summary: Facility Evaluation

raw_content:
Narrative:
On September 8, 2022 at 9:45am Licensing Program Analyst (LPA) Donald Martin, arrive at the above facility for the purpose of conducting a population reduction Case Management inspection. The purpose of this inspection is to reduce the STRTP capacity from 106 clients to 54 clients. LPA met with Troy McNair, Residential Director who escorted me through the inspection. Inspection is as follows: Frisco: There are Four bedrooms. Each room contains two beds and two stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There are two large windows in front of each bed that have large pull down window covers. The bathroom was equip with a shower, sink and toilet all in good condition. Rafael: There are Four bedrooms. Each room contains two beds and two stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There are two large windows in front of each bed that have large pull down window covers. The bathroom was equip with a shower, sink and toilet all in good condition. Flippo: There are Four bedrooms. Each room contains two beds and two stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There are two large windows in front of each bed that have large pull down window covers. The bathroom was equip with a shower, sink and toilet all in good condition. Fernando: There are Four bedrooms. Each room contains two beds and two stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There are two large windows in front of each bed that have large pull down window covers. The bathroom was equip with a shower, sink and toilet all in good condition. Cont. 9099-C Santa Cruz: Two very large bedrooms which contain two beds, two dressers, and now have 4 utility cabinets for hang up clothing storage and also converts to a desk area in each room. Each room also had two bathrooms per room. The bathrooms contained a sink, toilet and shower all in good working condition. Note: Curtains have been installed as an enclosure attached to the bedroom doorways for client privacy. LPA requested that a sign be posted as caution for stairs in the entry way of the bedroom. There is a day room with couches and a table with enough seating to accommodate staff and clients and a kitchen area with a refrigerator and a microwave. San Juan: Two very large bedrooms which contain two beds, two dressers, and now have 4 utility cabinets for hang up clothing storage and also converts to a desk area in each room. Each room also had two bathrooms per room. The bathrooms contained a sink, toilet and shower all in good working condition. Note: Curtains have been installed as an enclosure attached to the bedroom doorways for client privacy. There is a day room with couches and a table with enough seating to accommodate staff and clients and a kitchen area with a refrigerator and a microwave. St Anthony: The cottage has 7 individual bedrooms all equip with two beds, two stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There are two large windows in front of each bed that have large pull down window covers. Each room has its own bathroom that contains a sink, toilet and shower all in good working condition. There is a day room with couches and a table with enough seating to accommodate staff and clients and a kitchen area with a refrigerator and a microwave. There is a large TV attached to the wall and computers, computer tables and books for the clients use. Note: Open closets have been replaced with an additional cabinet for clothing storage. Blinds were replaced an new desks were added to the dorms. Corrections from previous inspection were made. Nothing further to report at this time.


state: CA

facility_name: RANCHO SAN ANTONIO BOYS HOME, INC

summary: Facility Evaluation

raw_content:
Narrative:
On December 15, 2022 at 11am Licensing Program Analyst (LPA) Donald Martin, arrive at the above facility for the purpose of conducting a Capacity Reduction Case Management inspection. The purpose of this inspection is to reduce the STRTP capacity from 54 clients to 16 clients. LPA met with Troy McNair, The name of the entire STRTP will be The Brother Johns House. LPA will use the existing names for a reference. LPA met with Troy McNair, Residential Director who escorted me through the inspection. Inspection is as follows: Frisco: There are Four bedrooms. Each room contains 1 bed and 2 stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There is an additional large desk located against the wall as well. There are two large windows that have large pull down window covers. Rafael: There are Four bedrooms. Each room contains 1 bed and 2 stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There is an additional large desk located against the wall as well. There are two large windows that have large pull down window covers. Flippo: There are Four bedrooms. Each room contains 1 bed and 2 stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There is an additional large desk located against the wall as well. There are two large windows that have large pull down window covers. Fernando: There are Four bedrooms. Each room contains 1 bed and 2 stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There is an additional large desk located against the wall as well. There are two large windows that have large pull down window covers. Cont. 9099-C Note: None of the rooms have doors/closures on them. Residential Director, Troy McNair provided LPA a receipt showing the purchase of the closures, but the parts wont be delivered until December 28, 2022. Bathroom: There are two large bathrooms with 4 sinks and 4 toilets and a large shower. There are more than one shower heads in the shower area, however clients are instructed to shower one at a time. Living Room: The Living Room has a large couch area with a TV. There is a bookshelf and a small kitchen area equip with a microwave, refrigerator, and sink. Snacks for clients are also kept in that area. There are no deficiencies cited at the time of the visit.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Troy McNair-Residential Director


summary: Facility Evaluation

raw_content:
Narrative:
On April 4, 2023 at 09:30am Licensing Program Analyst (LPA) Donald Martin, arrive at the above facility for the purpose of conducting an Annual/Random inspection. LPA met with Troy McNair and together, conducted an inspection of the The Brother John's House. The Brother John's House consists of one building with two sides: Frisco/Rafael & Flippo/Fernando. There are 4 hallways in total. 4 beds in each hallway with a total of 16 beds. The Brother John's House services 12- Minors and Non-Minor Dependents. The Inspection went as follows: Frisco: There are Four bedrooms. Each room contains 1 bed and 2 stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There is an additional large desk located against the wall as well. There are two large windows that have large pull down window covers. Rafael: There are Four bedrooms. Each room contains 1 bed and 2 stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There is an additional large desk located against the wall as well. There are two large windows that have large pull down window covers. Flippo: There are Four bedrooms. Each room contains 1 bed and 2 stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There is an additional large desk located against the wall as well. There are two large windows that have large pull down window covers. Fernando: There are Four bedrooms. Each room contains 1 bed and 2 stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There is an additional large desk located against the wall as well. There are two large windows that have large pull down window covers. Cont. 9099-C The common area in Frisco/Rafael and Flippo/Fernanado contain a sectional, two large book cases, a TV on the wall and a computer desk area. There are Therapists offices against the wall. The kitchen area has a sink, microwave and a room with a refrigerator in it. This area is for clients snacks and to heat up leftover food. Note: clients eat their meals in the cafeteria. No foods are prepared in the unit kitchens. The facility uses a cleaning service for the linen. The supply is kept in another building. Staff has access to them at anytime of the day and night. Dividing the hallways is a desk where staff sits. Behind that desk is a staff office where supplies for cleaning and snacks are kept locked up as well. The bathrooms contains 4 sinks, four urinals, four stalls that contain toilets, a water faucet and a large shower area with 4 shower head areas with dividers. Behind the bathroom area is the Laundry Room. The laundry room has two large machines for the clients clothing and towels. The overall facility was in good condition, Note: LPA discussed the importance of unit cleanliness with Residential Director, Troy McNair. The Flippo/Fernando side of the facility rooms and common areas were in disarray. LPA considered the fact that all 8 clients were home on spring break and the unit was actively being used. Staff and Clients were interviewed. Client and staff files are on the computer system and up to date. There were no citations given at the time of the inspection.

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
On O2/14/2024, Licensing Program Analyst (LPA), Donald Martin made an unannounced visit to the above facility for the purpose of concluding a Case Management - Incident Inspection. LPA spoke with Residential Director, Troy McNair. A health and safety assessment were conducted. On 02/11/2024, the department received an Incident Report, dated 02/10/2024, indicating that Child 1 (C1) was told by Staff 1 (S1) that they were off privileges due to negative behaviors. Staff 1 was instructed to disengage and sat in the lobby. C1 walked towards S1, called him an inappropriate name, and spat in S1 face. S1 got up off the sofa, grabbed C1, and the two stumbled out the lobby door, and wrestled C1 onto the ground briefly outside the unit. During the investigation process, LPA obtained the S1 termination letter, conducted interviews, and reviewed video recording of incident. On video recording S1 is observed inappropriately tackling C1 by placing both hands on C1, leading C1 through lobby door, and engaging in altercation with C1 after C1 spat on S1. LPA has determined that further investigation is needed to conclude this Case Management Investigation. An exit interview was conducted and a copy of this report was left with Troy McNair, Residential Director.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA), Donald Martin made an unannounced visit to the above facility for the purpose of concluding a Case Management - Incident Inspection. LPA spoke with Contracts and Compliance Director, Zeena Burse. A health and safety assessment were conducted. On 7/8/2024, the department received an Incident Report, dated 7/7/2024, indicating that Child 1 (C1) after having water thrown on him by Child #2 (C2), punched two holes in the wall. Incident Report further indicates that C1 will be charged for property damage. LPA spoke with Zeena Burse, S2 and S3 and discussed adding the properties of the Program Statement which indicates that restitution can be imposed on a child or non-minor dependent in a manner that is consistent with trauma-informed practices. RSA shall impose fines for acts of vandalism, damage of property and to replace stolen property only after review with Probation, DCFS, and/or a Child and Family Team (CFT) meeting. C1 was unavailable for comment. There was no evidence that restitution has been imposed without further review with placing agency. On 6/14/ LPA advised Administrator, Troy McNair to amend Program Statement and outline written policies ensuring that cash resources are not taken from children in care in the form of fines/restitution. Revisions should be submitted by 06/28/2024, for review. LPA has advised S2 to ensure that verbiage on future incident reports are consistent with the above revisions. Based on the information obtained, no further investigation is needed. An exit interview was conducted, and a copy of this report was left with Contracts and Compliance Director, Zeena Burse. There were no deficiencies cited at time.

