state: CA

facility_name: MAKADE BEHAVIORAL CENTER #1

summary: Facility Evaluation

raw_content:
Narrative:
**The purpose of the amendment is to change the Visit Type** On January 15, 2026, at 10:00am, Licensing Program Analysts (LPAs), Cynthia Robinson and Cynthia Urena arrived announced at the above facility for the purpose of conducting Pre-licensing inspection at the facility. LPAs were greeted by Akila Crane, Interim Chief Compliance Officer, and Jorge Cervantes, Chief Executive Officer. The Licensee above submitted a Short Term Residential Therapeutic Program (STRTP) application. Presently there are no clients in care at the proposed new location. The STRTP has an approved capacity of six and has obtained the fire clearance. The age range for the clients are 10-17, including possible non-minor dependents. The pre-licensing facility physical inspection was conducted with Jorge Cervantes and Laura Hartney, Interim Administrator. The facility is a two-story home with five bedrooms and three bathrooms, one upstairs loft and a two-car garage. The facility has a living room and dining room in the kitchen area with a large dining room table. There are two cameras' downstairs, one is in the living room facing the kitchen and the second camera is in the entry hallway pointing to the front door. There is one smoke detector and carbon monoxide combination located in the entry hallway. There is a landline telephone that is in working order that will be available to clients. There were no observable hazards or obstructions by the other walkways and entries/exits. There is one sliding door exit in the dining room/living room leading to the backyard. There are no pools of bodies of water present. The backyard has a covered patio along with a portable canopy, patio furniture, and three visible cameras. Two of the three cameras are pointed at the sides of the house, and the third camera is pointing at the open space of the backyard. (Continued on LIC 809C...) The central ac unit is in the backyard behind the house located on the right side of the house. The Applicant has a working fire extinguisher located by the kitchen. The garage will be made inaccessible to clients. The bedrooms will be arranged so that no more than two clients are in a room, and there will be one client per bed. There is one bedroom (bedroom #1) that will be used for two clients and one full bathroom (bathroom #1) downstairs that will be available for client use. There are four bedrooms upstairs and two full bathrooms. Three of the bedrooms will be utilized for client use and have two beds per room. All bedding was found to be in ready condition. The fourth bedroom will be utilized as the staff office and currently has two desks along with three locked cabinets for storing medical, client, and staff files. The facility plans to use the main bedroom walk in closet for the therapy room and has a table with chairs. The laundry room is located upstairs, has ample storage space and contains chemicals cleaners and client toiletries. The room is kept locked and inaccessible to clients without staff assistance. Per the Administrator's statement, client toiletries are available upon request and as needed. Medication is centrally stored in a locked box located in the staff room. Knives are kept in a locked box located in the kitchen in a locked cabinet made inaccessible to clients. The Applicants has sufficient dishes, cups and silverware for client use and the gas stove is in working order. The facility holds a loft upstairs that will be in use for client's workspace equipped with two desks and chairs and a sofa. LPA observed age-appropriate books, games, and puzzle for clients. The Applicant was advised that all individual beds must be in good repair, equipped with good springs, clean mattresses, and pillows. LPA tested the water, and it read at 107 degrees Fahrenheit. The Applicant was advised that the hot water should measure within 105 degrees Fahrenheit and 120 degrees Fahrenheit. Please note the facility is in a private residential community that contains a Homeowners Association (HOA). Per CEO, they previously had a conversation with HOA that gave verbal permission to open the STRTP facility. LPAs advised to receive a written agreement from HOA that permits the home to run the STRTP facility. Per CEO's statement, they will request the letter of agreement and HOA policies. The facility has one van that seats eight to ten present for transportation for clients and is in good working condition. A final file review will be conducted, and the facility will be submitted for licensure. Pre-Licensing inspection was completed, and a copy of this report was given to the Applicant, Jorge Cervantes.

