C1 felt like they were being held hostage and slapped S3. C1 then exited the elevator and ran from the facility. LPA interviewed C1, but C1 did not want to talk about the incident. C1 only shared that "Staff made me paranoid and untrusting. I have trauma from the incident. I have not seen the staff (S3) since the incident." UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Reagan Cohen LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290b El Segundo, CA Facility Name: St. ANNE'S STRTPFACILITY NUMBER: VISIT DATE: 08/21/2025

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

met_with: Daisy Delgado Administrator


summary: Facility Evaluation

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Narrative:
On August 24, 2022 at 9:13AM Licensing Program Analyst (LPA) Zena Phillips arrived at the above facility for the purpose of conducting a Case Management investigation regarding incident report. LPA met with Kamika Mason/ Associate Director who granted access to the facility. The department received a Special Incident Report SIR #823687 dated August 17, 2022. Kamika Mason stated was aware of the incident with Child #1. Stating that Child #1 was seen by medical doctor due to bites. The doctor determined bites were from bed bugs. Kamika Mason stated staff noticed red bumps and or rash on left arm, legs and stomach on Child #1 after returned from awol on 08/16/2022 about 8: PM. Child #1 stayed in room the whole night and in the morning Child #1 was taken to urgent care on 08/17/22 due to bites on body. The physician stated Child #1's bites were beg bugs. Child #1 admitted to staff that the home that Child #1 awol's to has bed bugs. After returning from urgent care a work order was placed as a preventive measure to exterminate the room and linens were removed and cleaned on 08/17/ Regular pest control maintenance was conducted on 08/18/2022. An additional work order was placed as a preventive measure for the entire circle. LPA observed Child #1's room and did not see any bugs. Talesha Payne / VP of Housing stated they are working to schedule CFTM due to chronic awol , bed bugs in home where Child #1 awols, and looking into providing family additional support to clean up bed bugs. Payne stated will reach out to DCFS to see if funds are available to assist family with dealing with infestation due to Child #1 is chronic run away to this home. Will work with CSW to support Child #1 and help family clean up home. Also in the CFTM looking to address possible approved visits to home to prevent future awol. con ton 809 c LPA requested a copy of the LIC 500, client roster, medical report from doctor, Needs and Services Plan for Child #1 and pest control invoice. All documents were provided to LPA Phillips. LPA Phillips reviewed association list and advised to remove names of employees no longer associated with the facility. Facility will provide LPA Phillips with completed extermination report and CFT notes once completed . LPA Phillips will follow up with facility once extermination is completed and request notes of upcoming CFT. LPA observed facility to clean safe and sanitary. There were no deficiencies cited at the time of the visit. Nothing further to report at this time. Exit interview was conducted and copy of report will be emailed to Talesha Payne / VP of Housing Program

met_with: Kamika Mason/Associate Director


summary: Facility Evaluation

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Narrative:
Report amended to state purpose of visit: Licensee Initiated Capacity Reduction On December 21, 2022 at 9: AM Licensing Program Analyst (LPA) Zena Phillips made an announced visit to ST, ANNE'S STRTP for the purpose of conducting a Case Management, (Licensee Initiated). LPA met Talesha Payne, VP of Housing and Carlos Tobar, Director of Quality Assurance who granted access to the facility and together with LPA Phillips, a tour was conducted. The purpose of today's inspection was licensee initiated capacity reduction from fifity (50) to sixteen (16). This facility provide services to Ambulatory Residents Ages 11-17: Infants Ages 0 through 3. This facility also provide care to non-minor dependents. The census on the date of this visit is fifteen (15). Currently residing in the facility are DCFS and Probation placement. LPA Phillips observed the facility is located in a residential area with 18 bedrooms, located on the second and third floors, with private bathrooms in each room. The unit has a total of 3 pods, and each pod have a total of 6 bedrooms. LPA Phillips observed the following on the 2nd floor: Pod 1: Six (6) Rooms are equipped with 1-2 twin size beds, cribs, adequate drawers and closet space and private bathrooms in each room. LPA observed baby toys and car seats available in the bedrooms. LPA Phillips observed two (2) vacant bedrooms. Pod 2: Rooms are equipped with 1-2 twin size beds, cribs, adequate drawers closet space and private bathrooms in each room. LPA observed baby toys and car seats available in the bedroom. cont on 809 c LPA Phillips observed the following on the 3rd floor: one (1 ) pod Pod 3: Six (6) Rooms are equipped with 1-2 twin size beds, cribs, adequate drawers and closet space and private bathrooms in each room. LPA observed baby toys and car seats available in the bedroom. LPA Phillips observed one (1) vacant room. There are 2 laundry rooms, staff offices, 4 recreation rooms in each circle (equipped with television, cable, and dining area), a medication room, a recreation/activity room (computers, board games, reading books, arts and crafts) cafeteria supplied with sufficient perishables and non-perishables with a posted menu. LPA Phillips observed lockers to store client's personal belongings. A physical plant inspection was completed and included the following checks. Facility grounds are clean and free of debris and observable hazards. Adequate indoor and outdoor activity space and materials were observed. Fire extinguishers were all properly charged and serviced. All posting requirements have been met. Medications are locked and centrally stored in the health services department. Individual beds were observed with appropriate clean linens and are in good repair. Facility has cameras in common areas of the facility. Facility appears to be meeting the terms and conditions of their license. Capacity reduction is approved based on LPA Phillips inspection of the facility. Exit interview was conducted, and a copy of this report will be emailed to the VP of Housing. There were no deficiencies cited at this time.

