summary: Facility Evaluation

raw_content:
Narrative:
On Friday 9/3/21 at 9:25AM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility for a required annual inspection. LPA met with Licensee Rod Nubla and informed of the purpose of the visit. Safety precautions were taken, including screening call, hand hygiene, and mask-wearing. LPA used the Inspection Tool to conduct the inspection. There are six children in care, and five children were at school. There are seven staff, and two staff are present, plus Licensee. LPA toured the facility site and observed: -- The facility site and grounds are clean, free of debris and hazards, and is well-maintained. -- Food is properly stored, is fresh and within date, and meets the 7-day nonperishable, 2-day perishable mandate to meet the needs of residents in care. The kitchen is stocked with utensils and dishware. -- Medications, sharps, and chemicals are all locked and inaccessible to residents in care. A razor was found in the cabinet in the hallway resident bathroom. Licensee stated residents are able to shave but are watched and assisted by staff, and per their care plans, no residents have self-harm behaviors involving sharp items. -- The smoke detectors were tested and are functioning. -- The first aid kit was centrally stored and contained all required items. -- Hot water and room temperature were maintained within permitted ranges, at 115. F and F, respectively. LPA inspected the facility files and observed: -- The client files are complete and contain all required documentation. Medication records are complete and indicate consistent and proper administration of medications. [Continued Next Page] -- LPA observed that the inventory of belongings were old (from 2017) and not current, or were missing. LPA advises, per California Code of Regulations (CCR), Title 22, Section 80070, that the facility update the inventories and ensure current records are maintained. -- LPA observed that the medication records were well organized, but the psychotropic medications, while logged separately, were not logged on a separate sheet. LPA advised that Licensee begin using the LIC 622B, or variation of, to log psychotropic medications. -- The staff files are complete and contain all required documentation. All staff are cleared and associated to the facility. Staff have current first aid training certificates. -- LPA observed that the training documentation does not reflect that the 20 hour annual training requirement, per CCR, Title 22, Section 84065, was met for 2020. Licensee stated that it has been a challenge to obtain training from outside agencies but training in the form of team meetings with Licensee and with behaviorist have been conducted in-house. LPA advised that Licensee develop an in-house training template to document in-house trainings. -- LPA observed that staff S1 (See LIC Confidential Names, dated 9/3/21) was cleared and associated to the sister facility also under Licensee but not to this facility. S1 works at the other facility and has only been working at this facility temporarily. However, as S1 has been working at this facility for at least a few months, LPA advises, per CCR, Title 22, Section 80019, that S1's clearance be transferred to this facility. -- The license, menu, emergency plan, and personal rights are posted in visible locations in the facility. -- LPA observed that the complaint procedures were not posted in the facility. LPA advises, per CCR, Title 22, Section 84072.2, that Licensee print and post the complaint procedures in the facility in a location visible to residents, authorized representatives, and visitors. LPA conducted resident observation and staff interviews: -- Resident present during visit appeared happy and was being engaged by attentive staff and participating in activities with staff. -- Staff are knowledgeable about the needs of residents in care, program procedures, and mandated reporter status. There are no citations. Six advisories were provided. An exit interview was conducted, and a copy of this report was left with Licensee Rod Nubla, whose signature on this form confirms receipt.

met_with: Licensee Rod Nubla


state: CA

facility_name: MONTECITO HOMES

summary: Facility Evaluation

raw_content:
Narrative:
On 4/13/22 at 3:16PM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility regarding an incident report that was submitted to the Licensing agency. LPA met with Lead Staff Jomar Delapena and informed of the purpose of the visit. Safety precautions were taken, including mask-wearing and pre-visit screening call with Licensee Rod Nubla. During visit, LPA interviewed three staff and attempted interviews with involved residents. LPA reviewed resident records and obtained relevant resident documents and authorized representative contact information. Further investigation is needed at this time. An exit interview was conducted, and a copy of this report was left with Lead Staff Jomar Delapena, whose signature on this form confirms receipt.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Lead Staff Jomar Delapena


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Alyssa Ng on 5/31/2022 at 11:15AM. During the inspection, LPA Ng met with Rod Nubla, Administrator and inspected the facility inside and out. LPA reviewed 6 of child's records on site at the facility at 12: PM. LPA reviewed 3 of staff personnel files on site at the facility at 2: PM. LPA reviewed 6 of child's psychotropic medications and medication records at 12: PM. LPA interviewed 2 of staff on site at 11: AM. LPA interviewed 0 of children currently taking psychotropic medication at 2: PM. Four clients were at school and two were on a community outing. All clients are non-verbal and unable to answer or understand interview questions. Therefore, LPA did not interview clients. LPA conducted exit interview with Rod Nubla, Administrator at 2: PM. LPA provided the Summary Report to Rod Nubla, Administrator upon completion. LPA did however, issue a Technical Assistance in regards to staff document maintenance. LPA conducted exit interview and left a copy of the report with the Administrator at 2: PM.

met_with: Rod Nubla


facility_name: MORADA HOME

summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
The interviews did not prove that facility staff made inappropriate comments to C1 nor did it show that facility staff refused to feed C1. In fact C1 stated that she refused dinner that was prepared for the evening. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove or disprove that a violation occurred; therefore, the above allegations are Unsubstantiated. There are no deficiencies being cited at this time. Exit interview was conducted, Appeal Rights and a copy of this report will be mailed to Oneisha James, Facility Administrator.

Investigation Findings:
13On October 12, 2021 at 1pm Licensing Program Analyst (LPA) Donald Martin conducted a follow-up complaint inspection and spoke to Oneisha James, Facility Administrator. The purpose of the inspection was to provide findings for the above complaint allegations. During the course of investigating the allegations for facility staff physically abused group home child, facility staff made inappropriate comments to group home child and facility staff denied group home child food as a form of punishment, LPA conducted interviews. The interviews did not produce corroborating evidence to support said allegations. Interviews revealed inconsistent statements and no witnesses to suggest allegations occurred. There was no evidence that facility staff physically abused the group home child. The police stated that there was no physical evidence of bruising on the child during the visit. 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 CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: MORADA HOMEFACILITY NUMBER: VISIT DATE: 10/12/2021

report_type: Complaint Investigation

met_with: Oneisha James-Facility Administrator

complaint_status: unsubstantiated


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Investigation Findings:
13On October 15, 2021 at 10: AM, Licensing Program Analyst (LPA) Charmetha White arrived at the above location for the purpose of concluding the investigation and to deliver findings on the above allegations. LPA met with Facility Administrator, Oneisha James and discussed the findings. During the course of this investigation, LPA interviewed pertinent parties and reviewed records. Interviews and records did not produce corroborating evidence to support the allegations. Staff denied the allegations. Staff stated they have never witnessed any staff smoking marijuana in the presence of minors. However, Staff #1 did confirm a staff was terminated for bringing marijuana to the facility. Staff stated none of the staff have ever pushed or physically abused any of the minors in care. Children interviewed stated the staff treat them fine and that staff do not push or hit them. LPA was unable to obtain a statement from Child #1 as Child was replaced and Child #1's bed was closed effective 11/07/2020. Based on information obtained, the allegation is found to be unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violations did or did not occur. No deficiencies cited. Exit interview completed and a copy of this report was left with Facility Administrator, Oneisha James. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Charmetha White 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 2

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

met_with: Facility Administrator - Oneisha James


raw_content:
Narrative:
Staff #1 and Staff #2 did assist Child #1 into the home from being seated on the lawn in front of the facility, however due to rainy conditions and after hours of crisis communication. Both Staff #1 and Staff #2 are CPI (Crisis Prevention Intervention) trained and current CPI cards are attached to the report. 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 September 19, 2024 at 2pm, Licensing Program Analyst (LPA) Donald Martin conducted a follow up complaint inspection and spoke with Facility Manager, Zerlene Graham. The purpose of this inspection was to deliver findings for the above complaint allegation. During the course of investigation the allegation for staff physically abused minor in care, 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. There was no evidence that staff physically abused minor in care. 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: MORADA HOMEFACILITY NUMBER: VISIT DATE: 09/19/2024

met_with: Zerlene Geraham-Facility Manager


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
A1 stole personal identifying information of approximately several individuals to file 72 fraudulent unemployment insurance and 19 fraudulent disability insurance claims from 2020 until present. A1 caused over $800,000 in unemployment insurance losses and over $200,000 in disability insurance losses to the State of California. Information obtained revealed in part that A1 pleaded guilty to fraudulently using stolen personal identifying information to file for unemployment insurance and disability insurance claims through Employment Development Department. Based on record review and confidential interviews, the preponderance of the evidence standard has been met. Therefore, the allegation that Licensee/Board member (A1) was arrested for COVID Insurance fraud and identity theft is substantiated. This poses an immediate health, safety, and personal rights risk of harm to children placed in care. The facility is issued citation in accordance with Health and Safety Code section Persons prohibited from employment; dismissal or removal. (See page LIC9099-D for cited deficiency). An exit interview was conducted. A copy of this report, and appeal rights were provided to Facility Administrator via email.