report_type: Facility Evaluation

visit_type: Prelicensing


facility_name: MAKADE BEHAVIORAL CENTER #2

summary: Facility Evaluation

raw_content:
Narrative:
On September 17, 2025, Licensing Program Analysts (LPA) Jessica Peete and Cynthia Urena met with Makade Behavioral Center applicant Jorge Cervantes to complete Component II, the face-to-face interview, for the Short Term Therapeutic Residential Program (STRTP) application process. Also present were Board Secretary Imelda Cervantes and Chief Operations Officer Akila Crane, who attended via Microsoft Teams, and the prospective Administrator Laura Hartney. The applicant previously attended Component I, the STRTP orientation, on February 25, 2025. The purpose of today's meeting was to address any questions or concerns and to review the application packet and process, ensuring that the applicant, designated administrator, and all relevant parties understand and can provide the services outlined in the Program Statement and Plan of Operations in compliance with Community Care Licensing regulations. LPA reviewed the application documents, addressing and correcting discrepancies on the LIC Application for Community Care Facility and LIC Applicant Information. Policies and procedures submitted as part of the application, including discipline policies, program description, population to be served, and personal rights, were also reviewed. The facility staff plan was discussed to ensure compliance. The applicant does not yet have direct care staff but stated that a temporary staffing plan is in place. LPA reminded the applicant of the required staff-to-client ratios and reviewed the relevant regulations outlined in STRTP Interim Licensing Standards (ILS) 87065.5. Additionally, LPA reviewed the qualifications and educational requirements for the Administrator, Social Worker, and Facility Manager. As the applicant is required to have three months of operating expenses, LPA reviewed the necessary financial LIC forms to ensure sufficient resources to operate the STRTP. LPA also discussed the required financial documentation, including the LIC Monthly Operating Statement and the supportive financial verifications. LPA informed the applicant and attendees of the next steps in the application process and requested the following documentation to be provided by or before the scheduled technical assistance meeting: Updated LIC Monthly Operating Budget LIC Personnel Report Administrator qualifications for prospective Administrator Laura Hartney Verification of social worker educational requirements LIC Designation of Facility responsibility with either the board meeting minutes or a resolution confirming the authorized designee is permitted to sign. An exit interview was conducted and a copy of this report was provided to the applicant