met_with: Talesha Payne / Vice President of Housing


summary: Facility Evaluation

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Narrative:
On May 16, 2023 at 9: AM, Licensing Program Analyst (LPA) Zena Phillips made an unannounced visit to St. Anne's Maternity Home for the purpose of an Annual Random Inspection. LPA met with Carlos Tobar/Quality Assurance Director, who granted access to the facility and a tour of the facility was conducted. This facility provides services to Ambulatory Residents Ages 11-17: Infants Ages 0 through 3. This facility also provide care to non-minor dependents. The census this day is 11. Currently residing in the facility are DCFS clients. The facility is located in a residential area with 18 bedrooms, located on the second and third floors, with private bathroom in each room. The unit has a total of 3 pods, and each pod have a total of 6 bedrooms. Pod 2B: Rooms are equipped with 1-2 twin size beds, crib or toddler bed, adequate drawers and closet space, desk with chair and private bathrooms in each room. LPA did not observe the rooms due to residents refused entry. Pod 2C: Rooms are equipped with 1-2 twin size beds, crib or toddler bed, adequate drawers closet space, desk with chair and private bathrooms in each room. LPA did not observe the rooms due to resident refused entry. Pod 3C: Rooms are equipped with 1-2 twin size beds, crib or toddler bed, adequate drawers, closet space desk with chair and private bathrooms in each room. LPA did not observe the rooms due to resident refused entry. Continue on 809-C There are 2 laundry rooms one on each floor, staff offices, 3 recreation rooms in each circle, equipped with television and couches. LPA observed car seats, strollers baby toys, and highchairs. A round table with adequate seating, computers, board games, reading books, arts and crafts. A locked medication room, a recreation/activity room, cafeteria supplied with sufficient perishables and non-perishables with a posted menu. LPA observed lockers to store clients personal belongings. A physical plant inspection was completed and included the following checks. Facility grounds are clean and free of debris and observable hazards. Adequate indoor and outdoor activity space and materials were observed. There is a hardwired alarm system and copy of the fire clearance will be emailed at a later date. Fire extinguishers observed to be all properly charged and serviced. All required forms are posted. Medications are locked and centrally stored in the health services department. Licensee has provisions for contraceptives to be held by clients or held by facility in the health services department unit located on the 2nd floor. Facility has cameras in common areas of the facility. The hot water measured at 113.5 degrees and is within the acceptable temperature range of 105 and 120 degrees. Licensee has a plan to ensure core services are provided and all staff are aware of it and are supportive and trained in their respective roles. Licensee is utilizing trauma informed care practices to ensure effective outcomes that promote permanency and client well-being. Licensee has a plan to ensure individual treatment needs are assessed at least every 30 days and recommendations are implemented. Licensee is aware and has established policies and procedures for participation in the Quality Parenting Initiative and Quality improvement project developed by the placing counties. Licensee has a plan for engaging families and providing support to clients during and after placement to promote permanency/well-being. Licensee has a designated mental health head of service staff who communicates and collaborates with county inter-agency placement committees to ensure specialty mental services are delivered. Clients are advised of their personal rights and house rules. Gender identity, expression and orientation are respected and kept confidential. Clients receive services, activities and support and are included in child and family teams regarding decisions about their plans. Clients can file a complaint or elevate concerns without retaliation. Licensee provides resident councils and forms for clients to raise issues. Clients receive or are asked if they want information about healthy sexual development. Continue on 809-C Administrator is present at the facility a minimum of 40 hours a week, as verified by staff schedule. Appropriate staff/client ratios were verified during this inspection. LPA inspected facility van and observed valid registration and insurance, first aid kits and fire extinguisher. Licensee will submit Law Enforcement (LE) contact documentation to licensing.Administrator and LPA discussed emergency intervention protocols utilized and proper documentation.Licensee obtained the Mental Health Certification effective date 02/24/2023; expiration date 02/23/2024. The Medi-Cal recertification is effective 04/13/2023 and renewed by 04/13/2025.. Licensee has obtained National Accreditation through Council of Accreditation. The Accreditation is valid through November 30, 2026. During the course of the inspection LPA conducted three (3) confidential interviews, reviewed five (5) staff files, five (5) client files. No resident interviews were conducted due to five (5) refused, three (3) sleep, and three (3) at school. LPA discussed the following with the Administrator: Incident reporting, including incidents related to Law Enforcement contacts and incidents involving Emergency Interventions. The facility has a camera waiver and are meeting the terms and conditions. LPA discussed procedures for CFT (Child and Family Team) meetings. There were no deficiencies observed or cited at the time of the Annual Random Inspection. At the time of the inspection, the facility was clean, safe, sanitary and in good repair An exit Interview was conducted, and a copy of this report will be emailed to Milena Melkonyan/ STRTP Director

