raw_content:
Narrative:
Confidential interviews reveal when a staff is separated from the facility more than one (1) person is responsible for packing personal belongings. The staff items were packed by two (2) who confirmed a observation log was not in the bag. Confidential interviews reveal staff are not allowed to remove residents files from the facility. Resident files are locked in the hall closet and not all staff have access to the key. The observation log is a black folder stored in the office locked cabinet. Confidential interviews with Child #1 and Child #3 that staff protect their privacy and talk to them privately about stuff away from other residents. Staff interviews reveal no work related items are taken from facility. Due to inconsistent statements LPA Phillips was not able to determine if the above said allegation occurred, therefore the allegation is found to be Unsubstantiated meaning that although the allegation may have happened or is valid there is not a preponderance of evidence to prove that the alleged incident occurred. No deficiencies cited at the time of this investigation. Exit interview was conducted, and copy of the report will be emailed to facility administrator/ Sueretta Small.

Investigation Findings:
13On July 8, 2022 @ 9: AM Licensing Program Analyst (LPA), Zena Phillips conducted a follow-up complaint investigation visit to New Concept and met with Keshia Marshall/ Facility Manager. The purpose of the visit was to deliver findings for the above complaint allegation. During the investigation of the allegation. Staff violated confidentiality of youth. LPA Phillips reviewed facility file and conducted confidential interviews with relevant parties. After conducting the confidential interviews and reviewing the following documentation: Staff HIPPA certificates, Observation log notebook, Facility activity calendar, and Client files. LPA Phillips was not able to determine whether staff violated confidentiality of youth due to inconsistent statements. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Zena Phillips LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: NEW CONCEPTFACILITY NUMBER: VISIT DATE: 07/08/2022

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

met_with: Keshia Marshal/ Facility Manager


state: CA

facility_name: NEW CONCEPT

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Staff #1 through Staff #6 deny that youth are selling drugs on the premises. All stated they have never seen any residents selling drugs or using drugs. Confidential interviews reveal that staff counsel youth if substance abuse is suspected. Staff reveal that they have confiscated a vape pen and provided counseling. Interviews reveal that facility provide substance abuse counseling on weekly basis for residents. Residents deny smoking or selling drugs on the premises. The schedules provided by the facility reveals that there is adequate staff members on duty during the day and overnight as required. Confidential interviews conducted stated there is always supervision at the facility. Residents deny that staff consume their food and state staff bring their own food. Residents and staff admit all eat together for celebrations. Confidential interviews with residents reveal that staff are always doing room checks. Due to inconsistent statements LPA Phillips was not able to determine if the above said allegations occurred, therefore the allegations were found to be Unsubstantiated meaning that although the allegations may have happened or are valid there is not a preponderance of evidence to prove that the alleged incidents occurred. No deficiencies cited at the time of this investigation. Exit interview was conducted, and copy of the report will be emailed to facility administrator.

Investigation Findings:
13On July 13, 2022 @ 2: PM Licensing Program Analyst (LPA), Zena Phillips conducted a follow-up complaint investigation visit to New Concept and met with Keshia Marshall/ Facility Manager. The purpose of the visit was to deliver findings for the complaint allegations. During the investigation of the allegations. Lack of supervision resulting in minors selling drugs on the premises. Staff not preventing minors from using drugs. Staff consuming minor's food. After conducting the confidential interviews and reviewing the following documentation: facility file, staff schedule, facility menu, observed staff refrigerator, activity calendar, substance abuse policy, NSP and conducted confidential interviews with relevant parties. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Zena Phillips LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: NEW CONCEPTFACILITY NUMBER: VISIT DATE: 07/13/2022

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

report_type: Complaint Investigation

complaint_status: unsubstantiated


raw_content:
Narrative:
Supporting evidence include the following Staff #1, Staff #2, Staff #3, Staff #4, Staff #5, Staff #6 & Staff #7 all deny that staff are smoking marijuana at the facility. All the staff interviewed stated that minors are not allowed to smoke at the facility and stated youth are counseled not to use drugs. Child #1, Child #2 and Child # 3 all deny that staff are smoking marijuana at the facility and they are not allowed to smoke in the facility. Based on the interviews conducted and documents obtained, the above allegations are found to unsubstantiated due to inconsistent statements. LPA Phillips was not able to determine if the above said allegations occurred, therefore the allegations are determined to be unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. Based on the observations made during today's inspection, no deficiencies cited. Exit interview was conducted, and a copy of this report will be emailed to the SUERETTA SMALL .

Investigation Findings:
13On September 2, 2022 at 11: AM Licensing Program Analyst (LPA), Zena Phillips conducted a follow-up complaint investigation visit to NEW CONCEPT and met with KeVon Branch Facility Manager who granted access to the facility. The purpose of the visit was to deliver findings for the complaint allegations. Facility staff smoke marijuana at the facility. Minors smoke marijuana at the facility. LPA Phillips conducted confidential interviews and reviewed the following documentation, facility files, client files, staff schedule, drug policy, Needs and Service Plan, and Child and Family Teams Meeting notes. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Zena Phillips LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: NEW CONCEPTFACILITY NUMBER: VISIT DATE: 09/02/2022

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

met_with: KeVon Branch/Facility Manager


raw_content:
Narrative:
Community pass log shows that residents do in fact sign out. It was reported to LPA Phillips that residents are not consuming alcohol at the facility. It was reported to LPA Phillips that residents are not allowed to consume alcohol and substance abuse counseling is available to residents. Staff reported that they have not see residents consume alcohol at the facility. Staff admit that some residents do have substance abuse and substance abuse counseling is available for all residents. Due to inconsistent statements LPA Phillips was not able to determine if the above said allegations occurred, therefore the allegations were found to be Unsubstantiated meaning that although the allegations may have happened or are valid there is not a preponderance of evidence to prove that the alleged incident occurred. No deficiencies cited at the time of this investigation. Exit interview was conducted, and copy of the report will be emailed Sueretta Small facility administrator.

Investigation Findings:
13On November 29, 2022 at 2: PM Licensing Program Analyst (LPA), Zena Phillips conducted a follow-up complaint investigation visit to NEW CONCEPT and met with Sueretta Small/ Administrator who granted access. The purpose of the visit was to deliver findings for the complaint allegations. During the investigation of the allegations: Staff did not prevent minors from AWOLing. Minors Consumed drugs and alcohol on the premises. LPA Phillips conducted confidential interviews and reviewed documentary evidence, SIR reports, community pass log sheet, activity calendar for June & July 2022. It was reported to LPA Phillips during confidential interviews that Staff try and prevent residents from awoling by offering community pass and redirection. It was reported to LPA Phillips staff try to encourage residents to stay at facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Zena Phillips LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: NEW CONCEPTFACILITY NUMBER: VISIT DATE: 11/29/2022

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

met_with: Sueretta Small/ Administartor


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
LPA Phillips was able to determine the above said allegation occurred, therefore the allegation is determined to be substantiated, meaning that the allegation happened and is valid, there is a preponderance of the evidence to prove that a violation occurred. Facility cited on the attached LIC 9099-D for violation of Interim Licensing Standards, regulation 87065. Direct Care Staff/Child Ratios Facility staff was asleep during shift. Exit interview was conducted, and a copy of this report will be emailed to the Sueretta Small/Administrator

Investigation Findings:
13On November 29, 2022 at 2: PM Licensing Program Analyst (LPA), Zena Phillips conducted a follow-up complaint investigation visit to NEW CONCEPT and met with Sueretta Small/ Administrator. The purpose of the visit was to deliver findings for the complaint allegation. Staff not providing adequate supervision. During the investigation of the allegation: LPA Phillips conducted confidential interviews, reviewed documentary evidence: facility files, Special Incident Reports and pictures of staff. Based on the interviews conducted and documentary evidence, the information gathered produced corroborating evidence to support the above said allegation. LPA Phillips observed photos of staff sleeping at the facility.. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Zena Phillips LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: NEW CONCEPTFACILITY NUMBER: VISIT DATE: 11/29/2022

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

met_with: Sueretta Small/ Administrator

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
Confidential interviews reveal that facility has working air conditioning and ceiling fans in the resident's bedrooms. It was reported to LPA Phillips that upstairs bedroom windows are sometimes opened while air conditioning is on no reason provided. All confidential interviews reveal that facility temperature is comfortable and air conditioning is working. Due to inconsistent statements LPA Phillips was not able to determine if the above said allegation occurred, therefore the allegation is found to be Unsubstantiated meaning that although the allegation may have happened or is valid there is not a preponderance of evidence to prove that the alleged incident occurred. No deficiencies cited at the time of this investigation. Exit interview was conducted, and copy of the report will be emailed to facility administrator.