met_with: Jorge Cervantes,Imelda Cervantes,Akila Crane, Laura Hartney


summary: Facility Evaluation

raw_content:
Narrative:
On January 13, 2026, at 11: AM Licensing Program Analyst (LPA) Jessica Peete met via Microsoft Teams with Makade Behavioral Center Short Term Residential Therapeutic Program (STRTP) Chief Operating Officer (CEO) Jorge Cervantes and Director Akila Crane to discuss and review the STRTP's second Revised Plan of Operations and Program Statement, submitted to Community Care Licensing by email on December 30, 2025. The meeting covered the Plan of Operation and Program Statement, focusing on the staff training plan for Peer Partners and Volunteers, as well as annual and Facility Manager Training. LPA also discussed Social Worker qualifications, Administrator qualifications, and the facility sketch. LPA advised the applicant that the facility sketch on file must include the dimensions of all areas used by the population served, as required by Interim Licensing Standards (ILS) 87022(5)(A). LPA also reviewed best practices, areas for improvement, and regulatory alignment. The facility currently has a qualified Administrator with an approved exception to be on the premises for at least 20 hours per week at each Makade location in Riverside and Corona to manage and administer the STRTP in compliance with ILS regulation 87064(b)(1). The CEO and Director were also told that corrections or revisions should be highlighted for easy reference during the review. The second revised Plan of Operation and Program Statement will be due January 15, 2026. The following is a summary of the review of the Plan of Operations and Program Statement completed by LPA Jessica Peete: (Continued on LIC C) Application and Supporting Documentation (LIC 281E) Social Worker Qualifications ILS 87065(c)- Standard Not Met · Provide Transcripts from an accredited school · Social work staff hired on or after January 1, 2017, shall meet the following education and experience requirements: · A master's degree from an accredited or state approved graduate school, as defined by the Department of Education, in social work or social welfare, marriage, family and child counseling, child psychology, child development, counseling psychology or social psychology · Completion of at least three (3) semester units or 100 days of field practice or experience in a public or private social service agency at the master's degree level. · At least nine (9) semester units of coursework related to children and families, or 18 months' experience in working with children and families. · At least three semester units in working with minority populations, or six months of experience in working with minority population; or six months in-service training in working with minority populations within the first year of employment as a condition of employment. · At least three semester units in child welfare, or two years' experience in a public or private child welfare social services setting. Administrator Qualifications ILS87064(c) -Standard Not Met · Makade Behavioral Center 1 #337900294-Verify current Administrator Certificate Plan of Operations A. Purpose and Goals-Standard Met · Will serve female/male youth ages 10-17 and non-minor dependents (NMD) up to the age of 21 (Continued on LIC C) B. Administrative Organization -Standard not Met · Page Update Job Duties and Responsibilities to include all the administrative duties as listed in ILS 87064(d)(1)-(10) · Page 49 update Social Worker required qualifications to align with the accepted degrees, work experience, and requirements as outlined in ILS 87065(c)(1)(A)-(F) and 87065(c)(2) · See Best Practice Notes C. Facility Sketch STRTP ILS Sections 87022, 87087, 87087.1, 87087.2-Standard not Met · The sketch should be updated to include the dimensions of all areas which will be used by the population(s) served. ILS 87022(5)(a). The facility sketches for both locations do not have room dimensions. Include all doors, windows, and exits. The facility sketches for Makade located at Manchester Circle Corona; CA does not show windows. D Staff Plan STRTP ILS Sections 87022, 87065, 87065.1, 87065.2, 87065.5, 87078.2, 87095.65-Standard Not Met · Page 73 under In-Service Training and Continuing Education references the incorrect ILS regulations for staff training mandates. Update to include the correct ILS regulation is ILS 87065. Annual Training Plan 87065.1(e) · Partially Missing (Page 88). The annual training must at minimum include all the topics as outlined