met_with: Carlos Tobar/ Quality Assurance Director


summary: Facility Evaluation

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Narrative:
On June 21, 2023, Licensing Program Analyst (LPA) C. White conducted an unannounced Plan of Correction (POC) visit to St. Anne's STRTP for the purpose of clearing a POC. LPA met with STRTP Director, Milena Melkonyan, The POC was originally cited on April 14, 2023 due to a substantiated complaint allegation: Facility staff do not ensure that children are fed nutritious meals. The POC was completed on 05/12/2023, as Licensee emailed LPA all requested documentation. There are no deficiencies cited at this time. An exit interview was conducted and a copy of this report and POC letter was provided to the Director.

met_with: STRTP Director - Milena Melkonyan


summary: Facility Evaluation

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Narrative:
On March 12, Licensing Program Analyst (LPA) Zena Phillips made an announced visit for the purpose of conducting a Case Management visit inspection. LPA was greeted by Carlos Tobar/Quality Assurance, who granted access to the facility. This facility provides services to Ambulatory Residents Ages 11-17: Infants Ages 0 through 3. This facility also provide care to non-minor dependents. The census this day is eleven (11) teens and five (5) babies. There are no residents currently residing on the 2nd floor due to remodel. LPA observed rooms labeled A201-A205 rocking chair, full-size bed with clean linens, one drawer night stand, five (5) drawer dresser, desk with one (1) drawer and chair, closet has built in shelving and toy chest, crib with attached changing table, shelving below changing table for storage. The on-suite bathroom has newly installed sink with faucet. Newly installed walk in shower with glass door, baby tub placed in each shower and newly installed toilets. LPA asked staff to flush toilet and confirmed working properly. Light automatically comes on upon entering the bathroom. One trash can with lid and area rug. LPA observed rooms labeled A206 large sitting chair, full size bed with clean linens, toddler bed, one drawer night stand, five (5) drawer dresser, desk with one (1) drawer and chair, closet has built in shelving and toy chest. The on-suite bathroom has newly installed sink with faucet. Newly installed walk in shower with glass door, and newly installed toilet. Light automatically comes on upon entering the bathroom. LPA observed room labeled B207 rocking chair, full-size bed with clean linens, one drawer night stand, five (5) drawer dresser, desk with one (1) drawer and chair, closet has built in shelving and toy chest, crib with attached changing table, shelving below changing table for storage. The on-suite bathroom is ADA compliant with large walk in shower no door and wall attached seat inside shower. There is newly installed sink with faucet. Light automatically comes on upon entering the bathroom. LPA observed baby tub placed in shower and newly installed toilets. cont on 809c LPA observed rooms labeled B208-B210 rocking chair, full-size bed with clean linens, one drawer night stand, five (5) drawer dresser, desk with one (1) drawer and chair, closet has built in shelving and toy chest, crib with attached changing table, shelving below changing table for storage. The on-suite bathrooms has newly installed sink with faucet. Newly installed walk in shower with glass door, baby tub placed in each shower and newly installed toilets. LPA asked staff to flush toilet to confirm working properly. LPA observed room labeled B211 currently spare room. LPA observed storage of four (4) cribs with changing tables, two (2) rocking chairs and one (1) large chair. LPA observed room labeled B212 rocking chair, full-size bed with clean linens, one drawer night stand, five (5) drawer dresser, desk with one (1) drawer and chair, closet has built in shelving and toy chest, crib with