Investigation Findings:
13On December 1, 2022 at 8: AM Licensing Program Analyst (LPA), Zena Phillips conducted a follow-up complaint investigation visit to New Concept and met with Keshia Marshall/ Facility Manager who granted access and provided the census. The purpose of the visit was to deliver findings for the complaint allegation. During the investigation of the allegation: Staff are not maintaining a comfortable temperature for clients in care. LPA Phillips conducted five (5) confidential interviews. review of documentary evidence, LPA observation of air conditioning motor in backyard and 71 degrees wall thermostat reading on 11/03/2022. LPA Phillips was provided business card of company that does annual check of HVAC system no repairs reported. Licensee reported to LPA Phillips the HVAC system was installed two (2) years ago and no service required as system continues to work without need for repairs.. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Zena Phillips LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: NEW CONCEPTFACILITY NUMBER: VISIT DATE: 12/01/2022

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

met_with: Keshia Marshall/ Facility Manager


raw_content:
Narrative:
Due to inconsistent statements LPA Phillips was not able to determine if the above said allegations occurred, therefore the allegation is found to be Unsubstantiated meaning that although the allegations may have happened or is valid there is not a preponderance of evidence to prove that the alleged incident occurred. No deficiencies cited at the time of this investigation. Exit interview was conducted, and copy of the report will be emailed to facility administrator.

Investigation Findings:
13On 01/18/2024 @ 10: AM Licensing Program Analyst (LPA) Zena Phillips made follow up visit for the purpose or delivering findings on the allegations listed: Staff made inappropriate comments to youth in care. Staff engaged in a physical altercation with youth in care. Staff did not seek youth in care appropriate medical attention. During the investigation LPA conducted confidential interviews, reviewed facility records, medical records and, Special Incident Reports. It was reported to LPA that no inappropriate comments were made to youth in care and no physical altercation happened with youth in care. Documentary evidence revealed that medical appoinments were refused by youth in care. Confidential interviews deny the allegations occured and residents are provided with medical appoinments as needed and may refuse appoinments. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Zena Phillips LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: NEW CONCEPTFACILITY NUMBER: VISIT DATE: 01/18/2024

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

met_with: Kevon Branch/Facility Manager


summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13Licensing Program Analyst Connie Jones-Steward investigated the above allegations. LPA interviewed all involved parties and reviewed Special Incident Report dated May 27, 2023. During the course of the investigation LPA received conflicting accounts of the incident. Staff persons denied engaging in a physical altercation other than using approved restraint techniques for approved purposes. Staff denied purposely causing injury to clients or speaking inappropriately to them. One client declined to be interviewed and another maintained that the staff conducted inappropriate restraints and spoke insults to the clients. All parties that were interviewed denied that clients did not receive proper medical assessment or treatment for their injuiries. Based on the available information, there is lack of consensus as to exactly what happened, therefore the allegations are resolved as unsubstantiated. An unsubstantiated finding means that although an allegation may be true, there is lack of of sufficient evidence to prove that it did happen UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Connie Jones-Steward LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Kevon Branch, Facility Manager


raw_content:
Investigation Findings:
13Licensing Program Analysts Zena Phillips and Connie Jones-Steward investigated the above allegations. LPA Phillips interviewed Staff and Clients. LPA Jones-Steward reviewed the work schedule, client roster, locker agreement and menus for September and October 2022. During the investigation, Staff denied that they mishandle or disrespect client property during room searches or speak to them inappropriately. Staff stated that the food served is of good quality & quantity and that appropriate hygiene products are provided. Administrator stated that during the time in question only one client requested a locker for his belongings. Staff stated that the only time the clients are not allowed to use the facility Internet during the day when they are home because they refused to attend school. LPA Jones-Steward observed on 08/2/2024 that the food supply met Title 22 requirements for fresh, non-perishable and snack foods. and that there were surplus hygiene products available for client use. Based on the investigation LPA Jones-Steward was not able to gather sufficient information to substantiate the above allegations. Therefore they are resolved as unsubstantiated. Unubstantiated means that although an allegation may have happened or is valid, there is not a preponderance of evidence that it did occur UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Connie Jones-Steward LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Shalane Brouchet, Program Manager


raw_content:
Narrative:
There was no evidence that the facility staff failed to treat the minor with respect or the facility staff yelled at the minor. There was no evidence to support the claims. C1 was unavailable for interview. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred; therefore, the above allegation is Unsubstantiated. There are no deficiencies being cited at this time.

Investigation Findings:
13On January 16, 2025 at 1pm Licensing Program Analyst (LPA) Donald Martin conducted a follow up complaint inspection and spoke with Supervisor, Kevon Branch and was allowed into the facility. The purpose of this inspection was to deliver findings for the above complaint allegation. During the course of investigation the allegations for staff does not treat minor with respect and staff yelled at minor, interviews were conducted and documents obtained. The interviews did not produce corroborating evidence to support said allegations. Interviews revealed inconsistent statements and no witnesses to suggest allegations occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: NEW CONCEPTFACILITY NUMBER: VISIT DATE: 01/16/2025

met_with: Kevon Branch-Supervisor


raw_content:
Narrative:
The facility is cited on the attached LIC 9099-D for violations of the Interim Licensing Standards (ILS) for STRTP, Section 87065.5(b)(2)(c), due to failure to maintain awake supervision and comply with direct care staff-to-child ratio requirements. Even if staffing ratios were met, a staff member sleeping in an area accessible to youth compromised supervision, posed security risks, and highlighted the need for stricter oversight to ensure regulatory compliance. An exit interview was conducted, and a copy of this report will be emailed to Sueretta Small, Administrator and Shalane Brouchet. The facility is required to submit a corrective action plan addressing the cited violations to ensure compliance with CDSS regulations and prevent the recurrence of similar incidents.

Investigation Findings:
13On 03/06/2025 at 10: AM, LPA Jarmin arrived at New Concept STRTP to discuss the findings of the investigation into staff sleeping during shifts. LPA met with the Office Manager and explained that the investigation concluded on February 12, 2025, at 4: PM. During the investigation, LPAs conducted confidential interviews, assessed health and safety conditions, and reviewed relevant documents. The findings confirmed the allegation, showing that the licensee violated staffing ratio requirements for a census of eight children and failed to enforce the facility's policy prohibiting sleeping during shifts. Evidence also revealed security and supervision concerns, indicating a failure to ensure proper oversight and protect personal dignity. Based on LPA interviews, record reviews, and evidence obtained, the preponderance of evidence standard has been met. Therefore, the allegation of Neglect/Lack of Supervision is SUBSTANTIATED. Deficiencies are cited to the facility for failure to provide adequate supervision as required by licensing regulations. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Enrique M Hernandez LICENSING EVALUATOR NAME: Dennis Jarmin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: NEW CONCEPTFACILITY NUMBER: VISIT DATE: 03/06/2025

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

met_with: SHALANE BROUCHET


summary: Facility Evaluation

raw_content:
Narrative:
On November 22, 2021 at 8: AM, Licensing Program Analyst (LPA) Zena Phillips arrived at the above facility, for the purpose of conducting a Annual inspection. LPA met Sueretta Small/ Administrator who granted access into the facility, and who provided a copy of LIC 500 and resident roster. A tour of the entire physical plant inside and out. This facility is designed to provide care/supervision for six (8) males, ambulatory only clients, ages 12-17 years. Plus, Non -minor Dependents, Ambulatory only. The home is set up as follows: This is two story, four (4) bedrooms, two & half (2.5) bathrooms home located in a residential neighborhood. There is also a covered patio with a table and adequate amount of seating. Yard is well maintained and has locked shed with yard tools. The sides of the house and clear of any debris and landscape is well maintained. Downstairs (main floor) has the following: There is a living room with 3 sofas. This room is equipped with a camera with a view of activities in living room. There are 3 bookshelves filled with books and games. a flat screen TV. There is desk equipped with computer and house phone. There is therapist room off front entrance way equipped with desk, computer, fireplace covered with security screen and adequate seating for client services. There is a storage room off the front entrance with locked sharps. Kitchen has fully charged fire extinguisher,upper cabinets with adequate bowls, plates and spices. Lower cabinets equipped with pots, pans and food storage containers. Dining room has seating for 8 residents. The kitchen is stocked with non-perishable foods for one week. There is an emergency doorway to facilitate evacuation from the front door, garage door off kitchen and back door off the living room. Garage is equipped with extra freezer and refrigerator for extra food supplies. There are 2 washers and 2 dryers for laundry with laundry soap and disinfectants in upper cabinets above washer. There is additional cabinet equipped with extra linens and laundry soap. continued on LIC 809 c There is additional closet off the main entryway equipped with fully charged fire extinguisher as well as extra supply of snacks and extra keys in locked box. Camera in front entrance with view of all activities in downstairs entrance way. Upstairs (2nd floor) equipped with camera with a view of all activities in hallway only. Bedroom #1: Is equipped with two (2) twin size beds. There are adequate drawers, closet space, lighting and functional smoke detector. Bedroom #2: Is equipped with one (2) twin size beds. There are adequate drawers, closet space, lighting and functional smoke detector. Bedroom #3: Is equipped with two (2) twin size beds. There are adequate drawers, closet space, lighting and functional smoke detector. This room has an attached bathroom with hot water is within an acceptable temperature range. Bedroom #4: Is equipped with one (2) twin size beds. There are adequate drawers, closet space, and functional smoke detector and lighting . Bathroom: full equipped tub and shower combination, sink, the hot water temperature is within an acceptable temperature range. Hall closet equipped with extra hygiene products and linens and extra household supplies. Facility is clean, safe, sanitary, and in good repair. Passageways, stairways, inclines, ramps, and open porches are unobstructed. Disinfectants, cleaning solutions, and poisons are made inaccessible. There are no firearms/dangerous weapons. Temperatures in rooms that clients occupy are maintained between 68 and 85 degrees (F). Hot water temperatures are maintained between 105 and 120 degrees (F). Children in care will be supervised and protected at all times; Children will attend school, extracurricular, cultural, and personal enrichment activities. All smoke detectors were tested and are operating properly in the home at the time of visit. Carbon Monoxide alarms were tested and functional in the home at the time of the visit. Medications locked and accessible only to employees responsible for stored medications. Facility posts child's rights on living room wall.Facility license posted in main office. Exit interview was conducted and no deficiencies cited at this time. LPA Phillips will travel to corporate office to view staff files. LPA will return at a later date to review client files. No parking was available at corporate office, administrator agreed to bring files on LPA return visit to facility. A copy of the report was emailed to administrator.

