summary: Facility Evaluation

raw_content:
Narrative:
On August 14,2025, at 10:15 am, Licensing Program Analyst (LPA) Guadalupe Munoz conducted an unannounced case management visit of the facility. LPA conducted a walk through of the facility, and no physical plant deficiencies were observed. LPA Munoz met with Facility Manager, Ann XXX. LPA informed facility that an investigation will be conducted regarding an incident that was reported on 08/02/25. On 08/02/25, Community Care Licensing (CCL) was notified of incidents that were documented on 07/30/25. It was reported by the facility that on 7/12/25, 7/27/25, 7/30/25,and 7/31/25 medication in bubble packs were determined to be slightly torn for Client 1 and C2, Facility reported that identified medication was removed from bubble pack and destroyed per Title 22 requirements. LPA requested and obtained documents necessary to the investigation. LPA conducted medication file review. Further information and interviews are required to resolve the concern therefore this investigation is being extended. The outcome of the investigation will be provided to the Facility Administrator. The facility is reminded not to discuss the ongoing investigation with any interested parties. An exit interview was conducted with Facility Manager and copy of this report and LIC 811 dated 08/14/25 was provided to the designee.

met_with: Anna Rodriguez


state: CA

facility_name: SOUTH COAST CHILDRENS SOCIETY-CALADIUM

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Based on confidential interviews and records reviewed that the allegation that staff are not utilizing the emergency intervention plan with minor in care, may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report and appeal rights were provided to Stephanie Cano, Facility Manager. A copy of this report will be placed in the facility file.

Investigation Findings:
13On November 6,2025, at 1: PM, Licensing Program Analyst (LPA) Guadalupe Munoz arrived unannounced at the facility and met with Stephanie Cano, Facility Manager, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on April 16, 2025, at 11:00 am, and no deficiencies were observed. LPA interviewed one Client (C1), three Staff (S1-3). LPA reviewed Staff Roster, Client Roster, Needs and Services Plans (NSPs) for clients, Client Safety Plans. On April 9, 2025, Community Care Licensing (CCL) received an allegation that staff are not utilizing the emergency intervention plan with minor in care. It was reported that C1 was engaging in unsafe behavior and that facility staff were not intervening. Confidential interviews revealed that there was not a clear understanding of the approved emergency intervention plan for the Facility. In addition, interviews revealed that NSPs and client safety plans were not current and not easily accessible to staff for review. Confidential interviews did not corroborate the allegation with a preponderance of evidence. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: SOUTH COAST CHILDRENS SOCIETY-CALADIUMFACILITY NUMBER: VISIT DATE: 11/06/2025

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

report_type: Complaint Investigation

met_with: Stephanie Cano

complaint_status: unsubstantiated


raw_content:
Narrative:
vehicle. Confidential interviews confirmed that keys to facility vehicle were left unattended and unsecured in the front living room. Interviews revealed that S2 entered the facility from an outing and placed the keys on top of the piano in the living room because S2 went to assist staff with de-escalating clients in crisis. Confidential interviews also revealed that C2 found the keys in the living room unattended and unsecured because C2 was alone and without their assigned 1:1 staff. Interviews further revealed that C1 and C2 were escalated and in crisis throughout the day and due to a staff shortage that day, there were not enough staff present to assign C1 and C2 a 1:1 staff. Based on confidential interviews, the preponderance of evidence standard has been met and the allegation that lack of supervision resulted in client obtaining keys to the facility vehicle is substantiated. The STRTP facility is being cited for violation of Interim Licensing Standards Version Section 80078(a) Responsibility for providing Care and Supervision. An exit interview was conducted, appeal rights were explained, and a copy of this report and Confidential Names List (LIC 811) dated 01/13/26 were provided to facility designee. Interviews confirmed that S1 came to assist S2 to de-escalate situation. Interviews further revealed that C1 was unwilling to let go of S2's hair and therefore S1 stepped in between C1 and S2 and that S1 placed their hands on the arms of C1 to release S2's hair. Confidential interviews revealed conflicting statements on whether or not S1 pushed C1. Confidential interviews confirmed that C1 had a nickel size bump on their head. Interviews also revealed conflicting statements as to how C1 obtained injury to head. Due to no witnesses observing S1 push minor or that C1 fell during the incident, thus it is unknown if S1 caused C1 to obtain the bump on their head. Based on confidential interviews and record review the allegations that staff pushed minor in care and that staff caused injury to minor due to inappropriate contact may have occurred, however, it is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights were explained, and a copy of this report and the Confidential Names List (LIC 811) was provided to facility designee

Investigation Findings:
13On January 13, 2026, at 11: AM, Licensing Program Analyst (LPA) Guadalupe Munoz met with facility representative, Breanna Tucker, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 06/10/25 at 9:30 am LPA observed that the facility did not have a designated Facility Manager on site. Please refer to Facility Evaluation Report (LIC 809) dated 6/16/2025, for violation of Title General Licensing Requirements Section 87065(f) Personnel Requirements. LPA interviewed four staff (S2-5) and two clients (C1, C2). S1 was not interviewed due to no longer working at the facility and no contact information. During the investigation, the facility documents and the clients' files were reviewed. On 06/05/25, Community Care Licensing (CCL) received an allegation that lack of supervision resulted in client obtaining keys to the facility vehicle. Specifically, it was reported that C2 was able to obtain keys that were unsecured to one of the facility vehicles and was able to get into the car, start the vehicle and move the SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: SOUTH COAST CHILDRENS SOCIETY-CALADIUMFACILITY NUMBER: VISIT DATE: 01/13/2026

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

met_with: Breanna Tucker


summary: Facility Evaluation

raw_content:
Narrative:
On April 16,2025, at 10:00 am, Licensing Program Analyst (LPA) Guadalupe Munoz conducted an unannounced case management visit of the Short-Term Residential Treatment Program (STRTP) facility. LPA conducted a walkthrough of the facility, and no deficiencies were observed. LPA Munoz met with Facility Manager Crystal Martinez to deliver findings for a case management investigation regarding an incident that was reported on 04/03/25. On April 3, 2025, Community Care Licensing (CCL) received information that three clients C1-C3 (please refer to Confidential Names List LIC 811), were left alone without staff supervision in C1s bedroom. Per confidential interviews, C1 and C2 are assigned 1:1 supervision at all times. C1's bedroom is located on the second floor of the facility and clients C1-C3 were able to barricade themselves in the bedroom while unsupervised. Clients were then able to throw a mattress out of the second-floor bedroom window and once the mattress was on the ground all three clients jumped out of the window and left the facility. LPA interviewed two staff (S1) and reviewed clients' (C1-C3) Needs and Services Plan. Confidential interviews and records reviewed confirmed that C1 and C2 assigned 1:1 staff did not follow 1:1 supervision protocol and left C1 and C2 unsupervised. In addition, all clients were left unsupervised in the bedroom which resulted in clients barricading door and jumping out of second floor window which posed an imminent safety risk to the clients. The STRTP is being cited for ILS v Article 06. Continuing Requirements Section80078(a) Responsibility for Providing Care and Supervision . Exit interview was conducted with Facility Manager, Crystal Martinez. A copy of this report, LIC 811 and Appeal Rights were provided to Facility Manager.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Crystal Martinez


summary: Facility Evaluation

raw_content:
Narrative:
On June 10,2025, at 9:30 am, Licensing Program Analyst (LPA) Guadalupe Munoz conducted an unannounced case management visit of the facility. LPA conducted a walk through of the facility, and no deficiencies were observed. The purpose of the inspection was to conduct an Incident Report (IR) follow up visit. LPA Munoz met with Program Supervisor, Ethan Ali.. Community Care Licensing (CCL) has only been provided with Incident Reports for clients that are past the seven days required to report an incident. In addition, the facility has not been notifying the department with a 24 hour notification of incidents that include law enforcement involvement, manual restraints and other incidents. The STRTP facility is being cited for violation of Title General Licensing Requirements, Section Reporting Requirements. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed to Ethan Ali, Program Supervisor.

met_with: Ethan Ali


summary: Facility Evaluation

raw_content:
Narrative:
On June 16,2025, at 11:00 am, Licensing Program Analyst (LPA) Guadalupe Munoz conducted an unannounced case management visit of the facility. LPA conducted a walk through of the facility, and no deficiencies were observed. The purpose of the inspection was to conduct a case management visit. LPA Munoz met with Program Supervisor, Ethan Ali. Based on confidential interviews and records reviewed, Community Care Licensing (CCL) has determined that the licensee doe not have a designated facility manager to be present at the facility at all times when one or more children are present as per Title General Licensing Requirements. The STRTP facility is being cited for violation of Title General Licensing Requirements Section 87065(f) Personnel Requirements. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed to Ethan Ali, Program Supervisor.

