summary: Facility Evaluation

raw_content:
Narrative:
On June 04, 2021, at 8: AM Licensing Program Analyst (LPA) Jesus Cervantes conducted an unannounced annual inspection. The facility converted from a Group Home to a STRTP (Short Term Therapeutic Program) on June 04, 2018. LPA was met at the facility by Residential Manager Karla Loera. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster, the Emergency Disaster Plan was also posted. Clients medications were observed to be inaccessible and stored in a locked file cabinet in the staff office. Medication records were reviewed and observed to be completed with dates and staff initials on dispensing records. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. All three bedrooms contain two twin beds. The facility has one full client bathroom and one-half client bathroom. The water temperature in the bathroom one of two was tested at 9: AM and registered at 115.8 degrees which is within the appropriate range of 105 degrees to 120 degrees. Per facility staff, no firearms or weapons are allowed in the facility. Administrator Amy Ahern is present at the facility a minimum of 20 hours a week, as verified by staff schedule and interviews. Appropriate staff/client ratios were verified during this inspection. See Page Two The facility employs one Intensive Services Director, one Administrator, one Clinical Supervisor, one Residential Manager, one Care Coordinator, two Rehab Specialist, two Mental Health Clinicians, and ten direct care staff that are used in accordance with regulatory requirements. Licensee obtained Mental Health (MH) Certification in December 2019. Due to delays caused by COVID-19, the Department of Health Care Services is in the process of renewing the facilities Mental Health Program Approval. Licensee has obtained National Accreditation through COA. The Accreditation is valid through October 31, 2021. Licensing fee payments are current. All the client files are stored and locked in the file cabinet in the staff office. At 10: AM, LPA reviewed a sample of five clients files during the time of inspection. Two clients, and two facility staff were interviewed during the inspection. Three clients declined to be interviewed. LPA discussed the following with the Administrator: Facility procedures related to requesting exceptions. Assembly Bill 388 law enforcement contacts as well as incidents involving emergency interventions. LPA discussed procedures for Child and Family Team (CFT) meetings, including an overview of required Core Services and Supports. LPA also discussed Reasonable and Prudent Parenting Standards, and resident involvement in development of planned activities. Due to time constraints and employee files being housed in their corporate office, LPA will return to the facility to conduct a continuation of staff file reviews. No deficiencies were found. Exit interview was conducted and a copy of this report was provided to Residential Manager Karla Loera

met_with: Residential Manager Karla Loera


state: CA

facility_name: OLIVE CREST TREATMENT CENTERS - MALENA

summary: Facility Evaluation

raw_content:
Narrative:
On June 08, 2021, at 11: AM Licensing Program Analysts (LPA) Jesus Cervantes, and Licensing Program Manager (LPM) Ann Valenzuela conducted an unannounced annual continuation inspection from June 01, 2021. Employee files were not located at the facility and required employee files to be reviewed at Olive Crest Headquarters located at E. Fourth Street, Santa Ana, CA 92705. LPA and LPM meet with Madison Mazzone and Denise Griffiths. Five random personnel files were reviewed to ensure they contained all required documentation per Title Regulations. Personnel Files are maintained on-site in a locked cabinet in the Human Resource office. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Client and staff interviews were conducted on 06/04/2021. No deficiencies were noted during time of inspection.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Madison Mazzone


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Dahl Larios conducted a case management inspection August 9, 2022, at 9:22 am based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection,10 out of Direct Care Staff and 6 out of 6 youth files were reviewed. 5 out of Direct Care Staff and 5 out of 6 youth were interviewed. (See the Confidential Names List, LIC 811, dated August 9, 2022). The Plan of Operation including policies and procedures were reviewed. Based on the analysis of the confidential interviews and youth file review including the care plan, and Child Family Team Meeting records, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Dahl Larios observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Program Supervisor Amy Ahern.

met_with: Program Supervisor - Amy Ahern


summary: Facility Evaluation

raw_content:
Narrative:
On March 6, 2023, at 10: AM Licensing Program Analyst (LPA) Sarah Lo conducted an unannounced annual inspection at Olive Crest - Malena Short-Term Residential Therapeutic Program (STRTP) located at Malena Drive, Santa Ana, CA 92705. LPA was met at the facility by Amy Ahern, STRTP Program Supervisor and Mayra Medina, Residential Coordinator. A physical plant inspection and was completed and included the following checks: Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster, the Emergency Disaster Plan was also posted. Clients' medications were observed to be inaccessible and stored in a locked file cabinet in the staff office. Medication records were reviewed and observed to be completed with dates and staff initials on dispensing records. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. All three bedrooms contained two twin sized beds. The facility has one full client bathroom and one-half client bathroom. The water temperature in the bathroom one of two was tested at 10: AM and registered at 118.3 degrees which is within the appropriate range of 105 degrees to 120 degrees. Per Residential Coordinator, there are no firearms or weapons are allowed in the facility. Administrator Michael Cabrera is present at the facility a minimum of 20 hours a week, as verified by Personnel Report (LIC 500). Appropriate staff/client ratios were verified during this inspection. (Continued on lIC 809-C) LPA reviewed five out of five staff files with STRTP Program Supervisor and Residential Coordinator and no deficiency was noted. All the client files are stored and locked in the file cabinet in the staff office, LPA reviewed four out of four client files during the time of inspection. At 12: PM, during client file review, LPA observed Client #1 is missing initial health examination. Per CCR 80069 (a) - Except for licensees of ARFs, prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client, as specified in Section 80069(c), which enables the licensee to determine his/her ability to provide necessary health related services to the client. The assessment shall be used in developing the Needs and Services Plan. At 12: PM, during client file review, LPA observed Client #1, #2 and #3 are missing tuberculosis (TB) test result. Per CCR 80068(c)(1) - The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases. At 01: PM, during client file review, LPA observed Client #1 and #2 are missing Admission Agreement. Per CCR 80070(b)(6) - Each record must contain information including, but not limited to, the following: (6) A signed copy of the admission agreement specified in Section 80068. Due to time constraints, LPA will return to complete the staff and client interview at a later date. An exit interview was conducted and a copy of this report was provided to STRTP Program Supervisor, Amy Ahern.

visit_type: Annual

met_with: Amy Ahern, STRTP Program Supervisor Mayra Medina, Residential Coordinator


summary: Facility Evaluation

raw_content:
Narrative:
On March 28, 2023, at 10: AM Licensing Program Analyst (LPA) Sarah Lo conducted an unannounced annual inspection at Olive Crest - Malena Short-Term Residential Therapeutic Program (STRTP) located at Malena Drive, Santa Ana, CA 92705. LPA was met at the facility by Youth Care Specialist, Jessica Ayala. Facility Manager, Michael Cabrera arrived to the facility at 10:20am to continue with the annual inspection. LPA Lo was here on March 06, 2023 and conducted an unannounced annual inspection of the physical plant and staff and client file reviews. The purpose of the visit today is conduct two staff interviews and two client interviews. The facility ground is observed to be clean and tidy. All interviews are done in the staff office. A copy of this report and LIC 811 was given to Facility Manager, Michael Cabrera.

met_with: Michael Cabrera, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Veronica Whitaker conducted a case management inspection on 6/13/23 based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 7 out of Direct Care Staff and 6 out of 6 youth files were reviewed. 2 out of Direct Care Staff and 2 out of 6 youth were interviewed. (See the Confidential Names List, LIC 811, dated 6/13/23. The Plan of Operation including policies and procedures were reviewed. Minutes from the Board of Directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review, including the needs and service assessments, youth case plans, quarterly assessments, and crisis intervention plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Veronica Whitaker observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Amy Ahern, Program Supervisor and Michael Cabrera, Facility Manager/Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On 11.27.23 at 7:00pm, Licensing Program Analyst (LPA) Jacqueline Garcia arrived unannounced to the facility for the purpose of conducting a collateral interview with one client that currently is residing at the facility. LPA met with Jorge Luis Lopez, Youth Care Specialist, and explained that the complaint investigation is not on their facility. LPA conducted one interview with one client. LPA toured the facility and the facility was in compliance therefore no deficiencies were cited. Due to printer malfunction, a copy of this report will be emailed to Jorge Luis Lopez-Youth care specialist.

