summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by Licensing Program Analysts (LPAs) Cynthia Galindo, and Vanessa Galvan traveled to Inspiring Pathways in Hanford, California. LPAs met with Administrator Shannon Blanchard and inspected the facility, inside and out. A physical plant inspection was completed and included the following checks. Adequate indoor and outdoor activity space and materials observed. The facility is maintained at 72 degrees. All facility smoke detectors are in appropriate working order, fire extinguisher is properly charged and serviced. Facility maintains an adequate supply of perishable and non-perishable foods. All required forms are posted. Medications are locked and centrally stored. Individual beds were observed. No firearms or weapons are allowed in the facility. There is no pool and no pets at the facility. LPAs reviewed client and staff files. LPAs interviewed two clients and two staff. Deficiencies were cited on todays visit, see LIC809-D. A copy of this report was left at the facility at the conclusion of inspection


state: CA

facility_name: INSPIRING PATHWAYS

summary: Facility Evaluation

raw_content:
Narrative:
On this date, Licensing Program Analyst (LPA) Cynthia Galindo conducted an unannounced Case Management inspection at Inspiring Pathways and met with direct care staff Zelisa Gayton. The purpose of the inspection was to clear a POC and discuss a few concerns observed during a previous an unannounced visit. LPA spoke with one client who was in the kitchen. LPA observed the menu to be in the office but staff explained that she was working on today's menu but it's usually placed in the kitchen. LPA asked staff if there were any recent hires. Staff said yes, Administrator hired two new staff, one has started working at the home and the other person is pending background check. There are no deficiencies to be cited on todays visit. A copy of this report was left at the facility at the conclusion of inspection.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Zelisa Gayton


summary: Facility Evaluation

raw_content:
Narrative:
On this date Licensing Program Analyst (LPA) Cynthia Galindo conducted an unannounced Case Management inspection at Inspiring Pathways and met with child care worker Zelisa. The purpose of the visit was to discuss a few incidents that occurred in the home. LPA interviewed staff and clients. No deficiencies were issued on today's visit.


summary: Facility Evaluation - 2 deficiencies

raw_content:
Narrative:
An unannounced annual inspection was conducted by Licensing Program Analyst (LPA) Cynthia Galindo traveled to Inspiring Pathways in Hanford, California. LPA met with Administrator Shannon Blanchard and facility manager Natalia Yado inspected the facility, inside and out. A physical plant inspection was completed and included the following checks. Adequate indoor and outdoor activity space and materials observed. The facility is maintained at 72 degrees. All facility smoke detectors are in appropriate working order, fire extinguisher is properly charged and serviced. Facility maintains an adequate supply of perishable and non-perishable foods. All required forms are posted. Medications are locked and centrally stored. Individual beds were observed. Accreditation is valid until July 31, 2022. STRTP was approved on May 2, 2019. The MHPA was approved since May 7, 2022. No firearms or weapons are allowed in the facility. There is no pool and no pets at the facility. LPAs reviewed client and staff files. LPAs interviewed one client and four staff. Deficiencies were cited on todays visit, see LIC809-D. A copy of this report was left at the facility at the conclusion of inspection

Deficiencies:
87095.61(f): Documentation and Reporting Requirements

(f) The licensee must maintain a monthly log of each use of manual restraints. The log must include
87068.2: (2)

visit_type: Annual

met_with: Natalia Yado

title: shall be updated at least every 30 days to determine the following


summary: Facility Evaluation

raw_content:
Narrative:
On this date, Licensing Program Analysts (LPAs) Cynthia Galindo and Reyna Martinez conducted an unannounced Case Management inspection at Inspiring Pathways and met with Shannon Blanchard. The purpose of the inspection was to clear a POC that was due on June 27, 2022. LPA reviewed the documentation submitted and reviewed a resident's file. The NMD NSP does not meet the standards but will work with the Department to improved them. POC is completed. There are no deficiencies to be cited on todays visit. A copy of this report was left at the facility at the conclusion of inspection.

met_with: Shannon Blanchard


summary: Facility Evaluation

raw_content:
Narrative:
On this date, Licensing Program Analysts (LPA) Cynthia Galindo conducted a Case Management inspection at Inspiring Pathways and met with house manager Natalia Yado. The purpose of the inspection was to discuss a few concerns identified in the home. LPA discussed house rules, covid protocol, clients' NSP and vehicles maintenance. There are no findings at this time and no deficiencies issued.


summary: Facility Evaluation

raw_content:
Narrative:
On this date, Licensing Program Analysts (LPA) Cynthia Galindo conducted a Case Management inspection at Inspiring Pathways and met with Administrator Shannon Blanchard. The purpose of the inspection was to discuss a few concerns identified in the home. LPA discussed the NSP, scheduled activities, phone curfew, protocol for visits and Board members involvement. Licensee said the NSP will be updated to include detail information about the youth's progress and behaviors and any restrictions. LPA reminded licensee that phone restrictions and safety plans need to be included in the NSP and discussed with the placement agency and youth. Licensee stated the facility has activities for the youth but will now have a more structured calendar. Licensee said there is a curfew for phone use but has difficulty enforcing it because the youth are defiant. LPA advised licensee to communicate with placement agency and inform of house rules. As far as the visits, licensee stated visits are coordinated and approved with the placement agency. In some cases, the county will allow visits as long as they are supervised. Licensee stated visitation information is listed on the youth's NSP. Lastly, licensee stated there will be a Board meeting in early October and will provide the minutes when available. There are no findings at this time and no deficiencies issued.


