raw_content:
Narrative:
The investigation revealed that the facility is a General and not a Specialized Small Family Home. It revealed that Client Ref. #1 is a non-verbal special needs client, but does not meet the criteria for a Individualized Health Care Plan. It revealed that the facility has partnered with a hospice care who provides nurses three times a week to check on Ref. #1, and assist with Ref. #1's medication and care. The Caregiver indicated that Ref. #1 is washed daily. The Caregiver indicated that the facility staff utilizes the Groupme Chat Application in order to document in real-time Ref. #1's status and condition, including medication and feeding, etc. throughout the day. The Caregiver indicated that the application is utilized to ensure that the staff are performing their duties for the clients. The LPA observed chats from the application that showed when Ref. #1 was washed, fed and the diaper was changed, etc. There was no evidence provided to support the allegations. The LPA was unable to corroborate the allegations. There was no preponderance of the evidence to substantiate the allegations. So, although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the allegations are unsubstantiated. There are no deficiencies to be cited regarding these allegations. A copy of this complaint was provided to the facility representative.

Investigation Findings:
13On March 6, 2025 at 11:25 a.m., Licensing Program Analyst (LPA), Karen McGee delivered the findings of the complaint investigation. The LPA met with Facility Director, Asia Armstrong. On November 6, 2024, the Monterey Park Children's Residential Program (MPCRP), received a complaint with the above mentioned allegations. Confidential interviews were conducted that included, but were not limited to: the Caregiver via telephone on February 26, 2025; the County Social Worker (CSW) via telephone on February 19, 2025. The LPA reviewed the Program Statement, Client Ref. #1's Needs & Services Plan, Discharge Summary, Placement Agreement, Preplacement Appraisal Information, Personnel Report, Staff Annual Training, G-Tube Training Log, Special Incident Reports and Community Care Licensing Annual Inspection dated July 30, 2024. The LPA toured the facility on November 6, 2024, January 23, 2025 and February 20, 2025. On November 6, 2024, the LPA observed one staff cleaning the open-air living room-kitchen area. On all three occasions, the LPA observed the facility to be clean, safe and in good repair. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Karen McGee LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: HILL SMALL FAMILY HOMEFACILITY NUMBER: VISIT DATE: 03/06/2025

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


state: CA

facility_name: HILL SMALL FAMILY HOME

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
The investigation revealed that Clients #2 and #5 shared their bedrooms with a roommate. The LPA was informed that according to Clients #2 and #5's Rate Letters, they were to reside in single occupancy bedrooms. A review of the Placement Agreements did not reveal information that the clients were to reside in single occupancy bedrooms. The investigation revealed that the facility was in compliance with the Small Family Home Building and Grounds Regulations. The Caregiver indicated that the issue was discussed with Client #2 and #5's CSWs and it was agreed that as long as the clients were matched they could reside with a roommate. At least two witnesses confirmed that the clients were to reside in single occupancy bedrooms, but did not provide the LPA with copies of the Rate Letters. The Caregiver denied that they did not participate in CFT meetings. The Caregiver indicated that at the CFT meetings the Caregiver wanted to be referred to by the title Caregiver and not their personal name in order to maintain confidentiality of the facility, address and clients. The investigation revealed that participants at the CFT wanted to use the Caregiver's name in the meetings. The LPA was informed that Ref. #5 had several missed therapeutic appointments or they had been cancelled, because there was no transportation available to get Ref. #5 to the appointment. The LPA was not given a specific time frame or number for the missed or cancelled appointments. The Caregiver denied that clients missed their medical appointments and indicated that if Ref. #5 missed their appointment it was due to illness. The Caregiver indicated that there are several vehicles available at the facility to take children to their appointments. It is determined that the allegations cannot be corroborated. There was no preponderance of the evidence to substantiate the allegations. So, although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the allegations are unsubstantiated. There are no deficiencies to be cited regarding these allegations. A copy of this complaint was provided via email to the facility representative.

Investigation Findings:
13On May 2, 2025 at 10:30 a.m., Licensing Program Analyst (LPA), Karen McGee, delivered the findings of the complaint investigation. The LPA met with Director, Asia Armstrong. On November 6, 2024, the Monterey Park Children's Residential Program (MPCRP), received a complaint with the above mentioned allegations. Confidential interviews were conducted that included, but were not limited to: the Caregiver via telephone on March 21, 2025; three County Social Workers (CSW) for Clients #4, #5 and #6 via telephone on February 19, 2025, April 14, 2025 and April 30, 2025, respectively. After several attempts calling, the LPA was unable to talk to three CSWs. The LPA reviewed six client placement agreements. There were statements that at least two Clients, Ref. #2 and #5 shared bedrooms with at least one other client; that the Caregiver did not want to participate in Child and Family Team Meetings (CFT) and provided no transportation to appointments. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Karen McGee LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: HILL SMALL FAMILY HOMEFACILITY NUMBER: VISIT DATE: 05/02/2025

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

report_type: Complaint Investigation

met_with: Asia Armstrong

complaint_status: unsubstantiated


summary: Complaint Investigation - Unsubstantiated - 3 allegations

raw_content:
Narrative:
On March 28, 2025, the Department received a complaint alleging that staff did not prevent minors in care from engaging in inappropriate interactions. During the interview(s) with C2, FA, S1, and S2, it was discovered that C1 and C2 previously shared a room at the SFH, however, due to C2 making complaints to staff regarding C1 evading his space, constantly taking C2's personal items and hiding them from C2, and C1 keeping C2 up late at night when C1 would experience nightmares, it was decided by staff to re-assign C1 to a different room and allow C2 to have the room to himself. There was no evidence that the staff allowed clients to engage in inappropriate behavior, nor if the client(s) took part in such behavior. During the investigation, it was also determined that while the clients are in their rooms during the day or night, staff at the SFH conduct room checks at intervals approximately between 30 - 45 minutes or as needed. During the initial inspection at the SFH, LPA observed an application (called "Group Me") that the clients (due to non-ambulatory status) use to stay in contact with the staff on duty if they need anything (such as, help to the bathroom, water, snack, etc....). The LPA's investigation revealed that due to conflicting statements gathered from confidential interviews via phone call and in person, the preponderance of evidence standard has not been met, therefore the above allegation is found to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not enough preponderance of evidence to prove the allegation. A signed copy of this report was discussed and provided to the Facility Representative. Exit interview conducted. No deficiencies cited at this time. Appeal rights provided to the Foster Family Agency.

Investigation Findings:
13On May 23, 2025, at 8:18 a.m., Licensing Program Analyst (LPA) Christopher J. Williams conducted a follow-up inspection at the Hill Small Family Home (SFH) for the purpose of delivering findings on the above allegations. LPA met with Ayan Hill, Facility Administrator (FA). LPA's investigation consisted of obtaining a statement from the Reporting Party (RP) on 04/02/2025 and a collateral visit with Client (C2) (See LIC811 - Confidential Names list dated: 05/22/2025) as well as an in-person interview with the C1, S1, and FA. On 4/28/2025, LPA scheduled and completed a phone interview with S2 due to her not being available the day of the initial inspection on 04/02/2025. On 3/28/2025, LPA conducted a review of the RFH's complaint history, reviewed documentation obtained from other agencies and Guardian / LIS systems. On 04/02/2025, LPA obtained and reviewed the LIC500 (Personnel Report), current client roster, initial needs and services plan for C1, and facility home sketch. Continued on LIC9099c. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Christopher J Williams LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: HILL SMALL FAMILY HOMEFACILITY NUMBER: VISIT DATE: 05/23/2025

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 55

met_with: Ayan Hill, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On July 7, 2022, Licensing Program Analyst (LPA), Johanna Lofton conducted an announced pre-licensing inspection for the the purpose of the relocation of the Hill Small Family Home. LPA Lofton met with the licensee, Ayan Ukash Hill. Licensee reported having three (3) clients currently placed at the facility. A physical plant inspection was completed and included the following checks: Bedroom 1 which will be occupied by Client #1. Bedroom 2 will occupied by Clients #2 and #3, Bedroom 3 which will be occupied by Client #4. Bedroom 4 (Master) will be occupied by licensee. There are three (3) full bathrooms and one (1) half bathroom. There is a kitchen, dinning area and living area. The facility is clean and in good repair. It's grounds are free of observable hazards. There is adequate indoor and outdoor activity space, including a backyard. The smoke and carbon monoxide detectors are in working order. Knives and sharps will locked in a kitchen drawer. All utilities were on during the inspection. Licensee reports the State License, Emergency Plan (LIC 601); and facility sketch will be placed the facility by the entrance. The fire department is scheduled to conduct the fire clearance inspection on 7/7/22 at 2:00pm. Licensee was informed to send LPA Lofton the fire clearance prior to moving/relocating. An exit interview was conducted and the SFH Licensee. LPA provided a signed copy of this report (LIC 809) and LIC 811 (Confidential Names) was provided to the facility representative.