met_with: Jorge Luis Lopez-Youth Care Specialist


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPA) Guadalupe Munoz 02/015/2024 at 11: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the visit, LPA Munoz met with Administrator Michael Cabrera and conducted a health and safety inspection of the facility. No immediate health or safety risks were observed. LPA reviewed 1 child's records and 3 of staff personnel files on site at the facility. LPA reviewed 1 child's psychotropic medications and medication records. LPA interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPA unable to interview 1 child currently prescribed psychotropic medication due to client being AWOL. LPA provided a copy of this licensing report to, Administrator Michael Cabrera. No deficiencies are being cited at this time, but the facility was provided with a Technical Assistance (TA) note. LPAs conducted exit interview with Administrator and provided a copy of this report and the TA.

met_with: Michael Cabrera


summary: Facility Evaluation

raw_content:
Narrative:
On May 14, 2025, at 3: PM Licensing Program Analyst (LPA) Stefanie Mutialu arrived at Olive Crest main office located at E. Fourth Street, Suite #200, Santa Ana, CA 92705 to conduct an annual inspection of the staff files. LPA met with Maria Orona, Human Resource Manager. Currently Olive Crest Malena is licensed to serve six clients and has a census of six clients. The facility is current with licensing fees. During the inspection LPA reviewed five staff files (S1-S5). Five out of five files contained the required documents including verification of criminal background check clearance, signed acknowledgment of mandated child abuse and neglect reporting requirements, and health screening. Due to time constraints LPA will return to continue the annual inspection at the facility on a later date. No deficiencies cited during today's inspection. An exit interview was conducted and a copy of this report, appeal rights, and LIC811 (confidential names) were discussed and emailed to Maria Orona, Human Resource Manager, due to technical issues a signature was not captured during the inspection. A signed copy of the report will be maintained in the facility file.

met_with: Human Resource Manager , Maria Orona


summary: Facility Evaluation

raw_content:
Narrative:
On May 21, 2025, at 9: AM, Licensing Program Analyst (LPA) Stefanie Mutialu made an unannounced visit for the for the purpose of conducting an annual inspection of the facility. LPA met with Residential Coordinator, Leticia Rodriguez and Residential Manager, Michael Cabrera. The Facility is licensed to serve six (6) ambulatory children ages 12-17 years old. Facility also provides services to nonminor dependents pursuant to W&I Code 16501.1(c)(1), The current census is six (6) children. The facility is a one story three-bedroom, three-bathroom home. A physical plant inspection was completed with Residential Coordinator and included the following checks: three client bedrooms, two client bathrooms, one staff bathroom, kitchen, living room, dining area, activity room, office, garage, laundry area, and backyard. All required forms are posted including Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster, the Emergency Disaster Plan was also posted. Clients' medications were observed to be inaccessible and stored in medication room. LPA reminded Residential Manager facility shall be clean and free of debris. There is adequate indoor and outdoor activity space. All facility carbon monoxide detectors were tested and observed to be in working order; fire extinguisher is properly charged and serviced on 11/15/2024. ****Continued on page 2**** Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the meals. LPA observed a minimum seven-day non-perishable and two-day perishable supply of food. LPA reminded Residential Manager to ensure menu is posted. Individual beds were observed with clean linens, pillows, comforters, and mattress in good repair. All three bedrooms contain two twin beds. The facility has two client bathrooms. The water temperature was tested in one bathroom measured at the appropriate range of 105 degrees to 120 degrees Fahrenheit. LPA reviewed five client files are stored and maintained on a secure internet database. LPA reviewed five client files to ensure clients had all required documents per Title 22. LPA reviewed five client medication records. The Short Term Residential Therapeutic Program is accredited through Council on Accreditation valid through October 31, No deficiencies cited. LPA will return on another day to conduct client and staff interviews. Per facility staff, no firearms or weapons are allowed in the facility. The licensing fee payments are current. An exit interview was conducted, and a copy of this report, LIC811 (cofindential names), and appeal rights were discussed and provided to Residential Manager, Michael Cabrera. A copy of this report will be placed in the facility file.

met_with: Residential Manager. Michael Cabrera


summary: Facility Evaluation

raw_content:
Narrative:
On June 04, 2025 at 9: AM, Licensing Program Analyst (LPA), Stefanie Mutialu continued the unannounced annual inspection, which was started on May 14 ,2025. LPA met with Residential Coordinator, Leticia Rodriguez. LPA conducted interviews with two staff (S1- S2). LPA conducted interviews with two clients (C1-C2). No deficiencies cited. An exit interview was conducted with Residential Coordinator, Leticia Rodriguez. A copy of this report and confidential names (LIC 811) dated 06/04/2025 was provided to Residential Coordinator, Leticia Rodriguez.


summary: Facility Evaluation

raw_content:
Narrative:
On June 23, 2025, at 12: PM, Licensing Program Analyst (LPA) Stefanie Mutialu conducted an unannounced case management inspection of the facility. LPA Mutialu met with Program Coordinator, Leticia Rodriguez. LPA conducted a walkthrough of the facility A case management has been opened regarding information reported to the Department on June 4, 2025, that the facility is not providing activities to the clients. LPA requested an updated Personnel Roster and a Client Roster. LPA conducted three (3) staff interviews and two (2) client interviews, please refer to Confidential Names List (LIC 811) dated June 23, 2025. Further information and interviews are required; therefore, this case management is being extended. The outcome of the investigation will be provided to the Facility Administrator. The facility is reminded not to discuss the ongoing investigation with any interested parties. An exit interview was conducted, and a copy of this report was provided to Program Coordinator, Leticia Rodriguez. A copy of this report will be placed in facility file.

met_with: Program Coordinator, Leticia Rodriguez


summary: Facility Evaluation

raw_content:
Narrative:
This is an amended report from LIC 809 completed on July 23, 2025. Licensing Program Analyst Veronica Whitaker and Latricia Rogers conducted a Joint Case Management Inspection on July 23, 2025, at 9: AM, based on the number of relevant law enforcement contacts reported by the facility, Pursuant to Health and Safety Code section 1538.7. During this inspection, 6 out of Direct Care Staff and 5 out of 5 youth files were reviewed. 3 out of Direct Care Staff and 2 out of 5 youth were interviewed. (See the Confidential Names List, LIC 811, July 23, 2025. The Plan of Operation, including policies and procedures, were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review, including the needs and service assessments, youth case plans, quarterly assessments, and crisis intervention plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPAs Veronica Whitaker and Latricia Rogers observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to (Michael Cabrera Residential Manager/Administrator).

met_with: Residential Manager/Administrator, Michael Cabrera


summary: Facility Evaluation

raw_content:
Narrative:
On June 23, 2025, at 12: PM, Licensing Program Analyst (LPA) Stefanie Mutialu conducted an unannounced case management inspection of the facility. LPA Mutialu met with Program Coordinator, Leticia Rodriguez. LPA conducted a walkthrough of the facility and deficiencies were observed. This case management has been opened while LPA conducted a case management regarding information reported to the Department on June 4, 2025, that the facility is not providing activities to the clients. LPA conducted a walkthrough of the facility and deficiencies were observed. LPA observed three bottles of disinfectant in client room 1 on top of the of headboard of twin bed two accessible to clients in care. LPA observed food that was uncovered, a bowl of onions and stored food in aluminum open and not fully covered and closed exposed on the third shelf of the refrigerator. LPA observed three sticks of used butter not covered, not fully wrapped, and exposed on refrigerator door storage at the top of the door. LPA observed a box of Texas toast not securely closed on freezer shelf and a unwrapped opened snack bar stored on freezer door top shelf. LPA observed two boxes of brown sugar with interior bag open and a package of bay leaves opened with bay leaves coming out. LPA observed bathroom shower, toilet, and sink had lime and dirt build up, LPA observed bathroom floor has dirt build up and reddish mold or rust near the tub behind the laundry basket. ****Continued on Page 2**** LPA observed bathroom dispenser to be overflowing with trash. LPA observed client bedrooms and found carpet stains and build up and dirt build up on twin bed frames. LPA observed marks, dirt, and stains on walls and ceilings throughout the facility. LPA observed kitchen cabinets and shelves have dirt and debris. The Short-Term Residential Therapy Program facility is being cited for violating of California Code of Regulations Title 22, Division 6, Section 80087(g):Building and Grounds, 80087(a): Building and Grounds, and 80076(a)(14):Food Services. An exit interview was conducted with with Program Coordinator, Leticia Rodriguez. A copy of this report and confidential names (LIC811) dated 06/23/2025 was provided to with Program Coordinator, Leticia Rodriguez.