in ILS 87065.1(e)(3)(A-F) . ILS asks for facility to ensure specific courses are available within the annual training: Missing courses include sexuality, educational needs of youth, & procedures for ensuring a harassment free environment for foster youth & oversight of psychotropic medications. · Describe how the annual training will be verified and documented in the personnel record for each direct care staff ILS 87065.1(e)(6)(A) and 87065.1(e)(7). · Within the annual training plan, include that the Annual training is in addition to first aid and CPR training, and other training as required in Section 87095.65 and ILS 87065.1(e)(8)(A). (Continued on LIC C) Facility Manager Training ILS 87065.1(b) · Page 88 of the Facility Manager Training Plan include or references all the required training as listed ILS 87065.1(b)(5)(A)-(M) the trainings listed do not corresponds the facility manager training listed under 87065.1(b)(5)(A)-(M) · See Best Practice Note-Facility Manager organization Training for Peer Partners and Volunteers 87065.1(f) (1)-(2), 87065.1(g)(1)-(2) : · If using peer partners and/or volunteers, provide, as part of the training plan, the training requirements and the minimum training as outlined, including timelines for completion. ILS 87065.1(f)(1)-(2) and 87065.1 and 87065.1(g)(1)-(2). Specify the requirements that must be met before peer partners and volunteers are allowed to work with the children in care ILS 87065.1(f)(1) and ILS 87065.1(g)(1). · Page 76 under Timelines for Completion include the provision that prior to working with children a peer partner shall be certified in cardiopulmonary resuscitation (CPR) and first aid as stipulated in 87065.1(f)(1). Also include that both peer partners and volunteers are required to receive 16 hours of training on all the topic listed under 87065.1 (f)(1)(A)-(E) for peer partners and 87065.1 and 87065.1(g)(1)(A)-(E) for volunteers. · Page 76 under Timelines for completion include within 90 days of starting peer partners and volunteers must complete an additional 16 hours of training in the following topics as listed under 87065.1(f)(2)(A)-(F) for peer partners and 87065.1(g)(2)(A)-(F) · Page 76 under Documentation and Personnel Records remove the reference to ILS 87065.1(f) and (g) as this section of the ILS makes no refence to documentation for peer partners and volunteers E. Policies Regarding Child Abuse/Neglect Reporting STRTP ILS Section 87022-Standard Met F. Administrative Policies and Procedures STRTP ILS Sections 87022, 87063- Standard Met G. Admission Determination Procedures STRTP ILS Sections 87022, 87068.05-Standard Met (Continued on LIC C) H Intake Policies and Procedures Title CCR Sections 80069, 80070; STRTP ILS 87022, 87068.1, 87068.11, 87068.12, 87078.2 87068.5-Standard Not Met · Page Requirements and Procedures Upon Admittance correct the referenced ILS section ILS 87070(b)(1)-(14) to ILS 87070(b)(1)-(19) Page Requirements and Procedures Upon Admittance correct the referenced ILS section ILS 87070(b)(1)-(14) to ILS 87070(b)(1)-(19) Intake Procedures for Non-Minor Dependents (NMD) Page 147-151 · Include all the required intake information the facility will request/ obtain from the placement agency as listed in ILS 87068.11(f)(2)(A)-(E): . The Health and Education Passport within 48 hours of placement . Any Need and Services Plan (NSP) . The Transitional Independent Living Case Plan . The Transitional Independent Living Plan . The assessment made by the Qualified Individual. · Page Under Emergency Admission of Non-Minor Dependents Include policy and procedures when a non minor dependent is accepted under emergency circumstances ILS 87068.11(h)(1)-(2) a nonminor dependent is placed in the facility under emergency circumstances, a licensee shall ensure the following requirements are met: . Placement of the non-minor dependent in the facility may not result in the facility exceeding its licensed capacity . No later than 30 days following the emergency placement, the administrator or social work staff shall: .Obtain intake information about the non-minor dependent as specified in subsection (f)(1) . Request intake information about the non-minor dependent as specified in subsection (f)(2). .Complete the needs and services plan for the non-minor dependent as specified in subsection (f)(3). I. Admission Agreement Title CCR Sections 80018, 80068; STRTP ILS Sections 87022, 87068.1, 87068.11, 87095.22- Standard met J. Removal and/or Transfer Policies and Procedures ILS Sections 