met_with: Zeena Burse-Contracts and Compliance Director


summary: Facility Evaluation

raw_content:
Narrative:
On May 5, 2025 at 10:00am Licensing Program Analyst (LPA) Donald Martin, arrive at the above facility for the purpose of conducting an Annual/Random inspection. LPA met with Troy McNair and together, conducted an inspection of the The Brother John's House. The Brother John's House consists of one building with two sides: Frisco/Rafael & Flippo/Fernando. There are 4 hallways in total. 4 beds in each hallway with a total of 16 beds. The Brother John's House services 12- Minors and Non-Minor Dependents. The Inspection went as follows: Frisco: There are Four bedrooms. Each room contains 1 bed and 2 stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There are two large windows that have large pull down window covers. Rafael: There are Four bedrooms. Each room contains 1 bed and 2 stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There are two large windows that have large pull down window covers. Flippo: There are Four bedrooms. Each room contains 1 bed and 2 stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There are two large windows that have large pull down window covers. Fernando: There are Four bedrooms. Each room contains 1 bed and 2 stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There are two large windows that have large pull down window covers. Cont. 9099-C The common area in Frisco/Rafael and Flippo/Fernanado contain a sectional, two large book cases, a TV on the wall and a computer desk area. There are Therapists offices against the wall. The kitchen area has a sink, microwave and a room with a refrigerator in it. This area is for clients snacks and to heat up leftover food. Note: clients eat their meals in the cafeteria. No foods are prepared in the unit kitchens. The facility uses a cleaning service for the linen. The supply is kept in another building. Staff has access to them at anytime of the day and night. Dividing the hallways is a desk where staff sits. Behind that desk is a staff office where supplies for cleaning and snacks are kept locked up as well. The bathrooms contains 4 sinks, four urinals, four stalls that contain toilets, a water faucet and a large shower area with 4 shower head areas with dividers. Behind the bathroom area is the Laundry Room. The laundry room has two large machines for the clients clothing and towels. The overall facility was in good condition, Note: LPA discussed the importance of unit cleanliness with Residential Director, Troy McNair. Both facility units, rooms and common areas were in disarray. Facility needs to come up with a plan to endorse unit cleanliness. It can be incentive based as well. Staff needs to understand that if they are unable to get the clients in care to keep the unit clean, it becomes their responsibility. Most of the clients were in school at the time of the visit. The unit should at least be clean when the unit is empty. Staff and Clients were interviewed. Client and staff files are on the computer system and up to date. There were no citations given at the time of the inspection.


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
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 November 18, 2025 at 12pm Licensing Program Analyst (LPA) Donald Martin arrived at the above facility. LPA met with Residential Director, Troy Mcnair and was allowed into the facility. The purpose of this visit is to deliver findings for the above complaint investigation. During the course of investigation confidential interviews were conducted and documents obtained. The interviews did not produce corroborating evidence to support allegation. Interviews revealed inconsistent statements and no witnesses to suggest allegation occurred. There was no evidence that staff did not allow child to make a telephone call. Telephone logs showed all clients daily phone activity 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: RANCHO SAN ANTONIO - BROTHER JOHN'S HOUSEFACILITY NUMBER: VISIT DATE: 11/18/2025

report_type: Complaint Investigation

complaint_status: unsubstantiated


summary: Facility Evaluation

raw_content:
Narrative:
On June 18, 2025, at 10:37 am, Erika Butler-Williams, Licensing Program Analyst (LPA) arrived at the above facility for the purpose of concluding an unannounced Case Management investigation pertaining to Special Incident Report. LPA met with John Wallace, STRTP Program Manager, and a health and safety assessment was conducted prior to entering facility. The department received an Incident Report dated June 9, 2025. The Incident Report disclosed that on June 7, 2025, Child 1 (C1) and S1 engaged in a verbal altercation in which escalated in S1 calling returned from the gym and sat in the lobby despite being on OP. Lead Supervisor Jackson During the investigation, LPA interviewed two staff, and 3 clients reviewed Personnel Report, client roster, C Placement Agreement and Needs and Services Plan, and staff disciplinary actions pertaining to incident, and training's. Based on the information obtained during this inspection, statements were consistent that S1 used inappropriate language, and called C1 out of their name, Continued on C Facility cited for violation of California Code of Regulations, Title Division Six, regulation Personal Rights. Staff 1 used inappropriate language, and call C1 out of their name. Exit interview was conducted with . Appeal Rights were issued, and a copy of this report will be emailed to. jawallace@ranchosanantonio.org

met_with: John Wallace, STRTP Program Manager


summary: Facility Evaluation

raw_content:
Narrative:
On O3/14/2024, Licensing Program Analyst (LPA), Donald Martin and Licensing Program Manager (LPM), JoAunne Griffin made an unannounced visit to the above facility for the purpose of concluding a Case Management - Incident Inspection. LPA and LPM spoke with Residential Director, Troy McNair. A health and safety assessment were conducted. On 02/11/2024, the department received an Incident Report, dated 02/10/2024, indicating that Child 1 (C1) was told by Staff 1 (S1) that they were off privileges due to negative behaviors. Staff 1 was instructed to disengage and sat in the lobby. C1 walked towards S1, called him an inappropriate name, and spat in S1 face. S1 got up off the sofa, grabbed C1, and the two stumbled out the lobby door, and wrestled C1 onto the ground outside the unit. During the investigation process, LPA obtained the S1 termination letter, conducted interviews, and reviewed video recording of incident. On video recording S1 is observed inappropriately tackling C1 by placing both hands on C1, leading C1 through lobby door, and engaging in altercation with C1 after C1 spat on S1. Due to the evidence obtained during the investigation the following deficiency is cited per Interim Licensing Standards (ILS) - Personal Rights. Staff 1 restrained C1 and engaged in an altercation. Cont 809-C An exit interview was conducted and a copy of this report was left with Troy McNair, Residential Director.


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Confidential interviews were conducted with clients placed in the facility and facility staff including the alleged perpetrator. During confidential interviews with C1 and the alleged perpetrator it was indicated that no inappropriate or sexual contact occurred between C1 and the alleged perpetrator. An interview with an alleged witness and facility client was attempted but the client declined to be interviewed. It was indicated during interviews with facility staff that there is no concrete evidence of inappropriate contact between C1 and the alleged perpetrator/staff member. It was reported that alleged perpetrator sets boundaries with clients and has not been witnessed hugging any clients by other staff members. The allegation is determined to be Unsubstantiated. A finding that is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. There are no deficiencies cited per California Code of Regulations, Title 22, at this time. A copy of this report was provided to the Residential Director via email.

Investigation Findings:
UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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

met_with: Troy McNair, Residential Director


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Investigation Findings:
13On February 24, 2026 at 11am Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for the purpose of delivering findings for the above allegation. LPA met with Director, Zeena Burse and was allowed into the facility. LPA collected Documentation and Confidential interviews which supported the allegation. C2 was found with crushed substance which appeared to be consistent with medication/drug paraphenailia. Facility is cited for: 80078(a) Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. SubstantiatedEstimated 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: RANCHO SAN ANTONIO - BROTHER JOHN'S HOUSEFACILITY NUMBER: 191202023

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

met_with: Zeena Burse-Compliance Director

complaint_status: SUBSTANTIATED


summary: Facility Evaluation

raw_content:
Narrative:
On October 20, 2022 at 10am Licensing Program Analyst (LPA) Donald Martin arrived at the above facility. The purpose of this visit is to complete a Pre-Licensing Inspection. LPA met with Troy McNair, Residential Director and Zeena Burse, Contracts and Compliance Director who escorted LPA through the inspection. Saint Anthony's Separation Unit/ Youth Support Annex: This unit will be used as a separation unit in conjunction with the Saint Anthony's dorm. The ratio of the dorm and Separation unit will stay at the capacity of no more than 16 clients. This unit will be used for Complex Care which will provide a more one on one assistance to clients in care. The unit consists of two very large bedrooms which contain one bed each, two dressers, and two utility cabinets for hang up clothing storage and also converts to a desk area in each room. Each room also has two bathrooms per room. The bathrooms contained a sink, toilet and shower all in good working condition. There is a day room with couches and a table with enough seating to accommodate staff and clients and a kitchen area with a refrigerator and a microwave. St Anthony: The cottage has 8 individual bedrooms all equip with two beds, two stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There are two large windows in front of each bed that have large pull down window covers. Each room has its own bathroom that contains a sink, toilet and shower all in good working condition. There is a day room with couches and a table with enough seating to accommodate staff and clients and a kitchen area with a refrigerator and a microwave. There is a large TV attached to the wall and computers, computer tables and books for the clients use. There were no deficiencies cited at the time of the visit.