report_type: Facility Evaluation

visit_type: Annual

met_with: Sueretta Small//Adminstrator


summary: Facility Evaluation

raw_content:
Narrative:
On December 6, 2021 at 9:20am, Licensing Program Analyst (LPA) Zena Phillips made an announced visit to New Concept to conduct a case management annual continuation inspection. The facility is licensed to provide care and supervision for eight (8) children, ages 12-17 years old, ambulatory only. This facility also provides services to non-minor dependents. The census on the date of this visit is eight (8). LPA Phillips met with Sueretta Small Administrator, who granted access into the home. Staff Records Review: LPA reviewed five (5) staff records stored in individual personnel file/binders provided by the Administrator. LPA ensured to thoroughly review the records of the primary active staff The Administrator, Primary Therapist, Facility Manager; and Direct Care Staff. LPA reviewed the Personnel Report (LIC 500) and confirmed that Direct Care Staff Ratio present for the eight (8) clients in placement. In review of the staff's records confirmed that all staff have required criminal record clearance. DOJ, FBI and Child Abuse Response. LPA interviewed 1 client who was not present at last inspection date. Client Records Review: LPA reviewed four (4) client records stored in individual personnel file/binders provided by the Administrator. LPA thoroughly reviewed the records of the clients including the Needs and Services Plan for each client along with Personal Rights. LPA reviewed the medication log. Medication log is up to date LPA was given a copy of fire clearance verification, emergency disaster plan for CRF, Licensee agreed to submit board meeting minutes next business day. Exit interview was conducted and no deficiencies cited at this time

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) David Torres conducted a case management inspection March 22, 2022 at 9:03am based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 10 out of Direct Care Staff and 8 out of 8 youth files were reviewed. 5 out of Direct Care Staff and 7 out of 8 youth were interviewed. (See the Confidential Names List, LIC 811, dated March 22, 2022). The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, youth case plans, quarterly assessments, and crisis intervention plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA David Torres observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Sueretta Small, Administrator.

met_with: Sueretta Small, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Rosslyn Gray, Zena Phillps,and Emelyn Sanchez P.,on January 26, 2023 at 8:30AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs Gray,Phillips, and Sanchez P. met with Suerrtta Small, Facility Administrator and inspected the facility inside and out. LPAs reviewed #1 of child's records and #3 of staff personnel files on site at the facility. LPAs reviewed #1 of child's psychotropic medications and medication records. LPAs interviewed #3 of staff on site to discuss the facilities policies and procedures of operation. LPAs interviewed #0 of the children currently prescribed psychotropic medication. LPAs provided a copy of this licensing reports to Suerrtta Small, Facility Administrator. No deficiency were cited per Interim Licensing Standards for STRTP Version 4. Exit interview was conducted, and a copy of this report was left with Suerrtta Small, Facility Administrator.

met_with: Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On March 14, 2023 at 2: PM Licensing Program Analyst (LPA) Zena Phillips arrived at the above facility for the purpose of conducting a Case Management Investigation. LPA met with Keschia Marshall who granted access to the facility and provided the census. On January 06, 2023, an Incident Report #840096, with limited information about resident awol. LPA conducted interview and advised to follow Reporting Requirements when submitting SIR. Marshall reported to LPA Phillips that In Service Training was conducted on 02/11/2023 on SIR and staff attended and completed sign in sheet. LPA was provided course power point and signature page of staff attendance. No deficiencies were cited at the time of the visit. This case does not required further investigation.


summary: Facility Evaluation

raw_content:
Narrative:
On March 14, 2021 at 8: AM, Licensing Program Analyst (LPA) Zena Phillips arrived at the above facility, for the purpose of conducting a Annual Random inspection. LPA met Sueretta Small/ Administrator who granted access into the facility, and who provided a copy of LIC 500 and resident roster. LPA conducted a tour of the entire physical plant inside and out. This facility is designed to provide care/supervision for six (8) males, ambulatory only clients, ages 11-17 years. This facility also provides services to non -minor dependents. Naloxone waiver on file. The current census is five (5). The home is set up as follows: This is a two story, four (4) bedrooms, two & half (2.5) bathrooms home located in a residential neighborhood. There is also a covered patio with a table and adequate amount of seating. There is a therapy pod in yard with phone, two large chairs, book case, desk with chair. Yard is well maintained and has locked shed with yard tools. The sides of the house are clear of any debris and yard is well maintained. Downstairs (main floor) has the following: There is a living room with 3 sofas. This room is equipped with a camera with a view of activities in living room. There are 3 bookshelves filled with books and games, two (2) flat screen television. There is desk equipped with computer and house phone, complaint box with forms available on wall mounted paper holder. There is therapist room off front entrance way equipped with three (3) desk, computer, fireplace covered with security screen and adequate seating for client services. There is a storage room off the front entrance with locked sharps. The kitchen has fully charged fire extinguisher, upper cabinets has adequate bowls, plates and spices. Lower cabinets equipped with pots, pans and food storage containers. The dining room has seating for 8 residents. The kitchen is stocked with non-perishable foods for one week. There is an emergency doorway to facilitate evacuation from the front door, garage door off kitchen and back door off the living room. Garage is equipped with two (2) extra freezers and refrigerators for extra food supplies. There are 2 washers and 2 dryers for laundry with laundry soap and disinfectants in locked upper cabinets above washer. There is an additional cabinet equipped with extra linens and laundry soap. cont on 809c There is an additional closet off the main entryway equipped with fully charged fire extinguisher as well as extra supply of snacks and extra keys in locked box. There is a camera in front entrance with view of all activities in downstairs entrance way. Fire pull station in hallway. There is staff office to the downstairs with three (3) desk and computers, storage cabinet for staff personal belongings, locked cabinets with extra gloves, mask,covid test kits and gaming controllers. LPA inspected two (2) facility vehicles Chrysler and Toyota mini van and confirmed all seat bels working, first aid kit and both have valid registration and insurance. Upstairs (2nd floor) equipped with camera with a view of all activities in hallway only. Bedroom #1: Is equipped with two (2) twin size beds. There are adequate drawers, closet space, lighting and functional smoke detector. Bedroom #2: Is equipped with one (2) twin size beds. There are adequate drawers, closet space, lighting and functional smoke detector. Bedroom #3: Is equipped with two (2) twin size beds. There are adequate drawers, closet space, lighting and functional smoke detector. This room has an attached bathroom with hot water is within an acceptable temperature range. Bedroom #4: Is equipped with one (2) twin size beds. There are adequate drawers, closet space, and functional smoke detector and lighting overhead with ceiling fan combo. Bathroom: equipped with tub and shower combination, sink. cont on 809 c . LPA conducted three staff interviews, LPA was able to conduct one (1) client interview and all other client in school or away from facility. LPA conducted three (3) client files and reviews NSP, admission agreement, client cash resources and confirmed in compliance. LPA reviewed medication log and confirmed compliance. Passageways, stairways, inclines, ramps, and open porches are unobstructed. Disinfectants, cleaning solutions, and poisons are made inaccessible. There are no firearms/dangerous weapons. Temperatures in rooms that clients occupy are maintained between 68 and 85 degrees (F). Children in care will be supervised and protected at all times; Children will attend school, extracurricular, cultural, and personal enrichment activities. All smoke detectors were tested and are operating properly in the home at the time of visit. Carbon Monoxide alarms were tested and functional in the home at the time of the visit. Medications locked and accessible only to employees responsible for stored medications. All sharps locked in cabinet and stored in locked box in the cabinet. LPA observed facility is clean, safe, sanitary, and in good repair. Exit interview was conducted and no deficiencies cited at this time. LPA will return at a later date to review staff and files. A copy of the report was emailed to administrator.

