summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 11/25/25 at 12:00 pm, Licensing Program Analyst (LPA) Nestor Gomez made an unannounced inspection to the above-mentioned facility, for the purpose of following up on a Case Management inspection regarding an incident report that was received on 10/15/2025. LPA met with Youth Rehab Specialist (S1), Jessica Moody, who granted access to the facility. No further investigation or interviews are required on the above incident. PER Health and Safety Code 1507.6(b)(1), there is one (1) deficiency to be cited at this time. See 809-D. Exit interview was conducted and a copy of this report will be emailed the Facility Administrator, Allison Jensen.

Deficiencies:
87075(c): Psychotropic medications shall be used only in accordance with the written
directions of the physician prescribing the medication and in accordance with
authorization requirements...

met_with: Jessica Moody - Youth Rehab Specialist

title:
1
2
3
4
5
6
7Health Related Services 87075(c)


state: CA

facility_name: TMHA-YOUTH TREATMENT PROGRAM

summary: Facility Evaluation

raw_content:
Narrative:
On 1/5/2026, at 8:56 am Licensing Program Analyst (LPA) Nestor Gomez made an unannounced inspection to the above-mentioned facility, for the purpose of conducting case management due to two (2) SIRs (Special Incident Report) that were received late. The two (2) SIRs were received on 12/30/2025 but the two incidents occurred on 12/19/2025. Both SIRs were regarding an argument between C1 and C2. The health and safety assessment was conducted upon arrival at the facility. LPA met with Youth Residential Counselor (S1), Jessica Moody, who granted access to the facility. No further investigation or interviews are required on the above incident. PER California Code Regulation 80061(b) there is one (1) deficiency to be cited at this time. See 809-D. Exit interview was conducted and a copy of this report will be emailed to the Facility Administrator, Allison Jensen.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Jessica Moody - Youth Residential Counselor


summary: Facility Evaluation

raw_content:
Narrative:
On September 26, 2024 at 8:00am Licensing Program Analysts (LPA) Enrique Hernandez conducted a Case Management - Incident inspection at TMHA-YOUTH TREATMENT PROGRAM, and met with the Facility Administrator Allison Jensen. During the course of the complaint investigation, it was revealed that on August 24, 2024, an incident occurred when Client #1 and Client #2, left the facility in the middle of the night. During a complaint investigation, it was discovered that During the period between 11: PM and 3: AM, Staff Member #2 (S2) performed bed checks. However, S2 was unable to visually confirm the presence of C1 or C2 in their beds as their bodies were not visible because their beds were covered with blankets. It was assumed that they were in their beds. Staff Member #2 (S2) arrived at the facility at 3:00 a.m. and performed bed checks. S2 observed that the beds had blankets, and after carefully checking for any signs of the clients, noticed that C1 and C2 were not in their beds and had left the facility. Additionally, C2 confirmed that both C1 and C2 planned to leave the facility at midnight. [See LIC Confidential Names List form (LIC811), dated 9/26/2024, for names]. PER California Code Regulation, TITLE 22, DIVISION 6, CHAPTERS 1, General Licensing Regulations, and Short Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS), the following deficiency has been cited. (See LIC809-D) Exit interview was conducted, and due to technical difficulties with the printer, a copy of this report will be emailed.

met_with: Allison Jensen/Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 3/25/26, at 1:43 pm Licensing Program Analyst (LPA) Nestor Gomez made an unannounced inspection to the above-mentioned facility, for the purpose of following up on a Case Management inspection regarding an incident report (SIR) that was received on 6/26/26. LPA met with Tania Moeller, who granted access to the facility. In the incident report, client (C1) reported to S1 that S2 would take clients on outings and leave them unsupervised. C1 also shared that on an outing S2 allowed clients to ride in the vehicle without wearing seat belts. Based on the interviews conducted, participants confirmed that there was a lack of supervision. No further investigation or interviews are required on the above incident. PER California Code Regulation 80078(a), there is one (1) deficiency to be cited at this time. See 809-D. Exit interview was conducted and a copy of this report will be emailed the Facility Administrator (FA).

met_with: Tania Moeller - Youth Rehabilitation Specialist


summary: Facility Evaluation

raw_content:
Narrative:
On 3/25/26, at 1:44 pm, Licensing Program Analyst (LPA) Nestor Gomez, made an unannounced visit to the above-mentioned facility, in order to conduct a case management incident inspection, regarding an SIR that was received on 3/18/2026. LPA Gomez was met by Facility Administrator (FA), Allison Jensen, who granted access to the facility. Per the incident report, client (C1) did not receive their morning medication because client left for a band trip. One (1) deficiency Type A has been determined at this time. The following deficiency has been cited: Health Related Services 87075(c). (See 809-D) An exit interview was conducted, and a Plan of Correction was developed and reviewed with the licensee. A copy of this report and appeal rights were discussed and emailed to the licensee.

met_with: Allison Jensen - Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 3/25/26, at 1: 43 pm, Licensing Program Analyst (LPA) Nestor Gomez, made an unannounced visit to the above-mentioned facility, in order to conduct a case management incident inspection, regarding an SIR that was received on 2/18/2026. LPA Gomez was met by Facility Administrator (FA), Allison Jenson who granted access to the facility. Per the incident report, client (C1) did not receive their 8:00 pm prescribed medication on 2/16/2026 because the medication was not available in the medication box. A repeat violation, (1) deficiency Type A has been determined at this time. The following deficiency has been cited: Health Related Services 87075(c). (See 809-D and LIC421FC) An exit interview was conducted, and a Plan of Correction was developed and reviewed with the licensee. A copy of this report and appeal rights were discussed and emailed to the licensee.

met_with: Facility Administrator - Allison Jenson


facility_name: TRINITY - APPLE VALLEY

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Based on confidential interviews and record review, the allegations that staff will talk rudely to the clients in care, that facility staff did not allow clients access to their allowance, that facility staff is serving food that is uncooked and the milk was curdled on at least one occasion, that staff are not assisting youth with educational needs and that facility staff are conducting unauthorized searches of youth's belongings, may have occurred, however they are not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. No deficiencies were cited. An exit interview was completed and a copy of this report, LIC811 and appeal rights were emailed to Elizabeth Tamough, for signature. A signed copy report will be placed in the facility file. This agency received allegation that facility staff did not allow clients access to their allowance. Confidential interviews disclosed that the staff are having the clients sign for their allowance but that it is being placed into their account to shop online. Other confidential interviews disclosed that the staff allow the clients to have $15.00 cash on hand to spend if needed. Confidential interviews revealed that clients were upset that they have had to shop online due to COVID. Interview with S1 revealed that the clients shop online due to the facility being positive for COVID and the facility being in lockdown. This agency received allegation that facility staff is serving food that is uncooked and the milk was curdled on at least one occasion. Confidential interviews disclosed that the clients would rather eat personal food, snacks due to not liking what is on the menu. Other confidential interviews disclosed the food looks greasy and disgusting. Interview with S1 revealed that the food is based off a healthy menu a lot like the school nutritional menu. On 03/03/21, LPA Flores observed the lunch brought to the dorm to be of a healthy meal and presented as edible. Record review of the food menu posted was healthy meals and of nutritional value. Other confidential interviews disclosed that the clients would rather eat junk food then the meals prepared and the staff offer alternate meals if the menu item is refused. This agency received allegation that staff are not assisting youth with educational needs. Confidential interviews disclosed that the staff will assist the clients with homework if the clients are asking for assistance. Other confidential interviews revealed that the staff will not assist C1 with scheduling for substance abuse classes or college course. Interview with Probation officer for C1 disclosed that C1 dropped a college course and wanted the staff to purchase a musical instrument for C1. Interview with staff #2 (S2) disclosed that the clients are scheduled for tutoring online when struggling with classwork or falling behind. . This agency received allegation that facility staff are conducting unauthorized searches of youth's belongings. Confidential interviews disclosed that staff are searching through C1's personal belongings without permission. Interview with S1, S2 and Staff #3 (S3) said the staff will conduct maintenance checks looking for broken drawers, graffiti, broken windows, and closets are in good repair. Confidential interviews disclosed that the staff allow clients to watch from outside the door during a maintenance check but most will watch television. Other confidential interviews revealed the staff will conduct room searches while the clients are outside. Interviews with P.O.'s and CSW's denied any issues with their clients while in the STRTP, clients have not complained about any of the allegations listed above. ()