visit_type: Prelicensing


summary: Facility Evaluation

raw_content:
Narrative:
On March 17, 2023 at 9am Licensing Program Analyst (LPA) Donald Martin and Deputy Director (DD) Kevin Gaines arrived at the above facility. The purpose of this visit is to complete a Post-Licensing Inspection. LPA met with Troy McNair, Residential Director who escorted us through the inspection. Saint Anthony's Youth Support annex: This unit has the capacity of no more than 16 clients ambulatory Minor and Non-Minor dependents ages 12-17yrs old. St Anthony: The cottage has 8 individual bedrooms all equip with two beds, two stand up closets that contain a clothes hanging area, two dresser drawers and two large desks. There are two large windows in front of each bed that have large pull down window covers. Each room has its own bathroom that contains a sink, toilet and shower all in good working condition. The day room is equip with couches and a dining table with enough seating to accommodate staff and clients. Adjacent to the day room is a kitchen area with a refrigerator, stove, toaster oven and a microwave. The kitchen is only used for snacks or heating up meals. Clients eat their meals in the dining hall located on the campus. There was perishable fruit accessible to clients and there were other snacks available on request. The TV room has a large mounted TV attached to the wall and a computer area that houses 3 computers for the clients use. There are two large bookshelves containing books for the clients use. The office is at the front of the hallway. Clients files, sharps, snacks and other items are kept in there. Clients on medication has it administered by nurses. The medication is kept in the infirmary. Note: The Pool is in a large locked building on the campus away from the dorm Cont 809-C The Laundry Room contains 2 washers and 2 dryers in good working condition. Inside the laundry room is a cabinet that has a lock on it where cleaning supplies are kept. The laundry room has a lock on the door. Clients must be allowed access to enter the laundry room. LPA advised Residential Director, Troy McNair the following things: Keep the cleaning supply cabinet locked at all times. Discard can goods (not expired, but no plans of use) that were kept stored in the kitchen cabinet. Place the word "Grievance" on the Suggestion box and check it daily. An Administrator or Facility Manager should be the only ones checking the box. Staff and clients interviewed. Staff and client files inspected. No deficiencies cited at the time of the inspection.

met_with: Troy McNair-Resident Director


summary: Facility Evaluation

raw_content:
Narrative:
On December 15, 2023 at 11am Licensing Program Analyst (LPA) Donald Martin, arrived at the above facility. The purpose of this inspection is to conduct an Annual/Random inspection and remove the facility from provisional to permanent status. LPA met with Troy McNair and together, conducted an inspection of St. Anthony's House. This unit has 8 rooms and a total of 16 beds. The St. Anthony's House services 12- Minors and Non-Minor Dependents. The Inspection went as follows: Saint Anthony's Youth Support annex: This unit has the capacity of no more than 16 clients ambulatory Minor and Non-Minor dependents ages 12-17yrs old. St Anthony: The cottage has 8 individual bedrooms all equip with two beds, two stand up closets that contain a clothes hanging area, two dresser drawers and two large desks. There are two large windows in front of each bed that have large pull down window covers. Each room has its own bathroom that contains a sink, toilet and shower all in good working condition. The day room is equip with 4 large couches. The dining room area has a dining table with 8 chairs. Adjacent to the day room is a kitchen area. The kitchen area has two refrigerators one for Clients and one for Staff. There is also a stove, toaster oven, coffee maker and a microwave. There is a large TV on the wall above the door. The kitchen is only used for snacks or heating up meals. Clients eat their meals in the dining hall located on the campus. There was perishable fruit accessible to clients and there were other snacks available on request. The office is at the front of the hallway. Clients files, sharps, snacks and other items are kept in there. Clients on medication has it administered by nurses. The medication is kept in the infirmary. Note: The Pool is in a large locked building on the campus away from the dorm Cont 809-C The Laundry Room contains 2 washers and 2 dryers in good working condition. Inside the laundry room is a cabinet that has a lock on it where cleaning supplies are kept. The laundry room has a lock on the door. Clients must be allowed access to enter the laundry room. Advisory Note: The overall unit was in good condition, however the trash cans in several of the clients rooms were full. Staff needs to create a system to have the trash cans emptied and the rooms clean on a consistent basis. Waiting on the clients to return to the unit to take out the trash is unacceptable and is citable. LPA will return to review the medication log/Infirmary and interview Staff and Clients within Days. No deficiencies cited at the time of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On January 19, 2024 at 10am Licensing Program Analyst (LPA) Donald Martin, arrived at the above facility. The purpose of this inspection is to conduct an Annual/Random inspection continuation. LPA met with Troy McNair and was allowed into the facility offices. LPA will complete the annual inspection. The St. Anthony's House services 12- Minors and Non-Minor Dependents. The Inspection went as follows: Saint Anthony's Youth Support annex: This unit has the capacity of no more than 16 clients ambulatory Minor and Non-Minor dependents ages 12-17yrs old. LPA reviewed files for S1, S2 and S3. LPA reviewed files for C1, C2, C3 and C4. LPA completed staff and client interviews. LPA reviewed the medication log, allowance "Canteen" log and training log. All files were complete and in order . LPA has concluded this annual inspection. There were no deficiencies sited at the time of the visit.


summary: Facility Evaluation

raw_content:
Narrative:
REPORT AMENDED ON 06/14/ TO CHANGE LANGUAGE On 06/14/2024, at 9: AM, Licensing Program Analyst (LPA), Donald Martin made an unannounced visit to the above facility for the purpose of concluding a Case Management - Incident Inspection. LPA spoke with Residential Director, Troy McNair. A health and safety assessment were conducted. On 02/03/2024, the department received an Incident Report, dated 02/02/2024, indicating that Child 1 (C1) was told by Staff 1 (S1) that he was unable to use the telephone to call a nonapproved telephone number. C1 escalated, walked out the office, and caused damage to cork board due to punching with right hand. Incident Report further indicates that C1 will be charged for property damage. LPA spoke with Troy McNair and obtained copy of Program Statement. Program Statement indicates that restitution shall be imposed on a child or non-minor dependent in a manner that is consistent with trauma-informed practices. RSA shall impose fines for acts of vandalism, damage of property and to replace stolen property only after review with Probation, DCFS, and/or a Child and Family Team (CFT) meeting. There was no evidence that restitution has been imposed without further review with placing agency. There was no evidence that C1 was not allowed to make a phone call. Evidence indicated that C1 was not allowed to make a call to a non-approved telephone number indicated in his intake documents. Children in care can make phone calls unless prohibited by information gathered in the initial CFT meeting. Facility representative was advised to amend Program Statement and outline written policies ensuring that cash resources are not taken from children in care in the form of fines/restitution. Revisions should be submitted by 06/28/2024, for review. Based on the information obtained, no further investigation is needed. An exit interview was conducted, and a copy of this report was left with Troy McNair, Residential Director.There were no deficiencies cited at time.


summary: Facility Evaluation

raw_content:
Narrative:
REPORT AMENDED ON 06/14/ TO CHANGE LANGUAGE On 06/14/2024, at 9: AM, Licensing Program Analyst (LPA), Donald Martin made an unannounced visit to the above facility for the purpose of concluding a Case Management - Incident Inspection. LPA spoke with Residential Director, Troy McNair. A health and safety assessment were conducted. On 01/26/2024, the department received an Incident Report dated 01/25/2024, indicating that Child 1 (C1) was told by Staff 1 (S1) that he was unable to use the telephone to call an ex-girlfriend as calls had not been approved by . C1 escalated, punched a hole into the wall adjacent to the STRTP staff office. Incident Report further indicates that C1 will be charged for property damage. LPA spoke with Troy McNair and obtained copy of Program Statement. Program Statement indicates that restitution shall be imposed on a child or non-minor dependent in a manner that is consistent with trauma-informed practices. RSA shall impose fines for acts of vandalism, damage of property and to replace stolen property only after review with Probation, DCFS, and/or a Child and Family Team (CFT) meeting. There was no evidence that restitution has been imposed without further review with placing agency. There was no evidence that C1 was not allowed to make a phone call. Evidence indicated that C1 was not allowed to make a call to a non-approved telephone number indicated in his intake documents. Children in care can make phone calls unless prohibited by court order. Facility representative was advised to amend Program Statement and outline written policies ensuring that cash resources are not taken from children in care in the form of fines/restitution. Revisions should be submitted by 06/28/2024, for review. Based on the information obtained, no further investigation is needed. An exit interview was conducted, and a copy of this report was left with Troy McNair, Residential Director. There were no deficiencies cited at time.