met_with: Sueretta Small/Admimistrator


summary: Facility Evaluation

raw_content:
Narrative:
On 05/09/2024, Licensing Program Analyst (LPA) Zena Phillips conducted an unannounced Case Management- Incident inspection in order to follow-up on an Incident Report # 1019472 that the Department received on 03/12/2024. LPA Phillips requested a copy of the LIC 500, client roster, CFTM, medical appointment notes and Department Of Health Services OD training. LPA conducted confidential interview and gathered documentary evidence about the incident. Based on interviews and documentary evidence reviewed, staff are aware of facility protocol in an medical emergency with a client. It was reported to LPA if there is a reasonable suspicion of drug use staff conduct additional room checks and monitoring of clients. Based on evidence provided and confidential interviews this case management is closed. PER California Code Regulation, there is one deficiency to be cited at this time. Exit Interview conducted, and a copy of this report will be emailed to Licensee Sueretta Small.

met_with: Shalene Brouchet/


summary: Facility Evaluation

raw_content:
Narrative:
On May 29, 2024, Licensing Program Analyst (LPA) Zena Phillips made an unannounced visit to New Concept, for the purpose of conducting a Follow up Case Management for Special Incident Report #1040662. LPA was met by Sueretta Small/ Licensee who granted access and provided the census. LPA requested LIC 500, client roster, Pro Act training certificate, video footage, CFTM, NSP and Special Incident Reports for May 2024 regarding Child #1. LPA observed video footage of incident and conducted confidential interviews. Additional interviews will be conducted on a later date. Based on interview and information gathered, this case management needs further investigation. Exit interview was conducted, and a copy of this report was emailed to Sueretta Small/Licensee.

met_with: Sueretta Small/ Licensee


summary: Facility Evaluation

raw_content:
Narrative:
On May 29, 2024, Licensing Program Analyst (LPA) Zena Phillips made an unannounced visit to New Concept, for the purpose of conducting a Follow up Case Management for Special Incident Report #1038511. The incident occurred 05/16/2024 and the incident report was received by the Department on 05/16/2024. LPA met with Sueretta Small/, Licensee and discussed the incident. During this visit, LPA conducted confidential interviews. Additional interviews will be conducted on a later date. LPA requested copies of the following documents: LIC 500, Client roster, NSP, CFTM, and Special Incident Reports for May 2024. Based on interview and information gathered, this case management needs further investigation. Exit interview was conducted, and a copy of this report was emailed to Sueretta Small/Licensee

met_with: Sueretta Small/Licensee


summary: Facility Evaluation

raw_content:
Narrative:
On 06/12/2023 at 10:30AM am, Licensing Program Analyst (LPA) Zena Phillips and (LPA) Kenrick Ellis arrived at the facility to deliver findings for the Case Management-Incident regarding SIR #1040662 . LPAs were greeted by Shalane Brouchet/Program Manager and granted access to the facility. On 05/23/2024 a Special Incident Report (SIR), SIR #1040662 was submitted in regard to a client that was restrained due to self harming. SIR indicated that client was engaged in self harming behavior. During the case management-incident, LPA conducted confidential interviews, reviewed documentary evidence, and reviewed video footage of incident. LPA observation of video footage reveal that a restraint was not conducted but safety intervention. Based on the incident reports, confidential interviews and documentary evidence; statements were consistent that appropriate emergency intervention procedures and protocols were implemented to support the needs and safety of the client and staff involved in the incidents on 05/23/2024. There was no corroborating evidence that supports that a violation has occurred. This case management-incident has been found to be unsubstantiated. There are no deficiencies cited at this time. Exit interview was conducted with Shalane Brouchet/Program Manager. A copy of this report will be provided to the facility Licensee.

met_with: Shalane Brouchet/Program Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 06/12/2023 at 1: PM, Licensing Program Analyst (LPA) Zena Phillips and (LPA) Kenrick Ellis arrived at the facility to deliver findings for the Case Management-Incident regarding SIR #1038511. On 05/16/2024 a Special Incident Report (SIR), SIR #1038511 was submitted in regard to a client that threatened harm with a knife. SIR indicated that client retrieved knife from room. During the case management-incident, LPA Phillips conducted confidential interviews, reviewed documentary evidence. It was reported to LPA the knife was obtained during unauthorized absence. Confidential interviews reveal knife was confiscated, removed from the facility and room was searched due to safety. Based on the incident reports, confidential interviews and documentary evidence; statements were consistent that appropriate emergency intervention procedures and protocols were implemented to support the needs and safety of the client and staff involved in the incidents on 05/16/2024. There was no corroborating evidence that supports that a violation has occurred. This case management-incident has been closed. Exit interview conducted and copy of report provided to facility.

met_with: Keshia Marshall/Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On July 18, 2024 at 11:30am Licensing Program Analyst (LPA) arrived at the above facility for the purpose of a Case Management Investigation. LPA spoke with Facility Manager, Keisha Marshall and was allowed into the facility. On July 10, 2024 the department received an email stating that on June 24, 2024 indicating that Staff #1 was bullying and calling Child #1 bad names. During the investigation LPA interviewed Staff #2 and Staff #3. Neither Staff #1 or Child #1 were present for interview. LPA has determined that further investigation is needed to conclude this Case Management Investigation. No deficiencies were cited at the time of the visit.