summary: Facility Evaluation

raw_content:
Narrative:
On July 16, 2025, at 03: PM, Licensing Program Analyst (LPA) Stefanie Mutialu conducted an unannounced inspection at the facility and met with the Residential Manager, Michael Cabrera. LPA conducted a walkthrough of the facility. A case management has been opened regarding information reported to the Department that staff (S1,S2, S3) are violating client's personal rights by speaking down to and belittling clients in care. LPA requested an updated Personnel Roster and a Client Roster. LPA conducted five (5) staff interviews and four (4) client interviews, please refer to Confidential Names List (LIC 811) dated July 16, 2025. Based on confidential interviews conducted, the Short-Term Residential Therapy Program facility is being cited for a type B violation of Interim Licensing Standards (ILS), version 6, subchapter 1, section 87072(c)(15): Personal Rights. An exit interview was conducted, and appeal rights were reviewed with Residential Manager, Michael Cabrera. A copy of this report, LIC 811, and appeal rights were provided to the Residential Manager, Michael Cabrera.

met_with: Residential Manager, Michael Cabrera.


summary: Facility Evaluation

raw_content:
Narrative:
On August 11, 2025, at 10: AM, Licensing Program Analyst (LPA) Stefanie Mutialu conducted an unannounced inspection at OLIVE CREST - MALENA Short-Term Residential Therapy Program (STRTP), and met with the Residential Manager, Michael Cabrera. LPA conducted a walkthrough of the facility. A Case Management has been opened regarding information reported to the Department that staff is violating client's Personal Rights by failing to refund C1 for a scooter returned in 2023. LPA requested an updated Personnel Roster and a Client Roster. LPA conducted two staff interviews and one client interview, please refer to Confidential Names List (LIC811) dated August 11, 2025. Confidential interviews provided consistent statements of being aware C1 was owed a refund. LPA was unable to conduct a record review to further support the statements provided, due to the facility not maintaining accurate financial records for C1. Based on confidential interviews conducted and the lack of records the facility is being cited for one type B violation of Interim Licensing Standards (ILS), version 6, subchapter 1, section 87072 (c)(8)(C): Personal Rights and one type B for or violating California Code of Regulations Title 22, Division 6, Section 80026 (h): Safeguards for Cash Resources, Personal Property, and Valuables of Residents. An exit interview was conducted, and appeal rights were reviewed with Residential Manager, Michael Cabrera. A copy of this report, LIC 811, and appeal rights were provided to the Residential Manager, Michael Cabrera.

met_with: Residential Manager, Michael Cabrera


summary: Facility Evaluation

raw_content:
Narrative:
On August 18, 2025, at 10: PM, Licensing Program Analyst (LPA) Stefanie Mutialu returned to the OLIVE CREST - MALENA Short-Term Residential Therapy Program (STRTP), to follow-up on a Plan of Correction (POC) that has not been received by Community Care Licensing (CCL). LPA Mutialu met with the Residential Manager(RM), Michael Cabrera, and conducted a walkthrough of the facility, and no deficiencies were observed. On June 04, 2025, the facility was cited for a type B violation of Interim Licensing Standards (ILS) standard 87061(b)(4) REPORTING REQUIREMENTS. Any unusual absence or failure of a child to return or inform the facility that they are not returning for a specific period of time. When the citation was issued Olive Crest - Malena's RM, stated the POC would be submitted via email by POC due date of 7/18/2025. On 7/18/2025, RM emailed LPA Mutialu requesting a two-week extension which was granted and a new POC due date of 7/29/2025 was given. On 7/29/2025, RM once again requested an extension due to scheduling issues. LPA Mutialu granted the second extension and provided a new POC due date of 8/15/2025. RM was advised at that time that no further extensions would be granted. On 8/15/2025, RM left a voicemail for LPA Mutialu notifying LPA that RM was unable to submit the POC. As of 8/18/2025, CCL has not received the POC. ****Continued on Page 2**** ****CONTINUED FROM PAGE 1**** The facility is receiving Civil Penalties for violation of California Code of Regulations, Title Division Six regulation 80054(f.) PENALTIES If any deficiency is not corrected by the date specified in the notice of deficiency, a penalty shall be assessed for each day following that date until compliance has been demonstrated. Civil Penalties are being assessed at $100 a day beginning on 8/15/2025 and will continue to accrue at $100.00 per day until deficiency is corrected. A copy of this report along with the LIC 809D deficiency page, LIC Civil Penalty Assessment and appeal rights were provided to Residential Manager, Michael Cabrera.


facility_name: OLIVE CREST TREATMENT CENTERS - SAYLOR

summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Other confidential interview revealed that the staff had recently left the GH and the new staff were not fully trained in the new positions. On 07/01/21, LPA observed the snack drawer to be empty, a lack of perishable foods in the refrigerator and no posted menu. Confidential interviews disclosed that the menu had not been posted for over a week. Interviews with staff revealed that the menu was torn down sometime the week before and that the staff are in the process of creating a grocery shopping list for today. Interview with Administrator (ADM) disclosed that the staff has recently changed and the new Residential Coordinator and Residential Manager have recently been scheduled for training in the next week. ADM informed LPA that quality assurance was in the STRTP last Tuesday and that they come once a month to be sure the STRTP is running up to licensing standards. ADM informed LPA the menu for July is in the process of being created and will be posted by end of day. Based on confidential interviews, LPA observations and record review the preponderance of evidence standard has been met and the department has determined the allegation that the STRTP did not have adequate food supply available for clients is substantiated. The facility is being cited for violation of the STRTP Interim Licensing Standards (ILS), section 87076(c) (1) Food Service, the STRTP did not have fresh perishable foods for a minimum of two days readily available to clients in care on at least one occasion. This poses a potential health, safety, or personal rights risk to the youth in care. An exit interview was completed and a copy of this report, LIC 811 and appeal rights were provided to facility representative.

Investigation Findings:
13On July 27, 2021 at 10: AM, Licensing Program Analysts (LPA's) Anastasia Flores and Valerie Wilso met with (STRTP) Olive Crest Treatment Center -Saylor House, Residential Manager Brittany Bounds, to deliver the findings on the above allegation. On July 1, 2021 at 10: AM, LPA conducted a health and safety inspection of the STRTP and found there were no immediate safety hazards present. However, LPA observed the GH to have less than a day's worth of snacks for the clients in care. Copies of STRTP grocery receipts, electronic copies of STRTP menus, client roster, LIC500 and photos of the STRTP food supply were obtained. Interviews were conducted with five of six clients (C1, C2, C3, C4, C5), two staff and facility Administrator. Client #6 (C6) was unavailable at the time of inspection. On June 29, 2021, this agency received allegation that the STRTP did not have adequate food supply available for clients. Confidential interviews disclosed that the staff had changed in the past two weeks, leaving the GH with a low amount of funds available for the staff to go shopping. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Anastasia Flores LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: OLIVE CREST TREATMENT CENTERS - SAYLORFACILITY NUMBER: 300605577