report_type: Facility Evaluation

visit_type: Prelicensing

met_with: Ayan Ukashi Hill- Licensee


summary: Facility Evaluation

raw_content:
Narrative:
On November 01, 2022, qt 10:00AM, Licensing Program Analyst (LPA) Humberto Flores, conducted an unannounced Post-Licensing Inspection at Hill Small Family Home (SMH) and met with Gregory Shelton. The purpose of the inspection was informed to the facility representative. During the inspection a copy of the Register of Facility Clients and Personnel Report was provided upon request. The following topics were inspected: PHYSICAL PLANT: A tour of the facility was conducted, along with the facility representative. The License was placed in a prominent place. LPA Flores observed that the facility is clean, safe, sanitary and in good repair. The passageways are unobstructed. The disinfectants and cleaning solutions were stored away from the kitchen areas, food preparation areas to the children. The food is safe and of the quality and the quantity necessary to meet the needs of the clients. Each meal meets at least 1/3 of the recommended in the USDA Basic Food Group Plan-Daily Food Guide. Supplies of staples non-perishable foods for one week and perishable foods for two days are maintained in the facility. # Medications are locked and accessible only to the Licensee and the Director. The temperature in the rooms that clients occupy are maintained between 68 and 85 degrees (F) and the hot water temperature was at 105 degrees (F). CLIENT RECORDS: LPA Flores reviewed the 1 (1) client file records. The files contain: Admission Agreement, Medical Assessment, Consent Forms, Emergency Information, Appraisal & Needs Service Plan, Immunization Record and Personal Rights. LPA Flores observed that in Child's Ref #1 (C1) (see Confidential Names form LIC811 dated 11/01/2022) the JV-223 / Order on Application for Psychotropic Medication is expired and Medication Ref #1 (M1) is not documented in a separate log. Staff Records: A total of 3 employees' file was reviewed. The files contain the following documentation: Child Abuse Index Checks/Department of Justice (DOJ)/Federal Bureau of Investigation (FBI) criminal record clearances, criminal record statement, health screening, tuberculosis test results and First Aid Certificate and Cardiopulmonary Resuscitation. OPERATIONAL REQUIREMENTS: During the inspection review, LPA Flores observed the facility maintained an updated roster of the clients with pertinent information. The Licensee and Director are the responsible and capable for communicating with emergency personnel if needed. # Further inspection is needed to complete this Post Licensing Inspection. A copy of this report, citation page, appeal rights and LIC811 were provided to the SMH representative. Exit interview conducted.

met_with: Gregory Shelton, Director


summary: Facility Evaluation

raw_content:
Narrative:
On November 07, 2022, at 11:00AM, Licensing Program Analyst (LPA) Humberto Flores, conducted an unannounced Post-Licensing Inspection at Hill Small Family Home (SMH) and met with Ayan Hill and Gregory Shelton. The purpose of the inspection was informed to the facility representative. During the inspection a copy of the Register of Facility Clients and Personnel Report was provided upon request. The following topics were inspected: CLIENT RECORDS: LPA Flores reviewed the three (3) client file records. The files contain: Admission Agreement, Medical Assessment, Consent Forms, Emergency Information, Appraisal & Needs Service Plan, Immunization Record and Tuberculosis Test. Child Ref #2 (C2): LPA Flores observed that in Child's Ref #2 file (C2) (see Confidential Names form LIC811 dated 11/07/2022) Psychotropic Medication Administration Records (PMAR) documents a count for medication Ref #1 (M1), that does not match with the number of pills in the bottle, exceeding in 5 pills the physical count in the bottle. cont.# The PMAR documents a count for medication Ref #2 (M2), that does not match with the number of pills in the bottle, exceeding in 4 pills the physical count in the bottle. The licensee did not ensure that a record of centrally stored prescription medications is maintained for C2. Child Ref #3 (C3): LPA Flores observed that in Child's Ref #3 file (C3) PMAR documents a count for medication Ref #3 (M3), that does not match with the number of pills in the bottle, exceeding in 5 pills the physical count in the bottle. The PMAR documents a count for medication Ref #4 (M4), that does not match with the number of pills in the bottle. The label says 30 pills, but there are 35 pills in it, exceeding in 5 pills the physical count in the bottle due to mixing medication from 2 bottles. The licensee did not ensure that a record of centrally stored prescription medications is maintained for C3. A copy of this report, citation pages, appeal rights and LIC811 were provided to the SMH representative. Exit interview conducted.

visit_type: Case Management

met_with: Ayan Ukash Hill, Licensee


summary: Facility Evaluation

raw_content:
Narrative:
On 07/27/23, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced inspection at the Small Family Home (SFH) above for the purpose of conducting an annual inspection. LPA met with the licensee of the home, Ms. Ayan Hill. Currently, there are three (3) minor non-ambulatory clients in placement. There are no bodies of water on the premises. A physical plant inspection was completed. The facility license, facility sketch, emergency disaster form and personal rights form were all prominently displayed in the home. All exits and hallways were observed to be free and clear of hazards and obstruction. Smoke detectors and carbon monoxide detectors are in working order. The water temperature was within regulatory guidelines. First aid kit was readily available and complete. Food supplies, both perishable and non-perishable, were checked and found to be sufficient. Knives and sharps are locked in a kitchen drawer. Medications are locked inside a cabinet located in the kitchen. Chemicals and cleaning products are locked in a cabinet in the garage. Ms. Hill confirmed there are no weapons and/or ammunition in the home. Overall, the facility is clean, safe and sanitary. The following sleeping arrangements were noted: Bedroom # Master Bedroom Bedroom #2 sleeps Client Bedroom #3 vacant room with two beds Bedroom #4 sleeps Client Bedroom #5 sleeps Client Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good condition. Each bedroom has sufficient drawer and closet space. There are three full bathrooms and one-half bathroom in the home, all in working order. The licensee is the main caretaker of the home. Client file is stored under lock and key in the file cabinet in the Master Bedroom. Emergency disaster drills are conducted at least every six (6) months. LPA reviewed three (3) client records and two (2) staff records. LPA checked required criminal record and child abuse index check clearance or exemption for all adults in the home. The client's files contained: Admission Agreement, Medical Assessment, Consent Forms, Emergency Information, Individual Family Service Plan, Immunization Record and Personal Rights. LPA interviewed two (2) staff members. Clients are non-verbal, and no client interview was conducted. No deficiency citations were issued during today's inspection. An exit interview was conducted and a copy of this report was provided to the licensee, Ms. Ayan Hill.

visit_type: Annual

met_with: Ayan Hill


summary: Facility Evaluation

raw_content:
Narrative:
On March 28, 2024 at 5: P.M.l Licensing Program Analyst (LPA) Demetris Teal conducted an unannounced case management investigation at Hill Small Family Home. LPA met with Ayan Hill-Administrator. Purpose of the visit was to initiate an investigation regarding incidents that occurred on March 16 and March 18, 2024. LPA requested the phone numbers for staff listed on confidential LIC 811. Administrator provided phone numbers of staff. Further investigation is required. Exit interview conducted and signed copy of this report was provided to Ayan Hill along with LIC 811 (Confidential Names list). Appeal rights given.

met_with: AYAN HILL-Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On May 30, 2024, Licensing Program Analyst (LPA) Joe Martinez, initiated a case management inspection at Hill Small Family Home (SFH) and met with the above caregiver. LPA Martinez reviewed 4 youth files and and retrieved a folder with state files. There are no deficiencies to be cited at this time. An exit interview was conducted, and LPA Martinez gave a copy of the signed LIC 809 to the SFH representative.

met_with: Ayon Hill


summary: Facility Evaluation

raw_content:
Narrative:
On June 6, 2024, at 12:30 p.m., Licensing Program Analyst (LPA) John Bonilla conducted an unannounced inspection at the Hill Small Family Home (SFH) for the purpose of delivering an amended report regarding complaint 32-CR-20240202143107 delivered on April 3, 2024. LPA met with Carissa Williams, Direct Care Staff. SFH was issued a Technical Advisory during this inspection as referenced on amended findings report. Exit interview conducted. A signed copy of this report and LIC9102-TA were provided to Carissa Williams, Direct Care Staff. Appeal rights provided and explained.

met_with: Carissa Williams, Direct Care Staff


summary: Facility Evaluation

raw_content:
Narrative:
On June 26, 2024, a meeting was held regarding the spike of complaints for Hill Small Family Home. Licensing Program Manager (LPM) Tira Logan informed Ayan Hill (Licensee) of Johanna Lofton being the newly assigned Licensing Program Analyst (LPA) to monitor the facility. The purpose of the meeting was to address the spike of facility's complaints. In attendance were: Tira Logan- Licensing Program Manager Johanna Aracena- Licensing Program Analyst Ayan Hill- Licensee Roberth Hahn- Ms Hill's Attorney During the meeting, the licensee reported the spike of complaints was generated because she took in care a very challenging youth who didn't want to be with her and made a lot of false allegations. She also reported the youth doesn't stay at a place very long. The youth was a placement out of San Diego County. The youth was placed at Hill Small Family Home from January 2024 through May 3, 2024. After the ending of this timed placement, the youth was removed but a week later she asked for a second chance and asked to return to Ms. Hill's (Hill SFH) on 06/06/24. Ms. Hill took her back but within 48hrs the youth was arrested for battery. Charges were later dropped, and youth was hospitalized on a 5150 hold. Ms. Hill reported, Youth told her that she was going to run the streets to get out of the system and if she had to lie, she would do it. Youth also stated she was going to destroy the home when she got discharged. On 6/10/24, Ms. Hill contacted youth's social worker and requested an emergency 24hrs removal because of the youth threats. Licensee reported the youth was dangerous to bring back to the facility. During the meeting it was agreed the licensee will review Hill SFH Program Statement to focus on staff training and care for the children. Licensee will reach out to LPA Lofton if she needs help or has any questions. Ms. Hill also addressed issues with other complaint allegations findings. She reported she has been up front with the information. Ms. Hill was advised by LPM Logan and LPA Lofton to appeal the findings. There were no questions or concerns to address, and the meeting was concluded.