Investigation Findings:
SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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

met_with: Facility Representative/Manager

complaint_status: SUBSTANTIATED


summary: Facility Evaluation

raw_content:
Narrative:
On December 7, 2021 at 9:49am, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Morada Home for the purpose of conducting an Annual/Required Inspection. LPA met with the licensee, Abiola Quadri who provided a tour of the facility. This facility is licensed to provide care and supervision to four (4) ambulatory, developmentally disabled male and female clients ages 7 -17 years old. The census today is three (3) clients. The home was observed to be set-up as follows: This is a single-story home located in a residential neighborhood with three (3) bedrooms, two (2) bathrooms, living room, dining area, kitchen, laundry area, detached garage, an office, and a backyard. Living Room: Is equipped with 3 sofas, a mounted TV, and a fireplace with a locked screen. Dining Area: Is equipped with a table and four (4) chairs. Kitchen: Is equipped with a stove with five (5) burners all working at this time. A microwave mounted above the stove, a dishwasher, and a refrigerator/freezer. The home was observed to have two days of perishable food and one week of nonperishable food supplies. Clients are provided nutritious snacks between meals. Trash can had a lid. Sharp knives are kept in a locked safe on the kitchen counter top. Medications that do not require refrigeration are kept in a locked kitchen cabinet. There are no clients that require refrigerated medications. Laundry Area: Is located along the hallway. There are two locked cabinets in the laundry area, one contains extra hygiene products for clients and the other contains laundry detergent and cleaning supplies. All cleaning solutions are made inaccessible to the clients. Office: Is located off the backyard and it is kept locked. The office is equipped with a desk, one (1) chair, and two (2) file cabinets. Client and staff files are stored in the office. Bedroom #1: Is occupied by Client #1 and the room is equipped with one twin size bed. The room has adequate drawers, closet space, lighting, and a window. Bedroom #2: Is VACANT and the room is equipped with one twin size bed. The room has adequate drawers, closet space, lighting, and a window. Bedroom #3: Is occupied by Clients #2 & 3. The room is equipped with two twin size beds. The room has adequate drawers, closet space, lighting, and a window. This room also contains BATHROOM #2. Bathroom #1: Is located along the hallway. Bathroom #2 is located inside of bedroom #3. Both bathrooms were checked and observed to be in good repair and working order. Continued on LIC 809-C The home is equipped with 2 regulation fire extinguishers. Smoke alarms and carbon monoxide detectors were tested and found to be in working order. The first aid kit was checked and found to be complete. Hot water kept at a safe temperature. The beds have comfortable mattresses, clean linens, blankets and pillows, all in good repair. There are no swimming pools or bodies of water on the premises. No weapons are at the facility. Overall LPA observed the home to be clean, safe, sanitary and in good repair. Passageways and open porches are unobstructed. The front and back yards were inspected and found to be clear of hazards and debris. The facility has a Grey Toyota Sienna, clean and in good repair to transport clients. Current automobile insurance is with Infinity Insurance Company. Children in care are supervised and protected at all times. Children are accorded dignity in personal relationships with staff and others. Children are not restricted in telephone use except by court order. Children can contact the licensing agency or Foster Care Ombudsman person in confidence without threats or punishment for making complaints. Children attend school, extracurricular, cultural and personal enrichment activities. Emergency Disaster Mass Casualty Plan: Current and available for review. All posting requirements were met. LPA reviewed following during the inspection: Staff Records Review: LPA reviewed six (6) staff records stored in individual personnel file/binders provided by Administrator. LPA ensured to thoroughly review the records of the primary active staff (i.e The Program Administrator, Facility Manager; and four (4) Direct Care Staff. LPA conducted a confidential interview with one (1) on duty staff. Additional confidential staff interviews will be conducted at a later date. LPA reviewed the Personnel Report (LIC 500) and confirmed that Direct Care Staff Ratio present for the three (3) clients in placement. In review of the staff's records LPA confirmed that All staff have required criminal record clearance. DOJ, FBI and Child Abuse Response. Continued on LIC 809-C LPA reviewed three (3) client records which contained copies of the Needs and Service Plans and Medical Authorizations signed by each child and their authorized representative. Children in care are supervised and protected at all times. Children are accorded dignity in personal relationships with staff and others. It was reported by Facility Manager that children attend school, extracurricular, cultural and personal enrichment activities. LPA will conduct confidential client interviews at a later date. LPA informed Administrator of licensing fees due by 12/27/2021. Facility cited for violation of California Code of Regulations, Title Division Six, regulation 80019(e)(2), Criminal Record Clearance. No transfer of staff criminal record clearance to facility. Facility cited for violation of California Code of Regulations, Title Division Six, regulation 80054(b), Penalties. Notwithstanding Section 80054(a) above, an immediate penalty of $100 per cited violation per day for a maximum of five (5) days shall be assessed if any individual required to be fingerprinted under Health and Safety Code Section 1522(b) has not obtained a California clearance or a criminal record exemption, requested a transfer of a criminal record clearance or requested and be approved for a transfer of an exemption as specified in Section 80019(e) prior to working, residing or volunteering in the facility. An exit Interview was conducted and a copy of this report, a copy of the AMENDED 809-D to include the above citations and the civil penalty assessment-background check will be emailed to the facility.

visit_type: Annual

met_with: Oneisha James - Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On December 10, 2021 at 9:49am, Licensing Program Analyst (LPA) Daphne Edison made an unannounced attempted visit to Morada Home for the purpose of conducting a Continuance Case Management Annual Required Inspection which took place on December 7, 2021. LPA rang the doorbell and there was no answer. LPA called and spoke with Oneisha James, Administrator by telephone at (323) 818-6398. Administrator stated that no one would be home until 4:30-5:00pm today. Administrator stated two (2) clients were in school and one (1) client had appointments today. Telephone call ended.


summary: Facility Evaluation

raw_content:
Narrative:
On January 18, 2022 at 2:15pm, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Morada Home for the purpose of a case management continuance for an annual required inspection which took place on December 7, 2021. LPA Edison rang the doorbell several times with no answer. LPA observed a gray Toyota Sienna van in the driveway of the home. LPA called and spoke with Oneisha James, Administrator at (323) 818-6398 at 2:28pm. Administrator informed LPA that no one was home. Administrator stated that the census for the day was three (3). Administrator stated that two (2) clients were at school and one (1) client was on a family visit. Administrator stated clients had appointments for a haircut after school. Administrator stated that staff was not there and that no one would be home until between 4:30pm-5:00p. Administrator requested LPA to follow up on an issue they are having with Guardian and associating staff to the facility. LPA will follow up on a later date. Telephone call ended.


summary: Facility Evaluation

raw_content:
Narrative:
On March 1, 2022 at 9:49am, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Morada Home for the purpose of conducting a case management continuance of an Annual/Required Inspection which took place on December 7, 2021. LPA met with Oneisha James, Administrator who granted access to the facility. This facility is licensed to provide care and supervision to four (4) ambulatory, developmentally disabled male and female clients ages 7 -17 years old. The census today is three (3) clients. The home was observed to be set-up as follows: This is a single-story home with three (3) bedrooms, two (2) bathrooms, living room, dining area, kitchen, laundry area, detached garage, an office, and a backyard. LPA conducted one (1) staff interview. LPA reviewed the Personnel Report (LIC 500) and confirmed that Direct Care Staff Ratio present for the three (3) clients in placement. In review of the staff's records LPA confirmed that all staff has the required criminal record clearance, DOJ, FBI and Child Abuse Response. LPA will conduct client interviews on a later date. Children in care are supervised and protected at all times. Children are accorded dignity in personal relationships with staff and others. Children can contact the licensing agency or Foster Care Ombudsperson in confidence without threats or punishment for making complaints. Children attend school, extracurricular, cultural and personal enrichment activities. Administrator was reminded to report changes in the plan of operation affecting service to clients. Emergency Disaster Mass Casualty Plan was current and available for review. Designation/staff assignments current. Facility operates within license conditions & limitations including capacity limitations. All posting requirements were met. Continued on LIC 809-C Based on the observations made during today's inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit Interview was conducted, and a copy of this report will be emailed to the Administrator.


facility_name: MORNING STAR

raw_content:
Investigation Findings:
13On 6/24/2022 at 10: AM, Licensing Program Analyst (LPA) Alyssa Ng conducted a follow-up complaint inspection at Morning Star and spoke with Administrator/Licensee Reggieanne Villar-Battung and Facility Manager Irma Battung. The purpose of the inspection was to deliver the findings for the above complaint allegations. During investigation, incident reports and records were reviewed, and confidential interviews were conducted. Based on interviews and record review, Morning Star conducted two sessions on August 19th and 20th for C1 in 2021. Other than that, Morning Star did not conduct any Applied Behavior Analysis (ABA) sessions in the facility. ABA sessions has been taken place at C1 and C2's fathers or grandmothers house. C1 and C2 have a maximum of 15 hours of ABA a week. They are currently using 6-9 hours a week. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation, Facility is not meeting minor's medical needs is found to be SUBSTANTIATED. California Code of Regulations,Title 22, Division 6 & Chapter 1, Health Related Services, 80075 (a) are being cited on the attached LIC 9099D. An exit interview was conducted, appeal rights prvoded and discussed, and a copy of this report was given to Reggieanne Villar-Battung, Administrator/Licensee. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Alyssa Ng 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 14-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, TRAEGER AVE., SUITE FACILITY NAME: MORNING STARFACILITY NUMBER: 075650120