met_with: Keisha Marshall-Facility Manager


facility_name: NEW CONCEPT II

summary: Facility Evaluation

raw_content:
Narrative:
On June 17, 2025, at 9: AM, Licensing Program Analysts (LPA's) C. White and C. Wilkerson arrived at New Concept II located at W 78th Street Inglewood, CA. 90305 for the purpose of conducting a Pre-Licensing Inspection. LPA's were met by Applicant, Sueretta Small and Administrative Assistant, Shalane Brouchet. The applicant is requesting to license the facility as a Short Term Residential Program to provide to provide care and supervision to six (6) male children, ages 12-17 years old, and Non-Minor Dependents, ambulatory only. Currently the census is zero (0). The home is set up as follows: This is a single story 3-bedroom, 3-bathroom, home located in a residential area. The home consists of a living room, dining room, kitchen, laundry area, 2 staffing offices, a backyard, a detached garage, and a detached shed. Living room: is equipped two (2) sofas, two (2) mounted TV's, a desk with a chair and a computer. Dining room: is equipped with a round table and four (4) chairs. Additionally, the kitchen has an extended bar countertop with four (4) bar chairs for clients to sit and eat. Kitchen: is equipped with a refrigerator/freezer, a five (5) burner gas stove (all burners were operational at the time of the inspection), a microwave (above the stove), an air fryer, and a blender. Sharp knives are kept in a double combination lock box, located in a locked hall cabinet and made inaccessible to children in care. LPA's observed a covered trash can, ample plates, cups, eating utensils, pots and pan. LPA's observed a posted menu and ample nonperishable food items. The applicant will ensure that three (3) nutritious meals and snacks will be provided to the clients. Laundry area: is adjacent to the mental health staff office. The area has a washer, dryer, built-in cabinets, and a door leading to the left side of the house. Report continued on LIC 809C (Page 1 of 3) Staffing Offices: one staffing office is located to the left of the front entrance. The office will be used by the STRTP staff and is equipped with three (3) desks, chairs, and computers. Additionally, the office has a mounted TV, a non-operational glass enclosed fireplace, lockers, a filing cabinet, a window that looks out into the living room, and a split door that has deadbolt locks. The second staff office is located past the kitchen and will be used by the Mental Health staff. The office is equipped with three (3) desks, chairs, and computers. Additionally, the office has an attached bathroom, and a window that looks out into the kitchen. Detached Garage: contains two (2) refrigerator/freezer for extra food supplies and medication requiring refrigeration; three (3) locked cabinets for disinfectants, cleaning supplies, extra bedding, and emergency food/water supplies; a table with chairs; and a locked gated water heater. Detached Shed: will be used as a therapy room. Currently the shed is unfurnished. Bedrooms: are bedrooms are equipped with two (2) twin beds, drawers, closets, a desk and chair, laundry baskets, two (2) small combination safes for client to store personal supplies, windows, and combination ceiling fan/lights. Bathroom #1: is located in the hallway between bedroom #1 and bedroom #2. The bathroom has a toilet, sink, and a tub/shower combination. The bathroom is equipped with a combination lock door as the bathroom contains a locked cabinet for medication storage and medication log. This bathroom will be utilized by staff only. Bathroom #2: is located inside Staff Office #2. The bathroom contains a toilet, sink, and a shower. Bathroom #3: is located adjacent to bedroom #3. The bathroom has a toilet, tub/shower combination, and double sinks. This bathroom will be used by clients. All bathrooms were checked and found to be in working order. Hot water was tested and found to be between 105-120 degrees. Vehicle: The applicant will use a White Chrysler Voyager to transport clients. The vehicle is in good condition with current registration through 10/10/2025 and insurance with Nonprofits Insurance Alliance that expires 04/04/2026. Report continued on LIC 809C (Page 2 of 3) LPA's observed two (2) regulation fire extinguishers. Extra linens and hygiene supplies are stored in locked hallway closet next to bedroom #1. The smoke alarm and carbon monoxide detectors were tested and found to be in working order. Disinfectants and cleaning solutions are kept in a locked cabinets in the laundry area and in the garage. Medications will be kept locked cabinet located in the staff bathroom. The First Aid kit was checked and found to be complete with scissors, tweezers, thermometer, and gauzes, antiseptic and First Aid Manual Guide. There are no security bars on the bedroom windows. There are no firearms or dangerous weapons in the home. There are no bodies of water on the premises. LPA's observed the home to be clean, safe, and sanitary. Passageways, stairways, inclines, ramps and open porches are unobstructed. The front and backyard were clean and free of debris. LPA's observed the electrical shut off valve located in the garage, the gas shut off valve is located on the right side of the home behind a gated fence, and the water shut off valve is located in the front of the home to the right of the entrance. The following was discussed with the facility Administrator: Children will be accorded personal rights. Children in care will be supported, encouraged to participate in extracurricular activities. Children in care will be able to contact the licensing agency. Children will be supervised and protected at all times. Children will be accorded dignity in personal relationships with others in the home. Children will not be restricted in telephone use except by court order. Applicant will provide and ensure three nutritious meals, snacks, and special diets. Applicant will ensure to have written authorization to obtain medical and dental care. Applicant will ensure to have personal rights forms in children's files. Applicant acknowledges abuse reporting requirements. Staff working in the facility will have DOJ/FBI criminal record clearances, and Child Abuse Index Checks. Facility will operate within license conditions and limitations including capacity limit. Facility meets posting requirements, including COVID-19 best practices signs and emergency telephone numbers are in prominent locations. An exit interview was conducted, and a copy of this report was emailed to Applicant, Sueretta Small. (Page 3 of 3)

visit_type: Prelicensing

met_with: Applicant - Sueretta Small and Administrative Assistant, Shalane Brouchet


summary: Facility Evaluation

raw_content:
Narrative:
On September 17, 2025, Licensing Program Analysts (LPA) C. White arrived at New Concept II for the purpose of conducting a Post Licensing Inspection. LPA were met by Licensee, Sueretta Small. The facility is licensed to provide care and supervision to six (6) male children, ages 12-17 years old, and Non-Minor Dependents, ambulatory only. Currently the census is zero (0). The home is set up as follows: This is a single story 3-bedroom, 3-bathroom, home located in a residential area. The home consists of a living room, dining room, kitchen, laundry area, 2 staffing offices, a backyard, a detached garage, and a detached shed. Living room: is equipped with sofas, mounted TV's, a desk, chair, and a computer. Dining room: is equipped with a round table and four (4) chairs. Kitchen: is equipped with a refrigerator/freezer, a five (5) burner gas stove (all burners were operational at the time of the inspection), an above stove microwave, an air fryer, and a blender. Sharp knives are kept in a double combination lock box, located in a locked hall cabinet and made inaccessible to children in care. There is an extended bar countertop with four (4) bar chairs for clients to sit and eat. The trash can has a covered lid, there are ample plates, cups, and eating utensils. The menu is posted and there is ample nonperishable food items in the home. Licensee will ensure that clients in care are provided with three (3) nutritious meals and snacks per day. Laundry area: Has a washer, dryer, and built-in cabinets that store cleaning supplies. Additionally, there is a door leading to the left side of the house. Report continued on LIC 809C (Page 1 of 3) Staffing Offices: one staffing office near the front entrance. The office is equipped with three (3) desks, chairs, and computers. The office has a mounted TV, a non-operational glass enclosed fireplace, lockers, a filing cabinet, a window that overlooks the living room, and a split door. The second staff office is located past the kitchen and is used by the Mental Health staff. The office is equipped with four (4) desks, chairs, and computers. Additionally, the office has an attached bathroom. Detached Garage: contains two (2) refrigerator/freezer for extra food supplies and medication requiring refrigeration; locked cabinets for disinfectants, cleaning supplies, extra bedding, and emergency food/water supplies; a table with chairs; and a locked gated water heater. Detached Shed: is used as a therapy room. The room is equipped with a desk, four (4) chairs, cabinets, and a mounted air conditioner/heater unit. Bedrooms: each bedroom is equipped with two (2) twin beds, drawers, closets, a desk and chair, laundry baskets, two (2) small combination safes for client to store personal supplies, windows, and combination ceiling fan/lights. Bathroom #1: is located in the hallway between bedroom #1 and bedroom #2. The bathroom has a toilet, sink, and a tub/shower combination. The bathroom is equipped with a combination lock and has a locked cabinet for medication storage and medication log. This bathroom will be utilized by staff only. Bathroom #2: is located inside Staff Office #2. The bathroom contains a toilet, sink, and a shower. Bathroom #3: is located adjacent to bedroom #3. The bathroom has a toilet, tub/shower combination, and double sinks. This bathroom will be used by clients. All bathrooms were checked and found to be in working order. Hot water was tested and found to be between 105-120 degrees. Vehicle: The facility has a White Chrysler Voyager to transport clients. The vehicle is in good condition with current registration through 10/10/2025 and insurance with Nonprofits Insurance Alliance that expires 04/04/2026. Report continued on LIC 809C (Page 2 of 3) LPA observed the home to have two (2) regulation fire extinguishers. The smoke alarm and carbon monoxide detectors were tested and found to be in working order. Disinfectants and cleaning solutions are kept in locked cabinets in the laundry area and in the garage. Medications will be kept locked in a cabinet located in the staff bathroom. Extra linens and hygiene supplies are stored in locked hallway closet next to bedroom #1. The First Aid kit was checked and found to be complete with scissors, tweezers, thermometer, and gauzes, antiseptic and First Aid Manual Guide. There are no security bars on the bedroom windows. There are no firearms or dangerous weapons in the home. There are no bodies of water on the premises. LPA observed the home to be clean, safe, and sanitary. Passageways, stairways, inclines, ramps and open porches are unobstructed. The front and backyard were clean and free of debris. The electrical shut off valve is located in the garage, the gas shut off valve is located on the right side of the home behind a gated fence, and the water shut off valve is located in the front of the home to the right of the entrance. LPA remined Licensee that children in care are to be supported and encouraged to participate in extracurricular activities. Children in care will be able to contact the licensing agency. Children will be supervised and protected at all times. Children will be accorded dignity in personal relationships with others in the home. Children will not be restricted in telephone use except by court order. Licensee will ensure the facility has a written plan of operation, written authorization to obtain medical and dental care for clients and ensure to have personal rights forms in children's files. Licensee acknowledges abuse reporting requirements. Licensee will provide the Personnel Report (LIC 500) and confirm that staff ratio meets the regulations. Licensee will ensure that all staff working in the facility will have DOJ/FBI criminal record clearances, and Child Abuse Index Checks. Facility meets posting requirements. An exit interview was conducted, and a copy of this report was emailed to Licensee, Sueretta Small.

met_with: Licensee - Sueretta Small


facility_name: NEW DAWN

raw_content:
Narrative:
On 4/14/23 the Department received a complaint alleging C1 has access to a vape pen and staff threatened client in care. It was alleged that C1 vapes in the facility and staff told C1 that they were going to have someone beat C1 up. The facility staff when interviewed indicated no staff has threatened to have C1 beaten up by someone else. Staff stated C1 did vape and smoke at the facility without permission. Staff would attempt to redirect C1 from smoking and staff would report each time C1 was found smoking or vaping. C1 when interviewed refused to answer questions and refused to participate in the interview. Two other clients interviewed indicated staff has not threatened any of the clients. Staff did not say they were going to have someone beat up any of the clients. The two clients stated C1 would smoke, however staff would redirect C1 who would not listen to staff. LPA reviewed CFT meeting notes and incident reports which indicated staff would report C1's smoking and attempted to redirect and seek help for C1's smoking. The other agency's investigative report and C1's interview indicated C1 denied any physical abuse by staff. All clients interviewed denied witnessing C1 get hit by staff. Based on the interviews and records reviewed the allegations is/are found unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove the allegations. Appeals rights were provided and discussed with the facility representative mention above. There were no deficiencies cited.