met_with: Ayah Hill- Licensee


summary: Facility Evaluation

raw_content:
Narrative:
On 07/30/24, Licensing Program Analysts (LPAs) Johanna Lofton and Dawn Mahecha conducted an unannounced inspection at the Small Family Home (SFH) above for the purpose of conducting an annual inspection. LPAs met with the Facility Administrator Ayan Hill. At the time of the visit there are three (3) non-ambulatory clients placed at the facility. Currently,there are four (4) minor non-ambulatory clients in placement. There are no bodies of water on the premises. A physical plant inspection was completed. The facility license, facility sketch, emergency disaster form and personal rights form were all prominently displayed in the home. All exits and hallways were observed to be free and clear of hazards and obstruction. Smoke detectors and carbon monoxide detectors are in working order. The water temperature was within regulatory guidelines. First aid kit was readily available and complete. Food supplies, both perishable and non-perishable, were checked and found to be sufficient. Knives and sharps are locked in a kitchen drawer. Medications are locked inside a cabinet located in the kitchen. Chemicals and cleaning products are locked in a cabinet in the garage. Ms. Hill confirmed there are no weapons and/or ammunition in the home. Overall, the facility is clean, safe and sanitary. The following sleeping arrangements were noted: Bedroom # Master Bedroom- Licensee Bedroom # Client Bedroom # Client Bedroom # Client Bedroom # Client Individual beds were observed in the bedrooms. Linen, pillows, comforters, and mattresses were observed to be clean and in good condition. Each bedroom has sufficient drawer and closet space. All three full bathrooms and half bathroom were observed to be in working order. LPAs observed the fire extinguisher to be up to date. The smoke and carbon monoxide detectors were tested and were in working order at the time of the inspection. There are six (6) direct care staff available at the facility. Licensee is still the main care taker for the clients. Client and staff files are electronic and kept on the licensee's computer. The licensee and facility director have access to them. Emergency disaster drills are conducted at least every six (6) months. Emergency disaster plan is posted and available for review. LPAs reviewed three (3) staff files and two (2) client records/files. All forms and documents were accounted for. Criminal record and Child Abuse Index clearance were reviewed and confirmed for all the adults at the facility. No deficiency citations were issued during the annual inspection. An exit interview was conducted and a copy of this report was provided to the licensee.

met_with: Ayan Hill- Licensee


summary: Facility Evaluation

raw_content:
Narrative:
On September 23, 2024, at 1:30 p.m., Licensing Program Analyst (LPA) John Bonilla conducted an unannounced inspection at the Hill Small Family Home (SFH) for the purpose of delivering an amended report regarding complaint 32-CR-20240202143107, originally delivered on April 3, 2024. LPA met with Ayan Hill, Licensee. No deficiencies were cited during this inspection. Exit interview conducted. A signed copy of this report was provided to Ayan Hill, Licensee. No further action required.

met_with: Ayan Hill, Licensee


summary: Facility Evaluation

raw_content:
Narrative:
On October 22, 2024, at 2: PM, Licensing Program Analyst (LPA) Winston Moroney carried out an unannounced inspection at the Hill Small Family Home (SFH) to present an amended report concerning complaint 32-CR-20240314111824, which was initially submitted on June 14, 2024. During this visit, LPA engaged with Ayan Hill, the Licensee. No deficiencies were cited during this inspection. Exit interview conducted. A signed copy of this report was provided to Ayan Hill, Licensee. No additional action is required.


summary: Facility Evaluation

raw_content:
Narrative:
On July 17, 2025, Licensing Program Analysts (LPA) Johanna Aracena conducted an unannounced inspection Hill Small Family Home (SFH) with the purpose of conducting an annual required inspection. LPA met with the Facility Administrator/Licensee Ayan Hill. At the time of the visit there are four (4) non-ambulatory and one (1) ambulatory clients placed at the facility. Two (2) of the clients in placement are non-minor dependents. A physical plant inspection was completed with the licensee. The facility license, facility sketch, emergency disaster form and personal rights form were all prominently displayed in the home. All exits and hallways were observed to be free and clear of hazards and obstructions. Smoke detectors and carbon monoxide detectors are in working order. The water temperature was within regulatory guidelines. First aid kit was readily available and complete. Food supplies, both perishable and non-perishable, were checked and found to be sufficient. Knives and sharps are locked in a lockbox in a kitchen cabinet. Medications are double locked in a kitchen cabinet. There are also two lockboxes for medication that require refrigeration. Chemicals and cleaning products are in a lockbox in the garage. The licensee confirmed there are no weapons or ammunition in the home. Overall, the facility is clean, safe, sanitary and in good repair. There are no bodies of water on the premises. The following sleeping arrangements were noted: Bedroom # Occupied by C1. Availability for two clients Bedroom # Occupied by C Bedroom # Occupied by C Bedroom # Occupied by C Bedroom # Occupied by the licensee Bedroom # Occupied by C Individual beds were observed in the bedrooms except bedroom #1 which is equipped with two (2) twin beds. Bedroom #4 was created by adding a wall and a door in March 2025. Per the city of Bakersfield, the licensee was not required to obtain permits due to not changing the structure of the home or adding square footage. Linen, pillows, comforters, and mattresses were observed to be clean and in good condition. Each bedroom has sufficient drawer and closet space. There are three (3) full bathrooms and half bathroom which were observed to be in working order. LPA observed the fire extinguisher to be up to date in service. The smoke and carbon monoxide detectors were tested and were in working order at the time of the inspection. There are seven (7) direct care staff and one (1) facility director working at the facility. Licensee is still the main care taker for the clients and have staff scheduled in 24hrs rotations for help. Client and staff files are electronic and kept on the licensee's computer. The licensee and facility director have access to them. Emergency disaster drills are conducted at least every six (6) months. Emergency disaster plan is posted and available for review. LPA reviewed five (5) staff files staff files and five (5) client records/files. All forms and documents were accounted for. Criminal record and Child Abuse Index clearance were reviewed and confirmed for all the adults at the facility. No deficiency citations were issued during the annual inspection. An exit interview was conducted and a copy of this report was provided to the licensee.

met_with: Ayan Hill - Licensee


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On March 6, 2024 at 4: P.M.l Licensing Program Analyst (LPA) Demetris Teal conducted an unannounced case management inspection at Hill Small Family Home. LPA met with Ayan Hill-Administrator. Purpose of the visit was to discuss incident reports received by CCL. CCL was notified late of incidents. On February 2, 2024, Community Care Licensing (CCL) received an email report for incidents that occurred on January 26, 2024 and January 27, 2024. On February 27, CCL received an email report for incidents that occurred on February 21, 2024 and February 23, 2024. Interview with administrator revealed that there was an understanding from the previous analyst of when reports need to be submitted to CCL. Administrator understood reports to be submitted within 7 days. Administrator said she reports same day or next day to the social worker. Administrator said she will include CCL on reports to social worker as well. Administrator was educated on the regulations for reporting. Administrator was shown on the LIC 624 reporting procedure time frame. Based on this review and response from Ayan Hill, facility is cited for violation of California Code of Regulation, Title 22, Division Section 80061 (b) Reporting Requirements. Facility failed to report the incident within the next working day as required. Exit interview conducted and signed copy of this report was provided to Ayan Hill along with LIC 811 (Confidential Names list). Appeal rights given.

Deficiencies:
80061(b): Upon the occurrence, during the operation of the facility, ..., a report shall be made to the licensing agency within the agency's next working day during its normal business hours....In addition, a written report... shall 1
2
3
4
5
6
7Facility will review reporting guidelines and submit occurrances the next working day, including CCL in same day/next day repoorts sent to social worker.
8
9
10
11
12
13
14

met_with: Ayan Hill- Administrator

title:
1
2
3
4
5
6
780061(b) Reporting Requirements


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
All confidentially interviewed parties reported the appointment was originally scheduled for 10/27/25; however, the appointment was changed to 10/22/25 by the client's social worker without notifying the caregiver. The caregiver reported not being available for the appointment on 10/22/25 due to another commitment with another client. Furthermore, the co-complainant confirmed the appointment on 10/22/25 was for a follow-up appointment for a broken femur rather than a scheduled surgery as stated by the complainant. Due to the information obtained during the investigation, it cannot be determined whether the above allegation occurred. Based on the compiled information the complaint allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations occurred. No deficiencies were cited. An exit interview was conducted, and a copy of this report provided to the above-named staff.

Investigation Findings:
13On March 4, 2026, Licensing Program Analyst (LPA) Johanna Aracena conducted an unannounced visit to Hill Small Family Home with the purpose of delivering findings for the above complaint allegation. LPA Aracena met with the Facility Administrator Ayan Hill and discussed the findings. During the investigation of the allegations, LPA Aracena could not contact the complainant for an interview. LPA Aracena interviewed facility staff and the facility administrator on 11/12/25. LPA Aracena interviewed the Co-Complainant on 1/09/26. LPA Aracena could not interview the client due to her being non-verbal. (See Confidential Names List-LIC 811 dated 03/04/2026). The allegation stated that the licensee did not ensure that minor in care received medical attention as necessary. The complainant reported that the administrator failed to take the client to a scheduled surgery on 10/22/25. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Johanna Aracena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: HILL SMALL FAMILY HOMEFACILITY NUMBER: VISIT DATE: 03/04/2026

met_with: Ayan Hill - Administrator


raw_content:
Narrative:
All parties reported the appointment was originally scheduled for 10/27/25; however, the appointment was changed to 10/22/25 by the client's social worker without notifying the caregiver. The caregiver reported not being available for the appointment on 10/22/25 due to another commitment with another client. Due to the information obtained during the investigation, it cannot be determined whether the above allegation occurred. Based on the compiled information the complaint allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the allegations occurred. No deficiencies were cited. An exit interview was conducted, and a copy of this report provided to the above-named staff.