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

report_type: Complaint Investigation

met_with: Brittany Bounds

complaint_status: SUBSTANTIATED


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Regarding the allegation that minor was not afforded privacy while in care; specifically that on 9/14/2021, C1 was not given privacy for religious practices and staff excessively checked on C1, confidential interviews revealed that C1's religious practices include burning candles. Confidential interviews revealed on 9/14/2021, C1 was in C1's bedroom with the door closed performing religious practices that included burning a candle and staff was informed by another client that C1 was burning a candle. One confidential interview revealed that staff were checking on C1 excessively that day, while other interviews revealed staff were checking on C1 every 15 minutes as required. Interviews revealed that once S1 learned of the candle being burned, S1 went into C1's bedroom and informed C1 that C1 was not able to burn the candle in the room. Confidential interviews revealed that clients are not allowed to have glass candles or to burn candles in the STRTP for safety reasons. Confidential interviews also revealed that C1 is afforded privacy to practice their religion and is also offered alternate places to perform their religious practices. Regarding the allegations staff did not prevent a minor from self-harming, staff behavior poses as a risk to the minor while in care, and staff did not seek timely medical services for a minor; specifically that S1 minimized C1's threats to self-harm and staff denied C1 mental health care. Confidential interviews and record review revealed that also on 9/14/2021, C1 became upset for not being able to burn a candle in the STRTP and as a result C1 wanted to leave the STRTP on respite care or wanted to be hospitalized. Interviews also revealed C1 wanted to speak with mental health staff and was making self-harming statements. Interviews revealed C1 requested to speak to a mental health staff while others revealed C1 did not. Confidential interviews further revealed that S4 who is a mental health clinician spoke to and evaluated C1 and C1 did not meet the criteria to be hospitalized, as C1 had no plan to self-harm. Interviews revealed C1 then went into C1's bedroom, broke the glass candle jar and cut C1's self with the broken glass. Interviews revealed staff then contacted the sheriff and EMT services. Confidential interviews revealed staff did not do anything until C1 actually self-harmed while other interviews revealed that staff were looking for other options for C1 and also offering C1 other coping mechanisms, however C1 refused. Interviews also revealed no staff were heard belittling or minimizing C1's feelings or threats of harm. (Continued on LIC 9099-C) Regarding the allegation staff did not provide adequate transportation for a minor and staff demonstrated an inappropriate form of discipline, confidential interviews and record review revealed that on 9/5/2021, C1 was on a self-transporting community pass and called the STRTP and requested a ride back to the STRTP. Interviews revealed C1 asked S3 for a ride and S3 denied C1 a ride and ended the call. As a result, C1 found their own ride and arrived back to the STRTP late from the community pass. This interview further revealed that as a consequence, C1 had their community passes taken away for a couple days. Other interviews revealed C1 did call the STRTP while on a community pass after the time C1 was supposed to be back and informed S3 that C1 would be returning to the STRTP, however C1 did not request a ride home. Interviews revealed that C1 was dropped off late near the STRTP by an unknown male who was not authorized to drive C1. This interview revealed C1 had their community passes taken away for 3 days as a consequence. Several interviews revealed that losing community passes is a known consequence of coming home late. Based on confidential interviews and conflicting statements, the allegations C1 was not afforded privacy while in care, staff did not prevent C1 from self-harming, staff behavior poses as a risk to C1 while in care, staff did not seek timely medical services for C1, S3 did not provide adequate transportation for C1, and staff demonstrated inappropriate form of discipline, may have occurred however is not supported or proven by evidence. Therefore, the above allegations are unsubstantiated. An exit interview was conducted and a copy of this report, LIC 811 and appeal rights were provided to Residential Coordinator Naomi Ruiz.

Investigation Findings:
13On December 30, 2021 at 1:00 pm, Licensing Program Analyst (LPA), Jessica Rubio met with Olive Crest Treatment Center (STRTP), Residential Coordinator, Naomi Ruiz to deliver the investigative findings for the above stated allegations. Residential Manager Amy Ahern gave LPA verbal authorization for Naomi Ruiz to sign the licesning report. On 9/27/2021 at 2:15 pm, LPA Jessica Rubio conducted a safety inspection of the STRTP and no safety hazards were observed and no deficiencies were cited. During the investigation, LPA Rubio interviewed four clients (C1, C2, C3, C4), six staff (S1, S3, S4, S5, S7, S8), and county social worker for C1 (CSW). LPA Rubio also reviewed the client and staff rosters and special incident reports for C1. On September 17, 2021, Community Care Licensing (CCL) received a complaint alleging minor was not afforded privacy while in care, staff did not prevent a minor from self-harming, staff behavior poses as a risk to the minor while in care and staff did not seek timely medical services for a minor. There were also allegations that staff did not provide adequate transportation for a minor and staff demonstrated inappropriate form of discipline. Allegations were related to events that occurred on 9/5/2021 and 9/14/2021. (Continued on LIC 9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Christina Barnes LICENSING EVALUATOR NAME: Jessica M Rubio LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: OLIVE CREST TREATMENT CENTERS - SAYLORFACILITY NUMBER: VISIT DATE: 12/30/2021

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

met_with: Naomi Ruiz

complaint_status: unsubstantiated


raw_content:
Narrative:
Confidential interviews reported that C1 returned from being absent without permission and that C1 had left placement two days prior. Confidential interviews reported that staff conducts their room checks on a routine basis. Confidential interviews reported that the facility is not a lockdown facility and that clients can run away by sneaking out of their room windows. Confidential interviews reported that staff would hear these windows opening and attempt to redirect a minor trying to run away. Confidential interviews reported that staff are aware when a client tries to run away from placement and supervises clients regularly. Confidential interviews indicated that staff attempts to prevent clients from leaving the facility without permission by encouraging them to stay at the facility. Based on inconsistent confidential interviews and since we were unable to interview client (C1), the allegation that lack of supervision resulted in a minor (C1) AWOling, may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted. A copy of this report and appeal rights were explained and provided to Residential Manager Priscilla Hernandez.

Investigation Findings:
13On 01/24/2023, at 12: PM, Licensing Program Analyst (LPA) Joon Choi conducted an unannounced visit to Olive Crest - Saylor Short Term Residential Treatment Facility (STRTP) to deliver the investigative findings for the allegation listed above. On 02/18/2022, LPA Jessica Rubio conducted an initial health and safety Inspection at the facility, and no immediate health and safety hazards were observed. On 12/29/2022, LPA Choi conducted a follow-up health and safety inspection of the facility, and no immediate health and safety hazards were observed. The investigation included interviews with client #2 (C2) and staff (S1 and S2). LPA obtained pertinent documentation during this investigation, such as the Special Incident Report relating to this complaint and the most recent County Court Report regarding the client (C1). LPA attempted to interview C1, but C1's whereabouts were unknown. On 02/11/2022, Community Care Licensing received an allegation that lack of supervision resulted in a minor (C1) running away from placement. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Joon R Choi LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: OLIVE CREST TREATMENT CENTERS - SAYLORFACILITY NUMBER: VISIT DATE: 01/24/2023

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

met_with: Priscilla Hernandez, Residential Manager


raw_content:
Narrative:
Based on interviews and record reviews the allegations that C1's belongings were not safeguarded and C1 did not feel safe in the home, may have occurred, however is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Aisea Tongilava.

Investigation Findings:
13On February 2, 2023 at 11:25 am , Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera conducted an unannounced inspection to the facility to deliver the findings of the above allegations. LPA met with Aisea Tongilava. LPA Jessica Rubio conducted an inspection of the facility on February 18, 2022 at 03:15 pm and no immediate deficiencies were observed. Three of three (C1, C2, C3) clients, three staff and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that C1's belongings were not safeguarded and C1 did not feel safe in the home. Confidential staff interviews reported that C1 and C2 got into a verbal argument and began insulting each other. Confidential staff interviews reported that staff separated C1 and C2 and C1 went to the staff office, while C2 was still being verbally aggressive. Confidential interviews reported that C2 and C3 then went into C1's bedroom and began destroying C1's personal belongings. Confidential staff interviews reported that staff was giving C2 and C3 verbal directives but were unsuccessful. Confidential interviews reported that law enforcement was contacted for assistance. The interviews that were provided to the LPA were not consistent regarding the allegations that C1's belongings were not safeguarded and C1 did not feel safe in the home and did not provide any further specific details regarding a personal rights violation. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Darlene Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: OLIVE CREST TREATMENT CENTERS - SAYLORFACILITY NUMBER: VISIT DATE: 02/02/2023

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

met_with: Aisea Tongilava


raw_content:
Narrative:
Other confidential interviews reported that S6 discovered C1 was in C2's bedroom during a routine 15-minute bedroom check. Confidential interviews reported that S6 provided verbal directions for C1 to exit C2's bedroom. Confidential interviews reported that while C1 was in C2's bedroom, C1 touched C2 inappropriately on C2's chest and groin area, and then C1 tried to choke C2 by grabbing their neck. Other confidential interviews reported that C2 was the one that inappropriately touched C1's chest and groin area and that it was C2 who grabbed C1's neck. Confidential interviews reported that S6 and S5 were able to separate C1 and C2 from the bedroom successfully. Confidential interviews reported that this incident was documented in a Special Incident Report. Confidential interviews also reported that a Police Report concluded that there was not enough evidence of inappropriate touching by any client (C1-C2). Based on inconsistent confidential interviews, the allegation that lack of supervision resulting in a child (C1) inappropriately touching another child (C2) in care, may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted. A copy of this report, LIC 811 and appeal rights were explained and given to Residential Manager Elvis Radillo.