met_with: Ethan Ali, Program Supervisor


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On June 17, 2025, at 10:45 am, Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced inspection at the facility and met with Ethan Alli, Facility Administrator. This inspection is to discuss information that was reported to the Department and records reviewed by LPA on March 25, 2025. LPA interviewed one Client (C1), six Staff (S2-5, S8-9), and LPA was unable to interview three Staff (S1, S6-7), despite multiple attempts to contact them. LPA reviewed the facility documents. Refer to Confidential Names (LIC 811) dated 06/17/2025. Community Care Licensing became aware of an incident of S2 pulling on C1's ankles while C1 was laying in their bed. Confidential interviews indicated that S2 was waking C1 up and S2 placed their hands on C1's ankles to pull them out of bed. C1 told S2 to stop, and S5 redirected S2 not to place hands on the clients to wake them up, and S2 stopped pulling on C1's ankles. Documents reviewed indicated that the Facility did not report the incident to CCL as required. Based on confidential interviews and record review, the facility is being cited for a Type B violation of the Interim Licensing Standards STRTP 87072(c)(15) Personal Rights. Facility is also being cited for a Type A violation of California Code of Regulations, Title 22 80061(b) Reporting Requirements. Facility was issued a civil penalty of $250.00 for repeat violation of California Code of Regulations, Title 22 80061(b) Reporting Requirements. Refer to LIC809D. An exit interview was conducted, and appeal rights were reviewed with Ethan Alli. A copy of this report, LIC 811, and appeal rights were provided to the facility.

Deficiencies:
80061(b): Upon the occurrence, during the operation of the facility, of any of the events specified.... below, 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 containing the information specified below...shall be submitted to the licensing agency within seven days following the occurrence of such event.
1
2
3
4
5
6
7Per Administrator, a training of Reporting Requirements is scheduled for 06/18/205. A copy of the training agenda and sign in sheet will be sent via email to LPA by end of day on 06/18/2025.
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9
10
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12
13
14

met_with: Ethan Alli

title:
1
2
3
4
5
6
7Reporting Requirements


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPA) Jacqueline Garcia on 07/23/2025 at 09: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the visit, LPA met with Ethan Alli, Administrator and Breanna Tucker, Program Director, and conducted a health and safety inspection of the facility. No immediate health or safety risks were observed. LPA reviewed 4 of child's records and 3 of staff personnel files on site at the facility. LPA reviewed 4 of child's psychotropic medications and medication records. LPA interviewed 2 of 3 staff on site to discuss the facilities policies and procedures of operation. LPA interviewed 4 of 4 children who are currently prescribed psychotropic medication. During the inspection LPA observed deficiencies (see attached 809D), case management, plan of corrections were discussed and appeal rights were provided. LPA provided a copy of this licensing report to Breanna Tucker, Program Director.

met_with: Ethan Alli-Administrator


raw_content:
Narrative:
Confidential interviews revealed that staff conducted frequent bedroom checks on the quarantined youth every 10 to 15 minutes. Other confidential interviews revealed that bedroom checks were not conducted frequently on the quarantined youth. Based on confidential interviews, the allegation of a lack of supervision resulting in inappropriate behaviors amongst clients, may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report, along with appeal rights were explained and provided to Administrator Joseph Hancock.

Investigation Findings:
13On February 2, 2022, at 12:13pm, Licensing Program Analyst (LPA) Adrian Mendez arrived unannounced to the facility and met with Administrator Joseph Hancock and Program Director Rich Boyer of Southcoast-San Rafael to discuss the investigative findings for the allegation noted above. LPA conducted an inspection with the facility on August 20, 2021 at 11:23am, no deficiencies were noted. During the investigation LPA interviewed four children (C1, C2, C3, C4), and two facility staff (S1, S2). On August 11, 2021, the Department received an allegation of a lack of supervision resulting in inappropriate behaviors amongst clients. It was reported that C1 and C2 were quarantined in their bedroom together due to testing positive for Covid-19. It was also reported that C1 had been showing C1's private area to C2 and that C1 urinated on the floor and masturbated in front of C2. Confidential interviews revealed that C1 used a water bottle to imitate urinating on the floor to be funny. Confidential interviews also revealed that C1 did not masturbate in front of C2. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Adrian Mendez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: SOUTH COAST CHILDRENS SOCIETY-SAN RAFAELFACILITY NUMBER: VISIT DATE: 02/02/2022

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

met_with: Joseph Hancock


raw_content:
Narrative:
Confidential interviews revealed that the facility was contacted to clarify why C1 did not start their supplement after their physician's appointment and the facility did not have an answer to why C1 did not start the supplement as prescribed by their physician. Other confidential interviews stated the physician wanted C1 to start the medications and supplements a week at a time, over the span of four weeks, so the physician could monitor for side effects. Other confidential interviews also stated that the physician wanted C1 to try a prescribed allergy medication before starting the supplements. Confidential reports do not show the medication and supplements that were prescribed on the medical exam report to start over several weeks and do not report any delays in starting any of the medications or supplements. Based on confidential interviews, the allegation that supplements are not being administered to C1 as prescribed by their physician may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted and a copy of this report, along with the appeal rights were explained and provided to Kevin Vivas, Facility Manager. A copy of the report was emailed due to printer not working.

Investigation Findings:
13On May 19, 2022, at 8:55 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility and met with Kevin Vivas, Facility Manager, to discuss the investigative findings for the allegation noted above. LPA conducted an inspection of the facility on March 30, 2022, at 9:40 am. No deficiencies were observed. During the investigation, LPA interviewed two staff (S1 and S2) and was unable to interview C1. LPA also reviewed the Client Roster, C1's Needs and Services Plan, dated 03/28/2022, Child Family Team Meeting Noes dated 01/27/2022 and 03/22/2022, C1's Medical Exam Report, dated 02/23/2022 and 01/04/2021, C1's Medication Administration Records for January-March 2022, C1's Doctor's Orders for Over-the-Counter Medication, LIC 500, dated 03/31/2022, and Special Incident Report for C1, dated 04/19/2022. On March 24, 2022, the Department received an allegation that supplements are not being administered to C1 as prescribed by their physician. Confidential interviews reported that C1 was prescribed a supplement and C1 did not start the supplement until a month past the physician's appointment. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: SOUTH COAST CHILDRENS SOCIETY-SAN RAFAELFACILITY NUMBER: VISIT DATE: 05/19/2022

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

met_with: Kevin Vivas, Facility Manager


facility_name: SOUTH COAST CHILDRENS SOCIETY-SAN RAFAEL

summary: Facility Evaluation

raw_content:
Narrative:
On June 15, 2021, at 10:41AM Licensing Program Analyst (LPA) Adrian Mendez, conducted an unannounced Post Licesning/Annual inspection of the facility. The facility converted from a Group Home to STRTP (Short Term Therapeutic Program) on September 16, 2019. LPA was met at the facility by Administrator Joseph Hancock, Facility Manager Kevin Vivas and Program Director Rich Boyer. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster, the Emergency Disaster Plan was also posted. Medications are locked and centrally stored in the staff office located in the downstairs hallway. Medication records were reviewed and observed to be completed with dates and staff initials on dispensing records. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. Two bedrooms contain one twin bed, and two bedrooms contained two twin beds. The facility has three bathrooms. The water temperature in the kitchen with the sink was tested at 12:06pm and registered at 108.1 degrees which is within the appropriate range of 105 degrees to 120 degrees. Per facility staff, no firearms or weapons are allowed in the facility. Administrator Joseph Hancock is present at the facility a minimum of 20 hours a week. Appropriate staff/client ratios were verified during this inspection. Cont. on 809-C The facility employs three Clinical Support Staff, four facility managers and 11 direct care staff that are used in accordance with regulatory requirements. Licensee obtained Mental Health (MH) Certification in April 2021. Program Director has stated that National Accreditation through COA is currently being processed. The Accreditation audit began on 05/26/2021. Licensing fee payments are current. LPA discussed the following with the Administrator: Core Services, Specialty Mental Health Service, Trauma Informed Care, Client Personal Rights, and Administrative Duties. Due to time constraints and employee files being housed in their corporate office, LPA will return to the facility to conduct a continuation of staff file reviews. One facility staff was interviewed during the inspection. No clients were present at the time of the inspection. No deficiencies were found. Exit interview was conducted and a copy of this report was provided to the Program Director Rich Boyer.