summary: Facility Evaluation

raw_content:
Narrative:
On December 30, 2024 at 11:30am Licensing Program Analyst (LPA) Donald Martin, arrived at the above facility. The purpose of this inspection is to conduct an Annual/Random inspection. LPA met with Troy McNair and together, conducted an inspection of St. Anthony's House. This unit has 8 rooms and a total of 16 beds. The St. Anthony's House services 12- Minors and Non-Minor Dependents. The Inspection went as follows: Saint Anthony's Youth Support annex: This unit has the capacity of no more than 16 clients ambulatory Minor and Non-Minor dependents ages 12-17yrs old. St Anthony: The cottage has 8 individual bedrooms all equip with two beds, two stand up closets that contain a clothes hanging area, two dresser drawers and two large desks. There are two large windows in front of each bed that have large pull down window covers. Each room has its own bathroom that contains a sink, toilet and shower all in good working condition. The day room is equip with 4 large couches. The dining room area has a dining table with 8 chairs. Adjacent to the day room is a kitchen area. The kitchen area has two refrigerators one for Clients and one for Staff. There is also a stove, toaster oven, coffee maker and a microwave. There is a large TV on the wall above the door. The kitchen is only used for snacks or heating up meals. Clients eat their meals in the dining hall located on the campus. There was perishable fruit accessible to clients and there were other snacks available on request. The office is at the front of the hallway. Clients files, snacks and other items are kept in there. Clients on medication has it administered by nurses. The medication is kept in the infirmary. Note: The Pool is in a large locked building on the campus away from the dorm Cont 809-C The Laundry Room contains 2 washers and 2 dryers in good working condition. Inside the laundry room is a cabinet that has a lock on it where cleaning supplies are kept. The laundry room has a lock on the door. Clients must be allowed access to enter the laundry room. The facility vans are kept in good working condition. The van inspected is registered and is insured through 2025. LPA reviewed 3 staff and 3 client files. LPA interviewed 3 staff and 3 residents during the visit. Clients were preparing to depart on a facility outing. No deficiencies cited at the time of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On February 13, 2026 at 11am Licensing Program Analyst (LPA) Donald Martin, arrived at the above facility. The purpose of this inspection is to conduct an Annual/Random inspection. LPA met with Residential Director, Troy McNair and together, conducted an inspection of St. Anthony's House/Support Annex. This unit has 8 rooms and a total of 16 beds. The St. Anthony's House services 12- Minors and Non-Minor Dependents. The Inspection went as follows: St Anthony: The cottage has 8 individual bedrooms all equip with two beds, two stand up closets that contain a clothes hanging area, two dresser drawers and two large desks. There are two large windows in front of each bed that have large pull down window covers. Each room has its own bathroom that contains a sink, toilet and shower all in good working condition. The day room is equip with 4 large couches. The dining room area has a dining table with 8 chairs. Adjacent to the day room is a kitchen area. The kitchen area has two refrigerators one for Clients and one for Staff. There is also a stove, toaster oven, coffee maker and a microwave. There is a large TV on the wall above the door. The kitchen is only used for snacks or heating up meals. Clients eat their meals in the dining hall located on the campus. There was perishable fruit accessible to clients and there were other snacks available on request. The office is at the front of the hallway. Clients files, snacks and other items are kept in there. Clients on medication has it administered by nurses. The medication is kept in the infirmary. Note: The Pool is in a large locked building on the campus away from the dorm Cont 809-C The Laundry Room contains 2 washers and 2 dryers in good working condition. Inside the laundry room is a cabinet that has a lock on it where cleaning supplies are kept. The laundry room has a lock on the door. Clients must be allowed access to enter the laundry room. There is a dispenser on the wall that disperses no toxic cleaning liquid for the clients use. The facility vans are kept in good working condition. The van inspected is registered and is insured through 2026. LPA reviewed 3 staff and LPA interviewed 3 staff residents during the visit. LPA will return to review client files and conduct client interviews. No deficiencies cited at the time of the inspection. A copy of this report will be mailed to Campus Supervisor, Ronald Mc Cloud


summary: Facility Evaluation

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Narrative:
On February 24, Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for the purpose of an Annual Inspection continuation. LPA was met by Compliance Director, Zeena Burse and allowed into the facility. LPA reviewed 3 client files and conducted 3 client interviews. All client files are up to date. All 3 client interviews were conducted. There were no deficiencies cited at the time of the visit.


facility_name: REACH TO WIN YOUTH HOME FACILITY 1

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

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

met_with: Gina Chriselle, Mental Health Rehab Specialist


raw_content:
Investigation Findings:
UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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

met_with: Tyisha Jefferson, Senior Facilty Manager


raw_content:
Narrative:
LPA is issuing citations of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87074 (e) Transportation, 87022 (f) Plan of Operation, and 87072 (c)(16) Personal Rights. (See LIC9099-D). An exit interview was conducted, appeal rights provided, and a copy of this report was left with the facility.

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 Manager, Tyisha Jefferson


met_with: Administrator, Alicia Culbertson

investigation_findings: UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

allegations: UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:


summary: Facility Evaluation

raw_content:
Narrative:
On January 26, 2023 at 1:45pm, Licensing Program Analyst (LPA) Monica Pavia conducted an announced pre-licensing inspection of the facility. LPA met and toured the facility with Licensee/applicant, Alicia Culbertson. This Short-Term Residential Therapeutic Program is a one story house located in a residential area. The facility consists of 3 client bedrooms, living and dining areas, kitchen and laundry area. The facility is clean, safe, sanitary, and in good repair. All passageways are unobstructed and all doors open freely. There is a hot tub on the facility premises, and meets safety standards. Fire arms are not allowed on the facility premises. At the time of visit, the following was observed: Fire extinguishers are throughout the house. Smoke detectors are throughout the house and operational. Carbon monoxide detectors are located in the hallway, outside of the client bedrooms. Each bedroom has a bed, clean linens, and adequate drawer/cabinet space. Facility has a fire clearance. First aid kit was observed. Hot water temperature measured at 108 degrees Fahrenheit. Staff and client files will be kept in a locked filing cabinet. Medications will be centrally stored and locked in the pantry. Disinfectants and other toxic materials will be locked in a cabinet, in the garage. Extra bedding and towels are kept in the hallway closet. Knives and sharps will be kept locked in the pantry. Head of Services (HOS) for this location will be hired. Personal Rights and client grievance forms will be posted in a community area. LPA Pavia will notify licensee, once POO/PS is approved and facility is licensed. Component II: LPA Pavia discussed with the following, with Licensee: - Administrator on site required hours - facility core services and support - facility emergency intervention plan

met_with: Alicia Culbertson


summary: Facility Evaluation

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Narrative:
On 2/23/24, Licensing Program Analyst (LPA) Mariah Hawkins and Health Program Specialist (HPS) Shamika Payne conducted a required annual inspection. LPA and HPS met with Administrator Alicia Culbertson and informed of the purpose of the visit. During the inspection, the CARE Inspection Tool was used. A tour of the inside and outside of the facility as well as a review of facility records were conducted. LPA and HPS discussed facility procedures and provided feedback on program implementation. The facility was observed to be in safe condition, with clean double-occupancy bedrooms ready for residents' use, sanitary kitchen and bathrooms, and clean activity spaces. There is ample storage for residents' personal belongings as well as locked storage for medications, chemicals, and dangerous household items, such as kitchen knives. Administrator agreed to obtain and post the foster care ombudspersons office personal rights poster. Additionally, Administrator agrees to submit a written waiver request for the cameras around the facility. Some areas in which technical support will be beneficial were documented on the LIC 9102s provided with this report. No deficiency citations were issued. An exit interview was conducted, appeal rights were discussed, and a copy of this report was left with Administrator Alicia Culbertson, whose signature on this form confirms receipt.

met_with: Administrator Alicia Culbertson


summary: Facility Evaluation

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Narrative:
On 03/11/2025 at 10:00am, Licensing Program Analyst (LPA) Kristin Pierotti and LPA Simran Nayyar conducted a required annual inspection. LPAs met with Facility Manager, Tyisha Jefferson and informed of the purpose of the visit. LPAs used the CARE Inspection Tool and conducted a tour of the facility site, review of 5 personnel records and 2 resident records, and confidential interviews with 1 staff member and 0 residents. Residents declined an interview. LPAs observed the facility to be in good condition, clean and well organized. Kitchen and bathrooms are sanitary. The facility currently has 2 residents and each resident has their own bedroom with individual beds and plenty of storage for personal items. The rooms and common spaces are nicely decorated and furnished. Medications, sharps, and chemicals are stored where inaccessible to the residents. Cameras are posted in public spaces, and the licensee recently submitted program statement revisions with surveillance camera procedures, as requested. LPAs observed personnel and resident records to be complete and had all necessary documents. Staff have full background clearances, valid intervention and first aid training certifications, and have completed their annual training hours. Residents' records contain current emergency contact information, complete care plans, and accurate medication and cash records. Based on interviews, LPAs observed staff to be knowledgeable of facility policies, mandated reporting, and intervention procedures. LPAs observed residents to each be provided 1:1 supervision, to be dressed in well-fitting, appropriate, and clean clothes, and to appear comfortable in care, showing no hesitation around staff or in responding to staff guidance.Continue on LIC809-C No deficiencies were observed. An exit interview was conducted, and a copy of this report was left with Facility Administrator, Alicia Culbertson whose signature confirms receipt.