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

met_with: Reggieanne and Irma Villa-Battung


summary: Facility Evaluation

raw_content:
Narrative:
At 3:08PM, Licensing Program Analyst (LPA) Madi Fremont met with the home above over Microsoft Teams to conduct a Regional Office Meeting. The purpose of this meeting was to discuss elements of the home's Noncompliance Plan, which was initiated on 03/18/2021. LPA met with Licensee/Administrator Reggieanne Villar-Battung, who helped facilitate this inspection. Also in attendance was Licensing Program Manager (LPM) Helga Wong. Currently in care are 5 ambulatory clients. On 03/18/2021, as part of the home's Noncompliance Plan requirements, the Licensee was asked to hire a new qualified Administrator to assist with daily operations and administrative duties for a minimum of 20 hours per week. The deadline for this requirement was set as June 1, 2021. The licensee has requested an extension for this deadline due to difficulties in the hiring process. During this meeting, it was discussed that the home would be granted an extension on this deadline, now set for Monday, October 4th, 2021. The licensee will provide regular updates on their progress in fulfilling this requirement. LPA Fremont will also reach out to the licensee periodically to check in on progress and provide any needed support. While the Licensee continues the process of hiring a new administrator, they have agreed to hire a qualified consultant to come to the home for 2-3 hours every week to provide technical assistance and improve the following areas: -Administrative organization and applicable regulations -Streamlining paperwork -Day-to-day operations -Staff schedules -Staff communication with outside agencies, authorized representatives, and other staff If the Licensee is not able to hire a new administrator by the 10/04/2021 deadline, it has been discussed that the two current assistant administrators, Irma Battung and Gilbert Battung, may step in after qualifications are verified. If this is the case, the consultant mentioned above will lead training for the new administrator. At this time, no deficiencies are being cited. An exit interview was conducted, and a copy of this report was emailed to Licensee/Administrator Reggieanne Villar-Battung to be signed and returned for the home's facility file.


summary: Facility Evaluation

raw_content:
Narrative:
At 9:51AM, Licensing Program Analyst (LPA) Madi Fremont traveled to the home above to conduct an unannounced Required Annual Inspection. LPA met with Administrator Reggieanne Villar-Battung, who helped facilitate this inspection. Also in attendance were LPA AmyLe Tran and Morning Star Assistant Administrator Irma Battung. Currently in care are 5 ambulatory clients. During this inspection, 0 clients and 6 staff were present in the home. 5 clients arrived as LPAs were leaving the home. LPAs toured the facility inside and out. The home is single storied, and has two double occupancy bedrooms and one single occupancy bedroom. All client bedrooms were equipped with comfortable furnishings which included ample storage space for clients' belongings, desks and chairs, and twin sized beds. Each bedroom has a closet with sliding doors for extra storage space. The home has a living room and a family room which are equipped with couches and chairs for clients. The home has a dining room with enough chairs for all clients to have meals together. The kitchen was observed to be clean and free of hazards or chemicals. The weekly menu was posted in the family room. LPAs observed at least 2 days of perishable foods and 7 days of nonperishable foods. Chemicals and cleaning supplies are kept locked in a cabinet that is inaccessible to clients. No firearms on the premises. Facility had a supply of emergency food items in the garage. All medications are kept in a locked cabinet. Facility as 3 first aid kits with all required supplies. Fire extinguisher was observed in the garage, and all carbon monoxide and smoke detectors were tested and observed to be functional. Client bathroom was clean and furnished with hygiene supplies for each client. LPAs observed extra linens in two closets in the hallway. All bathroom and kitchen faucets in use by clients were measured between 111-112 degrees Fahrenheit. Thermostat was set to 71 degrees Fahrenheit. Facility license, emergency plan, personal rights, client grievance policy, floor plan, and staff schedule are prominently posted. Sharps are kept locked and inaccessible to clients. (Continued on Lic809-c) The facility has a staff room that is kept locked and inaccessible to clients. Staff room has 3 beds for staff breaks, and a sliding glass door to the backyard that is also kept locked. LPAs toured the backyard and observed it to be free from hazards. There are two play structures which are anchored to the ground, and a sitting area in the backyard. The backyard is surrounded by a wooden fence with locked gates. Ground under the play structures is covered in tanbark for client safety if falls occur. The facility has a centralized AC unit in the side yard which is kept gated at all times and inaccessible to clients. No bodies of water on the premises. All walkways were free from debris or hazards. All window screens are in good condition. The facility has a fireplace which is not in use, and has a grate as well as a couch backed up to the front to ensure clients cannot access the fireplace. Facility has comfortable furnishings, accommodations, and ample lighting. All client and staff records are complete with all of the required documentation. During this inspection, LPA obtained copies of the facility's client roster, staff roster (LIC500), staff schedule, and immunization records for 2 clients. At this time, no deficiencies were observed or cited. An exit interview was conducted, and a copy of this report was emailed to Licensee/Administrator Reggieanne Villar-Battung.


summary: Facility Evaluation

raw_content:
Narrative:
At 1:15PM, Licensing Program Analysts (LPAs) Madi Fremont and Alyssa Ng traveled to the home above for the purpose of conducting an unannounced Case Management - Legal/Noncompliance inspection. LPAs me with Licensee/Administrator Reggieanne Villar-Battung who helped facilitate this inspection. Currently in care are 5 ambulatory clients. One client was present at the time of this inspection. The purpose of this inspection was to review the home's compliance as part of their Noncompliance Plan initiated in March 2021 (Please reference LIC9111 - Noncompliance Conference Summary dated 03/18/2021 for details). As part of this Department's review of this home's compliance, LPA asked to see the following documentation which is to be submitted upon request by the Licensing Agent per the Noncompliance Plan issued 03/18/2021: - Supervision and Staff Ratios: Administrator will document weekly hours for time performing Administrative duties and not Direct Care duties. Weekly hours will be readily available either electronically or in person upon request by Community Care Licensing (CCL). - Reporting Requirements: The licensee shall track trends and frequency of incidents through ongoing internal audit. Will be made readily available either electronically or in person upon request by CCL. - Health-Related Services: The licensee will create a monthly log of self-injurious behaviors, including antecedents to the incident, de-escalation techniques used, and any injuries sustained during the incidents. Monthly logs will be made readily available either electronically or in person upon request by CCL. (Continued on Lic809-c) - Administration: The licensee will schedule Monthly Review Meetings with each clients' authorized representatives regarding their plan of care, services, and needs. Summary of review meetings will be made readily available either electronically or in-person upon request by CCL. - Administration: The administrator will be present and working in the facility for at least 20 hours per week. Hours will be made readily available either electronically or in person upon request by CCL. Upon this request, the Licensee was unable to produce proof of compliance with the aforementioned "upon request" requirements of their Noncompliance Plan. Next, LPA Fremont inquired about missed documentation submission deadlines for the following requirements of the facility's Noncompliance Plan: - Supervision and Staff Ratios: - Updated LIC Staff Schedule every 6 months starting June 1, 2021 through June 1, 2023. - 5PM, June 1, 2021 - received during annual inspection on 06/16/2021 - 5PM, December 1, 2021 - not received - Updated 1:1 staff assignments every 6 months starting June 1, 2021 through June 1, 2023. - 5PM, June 1, 2021 - not received - 5PM, December 1, 2021 - not received - Education: - Beginning April 1, 2021 through April 1, 2023, the Licensee shall submit quarterly summaries of progress, challenges, and barriers to clients' education: - 5PM, April 1, 2021 - overdue (submitted 04/06/2021 at 12:38PM with no extension request) - 5PM, July 7, 2021 - submitted early (06/17/2021 at 11:40PM) - 5PM, October 1, 2021 - not received - 5PM, January 2, 2022 - extension requested 02/15/2022, not submitted) (CONTINUED ON LIC809-C) - Staff Training: - Beginning April 7, 2021 and continuing quarterly through April 7, 2023, the Licensee shall submit training sign-in sheets as well as training materials for all topics identified during Noncompliance Conference on 03/18/2021. - 5PM, April 7, 2021 - overdue (submitted 04/09/2021 at 5:03PM, no extension requested) - 5PM, July 7, 2021 - not received - 5PM, October 7, 2021 - not received - 5PM, January 7, 2022 - not received Upon request for aforementioned submissions, the Licensee could not provide LPAs with the requested documentation. When asked why the Licensee did not have this documentation available for review by this Licensing Agency, the Licensee stated they did not know who to submit documentation to (LPA Fremont transferred from San Bruno to San Jose Regional Office on October 1, 2021, but had informed licensee by email that any submissions, questions, or concerns could be communicated through LPA Fremont, LPM Helga Wong, LPM Zaid Hakim, or RM Nelson Martinez while the department hired a new LPA to take LPA Fremont's Place - email sent 09/30/2021, 4:01PM) Because no documentation could be produced at the time of this inspection, nor did LPA's receive any documentation submissions for the deadlines listed above, LPA Fremont could not proceed with this Noncompliance/Legal Case Management Inspection. LPA Fremont requested that all documentation listed above be provided over email no later than 5PM on Friday 02/25/2021. Licensee agreed to this deadline and stated they would requested a deadline extension before this deadline, if needed. At this time, no deficiencies were observed or cited. An exit interview was conducted, and a copy of this report was emailed to Licensee/Administrator Reggieanne Villar-Battung, whose signature on this form confirms receupt.