visit_type: Annual

met_with: Rich Boyer


summary: Facility Evaluation

raw_content:
Narrative:
On June 22, 2021, at 3:37PM Licensing Program Analyst (LPA) Adrian Mendez conducted an unannounced annual continuation inspection from June 15, 2021. LPA met with Facility Manager Mallory Mandell. Employee files were not located at the facility and required employee files to be reviewed at Southcoast-Santa Cruz located at Santa Cruz Circle, CA 92626. Five personnel files were reviewed to ensure they contained all required documentation per Title Regulations. Personnel Files are maintained off-site in the Human Resource office. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. No deficiencies were noted during time of inspection.

met_with: Mallory Mandell


summary: Facility Evaluation

raw_content:
Narrative:
On April 14, 2023 at 9:35am, Licensing Program Analyst (LPA) Adrian Mendez arrived unannounced at the facility to conduct a Random Annual inspection of the facility. The facility converted from a Group Home to STRTP (Short Term Therapeutic Program) on September 16, 2019. LPA was met at the facility by Facility Manager Kevin Vivas, and Administrator Joseph Hancock. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. The bathrooms were clean and in good repair. The hot water from the kitchen sink was measured at 118.7 degrees, which is within regulatory requirements. All hazardous items have been properly made inaccessible. The medications were stored and locked in the staff office. Cleansers/chemicals are locked and stored in locked cabinets in the laundry room. Sharp knives are inaccessible and stored in a locked box in the kitchen below the sink. The First Aid Kit is located in the staff office and contained all required supplies. The facility's smoke/carbon monoxide detectors in the hallways were checked and were operable. There are no guns or weapons in the facility as stated by Facility Manager Kevin Vivas. The following required posted items were observed accessible to clients: Facility License, Grievance Procedures, Personal Rights, Visitation policies, Emergency Disaster Plan and current menu. The facility outside grounds was also inspected and it was observed to be clean and well maintained. There is no swimming pool or body of water located on the property. Due to time constraints and the need to complete staff/client file reviews, and staff/client interviews, this inspection will need to be continued at a later date. Based on the facility inspection, there are no deficiencies found at this time. An exit interview was conducted, and a copy of this report was explained to Facility Manager Kevin Vivas. Due to printer malfunction, this report will be emailed to Facility Manager Kevin Vivas, and Administrator Joseph Hancock.

met_with: Kevin Vivas, Joseph Hancock


summary: Facility Evaluation

raw_content:
Narrative:
On April 18, 2023 at 10:17am, Licensing Program Analyst (LPA) Adrian Mendez arrived unannounced at the facility to conduct an Annual Continuation inspection of the Random Annual inspection that began on 04/14/2023. LPA met with Administrator Joseph Hancock, and Facility Manager Kevin Vivas. LPA reviewed five client files during the inspection. All client files had the required documents per Title Regulations. All client files are maintained on a secured internet database. LPA discussed and reviewed the following inspection components; Operational Requirements, Emergency Disaster Preparedness, Core Therapeutic Services, and the Emergency Intervention Plan. Due to time constraints and the need to complete staff file reviews, and client/staff interviews, this inspection will need to be continued at a later date. Based on the facility inspection, and file review, there are no deficiencies found at this time. An exit interview was conducted, and a copy of this report was explained to Administrator Joseph Hancock. Due to printer malfunction, this report will be emailed to Administrator Joseph Hancock.


summary: Facility Evaluation

raw_content:
Narrative:
On April 25, 2023 at 9:52am, Licensing Program Analyst (LPA) Adrian Mendez arrived unannounced at the facility to conduct an Annual Continuation inspection of the Random Annual inspection that began on 04/14/2023. LPA met with Administrator Joseph Hancock, and Facility Manager Kevin Vivas. During the inspection, LPA conducted interviews with two staff and one client. All remaining residents declined to be interviewed. All the staff records are accessible electronically via a secured records portal. LPA reviewed 5 staff files. All the staff have met the training and qualification requirements per regulation requirements. Per a review of the Community Care Licensing Information System (LIS), all staff met DOJ/FBI criminal record clearances and Child Abuse Index Check requirements. Based on the facility inspection, and file review, there are no deficiencies found at this time. An exit interview was conducted, and a copy of this report was explained to Administrator Joseph Hancock. Due to printer malfunction, this report will be emailed to Administrator Joseph Hancock.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Eduardo Barragan on July 14, 2022, at 9: AM. During the inspection, LPA Barragan met with Blake Asato, House manager and inspected the facility inside and out. LPA reviewed two clients records on site at the facility at 10 am During the review of the clients records, LPA Barragan observed 2 out of 2 clients did not have current/accurate information listed on their Psychotropic Medication Administration Record (PMAR) forms. Some of the information that was refection on the PMAR did not match the medication's. For instance the "Start and End dates" were missing on C1's forms. Additionally, the "consent dates" on C2's forms did not match his JV220. Lastly, the expiration dates wasn't indicated on C1 nor C2's PMAR either. LPA reviewed 1 of staff personnel files on site at the facility at 1: PM. LPA interviewed 1 of staff on site at 2: PM. LPA interviewed 0 of children currently taking psychotropic medication at 2: PM. LPA conducted exit interview with Blake Asato, house manager or at 2: PM LPA provided the Summary Report to Blake Asato, house manager upon completion. One deficiency was observed (refer to LIC 809D) and cited from the California Code of Regulations, Title 22, and Health & Safety Codes during the inspection

met_with: Blake Asato, House manager


raw_content:
Narrative:
Based on confidential interviews, the allegations that staff yells at minor, and staff handled minor in a rough manner, may have occurred, however are not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report, along with appeal rights were explained and provided to Program Director Rich Boyer.

Investigation Findings:
13On August 20, 2021, at 10:38am, Licensing Program Analyst (LPA) Adrian Mendez conducted an unannounced inspection with the facility and met with Program Director Rich Boyer of South Coast Children's Society-Santa Cruz to discuss the investigative findings for the allegations noted above. LPA conducted a tele-inspection with the facility on March 25, 2021, at 11:27am, no deficiencies were noted. During the investigation LPA interviewed five children (C1, C2, C3, C4, C5), and two facility staff (S1, S2). On March 17, 2021, the Department received allegations that S1 yells at C1, and S1 handled C1 in a rough manner. Confidential interviews revealed conflicting statements: Staff sometimes raise their voice so C1 can hear staff because C1 yells and screams at the facility, and S1 does yell at C1. Confidential interviews also revealed conflicting statements that no clients have been observed being handled in a rough manner, and other confidential interviews reveal that C1 was hit and pushed by S1. There were no witnesses to the alleged incidents. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Adrian Mendez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: SOUTH COAST CHILDRENS SOCIETY-SANTA CRUZFACILITY NUMBER: VISIT DATE: 08/20/2021

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


facility_name: SOUTH COAST CHILDRENS SOCIETY-SANTA CRUZ

summary: Facility Evaluation

raw_content:
Narrative:
On June 15, 2021, at 3:19PM Licensing Program Analyst (LPA) Adrian Mendez, conducted an unannounced Post Licesning/Annual inspection of the facility. The facility converted from a Group Home to STRTP (Short Term Therapeutic Program) on September 16, 2019. LPA was met at the facility by Administrator Jude Chavez, and Program Director Rich Boyer. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster, the Emergency Disaster Plan was also posted. Medications are locked and centrally stored in the staff office. Medication records were reviewed and observed to be completed with dates and staff initials on dispensing records. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. Two bedrooms contain one twin bed, and one bedroom contained two twin beds. The facility has two bathrooms. The water temperature of the kitchen sink was tested at 3:58pm and registered at 118.2 degrees which is within the appropriate range of 105 degrees to 120 degrees. Per facility staff, no firearms or weapons are allowed in the facility. Administrator Jude Chavez is present at the facility a minimum of 20 hours a week. Appropriate staff/client ratios were verified during this inspection. Cont. on 809-C The facility employs three Clinical Support Staff, six facility managers and 12 direct care staff that are used in accordance with regulatory requirements. Licensee obtained Mental Health (MH) Certification in April 2021. Program Director has stated that National Accreditation through COA is currently being processed. The Accreditation audit began on 05/26/2021. Licensing fee payments are current. LPA discussed the following with the Administrator: Core Services, Specialty Mental Health Service, Trauma Informed Care, Client Personal Rights, and Administrative Duties. Due to time constraints and employee files being housed in their corporate office, LPA will return to the facility to conduct a continuation of staff file reviews. One facility staff was interviewed during the inspection. No clients were present at the time of the inspection. No deficiencies were found. Exit interview was conducted and a copy of this report was provided to the Administrator Jude Chavez.