Investigation Findings:
13On 10/23/2023, at 10: AM, Licensing Program Analyst (LPA) Joon Choi conducted an unannounced visit to Olive Crest - Saylor Short Term Residential Treatment Program (STRTP) to deliver the investigative findings for the allegation listed above. On 04/18/2023, LPA Leslie Covarrubias visited the facility, obtained pertinent documents, interviewed clients and staff members, and conducted a health and safety inspection at the STRTP; no immediate health and safety hazards were observed. During the investigation, LPA Covarrubias interviewed Client 2 (C2), Client 3 (C3), Client 5 (C5), Residential Coordinator Staff 1 (S1) and Administrator Staff 2 (S2). LPA Choi interviewed Client 1 (C1), Client 4 (C4), Staff 3 (S3), Staff 4 (S4), Staff 5 (S5), and Staff 6 (S6). On 04/12/2023, Community Care Licensing received an allegation that lack of supervision resulted in a child (C1) inappropriately touching another child in care (C2). Confidential interviews reported that during an overnight shift at the facility, C1 entered C2's room without permission and staff (S5 and S6) noticing. CONTINUED ON THE NEXT PAGE UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Joon R Choi LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: OLIVE CREST - SAYLORFACILITY NUMBER: VISIT DATE: 10/23/2023

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

met_with: Elvis Radillo, Residential Manager


raw_content:
Narrative:
C1 and C2 discharge paperwork disclosed that the removal of C1 and C2 was due to aggressive behaviors, and they no longer reside in the facility. The Department also received an allegation that staff do not prevent children (C1-C2) from bringing drugs, drug paraphernalia, and alcohol into the group home. Confidential interviews indicated that C1 and C2 would leave the facility without permission and would bring back vape pens and alcohol bottles upon return. Confidential interviews stated that staff (S1-S6) would conduct individual searches for C1 and C2 upon return of absence without permission due to a history of C1 and C2 bringing contraband into the facility. The history of substance abuse was noted on the Child and Family Team Meeting (CFT) held for C1 on 05/02/2023 and 07/14/2023 and for C2 on 05/11/2023 and 06/08/2023. Confidential interviews indicated that the individual searches consisted of searching C1 and C2's pockets, shoes, socks, and bags, conducting room searches, and perimeter checks. Confidential interviews disclosed that C1 and C2 would hide vape pens in their undergarment. In addition, confidential interviews revealed that staff (S1-S6) would request C1 and C2 to hand over contraband. If C1 and C2 refused to turn it in, staff would document it, supervise C1 and C2, and confiscate the contraband when it's safe and appropriate. The Department also received an allegation that staff (S4) were involved in a physical altercation with a youth (C2). Confidential interviews corroborated that staff did not engage in a physical altercation with any clients in care. Confidential interviews revealed that C2 was aggressive and physically assaulted S4, while S4 stepped back and S6 verbally redirected C2. Confidential interviews stated that staff use verbal crisis intervention according to their emergency intervention plan, which minimize the aggression C2 had toward S4. S4 removed self to allow C2 to calm down, and S6 continued to use emergency intervention procedures. Per the record review, the facility's early emergency intervention plan is to de-escalate the youth using verbal crisis intervention, identifying consequences, and voluntary self-isolation. Per record review, restraints are used as a last resort if needed. Based on inconsistent confidential interviews, the allegation that staff are not providing a safe environment for the child (C4) in care, staff do not prevent children (C1-C2) from bringing drugs, drug paraphernalia and alcohol into the group home, and staff (S4) were involved in a physical altercation with youth (C2) are unsubstantiated. The allegations may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report and appeal rights were discussed and provided to Residential Manager, Elvis Radillo.

Investigation Findings:
13On December 28, 2023, at 12: PM, Licensing Program Analyst's (LPA's) Leslie Covarrubias and Cynthia Robinson met with Olive Crest Saylor Home (STRTP), Residential Manager, Elvis Radillo to deliver the findings for the above-stated allegations. On 06/15/2023 at 11: AM, LPA Covarrubias inspected the physical plant and observed no immediate health and safety hazards. The investigation included interviews with Clients (C1-C4), Staff (S1-S3 and S5-S6), and County Social Workers. LPA made several attempts to interview S4 but was unsuccessful due to S4 working the midnight shift and being unavailable. The Department received an allegation on June 8, 2023, that staff are not providing a safe environment for the child (C4) in care. Confidential interviews indicated that clients (C1 and C2) would be aggressive toward staff and other clients. Other confidential interviews revealed that staff would redirect clients (C1 and C2) when they became aggressive and follow the facility's emergency intervention plan. Confidential interviews indicated that S5 would offer C4 more community passes so that C4 could be more comfortable and away from home. (Continue on next page...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Leslie Y Covarrubias LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: OLIVE CREST - SAYLORFACILITY NUMBER: VISIT DATE: 12/28/2023

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

met_with: Residential Manager, Elvis Radillo


raw_content:
Narrative:
found the items. Confidential interviews indicated that the staff followed facility drug and alcohol policy and conducted room searches and attempted a search of youth when youth returned to the facility and there was a reasonable belief that the youth had hidden smoking paraphernalia on them, however youth would decline. Confidential interviews did not entail a safety plan for when the clients declined searches. It is unknown if a search of minors would have prevented youth smoking paraphernalia in the home. Based on confidential interviews, that facility staff did not prevent minors from bringing smoking paraphernalia into the home may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained. A copy of this report, LIC 811, and appeal rights was provided to the Administrator. Confidential interviews revealed that S4 would curse in conversations with the clients, roll their eyes at clients, and give clients a negative attitude when clients were not complying with S4's directives. Confidential interviews also confirmed that S4 was addressed multiple times to address this behavior. LPA viewed the video where S4 could be heard speaking to clients and making the statement "you're lucky this is a hands-off facility" to minors in care. LPA was unable to interview S4 because S4 no longer works at STRTP. Based on confidential interviews and records reviewed, the preponderance of evidence standard has been met and the allegations that staff do not treat minors with dignity and respect and that staff member emotionally abuses minors in care. is substantiated. The Short-Term Residential Treatment Program (STRTP) facility is being cited for violation of Interim Licensing Standards version 5, Article 6, Continuing Requirements: 87072(c)(15) Personal Rights. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Residential Manager. A copy of this report, LIC 811, and appeal rights was provided to the Residential Manager.

Investigation Findings:
13On July 17, 2024, at 10: AM, Licensing Program Analyst (LPA) Guadalupe Munoz arrived unannounced at the facility and met with Agustin Rojas, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 01/11/24 at 1:30 pm and no deficiencies were observed. LPA Interviewed four staff (S1-3, S5), S4 could not be interviewed due to no longer working at STRTP, interviewed four clients (C2-5), LPA attempted to interview two clients (C3, C6), however both clients declined. During the investigation, the following documents were reviewed: staff schedule, special incident reports, video recording, and needs and services plans for minors in care. On 01/03/2024, Community Care Licensing (CCL) received allegations that staff do not treat minors with dignity and respect, and that a staff member emotionally abuses minors in care. Specifically, it was reported that that there was a video made that showed S4 making the comment, "you're lucky this is a hands-off facility" to C1 and that S1 "curses at the youth." SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: OLIVE CREST - SAYLORFACILITY NUMBER: 300605577

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


raw_content:
Narrative:
marijuana at the facility and that on one occasion a "blunt" was obtained by S1 while at the facility and C6 was able to obtain the same "blunt" later the same day when it fell out of S1's pants pocket before it could be secured at the facility. Confidential interviews revealed conflicting statements on how S1 obtained the "blunt" and conflicting statements on how C6 later obtained the same "blunt" and whether S1 provided the "blunt" to minor. Based on confidential interviews, that staff is providing drugs (marijuana) to minors may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Ruta Peterson and Janessa Arauz. A copy of this report, LIC 811, and appeal rights was provided to the Administrator.