87022, 87061, 87068.4, 87068.11- Standard Not Met · Page Under Development of the Removal and/or Transfer Plan Include the removal and/or transfer procedures for NMD that fully comply with all the requirements of ILS 87068.4(g)(1)-(2) If a non-minor dependent transfers from the facility for other reasons, a licensee shall · Provide written notice to the non-minor dependent that they will transfer from the facility. · State the reason for the transfer of the non-minor dependent, including specific facts about any circumstance or event that resulted in the pending transfer of the non-minor dependent. · Provide a copy of the written notice via e-mail, fax, or overnight mail to the placement agency on the same day the notice is provided. · Page 190 under Documentation and Accountability correct the referenced ILS section 87068.4(g)-(h) to 87068.4(h)(2) and 87070. K Rate Setting and Refunds Policy STRTP ILS Section 87022-Standard Met L Handling of the Child's Money, Personal Property, and/or Valuables Title CCR Sections 80025, 80026; STRTP ILS Sections 87022, 87026- Standard Not Met · Policies and procedures ensuring that cash resources are not taken from the child in the form of fines. · Page 197 include policy and procedures for maintaining receipts Title CCR 80026 (h)(1)(A)-(C) · Page Policy and procedures for cash resources entrusted to the licensee and not kept in the licensed facility shall be deposited in any type of bank, savings and loan, or credit union account meeting the following requirements Title CCR 80026 (i)(1)-(4). Update to include the requirement that the licensee shall provide access to the cash resources upon demand by the client or his/her authorized representative. (Continued LIC C) ·Page Policy and procedures that address how all cash resources, personal property and valuables are handed upon the death of a client Title CCR 80026(I)(1)-(4) · Page Policy and procedure regarding all monetary gifts and of any other gift exceeding an estimated value of $100, provided by or on behalf of a client to the licensee, administrator or staff Title CCR 80026 (n)(1)-2). This does not apply to deceased clients M Consultant and Community Resources Utilized ILS Section 87022 -Standard Met N Trauma Informed and evidenced based interventions STRTP ILS Section 87022- Standard Met O. Plan for Use of Delayed Egress Devices Title CCR Section 80020; STRTP ILS Section Standard met · The facility does not plan to use delayed Egress Devices P. Conflict Of Interest Mitigation Plan STRTP ILS Section Standard Met · This section is not applicable as Makade will not be a county run facility Q Continuous Quality Improvement (CQI) STRTP ILS 87022, 87068.3, 87081- Standard Met Program Statement Populations to Served ILS Section 87022. Standard Met Makade #1 will serve male children ages 10-17 and male non-minor dependents Makade #2 will serve female children ages 10-17 and non-minor dependents 2. Emergency and Disaster Response Services ILS Section 87022.1; Title CCR Section Standard met 3. Transportation Arrangements STRTP ILS Sections 87022.1, Standard Met · See Best Practice note: Clarification is needed regarding the policy on non-minor dependent transportation (Continued on LIC C) 4. Core Supports and Services ILS Sections 87022.1, 87078. Standard met 5. Trauma Informed Interventions and Treatment Practices STRTP ILS Sections 87022.1, 87078.2, 87089.2-Standard Met Licensed Nursing Staff ILS Sections 87022.1, 87089. Standard met Development, Implementation and, Modification of Needs and Services Plans STRTP ILS Sections 87022.1, 87068.2, 87068.22, 87078. Standard met Planned Activities STRTP ILS Sections 87022.1, 87065, 87067, 87068.2, 87068.22, 87078, Standard Met · See Best Practice Note 9. Services During Placement and After Discharge STRTP ILS Section 87022. Standard Met 10. Plan for Participation in Child and Family Team (CFT) STRTP ILS Sections 87022.1, 87078. Standard Met Identification of Home-Based Setting and Family-Based Aftercare Support Plan and Aftercare Services ILS Sections 87022.1, 87089.1 -Standard Met Family and Sibling Participation Sections 87022.1, 87070, 87078.1 -Standard Met Complaints and Grievances Sections STRTP ILS Sections 87022.1, 87072.2, 87078.2-Standard Met Participation and Assistance in Initiatives to improve child Welfare System STRTP ILS Section 87022. Standard Met Family Visitation STRTP ILS Sections 87022.1, 87072, 87078.2, Standard Met 16. Personal Rights STRTP ILS Sections 87022.1, 87072, 87072.3, 87078. Standard Met (Continued on LIC C) 17. House Rules for Children and Non-Minor Dependents ILS Sections 87022.1, 87078.2-Standard Met 18. Positive Discipline Policies and Procedures ILS Sections 87022.1, 87065.2, 87072, 87072.1, 87078.2- Standard not met · Page 448 under Staff Responsibilities When Positive Discipline is Applied expand this section to include staff will do when a child is subject to positive discipline, as required in ILS 87072.1(e) to include conditions under which each type of discipline will be used. When a child is subject to positive discipline, a licensee shall do all of the following: . Discuss the reason and need for the licensee to impose a discipline on the child and provide the child with the opportunity to participate in choosing the appropriate form of discipline. . Document the decision to subject the child to the chosen form of discipline and the steps taken in subjecting the child to the form of discipline. . Develop a plan, including time limit, with the child to be subject to and comply with the chosen form of discipline that is trauma-informed, culturally relevant, and age and developmentally appropriate. · See Best Practice Notes Expectations and Consequences for Non-Minor Dependents ILS Sections 87022.1, 87072.11, and 87078. Standard Met Expectations and Consequences for Non-Minor Dependents ILS Sections 87022.1, 87072.11, and 87078. Standard Not Met · Partially missing- Include a provision that he signed copies of such policies and procedures (for the NMD) shall be maintained in the nonminor dependent's record, as specified in ILS 87070.1(d)(11). 20. Storage of Medications Title CCR Section 80075; STRTP ILS Sections 87022.1, Standard Met (Continued on LIC C) Safeguards for Cash Resources, Personal Property, and Valuables ILS Sections 87022.1, Standard Met Children's Direct Input ILS Sections 87022.1-Standard Met Documentation of Accreditation ILS Sections 87018, 87022.1, 87089-Standard Met · This section meets standards as a short-term residential therapeutic program shall have up to 24 months from the date of provisional licensure to obtain accreditation ILS 97089(b). However, if the applicant has started the accreditation process, the applicant shall submit documentation of accreditation, a copy of its application for accreditation, or a declaration of accreditation status with its application for licensure ILS 87089(c) Mental Health Program Approval ILS Sections 87022.1, 87089.1- Standard Met · See Best Practice Note Food and Nutritional Plan/Sample Menus/Schedule Title CCR Section 80076; STRTP ILS Sections 87022.1, 87070-Standard Met Emergency Intervention Plan (Including Runaway Plan) ILS Sections 87001, 87022.1, 87061, 87063, 87072, 87072.1, 87072.11, 87078.2, 87095.00, 87095.01, 87095.22, 87095.23, 87095.24, 87095.61, 87095.65, 87095.68, 87095.69]-Standard Met Emergency Intervention Plan-Standard met · See Best Practice Notes (Continued on LIC C) Best Practices Plan of Operations B. Administrative Organization -Standard not Met · Page 22 under Required Qualifications for Direct Care Support/Child Care Worker number 7 includes a typo referencing Administrator training that needs to be corrected to reference Direct Care Support/Child Care Worker or removed. · Page 31 under Required Qualifications for the Facility Manager number 7 includes a typo referencing Administrator training that needs to be corrected to reference Facility Manager training or removed · Page 34 under Required Qualifications for the Health, Safety Technical and Building Maintenance Supervisor number 9 includes a typo referencing Administrators that needs to be corrected to reference Health, Safety Technical and Building Maintenance Supervisor or removed · Page 35 under Required Qualifications for the Intensive Care Coordinator number 20 includes a typo referencing Administrator training that needs to be corrected to reference Intensive Care Coordinator or removed. · Page 42 under required qualifications for the Mental Health Rehabilitation Specialist number 7 includes a typo referencing Administrator training that needs to be corrected to reference Mental Health Rehabilitation or removed. · Page 43 under Required Qualifications for Peer Partners number 7 includes a typo referencing Administrator training that needs to be corrected to reference Peer Partners or removed. · Page 46 under Required Qualifications for Psychiatrist number 10 includes a typo referencing Administrator training that needs to be corrected to reference Psychiatrist or removed. · Page 