Investigation Findings:
13On January 10, 2026, Licensing Program Analyst (LPA) Johanna Aracena conducted an unannounced visit to Hill Small Family Home with the purpose of delivering findings for the above complaint allegation. LPA Aracena met with the Facility Administrator Ayan Hill and discussed the findings. During the investigation of the allegations, LPA Aracena conducted confidential interviews with the complainant on 1/09/26, facility staff and administrator on 11/12/25, and witnesses on 1/09/26. LPA Aracena could not interview the client due to her being non-verbal. (See Confidential Names List-LIC 811 dated 01/10/2026). During the investigation, the allegation of the licensee did not meet their duties and responsibilities as required was denied by the administrator and the facility staff. The complainant reported the administrator failed to take the client to a doctor's appointment on 10/22/25 for a follow up of the client's broken femur. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Johanna Aracena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: HILL SMALL FAMILY HOMEFACILITY NUMBER: VISIT DATE: 01/10/2026


facility_name: HINTON SMALL FAMILY HOME

summary: Facility Evaluation

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Narrative:
On 6/10/21, at 1:02 pm Licensing Program Analyst (LPA) Belinda Gilmer made an announced required annual inspection and met with Linda Hinton licensee. At 1:21 pm Licensee and LPA toured inside and outside of the home. During the outside tour LPA observed a blue nose pit bulldog. Currently there are no foster children placed in this home. There are five adults residing in the home at the time of this visit. (see confidential name form (LIC 811) dated 6/10/10. There were no foster children placed in the home at the time of this inspection. The home is set up as follows: This is a one-story home three bedrooms (the family room was converted into a bedroom approved by the city of West Covina making it a four bedroom, 1.5 bathrooms, kitchen, dining area/ living room. Bedroom # 1 - Sleeps licensee son that's pending conservator ship (medical bed, twin bed, dresser and portable closet space). Bedroom # 2 - occupied by licensee adopted daughter (twin bunk beds, dresser and closet space). Bedroom # 3 - occupied by licensee fourteen-year-old grandson and adopted son (one twin bed, dresser and closet space). Bedroom # 4 - occupied by licensee and caregiver share bedroom # 4 (king bed, dresser and closet space). There were appropriate furnishings in the home. There is a fireplace in bedroom/family room that's blocked off. The bathrooms were checked and were in operating condition. The home had adequate food supply. The kitchen trash can was covered. The gas stove was tested and working, the combination smoke detector/ carbon monoxide was tested in the bedrooms. The smoke detectors in the hallway was not tested as it's connected to the alarm system and goes directly to the fire department. The home had a locked container where medications will be stored. The disinfectants, cleaning solutions and other dangerous items were stored in a cabinet in the garage inaccessible to children. There are no foster children placed in home at the time of this inspection. Licensee has not completed her required training, nor did she have a current first aid CPR during this visit. In accordance with California Code of Regulation, Title 22, Division 6, a technical assistance advisory note alone with the licensee forms was emailed to licensee during this inspection. Exit interview was conducted with Licensee

met_with: Linda Hinton


summary: Facility Evaluation

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Narrative:
On May 9, 2022, Licensing Program Analyst (LPA), Claudia Portillo conducted an unannounced inspection at the small family home (SFH) above for the purpose of conducting an annual inspection. LPA met with the licensee of the home, Linda Hinton. There were no clients in care. A physical plant inspection was completed and included the following checks: small family home grounds are free of observable hazards. There is adequate indoor and outdoor activity space, including an outdoor yard. The smoke and carbon monoxide detectors are in working order. Knives and sharps are locked in a kitchen drawer. LPA observed the State License, Emergency Plan (LIC 601); and facility sketch throughout the facility. LPA obtained and reviewed the following updated documentation: · LIC Personnel · Approved Fire Clearance · Plan of operation/Program Design Continued on page 2.......... Continued page 2....... The Small Family Home (SFH) program was in full compliance with 3 applicable areas of the Compliance and Regulatory Enforcement (CARE) Tools, for Children's Residential licensees. Annual compliance Review consisted of the following domains: physical plant, operations, and staffing. Community care licensing (CCL) focuses its efforts on three priority areas: prevention, compliance, and enforcement. Due to the SFH not having clients in care, some domains were excluded. The Administrator was interviewed as part of this review. No citations were issued during this inspection. All staff members are associated to the SFH. An exit interview was conducted and the SFH Administrator, Linda Hinton. LPA provided a signed copy of this report (LIC 809) and LIC 811 (Confidential Names) was provided to the facility representative.

met_with: Linda Hinton, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Inspection Tool Didn't Final Print During Annual 05/9/22


summary: Facility Evaluation

raw_content:
Narrative:
On August 8, 2023, Licensing Program Analyst (LPA), Claudia Portillo conducted an unannounced inspection at the small family home (SFH) above for the purpose of conducting an annual inspection. LPA met with the licensee of the home, Linda Hinton. There were no clients in care. A physical plant inspection was completed and included the following checks: small family home grounds are free of observable hazards. LPA observed the State License, Emergency Plan (LIC 601); and facility sketch throughout the facility. The Small Family Home (SFH) program was in full compliance with 3 applicable areas of the Compliance and Regulatory Enforcement (CARE) Tools, for Children's Residential licensees. Annual compliance Review consisted of the following domains: physical plant and operations. Community care licensing (CCL) focuses its efforts on three priority areas: prevention, compliance, and enforcement. Due to the SFH not having clients in care, some domains were excluded. The Administrator was interviewed as part of this review. No citations were issued during this inspection. An exit interview was conducted and the SFH Administrator, Linda Hinton. LPA provided a signed copy of this report (LIC 809) and LIC 811 (Confidential Names) was provided to the facility representative


summary: Facility Evaluation

raw_content:
Narrative:
On January 31, 2024, Licensing Program Analyst (LPA), Claudia Portillo conducted an unannounced visit at the small family home (SFH) above for the purpose of conducting an annual inspection. LPA met with the licensee of the home, Linda Hinton. There were no clients in care.. An annual was conducted on August 8, 2023. The Small Family Home (SFH) program was in compliance with 3 applicable areas of the Compliance and Regulatory Enforcement (CARE) Tools, for Children's Residential licensees: physical plant, operations, and staff files. Community care licensing (CCL) focuses its efforts on three priority areas: prevention, compliance, and enforcement. NMDs weren't able to be interview due to being non-verbal. Based on observations and record review, no citations were issued on today's annual inspection. An exit interview was conducted with the SFH Administrator. LPA provided a signed copy of this report (LIC 809) and LIC 811 (Confidential Names) was provided to the facility representative.


summary: Facility Evaluation

raw_content:
Narrative:
On January 30, 2025, Licensing Program Analyst (LPA), Claudia Portillo conducted an unannounced visit at the small family home (SFH) above for the purpose of conducting an annual inspection. LPA met with the licensee of the home, Linda Hinton. There were no clients in care.. The Small Family Home (SFH) program was in compliance with 3 applicable areas of the Compliance and Regulatory Enforcement (CARE) Tools, for Children's Residential licensees: physical plant, operations, and staff files. The LPA has informed the the provider that she must update the POO/PS. Community care licensing (CCL) focuses its efforts on three priority areas: prevention, compliance, and enforcement. Based on observations and record review, no citations were issued on today's annual inspection. An exit interview was conducted with the SFH Administrator. LPA provided a signed copy of this report (LIC 809) and LIC 811 (Confidential Names) was provided to the facility representative.


summary: Facility Evaluation

raw_content:
Narrative:
On January 30, 2026, Licensing Program Analyst (LPA), Claudia Portillo conducted an unannounced visit to the small family home (SFH) above for the purpose of conducting an annual inspection. LPA met with the licensee of the home, Linda Hinton. There were no clients in care. LPA reviews the following sections using the Compliance and Regulatory Enforcement (CARE) Tools: physical plant, operations, and staff files. Community care licensing (CCL) focuses its efforts on three priority areas: prevention, compliance, and enforcement. LPA was conducting an inspection and interview with licensee; it was revealed that an Adult Resident (AR) has resided in the home without having obtained the required criminal record clearances. This poses an immediate, safety or personal rights risk to the children placed in care. Under Title 22, Section 80019 (2)(B) Criminal Record Clearance. These standard states that the Department shall conduct a criminal record review of all individuals specified in Health and Safety Code Section 1522(b) and shall have the authority to approve or deny a facility license, or employment, residence, or presence in the facility, based upon the results of such review. Any person, other than a client, residing in the facility. AR obtained his live scanned and last week which is still pending in the guardian system. A signed copy of this report, LIC811, LIC809-D, and appeal rights were provided to Ms. Hinton. Exit interview conducted.