met_with: Administrator Reggieanne Villar-Battung


summary: Facility Evaluation

raw_content:
Narrative:
On Friday June 17, 2022 at 10AM, San Jose Children's Residential Program Regional Manager Nelson Martinez, Licensing Program Managers (LPMs) Helga Wong and Carolyn Flynn, and Licensing Program Analyst (LPA) Madeleine Fremont conducted an in-person Regional Office meeting with Morning Star Licensee/Administrator Reggieanne Villar-Battung and Facility Manager Irma Battung. East Bay Regional Center representatives Derrick Levingston and Michael Minton joined virtually via Microsoft Teams. The purpose of this meeting was to discuss the following: - Non-Compliance Meeting conducted on 03/18/2021 where the home was placed on a two-year non-compliance plan. - Licensee/Administrator not completing or submitting their Non-Compliance Plan requirements. - The home continuing to have similar deficiencies and complaints. - The Licensee/Administrator not submitting Plans of Correction for previously-cited deficiencies. - Discussion of unprofessional conduct from the Licensee/Administrator, other facility personnel and CCL staff. - CCLD Inspection Authority - Administrative Action Through the first year of the Licensee's Non-Compliance Plan the Licensee has continued to be cited for similar issued and has not fulfilled the qualifications of their non-compliance plan. The Licensee will be referred to Community Care Licensing's Legal Department for revocation of licensure or decertification of the Administrator(s). An exit interview was conducted, and a copy of this report was sent to Licensee Reggieanne Villar-Battung, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 6/24/2022 at 11: AM, Licensing Program Analysts (LPAs) Alyssa Ng and Lisette Valenzuela made an unannounced case management to this facility. The purpose of the inspection was to review the facilities Non-Compliance. On 06/17/22 at 10: AM, an office meeting was held, and the facility had a plan in place, and are submitting all documents to the Department by 4: PM today. During facility visit, the following was discussed: Supervision and Staff Ratios: -LIC500 to be submitted directly to CCL every 6 months, starting June 1, 2021 through June 1, 2023. The licensee will keep an ongoing updated weekly schedule to ensure full staff coverage. Every 6 months, beginning June 1, 2021 and continuing through June 1, 2023, the licensee will submit updated staff assignments for each child requiring 1:1 supervision. -Administrator will document weekly hours for time performing Administrative duties and not direct care duties. Weekly hours will be made readily available upon request by CCL. Education: -The licensee/staff must communicate with each client's educators when requested by the school -The licensee/staff must report to school when clients are absent on the day of their absence before the session begins. -Licensee/staff must work with educators and responsible parties on their education plan and progress. -The licensee/staff must participate in IEP meetings for each client when scheduled. -Staff must be present at all times to assist with online education. -Beginning April 1, 2021 through April 1, 2023, the licensee will submit quarterly summary of progress as well as challenges/barriers to education. Staff Training: -Retrain all facility staff on providing care and supervision, personal rights, duties and responsibilities, health related services, reporting requirements, communication, providing education, ensuring the health and safety of the clients, and computer/technology/IT skills. (1 hour for each training topic). -Beginning April 7, 2021 and continuing quarterly through April 7, 2023, the licensee will submit training sign-in sheets as well as training materials for the above-mentioned topics to CCL. By June 24, 2022 at 4: PM, the licensee will submit a training timeline to CCL that includes topics, dates, and trainer information. Personnel Requirements and Duties: -The facility will hire a qualified administrator to assist with daily operations and administrative duties for a minimum of 20 hours per week. Deadline for this requirement is set as June 24, 2022 at 4: PM. Reporting Requirements: -The licensee will start evaluating unusual incidents on an individual basis to ensure that all parties are informed of incidents in a timely manner consistent with CCR 80061 - Reporting Requirements. -The Licensee will track trends and frequency of incidents through ongoing internal audit, and will make available upon request by this agency. Licensee/Administrator Reggieanne Villar-Battung agreed to submit all of the following no later than today by 4: PM. No Title 22 deficiencies were cited at today's inspection. Exit interview was conducted and a copy of the report was left with the facility.

met_with: Reggieanne and Irma Battung


summary: Facility Evaluation

raw_content:
Narrative:
On 6/24/22 at 12: PM, Licensing Program Analysts (LPA) Alyssa Ng and Lisette Valenzuela made an unannounced annual/required inspection to listed facility. The facility is licensed for six residents, and currently in placement are 5 clients. During this inspection,1 clients and 3 staff were present in the home. Later on during the inspection, the rest of the clients came back from summer school, along with three staff. Safety precautions were taken, including screening call, hand hygiene, and mask-wearing. LPA Ng toured the facility inside and out. The home is single storied, and has two double occupancy bedrooms and one single occupancy bedroom. All client bedrooms were equipped with comfortable furnishings which included ample storage space for clients' belongings, desks and chairs, and twin sized beds. Each bedroom has a closet with sliding doors for extra storage space. Client bathroom was clean and furnished with hygiene supplies for each client. The water temperature measured 110 degrees F. The thermostat measured 78 degrees. The facility is clean, safe and sanitary. The kitchen was observed to be clean and free of hazards or chemicals. Sharps were located in a locked cabinet. The weekly menu was posted in the family room. The facility has a fireplace which is not in use, and has a grate as well as a couch backed up to the front to ensure clients cannot access the fireplace. LPA's observed at least 2 days of perishable foods and 7 days of nonperishable foods. The smoke detectors and fire extinguishers are in working order. No bodies of water on the premises. All walkways were free from debris or hazards. LPA's observed extra linens in two closets in the hallway. LPA's toured the backyard and observed it to be free from hazards. There are two play structures which are anchored to the ground, and a sitting area in the backyard. The backyard is surrounded by a wooden fence with locked gates. The facility has a centralized AC unit in the side yard which is kept gated at all times and inaccessible to clients. ----------Cont. ON 809C------ All client records complete with all of the required documentation. Each client has their own separate binder of all required documents. Each psychotropic medication was observed to have its own Psychotropic Medication Administration Record (PMAR), as well as individual Centrally Stored Medication Destruction Records (CSMDR). All medications were consistent with these records. Staff has a centralized binder that contained their training, qualifications, and other personal information. LPA looked through all binders and were complete with all the required documentation. At this time, no deficiencies were observed or cited. An exit interview was conducted, and a copy of this report was emailed to Licensee/Administrator Reggieanne Villar-Battung.


summary: Facility Evaluation

raw_content:
Narrative:
On 1/24/2023 at 10: AM, Licensing Program Analyst (LPA) Alyssa Ng made an unannounced case management to this facility. LPA Ng met with Reggieanne Villar-Battung, Licensee & Irma Battung, Administrator who helped facilitate this inspection. Currently in care are 5 ambulatory clients. 0 clients was present at the time of this inspection. At 11: AM, 1 client returned from school. The purpose of this inspection was to review the home's compliance as part of their Noncompliance Plan initiated in March 2021 (Please reference LIC9111 - Noncompliance Conference Summary dated 03/18/2021 for details). As part of this Department's review of this home's compliance, LPA asked to see the following documentation which is to be submitted upon request by the Licensing Agent per the Noncompliance Plan issued 03/18/2021: - Supervision and Staff Ratios: Administrator will document weekly hours for time performing Administrative duties and not Direct Care duties. Weekly hours will be readily available either electronically or in person upon request by Community Care Licensing (CCL). - Reporting Requirements: The licensee shall track trends and frequency of incidents through ongoing internal audit. Will be made readily available either electronically or in person upon request by CCL. - Health-Related Services: The licensee will create a monthly log of self injurious behaviors, including antecedents to the incident, de-escalation techniques used, and any injuries sustained during the incidents. Monthly logs will be made readily available either electronically or in person upon request by CCL. ---------Cont. ON 809C------------- - Administration: The licensee will schedule Monthly Review Meetings with each clients' authorized representatives regarding their plan of care, services, and needs. Summary of review meetings will be made readily available either electronically or in-person upon request by CCL. - Administration: The administrator will be present and working in the facility for at least 20 hours per week. Hours will be made readily available either electronically or in person upon request by CCL. Administrator confirmed that there is no new Administrator currently working at the facility. All documents that were reviewed during the inspection were from October 2022- Present. LPA Ng reviewed: -Trends and frequency of ongoing incidents. All client documents were observed to be complete. -Monthly Review Meetings with each clients' authorized representatives regarding their plan of care, services, and needs. (including quarterly summary of progress as well as challenges/barriers to education) LPA Ng reviewed all quarterly summaries that included their progress and challenges. -Monthly log of self injurious behaviors, including antecedents to the incident, de-escalation techniques used, and any injuries sustained during the incidents. LPA reviewed each clients daily body checks and log of injurious behaviors. -Weekly hours for time performing Administrative duties and not Direct Care duties. Administrator Reggieanne showed LPA a log of her Administrator hours each week. -Updated staff assignments for each child requiring 1:1 supervision. LPA reviewed the "Additional Staff Person" (ASP) request and fading plan for all three clients needed 1:1 supervision. -Staff training regarding related topics. Administrator Villar-Battung showed all the staff training regarding providing care and supervision, personal rights, duties and responsibilities, health related services, reporting requirements, communication, providing education, ensuring the health and safety of the clients, and computer/technology/IT skills. -Administrator will send LPA updates with hiring process. Administrator Villar-Battung is currently consulting with other group home providers in the area. Facility has posted on job sites like Indeed and ZipRecruiter. At this time, no deficiencies were cited. An exit interview was conducted, and a copy of this report was given to Reggieanne Villar-Battung, Administrator whose signature on this form confirms receipt.