48 under Additional Preferred Qualifications for Social Worker number 5 includes a typo referencing Administrator training that needs to be corrected to reference Social Workers or removed. · Page 51 under Required Qualifications for Volunteers number 5 includes a typo referencing Administrator training that needs to be corrected to reference Volunteers or removed. (Continued on LIC C) NOTE: All short-term residential therapeutic programs shall have a qualified and currently certified administrator ILS 87064(b) NOTE: Work experience in juvenile dentation or an adult correctional facility, juvenile/criminal justice are not identified in the regulations as meeting the educational/experience requirements for Social Workers D Staff Plan STRTP ILS Sections 87022, 87065, 87065.1, 87065.2, 87065.5, 87078.2, 87095.65 · Within this section, it is recommended that a training matrix be arranged in a way that clearly shows staff (specify role and position) that must attend the training, including the following for each training as outlined in ILS 87065.1(b)(2), ILS 87065.1(c)(4) · Additional information on the Facility Manger Training Plan is found on page 84; for organizational purposes it is recommended that the Facility Manger Training information be combined in one section. Best Practices Program Statement 3. Transportation Arrangements STRTP ILS Sections 87022.1, Standard not Met Page Transportation Polices for non-minor dependents explain/expound upon why non-minors would not be transported by staff? Are non-minor dependents to solely rely on public transportation, their own vehicles or use of approved alternate/third party transportation. This contradicts the stated policy on page 241 that stated "MBS guarantees transportation... If this is a typo, please remove and describe arrangements for transporting children/NMDs including to and from health-related services, school, and extracurricular, personal enrichment, cultural, racial, ethnic, and social activities in accordance with the reasonable prudent parent standard specified in Section 87067. Planned Activities STRTP ILS Sections 87022.1, 87065, 87067, 87068.2, 87068.22, 87078, Standard Met · Youth Participation in Planning, Selecting, Conducting, and Evaluating Activities and Culturally Relevant, Trauma Informed Activities are duplicated on pages 307 and 312. This information can be addressed in one section please remove the duplicate information. 18. Positive Discipline Policies and Procedures ILS Sections 87022.1, 87065.2, 87072, 87072.1, 87078.2-Stndard not met · Page 451 expand this section Include a description of how discipline policies account for specialized populations (CSEC youth). CSEC youth" . Describe how MBC is committed to protecting youth from exploitation and prioritizes safety this can include, but not limited to the following: . Emphasis on safety, de-escalation rather than punishment . Expand to describe how safety plans will be developed with CSEC youth that algin with their treatment goals . Describe what the trauma-support strategies MBC will use to aide CSEC youth and how will these strategies be implemented proactively . How will staff address and/or respond to behaviors with an understanding of trauma triggers and how staff will address the underlying causes before implementing positive discipline strategies. Mental Health Program Approval ILS Sections 87022.1, 87089.1- Standard Met · MBC mentions throughout this section that they are contracted with the Riverside University Health System Behavioral Health (RUHS-BH). Please include a copy of the contract/MOU. If not contracted, please revise this language. Recommend changing the language around this. Emergency Intervention Plan (Including Runaway Plan) ILS Sections 87001, 87022.1, 87061, 87063, 87072, 87072.1, 87072.11, 87078.2, 87095.00, 87095.01, 87095.22, 87095.23, 87095.24, 87095.61, 87095.65, 87095.68, 87095.69]- Standard Met · Page 537 and 538 possible typo states that the Nurse will be responsible for the notification of the runway youth. If this is a typo, please correct to reference the correct staff member that will make the notification · Page 541 mentions the Clovis Police Department may be utilized to search for runaway youth. This appears to be a typo as neither Makade location is in the city of Clovis. Please update this information to reference the correct police department/agency. This report was emailed to CEO Jorge Cervantes for signature. The original, signed reports will be placed in the facility file.