met_with: Jude Chavez


summary: Facility Evaluation

raw_content:
Narrative:
On June 22, 2021, at 2:03PM Licensing Program Analyst (LPA) Adrian Mendez conducted an unannounced annual continuation inspection from June 15, 2021. LPA met with Facility Manager Mallory Mandell. During the inspection LPA reviewed five personnel files to ensure they contained all required documentation per Title Regulations. Personnel Files are maintained off-site at the Human Resources office. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. No deficiencies were noted during the time of the inspection.


facility_name: SOUTH COAST CHILDRENS SOCIETY - DAHLIA

raw_content:
Narrative:
Confidential interviews entailed that the residents were provided other options to Cup of Noodles. Based on confidential interviews, the allegation that staff are using inappropriate forms of discipline, may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report, along with appeal rights were explained and provided to Administrator Matthew Martinez.

Investigation Findings:
13On February 2, 2022, at 11:17am, Licensing Program Analyst (LPA) Adrian Mendez arrived unannounced to the facility and met with Administrator Matthew Martinez of Southcoast-Dahlia to discuss the investigative findings for the allegation noted above. LPA conducted an inspection with the facility on November 22, 2021 at 1:10pm, no deficiencies were noted. During the investigation LPA interviewed three children (C1, C2, C3), and one facility staff (S1). During the investigation, LPA reviewed the facility's meal menu. On November 17, 2021, the Department received an allegation that staff are using inappropriate forms of discipline. It was reported that the entire facility was being punished or on "lock down" because of the behavior of two other residents and were only allowed to eat Cup of Noodles. Confidential interviews revealed that due to a lock down the residents did not get to go on a dinner outing due to two resident's behavior. Confidential interviews also revealed that staff will maintain the dinner outing for those residents on good behavior if the facility is capable of maintaining ratio. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Adrian Mendez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: SOUTH COAST CHILDRENS SOCIETY - DAHLIAFACILITY NUMBER: VISIT DATE: 02/02/2022

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

met_with: Matthew Martinez


raw_content:
Narrative:
had occurred. Based on interviews and information obtained, the allegation that staff handled the child in a rough manner may or may not have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. A copy of this report was provided to and reviewed with Omar Gomez, Administrator, along with the appeal right and the LIC 811. A copy of this report will be placed in the Facility file. LPA reviewed the LIC 9099 via phone with Administrator, Matthew Martinez, and he gave permission via phone to LPA approving Omar Gomez to sign the LIC 9099.

Investigation Findings:
13On April 29, 2022, at 4:10pm, Licensing Program Analyst (LPA) Charmaine Linley made an unannounced complaint inspection at the facility. LPA Linley met with Omar Gomez, Interim Administrator, to discuss and deliver the investigative findings for the allegation noted above. LPA Linley conducted an unannounced inspection of the facility on April 14, 2022. No deficiencies were observed. During the investigation, LPA Linley and LPA Mendez interviewed three clients (C1, C2, C3) and three staff (S1, S2, S3) (see confidential name list, LIC 811, dated 04/29/22. LPA Linley reviewed the following documentation: C Needs and Services Plan, Quarterly Report, and Special Incident Reports. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: SOUTH COAST CHILDRENS SOCIETY - DAHLIAFACILITY NUMBER: VISIT DATE: 04/29/2022

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

met_with: Omar Gomez, Interim Administrator


raw_content:
Narrative:
Confidential interviews revealed that C1's injuries were sustained due to C1 fighting back during restraints. Confidential interviews revealed that S1 has been involved in restraints with C1 at the facility. Confidential interviews resulted in conflicting statements as to whether or not S1 has restrained C1 resulting in injury to C1. Based on confidential interviews and records reviewed, the allegation that S1 restrained C1 while in care resulting in injury, may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report, along with appeal rights were explained to Administrator Joseph Hancock. Due to printer malfunction, this report will be emailed to Administrator Joseph Hancock.

Investigation Findings:
13On August 23, 2022, at 10:38am, Licensing Program Analyst (LPA) Adrian Mendez arrived unannounced to the facility and met with Administrator Joseph Hancock of Southcoast-Dahlia to discuss the investigative finding for the allegation noted above. LPA conducted an inspection with the facility on June 30, 2022, at 11:41am, no deficiencies were noted. During the investigation LPA interviewed four children (C1, C2, C3, C4), and three facility staff (S1, S2, S3). During the investigation, LPA reviewed one Serious Incident Report (SIR) dated 06/18/2022, and staff Communication Log/Shift Reports dated 06/23/2022 and 06/24/2022. On July 28, 2022, the Department received an allegation that staff restrained minor while in care resulting in injury. It was reported that on 06/26/2022, C1 was taken to the hospital due to a headache. It was reported that C1 disclosed that C1's injuries, superficial scabbed over scrapes to C1's left elbow and right shoulder, were the result of being restrained at the facility by S1. Confidential interviews revealed that S1 has never been observed restraining C1 to have caused injury to C1. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Adrian Mendez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: SOUTH COAST CHILDRENS SOCIETY - DAHLIAFACILITY NUMBER: VISIT DATE: 08/23/2022

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


summary: Facility Evaluation

raw_content:
Narrative:
On June 15, 2021, at 1:07PM Licensing Program Analyst (LPA) Adrian Mendez, conducted an unannounced Post Licesning/Annual inspection of the facility. The facility converted from a Group Home to STRTP (Short Term Therapeutic Program) on September 16, 2019. LPA was met at the facility by Administrator Matt Martinez, Facility Manager Qoodseya Afredi and Program Director Rich Boyer. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster, the Emergency Disaster Plan was also posted. Medications are locked and centrally stored in the staff office located upstairs. Medication records were reviewed and observed to be completed with dates and staff initials on dispensing records. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. Two bedrooms contain one twin bed, and two bedrooms contained two twin beds. The facility has three bathrooms. The water temperature in one of the client bathrooms was tested at 1:22pm and registered at 114.2 degrees which is within the appropriate range of 105 degrees to 120 degrees. Per facility staff, no firearms or weapons are allowed in the facility. Administrator Matt Martinez is present at the facility a minimum of 20 hours a week. Appropriate staff/client ratios were verified during this inspection. Cont. on 809-C The facility employs three Clinical Support Staff, five facility managers and 6 direct care staff that are used in accordance with regulatory requirements. Licensee obtained Mental Health (MH) Certification in April 2021. Program Director has stated that National Accreditation through COA is currently being processed. The Accreditation audit began on 05/26/2021. Licensing fee payments are current. LPA discussed the following with the Administrator: Core Services, Specialty Mental Health Service, Trauma Informed Care, Client Personal Rights, and Administrative Duties. Due to time constraints and employee files being housed in their corporate office, LPA will return to the facility to conduct a continuation of staff file reviews. One facility staff was interviewed during the inspection. No clients were present at the time of the inspection. No deficiencies were found. Exit interview was conducted and a copy of this report was provided to the Administrator Matt Martinez.

met_with: Matt Martinez


summary: Facility Evaluation

raw_content:
Narrative:
On June 22, 2021, at 3:44PM Licensing Program Analyst (LPA) Adrian Mendez conducted an unannounced annual continuation inspection from June 15, 2021. LPA met with Facility Manager Mallory Mandell. Employee files were not located at the facility and required employee files to be reviewed at Southcoast-Santa Cruz located at Santa Cruz Circle, CA 92626. Five personnel files were reviewed to ensure they contained all required documentation per Title Regulations. Personnel Files are maintained off-site in the Human Resource office. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. No deficiencies were noted during time of inspection.