Investigation Findings:
13On August 15, 2023, at 11: AM Licensing Program Analyst Larry Cabral (LPA) conducted a follow-up inspection for the purpose of providing findings for the above complaint allegations. LPA Cabral met with the STRTP Administrator Sean Hardge. During the investigation, LPA Cabral interviewed two facility staff (AD & S1) and one client (C1) on 5/16/23. LPA interviewed two additional clients (C2 & NMD4) and attempted to interview one client (NMD3) on 5/26/23. LPA interviewed one facility staff on 8/4/23 (see Confidential Names Form LIC 811 dated August 15, 2023). LPA Cabral interview one county social worker (CSW) and others on 5/16/23. LPA reviewed C1's CFT meeting notes and an incident report. LPA reviewed the other agency's investigative report and interview with client on 8/7/23. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Larry Cabral LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: NEW DAWNFACILITY NUMBER: VISIT DATE: 08/15/2023

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

met_with: Sean Hardge, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by Licensing Program Analysts (LPAs) Carrie Palmer on December 23, 2022 at 10am. During this visit, LPAs met with Alejandra Kenya Ipina (Head of Service). The facility is licensed for a capacity of 6 clients. Current census is 3. The facility consists of one (1) building with the address of Walnut Valley Drive. This facility has 4 bedrooms; 1 of which is used as an office. The facility also has 3 bathrooms. One bathroom is used for clients and the other 2 are used by staff. There is also a kitchen, living room and dinning area. Outdoor activity space is also present and available for use. LPA Palmer was able to see food supply and verified there was enough perishables and non-perishables items. The facility was observed to be clean, safe, sanitary, in good repair and passageways were unobstructed. There were no bodies of water on the premises. Cleaning solutions, were not locked in the kitchen and staff bathroom. Over the counter medication was observed to be locked in a drawer. Smoke and carbon monoxide detectors were present and tested today and are working. During the inspection LPAs observed the children's Personal Rights, Ombudsman flyer, emergency disaster plan, facility sketch and foster youth bill of rights were posted. LPAs received a copy of the LIC500 and the Client Roster. An exit interview was conducted and a copy of this report was provided to staff. This annual requires a continuation.

met_with: Marilynn Lima


summary: Facility Evaluation

raw_content:
Narrative:
On 12/29/22 at 2:20pm, Licensing Program Analysts (LPA) Carrie Palmer conducted an unannounced inspection at New Dawn to complete a 2-Year Required inspection initiated on 12/23/22. LPAs met with resident Gerardo Medina, and stated the purpose of the inspection. LPA stated that the purpose of today's inspection was a continuation from the previous visit (12/23/22) and the focus would be staff interviews. LPA Carrie Palmer conducted staff interviews for Gerarado Medina and Kelly Jackson (both Residential Counselors). A copy of the LIC 809 and LIC 811 were provided to the facility representative and an exit interview was conducted.

met_with: Gerardo Medina


summary: Facility Evaluation

raw_content:
Narrative:
On 01/03/22 at 12:30pm, Licensing Program Analysts (LPA) Carrie Palmer conducted an unannounced inspection at New Dawn to complete a 2-Year Required inspection initiated on 12/23/22. LPA met with resident Evangelina Broadhurst, and stated the purpose of the inspection. LPA stated that the purpose of today's inspection was a continuation from the previous visit (12/29/22) and the focus would be staff interviews, client interviews and the review of operational requirements. LPA Carrie Palmer conducted 1 staff interview with the Facility Manager and 2 client interviews. LPA also conducting an inspection of operational requirements to included the request for a copy of their policy entitled, "Handling Money, Personal Property and Valuables." A copy of the LIC 809 and LIC 811 were provided to the facility representative and an exit interview was conducted.

met_with: Evangelina CAraveo - Broadhurst


summary: Facility Evaluation

raw_content:
Narrative:
On October 10, 2023, Licensing Program Analyst (LPA) Carrie Palmer conducted an unannounced follow up case management inspection at the agency above and spoke with the representative above regarding a special incident report (SIR) that was submitted to Community Care Licensing (CCL) on July 19, 2023. The SIR indicated the client disclosed using a razor blade found in the bathroom's medicine cabinet to self-harm. LPA Palmer toured the facility and interviewed children regarding the accessibility of sharp objects. During the review of the facility, LPA did not observe any sharp objects that might be accessible to the residents. LPA observed knives in a locked cabinet. LPA interviewed all residents present in the facility. All residents disclosed that they do not have access to sharp objects in the facility. However, C1 shared that C1 found a razor on the ground outside and C1 states C1 tried to cut himself with the razor. LPA Palmer interviewed The Facility Manager who states that staff conduct a detailed inventory of the children's belongings when they come home from school and every time residence come back to the STRTP. The Facility Manager also stated that a safety plan was developed and implemented and that C1 has met with C1s therapist for support. There are no violations of Title 22, of the California Code of Regulations. No deficiencies were cited during today's inspection. A copy of LIC 809 and LIC 811 was provided to the facility representative above and an exit interview was conducted.

met_with: Evangelina Caraveo-Broadhurst (Angel), Facilty Manager


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by Licensing Program Analysts (LPAs) Carrie Palmer on November 27, 2024. During this visit, LPAs met with Kouri Flye, who gave LPA Palmer a tour of the facility. The facility is licensed for a capacity of 3 clients. Current census is 3. The facility consists of one (1) building with the address of Walnut Valley Drive. This facility has 4 bedrooms; 1 of which is used as an office. The facility also has 3 bathrooms. One bathroom is used for clients and the other 2 are used by staff. There is also a kitchen, living room and dining area. Outdoor activity space is also present and available for use. LPA Palmer was able to see food supply and verified there was enough perishables and non-perishables items. The facility was observed to be clean, safe, sanitary, in good repair and passageways were unobstructed. There were no bodies of water on the premises. Cleaning solutions, were not locked in the laundry area, but was corrected during the visit. Over the counter medication was observed to be locked in a drawer. Smoke and carbon monoxide detectors were present and tested today and are working. During the inspection LPA Palmer observed the children's Personal Rights, Ombudsman flyer, emergency disaster plan, facility sketch, and foster youth bill of rights were posted. LPA Palmer received a copy of the LIC 500 dated September 30, 2024 and the Client Roster. The facility was unable to identify who the Facility Manager was on duty during the visit, but provided via email a client roster listing all residential counselors as Managers on Duty. The current facility manager listed on the LIC 500 was not present at the time of the visit. An exit interview was conducted, and a copy of this report was provided to staff. This annual requires a continuation. No deficiencies cited during the visit.

met_with: Kouri Flye, Resident Counselor


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Pamela Silva, Juliet Robles and Olena Maico on 01/24/2025 at 11: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs met with Sean Hardge, Administrator, and inspected the facility inside and out. LPAs reviewed 0 of child's records and 3 of staff personnel files on site at the facility. LPAs reviewed 0 of child's psychotropic medications and medication records. LPAs interviewed 2 of staff on site to discuss the facilities policies and procedures of operation. LPAs interviewed 0 of children currently prescribed psychotropic medication. LPAs provided a copy of this licensing report to Sean Hardge, Administrator. No deficiencies are being cited at this time. A Technical Advisory was given, see LIC9102TA. LPAs conducted exit interview with Sean Hardge, Administrator.

met_with: Sean Hardge


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Caitlin Chambers conducted a follow up inspection to the facility and met with Kelley Jackson for the purpose of documenting an inspection conducted on 2/6/25. LPA Chambers had conducted a case management inspection on 2/6/2024 at 2:18-2:21pm for following up an incident for a client who had a behavior issue. It was discovered during the inspection that this client resided in another facility. During the inspection on 2/6/ LPA Chambers did not leave a report. This is a record that the inspection was conducted. An exit interview was conducted and a copy of this report was given to Kelley Jackson.