Investigation Findings:
13On August 8,2024, at 2: PM, Licensing Program Analyst (LPA) Guadalupe Munoz arrived unannounced at the facility and met with Ruta Peterson, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 01/29/24 at 1:00 pm and no deficiencies were observed. LPA Interviewed five staff (S1-5), four clients (C1-4), and clients (C5-6) declined to be interviewed. LPA obtained and reviewed the following documents: Needs and Service Plans, Staff Schedule, Client Roster, and Incident Reports. On 01/26/24, Community Care Licensing (CCL) received an allegation that staff is providing drugs (marijuana) to minors. Specifically, that staff gave drugs (marijuana) obtained from a child to another child in the facility and that staff allowed another youth to smoke their wax pen. Confidential interviews confirmed that youth were using marijuana at the facility. Interviews revealed that on multiple occasions clients had UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: OLIVE CREST - SAYLORFACILITY NUMBER: VISIT DATE: 08/08/2024

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

met_with: Ruta Peterson and Janessa Arauz


raw_content:
Narrative:
Confidential interviews revealed that youth that declined to be searched were allowed to enter the facility without restrictions and room searches were conducted at a later time. It is unknown if searches of youth and upon refusal of a searches if increased supervision of the clients would have prevented youth from possessing unknown drug substances while in care. Based on confidential interviews, that staff is allowing minors to have possession of unknown drug substances while in care. may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Ruta Peterson and Janessa Arauz. A copy of this report, LIC 811, and appeal rights was provided to the Administrator.

Investigation Findings:
13On August 8,2024, at 3: PM, Licensing Program Analyst (LPA) Guadalupe Munoz arrived unannounced at the facility and met with Ruta Peterson, Facility Manager and Janessa Arauz, facility designee, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 02/07/24 at 1:00 pm and no deficiencies were observed. LPA Interviewed six staff (S1-6) and three clients (C1-3). LPA obtained and reviewed the following documents: Needs and Service Plans, Staff Schedule, Client Roster, and Incident Reports. On 02/05/24, Community Care Licensing (CCL) received an allegation that staff is allowing minors to have possession of unknown drug substances while in care. Confidential interviews confirmed that youth had unknown drug substances and were using drugs while in care. Interviews revealed conflicting statements as to whether staff allowed minors to possess unknown drug substance while in care. Interviews and documents reviewed indicated that youth often declined to be searched when returning to the facility. **this is an amended LIC 9099 that was signed on 8/08/24** UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: OLIVE CREST - SAYLORFACILITY NUMBER: VISIT DATE: 08/08/2024

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


raw_content:
Narrative:
inconsistent statements that could not validate the allegations. In addition, there were no witnesses to the alleged incidents. Based on confidential interviews, that staff (S1) threatened minors (C1 and C2) in care may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Agustin Rojas. A copy of this report, LIC 811, and appeal rights was provided to the Administrator.

Investigation Findings:
13On October 25, 2024, at 10: AM, Licensing Program Analyst (LPA) Guadalupe Munoz arrived unannounced at the facility and met with Residential Manager, Agustin Rojas to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 01/11/24 at 1:00 pm and no deficiencies were observed. LPA interviewed two staff (S2-3) and two clients (C1-2), LPA could not interview S1 due to S1 no longer being employed at the facility and the phone number on file was no longer in service. LPA obtained and reviewed the following documents: C1 and C2's Needs and Service Plans, Staff Schedule, Client Roster, and Incident Reports, and S1's employee file. On 01/09/24, Community Care Licensing (CCL) received an allegation that staff threatened minors in care. Specifically, it was reported that back in the year 2022, S1 would threaten minors in group home including C1 and C2 telling them, "I'm gonna beat or hit you if you don't listen." Although the Departmentreceived detailed information of clients' personal rights being violated, the confidential interviews provided UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: OLIVE CREST - SAYLORFACILITY NUMBER: VISIT DATE: 10/25/2024

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

met_with: Agustin Rojas


raw_content:
Narrative:
Confidential interviews revealed that the Facility had made arrangements to transport the clients to their other facility to take showers. It is unknown if a plumber could have repaired the shower sooner than the eight days, therefore it is unknown if the staff neglected to repair the shower in a timelier manner. Based on confidential interviews and records reviewed the allegations that facility shower is in disrepair which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Agustin Rojas. A copy of this report, LIC 811, and appeal rights was provided to the Administrator.

Investigation Findings:
13On January 24,2025, at 11: AM, Licensing Program Analyst (LPA) Guadalupe Munoz arrived unannounced at the facility and met with Agustin Rojas, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 05/06/24 at 11:30 am and no deficiencies were observed. LPA Interviewed four Staff (S1-4) and LPA interviewed four Clients (C1-4). During the investigation, the following documents were reviewed: Facility documents and Client files. On 04/30/2024, Community Care Licensing (CCL) received an allegation that facility shower is in disrepair. Specifically, it was reported that the facility shower was in disrepair for five days and clients are unable to shower. Confidential interviews and documents reviewed revealed that a work order was in place, however, the facility maintenance person is the sole individual for the region to make repairs at multiple Olive Crest facilities in Southern California, which delayed the repair of the shower. Confidential interviews also confirmed that the shower was broken, and clients were unable to use it for eight days. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: OLIVE CREST - SAYLORFACILITY NUMBER: VISIT DATE: 01/24/2025

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


summary: Complaint Investigation - Substantiated - 1 deficiency - 1 allegation

raw_content:
Narrative:
that staff were inside of the facility while C2 attempted to kiss C1 without consent. Based on confidential interviews and records reviewed, the preponderance of evidence standard has been met and the allegation that due to lack of supervision, minors are engaging in inappropriate interactions is substantiated. The Short-Term Residential Treatment Program (STRTP) facility is being cited for violation of Interim Licensing Standards version 5, Article 6, Continuing Requirements: 87065. Personnel Duties An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Residential Manager, Agustin Rojas and copy of this report, LIC 811, and appeal rights was provided to the Administrator.

Investigation Findings:
13On February 13,2025 at 1: PM, Licensing Program Analyst (LPA) Guadalupe Munoz arrived unannounced at the facility and met with Agustin Rojas, Residential Manager to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 05/06/24 at 11:30 am and no deficiencies were observed. LPA Interviewed four Staff (S1-4) and interviewed four Clients (C1, C3-5), LPA was unable to interview Client #2 (C2) because they had left the facility without permission and whereabouts are unknown. During the investigation, the following documents were reviewed: staff schedule, facility communication log, and special incident reports. On 05/06/2024, Community Care Licensing (CCL) received allegation that due to lack of supervision, minors are engaging in inappropriate interactions. Confidential interviews revealed that C2 attempted to forcibly kiss C1 while in the backyard of the facility. Interviews further revealed that three clients were hanging out in the backyard without any staff present for an unknown amount of time. Confidential interviews also confirmed SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: OLIVE CREST - SAYLORFACILITY NUMBER: VISIT DATE: 02/13/2025

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

Deficiencies:
87065.21: (1) Supervision, protection, and care of children at all times, individually and in groups.

title:
2
3
4
5
6
787065.2
Personnel Duties
(b) Direct care staff shall perform the following duties


raw_content:
Narrative:
household chores and cleaning their bedrooms and personal areas. Confidential interviews indicated conflicting statements as to whether youth are made to perform staff duties such as cleaning up after other clients in care; as some interviews entail that the clients are made to clean up after other clients and other interviews deny the allegation. Therefore, the allegation could not be confirmed. Based on confidential interviews, that youth are made to perform staff duties. may have occurred, however, it is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained. A copy of this report, LIC 811, and appeal rights was provided to the Administrator. "Mold was also observed in the shower and on the ceiling of the shower, the youth's bed was also dirty with trash stuffed inside the drawers (under the bed) and trash was also observed on the side of the bed". Regarding the allegations that the facility is unkept and the facility has mold, confidential interviews and LPA Munoz' observations confirmed that facility was unkept and that there was mold in the shower. On August 8, 2024, LPA observed that the shower and the surrounding walls to have scattered greyish-black dots of mold. In addition, LPA also observed youths' bedrooms to have trash covering the floor, in between the beds and in the bed drawers, graffiti on the bedroom walls, and a broken light fixture in a youth's bedroom. Regarding the allegation that staff do not provide a comfortable environment for youth(s), confidential interviews confirmed that when C4 was placed at the facility C4 was not provided a clean sleeping area; although the bed had clean linens there was trash in the dresser draws and trash around and under the bed. Regarding the allegation that you are not provided with activities, confidential interviews revealed that youth sometimes do not go on outings due to not having enough staff to transport them and the activities were cancelled instead of being rescheduled. Based on confidential interviews, LPA observation and records reviewed, the preponderance of evidence standard has been met and the allegations that facility is unkept, facility has mold, staff do not provide a comfortable environment for youth(s) and that youth are not provided with activities are substantiated. The Short-Term Residential Treatment Program (STRTP) facility is being cited for violation of Title 22, Division Chapter 1, Article 07. Physical Environment: 80087(a) Buildings and Grounds and Interim Licensing Standards version 5, Article 7, Continuing Requirements: 87072(c)(21) Personal Rights. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Agustin Rojas, Residential Manager. A copy of this report, LIC 811, and appeal rights was provided to the Administrator.