Investigation Findings:
13On April 30, 2021 at 2: PM, Licensing Program Analyst (LPA) Anastasia Flores met with (STRTP) Trinity Apple Valley Facility Campus Director Elizabeth Tamoush via tel-visit, to deliver the findings of the above allegations. On February 17, 2021 at 10:16AM, LPA Michael Almarez conducted an inspection of the facility and no health and safety concerns were noted. Copies of STRTP menu, STRTP staff roster and Panther dorm client roster were obtained. LPA's conducted interviews with nine out of 10 residents (C1, C2, C3, C4, C6, C7, C8, C9, C10), five staff, four Probation Officers and two Los Angeles County Social Workers. On February 8, 2021 this agency received allegation that staff will talk rudely to the clients in care. Confidential interviews disclosed that the staff will sometimes power struggle with the clients. Other confidential interviews revealed that the staff will assist the clients when they need to talk with someone. Team Supervisor (S1) denied allegations of talking inappropriately with clients. Other confidential interviews disclosed that staff will sometimes redirect the clients in a positive manner. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Christina Barnes LICENSING EVALUATOR NAME: Anastasia Flores LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 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: TRINITY - APPLE VALLEYFACILITY NUMBER: VISIT DATE: 04/30/2021

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

report_type: Complaint Investigation

met_with: Elizabeth Tamoush

complaint_status: unsubstantiated


raw_content:
Narrative:
Additional confidential witnesses reported that there is a nutritionist who prepares monthly menus for the facility, however, the nutritionist may not always be aware of the preferred meal choices provided by the foster youth as the nutritionist works outside of the facility. During LPA's visit at the facility, the prepared meal for dinner was beef stew and there were no alternative meal options provided on the menu. During confidential interviews, it was disclosed that multiple youth preferred not to eat the beef stew and would have to prepare an alternative meal for themselves. Based on confidential interviews, the preponderance of evidence standard has been met and the Department has determined the allegation that the facility does not ensure the foster youth's nutritional needs are being met is substantiated. The facility is being cited for violation of the Title Regulations, Division 6, Chapter 1, Article 6, Section 80076(a)(1): Food Services. Based on confidential interviews, there are no prepared meal alternatives provided by the facility and the youth are instructed to prepare a meat or peanut butter/jelly sandwich as an alternative meal which does not provide adequate nutritional value and poses a potential health, safety, or personal rights risk to the youth in care. An exit interview was completed and a copy of this report, LIC 811 and appeal rights were provided. S1 denied ever having a sexual relationship with any of the foster youth and reported never being alone with the foster youth as S1 does not work directly in the dorms where the youth reside. Several additional confidential witnesses reported never observing S1 or any other staff interact in an inappropriate manner with foster youth at the facility other than what has been previously reported and investigated by CCL. Based on confidential interviews, the allegation that S1 sexually abused foster youth at the facility, may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was completed, and a copy of this report, appeal rights, and LIC 811 were provided to facility representative.

Investigation Findings:
13On July 21, 2021 at 11: AM, Licensing Program Analyst (LPA), Anastasia Flores, met with Trinity Apple Valley Campus Director, Elizabeth Tamoush, to deliver the finding for the above stated allegation. The investigation was conducted by LPA Wilson, which included a review of records for the facility and four foster youth. In addition, interviews were conducted with six staff, four foster youth, and three County Workers. On 3/18/21, LPA Wilson conducted a safety inspection at the facility and there were no immediate safety hazards observed. On 3/11/21, Community Care Licensing received information that foster youth placed at the facility are not being fed properly and there is never any food at the facility. On 3/18/21, LPA Wilson made a visit to the facility and observed adequate food stored inside of the cafeteria. LPA Wilson interviewed several confidential witnesses who reported that although there is food at the facility, the youth do not always want to eat the meals prepared by the cafeteria staff and are then instructed to prepare their own meat or peanut butter/jelly sandwich as an alternative. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Christina Barnes LICENSING EVALUATOR NAME: Anastasia Flores LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 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: TRINITY - APPLE VALLEYFACILITY NUMBER: VISIT DATE: 07/21/2021

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


raw_content:
Narrative:
Confidential interviews revealed that they did not seen C1 behave manic. Campus director (S1) stated that facility staff had thought that C1 was administered the wrong medication, but assistant campus director (S2) reviewed the Medication Administration Record (MAR) and found that there weren't any errors. Other confidential witnesses stated that they had not been informed that clients were administered the wrong medication. S2 stated that C1 was discontinued a medication and this is where the confusion arose. S2 stated that facility staff talked to C1's authorized representative and explained the situation. S2 stated that he recalled a time where C1 seemed down after receiving news about C1's family. S2 stated that C1 was never extremely emotional or manic. Another confidential witness stated that C1 was informed by facility staff that C1 was administered the wrong medication and that this caused C1 to behave emotional and manic. Based on confidential interviews and record reviews, the allegations that on April 1, 2021, C1 was administered the wrong medication by facility staff and C1's authorized representative was not notified of C1 having spiraled into an emotional and manic state, may have occurred, however are not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Elizabeth Tamoush.

Investigation Findings:
13Licensing Program Analyst (LPA), Michael Almaraz, conducted an inspection and met with campus director, Elizabeth Tamoush, to issue the findings for the above stated allegations. The investigation was conducted by LPA Almaraz. LPA inspected the facility on April 27, 2021, at 3: PM and reviewed one client's records. During LPA inspection an interview was conducted with two facility staff. During the course of the investigation interviews were conducted with four additional facility staff and four of seven clients. Three of seven clients were unavailable for LPA interview. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Michael Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: TRINITY - APPLE VALLEYFACILITY NUMBER: VISIT DATE: 07/28/2021

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


raw_content:
Narrative:
CSW1 stated that it was never disclosed to her that C1 was inappropriately touched by C2. CSW2 stated that she had never been informed that facility staff provided poor supervision. Other confidential witness stated that C1 was inappropriately touched on two separate occasions while in the day room. It was also disclosed that staff were nearby during the inappropriate touching, but staff was not paying attention to the clients when C2 touched C1's private area. Based on confidential interviews and record reviews, the allegation that lack of supervision resulted in C1 being inappropriately touched by C2 may have occurred, however, it is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Ronnie Elenez.

Investigation Findings:
13On April 28, 2022, at 9: AM Licensing Program Analyst (LPA) Michael Almaraz arrived at the facility and met with assistant campus director, Ronnie Elenez, to issue the finding for the above stated allegation. On September 16, 2021, at 2: PM, LPA Almaraz arrived at the facility to initiate the investigation and conducted a safety inspection. During the safety inspection, LPA interviewed two facility staff and reviewed client records. Additionally, LPA conducted interviews with six clients (C1, C2, C3, C4, C5, C6) listed on the confidential names list (LIC 811) dated April 28, 2022, two staff and two county social workers. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Michael Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: TRINITY - APPLE VALLEYFACILITY NUMBER: VISIT DATE: 04/28/2022

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

met_with: Ronnie Elenez


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

raw_content:
Narrative:
Based on confidential interviews and record review, the preponderance of evidence standard has been met and the Department has determined that C1 didn't take a medication as prescribed, therefore, the allegation is substantiated. The facility is being cited for violation of the Interim Licensing Standards, Chapter 7. Short Term Residential Therapeutic Program, Articles 1 through 10, Version Health Related Services 87075(c). An exit interview was conducted and a copy of this report along with the appeal rights were provided to Elizabeth Tamoush.