summary: Facility Evaluation

raw_content:
Narrative:
On this date, Licensing Program Analysts (LPAs) Cynthia Galindo and Reyna Martinez conducted a Case Management inspection at Inspiring Pathways. LPAs met with Shannon Blanchard. The visit is part of the Non-compliance meeting agreement that took place on 08/24/2021. LPAs reviewed the following: -Five client files - NSP for all clients have improved. - staff schedule- facility staff is in ratio. - Nine staff files There were no issues found. The facility's Plan of Operation and Program Statement are currently being reviewed by SOC and CCL. There are no deficiencies issued on today's inspection. A copy of this report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On January 13, 2023, Licensing Program Analysts (LPAs) Briana Placencia and Cynthia Galindo conducted a Case Management inspection at Inspiring Pathways and met with Natalia Yado. The purpose of the inspection was to discuss concerns in regards to an incident report received by CCL, for an incident that occurred on January 3, 2023. LPAs attempted to interview clients that were present at the time, however all clients refused to speak with LPAs. LPAs reviewed clients files and obtained relevant documents. There are not findings or citations at this time. A copy of this report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On January 25, 2023, Licensing Program Analysts (LPAs) Briana Placencia and Cynthia Galindo conducted a Case Management inspection at Inspiring Pathways and met with Shannon Blanchard. The purpose of the inspection was to discuss concerns in regards to an incident report received by CCL, for an incident that occurred on January 3, 2023. LPAs reviewed clients files, obtained relevant documents and interviewed two minors. There are not findings or citations at this time. A copy of this report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On this date, Licensing Program Analysts (LPAs) Cynthia Galindo and Briana Placencia conducted a Case Management inspection at Inspiring Pathways. LPAs met with Shannon Blanchard and Natalia Yado. The purpose of the inspection was to issue a civil penalty. Licensee was cited for facility manager training on 02/2/2023. Licensee stated that as the Plan of Correction, the training would be completed and proof will be provided by 02/16/2023. Licensee did not submit their proof by the deadline. Based on this information, facility is being issued a civil penalty for failure to correct for two days.


summary: Facility Evaluation

raw_content:
Narrative:
On this date, Licensing Program Analysts (LPAs) Cynthia Galindo conducted an unannounced Case Management inspection at Inspiring Pathways and met with Natalia Yado. The purpose of the inspection was to clear a POC that was due on April 24, 2023. LPA reviewed the documentation submitted via email and reviewed a staff's files. The staff files had the missing information. As of today POC is completed. There are no deficiencies to be cited on todays visit. A copy of this report was left at the facility at the conclusion of inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On April 4, 2023, Licensing Program Analyst (LPA) Cynthia Galindo conducted a Case Management inspection at Inspiring Pathways and met with Shannon Blanchard. The purpose of the inspection was to discuss concerns on a two incident reports emailed to the Department. LPA discussed with licensee the following: Contraband, searches and probable cause: Licensee's response it these issues are to confiscate, reach out to social worker, hold CFTs, referred to drug abuse counselling services. Staff ratio and meeting the needs of the youth: Licensee said if there's still an issue on new hires being cleared, they will have to reconsider on cutting back on accepting youth. Also discussed was the STRTP's overall purpose to provide services to youth and keep them safe. Licensee is currently is updating the program statement and will submit updates by this week. A copy of this report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by Licensing Program Analyst (LPA) Cynthia Galindo traveled to Inspiring Pathways in Hanford, California and was met by Administrator Shannon Blanchard and facility manager Natalia Yado. Licensee's accreditation is valid until July 31, 2024 and the MHPA was is approved until May 1, 2024. There are no firearms or weapons are allowed in the facility. There is no pool and no pets at the facility. LPA reviewed five client files. Deficiencies were cited on todays visit, see LIC809-D. A copy of this report was left at the facility at the conclusion of inspection