met_with: Tyisha Jefferson, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 7/23/25, Licensing Program Analyst (LPA) Celeste Aparicio conducted a case management visit to the facility for the purpose of discussing initial staff training plans. LPA met with Tyisha Jefferson, Facility Manager and informed them of the purpose of the visit. During a virtual review of the a staff members personnel file, LPA was unable to view the the subject matter, learning objectives, number of hours per training session, qualifications of the trainer, or training evaluation for the initial 8 hour trainings for the involved staff member. During the inspection the facility was able to provide the required training documentation for the staff member and confirm the staff members date of employment. LPA identified an area in which a technical assistance maybe beneficial. LPA provided a technical assistance for Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87065.1 (b)(2)(A-E) Supervision, Evaluation and Training Requirements No deficiencies were observed or cited. An exit interview was conducted, and a copy of the report was given to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On 08/27/25, Licensing Program Analyst (LPA) Celeste Aparicio made a visit to the facility to conduct a case management inspection. LPA met with the facility Administrator, Alicia Culbertson and informed the Administrator on the purpose of the visit. The purpose of this visit is to discuss the reporting requirements under the California Code of Regulations. Based on documentation review, the facility set in four late incident reports on August 20, 2025 for incidents that occurred between August 7, 2025, to August 10, 2025. LPA went over reporting procedures with the facility and identified an area in which technical advisory could be beneficial. LPA is issuing technical violation for California Code of Regulations,Title 22, Section 80061 (b)(1) (E). An exit interview was conducted, and a copy of this report was left with Administrator Culbertson whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Celeste Aparicio and Hanako Primer on November 12, 2025 at 12:03PM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs Aparicio and Primer met with Alicia Culbertson, facility Administrator and inspected the facility inside and out. LPA reviewed 1 of child's records and 5 of staff personnel files on site at the facility. During the review of staff files, LPAs identified an area in which a Technical Assistance and Technical Violation would be beneficial. LPAs are issuing Technical Assistance for Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Sections 87068.2(g) Needs and Services Plan, 87065.1(d)(3)(M)Supervision, Evaluation and Training Requirements, and a Technical Violation for Section 87065.1(e)(7)Supervision, Evaluation and Training Requirements. {Reference related LIC9102} LPAs reviewed 1 of child's psychotropic medications and medication records. LPAs interviewed 2 of staff on site to discuss the facilities policies and procedures of operation. LPAs interviewed 1 of children currently prescribed psychotropic medication. An exit interview was conducted, and a copy of this report was provided to Administrator, Alicia Culbertson whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 2/24/26 at 10:30am, Licensing Program Analyst (LPA) Celeste Aparicio made an unannounced visit to the facility to conduct the annual inspection. LPA met with Facility Manager, Tyisha Jefferson who facilitated the visit. LPA toured the entire home, inside and out. The home is set up as follows: This is a one - story home with four bedrooms, two bathrooms, a living room, family room, kitchen, garage, side tool room (not used by facility), and a large shed in the backyard being utilized as a therapy room. Bedroom # 1 - vacant (single twin bed, 6 cube storage organizer, portable closet space, and ceiling lighting). Bedroom # 2 - occupied by one minor (two single twin bed, six cube storage organizer, closet space,and ceiling lighting ). Bedroom # 3 - occupied by one minor (two single twin bed, six cube storage organizer, closet space, and ceiling lighting ). Room #4 - Master bedroom occupied by staff used as a staff office. LPA observed the facility to be clean and in good repair. All kitchen, food preparation, utensils, and storage areas were kept clean and free of litter. LPA observed food supply to be an ample amount. The food is made available so that each client has three meals per day with snacks in between. (See LIC809-C for the continued report). LPA reviewed two client files and, as a result of its review, is issuing two technical violations and two technical assistance. (reference LIC9102 attached to report): Technical Violation 87068.2(f) Needs and Services Plan (NSP) - for no documentation in the child's needs and services plan on how family members are integrated into the treatment process for the child, including postdischarge, and how sibling connections are maintained to the extent clinically appropriate, consistent with any applicable court orders, and in accordance with the child's best interest 87070(b)(18)(A) Children's Records - for no documentation to support that the child was consulted in the process to determine the preferred family members they would like to interact with to the extent clinically appropriate. Technical Assistance 80069(c) Client Medical Assessment - LPA advised facility to utilize LIC602 form to ensure all essential medical information is captured during initial medical assessment. 87068.2(b)(6) Needs and Services Plan - for lack of documentation regarding residents visitation, including the frequency of and any other limitations on visits to the family residence and other visits inside and outside the facility within the needs and services plan. 1. The annual inspection is not complete at this time. A continuation visit will be conducted at a later date to complete this inspection. An exit interview was conducted, and a copy of this report was left with the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On 2/25/26 at 10:15am, Licensing Program Analyst (LPA) Celeste Aparicio made an unannounced visit to the facility to conduct the annual inspection. LPA met with Facility Manager, Tyisha Jefferson and Administrator, Alicia Culbertson who facilitated the visit. LPA toured the interior of the facility and reviewed the following areas utilizing the CARE Tool: Disaster Preparedness, Operations, Emergency Intervention, Core/therapeutic section. LPA also conducted two client interviews. During the review of the Emergency Intervention section, LPA determined that the facility's program statement requires all staff to be trained in Professional Assault Crisis Training (ProACT). However, based on record review and interviews, no current staff hold a ProACT certification due to the staffing ratio requirements necessary to complete ProACT. The facility primarily utilizes and maintains certification in verbal crisis prevention, intervention, and de-escalation techniques. LPA is issuing a citation under STRTP Interim Licensing Standards (ILS) Section 87095.66(b)Staffing Requirements. (See LIC809-D). LPA is also issuing one technical assistance in relation to documentation requirements for the emergency intervention training curriculum. (Reference LIC9102 attached to report). [Report continued on LIC809-C...] Based on a review of the emergency disaster drills and protocols, LPA observed that the facility did not conduct any drills from May 2025 through December 2025. As a result, LPA is issuing one technical violation. (See LIC 9102 attached to this report.) Additionally, LPA reviewed five staff files electronically on site at the facility. Staff files were complete and well organized. During inspection LPA obtained copies of the following documents: Updated LIC Client roster Client Needs and Services Plans Emergency/ Disaster drill report February activities calendar By end of business day 2/26/ Administrator will submit the following documents to LPA email: Updated LIC Facility Board minutes from Feb. 2025 to Feb LPA will conduct two staff interviews on 2/26/26. The required Annual Inspection is complete. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to Administrator, Alicia Culbertson whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On March 10, 2026 at 10:50am, Licensing Program Analyst (LPA) Celeste Aparicio conducted a case management visit to the facility to follow up on an incident reported to the Department that occurred on January 29, 2026. At the time of the inspection, there was one (1) client and one (1) staff present in the facility. It was reported that on January 29, 2026, a resident engaged in unsafe internet communication with unknown adults online. The Facility Administrator informed LPA Aparicio via email that the facility took the following actions in response to the incident: 1. Staff spoke with the resident regarding program expectations, internet safety, and the risks associated with communicating with unknown adults online. 2. Staff increased supervision of the resident's phone and internet use. 3. The treatment team reviewed the resident's existing safety plan and updated it to reflect the incident. 4. The clinician was informed so the matter could be addressed therapeutically during session. During the inspection, LPA Aparicio requested the following documents: the updated safety plan and clinician notes reflecting discussion of the incident in therapeutic session.[Report continued on LIC809-C] Based on the review of the submitted incident report, LPA observed that the facility did not include a description of trauma-informed interventions and practices used to identify and address the child's behavioral patterns in response to the incident, nor a description of the facility's plan for the child following the incident, including any modifications to the child's needs and services plan or safety plan. If the child has been involved in previous incidents, the report should also explain what previous modifications were made to the needs and services plan and safety plan. LPA is issuing Technical Assistance for STRTP Interim Licensing Standards (ILS) sections 87061(i)(3) Reporting Requirements and 87061(i)(5) Reporting Requirements as a reminder for the facility to include these details in incident reports submitted to the Department. An exit interview was conducted, and a copy of this report was provided to the facility.


raw_content:
Narrative:
Interviews conducted by LPAs were inconsistent that facility staff are not providing minor with adequate transportation to school. Facility Staff interviewed reported that they did everything they could to provide transportation to and from school for one minor, but on multiple occasions, the minor had behaviors which made it unsafe to transport the minor. LPA reviewed multiple SIRs that documented the minor became aggressive during the 2-hour transport from the minor's school of origin. It was documented that the minor was throwing items and attacking staff during transportation. On one occasion, the minor became so aggressive, they broke the car windows and door, and tore out the center console. For a period of possibly 5 days, or up to 2 weeks, based on interviews, the facility did not transport the minor, while researching and trying out other transportation options. There were some days, the minor refused being transported. The transportation concerns were discussed, and a behavioral plan was created at a CFT meeting. The youth is currently complying with transportation without unsafe behaviors. Based on LPA's interviews which were conducted, and records reviewed, although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove the violation did, or did not occur. Therefore, the allegation is UNSUBSTANTIATED. A signed copy of this LIC-9099 report, the LIC-9099C, and appeal rights were provided to the facility. An exit interview was conducted.