Investigation Findings:
13On May 5, 2022, at 9: AM Licensing Program Analyst (LPA), Michael Almaraz, arrived at the facility and met with campus director, Elizabeth Tamoush, to issue the finding for the above stated allegation. On April 28, 2022, 10: AM LPA Almaraz conducted a safety inspection at the facility. During the inspection LPA reviewed one client's records and conducted interviews with two clients and three staff. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Michael Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: TRINITY - APPLE VALLEYFACILITY NUMBER: VISIT DATE: 05/05/2022

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

Deficiencies:
87075: Based on confidential interviews and record review the facility failed to administer...1
2
3
4
5
6
7Per facility campus director facility staff who administer medication will be retrained on ILS Health Related Services 87075.

complaint_status: SUBSTANTIATED

title: (c) Psychotropic medications shall be used only in accordance with the written directions of the physician prescribing the medication...This requirement was not met as evidenced by


raw_content:
Narrative:
Continued from LIC 9099 page On March 23, 2022, Community Care Licensing received a complaint alleging that lack of supervision resulted in inappropriate interactions between minors. During investigation, confidential interview stated that C1 was held down by other clients during horse play but denied that C1 was touched inappropriately by other clients. Confidential interview added that C1 did not feel uncomfortable when being held down because C1 and other clients were joking around. Other confidential interviews denied witnessing C1 being held down or touched inappropriately by other clients. Confidential interviews also denied being touched inappropriately at the STRTP and expressed feeling safe. Other confidential interviews stated that C1 was involved in physical altercations with other clients at the STRTP. A confidential interview stated that sometimes bullying occurs in client dorms and stated witnessing an altercation involving C1, however, confidential interview denied that C1 was held down or touched inappropriately by other clients. Other confidential interviews denied knowing that C1 was held down or touched inappropriately by other clients while placed at the STRTP. Other Confidential interviews reported that clients are supervised by staff at the STRTP. Confidential interviews further stated that staff position themselves in the same area where clients are located at and when clients are in their dorms staff check on clients periodically. LPA received inconsistent information to determine if there was a lack of supervision resulted in inappropriate interactions. Based on the confidential interviews, the allegation that lack of supervision resulted in inappropriate interactions between minors, may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Trinity Apple Valley STRTP Campus Director, Elizabeth Tamoush.

Investigation Findings:
13On December 28, 2022, at 9: AM, Licensing Program Analyst (LPA) Cynthia Urena, met with Trinity Apple Valley Short Term Residential Therapeutic Program (STRTP) Campus Director, Elizabeth Tamoush to deliver the investigative finding for the above stated allegation. On March 30, 2022, at 09: AM, Licensing Program Analyst (LPA) Michael Almaraz initiated the investigation at the STRTP. LPA Almaraz conducted a health and safety inspection, and no immediate deficiencies were observed. LPA Almaraz reviewed two client files and conducted interviews with one staff member staff 1 (S1), and two clients (C3, C4). Additionally, LPA Almaraz interviewed client 1 (C1). On December 15, 2022, at 9: AM, LPA Cynthia Urena, interviewed client 5 (C5) and on Decembe19, 2022, LPA Urena interviewed staff 2 (S2). Continued on LIC C page 2... UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Cynthia Urena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: TRINITY - APPLE VALLEYFACILITY NUMBER: VISIT DATE: 12/28/2022

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

met_with: Campus Director, Elizabeth Tamoush


raw_content:
Narrative:
**Continued from LIC C page 1** In regard to the allegation that staff are not following doctor's order for resident in care, a confidential interview maintained that C1 had a follow-up medical appointment and was prescribed medication, however, staff did not transport C1 to the medical appointment or filled C1's medication as directed by a doctor. Other confidential interviews stated not being aware that staff did not refill C1's medication as directed. A confidential interview stated C1 did not inform staff that a medication needed to be refilled. Another confidential interview stated having knowledge of a prescription medication refill for C1 but was not aware of the reason why the medication was not refilled. Other confidential interviews stated that staff provided medication as needed. A confidential interview stated recalling a time when their medication ran out for a few days. Another confidential interview reported not having issues in obtaining prescription medication at the STRTP. Regarding the allegation that staff do not treat residents with dignity and respect, a confidential interview stated after a verbal altercation with a staff member, another staff member was heard using profanity when speaking to C1. Other confidential interviews stated that staff treat clients with dignity and respect and denied being disrespected by staff. Another confidential interview witnessed staff using a firm voice when clients were not listening. Other confidential interviews denied witnessing staff behaving disrespectful towards clients. Regarding the allegation that staff do not take residents on scheduled outings, confidential interviews stated staff shortage have caused client outings to be cancelled. Other confidential interviews stated that some clients get to participate in outings while others do not. A confidential interview stated that some outings and activities are earned, and outings can be revoked due to client behaviors. Another confidential interview stated clients are taken on outings and added that when there is staff shortage program staff find other alternatives while considering client safety. Regarding the allegation that the facility is in disrepair, it was specified that the facility air conditioner (AC) has not worked for over five years. A confidential interview reported witnessing the air conditioner undergoing maintenance. **Continued on LIC C page 3** ** Continued from LIC C page 2** Confidential interviewed continued stating that the STRTP has issues with the air conditioning every year during summer. Other confidential interviews reported that program staff purchased portable AC units for clients while the air conditioner was being repaired. Other confidential interviews reported that client dorms were hot despite having portable AC units. Based on the confidential interviews, the allegations that staff were not following doctor's order for C1, staff did not treat clients with dignity and respect, staff did not take clients on scheduled outings, and facility was in disrepair may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Trinity Apple Valley STRTP Campus Director, Elizabeth Tamoush.

Investigation Findings:
On Wednesday January 18, 2023, at 11: AM, Licensing Program Analyst (LPA) Cynthia Urena met with Trinity Apple Valley Short Term Residential Therapeutic Program (STRTP) Campus Director, Elizabeth Tamoush to deliver the investigative findings for the above stated allegations. On June 17, 2022, at 10: AM, Licensing Program Analyst (LPA) Michael Almaraz initiated the investigation at the STRTP. LPA Almaraz conducted a health and safety inspection, and no immediate deficiencies were observed. LPA Almaraz reviewed two client files and conducted interviews with three staff (S1, S2 and S3), and three clients (C1, C2 and C3). On June 14, 2022, Community Care Licensing received a complaint alleging that staff are not following doctor's order for resident in care, staff do not treat residents with dignity and respect, staff do not take residents on scheduled outings, and facility is in disrepair. **Continued on LIC C page 2** UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Cynthia Urena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: TRINITY - APPLE VALLEYFACILITY NUMBER: VISIT DATE: 01/18/2023