summary: Facility Evaluation

raw_content:
Narrative:
On this date, LPA arrived at the home to finish the annual inspection that started on 05/03/2023. LPA met with Administrator Shannon Blanchard and Facility Manager Natalia Yado. A physical plant was inspected and included the following checks: There is adequate indoor and outdoor activity space and material observed. The facility is maintained at 72 degrees and the water temperature was at 111. All facility smoke detectors are in appropriate working order, fire extinguisher is properly charged and serviced. Facility maintains an adequate supply of perishable and non-perishable foods. All required forms are posted. Medications are locked and centrally stored. Individual beds were observed and are in good conditions. LPA reviewed 5 staff files and conducted 3 staff interviews. Present in the home were 6 clients but only 3 wanted to be interviewed. LPA reviewed Board meeting minutes dated 03/17/2023 and biannual review of the EIP that was submitted on 02/09/2023. There are no issues. LPA reviewed the staff schedule and verified the staff ratio. LPA suggested the on-call staff for the NOC shift to be added on the schedule. LPA staff verified with staff and clients that Administrator is present in the home at least 20 hours. LPA reviewed training assessment forms for new staff hires and reviewed the NSP. LPA discussed with Admin the POO and PS updates which are currently pending with the Department. There are no citations issued in today's visit. A copy of this report was left in the home.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Melikian on August 22, 2023 at 10:45AM. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPA met with Shannon Blanchard, Administrator and inspected the facility inside and out. LPA reviewed 2 child's records and 2 staff personnel files on site at the facility. LPA reviewed 2 child's psychotropic medications and medication records as the facility. LPA interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPA interviewed 1 child on site. 1 child refused to be interviewed. LPA provided a copy of the licensing report to Administrator, Shannon Blanchard. No deficiencies are being cited at this time. LPA conducted exit interview with Shannon Blanchard, Administrator.


facility_name: JAMES PENNY HOUSE INC.

summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Clients became hostile and threatened first responders. One client attempted to vandalize first responders' vehicles. One of the staff went to the hospital only after the situation at the facility calmed down. No other staff reported for duty to assist. In addition, the facility plan of operation show that staff is to either accompany a client or follow the ambulance when a client has to be transported to an emergency facility. Based on information obtained, the preponderance of evidence standard was met, therefore, the above allegation is substantiated. This poses an immediate Health, Safety, or Personal Rights risk to clients in care. Deficiencies are being cited under STRTP General Regulations Responsibility for Providing Care and Supervision and STRTP Interim Licensing Standards (ILS) 87065.5 (g) Direct Care Staff/Child Ratios. It was revealed that alcohol and drugs are not allowed at the facility and these are confiscated if found by staff. Based on information obtained, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there was no preponderance of evidence found to support it. A copy of this signed report, the LIC 811 (Confidential Names dated 7/23/21) and appeal rights were provided to the facility representative at the conclusion of the inspection.

Investigation Findings:
13On July 27, 2021, Licensing Program Analyst (LPA) Irene Yamamoto conducted a complaint inspection at the facility to deliver the findings of the allegation. LPA met with the facility representative named above. The allegation was investigated by Community Care Licensing (CCL), Investigations Branch (IB) Investigator Maria Barragan. The Department received a complaint alleging multiple allegations on 4/12/21. IB Investigator Barragan investigated the allegation by conducting interviews and reviewing records such as, but not limited to, Register of Clients, Personnel Report, Placement Agency and Short Term Residential Therapeutic Program (STRTP) Agreements, hospital, police and ambulance records. LPA Yamamoto reviewed the facility plan of operation. It was alleged that staff did not accompany client who was transported to the hospital. Confidential interviews reveal that only one staff was present during the night shift, when the incident happened. Another staff reported to work but both staff remained with clients at the facility who became upset when an intoxicated client became uncooperative with first responders and had to be restrained for client's safety. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Irene Yamamoto LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200a Monterey Park, CA Facility Name: James Penny House INC.FACILITY NUMBER: VISIT DATE: 07/27/2021

report_type: Complaint Investigation

met_with: Danyelle Jones, Unit Coordinator

complaint_status: unsubstantiated


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
It was alleged that at least one staff member (S1; See LIC Confidential Names Form) at the facility failed to meet the needs of one client (C1) in care. More specifically, it was alleged that the staff member failed to take C1's comments seriously during an incident in which they were in a mental crisis. No injuries were sustained although C1 was taken to the hospital as a precaution. In interviews conducted with clients in the home, the clients all stated that they felt safe in the home and felt that the staff were able to meet their needs. The clients all denied feeling dismissed by the staff members in the facility and any time issues were brought up were addressed in a timely manner. In an interview conducted with C1, C1 stated that S1 was their favorite staff member in the facility and denied ever feeling dismissed by S1. S1 was always helpful and took their comments seriously. In interviews conducted with staff, the above comments were corroborated. S1 stated that on the date of the incident, they stayed with C1 the whole time that they were in a state of crisis and played games with them to try and redirect them per their individualized safety plan. S1 denied being dismissive of C1's feelings and stated that the facility had procedures in place to try and redirect clients in crisis prior to calling emergency services. An interview conducted with the facility social worker confirmed these statements. The social worker stated that they had never seen or heard of any staff members in the home being dismissive of clients and they had no concerns about it. Comments made by clients during times of crisis were always taken seriously. A review of C1's Needs and Services Plan and Admissions Agreement confirmed that C1 was known to have episodes of mental crisis and that attempts to redirect them prior to calling emergency services was standard. Based on interviews, redirection procedures for C1 involved constant supervision, board games, car rides, and more. Based on interviews conducted and records reviewed, there is not a preponderance of evidence to prove that the above allegation occurred. Although the allegation may have happened or may be valid, the preponderance of evidence standard has not been met. Therefore, the allegations are deemed UNSUBSTANTIATED. An exit interview was conducted and a signed copy of this report, along with the Licensee's Appeal Rights (LIC 9058 01/16) was provided to the Licensee.