Investigation Findings:
13On February 21, 2025, at 2: PM, Licensing Program Analyst (LPA) Guadalupe Munoz arrived unannounced at the facility and met with Administrator, Agustin Rojas, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 08/08/24 at 3:00 pm and deficiencies were addressed with the Administrator and the facility is being cited at this time. LPA Interviewed three staff (S1-3), LPA interviewed three out of six clients (C1-3), LPA attempted to interview one clients (C4), however client declined. During the investigation, the following documents were reviewed: staff schedule, special incident reports, work repair orders, activity schedules, and needs and services plans for minors in care. On 08/06/2024, Community Care Licensing (CCL) received allegations that facility is unkept, facility has mold, staff do not provide a comfortable environment for youth(s), and that youth are not provided with activities. Specifically, it was reported "that the facility was "filthy", the facility had an overflowing trash can, ***CONTINUED ON 9099C*** SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE This is an official report of an unannounced visit/investigation of a complaint received in our office on 08/06/2024 and conducted by Evaluator Guadalupe Munoz COMPLAINT CONTROL NUMBER: 22-CR- FACILITY NAME:OLIVE CREST - SAYLORFACILITY NUMBER: ADMINISTRATOR:KERRI DUNKLEBERGERFACILITY TYPE: ADDRESS: SAYLOR TERRACETELEPHONE: (714) 997- CITY:SANTA ANASTATE: CAZIP CODE: CAPACITY:6CENSUS: DATE: 02/21/ UNANNOUNCEDTIME BEGAN: 01: PM MET WITH:TIME COMPLETED:02: PM 9Youth made to perform staff duties. INVESTIGATION FINDINGS: 13On February 21, 2025, at 2: PM, Licensing Program Analyst (LPA) Guadalupe Munoz arrived unannounced at the facility and met with Administrator, Agustin Rojas, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 08/08/24 at 3:00 pm and deficiencies were addressed with the Administrator and the facility is being cited at this time. LPA Interviewed three staff (S1-3), LPA interviewed three out of five clients (C1-3), LPA attempted to interview one clients (C4), however client declined.. During the investigation, the following documents were reviewed: staff schedule, special incident reports, work repair orders, activity schedules, and needs and services plans for minors in care. On 08/06/2024, Community Care Licensing (CCL) received an allegation that youth are made to perform staff duties. Specifically, it was reported that youth are "signed up to clean the filth that was created by others". Confidential interviews confirmed that youth are encouraged and expected to participate in UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz 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: 4 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: OLIVE CREST - SAYLORFACILITY NUMBER: VISIT DATE: 02/21/2025

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


summary: Facility Evaluation

raw_content:
Narrative:
On June 1, 2021, at 1:53PM Licensing Program Analysts (LPA) Adrian Mendez, and Jesus Cervantes, and Licensing Program Manager (LPM) Ann Valenzuela conducted an unannounced annual inspection. The facility converted from a Group Home to STRTP (Short Term Therapeutic Program) on June 4, 2018. LPA's and LPM were met at the facility by Administrator Ethan Alli. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster, the Emergency Disaster Plan was also posted. Medications are locked and centrally stored in the bathroom which is within the staff office. Medication records were reviewed and observed to be completed with dates and staff initials on dispensing records. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. All three bedrooms contain two twin beds. The facility has two client bathrooms, however only one is used to bathe. The water temperature in the bathroom with the sink was tested at 2:27pm and registered at 113.5 degrees which is within the appropriate range of 105 degrees to 120 degrees. Per facility staff, no firearms or weapons are allowed in the facility. Administrator Ethan Alli is present at the facility a minimum of 20 hours a week, as verified by staff schedule and interviews. Appropriate staff/client ratios were verified during this inspection. Cont. on 809-C The facility employs three Clinical Support Staff, four facility managers and 9 direct care staff that are used in accordance with regulatory requirements. Licensee obtained Mental Health (MH) Certification in June 2019. Licensee has obtained National Accreditation through COA. The Accreditation is valid through October 30, 2021. Licensing fee payments are currently past due. Administrator stated that the licensing fees will be paid in full by the end of this week. LPA discussed the following with the Administrator: Facility procedures related to requesting exceptions. Assembly Bill 388 law enforcement contacts as well as incidents involving emergency interventions. LPA discussed procedures for Child and Family Team (CFT) meetings, including an overview of required Core Services and Supports. LPA also discussed Reasonable and Prudent Parenting Standards, and resident involvement in development of planned activities. Due to time constraints and employee files being housed in their corporate office, LPA will return to the facility to conduct a continuation of staff file reviews. Two clients, and three facility staff were interviewed during the inspection. Three clients declined interviews. No deficiencies were found. Exit interview was conducted and a copy of this report was provided to the Administrator Ethan Alli.

met_with: Ethan Alli


summary: Facility Evaluation

raw_content:
Narrative:
On June 08, 2021, at 10: AM Licensing Program Analysts (LPA) Jesus Cervantes, and Licensing Program Manager (LPM) Ann Valenzuela conducted an unannounced annual continuation inspection from June 01, 2021. Employee files were not located at the facility and required employee files to be reviewed at Olive Crest Headquarters located at E. Fourth Street, Santa Ana, CA 92705. LPA and LPM meet with Madison Mazzone and Denise Griffiths. Five random personnel files were reviewed to ensure they contained all required documentation per Title Regulations. Personnel Files are maintained on-site in a locked cabinet in the Human Resource office. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Client and staff interviews were conducted on 06/01/2021. No deficiencies were noted during time of inspection.

met_with: Madison Mazzone


summary: Facility Evaluation

raw_content:
Narrative:
On March 20, 2023, at 09:53 am Licensing Program Analysts (LPA) Sarah Lo conducted an unannounced annual inspection at Olive Crest Treatment Centers - Saylor Short-Term Therapeutic Program (STRTP), located at Saylor Terrance, Santa Ana, CA 92705. The facility converted from a Group Home to STRTP on June 4, 2018. LPA was met at the facility by Residential Manager/Administrator, Priscilla Hernandez and Residential Coordinator, Elvis Radillo for a physical plant inspection. STRTP Program Supervisor, Amy Ahern arrived at 10:15 am to assist the process of inspection as well. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster, the Emergency Disaster Plan was also posted. Medications are locked and centrally stored in locked cabinet which is within the staff office. Medication records were reviewed and observed to be completed with dates and staff initials on dispensing records. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. All three bedrooms contain two twin beds. The facility has two client bathrooms, however only one is used to bathe. The water temperature in the bathroom with the sink was tested at 10:24 am and registered at 107.2 degrees which is within the appropriate range of 105 degrees to 120 degrees. Per facility staff, no firearms or weapons are allowed in the facility. (Continued on LIC 809-C) Residential Manager/Administrator, Priscilla Hernandez, is present at the facility a minimum of 20 hours a week, as verified by staff schedule and interviews. Appropriate staff/client ratios were verified during this inspection. The facility employs one Clinical Director, one STRTP Program Supervisor, one Program Supervisor, one Residential Manager, one Residential Coordinator eight Youth Care Specialist, two Mental Health Clinician, one Clincial Director and one Rehabilitation Specialist that are used in accordance with regulatory requirements. Licensee obtained Mental Health (MH) Certification in June 2019 and it is valid through May 20, 2023. Licensee has obtained National Accreditation through COA and the Accreditation is valid through October 31, 2025. LPA reviewed five out of five staff files and below are the deficiencies cited: At 11:50 am, Staff #2 is missing a signed by medical physician the initial health screening and Tuberculosis (TB) test result. Per CCR 80066(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g) and per CCR 80065 (1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure and per CCR 80066 (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g). LPA reviewed three out of three client files and below are the deficiencies cited: At 12:26 pm, Client #3 is missing initial medical health screening. Per CCR 80069 (a) Except for licensees of ARFs, prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client, as specified in Section 80069(c), which enables the licensee to determine his/her ability to provide necessary health related services to the client. The assessment shall be used in developing the Needs and Services Plan. Due to time constraints, LPA will return to the facility to conduct a continuation of staff and client interviews. A copy of this report and LIC 809-D, appeal rights was given to STRTP Program Supervisor, Amy Ahern.