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


raw_content:
Narrative:
** Continued from LIC C page 3** Based on observations, record review, and confidential interviews, the allegation that staff do not provide an adequate amount of hygiene supplies, facility has inadequate staffing, clients had access to cleaning supply cabinet while in care, clients rooms are not properly maintained, clients are not properly groomed while in care, staff did not prevent C1 from causing self-harm, staff do not provide adequate food services for clients, and staff do not address clients clothing needs while in care, may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Trinity Apple Valley STRTP, Campus Director, Elizabeth Tamoush **Continued from LIC C page 2** A confidential interview stated that staff dock point from clients whose rooms are not cleaned. Confidential interview continued stating that there were times when staff clean client's rooms when clients were not in rooms. Other confidential interviews stated that program staff educate clients on the importance of cleanliness and grooming. Regarding the allegation that staff did not prevent C1 from causing self-harm, confidential interviews stated staff reacted immediately when clients were exhibiting self-harming behaviors. A confidential interview stated witnessing staff providing prevention care to C1. Another confidential interview stated that staff provided C4 with the adequate services when C4 exhibited self-harming behaviors. Other confidential interviews reported feeling safe in placement. Regarding the allegation that staff did not provide adequate food services for clients, confidential interviews stated the food at the facility was good, and on weekends staff purchase fast food for all clients. Other confidential interviews denied that clients have become ill from the food provided at the facility. Confidential interviews further stated that there has not been issue with food at the facility. Other confidential interviews reported that clients enjoy when staff purchase fast food on the weekends. Another confidential interview stated disliking the cafeteria food that is provided at the facility and continued stating enjoying when staff purchase pizza for clients. In regard to the allegation that staff did not address the minors clothing needs while in care, a confidential interview stated that the STRTP provides a monthly clothing allowance to all clients in placement. Confidential interview continued stating clients are provided $83.00 of clothing allowance and have the option to accumulate $240.00 on a quarterly basis. Confidential interview also stated that clients are taken shopping by program staff. Other confidential interviews stated not having issues with clothing allowance at the facility. Confidential interviews continued stating clients have clothes and are provided a monthly clothing allowance. **Continued on LIC C page 4** **Continued from LIC 9099 page 1** adequate amount of hygiene supplies, facility has inadequate staffing, clients had access to cleaning supply cabinet while in care, clients rooms are not properly maintained, clients are not properly groomed while in care, staff did not prevent Client 1 (C1) from causing self-harm, staff do not provide adequate food services for clients, staff do not address clients clothing Regarding the allegation staff do not provide an adequate amount of hygiene supplies, confidential interviews stated having access to hygiene products. Confidential interviews added that staff provide clients with hygiene products when needed. Another confidential interview stated that hygiene products are purchased when there is a shortage on supplies. Confidential interview continued stating not knowing how often staff purchase hygiene supplies. Additional a confidential stated a request was made for body lotion multiple times and they were not sure when the lotion was provided. In regard to the allegation facility has inadequate staffing, confidential interviews stated that due to COVID-19, there has been staff shortage. The confidential interview denied that the facility was out of ratio. A confidential interview stated that on weekends, there were two or three staff on duty. Confidential interview further stated staff are on call and available to report to the STRTP as needed. Other confidential interviews stated clients are supervised by staff accordingly and denied staff shortage. Another confidential interview disclosed that staff were on their cell phones when supervising clients and worries about clients received appropriate supervision. Regarding the allegation that clients had access to cleaning supply cabinet while in care, confidential interviews denied having access to chemicals while in care. Other confidential interviews stated cabinets that store the facility's chemicals remains locked and inaccessible to clients. Other confidential interviews denied witnessing the chemical cabinet open and accessible to clients. Regarding the allegations that client's rooms were not properly maintained, and minors were not properly groomed while in care. all confidential interviews stated staff encourage clients to maintain rooms clean, and to groom daily, however, not all clients follow staff requests. **Continued on LIC C page 3**

Investigation Findings:
13On January 25, 2023, at 10: AM, Licensing Program Analysts (LPAs) Cynthia Urena and Karen Beal met with Trinity Apple Valley Short Term Residential Therapeutic Program (STRTP) Campus Director, Elizabeth Tamoush to deliver the investigative finding for the above stated allegations. On February 9, 2022, at 9: AM, Licensing Program Analyst (LPA) Michael Almaraz initiated the investigation at the STRTP. LPA Michael Almaraz conducted a safety inspection of the facility, and no immediate deficiencies were observed. LPA Almaraz reviewed two client files and conducted interviews with two staff member staff (S1, S2) and three clients (C2, C3, C4). On December 28, 2022, at 10: AM, LPA Cynthia Urena conducted a walkthrough of the facility with S2. On February 04, 2022, Community Care Licensing received a complaint alleging that staff do not provide an **Continued on LIC C page 2** UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Cynthia Urena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: TRINITY - APPLE VALLEYFACILITY NUMBER: VISIT DATE: 01/25/2023

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


raw_content:
Narrative:
County social workers did not have concerns of lack of supervision occurring at the facility. County social worker (CSW) stated that he was informed that C1 had inappropriate photos on a cellular phone. Other confidential witness informed LPA that they had seen C1 using a cellular phone while at the facility. Based on confidential interviews and records review, the allegation that due to lack of supervision C1 had inappropriate photos on a cellular phone may have occurred, however, it is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Elizabeth Tamoush.

Investigation Findings:
13On June 15, 2023, at 1: PM Licensing Program Analyst (LPA) Michael Almaraz arrived at the facility and met with Campus Director, Elizabeth Tamoush, to issue the finding for the above stated allegation. This complaint investigation was conducted by LPA Almaraz. On March 2, 2023, at 10: AM, LPA arrived at the facility to initiate the investigation, conducted a safety inspection; reviewed one client file, interviewed one client and interviewed three staff. During the course of the investigation, LPA Almaraz conducted three staff interviews, six client interviews (C1, C2, C3, C4, C5, and C6) see confidential names list (LIC 811) dated June 15, 2023 and two county worker interviews. On February 21, 2023, the Department received a complaint that alleged minor had access to inappropriate pictures on their phone while in care. It was specifically alleged that due to lack of supervision, C1 had inappropriate photos on a cellular phone. Confidential witness' interviews revealed that staff provided appropriate supervision to clients. Furthermore, it was revealed that C1 was not seen in possession of a cellular phone while at the facility. (continued on page 2...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Michael Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: TRINITY - APPLE VALLEYFACILITY NUMBER: VISIT DATE: 06/15/2023

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


raw_content:
Narrative:
Another confidential witness stated that after a physical altercation staff did not offer C1 medical attention and C1 had to ask staff for it but C1 was denied. Based on confidential interviews and record review, the allegation that C1 was denied medical attention by facility staff after C1 suffered an injury during a physical altercation, may have occurred, however it is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Elizabeth Tamoush.

Investigation Findings:
13On July 27, 2023, at 11: AM Licensing Program Analyst (LPA), Michael Almaraz, met with facility Campus Director, Elizabeth Tamoush, to issue the finding for the above allegation involving the clients listed on the confidential names list (LIC 811) dated July 27, 2023. The complaint investigation was conducted by LPA Almaraz. On April 13, 2023, at 8: AM, LPA inspected the facility. During the inspection, LPA reviewed one client's file, interviewed two clients, and interviewed one staff. Additionally, LPA interviewed three clients, LPA interviewed four staff, and one county social worker (CSW). On April 3, 2023, the Department received a complaint alleging that staff refused minor medical attention. It was specifically alleged that client 1 (C1) was denied medical attention by facility staff after C1 suffered an injury during a physical altercation. Confidential witnesses informed LPA that clients were always offered medical attention after physical altercations. Confidential witnesses added that if a client suffered any injury facility staff would offer medical attention. CSW stated that she was not aware of an incidient where C1 was not offered medical attention after a physical altercation. (continued on page 2...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Michael Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: TRINITY - APPLE VALLEYFACILITY NUMBER: VISIT DATE: 07/27/2023

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


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
During the investigation, all confidential interviews revealed that there was an altercation between C1 and C2 that resulted in C2 stabbing C1 while in care. Confidential interviews further stated that C2 was exhibiting ongoing aggressive behaviors towards peers and staff that included breaking facility windows, and handling glass, while in care. Confidential interviews also stated that S1 did not intervene during the altercation between C1 and C2 that resulted in another client intervening, where ultimately C1 sustained multiple stabbed wounds while under the care and supervision of S1. Other confidential interviews reported witnessing S1 giving verbal commands to C1 and C2 to stop the altercation from outside, but it was not enough to stop the fight and prevent C2 from stabbing C1 in care. Confidential interviews further maintained that S1 did not intervene during the altercation and that it was C3 who attempted to stop the altercation but was unsuccessful. Other confidential interviews stated that based on C2's history and individual needs C2 required one-on-one care however, the facility did not provide that type of care and supervision posing a risk to self and others resulting in C1 being stabbed by C2 in care. All confidential interviews reported that due to C1's stab wounds C1 required medical intervention due to the seriousness of injuries sustained from being stabbed by C2 while in care. Based on confidential interviews and record review the preponderance of evidence standard has been met, and the allegation that due lack of supervision, C2 stabbed C1 in care resulting in serious injuries is supported and proven by evidence, therefore the allegation is substantiated at this time. The facility is cited, and immediate civil penalty was issued for violation of California Code of Regulations (CCR) regulation 80078(a) Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. An enhanced civil penalty (ECP) determination is pending. If an ECP is assessed a Community Care Licensing (CCL) representative will return to the facility to deliver the penalty assessment. A copy of this report was discussed, and provided along with appeal rights, LIC811 confidential names list and LIC 421IM to Trinity Apple Valley STRTP Campus Director, Elizabeth Tamoush.