met_with: Reggieanne Villar-Battung & Irma Battung


facility_name: MOSAIC OF FRIENDS

raw_content:
Investigation Findings:
13On September 29, 2023, Licensing Program Analyst (LPA) C. White made an unannounced visit to Mosaic of Friends IV, located at 7344 87th Street Westchester, CA. 90045 for the purpose of delivering findings on the above complaint allegation. LPA met with Administrator, Gia Williams and discussed the investigation. During the course of this investigation, confidential interviews were conducted with pertinent parties. Interviews did not produce corroborating evidence to support the allegation. LPA was unable to interview Client #1 as client was replaced with family. Additionally, there was no evidence or witnesses to support the allegation that minor sustained injuries while in care. Based on information obtained, the allegation is found to be unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violations did or did not occur. No deficiencies cited. Exit interview completed and a copy of this report was left with the Administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Charmetha White 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: Administrator - Gia Griffin


summary: Facility Evaluation

raw_content:
Narrative:
On February 03, 2022 at 11: AM, Licensing Program Analyst (LPA) Rosslyn Gray arrived at the above facility for the purpose of conducting Annual Required Inspection. LPA met with Facility Manager Gia Williams, and together a tour of the entire facility. The facility is licensed for 5 developmentally disable children ages 11 through 17 years old, Ambulatory only. Currently there is one (1) minor and two (2) male NonMinor Dependents (NMD) in placement by Westside Regional Centers. LPA observed that there are no bodies on water on the premises. The Administrator confirmed that there are no firearms or dangerous weapons in the facility. The Group Home Overview: This is a one (1) story home located in a residential neighborhood. There is a Living room; Dining room, Kitchen. There is a locked two (2) car garage, currently utilized as a storage and other miscellaneous item. The Hot Water Heater is strapped located out of the house. There is one (1) vehicle parked outside inspected to be in good operating condition (The vehicles car was checked for tires, headlights, tail lights, turn signals, horn and windshield wipers). Car # Make and Model 2018 BMW; Proof of Insurance (GICO 2/20/2022); Car Registration (Expiration 11/23) and current Driver's License. The Licensee ensured that no smoking is allowed in the vehicles. BEDROOMS: All three (3) bedrooms are equipped with one (1) twin bed, comfortable mattress, linen, blanket and pillows; adequate drawer space and a closet. Bedroom #1: Occupied by a minor C1; Bedroom #2: Occupied by C2- NMD. This bedroom is equipped with two (2) twins sized beds. There is an exit that leads to the backyard. Bedroom #3: Occupied by C3- NMD BATHROOMS: Bathroom #1 and # All were inspected and found to be clean. LPA test the water temperature, bathroom sinks and ensured that all toilets flushed. The water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. Living room: Is equipped with a two (2) recliner chairs. A sofa, a television that is mounted in the wall; entertainment stand filled with age appropriate books and games. There is a non-operational fireplace. The house is central heating system with a monitored thermostat. Dining Room Table: in good condition and sturdy with four (4) wooden chairs. Kitchen: Is equipped with a four (4) burner gas stove/oven, refrigerator/freezer, a microwave, and a dishwasher that is not operable. The facility has adequate perishable/nonperishable supply of food. Facility staff provide nutritious meals and snacks. One (1) NMD is provided with special snacks to meet his needs. Clients are served 2-3 hot meals are prepared per day based active school days. The kitchen trash has a lid cover. All knives, medications, cleaning supplies, and hazardous materials are kept locked and inaccessible to clients in care. There is adequate hygiene and grooming supplies and ample amount of extra clean linen. Laundry room: is located near the kitchen on the enclosed back porch. It is equipped with a washer and dryer and observed to be in good condition. There is an operable facility telephone readily accessible to clients. LPA observed combined Smoke detector and Carbon Monoxide; tested to be operable. All the prescribed medications; medication logs, files and are locked key in the office on the second floor. The First Aid kit is in the kitchen area cabinet. It has the required items inside (age-appropriate, and scissors, tweezers, thermometer, and gauzes, antiseptic and First Aid Manual Guide. Outdoor Area: The outdoor perimeter front yard, and backyard were inspected and found cleared of debris and hazards materials. The stairways, and open porches are unobstructed. LPA observed all windows and screens to be in good condition. There are security bars on the side windows and back porch. Blinds and drapes from the inside and outside were observed to be in good condition. LPA observed utility shut-off valves for gas and water located on side of house. Clients in care are supervised, protected, and are accorded dignity in personal relationships with staff and others. The facility staff ensures that the clients are transported to school and accompany to extracurricular, cultural and personal enrichment activities. The facility met all posting requirements and operates within license capacity and limitations. LIC809C continued Page 2 of 3. LPA observed that Administrator ensures that CDC Guidelines are implemented in effort to prevents other from contracting the COVID-19 virus (i.e wash hands with alcohol based, wipes, hand sanitizes and gloves) and signs posted. The Licensee will report changes in the plan of operation affecting service to clients. LPA reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. Client Records: LPA reviewed three (3) Client files and found the records to have authorization for emergency medical care signed by each child's authorized representative. Clients' records also contain signed Personal Rights forms. Client Interviews: Clients were unable to be interview due Developmentally Disabilities. Staff Records: Two (2) staff. LPA obtained the Facility Profile and Personnel Report and confirmed that the Licensee have required criminal record clearance. DOJ, FBI and Child Abuse Response; which meet qualification. LPA obtained a current copy of the LIC 500. LPA and reviewed two (2) staff files. LPA observed all staff records included which included current First Aid/CPR cards, all staff have met the education and experience requirements, and have completed the required trainings. Staff Interviews: LPA conducted a confidential interview with the Licensee Administrator and two (2) other staff. PER California Code Regulations, TITLE 22, DIVISION 6, CHAPTERS 5 no deficiencies were cited. There were no deficiencies noted on this date. LPA's concluded the Annual Required Inspection. An exit interview was conducted, and a copy of this report was signed and left at the facility with the Program Administrator Licensee on 02/03/2022

met_with: ADMINISTRATOR


facility_name: MOSAIC OF FRIENDS INC

summary: Facility Evaluation

raw_content:
Narrative:
On 12/06/2022 at 2:15pm Licensing Program Analyst (LPA's) Rosslyn Gray made a previously announced visit to MOSAIC OF FRIENDS INC. to conduct Pre-Licensing Inspection. LPA met with the administrator who granted access to the facility. The facility is licensed for four (4) developmentally disable children ages 11 through 18 years old, Ambulatory only. Clients are currently placed by Regional Centers. Currently are no clients in placement. LPA observed that there are no bodies on water on the premises. The Licensee confirmed that there are no firearms or dangerous weapons in the facility. LPA- Gray observed the follow during the inspection: The Group Home Overview: This is a 1-story, Charcoal Grey painted 3 bedrooms 2 bath home, located in a residential neighborhood. There a living room, dining room, kitchen, and a Family Room. The staff office is in the living room, identified by a computer desk and the staff will utilize iPads. There is two (2) car garage. Currently there is not a vehicle utilized to transport the clients. The administrator will provide information about the company vehicle later to be inspected to be operating in good condition. Outdoor Area: The activity space is free of hazard materials and debris. The ground is completed covered with green turf grass. There is a metal wall that surrounds the entire back yard purpose for security and privacy. There is grey picnic bench and not outside recreational equipment. There is a locked metal gate that stores the electrical utilities. Inside the metal gate are the shut-off valves for gas and water, a tank-less Hot Water Heater and central heat and air conditioning unit. The facility trash cans are located on the north side of the back yard. LPA observed all windows, screens, and drapes from the inside and outside of the facility were observed to be in good condition. The passageways and porches are unobstructed. All posting requirements were met, (i.e food menu, regulations,emergency disaster plan, the personal rights, facility visitation rules, the facility sketch, and contact for local physicians, dental and mental health professional. LIC- Page 1 of The two (2) car garage utilized for extra storage, food supply and (PPE) Personal Protection Equipment. The facility keeps an inventory of the PPE supplies and to report when they are depleted. The cleaning supplies solutions, disinfectants sharp knives are also inaccessible in key locked cabinet in the under the kitchen sink. LPA observed a hard wired enter connected combined Smoke detector and Carbon Monoxide; tested to be operable. The Living Room is fully furnished with a black chess utilized to for clients' files. There is a fireplace that is inoperable and an office desk. Dining room/Kitchen: Observed to be clean and organized; The Kitchen stove is gas operated with 5 burners a double door refrigerator with bottom freezer. The is also an additional refrigerator freezer located in the garage. The dining table is equipped with a round table with four (4) chairs. LPA observed coverage trash cans throughout the facility and on the back porch. The laundry room is adjacent to the kitchen. It is equipped with a whirlpool washer and dryer unit. The detergent, chemical and cleaning supplies are stored in a locked cabinet above the laundry unit. LPA observed one (1) Fire Extinguishers located in the kitchen adjacent to the kitchen and laundry room. There are three (3) Bedrooms: Each bedroom is equipped with comfortable mattresses, clean linen, double sliding closet doors, 3 drawer dresser, a lounge chair, a ceiling fan and a television. There is adequate lighting and the windows and drapes. All rooms are currently unoccupied. Bedroom # 1: Is currently unoccupied equipped with two (2) twin sized beds observed to observed to be in good condition. Bedroom # 2: Is currently unoccupied equipped with a Queen sized bed observed to be in good condition. Bedroom # 3: Is currently unoccupied equipped with Queen a sized bed observed to be in good condition. Bathroom #2 is located inside this room it is equipped with a shower, sick and toilet. There is window with no view. LIC- Page 2 of Bathrooms: There are two (2) Bathrooms inspected and found to be clean. Bathroom #1 is located in between bedroom #2 and #3. This is a full-size bathroom with a tub, shower, sink and toilet. Bathroom #2 is located adjacent to bedroom #3. It is equipped with a shower, a sink and a toilet. There is window with no view. LPA ensured that all toilets flushed, and tested water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. All the clients prescribed medications; medication logs, files and medical devices are locked in a medication box above the laundry unit. There are three (3) First Aid kit is located in a locked cabinet above the laundry until. It was observed to be equipped with the required items inside (age-appropriate, scissors, tweezers, thermometer, and gauzes, antiseptic, and First Aid Manual Guide. The facility has a working telephone and clients can use the telephone unless restricted by court order. The staff will accompany clients to local recreational facilities based on the rules of the COVID-19. The licensee also plans have basketball court mounted on the garage. Clients are accorded dignity in personal relationships with staff and others. LPA observed that facility ensures that CDC Guidelines are implemented in effort to prevent other from contracting the COVID-19 virus (i.e wash hands with alcohol based hand sanitizer, display colorful preventative hygiene posters, temperature checks, in the event there also social distancing (six feet of space signs), disinfect commonly used areas and items (remote controls, mouse's, playing, cards cell phones, practice "cough etiquette". The facility will operate within license conditions and limitations including capacity limitations. The Administrator ensured the facility will have the written plan of operation. Facility personnel are instructed to report violations of personal rights. Licensee will report changes in the plan of operation affecting service to clients. Licensee will report client injuries requiring medical treatment. The administrator will provide the Personnel Report (LIC 500) and confirmed that the staff ratio presents for the four (4) clients in placement. The administrator ensured that all will have required criminal record clearance. DOJ, FBI and Child Abuse Response that will meet qualification. There were no deficiencies cited at this time. LPA concluded the Pre-License Inspection. An exit interview was conducted, and a copy of this report was left at the facility with the Administrator on 12/06/2021