met_with: Amy Ahern, STRTP Program Supervisor


summary: Facility Evaluation

raw_content:
Narrative:
On March 28, 2023, at 11: AM Licensing Program Analyst (LPA) Sarah Lo conducted an unannounced annual inspection at Olive Crest - Saylor Short-Term Residential Therapeutic Program (STRTP) located at Saylor Terrace, Santa Ana, CA 92705. LPA was greeted at the facility by Youth Care Specialist, Jessica Ayala and Residential Manager, Priscilla Hernandez. LPA Lo was here on March 20, 2023 and conducted an unannounced annual inspection of the physical plant and staff and client file reviews. The purpose of the visit today is conduct two staff interviews and two client interviews. The facility ground is observed to be clean and tidy. All interviews are done in the kitchen counter or outside in the backyard. A copy of this report and LIC 811 was given to Residential Manager, Priscilla Hernandez.

met_with: Priscilla Hernandez, Residental Manager


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Manager, Angela King and Licensing Program Analyst Veronica Whitaker conducted a case management inspection on 6/20/23 based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 5 out of Direct Care Staff and 4 out of 4 youth files were reviewed. 2 out of Direct Care Staff and 1 out of 4 youth were interviewed. (See the Confidential Names List, LIC 811, dated 6/20/23. The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review, including the needs and service assessments, youth case plans, and crisis intervention plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Veronica Whitaker and Licensing Program Manager, Angela King, observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Amy Ahern, Program Supervisor/Administrator.

met_with: Amy Ahern, Program Supervisor/Adminstrator


summary: Facility Evaluation

raw_content:
Narrative:
On June 25, 2024, at 1:00 pm, Licensing Program Analyst (LPA) Guadalupe Munoz conducted an unannounced case management inspection of the facility. LPA conducted a walk through of the facility, and no deficiencies were observed.. LPA Munoz met with Residential Manager, Agustin Rojas. LPA informed facility that an investigation will be conducted regarding an incident that was reported on 6/20/24. On 6/20/24, Community Care Licensing (CCL) was notified of a concern regarding inappropriate interactions taking place between clients during the overnight hours due to possible lack of supervision. LPA interviewed three clients during todays visit. Further information and interviews are required to resolve the complaint therefore this investigation is being extended. The outcome of the investigation will be provided to the Residential Manager. The facility is reminded not to discuss the ongoing investigation with any interested parties. An exit interview was conducted with Residential Manger and copy of this report and LIC 811 dated 6/25/24 was provided to the designee.


summary: Facility Evaluation

raw_content:
Narrative:
On July 12, 2024 at 1:00 pm, Licensing Program Analyst (LPA) Guadalupe Munoz conducted an unannounced case management inspection of the facility. LPA conducted a walk through of the facility, and no deficiencies were observed. The purpose of the inspection was to follow up on a case management visit on 09/11/2023. LPA Munoz met with Residential Manager, Agustin Rojas. On 6/20/24, Community Care Licensing (CCL) was notified of a concern regarding inappropriate interactions taking place between clients during the overnight hours. Confidential interviews reported conflicting information. Thus, no deficiencies were noted, and the facility is in compliance. An exit interview was conducted with Residential Manger and copy of this report was provided to the designee.


summary: Facility Evaluation

raw_content:
Narrative:
On 8/15//2024, Licensing Program Analyst (LPA) Guadalupe Munoz arrived to Olive Crest Saylor STRTP for the purpose to amend an LIC 9099 that was signed on 8/08/24. LPA met with Agustin Rojas, Residential Manager. .


summary: Facility Evaluation

raw_content:
Narrative:
On May 14, 2025, at 9: AM, Licensing Program Analyst (LPA) Stefanie Mutialu made an unannounced visit for the for the purpose of conducting an annual inspection of the facility. LPA met with Residential Coordinator, Emylee King. Residential Manager. Augustin Rojas and Program Supervisor, Brenda Solano arrived at 10: AM. The Facility is licensed to serve six (6) ambulatory children ages 12-17 years old. Facility also provides services to nonminor dependents pursuant to W&I Code 16501.1(c)(1), The current census is five (5) children. The facility is a one story three-bedroom, three-bathroom home. A physical plant inspection was completed with Residential Manager and included the following checks: three client bedrooms, two client bathrooms, one staff bathroom, kitchen, living room, dining area, family room, office, garage, laundry room, and backyard. LPA observed a bottle of Citrusafe barbeque cleaner accessible to clients in the backyard on the left side of patio door located next to a bag of charcoals. LPA observed laundry detergent in unlocked laundry room. The facility is receiving a type A citation for hazardous chemicals/cleansers accessible to clients. LPA observed items missing in the first aid kit including tweezers. Facility is receiving a type B citation. All required forms are posted including Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster, the Emergency Disaster Plan was also posted. Clients' medications were observed to be inaccessible and stored in medication room. ****Continued on Page 2***** Facility grounds are free of debris. LPA reminded Residential Manager, Augustin Rojas facility grounds shall be clean and in good repair at all times. There is adequate indoor and outdoor activity space. Facility carbon monoxide detectors were tested and observed to be in working order; fire extinguisher is properly charged. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. LPA observed a minimum seven-day non-perishable and two-day perishable supply of food. Individual beds were observed with clean linens, pillows, comforters, and mattress in good repair. All three bedrooms contain two twin beds. LPA observed client 1 and 3 bedroom twin beds are less than 2 feet apart and does not allow for easy passage. Facility is receiving a type B violation for bedrooms not allowing easy passage. The facility has two client bathrooms. The water temperature was tested in one bathroom and measired the appropriate range of 105 degrees to 120 degrees Fahrenheit. All client files are stored and maintained on a secure internet database. LPA reviewed five client files to ensure clients had all required documents per Title 22. LPA reviewed client client medication records. LPA conducted two staff interviews and two client interviews. The Short Term Residential Therapeutic Program is accredited through Council on Accreditation valid through October 31, Facility cited for violation of California Code of Regulations, Title Division six, regulation 80087(g): Buildings and Grounds, 80075(g)(1)(F):Healt-Related Services, and 87087(b)(2):Building and Grounds. Due to time constraints staff records located at the main office LPA will visit main office at a later time to review staff records and complete inspection. Per facility staff, no firearms or weapons are allowed in the facility. The licensing fee payments are current. An exit interview was conducted, and a copy of this report, LIC811 (confidential names), and appeal rights were discussed and provide to Residential Coordinator. Emylee King. A copy of this report will be placed in the facility file.

met_with: Oggie


summary: Facility Evaluation

raw_content:
Narrative:
On May 14, 2025, at 3: PM, Licensing Program Analyst (LPA), Stefanie Mutialu continued the unannounced annual inspection, which was started on May 14 ,2025. LPA met with Program Supervisor, Brenda Solana. LPA reviewed five staff (S1-S5) files to ensure staff had all required documents per Title 22 regulations. Staff records are stored in a secured database. Per a review of Guardian, all staff have a criminal record clearance. No deficiencies cited. An exit interview was conducted, and a copy of this report, LIC811 (confidential names), and appeal rights were discussed and provided to Program Supervisor, Brenda Solana. A copy of this report will be placed in the facility file.

met_with: HR Manager , Maria Orona