Investigation Findings:
13On September 13, 2023 at 9: AM, Licensing Program Analyst (LPA), Cynthia Urena met with Trinity Apple Valley Short Term Residential Therapeutic Program (STRTP) Campus Director, Elizabeth Tamoush to deliver the investigative finding for the above stated allegation. On May 18, 2023, at 11: AM, Special Investigator (SI) Dennis Douglas with the California Department of Social Services, (CDSS), Community Care Licensing Division (CCLD), Investigations Branch Bureau initiated the investigation at the STRTP and collected pertinent documents to assist with the investigation process. SI Douglas interviewed six staff members (S1, S2, S3, S4, S5, S6), four clients (C1, C2, C3, C4) (see confidential names list LIC811 dated 09/13/23), and a County Social Worker (CSW). On May 15, 2023, Community Care Licensing (CCL) received a complaint alleging that due to lack of supervision, a minor stabbed another minor in care resulting in serious injuries. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Cynthia Urena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: TRINITY - APPLE VALLEYFACILITY NUMBER: 366401747

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


raw_content:
Narrative:
CSW stated that she was not informed that C1 was hit by staff at the facility. An additional confidential witness stated that staff 6 (S6) pushed C1 when C1 was trying to walk to the front office. LPA received conflicting information regarding this allegation. Regarding the allegation that staff yelled at C1. Confidential witnessed stated that that they did not believe facility staff yelled at the clients. Additionally, it was reported that staff may raise their voices but not yell at the clients. CSW stated that she was informed that staff yelled at C1. Additionally, a confidential interview maintained that facility staff often yelled at the clients. In regard to the allegation that staff made inappropriate statements toward C1. Confidential witnesses stated that staff did not make inappropriate statements toward clients. A confidential interview stated that information was received indicating that staff would talk down on C1. An additional witness corroborated that S6 made inappropriate statements toward C1. Based on confidential interviews and record reviews, the allegations that facility staff hit C1, facility staff yelled at client C1, and staff made inappropriate comments toward C1 may have occurred, however, there was not a preponderance of evidence to support the alleged violations, therefore, these allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Elizabeth Tamoush.

Investigation Findings:
13On October 18, 2023, at 11: AM Licensing Program Analyst (LPA) Michael Almaraz arrived at the facility and met with Campus Director, Elizabeth Tamoush, to issue the finding for the above stated allegations. This complaint investigation was conducted by LPA Michael Almaraz. On July 27, 2023, 9: AM, LPA arrived at the facility to initiate the investigation, LPA reviewed one client's files, conducted a safety inspection, interviewed three staff and six clients. Additionally, LPA Almaraz conducted interviews with three staff one client, and one county worker (CSW). On July 19, 2023, the Department received a complaint that staff hit minor, staff yelled at minor and staff made an inappropriate comment towards minor. It was specifically alleged that facility staff hit client #1 (C1), facility staff yelled at client C1, and staff made inappropriate comments toward C1. Confidential witness' interviews stated that they have not observed or heard facility staff hitting or exhibiting physical aggressions towards clients. (continued on page 2...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Michael Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: TRINITY - APPLE VALLEYFACILITY NUMBER: VISIT DATE: 10/18/2023

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


raw_content:
Narrative:
On October 3, 2023, Community Care Licensing (CCL) received a complaint alleging that staff did not prevent a minor from engaging in an illegal activity, and that staff did not prevent a minor from having access to an unknown substance. During the investigation there was no corroborating evidence to support the allegations. It was revealed that C1 had a history of substance use, specifically engaging in marijuana use prior to arriving at the facility. Some confidential interviews denied that C1 engaged in illegal activity on facility grounds while other confidential interviews reported witnessing C1 smoking marijuana on facility grounds without staff knowledge. Other confidential interviews denied observing C1 having access to an unknown substance specifically a white powder substance while in care. Confidential interviews further reported that C1 was out of the facility often and did not have access to a phone while on facility grounds. Confidential interviews also stated that C1 would "brag" to peers about engaging in illegal activity while out of care but was not observed engaging in these behaviors while at the facility and under staff supervision. However, it was reported to LPA that C1 was observed to be in possession of an unknown white powder substance in care, and the substance was confiscated by a facility staff member and discarded. Other confidential interviews denied the incident or having knowledge of the information. Confidential interviews further reported that incidences involving illegal activity or drug paraphernalia are reported, and items are provided to administrative staff for further action. There were no other known witnesses to the allegations. The department received inconsistent statements about whether the allegations of C1 engaging in illegal activity, and C1 having access to an unknown substance occurred while in placement and under staff supervision or while C1 was out of care. Based on confidential interviews, and record review the allegations that staff did not prevent a minor from engaging in an illegal activity, and that staff did not prevent a minor from having access to an unknown substance, may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Campus Director, Elizabeth Tamoush.

Investigation Findings:
13On January 31, 2024, at 9: AM, Licensing Program Analyst (LPA), Cynthia Urena met with Trinity Apple Valley Short Term Residential Therapeutic Program (STRTP) Campus Director, Elizabeth Tamoush to deliver the investigative finding for the above stated allegations. On October 11, 2023, at 11: AM, Licensing Program Analyst (LPA) Cynthia Urena initiated the investigation at the STRTP and collected pertinent documents from the STRTP program staff and client files to assist with the investigation process. A Health and Safety inspection of the facility was conducted with the Campus Director and no deficiencies were observed. LPA advised Campus Director that Wilfredo Vasquez with the Community Care Licensing Division (CCLD) Investigations Branch (IB) would be leading the investigation. Investigator, Vasquez interviewed one client (C1) and two witnesses. LPA Urena conducted additional interviews with four clients (C2, C3, C4, C5), five facility staff members, and a Probation Officer. (**Continued on LIC C**) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Cynthia Urena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: TRINITY - APPLE VALLEYFACILITY NUMBER: VISIT DATE: 01/31/2024

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


raw_content:
Narrative:
Furthermore, LPA was informed that S2 made an inappropriate statement toward C1 after C1 became verbally aggressive with S2. Based on confidential interviews the preponderance of evidence standard has been met and the Department has determined that S1 and S2 antagonized C1 and that S2 called C1 an inappropriate name. Therefore, the allegation is substantiated. The facility is being cited for violation of the Interim Licensing Standards, Chapter 7. Short-Term Residential Therapeutic Program, Articles Through 10, Version 5 87072 (c)(1) Personal Rights. An exit interview was conducted, appeal rights explained, and a copy of this report and LIC 811 was provided to Elizabeth Tamoush.

Investigation Findings:
13On February 20, 2025, at 10: AM Licensing Program Analyst (LPA) Michael Almaraz met with Trinity Apple Valley Administrator, Elizabeth Tamoush, to issue the finding for the above allegation involving client 1 (C1), staff 1 (S1), staff 2 (S2) listed on the confidential names list (LIC 811) dated February 20, 2025. On July 23, 2024, at 9: AM LPA inspected the facility and conducted a health and safety inspection, and no immediate health and safety hazards were observed. During LPA inspection LPA reviewed clients' records, interviewed one staff, and interviewed six clients (C1, C2, C3, C4, C5, C6). Additionally, LPA Almaraz conducted interviews with one county social worker (CSW) and three additional staff. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Michael Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 61-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: TRINITY - APPLE VALLEYFACILITY NUMBER: VISIT DATE: 02/20/2025

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


raw_content:
Narrative:
It was specifically alleged that the STRTP did not provide C1 with additional support or any mental health care after finding C1 in a crisis on May 20, 2025, when C1 used a pencil cut C1's veins, causing C1 to bleed. Confidential witnesses provided consistent statements that the facility ensured that C1's emotional needs were met. Furthermore, LPA was informed that facility staff checked on C1 and all other clients to ensure that they were well emotionally. LPA was informed that all clients including C1 received mental health care and when in crisis clients met with a therapist. An additional confidential witness informed LPA that staff had heard C1 make statements that C1 was not well emotionally and staff ignored C1's statements. Regarding the allegation that staff are not providing proper supervision to minor exhibiting self-harming behavior confidential witnesses informed LPA that on May 20, 2025, they did not observe C1 engaging in self-harming behavior. Furthermore, LPA was informed that if clients engaged in self-harm or made statements suggesting that they were considering self-harm staff took immediate action. Additionally, LPA was provided consistent statements that on and around May 20, 2025, C1 was not observed with injuries suggesting C1 tried to cut C1's veins. Another confidential witness informed LPA that around May 20, 2025, they observed C1 with superficial injuries to C1's wrist but they were not informed when and where C1 sustained those injuries. LPA received conflicting information regarding both allegations. Based on record review and confidential interviews the allegations staff are not meeting C1's emotional needs and staff were not providing proper supervision to C1 when C1 was exhibiting self-harming behavior, may have occurred, however, they are not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Elizabeth Tamoush.