visit_type: Prelicensing

met_with: Facility Adminstrator


summary: Facility Evaluation

raw_content:
Narrative:
On 04/21/2023 at 12: PM Licensing Program Analyst (LPA's) Rosslyn Gray made unannounced visit to MOSAIC OF FRIENDS INC.,to conduct POST LICENSING INSPECTION. Due to an internal emergency A Health and Risk assessment was conducted upon arrival at the facility LPA met with the Facility Manager who granted access to the facility. The facility is licensed for four (4) developmentally disable children ages 11 through 18 years old, Ambulatory only. Clients are currently placed by Regional Centers. LPA observed that currently there are no clients in placement; and there are no bodies on water on the premises. The Licensee confirmed that there are no firearms or dangerous weapons in the facility. LPA- Gray observed the follow during the inspection: The Group Home Overview: This is a 1-story, Charcoal Grey painted 3 bedrooms 2 bath home, located in a residential neighborhood. There is a living room, dining room, kitchen, and a family room. The staff office is in the living room, identified by a computer desk and the staff will utilize iPads. There is two (2) car garage. Currently there is not a vehicle utilized to transport the clients. The Facility Manager will provide information about the company vehicle later to be inspected to be operating in good condition. Outdoor Area: The activity space is free of hazard materials and debris. The ground is completed covered with green turf grass. There is a metal wall that surrounds the entire back yard purpose for security and privacy. There is grey picnic bench and no outside recreational equipment. There is a locked metal gate that stores the electrical utilities. Inside the metal gate are the shut-off valves for gas and water, a tank-less Hot Water Heater, central heat and air conditioning unit. The facility trash cans are located on the north side of the back yard. LPA observed all windows, screens, and drapes from the inside and outside of the facility were observed to be in good condition. The passageways and porches are unobstructed. All posting requirements were met, (i.e Facility License, food menu, regulations, the Emergency Disaster plan, the personal rights, facility visitation rules, the facility sketch, and contact for local physicians, dental and mental health professional. LIC- Page 1 of The two (2) car garage is utilized for extra storage, food supply and (PPE) Personal Protection Equipment. The facility keeps an inventory of the PPE supplies and when depleted will replenish the needed supplies. The cleaning supplies solutions, disinfectants sharp knives are also inaccessible in key locked cabinet in the under the kitchen sink. LPA observed a hard wired enter connected combined Smoke detector and Carbon Monoxide; tested to be operable. The Living Room There is a fireplace that is inoperable and an office desk with office equipment and office supplies. The Den: Adjacent to the Living Room is a small step down the leads into the Den area. It is fully furnished with a Black Chess utilized to for clients board games and electronic games. A black reclining chair, grey sofa with a connected ottoman, a black chair and a 65' television. Dining room/Kitchen: Observed to be clean and organized; The Kitchen stove is gas operated with 5 burners a double door refrigerator with bottom freezer. The is also an additional refrigerator freezer located in the garage. The dining table is equipped with a round table with four (4) chairs. LPA observed covered trash cans throughout the facility and on the back porch. The laundry room is adjacent to the kitchen. It is equipped with a whirlpool washer and dryer unit. The detergent, chemical and cleaning supplies are stored in a locked cabinet above the laundry unit. LPA observed one (1) Fire Extinguishers located in the kitchen adjacent to the kitchen and laundry room. There are three (3) Bedrooms: Each bedroom is equipped with comfortable mattresses, clean linen, double sliding closet doors, 3 drawer dresser, a lounge chair, a ceiling fan and a television. There is adequate lighting and the windows and drapes. All rooms are currently unoccupied. Bedroom # 1: Is currently unoccupied equipped with two (2) twin sized beds observed to observed to be in good condition. Bedroom # 2: Is currently unoccupied equipped with a Queen sized bed observed to be in good condition. Bedroom # 3: Is currently unoccupied equipped with Queen a sized bed observed to be in good condition. Bathroom #2 is located inside this room it is equipped with a shower, sick and toilet. There is window with no view. LIC- Page 2 of Bathrooms: There are two (2) Bathrooms inspected and found to be clean. Bathroom #1 is located in between bedroom #2 and #3. This is a full-size bathroom with a tub, shower, sink and toilet. Bathroom #2 is located adjacent to bedroom #3. It is equipped with a shower, a sink and a toilet. There is window with no view. LPA ensured that all toilets flushed, and tested water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. All the clients prescribed medications; medication logs, files and medical devices are locked in a medication box above the laundry unit. There are four (4) First Aid kits are located in a locked cabinet above the laundry unit. It was observed to be equipped with the required items inside (age-appropriate, scissors, tweezers, thermometer, and gauzes, antiseptic, and First Aid Manual Guide. The facility has a working telephone and clients can use the telephone unless restricted by court order. The staff will accompany clients to local recreational facilities. The licensee also plans have basketball court mounted on the garage. Clients are accorded dignity in personal relationships with staff and others. LPA observed that the facility ensures that CDC Guidelines are implemented in effort to prevent other from contracting the COVID-19 virus (i.e wash hands with alcohol based hand sanitizer, display colorful preventative hygiene posters, temperature checks, in the event of an outbreak the facility will implement social distancing six feet and post of space signs, disinfect commonly used areas and items (remote controls, mouse's, playing, cards cell phones, practice "cough etiquette". The facility will operate within license conditions and limitations including capacity limitations. The Administrator ensured the facility will have the written plan of operation. Facility personnel are instructed to report violations of personal rights. Licensee will report changes in the plan of operation affecting service to clients. Licensee will report client injuries requiring medical treatment. The administrator will provide the Personnel Report (LIC 500) and confirmed that the staff ratio presents for the four (4) clients in placement. The administrator ensured that all will have required criminal record clearance. DOJ, FBI and Child Abuse Response that will meet qualification. In addition to training's and certification for First Aid CRP, CPI, Personal Rights and all licensee forms will be available. There were no deficiencies cited at this time. LPA concluded the Pre-License Inspection. An exit interview was conducted, and a copy of this report was left at the facility with the Facility Manager on 04/21/2023