Investigation Findings:
13Licensing Program Analyst (LPA) Lyta Vue arrived unannounced at the facility on this date for the purpose of delivering findings for the complaint investigation. LPA met with Progam Manager, Amanda Shelton. LPAs Misty Valencia, Lyta Vue, and Kellie McKinley conducted the complaint investigation. LPA McKinley initiated the investigation with the facility on 12/10/2024 and met with Program Manager, Amanda Sheltonl and conducted a Health and Safety Inspection. During the course of the investigation, interviews were conducted with four facility staff members, one County Social Worker (CSW) and the Reporting Party. LPAs reviewed records including staff and client roster from September, October and November 2024, Needs and Services, CFT notes, Case notes, Serious Incident reports (SIR)'s for one client between September, October, and November 2024, IEP meetings, and a School Attendance Records from October to January. Report continued on 9099c UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Hillary Hall LICENSING EVALUATOR NAME: Lyta Vue 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 25-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CHICO - RESIDENTIAL, COHASSET RD., STE. FACILITY NAME: REDWOOD COMMUNITY SERVICES, INC - SEQUOIA HOUSEFACILITY NUMBER: VISIT DATE: 03/12/2025

met_with: Progam Manager, Amanda Shelton


summary: Complaint Investigation - Substantiated - 1 deficiency

raw_content:
Narrative:
During the complaint investigation of the allegation: Staff do not ensure that the facility is free of pests, interviews were consistent that staff saw rats and rat droppings after the last client exited on 09/19/25. On the same day, Support Services Manager (SSM) and Program Supervisor (PS) took immediate action, and a maintenance request was made. Staff reported that pest control was contacted and scheduled, but it was later cancelled because the facility planned for maintenance staff to set out traps and rat boxes first. SSM and PS reported that the next step if the traps failed, would be to reach out to pest control. While conducting the facility inspection on 10/15/25, LPA and two staff observed rat droppings in the new client's bedroom and in a closet that was used for the client's belongings. Rat droppings were also observed in the client's bathroom and hallway, which poses a risk to client's health. LPA also observed a flap in the wall in the closet which was easily opened to the ground under the facility, from which rodents could enter the home . Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. One citation is being issued for violating Title 22, Division 6, Section 80087(a) Buildings and Grounds documented on subsequent LIC-9099D. A signed copy of this LIC-9099 report, the LIC-9099C, and LIC-9099D were provided to the facility. An exit interview was conducted. Appeal rights were provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Lyta Vue arrived unannounced at the facility on this date for the purpose of delivering findings for the complaint investigation. LPA met with Chris Jeffrey, Program Supervisor (PS). LPA Vue conducted the complaint investigation. LPA initiated the investigation with the facility on 10/15/25 and met with Chris Jeffrey, Program Supervisor (PS) and conducted a Health and Safety Inspection. During the course of the investigation, LPA interviewed nine (9) additional facility staff, and one (1) confidential interview. LPA reviewed records including Staff Personnel Report-LIC500, Staff Schedule, Client Roster/Register, Maintenance and Repair Log, Time Clock log requesting services, emails and text messages. Report continued on 9099c SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Hillary Hall LICENSING EVALUATOR NAME: Lyta Vue 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 25-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CHICO - RESIDENTIAL, COHASSET RD., STE. FACILITY NAME: REDWOOD COMMUNITY SERVICES, INC - SEQUOIA HOUSEFACILITY NUMBER: VISIT DATE: 11/03/2025

Deficiencies:
80087(a): (a)

met_with: Chris Jeffrey, Program Supervisor (PS)

title: Buildings and Grounds

description: (a)


facility_name: REDWOOD COMMUNITY SERVICES, INC - SEQUOIA HOUSE

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Lyta Vue conducted an announced Pre-licensing inspection on 10/23/23 at 12: PM at the above location, as required for the Short Term Residential Therapeutic Program (STRTP) licensure. LPA met with Lorraine Montano, Administrator. During the pre-licensing visit, LPA conducted a Health and Safety inspection using the CARE tool. LPA observed the facility was clean inside and safe. The outside of the facility is fenced in the backyard, and spacious, clean and well maintained for outdoor activities. LPA observed that there are two floors to the facility. LPA observed three client bedrooms, equipped with appropriate furniture, bedding, and supplies for clients. Sufficient storage space for client's personal belongings was observed in each room. The facility is requesting to be licensed for 3 clients. (10 staff are hired but staff will work according to ratio, and additional staff will be on-call). LPA observed a medication cabinet in the medication room with a medication fridge which was empty, but locked, and accessible only to designated staff. The kitchen area was equipped with an adequate number of utensils, dining supplies, and cups for clients. No food was observed as there are no clients, and no pending placement at this time. Facility will verify required food on hand at time of client placement. LPA observed a staff office space that is locked and inaccessible to clients, where client records will be locked in file cabinets in a lock closet. Facility has a garage used for maintenance supplies and is locked and made inaccessible for clients. The laundry room does not have a door, but all cleaning supplies are locked up high in cabinets. The smoke detectors were tested and found to be functional during the inspection and there were functioning carbon monoxide detectors on each floor of the facility. Four fire extinguishers were present with a recent inspection date of 9/30/23. A fully equipped first aid kit was in the kitchen area. Pre-licensing report continued on 809c The Foster Youth Bill of Rights was posted in a conspicuous location. There are two bathrooms in the facility that are accessible to client use. The water temperature was tested and found to be DEGREES. The facility is ready for licensure as a STRTP and LPA recommends that the facility be licensed. A signed copy of this report was provided to Lorraine Montano, Administrator. End of report.

met_with: Lorraine Montano, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Lyta Vue conducted an unannounced Post-licensing inspection on 2/28/24 at 12: PM at the above location, as required for the Short Term Residential Therapeutic Program (STRTP) licensure. LPA met with Michelle Gibbons, Program Supervisor (PS). During the post-licensing visit, LPA conducted a Health and Safety inspection using the CARE tool. LPA observed the facility was clean inside and safe. The outside of the facility is fenced in the backyard, and spacious, clean and well maintained for outdoor activities. LPA observed that there are two floors to the facility. LPA observed two client bedrooms, equipped with appropriate furniture, bedding, and supplies for clients. Sufficient storage space for client's personal belongings was observed in each room. The facility is licensed for 2 clients and 2 clients are currently in placement. An LIC 500 was received, and the facility has 9 staff. Staff to client ratio is 1:1, and the ratio for staff to client at 10: PM to 7: AM is a 1:2. LPA observed the medications to be stored and locked in the staff office in the cabinet. The kitchen area was equipped with an adequate number of utensils, dining supplies, and cups for clients. LPA observed 3 days of perishable food and 7 days of non-perishable food on site. LPA observed a staff office space that is locked and inaccessible to clients, where client records are locked in file cabinets in a locked closet. The facility has a garage used for maintenance supplies and is locked and made inaccessible to clients. The laundry room does not have a door, but all cleaning supplies are locked up high in cabinets. The smoke detectors were tested and found to be functional during the inspection and there were functioning carbon monoxide detectors on each floor of the facility. Five fire extinguishers were present with a recent inspection date of 9/30/23 and will expire on 9/2024. A fully equipped first aid kit was in the kitchen area. Report continued on 809c LPA observed the following items posted: - Personal Rights - Emergency Disaster - Exit signs - Foster Care Bill of Rights - Facility Sketch with emergency exit routes identified There are three bathrooms in the facility and one is made accessible for client use. The water temperature was tested and found to be within regulatory temperature. Post-Licensing is not completed, will be completed on a later day.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Lyta Vue returned to the facility to finish conducting an unannounced Post-licensing inspection on 2/29/24 at 9: AM at the above location, as required for the Short Term Residential Therapeutic Program (STRTP) licensure. LPA met with Michelle Gibbons, Program Supervisor (PS). During today's post-licensing visit, LPA finished conducting a Health and Safety inspection using the CARE tool. LPA conducted 3 staff interviews and 0 of clients interviews (Clients left facility Unauthorized Absences- no clients on site). LPA reviewed 5 staff files and 2 client files. This facility meets Interim Licensing Standards mandates and is clean safe, sanitary and in good repair. LPA recommends the facility obtains permanent license with management approval. A signed copy of this report was provided to Michelle Gibbons, Program Supervisor (PS) . End of report.