Investigation Findings:
13On October 10, 2025, at 9: AM Licensing Program Analyst (LPA) Michael Almaraz met with Trinity Apple Valley Short Term Residential Therapeutic Program (STRTP) Campus Director, Elizabeth Tamoush, to issue the finding for the above allegations involving client (C1) listed on the confidential names list (LIC 811) dated October 10, 2025. The complaint was jointly conducted by LPA Almaraz and LPA Rachel Vanegas. On May 28, 2025, at 12: PM LPA Vanegas conducted a health and safety inspection of the STRTP, and no immediate deficiencies were observed. Furthermore, LPA Vanegas reviewed clients' files and copies of pertinent documents were obtained. During the investigation LPA Almaraz interviewed ten clients (C1, C2, C3, C4, C5, C6, C7, C8, C9, C10) and four staff (S1, S2, S3, CD). On May 22, 2025, the Department received a complaint alleging staff are not meeting minor's emotional needs and staff are not providing proper supervision to minor exhibiting self-harming behavior. (continued on page 2...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Michael Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 61-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: TRINITY - APPLE VALLEYFACILITY NUMBER: VISIT DATE: 10/10/2025

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


summary: Facility Evaluation

raw_content:
Narrative:
On September 8, 2021 at 10: A.M., Licensing Program Analysts (LPA's) Michael Almaraz, Darlene Almaraz, and Lisi Leon, conducted an Annual Required Inspection and met with Campus Director, Elizabeth Tamoush and Assistant Director, Ronnie Elenez. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Campus Director and Assistant Director. The facility converted from a Group Home to STRTP (Short Term Therapeutic Program) on September 14, 2017. At 10: AM a physical plant inspection was completed and included the following checks: The facility consists of 4 dorms with 6 bedrooms and three bathrooms each. Each dorm has a kitchen and living room area for clients use. Each dorm has an office space for staff and staff restrooms. Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for client'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 Team Administrator's office. Individual beds were observed with appropriate clean linen, pillows, comforters, and mattresses in good repair. The hot water in the client's bathroom was measured to be 109 degrees. Facility has cameras in common areas of the dorms. The facility has an exception on file to use the cameras and are meeting the terms and conditions. Per facility staff, no firearms or weapons are allowed in the facility. Facility appears to be meeting the terms and conditions of their license. (...) Personnel files were reviewed to ensure they contained all required documentation per Title Regulations. Personnel files were maintained on-site in a locked cabinet in staff office. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index checks clearances and exemptions. A review of client records was also completed on this date. Client and staff interviews were conducted and there were no health and safety concerns at this time. The facility was issued a technical violation due to LPAs observing that the facility did not provide locked containers for client's contraceptives. Exit interview conducted and a copy of the LIC 809, LIC 809c and 9102 were provided and explained to Elizabeth Tamoush.

visit_type: Annual

met_with: Campus Director Elizabeth Tamoush


summary: Facility Evaluation

raw_content:
Narrative:
On June 15, 2022, at 10: AM Licensing Program Analyst (LPA), Michael Almaraz, arrived at Trinity Apple Valley Short Term Residential Therapeutic Program (STRTP) and met with assistant Campus Director Ronnie Elenez. The purpose of the inspection was to interview client #1 (C1) see confidential names list (LIC 811) dated June 15, 2022, in regard to a previous placement. A copy of the LIC 811 and LIC 809 was provided and explained to Ronnie Elenez.


summary: Facility Evaluation

raw_content:
Narrative:
On December 19, 2022, at 12: PM Licensing Program Analyst (LPA), Michael Almaraz, arrived at Trinity-Apple Valley Short Term Residential Therapeutic Program (STRTP) and met with campus director, Elizabeth Tamoush, to conduct a case management visit for the purpose of decreasing the capacity for clients' placement as requested by the licensee. The STRTP was licensed to provide care for 44 ambulatory clients. The licensee requested a capacity decrease to a total capacity 16 clients. The STRTP had 12 clients placed on the date of inspection. At 1: PM, LPA began the inspection of the facility with Elizabeth Tamoush. LPA toured the facility inside and out. LPA observed that there was a total of five buildings. Building one was the front office. Building two was the laundry, maintenance office. Building three was a cafeteria, training room and mental health offices. Building four and five acted as dorms for the clients. Building four had a team administrator's office along with two dorms. The dorms had six bedrooms, a staff office, staff break room, and four restrooms each. Building five had two empty dorms with six beds and four restrooms in each. No clients were being housed in building five at the time of inspection. Dorm one in building four Bedroom #1: consisted of two single beds and slept one client age 13. Bedroom #2: consisted of two single beds and slept one client age 14. Bedroom #3: consisted of two single beds and slept one client age 14. Bedroom #4: consisted of two single beds and slept one client age Bedroom# 5: consisted of two single beds and slept one client age 14. Bedroom#6: the room consisted of one single bed and slept a client age 13. Dorm two in building four Bedroom #1: consisted of two single beds and slept one client age 10. Bedroom #2: consisted of two single beds and slept one client age 16. (...) Bedroom #3: consisted of two single beds and slept one client age 13. Bedroom #4: consisted of two single beds and slept two client age 15 and Bedroom# 5: consisted of two single beds and slept one client age 13. Bedroom#6: the room consisted of one single bed was vacant. Bedroom were arranged so that no more than two clients share a room, and there was one client per bed. There was adequate shelf and closet space for client's belongings. The bathrooms were clean and in good repair. The hot water in the client bathroom was measured to be 115 degrees Fahrenheit. All hazardous items have been properly made inaccessible to areas where clients will have access. Cleansers/chemicals were locked and stored in a locked cabinet located in the staff restroom. Sharp knives were inaccessible and stored in a locked cabinet in an office located in the cafeteria. The First Aid Kit is located in the team administrator office and contained all required supplies. The facility's smoke/carbon monoxide detectors located in client's bedrooms and in the dorm dayrooms were checked and were operable. A Fire extinguisher was observed and properly charged. There are no guns or weapons in the facility as stated by Elizabeth Tamoush. Client's medications were observed to be inaccessible and stored in the team administrator office. LPA observed a minimum 7-day non-perishable and a 2-day perishable supply of food. There was a variety of snacks available for clients as well. Proper storage of all food was discussed. Trash cans for storage of solid waste have tight fitting lids. The facility outside grounds was also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. The Facility Sketch, Emergency Disaster Plan, visitation policy and Personal Rights were posted. Facility will complete a fire safety inspection for the approved decreased capacity of 16 clients and a copy of the approved fire safety clearance will be sent to the Department. There are no deficiencies to be cited at this time. The request for the license capacity change will be forwarded to Licensing Program Manager for final approval. An exit interview was conducted, and a copy of this report was provided to Elizabeth Tamoush.