facility_name: ST JOHN RECOVERY HOME

summary: Facility Evaluation

raw_content:
Narrative:
On August 10, 2022 at 9:30am, Licensing Program Analyst (LPA) Monica Pavia conducted an announced pre-licensing inspection of the facility. LPA met and toured the facility with Abigail Anokwuru, Administrator, Brian Phillips, Facility Manager, Giovanna Verdin, Assistant Facility Manager, and Dave Detmers, facility maintenance. This Short-Term Residential Therapeutic Program is a one story facility located in a residential area. The facility consists of 3 client bedrooms and 1 client bathroom, living and dining areas, kitchen, laundry area, gym, and detached counseling conference room. The facility is clean, safe, sanitary, and in good repair. All passageways are unobstructed and all doors open freely. There are no bodies of water on the facility premises. Fire arms are not allowed on the facility premises. At the time of visit, the following was observed: Fire extinguishers are throughout the house. Smoke detectors are throughout the house and operational. Carbon monoxide detectors are located in the hallway, outside of the client bedrooms. Each bedroom has a bed, clean linens, and adequate drawer/cabinet space. Facility has a fire clearance. First aid kit was observed. Hot water temperature measured at 105 degrees Fahrenheit. Staff records will be kept at Advent's main office in San Jose, and will be readily available for review. Client files and medications will be centrally stored and locked in the staff office. There is a taped area outside the staff office to show clients where to stand, when medication is administered. Disinfectants and other toxic materials will be locked in the hallway closet. Extra bedding and towels are kept unlocked, in the hallway closet. Main food pantry will remain unlocked in the kitchen. The secondary pantry in the kitchen is allowed to be locked. There is a space utilized for a gym, with gym equipment. All gym equipment is in working order. Knives and sharps will be kept locked in the staff office. Site location has a live in staff bedroom and bathroom that is kept locked, and meets prelicensing requirements. Head of Services (HOS) for this location is Calvin Temple. Site location already has cameras installed. Cameras are ok to leave installed, while waiting for regulations to be written. Licensee keeps video footage for a maximum of 30 days. CCL will need access to camera video footage, at all times. Licensee agrees to meet current County safety guidelines. This property is ready for licensure, once their Plan of Operation/Program Statement (POO/PS) is approved. LPA Pavia will notify licensee, once POO/PS is approved and facility is licensed. Component II: LPA Pavia discussed with the following, with Administrator: - Administrator on site required hours - facility core services and support - facility emergency intervention plan

visit_type: Prelicensing

met_with: Abigail Anokwuru


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Shikya Belfield made an unannounced inspection to the above facility on 9/13/2023 at 11: AM. The above facility had a plan for closure on 8/23/2023. When LPA Belfield arrived at that the above facility it was observed to have no clients or staff inside. the facility was observed to be no longer operating at this home / address. LPA Belfield concluded the inspection. A copy of this report will be sent to Licensee Daniel Mahan.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Shikya Belfield, Licensing Program conducted an unannounced case management inspection with the above facility on 7/20/2023 at 12: PM. Present during this inspection were four staff. Facility Manager Mark Carpenter assisted with the inspection. The purpose of this inspection is to follow up with the facility regarding the program operations. Currently there are no clients in placement. This program is licensed as a Short Term Residential Therapeutic Program (STRTP) to serve clients ages 7 to 17 and Non minor Dependents. The Interim Licensing Standards require that all referrals made to an STRTP be kept in a log and that an assessment be completed to determine program eligibility. Based on a review of the facilities program statement and confidential interviews conducted, the program is confirmed to be operating out of compliance with the licensing regulations and their program statement by not accepting STRTP eligible clients and not conducting assessments for determination. The program does not have a record of referrals received for placement's. Facility cited for violation of Interim Licensing Standards, Section 87068.1(b) Intake procedures and 87068.05(b) Admission Determination Procedures, as described on the following page LIC 809D. An exit interview was conducted a copy of this report along with appeal rights will be sent to Facility manager Mark Carpenter, administrator Abigail Anokuwru and Licensee Daniel Mahan.

met_with: Mark Carpenter


facility_name: STARSHINE-40TH STREET

summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Regarding the allegation that facility staff treated youth differently than other youths at the facility, it was specifically alleged that C1 has different rules from other clients. During the investigation, confidential interviews denied that C1 was treated differently than other youths in the home. An additional confidential interview stated that C1 never reported being treated differently by staff. LPA attempted to interview C1, C3 and C6 on multiple occasions but LPA was not able to. LPA was unable to gather additional information. Other confidential witnesses didn't disclose any relevant information regarding the allegation. In regard to the allegation that facility staff made fun of youth, confidential interviews denied that staff made fun of C1 or any other client. LPA attempted to interview C1, C3 and C6 on multiple occasions but LPA was not able to. LPA was unable to gather additional information. Concerning the allegation that facility staff called youth names, it was specified alleged that C1 is called names. During the investigation, confidential interviews denied that staff called C1 or any other client names. LPA attempted to interview C1, C3 and C6 on multiple occasions but was not able to. LPA was unable to gather additional information. Based on confidential interviews, the allegations that facility staff treated C1 differently than other youths at the facility, facility staff made fun of C1, and facility staff called C1 names may have occurred, however, there was not a preponderance of evidence to support or deny the allegations. Therefore, the above allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report along with the appeal right were reviewed and provided to facility representative.

Investigation Findings:
13On June 18, 2024, Licensing Program Analyst (LPA) Rafael Enriquez arrived at Starshine Short Term Residential Therapeutic Program (STRTP) and met with Administrator Felicia Williams to deliver the finding for the allegations stated above involving the STRTP staff and clients (C1, C2, C3, C C5 and C6) as listed on the Confidential Names List (LIC 811) dated June 18, 2024. On January 10, 2024, LPA Enriquez initiated the investigation at the STRTP and obtained pertinent documents. Additionally, LPA conducted a safety inspection of the STRTP, no immediate health and safety hazards were observed. During the inspection, LPA interviewed staff 1 & 2 (S1, S2), C2, C4, C5. LPA attempted to interview C1, C3 and C6 on multiple occasions. On January 10, 2024, Community Care Licensing (CCL) received a complaint alleging that facility staff treated youth differently than other youths at the facility, facility staff made fun of youth and facility staff called youth names. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Rafael Enriquez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE N CRP RO, MAIN ST., SUITE FACILITY NAME: STARSHINE-40TH STREETFACILITY NUMBER: VISIT DATE: 06/18/2024

met_with: Administrator -Felicia Williams


summary: Facility Evaluation

raw_content:
Narrative:
On October 1, 2021, at 9: AM Licensing Program Analysts (LPAs) Shanae Pharaoh and Adelayci Caballero arrived at Starshine - 40th Street Short Term Residential Program (STRTP). LPA, was met by Administrator Felicia Williams and granted access to the facility. The purpose of the visit is to conduct an annual inspection of the facility. At 10: AM, Administrator Felicia Williams, led the physical inspection of the facility with LPA Pharaoh. The home is set up as follows: Bedroom #1- Was furnished with two twin separate beds. Sleeps C1 & C2. Bedroom #2- Was furnished with two twin separate beds. Sleeps C3 & C4. Bedroom #3- Was furnished with two twin separate beds. Sleeps C5 & C6. Bedroom #4- Is designated as the staff office and has one bathroom inside. Bedrooms are arranged so that no more than two children share a room, and there is one child per bed. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. There is adequate drawer and closet space for children's belongings. A physical plant inspection was completed and included the facility's kitchen area, three refrigerators/freezers, food storage areas, client rooms, two bathroom/showers, and community gathering area and dining area. Facility grounds are clean and free of debris and observable hazards. Sports equipment/toys/books/games were observed for client's recreation time. There is adequate indoor and outdoor activity space. Facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods and the menus were posted. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsperson poster. Medications are locked and centrally stored inside staff office. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The hot water in the client's bathrooms was measured to be an appropriate temperature. Per the Administrator, no firearms or weapons are allowed in the facility. Licensee has Mental Health Program Approval that is valid through 06/2022. Licensee has obtained National Accreditation through CARF. The Accreditation is valid through 02/2022. Licensing fee payments have been paid and there is currently a balance of $0. There were no clients present at the facility during the inspection. LPA Pharaoh discussed core services with the Administrator, based on discussion all licensing standards have been met. LPA Pharaoh discussed the board minutes based on review of meeting minutes, the facility was found to comply with all applicable regulations. LPAs reviewed 5 of 6 client files. One client file was reviewed previously. All Needs and Services plans were up to date. LPA observed all documents to be signed by required representatives and clients. LPAs also reviewed 6 personnel files to ensure they contained all required documentation per Title Regulations and Interim Licensing Standards (ILS). See Confidential Names List (LIC 811) dated 10/1/2021. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Personnel files are retained at the administration building located in the human resources office, including hard copy and online files, and will be available to the department for review upon request. LPAs reviewed the Personnel Report (LIC 500) and schedules to ensure appropriate staffing ratios. Administrator, Felicia Williams is present at the facility a minimum of 20 hours a week, as verified by staff schedule. Appropriate staff/client ratios were verified during this inspection. All staff have updated CPR and First Aid Training in the files. S4 did not have sufficient training hours. Based on review of personnel files. The facility is being cited for violation of the Interim Licensing Standards, Version 3.1, Chapter 7.5, Section 87065.1(d)1),Training Requirements. LPA Pharaoh conducted interviews with one staff. Staff person was able to provide sufficient information in relation to the facility's STRTP Program Statement, Emergency Intervention Plan, clients' Needs and Services plan, and Reporting Requirements. Based on interviews with staff, the facility appears to be meeting Core Services/Supports requirements. An exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Administrator, Felicia Williams.