attached changing table, shelving below changing table for storage. The on-suite bathroom is ADA compliant with large walk in shower no door and wall attached seat inside shower. LPA observed newly installed sink with faucet. Baby tub placed in each shower and newly installed toilets. LPA asked staff to flush toilet to confirm working properly. LPA observed rooms labeled C213-C218 rocking chair, full-size bed with clean linens, one drawer night stand, five (5) drawer dresser, desk with one (1) drawer and chair, closet has built in shelving and toy chest, crib with attached changing table, shelving below changing table for storage. The on-suite bathroom has newly installed sink with faucet. Newly installed walk in shower with glass door, baby tub placed in each shower and newly installed toilets. LPA asked staff to flush toilet to confirm working properly. Light automatically comes on upon entering the bathroom. LPA confirmed with thermometer water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. cont on 809c LPA inspected the kitchen on the 1st floor and observed newly installed double stainless steel sink and dishwasher. LPA confirmed all five (5) burners on stove self ignite. LPA observed refrigerator fully stocked with eggs, milk, juice, fresh fruit, snack packs, butter, lunch meat, tortillas and condiments. LPA observed basket with fresh fruit on counter next to refrigerator. The upper cabinets have dry goods such as pasta, rice, can good and spices. Over the stove cabinets have two (2) cans of Pam spray. LPA observed utensils in drawer to the left of the fridge. Lower drawer has ziploc bags, plastic wrap and other food storage containers. LPA observed boxes of cereal, large bottles of vegetable oil for cooking. LPA observed paper plates, bowls and napkins in cabinets. LPA observed the kitchen to clean and fully stocked for residents. LPA observed at the time of the inspection, the facility was clean, safe, sanitary and in good repair. LPA observed the facility is placement ready. An exit Interview was conducted, and a copy of this report will be emailed to Carlos Tobar/Quality Assurance

met_with: Carlos Tobar/Quality Assurance


summary: Facility Evaluation

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Narrative:
On March 12, Licensing Program Analyst (LPA) Zena Phillips made an announced inspection for the regarding incident 0213-3244-0537-1089631. The incident occurred 11/01/2023 and the incident report was received by the Department on 11/02/2023. LPA met with Carlos Tobar/ Quality Assurance and discussed the incident. LPA conducted confidential interviews and requested internal investigation report, incident report and discharge documentation. Based on interviews and information gathered, this case management is closed and does not require further investigation. It was reported to LPA that no staff or peer were involved with the incident. Exit interview was conducted, and a copy of this report will be provided to Carlos Tobar/Quality Assurance.


summary: Facility Evaluation

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Narrative:
On May 09, Licensing Program Analyst (LPA) Zena Phillips made an unannounced visit for the purpose of conducting a Case Management visit inspection due to incident report #0213-3244-0537-1089631. The incident was received 11/02/2023 by the department due to client unauthorized absence from the facility. LPA requested LIC 500, client roster and incident report with addendum and discharge report. LPA conducted confidential interviews. Based on information gathered client was away from the facility during the incident and facility followed procedures upon clients return. Based on interviews and information gathered this case management needs no further investigation. Exit interview was conducted, and a copy of this report will be emailed to Daisy Delgado /STRTP Director of Residential Services and Carlos Tobar/Quality Assurance.