Investigation Findings:
13On September 03, 2021 at approximately 12: PM, Licensing Program Analyst (LPA) Raymond Wu conducted a follow-up complaint inspection with the facility to deliver the findings of a complaint investigation concerning the allegation above. LPA discussed the finding with the facility representative named above. During the course of the investigation, LPA interviewed the facility social worker on 08/27/21, the facility clients on 07/19/21 and staff members on 07/19/21 and 08/09/21. LPA also reviewed documents on 08/09/21 and 08/27/21 including but not limited to the client's admissions agreement, their Needs and Services Plans, their medication log, and Special Incident Reports. (Continued) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Yan Yeung LICENSING EVALUATOR NAME: Raymond Wu LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200a Monterey Park, CA Facility Name: James Penny House INC.FACILITY NUMBER: VISIT DATE: 09/03/2021

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

met_with: Facility Manager Joshlyn Sanders


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
It was reported staff (S1) used inappropriate language toward a client (C1) in care. S1 admitted the reported alleged incident occurred. S1 stated C1 asked another client at the facility to bring her water. S1 reported she asked the other client to not bring C1 water. C1 became escalated and began cursing at S1. S1 reported she was triggered by C1 cursing at her and cursed back at C1. Based on information obtained from interviews conducted and records reviewed the allegation was Substantiated. C1's personal rights were not afforded as require by the Interim Licensing Standards (ILS) Ver. 3. Sec. 87072(d)(11). The allegation is valid because the standard of the preponderance of evidence has been met. Facility cited for violation of Interim Licensing Standards (ILS) Ver. 3. Sec. 87072(d)(11): Personal Rights. Statements obtained from interviews conducted corroborated the allegation that a staff used inappropriate language toward a client in care. Exit interview conducted and a copy of this report along with a LIC9099D and LIC811 were provided to the facility representative. Appeals rights were discussed and provided.

Investigation Findings:
13An unannounced follow up complaint inspection was conducted by Licensing Program Analyst (LPA) Christopher Larios on 9/24/21 at 12: PM. During the inspcetion LPA Larios met with Unit Coordinator Danyelle Jones. The purpose of the inspection was to deliver findings for the above-mentioned complaint allegation. During the course of the investigation LPA Larios conducted a record review on 4/12/21 and copies of the following documents were obtained: Staff Roster, Client Roster, Clients' Needs and Services Plans, Special Incident Reports from March - April 2021. LPA Larios conducted interviews with one staff (S1) on 4/23/21, three clients on 4/12/21, two clients on 4/23/21 and three County Social Workers (CSWs) on 8/19/21. One client declined to provide a statement regarding the allegation and two CSWs were unavailable for an interview. (Reference Confidential Names list LIC811 dated 9/24/21) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Deborah A Santos LICENSING EVALUATOR NAME: Christopher Larios LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200a Monterey Park, CA Facility Name: James Penny House INC.FACILITY NUMBER: VISIT DATE: 09/24/2021

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

met_with: Danyelle Jones

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
children left facility on unauthorized leave. Identified within those reports showed what transpired in the home with children and how staff were able to address any issues reported to them by clients. Staff denied not being present to provide services or meet the needs of client. Staff also denied any clients ever making complaints or notifying staff of issues. Child identified as being in the home during the time in which this incident occurred of staff not monitoring a child who was experiencing suicidal ideations denied allegation and stated that they were unaware of any issues with staff regarding a client with suicidal ideations. Interviews conducted with other children currently residing in the home had similar statements and denied the allegation and stated that staff are present to rectify any complaints or concerns. LPA was unable to contact county social worker, but no documents identified a problem with clients placed in the home or facility staff. Based on the information gathered, although the allegation may have happened or is valid, the preponderance of evidence to prove the allegation was not met, therefore the allegation is unsubstantiated. An exit interview was conducted. A copy of this report Confidential Names Form, and Appeal Rights were provided to the facility representative. There were no deficiencies cited during this inspection.

Investigation Findings:
13On 4/13/ Licensing Program Analyst (LPA) Dawn Mahecha made an announced visit to the James Penny House facility for the purpose of a complaint investigation. LPA met with Unit Coordinator (Raeanna Howard) regarding above identified allegation. Investigation consisted of the following: LPA met with and interviewed two (2) staff, unit coordinator and facility manager. Additionally, LPA obtained copies of current staff/client roster, clients needs and service plan, staff recently completed training, staff daily logs from July to August for one client and client discharge log. LPA attempted to interview two children identified as being in the home during the time of the identified incident one child declined to meet with LPA. LPA interviewed four (3) additional children in the home. Investigation revealed the following: It was alleged that minors were not properly supervised while in care. Interviews conducted with staff did not identify an issue with staff monitoring children. Staff had similar statements in stating that there are two (2) staff on duty during the day and one (1) overnight. Staff further stated that there have been no issues working with the children or overseeing the children in care. Staff provided documented incident reports, daily logs of incidents that occurred in the home and times in which UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Yan Yeung LICENSING EVALUATOR NAME: Dawn Mahecha LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200a Monterey Park, CA Facility Name: James Penny House INC.FACILITY NUMBER: VISIT DATE: 04/13/2022