met_with: Facility Manager Kelley Jackson


summary: Facility Evaluation

raw_content:
Narrative:
On April 25, 2025 at approximately 11:00AM, Licensing Program Analyst (LPA) Carrie Palmer conducted an unannounced visit to the facility for the purpose of continuing a Required Annual Inspection. LPA Palmer met with the representative listed above and discussed the purpose of the visit. LPA Palmer reviewed the following domains: Operations,Emergency Disaster Preparedness, Emergency Interventions, Client Files, Staff Files, and Clients with Special Health Care Needs and Core Therapeutic Services. LPA Palmer requested a copy of the following: LIC 500 (Personnel Report), LIC 9020 (Client/resident roster), Board Meeting Minutes, LIC C, Emergency Disaster Plan & written disaster and mass casualty plan of action, Proof of quarterly drills, Copies of Procedures on Medication Storage, Copies of Medication List, Copies of First Aid Cert from the staff files reviewed, Copy of Administrator certification. Currently, the facility has 2 vehicles. OPERATIONS and DISASTER Preparedness: Facility maintains a register of clients and the register is available upon request. The clients attending physicians name, address, and phone number were not present on the register list of clients. and the disaster plan should be updated to include how medications requiring refrigeration will be stored to maintain appropriate temperatures. The facility was unable to provide board of directors meeting minutes during the visit. Emergency Intervention Plan: During the review of the Emergency Intervention Plan domain, it was determined that staff files, Relias (training tracking system) AND the Facility Manager Reference Guide was present to demonstrate that required training's have been completed. Additionally, staff was also able to show that Relias provides certifications after completion of training's. Staff Records: During the review of staff files, it was determined that staff received background checks prior to working at the facility. It was also observed that staff receives ongoing training that consists of, but not limited to the following: Staffing, Personal Management, Transportation, Miscellaneous Topics such as Grievances, Incident Reports, Cell Phone Policy, Licensing Visits. Dealing with Difficult Patients, Management of Behaviors, Trauma Informed Care, Emergency Management. Job Descriptions, resumes, associates and bachelors degrees were also observed within the staffs files. The administrator's certificate was provided. Staff 1s file was not available during the visit. Client Records: Three (3) out of four (4) client files were reviewed. One file was not available because the client was recently placed. The facility was able to present the P and I (Personal and Incidentals), which includes the clients personal belongs. LPA Palmer was also able to review the MAR (Medication Administration Record) and consent forms, which includes: the name of the medications, the side effects, the signature for staff after the dosage is provided to the client. The staff was able to provide medical/dental exams. Clients with Special Health Care Needs: There are no clients with special health care needs at this time. No deficiencies were cited during today's visit. An exit interview was conducted, and a copy of this report and the LIC 811 was provided to the licensee.

met_with: Jasmine Martinez, Resident Counselor (Manager on Duty) | Marlene Pierce, Exective Assistant, QA, HR.


summary: Facility Evaluation

raw_content:
Narrative:
On 12/23/ LPA Carrie Palmer conducted an unannounced visit to the facility to conduct an annual inspection. During the visit, LPA Palmer requested to speak to the manager. Staff (residential counselor) responded by stating there was no manager present. The Interim Licensing Standards 87065 (f) states: the licensee shall designate at least one facility manager to be present at the facility at all times when one or more children are present. During the visit on 4/7/23, there was no manager present. LPA requested a copy of the most current LIC 500 dated January 19, 2023. The current census, per staff is 2 (17 year old and a 14 year old). A copy of this report LIC 809 and 809-D were provided to the facility representative and an exit interview was conducted.

met_with: Kelly Jackson - Residential Counselor


summary: Facility Evaluation

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Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Timika Martin and Pamela Silva on 1/14/26 at 9: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs met with Facility Manager, Evangelina Caraveo-Broadhurst and inspected the facility inside and out. LPAs reviewed 1 child record and 2 of staff personnel files on site at the facility. LPAs reviewed 1 child psychotropic medications and medication records. The child currently prescribed psychotropic medication was unavailable for interview at the time of inspection. LPA Martin will attempt to interview child at a later time. LPA interviewed 1 of staff on site to discuss the facility's policies and procedures of operation. During the inspection one (1) Technical Violation was issued (see LIC 9102). LPAs provided a copy of this licensing report and LIC 9102 to Facility Manager, Evangelina Caraveo-Broadhurst.


raw_content:
Narrative:
During the course of the investigation Licensing Program Analyst (LPA) Dawn Mahecha conducted a record review on 8/6/21 and obtained copies special incident reports, client's (C1) needs and services plans, health and education passport, placement agreement, entrance survey, special interest form, court documents, child family team meeting notes and medical and medication records. Investigator Douglas Real conducted interviews with one County Social Worker (CSW) on 8/16/21, interviewed one House Manager 9/1/21, one Detective on 9/8/21, one Therapist on 9/29/21, one Client (C2) on 10/13/21, one Residential Counselor (RC1) on 10/21/21, one Assistant Director on 10/21/21, a second Residential Counselor (RC2) on 10/21/21, a third Residential Counselor (RC3) on 10/30/21, a fourth Residential Counselor (RC4) on 10/31/21, one Care Giver (CG1) on 11/2/21, a second Care Giver (CG2) 11/12/21. Investigator Real obtained a copy of the Chino Police Department police report regarding the incident on 9/8/21. On 8/5/21 the Department received a complaint alleging facility staff failed to conduct safety checks on C1 every fifteen minutes. The investigation revealed staff were notified via email on 8/3/21 at 6: PM of C1 requiring a higher level of care. The email instructed staff to conduct safety checks on C1 every fifteen minutes for the next twenty-four hours. Additionally, staff were informed C1 would be reassessed and they would be notified if fifteen-minute safety checks would continue. Statements obtained from interviews conducted with staff indicated the facility therapist reassessed C1 on 8/4/21, no concerns regarding self harm were observed. The facility therapist stated she verbally informed staff on shift to continue fifteen minutes safety checks. However, interviews conducted with staff provided conflicting statements. Staff stated they were not informed to continue fifteen-minute safety checks on C1. Based on statements gathered from interviews conducted and records reviewed the allegation is unsubstantiated. Although the allegation may have happened or is valid, the preponderance of evidence standard was not met. Exit interview conducted and a copy of this report and Confidential Names form LIC 811 dated 1/10/22 were provided to the above-mentioned facility representative. No deficiencies were cited.

Investigation Findings:
13A follow up complaint inspection was conducted by Licensing Program Analyst (LPA) Christopher Larios on 3/29/22 at 4: PM. During the inspection LPA Larios met with Facility Manager Regina Head and delivered findings for the above-mentioned complaint allegation. The complaint was investigated by Community Care Licensing Division (CCLD), Investigations Branch (IB) Investigator Douglas Real. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Christopher Larios 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: NEW DAWNFACILITY NUMBER: VISIT DATE: 01/10/2022

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

met_with: Regina Head


raw_content:
Narrative:
During the course of the investigation Licensing Program Analyst (LPA) Dawn Mahecha conducted a record review on 8/6/21 and obtained copies special incident reports, client's (C1) needs and services plans, health and education passport, placement agreement, entrance survey, special interest form, court documents, child family team meeting notes and medical and medication records. Investigator Douglas Real conducted interviews with one County Social Worker (CSW) on 8/16/21, interviewed one House Manager 9/1/21, one Detective on 9/8/21, one Therapist on 9/29/21, one Client (C2) on 10/13/21, one Residential Counselor (RC1) on 10/21/21, one Assistant Director on 10/21/21, a second Residential Counselor (RC2) on 10/21/21, a third Residential Counselor (RC3) on 10/30/21, a fourth Residential Counselor (RC4) on 10/31/21, one Care Giver (CG1) on 11/2/21, a second Care Giver (CG2) 11/12/21. Investigator Real obtained a copy of the Chino Police Department police report regarding the incident on 9/8/21. On 8/5/21 the Department received a complaint alleging a facility client died from a drug overdose due to neglect by staff. Facility employees denied the allegation. Statements obtained from confidential interviews conducted revealed facility staff do not permit clients to use drugs and conduct safety checks every thirty minutes. Staff reported C1 did not disclose or present with behaviors indicating he intended to self-harm. However, C1 stated he wanted to "get high" while he and the facility therapist were processing a recent family visit. Staff reported safety checks were conducted on C1 every thirty minutes. Record review revealed the safety checks were notated on C1's activity log. Based on information gathered through interviews conducted and record review the allegation is found unsubstantiated. Although the allegation may have happened or is valid the standard of the preponderance of evidence was not met. Exit interview conducted and a copy of this report and confidential names form dated 1/10/22 was provided the above-mentioned facility representative. No deficiencies were cited.