summary: Facility Evaluation

raw_content:
Narrative:
On 12/11/24, Licensing Program Analyst (LPA) Kellie McKinley arrived unannounced at the facility and met with Amanda Shelton - Clinical Program Manager. The purpose of the visit was to conduct a Required, Two year Annual Inspection of the facility. This is the facility's first inspection. LPA utilized the CARE Tool to complete the Annual inspection. LPA conducted an inspection of the physical plant, and checked for all necessary requirements. The facility was clean and organized, and maintained an acceptable room temperature. The facility is a home like setting, with five client bedrooms, two which are used as offices, one is a recreation room and the other two are client bedrooms. There is a large open kitchen with an attached dining area, and living room with a fire place made inaccessible to clients in care. Each client had a closet and dresser in good repair. Mattresses and bedding were observed to be clean. Clients were able to decorate their rooms with their personal belongings. There is no backyard, but does have a fenced side yard with a punching bag and grass area for a badminton set which is not out all the time. A variety of games can be found in a locked closet inside the facility for use. LPA observed the proper postings including: facility license, complaint hotline, client personal rights, and emergency disaster plan. The facility has one client bathroom and two staff bathroom. All were observed to be clean and fully functioning. Smoke alarms were in working order, fire extinguishers were current, and a first aid kit was fully stocked. LPA observed the kitchen to have at least 2 days of perishable food and 7 days of non-perishable food on hand, with additional food stored in the office refrigerator. The garage is used for storage of needed supplies and equipment. LPA observed client files and client medications were stored in a locked cabinet in the locked staff office back room. The facility has no outstanding fees. The facility currently has 2 clients, with a licensed maximum capacity of 2. Staff to client ratio is 3 staff to two clients. LPA reviewed 3 staff files. Staff files had completed criminal record clearances and all required initial and annual training. All First Aid and CPR certifications were up to date for staff. LPA interviewed 3 staff on site. continued on 809-C page LPA reviewed 2 client files. All clients had signed Admission Agreements on file. Client files had completed initial Needs and Service Treatment Plans and updated Needs and Service plans every 30 days. The facility had evidence of attempting to obtain signatures from placing agencies. Needs and Service Plans detailed adequate supportive services the facility offers to the clients. Clients were current on CHDP physical exams and dental exams. 1 of 2 clients were taking court ordered psychotropic medications and had current JV-220's on file. A signed copy of this LIC-809 an additional documents of the report was provided to Amanda Shelton Clinical Program manager. An exit interview was conducted.


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Narrative:
Continued from It was alleged one staff member took a youth's belongings on one occasion. Interviews and records reviewed were inconsistent. Seven of 9 interviews reported that they had never witnessed or heard of any youth's personal belongings being taken. One staff reported seeing one other staff take one item that had been confiscated from the youths belongings. One interview out of nine reported they had heard of staff making inappropriate comments to and around youth, but no staff reported hearing inappropriate comments directly. Support Services Manager denied having knowledge of the allegations prior to the investigation but subsequently held a team meeting to review policies and procedures on safeguarding client's belongings and maintaining boundaries in conversation with youth. Based on LPA's interviews which were conducted, and records reviewed, although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove the violations did, or did not, occur. Therefore, the allegations are UNSUBSTANTIATED. A signed copy of this LIC-9099 report, the LIC-9099C, and appeal rights were provided to the facility. An exit interview was conducted.

Investigation Findings:
13Licensing Program Manager (LPM) Hillary Hall arrived unannounced at the facility on this date for the purpose of delivering findings for the complaint investigation. LPM met with Steven Stewart, Therapeutic Skills Coach. LPA Vue conducted the complaint investigation and initiated the investigation with the facility on 11/03/25 and met with Chris Jeffrey, Program Supervisor (PS). LPA also conducted a Health and Safety Inspection. During the course of the investigation, LPA interviewed the Reporting Party, seven (7) facility staff, and one (1) youth. LPA reviewed records including Staff Schedule, Staff Personnel Report-LIC500, Staff Contact List, and Staff Training Log. LPA also reviewed Client Roster, Need and Services Plan, Child and Family Team Meeting notes, Case Notes for one youth, Facility's Team Meeting notes, Client Personal Property, Serious Incident Reports, and Hiring interview questions. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Margo Castaneda LICENSING EVALUATOR NAME: Hillary Hall 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 25-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CHICO - RESIDENTIAL, COHASSET RD., STE. FACILITY NAME: REDWOOD COMMUNITY SERVICES, INC - SEQUOIA HOUSEFACILITY NUMBER: VISIT DATE: 12/18/2025

met_with: Steven Stewart, Therapeutic Skills Coach IV


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
Licensing Program Analyst (LPA) Lyta Vue arrived unannounced at the facility for the purpose of a Case Management following the review of Serious Incident Reports submitted by the facility to the Department. LPA met with Program Manager, Amanda Shelton. On March 4, 2025, Licensing Program Manager (LPM) Hillary Hall conducted a review of the Serious Incident Reports (IRs) which were submitted to the Department between December 2024 and February 2025. LPM determined eleven (11), 24-hour IR's were submitted late, and 15 full IR's were submitted late. Three of the full IR's submitted late, were not preceded by a 24-hour report. Four of the 24-hour IR's did not have a corresponding full report submitted to the Department at the time of the review. Five IR's involving law enforcement did not have a corresponding LIC Law Enforcement contact form as required. The requirement of the facility is that 24-hour IR's are submitted to the Department within 24 hours of the incident. Full reports are to be submitted within 7 days. Facility is issued a citation per Title 22, Division 6, Section 80061(b): Reporting Requirements: (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. A signed copy of this LIC 809 and 809D were provided to the facility along with appeal rights. Exit interview conducted.

Deficiencies:
80061(b): Reporting Requirements: (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business ...............1
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7Staff (supervisor-SV) did IR training on 03/11, will submitt training; Facility plan a time frame for SV to be available and dedicated to IRs and emials; 03/19- Program Coordinator schduled training with all Sequoia house staff, will submit training w/ content, sign-in sheet, date, time, hours
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met_with: Program Manager, Amanda Shelton

title:
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780061(b)


facility_name: REDWOOD COMMUNITY SERVICES, INC MCCC

summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Brian Bertoli met with Program Manager Paulita Peredia regarding a complaint investigation at the Short-Term Residential Therapeutic Program. The purpose of the inspection was to deliver the findings for the above allegation. During the course of the investigation, LPA Bertoli inspected the Facility, interviewed youth and staff, and reviewed documentation. LPA confirmed through confidential interviews and incident reports that a staff person engaged in intentional physical contact with youth by pushing or hitting youth with a laptop computer. Based on the information obtained, there is a preponderance of the evidence to prove that the staff violated personal rights of client. Therefore, the above allegation is substantiated. Title 22 deficiencies were cited regarding the physical abuse. Appeal Rights were provided and discussed with the facility. An exit interview was conducted and a copy of the report was left with the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Mendoza LICENSING EVALUATOR NAME: Brian Bertoli 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 21-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, NEOTOMAS AVENUE, STE. FACILITY NAME: REDWOOD COMMUNITY SERVICES, INC MCCCFACILITY NUMBER: 236890071

met_with: Paulita Peredia


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Brian Bertoli conducted an unannounced inspection for the purposes of completing an Annual/Required Inspection and met with Program Supervisor. A pre-screening call was done prior to arrival, and Supervisor Peredia indicated that no one was Covid positive, symptomatic, or had known exposure. The Physical Plant was toured inside and out by LPA Bertoli at 10:30am. Water temperatures were measured at 111 degrees. Seven-day Non-perishable food supply was inspected and was found to be adequate. Two-day perishable food supply was inspected and were found to be adequate and consistent with the menu. LPA inspected bedrooms and found that there were adequate linens and each bed had mattress pads. The home is clean and in good repair. There are no firearms in the facility. There are no open bodies of water on the property. Medications are locked in the office. Toxics and cleaning solutions are locked in the laundry closet. Required documents are posted. There are charged operable fire extinguishers. Carbon monoxide and smoke detectors are in the facility. Five staff and three clients were interviewed. Three client files were reviewed and staff files will be reviewed on another date. Per Title Regulations, no deficiencies were cited during this inspection. An exit interview was conducted and a copy of the report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Brian Bertoli conducted an unannounced inspection for the purposes of completing an Annual/Required Continuation Inspection and met with Program Supervisor Paulita Peredia. A pre-screening call was done prior to arrival, and there were no changes since last visit. The staff records were reviewed at the administrative office on South Orchard St in Ukiah and were acceptable. The Emergency Intervention and Disaster Preparedness were reviewed at the facility. The Annual/Required inspection is complete. Per Title Regulations, no deficiencies were cited during this inspection. An exit interview was conducted and a copy of the report was left at the facility.