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

met_with: Raeanna Howard, Unit Coordinator


raw_content:
Narrative:
CONTINUED FROM PAGE The Department received a complaint alleging staff at the facility pulled a client by her hair, touched her chest underneath her clothing, pulled her pants down and threatened to lock her in a closet. Staff denied the allegations. Staff reported Ref. #1 (See Confidential Names List LIC811 dated 10/11/22) informed them she did not want to be placed at the facility and staff believe the allegations were made in order to move her to another facility. Statements obtained from interviews conducted with social workers revealed, while Ref #1 was in placement, she was not informed of the alleged incidents reported to the Department. Statements obtained from confidential interviews conducted were unable to corroborate the allegations. There were no witnesses to the alleged incidents. Based on information gathered from interviews conducted and record review, the allegations are unsubstantiated. Although the allegations may have happened or are valid the standard of the preponderance of evidence was not met. A copy of this report and Confidential Names Form LIC811 dated 10/11/22 were given to the above-mentioned facility representative. Exit interview conducted. No deficiencies were cited.

Investigation Findings:
13An unannounced follow up complaint inspection was conducted by Licensing Program Analyst (LPA) Christopher Larios on 10/11/22 at 2: PM. During the inspection LPA Larios met with Facility Manager Danielle Bell. The purpose of the inspection was to deliver findings for the above-mentioned complaint allegations. The investigation was conducted by Community Care Licensing Division (CCLD) Investigations Branch (IB) State Investigator Ruben Munoz and LPA Larios. During the course of the investigation Investigator Munoz conducted interviews with a facility staff on 07/05/22, a County Social Worker (CSW) and one client on 07/06/22 and a placing agency investigator on 07/12/22. LPA Larios conducted interviews with five clients on 07/12/22 and three facility staff on 10/07/22. LPA Larios conducted a record review and obtained copies of client daily logs, special incident reports, client roster and staff roster/contact list on 07/12/22. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Christopher Larios LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200a Monterey Park, CA Facility Name: James Penny House INC.FACILITY NUMBER: VISIT DATE: 10/11/2022

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

met_with: Danielle Bell


raw_content:
Narrative:
It was alleged that staff members (S1, S3) made inappropriate comments while minors were present and encouraged the client (C1) to fight another client residing in the home. Staff (S1, S2, S3) denied the alleged allegations further indicating that all staff members are trauma-informed and understand the importance for each client to complete their individualized program. Staff further indicated that they have not heard nor have clients reported to them any incidents regarding staff using inappropriate language. All staff members denied encouraging anyone to fight, however, further disclosed that an incident occurred involving two clients (C1, C5) who were involved in a physical altercation outside of the facility. S1 further indicated that they were transporting C1 in the vehicle and received a call from another staff member (S2) informing them that C5 had just gone AWOL. S1 indicated that on the way back to the facility they observed C5 less than a block away from the facility, so they (S1) stopped to verbally redirect C5, and in doing so, C1 jumped out of the vehicle and started an altercation with C5. S1 indicated that she attempted to verbally redirect the clients but was not having any luck, so S1 called another staff member (S2) who assisted in separating the clients and taking them back to the facility without any further disruption. An incident report was completed, and all supporting agencies were notified in a timely manner. Information obtained from the above clients denied the alleged allegations further indicating the clients are the ones who threaten and use foul language toward staff when upset. Clients indicated that the staff does a good job of avoiding shouting matches and de-escalating situations that may arise in the facility between clients. Clients further stated that they feel safe and supported by the staff members at the facility. Clients denied that staff encourage them to fight each other. C1 further disclosed that she did get into an altercation outside the facility with a former client (C5). C1 indicated that they were being transported by S1 back to the facility and they had stopped to pick up C5 who had just gone AWOL. C1 stated that she got out of the car and started a verbal altercation with C5 which turned physical and was separated by S1 and S2. Therefore, based on the information received, the above allegations are determined to be unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the allegations are found to be unsubstantiated. Appeal Rights were provided and discussed with the Facility Administrator. There are no deficiencies to be cited at this time. An exit interview was conducted and a copy of the report along with the (LIC 811) was left with the Facility Administrator.