summary: Facility Evaluation

raw_content:
Narrative:
On 12/21/2023 at 9:30AM Licensing Program Analyst (LPA) Rosslyn Gray made unannounced visit to MOSAIC OF FRIENDS INC.Group Home to conduct Annual/Required. A Health and Risk assessment was conducted upon arrival at the facility. LPA met with the Administrator/Gia Griffin who granted access to the facility. The facility is licensed to provide care and supervision for four (4) developmentally disable children ages 11 through 18 years old, Ambulatory only and (NMD) Non Minor Dependents. LPA observed that currently there are no clients in placement. The administrator reported that she is in the process of assessing referrals from the placement agency Regional Centers that are a good fit for the facility. There are no bodies on water on the premises and the Licensee confirmed that there are no firearms or dangerous weapons in the facility. LPA-Gray observed the follow during the inspection: The Group Home Overview: This is a 1-story, Charcoal Grey painted 3 bedrooms 2 bath home, located in a residential neighborhood. There is a living room, dining room, kitchen, and a family room. The staff office is in the living room, identified by a computer desk and the staff will utilize iPads. There is two (2) car garage utilized for extra storage, food supply and (PPE) Personal Protection Equipment. There are two (2) cars that will be utilized to provide transportation for the clients. Currently there is one (1) vehicle parked outside inspected to be in good operating condition (The vehicles were checked for tires, headlights, tail lights, turn signals, horn and windshield wipers). Care # Make and Model 2018 BMW; Proof of Insurance (GICO August 1, 2024); Registration (Expiration 11/24) and current Driver's License. Car #2 will be utilized as needed. The Make and Model (2018 BMW) Proof of Insurance (Farmers 06/14/2024); Registration (Expiration 09/28/2024 and current Driver's License. The Licensee ensured that no smoking is allowed in in either of the vehicles. Outdoor Area: The activity space is free of hazard materials and debris. The ground is completed covered with green turf grass. There is a metal wall that surrounds the entire back yard purpose for security and privacy. LIC- Page 1 of There is grey picnic bench and no outside recreational equipment. There is a locked metal gate that stores the electrical utilities. Inside the metal gate are the shut-off valves for gas and water, a tank-less Hot Water Heater, central heat and air conditioning unit. The facility trash cans are located on the north side of the back yard. LPA observed all windows, screens, and drapes from the inside and outside of the facility were observed to be in good condition. The passageways and porches are unobstructed. All posting requirements were met, (i.e Facility License, food menu, regulations, the Emergency Disaster plan, the personal rights, facility visitation rules, the facility sketch, and contact for local physicians, dental and mental health professional. The cleaning supplies solutions, disinfectants sharp knives are also inaccessible in key locked cabinet in the under the kitchen sink. LPA observed a hard wired enter connected combined Smoke detector and Carbon Monoxide; tested to be operable. The Living Room There is a fireplace that is inoperable and an office desk with office equipment and office supplies. The Den: Adjacent to the Living Room is a small step down the leads into the Den area. It is fully furnished with a Black Chess utilized to for clients board games and electronic games. A black reclining chair, grey sofa with a connected ottoman, a black chair and a 65' television. Dining room/Kitchen: Observed to be clean and organized; The Kitchen stove is gas operated with 5 burners a double door refrigerator with bottom freezer. The is also an additional refrigerator freezer located in the garage. The dining table is equipped with a round table with four (4) chairs. LPA observed covered trash cans throughout the facility and on the back porch. The laundry room is adjacent to the kitchen, equipped with a whirlpool washer and dryer unit. The detergent, chemical and cleaning supplies are stored in a locked cabinet above the laundry unit. LPA observed one (1) Fire Extinguishers located in the kitchen adjacent to the kitchen and laundry room. There are three (3) Bedrooms: Each bedroom is equipped with comfortable mattresses, clean linen, double sliding closet doors, 3 drawer dresser, a lounge chair, a ceiling fan and a television. There is adequate lighting and the windows and drapes. All rooms are currently unoccupied and observed to be in good condition Bedroom # 1: Is currently unoccupied equipped with two (2) twin sized beds. Bedroom # 2: Is currently unoccupied equipped with a Queen sized bed. Bedroom # 3: Is currently unoccupied equipped with Queen a sized bed. LIC- Page 2 of Bathroom #2 is located inside this room it is equipped with a shower, sick and toilet. There is window with no view. Bathrooms: There are two (2) bathrooms inspected and found to be clean. Bathroom #1 is located in between bedroom #2 and #3. This is a full-size bathroom with a tub, shower, sink and toilet. Bathroom #2 is located adjacent to bedroom #3. It is equipped with a shower, a sink and a toilet. There is window with no view. LPA ensured that all toilets flushed, and tested water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. All the clients prescribed medications; medication logs, files and medical devices will be locked in a medication box above the laundry unit. There are four (4) First Aid kits are located in a locked cabinet above the laundry unit. It was observed to be equipped with the required items inside (age-appropriate, scissors, tweezers, thermometer, and gauzes, antiseptic, and First Aid Manual Guide. The facility has a working telephone and clients can use the telephone unless restricted by court order. The staff will accompany clients to local recreational activities. Clients are accorded dignity in personal relationships with staff and others. LPA observed that the facility ensures that CDC Guidelines are implemented in effort to prevent other from contracting the COVID-19 virus (i.e wash hands with alcohol based hand sanitizer, display colorful preventative hygiene posters, commonly used items are disinfected (i.e remote controls, mouse's, playing, cards cell phones, practice "cough etiquette". The facility will operate within license conditions and limitations including capacity limitations. The Administrator ensured the facility will have the written plan of operation. Facility personnel are instructed to report violations of personal rights. Licensee will report changes in the plan of operation affecting service to clients. Licensee will report client injuries requiring medical treatment. The administrator will provide the Personnel Report (LIC 500) and confirmed that the staff ratio presents for the four (4) clients in placement. The administrator ensured that all will have required criminal record clearances. DOJ, FBI and Child Abuse Response that will meet qualification. In addition to training's and certification for First Aid CRP, CPI, Personal Rights and all licensee forms will be available. The Licensee will report changes in the plan of operation affecting service to clients. LIC- Page 3 of Client Records: Currently there are no clients in placement and no files were reviewed. Staff Records: LPA reviewed one (1) staff record. The remained staff listed on the LIC 200 are available upon placement. Client Interviews: Currently there are no clients in placement to be interviewed. LPA will observe and assess the clients that qualify to be interviewed. Staff Interviews: LPA interviewed one (1) staff on duty identified as the administrator. Other staff listed on the LIC 200 are available for placement. LPA's concluded the Annual Required Inspection. There were no deficiencies cited at this time. LPA concluded the Annual/Required. An exit interview was conducted, and a copy of this report was left at the facility with the Administrator/Gia Griffin on 12/21/ LIC- Page 4 of 4

met_with: Administrator/Gia Griffin


summary: Facility Evaluation

raw_content:
Narrative:
On 12/23/2024 at 10:30AM Licensing Program Analyst (LPA) Rosslyn Gray made unannounced visit to MOSAIC OF FRIENDS INC.,Group Home to conduct Annual/Required inspection. A Health and Risk assessment was conducted upon arrival at the facility. LPA met with the Administration Assistant Gia Griffin who granted access to the facility. The facility is licensed to provide care and supervision for four (4) developmentally disable children ages 11 through 18 years old, Ambulatory only and (NMD) Non Minor Dependents. Currently there is one (1) client in placement. S1 reported that she is in the process of waiting for referrals from the placement agency Westside Regional Center. There are no bodies on water on the premises and the Licensee confirmed that there are no firearms or dangerous weapons in the facility. LPA-Gray observed the follow during the inspection: The Group Home Overview: This is a 1-story, Charcoal Grey painted 3 bedrooms 2 bath home, located in a residential neighborhood. There is a living room, dining room, kitchen, and a family room. The staff office is in the living room, identified by a computer desk and the staff will utilize iPads. There is two (2) car garage utilized for extra storage, food supply and (PPE) Personal Protection Equipment. There are two (2) cars that will be utilized to provide transportation for the clients. Currently there is one (1) vehicle parked outside inspected to be in good operating condition (The vehicles were checked for tires, headlights, tail lights, turn signals, horn and windshield wipers). Car # Make and Model 2018 BMW; Proof of Insurance (State Farm September 2022- March 22, 2025); Car Registration (Expiration 11/24) and current Driver's License. The Licensee ensured that no smoking is allowed in the vehicles. The Licensee ensured that no smoking is allowed in in either of the vehicles. Outdoor Area: The activity space is free of hazard materials and debris. The ground is completed covered with green turf grass. There is grey picnic bench and no outside recreational equipment. There is a locked metal gate that stores the electrical utilities. Inside the metal gate are the shut-off valves for gas and water, a tank-less Hot Water Heater, central heat and air conditioning unit. The facility trash cans are located on the north side of the back yard. There is a metal wall that surrounds the entire back yard purpose for security and privacy. LIC- Page 1 of The facility trash cans are located on the north side of the back yard. LPA all windows, screens, and drapes from the inside and outside of the facility were observed to be in good condition. The passageways and porches are unobstructed. All posting requirements were met, (i.e Facility License, food menu, regulations, the Emergency Disaster plan, the personal rights, facility visitation rules, the facility sketch, and contact for local physicians, dental and mental health professional. The cleaning supplies solutions, disinfectants sharp knives are also inaccessible in key locked cabinet in the under the kitchen sink. LPA observed a hard wired enter connected combined Smoke detector and Carbon Monoxide; tested to be operable. The Living Room There is a fireplace that is inoperable and an office desk with office equipment and office supplies. The Den: Adjacent to the Living Room is a small step down the leads into the Den area. It is fully furnished with a Black Chess utilized to for clients board games and electronic games. A black reclining chair, grey sofa with a connected ottoman, a black chair and a 65' television. Dining room/Kitchen: Observed to be clean and organized; The Kitchen stove is gas operated with 5 burners a double door refrigerator with bottom freezer. The is also an additional refrigerator freezer located in the garage. The dining table is equipped with a round table with four (4) chairs. LPA observed covered trash cans throughout the facility and on the back porch. The laundry room is adjacent to the kitchen, equipped with a whirlpool washer and dryer unit. The detergent, chemical and cleaning supplies are stored in a locked cabinet above the laundry unit. LPA observed one (1) Fire Extinguishers located in the kitchen adjacent to the kitchen and laundry room. There are three (3) Bedrooms: Each bedroom is equipped with comfortable mattresses, clean linen, double sliding closet doors, 3 drawer dresser, a lounge chair, a ceiling fan and a television. There is adequate lighting and the windows and drapes. All observed to be in good condition Bedroom # 1: Is currently unoccupied equipped with (1) twin sized bed. Bedroom # 2: Is occupied by one (1) client equipped with a Queen sized bed. Bedroom # 3: Is currently unoccupied equipped with Queen a sized bed. LIC- Page 2 of Bathroom #2 is located inside this room it is equipped with a shower, sick and toilet. There is window with no view. Bathrooms: There are two (2) bathrooms inspected and found to be clean. Bathroom #1 is located in between bedroom #2 and #3. This is a full-size bathroom with a tub, shower, sink and toilet. Bathroom #2 is located adjacent to bedroom #3. It is equipped with a shower, a sink and a toilet. There is window with no view. LPA ensured that all toilets flushed, and tested water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. All the clients prescribed medications; medication logs, files and medical devices will be locked in a medication box above the laundry unit. There are four (4) First Aid kits are located in a locked cabinet above the laundry unit. It was observed to be equipped with the required items inside (age-appropriate, scissors, tweezers, thermometer, and gauzes, antiseptic, and First Aid Manual Guide. The facility has a working telephone. The staff accompanies clients to local recreational activities. Clients are accorded dignity in personal relationships with staff and others. LPA observed that the facility ensures that CDC Guidelines are implemented in effort to prevent other from contracting the COVID-19 virus (i.e wash hands with alcohol based hand sanitizer, display colorful preventative hygiene posters, commonly used items are disinfected (i.e remote controls, mouse's, playing, cards cell phones, practice "cough etiquette". The facility will operate within license conditions and limitations including capacity limitations. The Licensee will ensured the facility has the written plan of operation. Facility personnel are instructed to report violations of personal rights. Licensee will report changes in the plan of operation affecting service to clients. Licensee will report client injuries requiring medical treatment. Administration Assistant provided the Personnel Report (LIC 500) and confirmed that the staff ratio presents for the four (4) clients in placement. The Administration Assistant ensured all staff have required criminal record clearances; DOJ, FBI and Child Abuse Response that met meet qualification. The Licensee will report changes in the plan of operation affecting service to clients. LIC- Page 3 of LPA reviewed the staff training's requirements and certification of completion for the facility type. Client Records: LPA reviewed records for one (1) client in care. Client Interviews: LPA did not interview the one (1) client in placement due to developmentally delayed and partially verbal. Staff Records: LPA reviewed three (3) staff records Staff Interviews: LPA interviewed with two staff (2) on duty staff. There were no deficiencies cited at this time. LPA concluded the Annual/Required Inspection on this day 12/23/2024. An exit interview was conducted, and a copy of this report will be provided via email to the Administration Assistant Gia Griffin. LIC- Page 4 of 4