summary: Facility Evaluation

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Narrative:
On October 5, 2023, at 9: A.M., Licensing Program Analyst (LPA), Michael Almaraz, conducted an Annual Required Inspection and met with Campus Director, Elizabeth Tamoush, and Assistant Director, Ronnie Elenez. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Campus Director and Assistant Director. The facility converted from a Group Home to STRTP (Short Term Therapeutic Program) on September 14, 2017. At 12: PM a physical plant inspection was completed and included the following checks: The facility consists of 4 dorms with 6 bedrooms and three bathrooms each. Each dorm has a kitchen and living room area for clients use. Each dorm has an office space for staff and staff restrooms. Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for client'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 Team Administrator's office. Individual beds were observed with appropriate clean linen, pillows, comforters, and mattresses in good repair. The hot water in the client's bathroom was measured to be 106 degrees. Facility has cameras in common areas of the dorms. The facility has an exception on file to use the cameras and are meeting the terms and conditions. Per facility staff, no firearms or weapons are allowed in the facility. Facility appears to be meeting the terms and conditions of their license. (continued on page 2...) During LPA inspection LPA inspected Physical Plant, Disaster Preparedness, and Client Records. Based on observation the facility is being cited on the following area: Client Records. Deficiencies were observed and cited on 809Ds. An annual continuation inspection will be conducted at a later date to complete the annual inspection. An exit interview was conducted and a copy of the LIC 809, LIC 809C, LIC 809D, and LIC 811 were provided and explained to Elizabeth Tamoush.


summary: Facility Evaluation

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Narrative:
On October 6, 2023, Licensing Program Analyst (LPA) Leslie Covarrubias arrived at Trinity Apple Valley and met with Campus Director, Elizabeth Tamoush. The purpose of the visit was to amend a report that was originally created from a previous visit. A copy of this report was handed to Campus Director, Elizabeth Tamoush.


summary: Facility Evaluation

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Narrative:
On October 18, 2023, at 9: AM, Licensing Program Analyst (LPA), Michael Almaraz, conducted an unannounced inspection and met with Campus Director Elizabeth Tamoush. The purpose of the inspection was to complete the continuation inspection for STRTP annual inspection that was initiated on October 5, 2023. LPA already completed the Physical Plant, Disaster Preparedness, and Client Records review. During this annual inspection continuation LPA reviewed Core/Therapeutic Services, Operational Requirements, Emergency Intervention Plan, and Staffing Records. LPA reviewed six personnel files to ensure they contained all required documentation per Title Regulations and Interim Licensing Standards (ILS). All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Personnel files were locked in the staff office. LPA reviewed the Personnel Report (LIC 500) and schedules to ensure appropriate staffing ratios. Lpa M. Almaraz conducted interviews with four available staff. Staff was able to provide sufficient information in relation to the facility's STRTP Program Statement, Emergency Intervention Plan, clients' Needs and Services plan, and Reporting Requirements. Based on interviews with staff, the facility appears to be meeting Core Services/Supports requirements. Based on the facility inspection and file reviews on this date, no deficiencies were cited. Facility appears to be meeting the terms and conditions of their license. An exit interview conducted and a copy of the LIC 809 was provided and explained to Elizabeth Tamoush.


summary: Facility Evaluation

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Narrative:
On November 8, 2023 at 4: PM, Associate Governmental Program Analyst (AGPA) Kim Robinson met with the short term residential treatment program (STRTP) director, Gil Quinbar, by telephone and Teresa Valles, the Yucaipa campus administrator in order to assess an Enhanced Civil Penalty (ECP). On September 13, 2023, the Department concluded a complaint investigation alleging that staff #1 (S1) did not provide supervision to meet the needs of children in care, resulting in client #2 (C2) sustaining multiple stab wounds to the leg and arm. These allegations were determined substantiated, and the STRTP was cited from the Title 22, California Code of Regulations Section 80078 (a), Responsibility for Providing Care and Supervision. The citation included an immediate civil penalty assessment of 500.00. See the Confidential Names List, LIC 811, dated September 13, 2023. Based on the analysis of the interviews, medical reports and findings from the San Bernardino Sheriff report the Department has determined that an enhanced civil penalty is warranted for S1 neglecting to supervise and provide care and supervision to meet the needs of the children in care. The Penal Code Section 243 defines serious bodily injury as a serious impairment of physical condition, including, but not limited to a wound requiring extensive suturing. This section describes a number of more or less direct and (always) willful acts that constitute physical abuse. Pursuant to the Enhanced Civil Penalty law, Health & Safety Code section 1548 (f)(1)(C), the Department will be issuing an immediate civil penalty of $2,000.00. An exit interview was completed, and appeal rights discussed. A copy of this report, the Confidential Names List, and a Civil Penalty Assessment - Serious Bodily Injury/Physical Abuse (Form 421-D) were provided to the director and administrator. The signed copy will be retained in the facility file.

met_with: Administrator


summary: Facility Evaluation

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Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Sarah Lo on 10/31/24 at 10:12 am. The case management inspection is conducted pursuant to Health and Safety Code Section 1538.9(a)(2). During the inspection, LPA met with Elizabeth Tamoush, Campus Director and Ronnie Elenez, Assistant Campus Director and inspected the facility inside and out. LPA reviewed five children's records on site at the facility. LPA reviewed five staff personnel files on site at the facility. LPA reviewed five child's psychotropic medications and medication records. LPA interviewed three children that is currently prescribed psychotropic medication at their school. No deficiencies are being cited at this time. LPA provided a copy of this licensing reporting and conducted an exit interview with Elzabeth Tamoush, Campus Director.

met_with: Elizabeth Tamoush, Campus Director Ronnie Elenez, Assistant Campus Director


summary: Facility Evaluation

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Narrative:
On July 22, 2025, at 9: A.M., Licensing Program Analyst (LPA), Jacob Ortega, conducted an Annual Required Inspection and met with Assistant Director, Ronnie Elenez and Campus Director Elizabeth Tamoush. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Campus Director and Assistant Director. LPA toured the facility with Assistant director (AD) The facility consists of 4 dorms with 6 bedrooms and three bathrooms each. Each dorm has a kitchen and living room area for clients use. Each dorm has an office space for staff and staff restrooms. Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for client'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 Team Administrator's office. Individual beds were observed with appropriate clean linen, pillows, comforters, and mattresses in good repair. LPA reviewed five personnel files to ensure they contained all required documentation per Title Regulations and Interim Licensing Standards (ILS). All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Personnel files were locked in the staff office. Continued on c page LPA reviewed five client files. All client records reviewed had the required documents including admission agreements, personal rights, medical history, immunization records, medical consent form, and an initial or updated needs and services plan on file. During client file review LPA observed that Client (C4) did not have evidence of a TB test. A Technical violation was issued in lieu of a citation, as evidence of TB test will be obtained through C4 authorized representatives. per California Code of Regulations (CCR) 80069(c)(1) "All client records reviewed had the required documents including admission agreements, personal rights, medical history, immunization records, medical consent form, and an initial or updated needs and services plan on file." During client file review LPA also noted that Client (C5) did not have a current JV-220 form. Due to this a Type A violation was given per Interim Licensing Standards 87070 (b) (13) "(b) The following information regarding the child shall be obtained and maintained in the child's record: (13) A copy of the current court order, or written authorization of the child's parent or guardian, for each psychotropic medication, as defined in Section 87001(p)(9)." LPA also observed that an up to date fire clearance approval letter had not been received. Due to this a Technical violation was given per CCR 80020(a) "(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal." LPA interviewed four staff and three clients. A copy of this report and LIC 811 was given to Campus Director Elizabeth Tamoush.


summary: Facility Evaluation

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Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPA's) Jacqueline Garcia, Rachel Vanegas and Carissa Aviles on August 06, 2025 at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA's met with Elizabeth Tamoush, Campus Director and Ronnie Elenez, Assistant Campus Director and inspected the facility inside and out. LPA's reviewed 5 child records and 5 staff personnel files on site at the facility. LPA's reviewed 5 child's psychotropic medications and medication records. LPA's will return to conduct client and staff interviews to discuss the facilities policies and procedures of operation. No deficiencies are being cited at this time. The facility was provided with a Technical Assistance (TA) note. LPA's provided a copy of this licensing report and conducted an exit interview with Elizabeth Tamoush, Campus Director .