facility_name: HOLDING HEARTS SMALL FAMILY HOME

summary: Facility Evaluation

raw_content:
Narrative:
On 08/07/2024 at 2: PM, the COMPONENT II of the application process for Holding Hearts, located at S Vermont Ave Unit #1, Gardena, CA 90247, was held at the California Department of Social Services, Community Care Licensing Division - Children's Residential Program - Regional Office in El Segundo. In attendance were Licensing Program Analysts (LPAs) Dennis Jarmin and Justine Armstrong, and applicant Meagan Gossett. The purpose of this Component II meeting was to review the submitted application and Program Statement, specifically to address and resolve any outstanding items or concerns. The discussion focused on several incomplete application forms: 1. Designation of Administrative Responsibility (LIC 308): A designated individual is required to be authorized to act in the licensee's absence. 2. Health Screening Report - Facility Personnel (LIC 503): The tuberculosis (TB) test section of the form needs to be completed, including results, or a separate test verification must be provided. 3. Facility Sketch (LIC 999): The sketch must include the dimensions of all rooms, designate their use, and show door and window exits. Exit routes should be indicated by number, as shown on the LIC 610/LIC 610A. Emergency Disaster Plan. Rooms used by non-ambulatory clients/residents and staff need to be identified, along with two evacuation sites for emergencies. (Cont) Program Statement Discussions: - Detailed discussions included topics such as medication destruction procedures, dietary options with a sample meal plan for school, and the process for a 30-day client post-admission assessment. Important Dates: The applicant, Ms. Gossett, was advised that revisions and/or corrections to the application are due by August 13, 2024. A Pre-Licensing Inspection is scheduled to be conducted on August 14, 2024, at 9: AM. A copy of this report will be provided to Ms. Gossett.

met_with: Meagan Gossett


summary: Facility Evaluation

raw_content:
Narrative:
On 08/14/2024 at 09: AM, Licensing Program Analyst (LPA) Dennis Jarmin and LPA Justine Armstrong conducted a Pre licensing visit with the Applicant Meagan Gossett at the above address. The following was observed. This is a three story home with 3 bedrooms and 3 full bath and 1 half bathroom. Currently there are no children residing in the home. The furniture in the home appears to be in good condition. The living room has sofa, wall mounted television, overhead lighting and recessed lighting in good repair. The family room is complete with sofa, TV, and appropriate amount of space for family time. There are appropriate amount food and water observed which includes all four food groups. LPA's confirmed operable smoke detectors in bedrooms and hallways, fire extinguisher is located in kitchen- wall mounted next to the kitchen sink. First Aid kit is available and will be maintained in the locked cabinet. There is a two car garage in the first floor of the home. The home has surplus of cabinets for use and 6 burner stove with microwave on top. The home has a Medication lock box stored in the staff bathroom. Hot water temperature is between 105 to 120 degrees. Central air and heat, free of debris and other hazardous items. There is locked shed in the garage and applicant was advised must keep locked and inaccessible to clients in care. There are no bodies of water on the premises. LPA's observed no camera at this time and Applicant confirmed no firearms in the home. Bedroom #1, not occupied by applicant, twin size bed, night stand with drawers. Bedroom #2 is currently not occupied by Applicant and observed two twin beds, and overhead lighting with night stand with four drawers. Bedroom #3 is occupied by applicant with king bed and has a full bathroom inside. All window observed with blinds that is in good repair inclduing window screens. Bathroom has shower and sink. Hot water was tested and found to be between 105-120 degrees (F). Cont. The following items were identified and recommended: 1. Applicant was advised to replaced bathrooms trashcan with a trashcan with a lid. 2. Bedroom #1 wall behind door needs to be repaired. 3. Applicant advised to send a copy of the CA ID of the designee employee and the criminal statement LIC 508D. The home is extremely clean and organized and had appropriate furnishing throughout the home. Exit interview conducted with applicant.

met_with: Maegan Gossett


summary: Facility Evaluation

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Narrative:
On 10/25/2024 at 09: AM, Licensing Program Analyst (LPA) Dennis Jarmin conducted a Pre-licensing visit with Applicant Meagan Gossett at the above address. The following was observed. This is a one story home with 3 bedrooms 2 full bathroom. Currently, there are no children residing in the home. The furniture in the home appears to be in good condition. The living room has a sofa, wall-mounted television, overhead lighting, and recessed lighting in good repair. The family room is complete with a sofa, TV, and an appropriate amount of space for family time. There is an open faced fireplace not in use with covering but needs to be secured and inaccessible. There are appropriate amount of food and water observed which includes all four food groups. LPA's confirmed operable smoke detectors in bedrooms and hallways, and a fire extinguisher is located in the kitchen- wall mounted next to the kitchen sink. First Aid kit is available and will be maintained in the locked cabinet. There is a two-car garage in the front area of the home. The home has a surplus of cabinets for use and a 4-burner stove, a dual conventional oven and large refrigerator with freezer. The home has a Medication lock box stored in the staff applicant bedroom. The hot water temperature is between 105 to 120 degrees. Central air and heat, free of debris and other hazardous items. There is a locked shed in the backyard that is inaccessible. There are no bodies of water on the premises. LPA's observed two camera inoperable at the living room and dining area at this time. Applicant confirmed no firearms in the home. Bedroom #1, occupied by applicant, queen size bed, nightstand with drawers. Bedroom #2 is currently not occupied by Applicant and observed two twin beds and overhead lighting with two nightstand/cabinet with four drawers. Bedroom #3 is not occupied by applicant with two twin bed and a built cabinet for each future client. All windows observed with blinds that are in good repair including window screens. The bathroom has a shower and sink. Hot water was tested and found to be between 105-120 degrees (F). Cont. The following items were identified and recommended: 1. Open fireplace must be must have covering and inaccessible. The home is extremely clean and organized and had appropriate furnishing throughout the home. Exit interview conducted with applicant.


summary: Facility Evaluation

raw_content:
Narrative:
On 01/23/2025 at 09: AM, LPA Licensing Program Analyst - Dennis Jarmin and LPA Justine Armstrong arrived at the Holding Hearts to conduct the Post Licensing inspection. LPA's conducted a walk through of the home to verify compliance with SFH standards. The following were observed: This is a one story home with 3 bedrooms and 2 full bathroom. Currently, there are no child residing in the home. The furniture in the home appears to be in good condition. The living room has a sofa, wall-mounted television, overhead lighting, and recessed lighting in good repair. The family room is complete with a sofa, TV, and an appropriate amount of space for family time. There is one open faced fireplace not in use but secured and inaccessible. There are appropriate amount of food and water observed which includes all four food groups. LPA's confirmed 6 operable smoke/carbon monoxide detectors in bedrooms and hallways, and a fire extinguisher located in the kitchen and garage mounted in the wall. First Aid kit is available and will be maintained in the locked cabinet. There is an outside space accessible to the minor in the rear side of the home that is free of debris and/or hazards. The home has a surplus of cabinets for use and a 4-burner stove, a dual conventional oven and large refrigerator with freezer and a dishwasher that is operable and in good repair. The home has a Medication lock box stored in the licensee's bedroom. The hot water temperature is between 105 to 120 degrees. There are natural air and plenty of windows that has screen covering in good repair. There is also central air and heat around the home. There is a locked shed in the backyard that is inaccessible. There are no bodies of water on the premises. The Facility license, emergency contact numbers, monthly planner and meal menu posted and available for review LPA observed camera inside the dining area close to the kitchen that is not operable. Applicant confirmed no firearms in the home. Bedroom #1 not occupied and has two twin size bed, night stands with drawers. Bedroom #2 is not occupied with two twin size bed with two closet space for each client and bedroom 3 is occupied by the licensee with a queen bed. All windows observed with blinds that are in good repair including window screens. The bathroom has a shower and sink. Currently, there is no client in the facility and no files were reviewed except staff 1. The home is extremely clean and organized and had appropriate furnishing throughout the facility. Exit interview conducted with the licensee.


facility_name: HOME AWAY

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Itzel Suarez and Licensing Program Manager (LPM) Lakescia Smith met in person with applicant Kefelegn Yeshiharge for the Component II Interview. The meeting was to review the application and program details for her small family home, Home Away. What Was Reviewed and Discussed: 1. Component I Certificate: The team confirmed that the applicant completed the required orientation. 2. Identification: A copy of the applicant's ID was made for the records. 3. Background Check: The applicant and her son's the criminal background is pending. 4. Forms: LIC 200: Title needs to correct, e-mail, landline needs be installed, and county added. LIC 400: The applicant added the required date. LIC 500: The applicant was asked to correct the job title listed for herself and son. LIC 308: The person designated will be changed to her son. Emergency Evacuation: Address for locations were missing. Continuation on LIC 809-C 5. Facility Sketch: The layout needs to be revised to meet guidelines. 6. Fire Clearance: Approval is still pending. The applicant must install proper fire alarms and a pool fence. · B7 - Program Design (Needs Revisions): Several parts of the program design are not in compliance and must be updated. The following items must be revised or added: · Remove references to caring for "non-ambulatory" clients. · Include a one-month activity schedule for the children. · Add a weekly food menu. · Provide clear procedures for handling medical emergencies. · Describe how transportation to doctor and dental appointments will be arranged. · List community resources and consultants the home will use. Add procedures for how incidents and complaints will be handled. B8 - Discipline Policy: Must remove all references to "Nate House." Admission Policies (B9): Several documents were incomplete or incorrect, including: · Needs and Services Plan · Medical Assessment Continuation on LIC 809-C - Emergency Information · Sign-in/sign-out procedures · Admission agreement, refund policy, and modification conditions The application and Program Design were returned to the applicant for corrections. The revised documents, including the updated LIC 200 form, are due by July 7, 2025. Additional Notes: LPA and LPM discussed which placement agency the applicant plans to work with to receive clients. They also reviewed licensing responsibilities, especially Small Family Home Regulation Section 83064. LPA and LPM provided Applicant with forms 200, 400, 500, and Application Instructions for A Facility License. · Copy of Orientation/ Application Process Certificate of Completion was provided to the Applicant. · Sketch was provided to the Applicant. · Copy on Buildings and Grounds was given to the Applicant. · Sample of activities and menu was given to the Applicant. Next Step: A Pre-Licensing Visit for Home Awayis scheduled for July 14, 2025, at 9: AM.