met_with: Administrator - Felisha Williams


summary: Facility Evaluation

raw_content:
Narrative:
On August 16, 2023, at 8: AM, Licensing Program Analysts (LPAs) Rafael Enriquez and Adaleyci Caballero conducted an unannounced required 2-year inspection and met with Administrator Felicia Williams. LPA disclosed the purpose of the visit and was granted entry into the facility. No clients were present and four staff were present in the facility during the inspection. The facility is a three-bedroom, two-bathroom house composed of an office, living room, dining area and kitchen. One bathroom is located inside the office for staff but used by clients for hygiene and shower purposes only. The facility has an outdoor space accessible to clients in care. Administrator Felicia Williams accompanied LPAs inside and out of the facility during inspection. A physical plant inspection was completed and included the following areas: Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment/video games/movies were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster. Medications are locked and centrally stored in a locked closet in the staff office. Licensee had provisions for contraceptives to be held in individually locked containers by clients. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The hot water in the client's bathroom was measured to be 125 degrees. Facility has cameras in common areas of the facility. The facility has an exception on file to use the cameras and are meeting the terms and conditions. Administrator Felicia Williams is present at the facility a minimum of 20 hours a week, as verified by LIC Personnel Report. Appropriate staff/client ratios were verified during this inspection. The facility employs one Psychologist, three Clinical Social Workers, and three Facility Managers. Licensee has obtained a Mental Health contract with San Bernardino County. Licensee has obtained National Accreditation through Commission on Accreditation of Rehabilitation Facilities (CARF). The Accreditation is valid through February 28, 2025. Licensing fee payments have been paid and there is currently a balance of $0.00. Personnel files were reviewed to ensure they contained all required documentation per Title Regulations. Personnel files are maintained off-site at Garden Dr. San Bernardino, CA 92404 locked in the staff office. All appropriate personnel who require Caregiver Background Checks have received Criminal Record and Child Abuse Index clearances. A review of clients' records was also completed. Client and staff interviews were conducted and revealed no health and safety concerns. An exit interview was conducted with Administrator Felicia Williams. A copy of this report and Confidential Names List (LIC 811) was given to Felicia Williams

met_with: Administrator - Felicia Williams


facility_name: STARSHINE-GARDEN DRIVE

raw_content:
Narrative:
On January 26, 2023, LPA Enriquez conducted collateral interviews at the STRTP. LPA interviewed C1, C2, S1 and S2. Regarding the allegation that staff speak inappropriately to minors in care, it was specified that staff uses profanity words towards the minors. During investigation, confidential interview stated that staff was trained on staff and client relation topic which covered appropriate language used around the clients. Confidential interviews and witnesses denied ever saying inappropriate things or hearing other staff saying inappropriate things to clients. Other confidential interviews stated that client has never had a staff curse or say anything in appropriate any clients. It was added that client has never heard staff saying profanity. In regard to the allegation that staff force minors to clean the facility multiple times a day, it was specifically alleged that staff would "drag" the minors out of bed at AM to "force" them to clean four to five times throughout the day. Confidential interviews disclosed that staff wake up clients at 5: AM to do their chores, get ready for school and eat breakfast. It was added that clients only clean twice a day, in the morning and evening. Confidential interviews stated that clients get woken up at 5:00 to do chores and get ready for school. It was added that they only clean twice a day. LPA received a conflicting information. Based on confidential interviews, the allegations that staff speak inappropriately to clients in care and that staff force clients to clean the facility multiple times a day may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, these allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report was reviewed and provided to facility representative.

Investigation Findings:
13On February 09, 2023, Licensing Program Analyst (LPA) Rafael Enriquez arrived at Starshine Treatment Center, Inc. Short Term Therapeutic Program (STRTP) and met with Facility Administrator Cynthia Horne to deliver the finding for the allegations stated above involving the STRTP staff and foster children (C1 & C2) as listed on the Confidential Names List (LIC 811) dated February 9, 2023. On August 08, 2022, Community Care Licensing (CCL) received a complaint alleging that staff speak inappropriately to minors in care and staff force minors to clean the facility multiple times a day. On August 31, 2022, at 11: AM, LPA Enriquez initiated the investigation at the STRTP and obtained documents from the files and conducted a safety inspection. There were no immediate hazards observed. LPA was unable to contact the County Social Worker. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Rafael Enriquez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: STARSHINE-GARDEN DRIVEFACILITY NUMBER: VISIT DATE: 02/09/2023

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

met_with: Facility Administrator - Cynthia Horne


summary: Facility Evaluation

raw_content:
Narrative:
On September 16, 2021, Licensing Program Analysts (LPAs) Cindy Hamilton and Adaleyci Caballero met with Antoinette Borders-Frazier, Program Coordinator and Sheri Heckman, Facility Manager II. The purpose of this visit was to conduct an annual inspection of the Short Term Residential Therapeutic Program (STRTP). The facility converted from a Group Home to Short Term Therapeutic Program (STRTP) on September 14, 2017. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment is located in the backyard. Books/games were observed for client's recreation time in the dining area. There is also a laptop available for client use. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of non-perishable foods. Currently, there are no clients in placement so no perishable foods were on grounds. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster. Medications are locked and centrally stored in a locked cabinet in the locked staff office. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The hot water in the client's hallway bathroom was measured to be 117.1 degrees Fahrenheit, which is within the allowed range of 105-120 degrees Fahrenheit. The facility does not have a pool. Per Program Coordinator, no firearms or weapons are allowed in the facility. Licensee is in the process of being recertified for Mental Health Program Approval. Licensee has obtained National Accreditation through Commission on Accreditation of Rehabilitation Facilities (CARF). The Accreditation is valid through 02/28/2022. Licensing fee payments have been paid and there is currently a balance of $0.00. LPA Caballero discussed the following with the Facility Manager, II and Program Coordinator: Incident reporting, including incidents related to Assembly Bill 388 law enforcement contacts as well as incidents involving emergency interventions. LPA discussed procedures for Child and Family Team (CFT) meetings, including an overview of required Core Services and Supports. Based on this discussion the facility appears to be meeting the mission values of the facility and needs of services when clients are present.. Due to facility not having placements, no client file reviews or interviews were conducted. No deficiencies were noted in the areas during time of inspection. A copy of this report was provided to Program Coordinator Antoinette Borders-Frazier, with the Confidential Names List, LIC 811 and appeal rights..