met_with: Administraton Assistant /Gia Griffin


summary: Facility Evaluation

raw_content:
Narrative:
On May 30, 2025, at 11: AM, Licensing Program Analyst (LPA), Rosslyn arrived at the above facility for the purpose of conducting a Case Management-Other inspection. LPA met with Administrator Assistant Gia Griffin. A health and risk assessment were conducted. During a complaint investigation, LPA reviewed facility staff associations and observed that Staff #3 is not associated to the facility. Review of Staff #3 personnel file indicates that they have worked in the facility since January 1, 2025. Incident Reports dated May 19th - May 22nd, 2025, indicate that Staff #3 was present working in the facility without a criminal record clearance and/or clearance transfer. Facility cited for violation of California Code of Regulations, Title Division Six, regulation 80019(a)(D) Criminal Record Clearance. Documentation indicates that Staff #3 worked in facility May 19th - May 22nd, 2025, without a criminal record clearance and/or clearance transfer. Exit interview was conducted. A copy of this report and Appeal Rights were provided to the Administrator Gia Griffin.

met_with: Administrator Gia Griffin


summary: Facility Evaluation

raw_content:
Narrative:
On 01/21/2026 at 8:45AM Licensing Program Analyst (LPA) Cheri Wilkerson made unannounced visit to MOSAIC OF FRIENDS INC., to conduct Annual Required Inspection. LPA met with the Administrator, Gia Griffin Williams, and Jasmine Claiborne, Lead Direct Support who granted access to the facility and provided a tour. The facility is licensed to provide care and supervision to four developmentally disable children ages 11 through 18 years old, Ambulatory only and (NMD) Non-Minor Dependents. Currently there is one client in placement. Administrator indicated that she is in the process of waiting for referrals from the placement agency Westside Regional Center. There are no bodies on water on the premises and the Licensee confirmed that there are no firearms or dangerous weapons in the facility. A Health and Risk assessment was conducted upon arrival at the facility. Home Overview: This is a 1-story, smoke grey colored home, in a residential neighborhood. This 3-bedroom, 2-bath home has a living room, dining room, kitchen, and a family room with an open concept. The staff office is in the living room, identified by a computer desk, and the staff will utilize iPads. There is a two-car garage utilized for extra storage and food supply. There is one car that will be utilized to provide transportation for the clients. The vehicle was checked for thread on tires, headlights, taillights, turn signals, horn and windshield wipers. The car Model 2018 BMW; Proof of Insurance (Geico September 2025- March 18, 2026); Car Registration (Expiration 11/26) and current Driver's License. The Licensee ensured that no smoking is allowed in the vehicles. The Licensee ensured that no smoking is allowed in the vehicle. LIC- Page 1 of Outdoor Area: The activity space is free of hazard materials and debris. The ground is completed covered with green turf grass. There is a grey picnic bench and no outside recreational equipment. There is a locked metal gate that stores the electrical utilities. Inside the metal gate are the shut-off valves for gas and water, a tank-less Hot Water Heater, central heat and air conditioning unit. The facility trash cans are located on the north side of the back yard. There is a metal wall that surrounds the entire back yard for security and privacy. LPA Wilkerson checked all windows, screens, and drapes from the inside and outside of the facility. The windows were observed to be in good condition. The passageways and porches are unobstructed. All posting requirements were met. All forms, Facility License, food menu, the Emergency Disaster plan, the personal rights, facility visitation rules, and the facility sketch. The cleaning supplies solutions, disinfectants sharp knives are also inaccessible in key locked cabinets under the kitchen sink. LPA observed a hard wired enter connected combined Smoke detector and Carbon Monoxide; tested to be operable. The Living Room There is a fireplace that is inoperable and an office desk with office equipment and supplies. The Den: Adjacent to the Living Room is a small step down the leads into the Den area. It is fully furnished with a Connect Four Large Game utilized for client's board games and electronic games. A black reclining couch, grey sofa with a connected ottoman, a black chair and a 65' television. Dining room/Kitchen: Observed to be clean and organized; The Kitchen stove is gas operated with 5 burners a double door refrigerator with bottom freezer. The is also an additional freezer refrigerator located in the garage. The dining table is equipped with a round table with four chairs. LPA observed covered trash cans throughout the facility and on the back porch. The laundry room is adjacent to the kitchen, equipped with a whirlpool washer and dryer unit. The detergent, chemical and cleaning supplies are stored in a locked cabinet above the laundry unit. LPA observed one Fire Extinguisher located in the kitchen adjacent to the kitchen and laundry room. There are three (3) Bedrooms: Each bedroom is equipped with comfortable mattresses, clean linen, double sliding closet doors, 3 drawer dressers, a lounge chair, a ceiling fan and a television. There are adequate lighting and the windows and drapes. All observed to be in good condition LIC 809-Page 2 of Bedroom 1: Is currently unoccupied equipped with twin sized bed. Bedroom 2: Is occupied by one client equipped with a Full-size bed. Bedroom 3: Is currently unoccupied equipped with Full- size bed. Bathroom #2 is located inside this room, equipped with a shower, sick and toilet. There is window with no view. Bathrooms: There are two bathrooms inspected and found to be clean. Bathroom 1 is located between bedroom 2 and 3. This is a full-size bathroom with a tub, shower, sink and toilet. Bathroom 2 is located adjacent to bedroom 3. It is equipped with a shower, a sink and a toilet. There is window with no view. LPA Wilkerson ensured that all toilets flushed, and tested water temperature measured within safe temperatures, at not less than 105 degrees and did not exceed 120 degrees Fahrenheit. All the clients prescribed medications; medication logs, files and medical devices were observed and locked in a medication box above the laundry unit. There are two First Aid kits in a locked cabinet above the laundry unit. It was observed to be equipped with the required items inside (age-appropriate, scissors, tweezers, thermometer, and gauzes, antiseptic, and First Aid Manual Guide. The facility has a working telephone. The staff accompany clients with local recreational activities. Clients are accorded dignity in personal relationships with staff and others. The facility will operate within licensing conditions and limitations including capacity limitations. The Licensee will ensure the facility has a written plan of operation. Facility personnel are instructed to report violations of personal rights. License will report changes in the plan of operation affecting service to clients. Licensee will report client injuries requiring medical treatment. Administration Assistant provided the Personnel Report (LIC 500) and confirmed that the staff ratio presents for the client in placement. LIC 809-Page 3 of The Administration Assistant ensured all staff have required criminal record clearances; DOJ, FBI and Child Abuse Response that met meet qualification. The Licensee will report changes in the plan of operation affecting service to clients. LPA reviewed the staff training's requirements and certification of completion for the facility type. Client Records: LPA reviewed records for one client in care. Client Interviews: LPA interviewed one client in placement due to developmentally delayed and partially verbal. Staff Records: LPA reviewed three staff records Staff Interviews: LPA interviewed with two staff on duty staff. There were no deficiencies cited at this time. LPA Wilkerson will check to see if there should be a JV220 at this type of facility due to medications. LPA concluded the Annual Required Inspection on this day 01/21/2026. An exit interview was conducted, and a copy of this report will be emailed to Gia Griffin Williams at Mosaicoffriends2@gmail.com. LIC- Page 4 of 4

met_with: Gia Griffin Williams