met_with: Applicant


summary: Facility Evaluation

raw_content:
Narrative:
On July 14, 2025 at 9: AM, Licensing Program Analyst (LPA) Itzel Suarez and Licensing Program Manager Lakescia Smith arrived at the above facility, for the purpose of conducting a Pre- licensing inspection for a Small Family Home License. LPA met with applicant, Kefelegn Yeshiharge who granted access into the home. The applicant and LPA and LPM toured the facility both inside and out. Currently residing in the home is applicant and adult son. Applicant is requesting to be licensed for 3 clients ages 3-17 ambulatory only. The home was inspected and the following was observed: The home is a one-story residence with a two-car garage and a fenced backyard that includes a swimming pool. Living Room: There is adequate furniture which is in good condition. The area is equipped with a sofa, two chairs, and a small table. There is vinyl flooring with an area rug located in the living room in front of the sofa. Family Room: Furnished with a sofa, one straight-back chair, a coffee table, and a mounted 77" television. A fireplace is located beneath the television; it is enclosed with doors and a safety screen. Adjacent dining area includes a six-seat dining table with six straight-back chairs. Six smoke detectors and one carbon monoxide detector were tested and found to be operational. Continuation on 809-C Each bedroom contains one smoke detector, with additional detectors located in the hallway and dining area. Formal Dining Area: Contains a six-seat dining table. Kitchen: with a mounted, operable fire extinguisher. Functional five-burner stove, refrigerator/freezer, and small kitchen appliances. The menu is not available. Cleaning supplies and sharps are stored and inaccessible to clients. The kitchen island has three chairs for additional seating. Bedroom #1: is equipped with 1 king sized bed and it occupied by applicant. There is one bathroom inside the room with one shower, toilet, and sink. Bedroom #2: is located to the right of hallway and is equipped with 1 queen size bed, clean bedding, adequate closet, computer and desk, operation ceiling fan and this room is occupied by applicant's adult son. Bedroom #3: Queen size bed, bed frame has drawers, 1 nightstand and closet. The bed had clean bed sheets and linens. Applicant will add to twin beds for two clients to occupy the room. Bedroom #4: 1 full size bed, bed frame has drawers, 1 nightstand and one closet. The bed had clean bed sheets and linens. The room will be available for one client. All rooms are clean, safe, sanitary and have operable windows. Outdoor: Pool is gated. The backyard needs to be clean. Wood and cleaning tools need to be removed. Safety Items: The first aid kit checked and is missing tweezers. Fire Extinguisher available in the home and fully charged. Continuation on 809-C Telephone: Applicant will be using a cellphone that will always remain in the facility. Applicant will keep the phone in the kitchen area. The cellphone number is (424) 360-7091. Cameras: There are two cameras in the home. One is in the backyard and one in the front of the home that monitors the exterior of the property. The applicant monitors the camera through her phone. Vehicles: The home will utilize Toyota Prius to transport clients in care. Current automobile registration is valid until March 2026 and car insurance is with Allstate Insurance Company and is current until 9/12/2025. Vehicle was inspected and is in good operating order. Prior to being licensed the following is required: · Water temperature must measure between 105-120 in bathroom. -Tweezers need to be added to the First Aid Kit. -In bedroom# 3 applicant will add two twin size beds. · Cleaning tools, wood, and trash must be remove from the backyard and made inaccessible which poses a potential safety hazard. -Linen closet locks need to be fixed and organized. -Heater closet lock needs to be fixed with a proper hook to make it inaccessible. -Pool fence locking mechanism door needs to swing outward without having to unlock it from the outside. -Nails protruding from the bricks needs to be remove. -Emergency Disaster Plan needs to be printed and posted - Menu needs to be available and accessible. - Applicant will purchase additional non-Perishable food for the home. Exit Interview was conducted and a copy of this report was left with the applicant


summary: Facility Evaluation

raw_content:
Narrative:
On July 24, 2025 at 9: AM, Licensing Program Analyst (LPA) Itzel Suarez arrived at the above facility, for the purpose of conducting a Pre- licensing inspection for a Small Family Home License. LPA met with applicant, Kefelegn Yeshiharge who granted access into the home. The applicant and LPA and LPM toured the facility both inside and out. Currently residing in the home is applicant and adult son. Applicant is requesting to be licensed for 3 clients ages 3-17 ambulatory only. The home was inspected and the following was observed: The home is a one-story residence with a two-car garage and a fenced backyard that includes a swimming pool. Living Room: There is adequate furniture which is in good condition. The area is equipped with a sofa, two chairs, and a small table. There is vinyl flooring with an area rug located in the living room in front of the sofa. Family Room: Furnished with a sofa, one straight-back chair, a coffee table, and a mounted 77" television. A fireplace is located beneath the television; it is enclosed with doors and a safety screen. Adjacent dining area includes a six-seat dining table with six straight-back chairs. Six smoke detectors and one carbon monoxide detector were tested and found to be operational. Each bedroom contains one smoke detector, with additional detectors located in the hallway and dining area. Telephone: Applicant will be using a cellphone that will always remain in the facility. Applicant will keep the phone in the kitchen area. The cellphone number is (424) 360-7091. Cameras: There are two cameras in the home. One is in the backyard and one in the front of the home that monitors the exterior of the property. The applicant monitors the camera through her phone. Vehicles: The home will utilize Toyota Prius to transport clients in care. Current automobile registration is valid until March 2026 and car insurance is with Allstate Insurance Company and is current until 9/12/2025. Vehicle was inspected and is in good operating order. Prior to being licensed the following is required: · Water temperature must measure between 105-120 in bathroom. -Tweezers need to be added to the First Aid Kit. -In bedroom# 3 applicant will add two twin size beds. · Cleaning tools, wood, and trash must be remove from the backyard and made inaccessible which poses a potential safety hazard. -Linen closet locks need to be fixed and organized. -Heater closet lock needs to be fixed with a proper hook to make it inaccessible. -Pool fence locking mechanism door needs to swing outward without having to unlock it from the outside. -Nails protruding from the bricks needs to be remove. -Emergency Disaster Plan needs to be printed and posted - Menu needs to be available and accessible. - Applicant will purchase additional non-Perishable food for the home. Exit Interview was conducted and a copy of this report was left with the applicant Formal Dining Area: Contains a six-seat dining table. Kitchen: with a mounted, operable fire extinguisher. Functional five-burner stove, refrigerator/freezer, and small kitchen appliances. The menu is not available. Cleaning supplies and sharps are stored and inaccessible to clients. The kitchen island has three chairs for additional seating. Resource Parent did have perishable and l non-perishable food available. Bedroom #1: is equipped with 1 king sized bed and it occupied by applicant. There is one bathroom inside the room with one shower, toilet, and sink. Bedroom #2: is located to the right of hallway and is equipped with 1 queen size bed, clean bedding, adequate closet, computer and desk, operation ceiling fan and this room is occupied by applicant's adult son. Bedroom #3: Queen size bed, bed frame has drawers, 1 nightstand and closet. The bed had clean bed sheets and linens. Applicant will add to twin beds for two clients to occupy the room. Bedroom #4: 1 full size bed, bed frame has drawers, 1 nightstand and one closet. The bed had clean bed sheets and linens. The room will be available for one client. All rooms are clean, safe, sanitary and have operable windows. Outdoor: Pool is gated and backyard was clean. Safety Items: The first aid kit checked and it had all the requirement items. Fire Extinguisher available in the home and fully charged. Continuation on 809-C


summary: Facility Evaluation

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Narrative:
On July 24, 2025, at 1: PM, Licensing Program Analyst (LPA) Itzel Suarez met in person with applicant Kefelegn Yeshiharge to conduct the Component II Interview. The purpose of the meeting was to review the application and program details for her small family home, Home Away. During the meeting: LPA Suarez informed the applicant that several required forms that need correction and need to be submitted. These include: LIC 200, LIC 610C, LIC 999, and LIC 9054. LPA Suarez reviewed the revised Program Design submitted on July 12, 2025. However, it still does not meet the requirements of the Small Family Home Regulations and General Licensing Rules. The applicant will need to update documents B7-B9 according to the application instructions. LPA Suarez went over the application and Program Design Instructions with the applicant and requested additional revisions. The applicant agreed to submit the updated and corrected documents by July 28, 2025. The meeting concluded with an exit interview.

met_with: Kefelegn Yeshiharge


summary: Facility Evaluation

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Narrative:
On July 24, 2025, at 1: PM, Licensing Program Analyst (LPA) Itzel Suarez met in person with applicant Yeshiharge Kefelegn to conduct a Small Family Home (SFH) Component III office meeting. LPA Itzel Suarez. met with Applicant to discuss forms required to be maintained, available, and posted at the facility for inspections. We discussed child and personnel records that are required to be documented, retained and available for inspection. We also discussed specific requirements, concerns and issues operating a Small Family Home (SFH), such as, reporting requirements, finances, basic services, accountability, personnel requirements, admission agreements, client medical assessment, client records, telephone usage, transportation, health services, food services, responsibility for providing care and supervision, building and grounds, licensing inspections, waivers and exceptions, civil penalties, reasonable and prudent parenting standards, needs and services plan, children's records, personal rights, discipline, and activities. Licensing of facility is pending final approval due to revisions needed for the application LIC forms and Program Design as well as the final inspection visit. A copy of this report was provided to the Applicant,Yeshiharge Kefelegn .