Investigation Findings:
13A follow up complaint inspection was conducted by Licensing Program Analyst (LPA) Christopher Larios on 1/10/22 at 10: AM. During the inspection LPA Larios met with Resididential Counselor Reneee Landreaux and delivered findings for the above-mentioned complaint allegation. The complaint was investigated by Community Care Licensing Division (CCLD), Investigations Branch (IB) Investigator Douglas Real. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Christopher Larios 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: NEW DAWNFACILITY NUMBER: VISIT DATE: 01/10/2022

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

met_with: Renee Laundreaux


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
On 09/28/2022, the Department received a complaint alleging allegations that the facility was not maintaining a comfortable temperature for clients in all areas inside. The Administrator denied the allegation that the central air conditioning (AC) was not working and stated preventive maintenance was performed, however, it was then stated that another service technician was called to inspect the system on or about 03/22/2022. The Administrator stated that staff workers never informed him that the AC was not working. In confidential interviews, individuals associated with the facility (staff & clients) provided consistent statements that the AC system was not working for at least several months. It was disclosed that there were several times that a service repair technician was observed working on the AC system but was not operational and continued to remain in this state. Licensing Program Analyst observed a small window air condition unit in the living room area and was informed by the Administrator that it was recently installed because "it was hot". LPA also observed several (3-4) pedestal fans that were provided for the clients in each bedroom as a result of the AC not working. LPA Vargas together with the Administrator and then separately with the House Manager conducted a room temperature check in different areas within the facility using an infrared thermometer. The following readings were obtained: all client bedrooms were between 89 -90 degrees, the staff office was 90 degrees, the living room/dining area was 89 degrees and the window ac unit was already turned on. The central AC unit was running on cool mode, the air temperature exiting from the vents was 89 degrees at 12: PM. It should be mentioned that during the months of August and September 2022, there were days with temperatures that exceeded 100 degrees based on historical reports using the website Weather.com. Based on the information obtained, there is a preponderance of the evidence to prove that the facility was not maintaining a comfortable temperature inside the facility as a result of the air conditioning system (AC) not being operational and repaired in a timely manner. Therefore, the above allegation is substantiated. Following a review of the deficiencies cited per Title 22, Division 6, Chapter 8.8 of the California Code of Regulations, and listed on the LIC 9099D on page 2 of this report, LPA Vargas conducted an exit interview, explain appeal rights.

Investigation Findings:
13On 10/28/2022 at 10: AM, Licensing Program Analyst (LPA) Joseph Vargas conducted a follow-up inspection for the purpose of providing findings for the above complaint. LPA met with Ms. Head, Facility House Manager. During the course of the investigation, LPA conducted in-person visits, and telephonic interviews with Facility Administrator, Staff workers, clients that were present at the facility on 09/29/2022, including the L.A. County Ombudsperson (reference confidential names list LIC811 dated 10/28/2022). During the inspection, LPA Vargas requested for review and obtained a copy of the current LIC500 and client roster. In addition, LPA Vargas researched for any prior history of complaints on file for the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Joseph Vargas LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: NEW DAWNFACILITY NUMBER: VISIT DATE: 10/28/2022

met_with: Ms. Regina Head, House Manager


raw_content:
Narrative:
Confidential interviews revealed that staff are not following the approved plan of operation/program statement which identifies the proper way to discard discontinued medications. The staff were utilizing an RX destroyer pharmaceutical disposal liquid to dispose medication at the facilty but never informed Community Care Licensing (CCL) of the change. The STRTP is allowed to change a policy with an approval from CCL. In addition, the staff were not documenting the disposal on the Centrally Stored Medication and Destruction Record form (LIC 622) for destroying prescription medications when no longer needed by clients or residents correctly. In addition, the staff are not documenting an explanation on why the client refused their psychotropic medication on specific dates on the PMAR or equivalent form. The equivalent form is missing specific information required to be on the separate log. Confidential interviews indicated that the staff failed to log the forms correctly and were informed by the department of mental health to not utilize the LIC 622B form from CCL and to create a new form. LPA Portillo did not receive documentation on the denial from DMH. Based on interviews and information gathered during the investigation, the preponderance of evidence standard has been met and the Department has determined the allegations that the STRTP is not utilizing the forms correctly to document refusal or destruction on medications for record keeping purposes is substantiated. This posed a potential health and safety risk to the children placed in care. These actions are in violation of the Health and Safety 1507.6 and Title 22 Health Related Services. See attached LIC 9099D for cited deficiency. An exit interview was conducted, and a copy of the report and appeal rights were provided. Confidential interviews denied allegations that facilty staff failed to accommodate the needs of C1s medical treatment by not checking his glucose on time and not taking clients to their scheduled medical appointments. In addition, LPA toured the facilty and observed a lack of forks for clients that should have been accessible for clients. However, staff had additional utensils in the staff office to replenish the use of silverware. According to confidential interviews, the staff are proactive with the clients' medical needs and utilize the company vans to transport them to scheduled appointments such as medical, dental, school, outings etc. Other confidential information received stated that the reason for a shortage of forks is due to the clients throwing them away in the trash, taking them in their room or hiding them. Therefore, the staff monitor the silverware that's available for usage when requested. In addition, LPA Portillo inquired about the availability of plastic forks and the facilty placed some out for usage in case the clients prefer to throw them out due to specific reasons such as COVID. LPA spoke to C1s assigned County Social Worker (CSW1) who stated that at this time they did not have any concerns regarding C1's safety or the STRTPs level of care. There were no other known witnesses to this incident. Confidential interviews did not corroborate the allegations with a preponderance of evidence. Based on interviews and confidential information obtained during the course of this investigation, the allegation that staff are not equipped with enough medical supplies, lack of transportation or denial of silverware, may have occurred, however is not supported or proven by evidence. Therefore, the above allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report along with an advisory note was provided.

Investigation Findings:
13Licensing Program Analyst (LPA), Claudia Portillo met with Short Term Residential Therapeutic Program (STRTP) administrator to discuss the investigative findings for the above stated allegations (see Lic 811 confidential name list). Licensing Program Analyst, Claudia Portillo conducted an inspection to the STRTP on February 24, 2023, at 8:55 am. LPA Portillo interviewed County Social Worker 1(CSW1), two staff members (S1, S2) and three clients (C1, C2, C3), as well as reviewed clients and facility records. On February 15, 2023, Community Care Licensing received information alleging that the facility staff does not properly discard discontinued medications of children and facility staff does not ensure children's records are properly maintained. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Claudia Portillo 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: NEW DAWNFACILITY NUMBER: VISIT DATE: 05/30/2023

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 statements obtained during the investigation were unable to corroborate the allegation as details obtained provided inconsistencies as one foster child did not want to speak to LPA and the other one denied feeling uncomfortable with the temperature of the air conditioning (AC) claiming that it was broken but repaired immediately. Foster children indicated fans were provided and the temperature was at a reasonable temperature. Interviews with staff denied the allegation that the temperature was uncomfortable for staff and clients. It was reported by one staff member that the central AC unit was not working, however the other wall ACs units were operational. Based on record review, it was determined that the AC outlet was broken and repaired by the maintenance crew in a timely manner. Staff and foster children reported that group meetings are part of the program and clients are highly recommended to attend to ensure they get the full benefits of the program. Resident council meetings are voluntary and highly recommended for clients to attend in order to voice their concerns and make suggestions. It was denied that the fans were removed from their rooms if they didn't attend group meetings. Based on the information gathered, the allegation is unsubstantiated as the preponderance of evidence to prove the allegation was not met although the allegation may have happened or is valid. A copy of this report, Confidential Names Form and Appeal Rights were provided to the facility representative. There were no deficiencies cited during this inspection.

Investigation Findings:
13On October 17, 2023 at 1: PM, Licensing Program Analysts (LPA) Claudia Portillo conducted a follow-up inspection to deliver the findings of a complaint investigation concerning the allegation above. LPA Portillo discussed the findings with the facility representative named above. During the course of the investigation, LPA interviewed two foster children placed and two staff on 10/10/23 (see Confidential Names Form dated October 17, 2023). LPA also reviewed documents including workorder, invoice and hardware receipts. It was alleged that the staff did not provide a comfortable environment for minors UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Claudia Portillo 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: NEW DAWNFACILITY NUMBER: VISIT DATE: 10/17/2023

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

met_with: Regina Head, House Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 6/23/2021 at 1: PM Licensing Program Analyst (LPA) Dawn Mahecha made an announced visit to the New Dawn STRTP for the purpose of a Case Management-Incident inspection. LPA met with Facility manager Regina Head and discussed special incident that was received 12/1/2020. Facility manager stated the following: C1 was at location for a short amount of time. During the time that C1 was placed within facility C1 would talk with staff about previous incidents occurring of being involved with CESEC population. However, staff would redirect C1 to discuss incidents during appropriate therapy sessions. C1 never disclosed specific information of perpetrators, disclosed names or specific information of dates and times to staff. Staff ensured C1 was safe while staying at facility. Exit interview completed, no deficiencies cited and a copy of this report was left with facility manager.

met_with: Regina Head, Facility manager