met_with: Elizabeth Tamoush-Campus Director


summary: Facility Evaluation

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Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Jacqueline Garcia on 08/18/25 at 11: AM . This Case Management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the visit, LPA Garcia met with Elizabeth Tamoush, Campus Director and Ronnie Elenez, Assistant Campus Director. This visit is a follow up visit to the Case Management inspection conducted on 08/06/2025 by Licensing Program Analysts (LPA's) Jacqueline Garcia, Rachel Vanegas and Carissa Aviles. LPA Garcia interviewed 2 client's who are currently prescribed psychotropic medication. LPA Garcia interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPA Garcia conducted an exit interview and provided a copy of this licensing report along with LIC 811 to Campus Director, Elizabeth Tamoush.


summary: Facility Evaluation

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Narrative:
On December 15, 2021, Licensing Program Analyst (LPA), Michael Almaraz, met with facility assistant campus director Ronnie Elenez to complete a Case Management inspection based off information received in a special incident report (SIR) dated December 12, 2021. The SIR reported to the Department that facility staff #1 (S1) administered medication in error to client #1 (C1) Refer to Confidential Names (LIC 811) dated December 15, 2021. During LPA inspection of the facility LPA completed an interview with one staff and two clients. LPA collected copies of the information relevant to the case management. During LPA visit it was discovered that client #2's (C2) medication was issued to C1 and the medication error was not logged on C2's Psychotropic Medication Administration Record LIC 622B. Based on confidential interviews and record review the facility failed to log instructions for control and custody of C2's medication. The facility will be cited for a violation of California Code of Regulations, Title 22, Division Six, regulation 80075(k)(7)(H): Health Related Services. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Ronnie Elenez.


summary: Facility Evaluation

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Narrative:
***This is an amended report of the original report dated 9/7/2023*** An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Leslie Covarrubias on September 7, 2023 at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Covarrubias met with Campus Director, Elizabeth Tamoush and inspected the facility inside and out. LPA reviewed five of child's records and five of staff personnel files on site at the facility. LPA reviewed five of child's psychotropic medications and medication records. LPA interviewed five of staff on site to discuss the facilities policies and procedures of operation. LPA interviewed five of children currently prescribed psychotropic medication. No deficiencies are being cited at this time. LPA conducted an exit interview with Campus Director, Elizabeth Tamoush.


summary: Facility Evaluation

raw_content:
Narrative:
On September 13, 2023 at 10: AM, Licensing Program Analyst (LPA), Cynthia Urena met with Trinity Apple Valley Short Term Residential Therapeutic Program (STRTP) Campus Director, Elizabeth Tamoush to discuss an issue that arose involving Client 1 (C1), Client 2 (C2) and Staff 1 (S1) (see LIC 811 confidential names list dated 09/13/23). During interviews conducted by Special Investigator (SI) Dennis Douglas with the California Department of Social Services, (CDSS), Community Care Licensing Division (CCLD), Investigations Branch Bureau, it was revealed that the facility operated outside of the State regulated staff to client ratio. Consistent confidential interviews disclosed on 04/23/23 the facility had 15 clients and 3 staff in which the facility was not within ratio. Confidential interviews disclosed that the facility was outside of ratio due to three staff members calling off on this date. Consistent confidential interviews further reported that while the facility operated outside of the State regulated staff to client ratio resulted in C2 breaking into a room at the facility, confining self in a room, and in an altercation between C1 where C1 sustained serious injuries while in care. Based on information obtained, the facility operated outside of required client to staff ratio; facility is cited for violation of Interim Licensing Standards (ILS) version four SECTION 87065.5(b)(1)(C) Direct Care Staff/Child Ratios which posed an immediate health and safety risk to clients in care. A copy of this report was discussed, and provided along with appeal rights and LIC811 confidential names list to Trinity Apple Valley STRTP Campus Director, Elizabeth Tamoush.


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Narrative:
Based on confidential interviews the preponderance of evidence standard has been met and the Department has determined licensee did not ensure required staffing ratios were maintained. Therefore, the allegation is substantiated. The facility is being cited for violation of the Interim Licensing Standards, Chapter 7. Short-Term Residential Therapeutic Program, Articles Through 10, Version 5 87065.5 (b)(1)(C) Direct Care Staff/Child Ratios. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Elizabeth Tamoush. Confidential witness provided consistent statements that they had not heard or observed S1, or any other staff member intentionally provoke clients or attempt to provoke clients. Furthermore, LPA was informed by confidential witnesses that they were never notified that S1 or other staff members were provoking clients. PO informed LPA that PO was never provided information regarding this allegation occurring at the facility. Other confidential witness statements revealed staff have provoked clients in the manner that staff speak to the clients and staff S1 attempted to purposely upset client (C1) to test if C1's anger management was working. Regarding the allegation staff spoke to minors in an inappropriate manner confidential witnesses denied that S2 or any other staff had yelled or cursed at the clients. Additionally, LPA was informed that facility staff may raise their voice while speaking to clients but not yell at the clients. PO added that PO was never informed that staff were speaking to clients in an inappropriate manner. Other confidential witnesses stated that S2 and other staff have cursed and yelled at clients on several different occasions. LPA received conflicting information regarding all allegations. Based on confidential interviews the allegations staff intentionally provoked minors and staff spoke to minors in an inappropriate manner, may have occurred, however, they are not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Elizabeth Tamoush.

Investigation Findings:
13On March 12, 2026, at 11: AM Licensing Program Analyst (LPA) Michael Almaraz met with Trinity Apple Valley Short Term Residential Therapeutic Program (STRTP) Campus Director, Elizabeth Tamoush, to issue the finding for the above allegation see confidential names list (LIC 811) dated March 12, 2026. The complaint was conducted by LPA Almaraz. On August 22, 2025, at 11: AM LPA Almaraz conducted a safety inspection of the facility, and no immediate health and safety hazards were observed. During the investigation LPA Almaraz interviewed ten clients, three facility staff, and one Probation Officer (PO). On August 15, 2025, the Department received a complaint alleging licensee did not ensure required staffing ratios were maintained. It was specifically alleged that the facility was short staffed and a staff member was observed struggling to manage eight clients alone. Confidential witnesses provided consistent statements that there were times during the hours of 7: AM and 10: PM that one staff member was tasked with providing supervision to five or more clients. (continued on page 2...) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Michael Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 61-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: TRINITY - APPLE VALLEYFACILITY NUMBER: VISIT DATE: 03/12/2026

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:


facility_name: TRINITY - EL MONTE

raw_content:
Narrative:
During interviews, case manager stated there was communication with the client, but stated there was a day that the internet was not working and they still had cell phones available for communication. Client denied the allegations. Based on interviews and records reviewed there was no corroborating information to substantiate the allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the above allegations did or did not happen, therefore, the above allegations are being closed unsubstantiated. No deficiencies were cited during this inspection.

Investigation Findings:
13On 07/22/2021 at 2:30PM, Licensing Program Analyst (LPA) Pedro Ramos conducted a follow up complaint inspection to the above group home. The purpose of the inspection was to deliver findings for the above complaint allegations. LPA spoke with Jaime Acosta, Administrator during the inspection. During the course of this investigation, LPA conducted telephone interviews with the facility Administrator on 3/26/21, Case Manager and one client on 03/26/21. (refer to Confidential Names LIC 811 dated 07/22/2021). LPA reviewed and obtained the following documents; email documents, Needs and Services Plan and Special Incident Report. It was alleged minor did not have access to telephone while in care and staff demonstrated inappropriate form of punishment. The Administrator denied the allegations and disclosed that the facility did have a problem with their internet service, but the clients did have access to phones. He also stated the clinet was moved to a different cottage due to safety concerns due to an incident with another client. He stated it was a safety protocol they follow. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Pedro Ramos LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: TRINITY - EL MONTEFACILITY NUMBER: VISIT DATE: 07/22/2021

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

met_with: Jaime Acosta, Administrator