summary: Facility Evaluation

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Narrative:
On 12/16/25, Licensing Program Analyst (LPA) Andrea Aceves and Licensing Program Manager (LPM) Lakescia Smith met with applicant Kefelegn Yeshiharge at the El Segundo Regional Office to follow up on her pending Small Family Home application During a review of the application, there is a confusing information that pertains to the operation of a group home. LPA and LPM discussed compliance concerns and requested that applicant to submit revisions to CCL. LPA would like to remind the applicant regarding the following responsibilities to operate a Small Family Home: Licensee Duties and Responsibilities (a) The licensee shall be responsible for: (1) Participating with the child in activities. (2) Participating with agencies and other responsible persons in planning for the needs of the child. (3) Ensuring that the child is clean and providing the child with training in personal cleanliness and hygiene. (4) Protecting the child from home accidents. See LIC809-C (5) Making provisions for the child to attend available community treatment or training programs when the child has needs which can be met by such programs. (6) Participating in activities which increase the licensee's own understanding of, and skill in, caring for children. (7) Providing for and meeting service needs of the child as identified in the needs and services plan required by Section 83068.2. (8) Assisting the child in the development of goals and encouraging them to reach those goals. (9) Supervising the provision of basic services within the home. (10) Unless restricted by the case plan adopted by the court or other court order, the licensee shall permit and facilitate connections between the child and the child's siblings, family members, relatives, and non-relative extended family members. Nothing in this section shall be interpreted to require a provider to take any action that would impair the health and safety of children in out-of-home placement (b) The licensee shall be regularly present in the home when children are in the home full time. (1) If all children are involved in out of home programs, such as school or day care, the licensee shall be permitted to be regularly absent during those hours. (2) When the licensee is absent from the home while children are present the licensee shall provide for supervision of the children by a responsible adult unless otherwise agreed to in advance by the licensing and placing agencies. Applicant agreed to submit revision to CCL by Friday, December 19, 2025. Exit interview conducted and a copy of this report was provided to applicant.

met_with: Applicant-Kefelegn Yeshiharge


facility_name: HOOKS FAMILY HOME

summary: Facility Evaluation

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Narrative:
On April 15, 2025 at 3:00PM, Licensing Program Analyst (LPA) Adaleyci Caballero met with Applicant Steven Joseph Hooks Sr for a Component II of the application process. Lpa a. Caballero went over revisions needed for the application prior to license and are due no later than May 13 , 2025. Lpa a. Caballero provided applicant with a copy of the LIC 184, Notice of Incomplete Application and additional correspondence to assist with the revisions needed to the application. A copy of this report was provided to applicant via email. The original signed copy of this report will be placed in the facility file.

met_with: Applicant- Steven Joseph Hooks Sr


summary: Facility Evaluation

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Narrative:
On June 4, 2025, at 9:45AM, Licensing Program Analyst (LPA) Adaleyci Caballero completed a pre-licensing inspection of Hooks Small Family (SFH). LPA met with Applicant Steven Hooks Sr. who led a tour of the home. The facility was toured both inside and out with the applicant. There are no clients in placement. The home is a two-story building with five bedrooms and three full bathrooms which are set up as follows: Bedroom #1(first floor)- It consisted of one single bed. The beds had linen, comforters, and pillows. It will sleep adult son. Bedroom #2- It consisted of one single bed. The bed had linen, comforters, and pillows. It will sleep applicants' bio daughter. Bedroom #3- It consisted of two single beds. The beds had linen, comforters, and pillows. It will sleep two clients. Bedroom #4- It consisted of a set of bunk beds and a single bed. The beds had linen, comforters, and pillows. It will sleep three biological sons. Bedroom #5- (applicant) It consisted of one king bed. It will sleep applicant. A living room, dining room, kitchen, family room, laundry room, three car garage, and a backyard. The garage will be utilized for storage. The clients' bedrooms were arranged so that no more than two clients will be in a room. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. There was adequate closet space for the clients' belongings. There was a smoke detector in every bedroom. The eight smoke detectors were checked and working properly. The three Carbon Monoxide detectors were connected to the smoke detectors in the first floor. The home's central air conditioning modules were in the backyard. The water heater was in the garage. The appliances were in working order. There was adequate food storage space and a supply of perishable food and non-perishable food. The home had a trash can for storage of solid waste with a tight fitting lid. The client and staff files will be locked inside a locked filing cabinet in the applicant's bedroom. The sharp knives and chemicals were locked in a storage closet in the downstairs hallway inaccessible to children in care. Medications will be locked in a lock box in the downstairs bathroom. The hot water was at a temperature of 117.5 degrees Fahrenheit. There were two fire extinguishers present in the home located in the kitchen and upstairs hallway. The First Aid Kit was accessible and placed in the kitchen wall. There are no firearms in the home. There is no pool at the home. The backyard is fully fenced and free of debris. The home has four cameras on the outside premise of the home and six cameras in the common areas and hallways of the home. Corrections: Window screens need to be repaired. Pending Fire Inspection approval The Facility Sketch, Emergency Disaster Plan, Personal Rights, Visitation policies, and House Rules need to be posted. Component III was conducted. An exit interview was conducted, and a copy of this report was provided to applicant Steven Hooks Sr. via email due to technical difficulties. Application will be forwarded to Licensing Program Manager Abdoulaye Traore for licensure once corrections are received.

met_with: Applicant-Steven Hooks Sr.


summary: Facility Evaluation

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Narrative:
On August 19, 2025 at 3:45PM, Licensing Program Analysts (LPAs) Adaleyci Caballero and Maya Chavez met with Applicant Steven Joseph Hooks Sr to go over revisions that are still needed for the application prior to license and are due no later than September 19, 2025. A copy of this report and additional correspondence to better assist applicant with the corrections were provided to applicant via email. The original signed copy of this report will be placed in the facility file.

met_with: Applicant-Steven Hooks


facility_name: HOPE HARBOR SMALL FAMILY HOME

summary: Facility Evaluation

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Narrative:
On June 25, 2025 at 11:05 am, Licensing Program Analysts (LPAs) Charmaine Linley and Stefanie Mutialu met with applicant Stephen Barimah for Component II Orientation for a Small Family Home. Mr. Barimah confirmed the acknowledgement of the revisions needed and will submit the revisions and training certificates via email to LPA by end of day of July 10, 2025. Due to printer difficulties, a copy of this report was emailed to the applicant along with the signed Orientation form indicating Component II has been completed. A copy of this report will be placed in the facility file.

met_with: Stephen Barimah


summary: Facility Evaluation

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Narrative:
On the date listed above, Licensing Program Analyst (LPA) Charmaine Linley conducted Component III - Category Specific Orientation Training for Small Family Homes with applicant Stephen Barimah, via Microsoft Teams. The Pre-Licensing Inspection has been scheduled for August 18, 2025, at 10:00 am. LPA sent a copy of this report to the applicant via email for signature. A copy of the signed Orientation Certificate for completing Component III was also emailed to the applicant. A copy of the signed report will be placed in the applicant's facility file.


summary: Facility Evaluation

raw_content:
Narrative:
On August 18, 2025, at 10:10 am, Licensing Program Analyst (LPA) Charmaine Linley arrived at the home to conduct a pre-licensing inspection of the facility. LPA met with Applicant, Stephen Barimah, who led a tour of the facility. The facility was toured inside and outside with the Applicant. Currently, there are no clients in placement. The facility is a two-story building with five bedrooms and three bathrooms which is set up as follows: Bedroom #1 (Master) has a King-Sized bed and sleeps the Licensee and his spouse. Bedroom #2 (Client) has one queen-sized bed and will sleep one client. Bedroom #3 (Client) has one queen-sized bed and will sleep one client. Bedroom #4 (Client) has one full-sized bed and will sleep one client. Bedroom #5 (Personal) has one queen-sized bed and is used for a personal bedroom. No clients will sleep in this bedroom. If this bedroom is going to be used as a client bedroom, the Licensee will provide an updated facility sketch and communicate with their LPA before making any changes. The Client's bedrooms were arranged so that no more than two client's will be in a room. No room commonly used for other purposes is used as a bedroom and no bedroom serves as a passageway to another room. The facility also consists of a great room, dining room, kitchen, a loft on the second floor, a laundry room located in the hallway on the second floor, a two car garage, and the backyard. *** There is no pool at the home at the time of this inspection. There was adequate closet space for the client's belongings. There were seven smoke/carbon monoxide detectors in every bedroom and the downstairs hallway and upstairs hallway. The combo detectors were checked and in properly functioning order. The home's central air conditioning module was located in the backyard. The home's water heater was located in the garage. The home appliances were in working order at the time of this inspection. The Client and Staff files will be locked in a cabinet located in the kitchen. There was adequate food storage space. LPA observed some non-perishable food, however, will return for a follow up inspection to check if the food available is sufficient for three meals over three days and snacks. A trash can for storage of solid waste had a tight-fitting lid and was present in the kitchen. The sharp knives are in a locked cabinet over the stove, inaccessible to clients. The medications will be located in a locked cabinet in the kitchen. The hot water in the kitchen was measured and registered at 111 degrees at 10:29 am, which is within the regulatory requirements. The home's First Aid kit was accessible and is located in the front hallway and contained all required supplies. The facility did not have a first aid manual. There were two fire extinguishers present in the home located in the front hallway and one fire extinguished located upstairs next to the laundry room. They were observed to be properly charged and inspected by the fire department. There are no firearms or weapons in the home as stated by the applicant. The backyard where clients will have access to play is fenced. The home has two security cameras located on the inside perimeter of the home (kitchen, upstairs loft and to be reinstalled in the front driveway, and backyard). The following corrections need to be made to the home: Drawer space for the client's bedrooms, linens on each of the bed, a mattress in bedroom #4, food sufficient for three meals over three days, and the posted grievance/complaint form, menu, LIC 610, first aid manual, and additional recreational activities for the clients. LPA will return to check for the corrections on August 28, 2025 at 12:00 pm. An exit interview was conducted, and a copy of the report was provided to Stephen Barimah. A copy of this report will be placed in the facility file.