Investigation Findings:
13On October 21, 2022, at 10: AM, Licensing Program Analyst (LPA) Winston Moroney conducted a complaint inspection of the above Short Term Therapeutic Program (STRTP) and met with the STRTP Facility Manager. The purpose of the inspection was to deliver the findings for the above complaint allegations. On June 30, 2022, the California Department of Social Services Community Care Licensing Division received a complaint from Centralized Complaint and Information Bureau (CCIB) with the following allegations: Staff using profanity toward minors, and staff encouraging youth to fight other youth in care. The investigation of the above allegations was conducted by this LPA, and it consisted of but was not limited to a review of records, including the client's needs and services plans, medical records, and interviews with three staff members (S2, S3) on 8/4/22, S3 on 8/11/22, and four clients (C1, C2, C3, C4) on 8/4/22. (No statement was obtained from C5 due to them declining to be interviewed). (Reference Confidential Names Form LIC 811, dated October 21, 2022). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Yan Yeung LICENSING EVALUATOR NAME: Winston Moroney LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200a Monterey Park, CA Facility Name: James Penny House INC.FACILITY NUMBER: VISIT DATE: 10/21/2022

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

met_with: Destiny Tatum - Facility Manager


raw_content:
Narrative:
Page The investigation of the above allegation was conducted by LPA Winston Moroney, and it consisted of but was not limited to a review of records, including the client's needs and services plans, medical records, and interviews with three staff members (S1, S2, S3) on 10/21/22, four clients (C1, C2, C3, C4) on 10/28/22, and the CSW on 11/2/22. (Reference Confidential Names Form LIC 811, dated February 10, 2023). It was alleged that the facility staff handled a client (C4) in a rough manner while trying to redirect them resulting in staff pushing the client into a wall and hitting said client with an object. Information obtained from staff members (S1, S2, S3) denied the alleged allegations further indicating that all staff members are trauma informed and understand the importance of maintaining a healthy relationship with all clients and supporting them in successfully completing their individual programs. Facility staff further indicated that the facility is a hands-off facility and will only place hands on a client to prevent self-harm or bodily harm to others. Staff further disclosed that an incident involving (S3) and C4 occurred on 9/23/22 where (C4) had taken the cell phone into their room knowing that their CSW had informed staff that (C4) was not allowed to use their cellphone unless being supervised by a staff member. S4 indicated that supervision was required due to (C4) sending and receiving inappropriate messages from an unknown male. S3 indicated that when they attempted to retrieve the cell phone C4 ran into the room and began punching a hole in the wall, S4 attempted to verbally redirect and de-escalate the situation from the bedroom doorway when C4 ran and nudged S3 out of the way. S3 further disclosed that after two minutes of using verbal redirection C4 calmed down and proceeded to the living room where staff gave C4's phone back without further incident. Staff indicated that the incident was documented and sent to the appropriate agencies. Information obtained from CSW indicated that they were aware of the incident and when they spoke with C4, they didn't disclose any information indicating that everything was good and that they felt safe. Therefore, based on the information received, the above allegations are determined to be unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the allegations are found to be unsubstantiated. Appeal Rights were provided and discussed with the Facility Administrator. There are no deficiencies to be cited at this time. An exit interview was conducted and a copy of the report along with the (LIC 811) was left with the Facility Administrator.

Investigation Findings:
13On February 10, 2023, at 1: PM, Licensing Program Analyst (LPA) Christopher Larios conducted a complaint inspection of the above Facility on behalf of LPA Winston Moroney and met with Administrator Raeanna Howard. The purpose of the inspection was to deliver the findings for the above complaint allegations. On October 11, 2022, the California Department of Social Services Community Care Licensing Division received a complaint from Centralized Complaint and Information Bureau (CCIB) with the following allegations: Staff handled a minor in a rough manner while in care and Staff do not provide a safe environment for a minor in care. [Continued on Page 2] UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Christopher Larios LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200a Monterey Park, CA Facility Name: James Penny House INC.FACILITY NUMBER: VISIT DATE: 02/10/2023

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

met_with: Raeanna Howard


raw_content:
Narrative:
It was alleged that the staff did not report incidents to appropriate agency, staff did not accept the client back into the facility and facility did not follow the minor's treatment plan. The Ref. #1 (see Confidential Names, LIC Ref. #1 dated February 15, 2023) was placed at the facility on 6/30/22. CCL received Special Incident Report (SIR) dated 7/1/22 stating Ref. #1 attempted to AWOL on 7/1/22 at 5: PM and brought back to the facility by Law Enforcement (LE) on 7/2/22 at 12: AM. Ref. #1 became agitated and walked out of the facility stating they were leaving the facility. Ref. #1 picked up rocks from the flower bed and began throwing rocks at staff and facility's vehicles breaking windows. LE was called and when the Officer arrived, the Officer transported the Ref. #1 to Mark K Shell for 5150 hold. At 6: AM, the Officer called and informed a staff that Ref. #1 made threats to others in the facility so the LE Officer recommended that Ref. #1 not return to the facility. The facility received a call from the hospital requesting to pick Ref. #1 up as they will be discharged. The facility did not pick Ref. #1 up from the hospital because the Ref. #1's bed was closed. The facility contacted the placement county, Fresno Social Worker, regards to discharge of the client; due to immediate danger to staff and clients in the facility, the Ref. #1's bed was closed. The Ref. #1 was placed in the facility without the medication. The facility was informed the Ref. #1's medication will be brought to the facility next day, but the medication never came. Ref. #1's CSW stated that the emergency refill was requested. Staff stated the incidents are reported to appropriate agencies and CCL. Clients interviewed stated incidents are reported to their CSWs as they knew of the incidents. Based on the information gathered, although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that alleged violations occurred, therefore the allegations are unsubstantiated. There were no deficiencies cited during this inspection. An exit interview was conducted. A copy of this report, Confidential Names Form, and Appeal Rights were provided to the facility representative via electronic mail.