facility_name: REDWOOD COMMUNITY SERVICES, INC.-BIRCH HOUSE

raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Brian Bertoli met with Program Manager Paulita Peredia regarding a complaint investigation at the Short-Term Residential Therapeutic Program. The purpose of the inspection was to deliver the findings for the above allegation. During the course of the investigation, LPA Bertoli inspected the facility, attempted to interview youth, interviewed staff and Authorized Representatives, and reviewed documentation. While youth in the home stated to others that the staff had verbally and physically abused them, the youth declined to be interviewed, and both staff and authorized representatives indicated they had no knowledge of any such occurrences, and they all stated that the youth has a history of making unfounded accusations. Based on interviews conducted, LPA was unable to determine if foster youth was physically assaulted or if staff spoke inappropriately to the youth. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that foster youth was either physically assaulted or suffered verbal abuse; therefore, the above allegation is unsubstantiated. Appeal Rights were provided and discussed and no deficiencies were cited. An exit interview was conducted and a copy of the report was left with the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Mendoza LICENSING EVALUATOR NAME: Brian Bertoli 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 3


raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Cheyenne McCambridge met with Theraputic skills coach Zach Crossman regarding a complaint investigation at the Short-Term Residential Therapeutic Program. The purpose of the inspection was to deliver the findings for the above allegation. During the investigation, LPA Brian Bertoli inspected the facility, interviewed youth, staff and Authorized Representatives, and reviewed documentation. The youth in the home stated that staff had not been physically abusive or rough with her, and both staff and authorized representatives indicated they had no knowledge of any such occurrences, and they all stated that the youth has a history of making unfounded accusations. Based on interviews conducted, LPA was unable to determine if foster youth was handled in a rough manner. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that foster youth was handled in a rough manner; therefore, the above allegation is unsubstantiated. Appeal Rights were provided and discussed, and no deficiencies were cited. An exit interview was conducted, and a copy of the report was left with the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Cheyenne McCambridge 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 3

met_with: Zach Crossman


raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Brian Bertoli met with STRTP Coordinator Rebecca Diaz regarding a complaint investigation at the Short-Term Residential Therapeutic Program. The purpose of the inspection was to deliver the findings for the above allegation. During the investigation, LPA Bertoli inspected the facility, interviewed youth, staff, and Authorized Representatives, and reviewed documentation. All parties interviewed indicated that the youth had received mental health services and was supported by the facility staff in engaging in those services. Youth was known to engage in self-harm and staff was alert to the issue and made efforts to reduce the behavior. Youth was documented as attending mental health services regularly. Based on interviews conducted and documents reviewed, LPA did not observe any indication that the youth was not receiving appropriate mental health services. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that Staff are not ensuring minor's mental health needs are met; therefore, the above allegation is Unsubstantiated. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Brian Bertoli 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: Rebecca Diaz


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Brian Bertoli conducted an unannounced inspection for the purposes of completing an Annual/Required Inspection and met with administrator Lorraine Montano. A pre-screening call was done prior to arrival, and Program Supervisor Paulita Peredia indicated that no one was Covid positive, symptomatic, or had known exposure. The Physical Plant was toured inside and out by LPA Bertoli. Water temperatures were measured at 114 degrees. Seven-day Non-perishable food supply was inspected and was found to be adequate. Two-day perishable food supply was inspected and were found to be adequate and consistent with the menu. LPA inspected bedrooms and found that there were adequate linens and each bed had mattress pads. The home is clean and in good repair. There are no firearms in the facility. There are no open bodies of water on the property. Medications and sharps are locked in the office. Toxics and cleaning solutions are locked in the laundry room. Required documents are posted. There are charged operable fire extinguishers, carbon monoxide and smoke detectors are in the facility. Four staff were interviewed. Client files and staff files were requested and will be reviewed on another date. Per Title Regulations, no deficiencies were cited during this inspection. An exit interview was conducted and a copy of the report was left at the facility.

met_with: Lorraine Montano


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Brian Bertoli conducted an unannounced inspection for the purposes of completing an Annual/Required Continuation Inspection and met with Program Supervisor Paulita Peredia. A pre-screening call was done with Administrator Lorraine Montano prior to arrival, and there were no changes since last visit. The staff records were reviewed at the administrative office on South Orchard St in Ukiah and were acceptable. The client records were reviewed at the facility and found to be acceptable. A Technical Advisory was issued for Title 22 80023(d)(2) and Health and Safety Code 1565(a)(6) and 1565(a)(7)(A) Regarding the Disaster Plan. The Annual/Required inspection is complete. Per Title Regulations, no deficiencies were cited during this inspection. An exit interview was conducted and a copy of the report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Carolyn Flynn on 9/17/2021 at 10: AM. During the inspection, LPA Flynn met with Kate Napp, Program Administrator at the main office to review staff files and facility file. LPA then moved to the facility at 11: AM and was met by Zobeyda Borjorquez, Lead Therapeutic Skills Coach III and inspected the facility inside and out. LPA reviewed three of staff personnel files and the facility program statement on site at the main office at 10: AM. LPA reviewed one of child's psychotropic medications and medication records at 12: PM LPA attempted to interviewed one of children currently taking psychotropic medication at 1: PM LPA reviewed one of child's records on site at the facility at 12: PM LPA interviewed three of staff on site. The first at 1: PM, the second at 1: PM, and the third at 2: PM LPA provided the Summary Report to Kate Napp, Program Administrator upon completion No deficiencies are being cited at this time, but one Advisory Note (Technical Violation see LIC9102 dated 09/17/2021) was issued by LPA Flynn who conducted exit interview with Kate Napp, Program Administrator at 23: PM.

met_with: Kate Napp


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Brian Bertoli on 8/2/22 at 10:10am. During the inspection, LPA Bertoli met with Zobeyda Bojorquez, TSC V and inspected the facility inside and out. A COVID pre-screening call was completed prior to arrival with Program Supervisor Paulita Peredia, and she confirmed that there are no COVID positives, know exposures, or symptomatic persons present at the facility. LPA reviewed 1 child's records on site at the facility at 10:30am. LPA reviewed 5 of staff personnel files on site at the facility at 2:40pm. LPA reviewed 1 child's psychotropic medications and medication records at 1:30pm. LPA interviewed 2 of staff on site at 11:15am. LPA attempted interview of 1 child currently taking psychotropic medication at 11:45am. LPA provided the Summary Report to Supervisor Peredia upon completion. No deficiencies are being cited at this time. LPA conducted an exit interview with TSC V Bojorquez at 2:30pm.

met_with: Zobeyda Bojorquez


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Brian Bertoli on September 1, 2023 at 10:15am. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Bertoli met with Rebecca Diaz, STRTP Coordinator, and inspected the facility inside and out. LPA did not review any children's records due to no current placements. Three staff personnel files were reviewed at the administrative office on S Orchard St in Ukiah. LPA did not review any children's psychotropic medications and medication records. LPA interviewed three staff on site to discuss the facilities policies and procedures of operation. LPA did not interview children. LPA provided a copy of this licensing report to Rebecca Diaz, STRTP Coordinator. No deficiencies are being cited at this time. LPA conducted an exit interview with Rebecca Diaz, STRTP Coordinator.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date Licensing Program Analyst (LPA) Brian Bertoli conducted an unannounced inspection at the facility and met with Administrator Paulita Peredia and STRTP Coordinator Rebecca Diaz regarding a Special Incident Report (SIR) that was submitted to Community Care Licensing. The incident took place on 04/30/2024 and the SIR was written to report an disclosure by youth regarding alleged abuse by another youth at the facility. LPA Bertoli discussed the incident with Administrator Peredia who stated that there have not been further concerns from the youth and that they will monitor the situation. Administrator Peredia also stated that youth have from 3-5 staff to supervise when they are at the facility during the day and that one youth bedroom is upstairs and the other is downstairs with a staff person in-between at night who can monitor activity. No deficiencies were cited. An exit interview was conducted and a copy of the report and appeal rights were provided to the facility.

met_with: Paulita Peredia and Rebecca Diaz


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Brian Bertoli on September 1, 2023 at 11:15am. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Bertoli met with Paulita Peredia, STRTP Administrator, and inspected the facility inside and out. Staff files were reviewed at the Administrative office in Ukiah with the help of HR Administrator Karina Gonsalez. LPA reviewed one child's records on site and three staff personnel files at the administrative office in Ukiah. LPA reviewed one child's psychotropic medications and medication records. LPA interviewed three staff on site to discuss the facilities policies and procedures of operation. LPA interviewed one child currently prescribed psychotropic medication. LPA provided a copy of this licensing report to Paulita Peredia, STRTP Administrator. No deficiencies are being cited at this time. LPA conducted an exit interview with Karina Gonsalez, HR Administrator.

met_with: Paulita Peredia and Karina Gonsalez


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Brian Bertoli conducted an unannounced inspection for the purposes of completing an Required 2-Year Inspection and met with Administrator Paulita Peredia. LPA inspected the facility, reviewed records, and conducted confidential interviews. All parts were completed with the exception of staff file reviews, which will be conducted at a later date at the Administrative office. Per Title Regulations, no deficiencies were cited during this inspection. An exit interview was conducted and a copy of the report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Brian Bertoli conducted an unannounced inspection for the purposes of a Case Management visit and met with Administrator Paulita Peredia. LPA inspected the facility, reviewed records, and conducted confidential interviews. LPA reviewed a report with the Administrator regarding a youth that was involved in self-harm and they discussed supervision and staffing measures to monitor the youth's activities. Per Title Regulations, no deficiencies were cited during this inspection. An exit interview was conducted and a copy of the report was left at the facility.