met_with: Stephen Bamirah


summary: Facility Evaluation

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Narrative:
On August 26, 2025, at 12:05 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived at the home to conduct a continuation of the pre-licensing inspection of the facility. LPA met with Applicant, Stephen Barimah, who led a tour of the facility. The facility was toured inside of bedrooms #2, #3, #4, entryway, kitchen and dining room with the Applicant. Currently, there are no clients in placement. The facility is a two-story building with five bedrooms and three bathrooms which is set up as follows : Bedroom #2 (Client) has one queen-sized bed and will sleep one client. There is adequate drawer space for the client's belongings. Bedroom #3 (Client) has one queen-sized bed and will sleep one client. There is adequate drawer space for the client's belongings. Bedroom #4 (Client) has one double-sized bed and will sleep one client. There is adequate drawer space for the client's belongings. The mattress was replaced and now has a double sized bed. There is sufficient linens to allow changing of the linens at least once a week on each of the client's beds. There is non-perishable food sufficient for three meals over three days. LPA observed the posted forms: Menu, Activity Calendar, Grievance/Complaint form, and LIC 610: Emergency Disaster Plan. LPA observed the first aid manual in the entryway next to the first aid kit. *** The Licensing Program Manager will review the application and this report and once approved, the Facility License will be printed out and emailed to the applicant. An exit interview was conducted, and a copy of the report was provided to Stephen Barimah. A copy of this report will be placed in the facility file.


facility_name: HOPE HAVEN

summary: Facility Evaluation

raw_content:
Narrative:
On June 27, 2025, at 12:50PM, Licensing Program Analyst (LPA) Rachel Vanegas met with Hope Haven Small Family Home Applicant, Mayra Gaona, at the Riverside Children's Residential Program Regional Office for the purpose of conducting a Component II meeting. LPA discussed corrections and revisions needed for the Program Statement. The following is a summary of the corrections and revisions discussed and requested. These revisions are due by close of business on July 14, 2025. A2. Applicant Information (LIC 215) - Please review and revise to include additional experience and certificates for child development training, reference letters supporting childcare and supervision experience, etc. A3. Applicant Information (LIC 308) - Please review and revise Title of the authorized representative for this document A10. Personnel Report (LIC 500) - Please review and revise to provide days and times for 24hr/7days per week childcare and supervision - Please provide LIC 500 for identified Adult Residential Facility A11. Personnel Records (LIC 501) Please complete and provide this document for identified support personnel on LIC 308 and any additional staff identified on the LIC A14. Emergency Disaster Plan (LIC 610C) - Please review and provide permission letters from the identified relocation sites A15. Facility Sketch (LIC 999) - Please review and revise to include identification for doors and dimensions for all rooms **** Program Statement Corrections Needed B7. Facility Program Description - Please review and include corresponding page numbers to the Table of Contents - Please remove "eviction" from Page 3 on Table of Contents - Please review and remove mention of Group Home Program Statement on Page 3 of Table of Contents - Please review and revise "LIC 604" under Sample Forms of the Table of Contents on Page 4. This document is only a guide and not to be used as the Admission Agreement for the home. - Please identify source of placement clearly on Page 5 - Please review and remove "as necessary" for 24hr 7 days a week care and supervision for children in care, Page 6. - Please review and clarify special care needs identified on Page 6. - Please review and identify house rules and expectations mentioned on Page 6 - Please review and revise how behavior and punishment will be documented, Page 6. - Please review and clarify the use and monitoring of identified "Goals", whether that is on a Needs and Services Plan, etc., Page 7. Days and Hours of Operation - Please review and revise statement of "if the children are present" in reference to hours of operation, Page Basic Services Provided - Please describe how the facility will obtain consent forms for the facility to authorize medical care Optional Services - Please review and revise that the authorized representative or placing agency will sign the written agreement, Page 12. Assistance with Bedside Care and Medication - Please review, include, and provide information regarding where medication administered will be logged, Page 13. Medication Procedures - Please review and identify the use of the appropriate Medication Administration Record (MAR) (LIC 622A or LIC 622B) that will be used to log medication administration, Page 15. **** - Please review and identify that any medication refusal by a client is considered a "Special Incident" and a report needs to be completed and submitted to Community Care Licensing (CCL), per reporting requirements timeframes, Page 15. - Provide a statement that medication errors will need to be reported and documented to CCL, per reporting requirements timeframes. - Please review and identify the use of the appropriate MAR on #11, Page 16. - Please review and revise the responsible party to purchase over the counter medication for children in care, Page 16. Self-Administered Medications - Please review and clearly state that medication will be locked AND "inaccessible to the children..." Page, 17. - Please include that there can be temporary administration of psychotropic medication authorized on the JV220(A) Physician's Statement while the JV223 is pending - Please review and include policy for psychotropic medication use, documentation (LIC622B), administration, how the facility will obtain a copy of the current court order, or written authorization for each psychotropic medication, Page 17. - Please review and provide more information regarding documentation for medication refusal policy, etc. Transportation: - Please review and revise that smoking any substances in a vehicle used to transport children in care is prohibited whether or not children are present, Page 18. - Please review and revise reference to the California Car Seat Law requirements for child seat belt requirements to include the use of booster seats, etc., Page 18. Community Resources and Consultants - Please review and include the name of your home to remove the (Name of my Home) template, Page 19. - Please note the foster youth's right to attend their school of origin when identifying the public schools on Page 20. **** Immediate Response to Incidents and Complaints - Please include the complaint hot line number and information in this section as well, Page 21. - Please review and include a timeline for review of internal incident investigations, Page 21. - Please identify the documentation that will be utilized for incident reporting (LIC 624, etc.), Page 21. Please include a statement regarding notification to CCL if the Licensee will be out of the home for longer than 48hrs. Procedures for Reporting Abuse - Please review and revise reporting requirements to ensure compliance as a mandated reporter, Page 22. Water of Bodies/Pools and Supervision - Please review and clarify if there is an identified body of water at your home location, etc., Page 23. If there is, please update your facility sketch as well. B8. Discipline Policies and Personal Rights - Please review and remove reference to "eviction", Page 24. - Please include Personal Rights, they are not identifiable in this section as titled. - Please describe how the child and authorized representative will sign the personal rights form at intake and each time a new right has been added. You may utilize the LIC 613B (06/22). House Rules - Please review and clarify #8 to align with Page 9's identified schedule regarding bedtime, Page 25. Enforcement of House Rules - Please review and remove reference to "eviction", Page 26. Children's Personal Rights - Please review and revise this section to align with Page 24, as discussed, (Page 27). Runaway Plan - Please review and revise reference to restraint, Page 28. Please include documentation of an incident report for unauthorized absence and law enforcement contact to CCL and Authorized Representative as per reporting requirements, Page 29. Handling Complaints from the Children and Grievance Procedure - Please review and include contact numbers for identified Ombudsperson and CCL, Page 29. **** - Please identify the documentation that will be utilized for incident reporting (LIC 624, etc.), Page 29. Handling Complaints from Staff - Please identify what "immediately" will be in response to reporting concerns, etc. Page 30. CCL Investigative/Complaints on Second Chances Small Family Home Please review and revise "Second Chances Small Family Home", Page 30. Special Incident Reports - Please review and revise reference to "immediately" reporting incidents and contradiction statement for "by the working next business day", Page 30. - Please review and identify who the written report will be sent to, Page 30. Ground of Dismissal/Discharge and 14-Day Notice - Please review and revise the repeated information on Page 31 to maintain alignment with Page 43. #1 and #6 do not match on Page 31. Remove if not applicable. Eviction/Relocation/Removal from Placement - Please review and remove reference to eviction, Page 32. Health Related Services - Please review and identify the type of documentation that will be used in this section and where the documentation will be stored, Page 37. Loss of Placement/ Day-Notice - Please review and revise the repeated information on Page 43 to maintain alignment with Page 31. #1 and #6 do not match on Page 43. Remove if not applicable. Sample Menu - Please review and revise the sample menu provide to align with the weekday schedule provided on Page 9, Page 44. Admission Agreement - Please review and remove "Eviction Procedures" and revise the admission agreement to align with previous B16. First Aid Card - Please provide first aid and cardiopulmonary resuscitation card for the applicant, Mayra Gaona. Please review and include information regarding Camera Uses and Locations in accordance with Children's Residential Program Provider Information Notice 24-09. LPA Vanegas conducted an exit interview and a copy of this report along with the signed LIC 281C, Care Tools Pre-licensing form, and Children's Residential Program Provider Information Notice 24-09 were reviewed and provided to the applicant, Mayra Gaona.

met_with: Applicant - Mayra Gaona