visit_type: Annual

met_with: Chief Operating Officer Jorge Cervantes and Director Akila Crane


summary: Facility Evaluation

raw_content:
Narrative:
On January 21, 2026, at 10:00am, Licensing Program Analysts (LPAs), Cynthia Robinson and Cynthia Urena arrived announced at the above facility for the purpose of conducting Pre-licensing inspection at the facility. LPAs were greeted by Akila Crane, Interim Chief Compliance Officer, Jorge Cervantes, Chief Executive Officer (CEO), and Laura Hartney, Administrator. The Licensee above submitted a Short Term Residential Therapeutic Program (STRTP) application. Presently there are no clients in care at the proposed new location. The STRTP has an approved capacity of six and has obtained the fire clearance. The age range for the clients are 10-17 including possible non-minor dependents. Upon arrival to the facility LPAs observed that the facility is located in a residential community with accessible entry to the front door. The facility is a two-story residential dwelling equipped with four bedrooms and two and half bathrooms, an attached three car garage, and accessible parking. The pre-licensing facility physical inspection was conducted with Administrator Laura Hartney, The first floor of the facility is equipped with a living room, dining room, kitchen, study area, a laundry room, and half bathroom. There are two cameras' downstairs, one is located in the living room and the second camera is in the kitchen/study room area. LPA observed age-appropriate books, games, and puzzle for clients. Knives are kept in a locked box located in the kitchen in a locked cabinet made inaccessible to clients. The Applicants has sufficient dishes, cups and silverware for client use and the gas stove is in working order. The Applicant has two working fire extinguishers one located by the kitchen and the second located in the second floor of the home. Carbon monoxides and smoke detectors were observed in the first and second floor of the facility. (**Continued on the next page**) There is a landline telephone that is in working order that will be available to clients. There were no observable hazards or obstructions by the walkways and entries/exits of the facility. There is one sliding door exit in the kitchen area leading to the backyard. There are no pools of bodies of water present. The backyard has a covered patio along with patio furniture. The central air conditioner unit is in the backyard located on the left side of the home. LPAs observed three cameras two of the three cameras are pointed at the sides of the home, and the third camera is pointing at the open space of the backyard. The second floor of the facility consists of one master bedroom, master bathroom, three bedrooms, and one full bathroom. The bedrooms are arranged so that no more than two clients are in a room, and there will be one client per bed. All bedrooms will be utilized for client use and have two beds per room. All bedding was found to be clean, and ready to use condition. A locked cabinet in the hallways was observed with an ample storage for client toiletries. The room is kept locked and inaccessible to clients without staff assistance. Per the Administrator's statement, client toiletries are available upon request and as needed. Medication is centrally stored in a locked box located in the staff office which is located in the garage. During this visit the Applicant was advised that all individual beds must be in good repair, equipped with good springs, clean mattresses, and pillows. LPA tested the water, and it read at 107 degrees Fahrenheit. The Applicant was advised that the hot water should measure within 105 degrees Fahrenheit and 120 degrees Fahrenheit. The facility has one van that seats eight to ten present for transportation for clients and is in good working condition. Components three were completed and discussed with CEO, Jorge Cervantes, and Administrator, Laura Hartney. All special incidents reports will be sent via email to: cclpaccr@dss.ca.gov. The reporting requirements were reviewed with CEO, Jorge Cervantes, and Administrator, Laura Hartney. LPA explained that once the license is approved, all employees shall have an approved criminal record clearance for CCL and be associated to this facility. The following deficiencies were observed: LPAs observed that the home's three car garage has been converted into a staff office, and conference/counseling room. (**Continued on the next page**) In the space where the two garage space area is located LPAs observed three staff desks, cabinets that will be utilized for client and staff files, and medical record storage. LPAs further observed that the third car garage space area is set up as conference room/counseling room for client purposes. In this space a small refrigerator was observed that will store medication in need of refrigeration. The Applicant has been informed that the garage cannot be utilized for client or staff usage/purposes until Community Carre Licensing (CCL) receives a fire clearance approval. The applicant has agreed not to use the garage for staff and or client purposes until the applicant provides CCL the necessary fire clearance approval. The applicant has agreed to relocate the staff office into the master bedroom and will be submitting pictures, and updated facility sketch to LPA to support these changes. The applicant stated that they want to move forward with licensure with current fire clearance that is on file. The facility was advised that the plan of correction of a fire clearance for the garage to be used for staff office and conference room/counseling room is due by March 23, 2026. After the above deficiencies are corrected an in-person, a final file review will be conducted, and the facility will be submitted for licensure. Pre-Licensing inspection was completed, and a copy of this report was given to the Applicant, Jorge Cervantes

visit_type: Case Management