Investigation Findings:
13On February 15, 2023, at 1: PM, Licensing Program Analyst (LPA), Karen Suh, conducted a follow-up complaint inspection to deliver the findings of an investigation concerning to the allegations above. The LPA met with the representative named above and discussed the findings. During the course of the investigation, LPA Elnora Smith interviewed four clients on 1/13/23 and 1/17/23, two staff on 1/13/23 and 1/19/23, Administrator on 1/18/23, reporting party on 1/19/23 and one County Social Worker on 1/30/23. The LPA was able to interview one client due to the client is placed at Fresno County Juvenile Hall and one client refused to be interviewed. LPA Karen Suh reviewed copies of documents: SIR dated 7/1/22, Ongoing Foster Placement Request, Health and Education Passport, JV- Order on Application for Psychotropic Medication, JV-220(A) Physician's Statement Attachment, Birth Certificate, IRPC Placement Recommendation, Admission Agreement, Intake Check List, Intake Facesheet, Treatment Recommendations, Need for Care, Nutritional & Physical Functioning Screening, Placement Information, Statement of Dangerous Behaviors, and Preplacement Appraisal Information. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Yan Yeung LICENSING EVALUATOR NAME: Karen Suh LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200a Monterey Park, CA Facility Name: James Penny House INC.FACILITY NUMBER: VISIT DATE: 02/15/2023

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

met_with: Penny Brown, Unit Coordinator


raw_content:
Narrative:
The investigation revealed that staff were present, attempted to redirect Ref. #2 and attempted to shield Ref. #1 from Ref. #2. Interviews with the CSW revealed no concerns with the facility. Ref. #2's CSW did not the attribute the client's behavior to lack of supervision on the part of the staff. The LPA was unable to corroborate the allegations There was no preponderance of the evidence to substantiate the allegation. So, although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the allegations are unsubstantiated. There are no deficiencies to be cited regarding this allegations. A copy of this complaint was provided to the facility representative.

Investigation Findings:
On April 14, 2023 at 3:10 p.m., Licensing Program Analyst (LPA), Karen McGee, delivered the findings of a complaint investigation to the facility. The LPAs met with Facility Manager, Danielle Bell. On January 17, 2023, the Monterey Park Children's Residential Program (MPCRP), received a complaint with the above mentioned allegations. Confidential interviews were conducted that included, but were not limited to: the Administrators and the Client, Ref. #1 at the facility on January 20, 2023; County Social Worker (CSW) for Ref. #1 and #2 via telephone on April 5, 2023. The LPA was unable to locate Ref. #2 in order to interview Ref. #2. The LPA reviewed the clients' Needs and Services Plans and Special Incident Reports. The investigation revealed that Ref. #2 was angry and instigated a fight with Ref. #1, because Ref. #2 believed that Ref. #1 was taking to long in the bathroom. The investigation revealed that Ref. #1 was on the telephone in the bathroom. It revealed that the staff told Ref. #2 to use the other bathroom. The investigation revealed that a staff announced to Ref. #1 that they were going to unlock the bathroom door, because Ref. #1 had been in there about 40 minutes. It revealed that when the staff unlocked the door, Ref. #2 went around the staff to fight Ref. #1. The investigation revealed that the staff separated the clients. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Karen McGee LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200a Monterey Park, CA Facility Name: James Penny House INC.FACILITY NUMBER: VISIT DATE: 04/14/2023

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


raw_content:
Narrative:
The staff was able to remove the Pinesol from C1's hands and the crisis team had to be called in order to deescalate C1's behavior. The staff was sent home remainder of the staff's shift due to staff could not see, especially with staff's left eye. During confidential interviews with clients revealed that two clients indicated that the staff spoke inappropriately to C1. One client did not deny or confirm the allegation and another client refused to be interviewed. Statements obtained from the confidential interviews provided contradictory information regarding the allegation and did not provide sufficient information to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that alleged violation occurred, therefore the allegation is unsubstantiated. There were no deficiencies cited during this inspection. An exit interview was conducted. A copy of this report, Confidential Names Form, and Appeal Rights were provided to the facility representative via electronic mail.