summary: Facility Evaluation

raw_content:
Narrative:
On September 14, 2023, at 10: AM, Licensing Program Analysts (LPAs) Rafael Enriquez and Karen Beal conducted an unannounced required 2-year inspection and met with Administrator Cynthia Horne. LPAs disclosed the purpose of the visit and was granted entry into the facility. Two clients were present and five staff were present in the facility during the inspection. The facility is a two-bedroom, two-bathroom house composed of two offices, living room, dining area, garage and kitchen. Garage is used and laundry room and game room for clients. One bathroom is located inside the office for staff. The facility has an outdoor space accessible to clients in care. Administrator Cynthia Horne accompanied LPAs inside and out of the facility during inspection. A physical plant inspection was completed and included the following areas: Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment/video games/movies were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster. Medications are locked and centrally stored in a locked cabinet in the staff office. Licensee had provisions for contraceptives to be held in individually locked containers by clients. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The hot water in the client's bathroom was measured to be 125 degrees and had caution signs near all faucets. Facility has cameras in common areas of the facility. The facility has an exception on file to use the cameras and are meeting the terms and conditions. Administrator Cynthia Horne is present at the facility a minimum of 20 hours a week, as verified by LIC Personnel Report. Appropriate staff/client ratios were verified during this inspection. The facility employs one Psychologist, three Clinical Social Workers, and six Facility Managers. Licensee has obtained a Mental Health contract with San Bernardino County. Licensee has obtained National Accreditation through Commission on Accreditation of Rehabilitation Facilities (CARF). The Accreditation is valid through February 28, 2025. Licensing fee payments have been paid and there is currently a balance of $0.00. Personnel files were reviewed to ensure they contained all required documentation per Title Regulations. Personnel files are maintained on site locked in the staff office. All appropriate personnel who require Caregiver Background Checks have received Criminal Record and Child Abuse Index clearances. A review of clients' records was also completed. Client and staff interviews were conducted and revealed no health and safety concerns. An exit interview was conducted, and a copy of this report was given to Cynthia Horne.

met_with: Administrator -Cynthia Horne


facility_name: STARSHINE TREATMENT CENTER, INC.

raw_content:
Narrative:
On October 20, 2022, LPA Enriquez conducted collateral interviews at the STRTP. LPA interviewed FC1, FC2, FC3, FC4, S1, S2 and S3. On October 24, 2022, LPA conducted a collateral interview for FC5 and FC2 at San Gorgonio High school, LPA was unable to interview FC2 due to FC2 was in absence without leave (AWOL). Regarding the allegation that staff does not treat children equally, it was specifically alleged staff show favoritism among children and don't treat all children equally. Confidential interview stated that FC1 felt they were treated equally as everyone else. Additionally, confidential interview stated foster children like their relationship with staff. Confidential interviews stated staff treat all children equally. It was added that every child requires a different level of attention and if staff sees that a child needs more attention seeking due to any challenges then they provide the attention to the child needs. Confidential interviews denies treating foster children unequally. In regard to the allegation that staff speaking inappropriately about child in care, it was specifically alleged that a staff member saw FC5 without the mask and commented that FC5 "looked like a camel". Confidential interviews disclosed that they did not hear staff say FC5 looked like a camel. It was added that staff would not say anything inappropriate to foster children. Confidential interviews denied speaking inappropriately to foster children. The confidential interview reported that due to the children's ages staff sometimes need to speak very directly to them if there are any behavior issues. Based on confidential interviews, the allegations that staff does not treat children equally and that staff spoke inappropriately to FC5, may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, these allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report was reviewed and provided to facility representative.

Investigation Findings:
13On November 30, 2022, Licensing Program Analyst (LPA) Rafael Enriquez arrived at Starshine Treatment Center, Inc. Short Term Therapeutic Program (STRTP) and met with Facility Administrator Christina Garcia to discuss the finding for the allegations stated above involving the STRTP staff and foster children (FC1, FC2, FC3, FC4 and FC5) as listed on the Confidential Names List (LIC 811) dated November 30, 2022. On June 23, 2022, Community Care Licensing (CCL) received a complaint alleging staff does not treat children equally and staff spoke inappropriately about child in care On July 01, 2022, at 01: PM, LPA Enriquez and Licensing Program Manager (LPM) Traore initiated the investigation at the STRTP and obtained documents from the files and conducted a safety inspection. There were no immediate hazards observed. LPA was unable to contact the County Social Worker. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Rafael Enriquez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., Suite Riverside, CA Facility Name: Starshine Treatment Center, INC.FACILITY NUMBER: VISIT DATE: 11/30/2022

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

met_with: Facility Administrator Christina Garcia


raw_content:
Narrative:
Regarding the allegation that staff hits minor(s) in care, it was specifically alleged that S4 has physically assaulted C1 on multiple occasions. During investigation, confidential interviews stated that C1 was hit by S4. It was added that C1 was punched in the shoulder, poked, ear flicked and slapped behind the head, and that happened multiple times, however, additional confidential interviews stated that they had not seen S4 hitting C1 or any other client in care. LPA unable to gather additional information. In regard to the allegation that staff handles minor(s) in rough manner, it was specifically alleged that a staff member placed C1 in a chokehold. Confidential interviews stated that C1 was put in a chokehold by S4. Additional confidential interviews stated that they had not seen S4 putting C1 or any other client in care in a chokehold. LPA unable to gather additional information. Other witnesses didn't provide information pertaining directly to the incidents. Concerning the allegation that staff speaks inappropriately to minor(s) in care, it was specifically alleged that a staff member taunted C1 saying, now I got your ass, what are you going to do. Confidential interviews stated that S4 had not spoken to C1 inappropriately but did to other clients. Additional confidential interviews denied that S4 spoke inappropriately to clients in care. LPA was not able to interview S4. LPA unable to gather additional information. Based on confidential interviews, the allegations that S4 hits minor(s) in care, staff handles minor(s) in rough manner and staff speaks inappropriately to minor(s) in care may have occurred, however, there was not a preponderance of evidence to support or deny the allegations. Therefore, the above allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report was reviewed and provided to the facility representative.

Investigation Findings:
13On February 09, 2024, Licensing Program Analyst (LPA) Rafael Enriquez arrived at Starshine Treatment Center, Inc. Short Term Therapeutic Program (STRTP) and met with Program Coordinator- Antoinette Borders-Frazier to discuss the finding for the allegations stated above involving the STRTP staff and clients (C1, C2, C3, C C5 and C6) as listed on the Confidential Names List (LIC 811) February 09, 2024. On August 10, 2023, at 12: PM, LPA Enriquez initiated the investigation at the STRTP and obtained documents from the files and conducted a safety inspection, no immediate hazards observed. LPA interviewed C1, C2, C3, C4, C5, S1, S2 and S3. LPA was unable to contact S4 due to S4 termination with the STRTP and not having a valid contact information. On July 31, 2023, Community Care Licensing (CCL) received a complaint alleging staff hits minor(s) in care, staff handles minor(s) in rough manner and staff speaks inappropriately to minor(s) in care. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Rafael Enriquez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., Suite Riverside, CA Facility Name: Starshine Treatment Center, INC.FACILITY NUMBER: VISIT DATE: 02/09/2024

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


summary: Facility Evaluation

raw_content:
Narrative:
On the above date Licensing Program Analyst (LPA) Daniel Mena met with Administrator, Christina Garcia who guided analyst on an inspection to the home. The purpose of this visit is to conduct an annual inspection of the Short Term Residential Therapeutic Program (STRTP). The home was toured both inside and out with Ms. Garcia. Presently there are six foster children in placement and none were present during time of inspection (See LIC 811). The home is a one story, four bedroom and two bathroom home. The home is set up as follows: Bedroom #1- Was furnished with two twin separate beds. Sleeps C5 & C6. Bedroom #2- Was furnished with two twin separate beds. Sleeps C2 & C4. Bedroom #3- Was furnished with two twin separate beds. Sleeps C1 & C3. Bedroom #4- Is designated as the staff office and has one bathroom inside. Bedrooms are arranged so that no more than two children share a room, and there is one child per bed. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. There is adequate drawer and closet space for children's belongings. Inside the facility there are operable smoke detectors located in each bedroom. There is also an operable carbon monoxide detector located in the TV room. The fireplace is properly screened. The medications are locked and stored in a locked box inside a locked medicine cabinet. Cleansers/chemicals are locked and stored in a locked cabinet inside the garage. Sharp knives are inaccessible and stored in a locked cabinet in the office. The First Aid Kit is located in the kitchen and contains all required items. There are no guns or weapons in the home. The hot water temperature was tested and noted to be 107. Proper storage of all food was noted. The Emergency Disaster Plan posted at this time. A copy of the license was readily available to LPA during time of inspection. The backyard where children will have access to play is completely fenced and free of hazards. Games and equipment is safe, clean and age appropriate for the age group of children to be cared for both inside and outside the facility. A review of five staff records and all six clients residing in facility were made. All adults in the home or providing care and supervision to children have received fingerprint and child abuse index check clearances. There were no deficiencies cited at this time. Exit interview conducted and a copy of this report was reviewed and given to Ms. Garcia with the LIC 811.

met_with: Christina Gracia


summary: Facility Evaluation

raw_content:
Narrative:
On August 30, 2023, at 10: AM, Licensing Program Analysts (LPAs) Rafael Enriquez and Adaleyci Caballero conducted an unannounced required 2-year inspection and met with Administrator Christina Garcia. LPAs disclosed the purpose of the visit and was granted entry into the facility. Four clients were present and five staff were present in the facility during the inspection. The facility is a three-bedroom, two-bathroom house composed of two offices, living room, game room, dining area and kitchen. One bathroom is located inside the office for staff. The facility has an outdoor space accessible to clients in care. Administrator Christina Garcia accompanied LPAs inside and out of the facility during inspection. A physical plant inspection was completed and included the following areas: Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment/video games/movies were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster. Medications are locked and centrally stored in a locked cabinet in the staff office. Licensee had provisions for contraceptives to be held in individually locked containers by clients. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The hot water in the client's bathroom was measured to be 125 degrees and had caution signs near all faucets . Facility has cameras in common areas of the facility. The facility has an exception on file to use the cameras and are meeting the terms and conditions. Administrator Christina Garcia is present at the facility a minimum of 20 hours a week, as verified by LIC Personnel Report. Appropriate staff/client ratios were verified during this inspection. The facility employs one Psychologist, one Clinical Social Worker, and Facility Managers. Licensee has obtained a Mental Health contract with San Bernardino County. Licensee has obtained National Accreditation through Commission on Accreditation of Rehabilitation Facilities (CARF). The Accreditation is valid through February 28, 2025. Licensing fee payments have been paid and there is currently a balance of $0.00. Personnel files were reviewed to ensure they contained all required documentation per Title Regulations. Personnel files are maintained on-site in locked cabinets in the staff office. All appropriate personnel who require Caregiver Background Checks have received Criminal Record and Child Abuse Index clearances. A review of clients' records was also completed. Client and staff interviews were conducted and revealed no health and safety concerns. An exit interview was conducted, and a copy of this report was given to Christina Garcia.

met_with: Administrator- Christina Garcia


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Sarah Lo and Joon Choi on 01/23/2024 at 09: AM. The case management inspection is conducted pursuant to Health and Safety Code Section 1538.9(a)(2). During the inspection, LPAs met with Christina Garcia, Administrator and inspected the facility inside and out. LPAs reviewed 1 children's records on site at the facility. LPAs reviewed 5 staff personnel files on site at the facility. LPAs reviewed 1 child's psychotropic medications and medication records. LPAs interviewed two staff on site to discuss the facilities policies and procedures of operation. LPAs will interview 1 child that is currently prescribed psychotropic medication after the facility visit. No deficiencies are being cited at this time. LPAs provided a copy of this licensing reporting and conducted an exit interview with Christina Garcia.

met_with: Christina Garcia, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On August 7, 2024, at 8: AM, Licensing Program Analyst (LPA), Cynthia Urena met with Starshine Treatment Center, Inc. Short Term Residential Therapeutic Program (STRTP) Administrator, Cynthia Horne regarding a case management inspection at the facility. The purpose of the inspection is to obtain additional information regarding information received by LPA on 07/29/24. LPA Urena conducted interviews with five staff members (S1, S2, S3, S4, S5) and two clients (C1, C2). Additionally, LPA requested copies of pertinent documentation to further assist with the case management. A copy of this report was provided to Starshine Treatment Center, Inc. Short Term Residential Therapeutic Program (STRTP) Administrator, Cynthia Horne.

met_with: Administrator, Cynthia Horne


summary: Facility Evaluation

raw_content:
Narrative:
On December, 31 2024 , at 9: AM, Licensing Program Analyst (LPA), Jacob Ortega and Licensing Program Manager (LPM) Nicole Strickland met with Facility Manager Sheri Heckman, regarding a case management inspection at the facility.The purpose of the inspection is to obtain additional information regarding information received by LPA on 12/16/24. LPA Ortega conducted two interviews. Additionally, LPA requested copies of pertinent documentation to further assist with the case management. A copy of this report was provided to Sheri Heckman, Facility Manager.

met_with: Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On January, 7 2024 , at 10: AM, Licensing Program Analyst (LPA), Jacob Ortega and Licensing Program Manager (LPM) Nicole Strickland met with Facility Administrator Christina Garcia, regarding a case management incident initiated on January 31, 2024 .While at the facility LPA and LPM conducted two interviews and collected additional pertinent documents. No deficiencies cited at this time. A copy of this report was provided to Christina Garcia, Facility Administrator.

met_with: Christina Garcia


summary: Facility Evaluation

raw_content:
Narrative:
On January 29, 2025, at 9: AM, Licensing Program Analyst (LPA), Jacob Ortega, met with Christina Garcia, Administrator of STARSHINE TREATMENT CENTER, INC., to deliver a case management deficiencies report. Information obtained by Community Care Licensing (CCL) revealed a concern regarding staff supervision practices following an incident where staff failed to maintain line-of-sight supervision, as required by facility protocol. A case management-incident was initiated with the facility on December 31, 2024, regarding the concern. The case management investigation included interviews with two staff (S1 and S3) and two clients (C1 and C2) and a review of facility records. Confidential interviews and record reviews provided consistent statements indicating this was an isolated incident. The incident was reported by the facility to CCL via a Special Incident Report (SIR). The facility conducted an internal investigation, removed the involved staff member (S2) from the schedule, and provided additional training to all staff on facility supervision protocols. The incident did demonstrate a violation of Interim Licensing Standards (ILS) standard 87065.2(b)(1) PERSONNEL DUTIES. The facility is being issued a Technical Violation of ILS 87065.2(b)(1) PERSONNEL DUTIES (b) Direct care staff shall perform the following duties: (1) Supervision, protection, and care of children at all times, individually and in groups, in lieu of a citation at this time, for the following reason. The facility demonstrated appropriate measures in response to the incident by reporting it to CCL, addressing concerns promptly, and taking proactive steps to prevent recurrence A copy of this report was discussed with and provided to Christina Garcia, Administrator of STARSHINE TREATMENT CENTER, INC., along with appeal rights.


facility_name: STELLA MARIS GROWTH CENTER II

summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
asked to sign in, report temperature, wash or sanitize hands, or wear a mask. Information obtained from staff stated that CDC guidelines were being followed and the facility was put on quarantine status after the positive test results were received. It was also advised that authorized representatives were not advised on the onset of symptoms. It was reported that the facility did allow Client #6 to go on a visit while experiencing Covid-19 related symptoms and waiting for test results. Information obtained from confidential interviews stated that staff were enforcing quarantine status, wearing masks, and washing hands and disinfecting the facility often. LPA Harris requested and reviewed facility's log book and observed that a visitor was allowed in the home while waiting for test results. Based on interviews, there is a preponderance of evidence to prove that the facility failed to take necessary precautions to prevent the spread of Covid-19. Therefore, the above allegation is substantiated. This poses a health, safety, and/or personal rights risk to the foster children in care. The facility will be cited on California Code of Regulations (CCR) 84072(d) Personal Rights. Exit interview conducted. A copy of the report was explained and provided to the representative.

Investigation Findings:
13On October 6, 2021, at 3: PM, Licensing Program Analyst, (LPA) Jazmond Harris conducted a visit to the Short Term Residential Treatment Program (STRTP) and met with Facility Manager, Tracy Mitchell. The visit was conducted in order to provide the findings for the investigation pertaining to the listed allegation. LPA Harris initiated the investigation on August 13, 2021 at 2: PM. During the investigation, LPA Harris conducted interviews with Facility Manager, Staff Member, two out of six clients (See Confidential Names List (LIC 811) date October 6, 2021), and additional witness. Two clients refused to be interviewed and two clients were and remained on AWOL (absent without leave) status. LPA Harris was unable to obtain contact with assigned county social workers. On August 3, 2021, Community Care Licensing (CCL), received information which stated facility failed to take necessary precautions to prevent the spread of Covid-19. It was reported that after clients reported symptoms and were awaiting test results and the facility allowed a visitor to the home. It was reported that the visitor was allowed access inside the home and bathroom area. It was also advised that upon entrance the visitor was not asked to sign in, report temperature, wash or sanitize hands, or wear a mask. Information obtained from SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Jazmond D Harris LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: STELLA MARIS GROWTH CENTER IIFACILITY NUMBER: VISIT DATE: 10/06/2021

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

met_with: Facility Manager-Tracy Mitchell

complaint_status: SUBSTANTIATED