Investigation Findings:
13On January 23, 2024, at 1: PM, Licensing Program Analyst (LPA) Karen Suh conducted a follow-up complaint inspection to deliver the finding of an investigation concerning to the allegation above. The LPA met with the representative named above and discussed the finding. The investigation included confidential interviews that consisted of but were not limited to: four clients, two staff on August 11, 2023, and Administrator on December 13, 2023. The LPA was unable to contact the County Social Workers (CSW) after several attempts. The LPA reviewed client's (C1; see Confidential Names LIC 811, dated January 23, 2024) Needs and Services Plan, Child and Family Team (CFT) Meetings Report, Special Incident Report, and Daily Logs. It was alleged that staff spoke inappropriately to a client. Staff denied the allegation. It was revealed that staff was cleaning and had the Pinesol out. C1 became upset with the staff and sprayed the Pinesol on staff's face and clothes. (cont.) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Yan Yeung LICENSING EVALUATOR NAME: Karen Suh LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200a Monterey Park, CA Facility Name: James Penny House INC.FACILITY NUMBER: VISIT DATE: 01/23/2024

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

met_with: Raeanna Howard, Administrator


raw_content:
Narrative:
Based on the information obtained during the investigation, it cannot be determined whether the above allegation occurred. Based upon interviews, the complaint findings are unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations occurred. No deficiencies were cited. An exit interview was conducted, and a copy of this report was emailed to the above-named facility staff.

Investigation Findings:
13On 04/17/23, Licensing Program Analyst (LPA) Johanna Lofton conducted an unannounced inspection visit at James Penny House STRTP with the purpose of delivering findings regarding the above complaint allegation. During the visit, LPA Lofton met Facility Administrator Raeanna Howard and discussed the findings. During the investigation, LPA Lofton interviewed facility staff regarding the allegation. LPA Lofton attempted to interview the complainant, clients, and social workers (See LIC811-Confidential Names List dated 041724). Confidential interviews revealed the allegation did not take place at the facility. It was reported that clients awol and during the unauthorized absence they have sexual contact and give hickeys to one another. Furthermore, during a casual conversation with LPA, clients confirmed the incidents did not happen at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Johanna Lofton LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200a Monterey Park, CA Facility Name: James Penny House INC.FACILITY NUMBER: VISIT DATE: 04/17/2024

met_with: Raeanna Howard- Facility Administrator


raw_content:
Narrative:
Based on the information obtained during the investigation, it cannot be determined whether the above allegation occurred. Based upon interviews, the complaint findings are unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations occurred. No deficiencies were cited. An exit interview was conducted, and a copy of this report was emailed to the above-named facility staff.

Investigation Findings:
13On 04/17/23, Licensing Program Analyst (LPA) Johanna Lofton conducted an unannounced inspection visit at James Penny House STRTP with the purpose of delivering findings regarding the above complaint allegation. During the visit, LPA Lofton met Facility Administrator Raeanna Howard and discussed the findings. During the investigation, LPA Lofton interviewed facility staff regarding the allegation. LPA Lofton interviewed the complainant and facility staff. LPA attempted to interview clients, and social workers (See LIC811-Confidential Names List dated 04/17/24). Interviewed parties denied the allegation. Facility staff reported being vigilant of the clients at the facility because they have observed clients acting inappropriately with one another. Furthermore, it was denied such allegation happened at the facility. It was reported clients during clients' unauthorized absences, they have sexual contact and give hickeys to one another. During a casual conversation with LPA, clients confirmed the incidents did not happen at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Johanna Lofton LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200a Monterey Park, CA Facility Name: James Penny House INC.FACILITY NUMBER: VISIT DATE: 04/17/2024

met_with: Raeanna Howard-Facility Administrator


raw_content:
Narrative:
It was alleged staff transported minors in care without providing proper accommodation. Staff denied the allegation. Staff stated that when clients are transported, there are at least two staff in the car. On the day of incident, there were staff with two clients in transit. Client 1 (C1) became upset when the staff did not open the van window enough to stick their head out the window. C1 then removed their seat belt off and refused to put it back on. C1 then stood up and tried to reach for steering wheel. A staff intervened and moved to the back seat of the van and staff provided multiple redirections. C1 continued to stand up inside the van trying to reach for the steering wheel. Staff pulled over on the side of the road and that is when C1 climbed into the front seat and left the van. C1 ran into the middle of the road and staff followed and provided redirections. However, C1 refused and sat in the middle of the street and refused to get up. Law enforcement was contacted and C1 was transported to the hospital. The LPA was unable to obtain any statements from clients as they declined to be interviewed. The statements obtained from the confidential interviews did not provide sufficient information to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that alleged violation occurred, therefore the allegation is unsubstantiated. There were no deficiencies cited during this inspection. An exit interview was conducted. Appeal rights explained and a copy of this report, and Appeal Rights were provided to the facility representative.

Investigation Findings:
13On May 13, 2025, at time, Licensing Program Analyst (LPA), Caitilin Chambers, delivered the finding on behalf of LPA Karen Suh, the investigating LPA. The LPA met with the Facility Manager, Aeesha Bell were not limited to: Administrator on November 22, 2024, and two staff on December 11, 2024. The LPA was unable to interview three clients (see Confidential Names LIC 811, dated May 13, 2025) as they declined to be interviewed. The LPA was unable to contact the County Social Workers (CSW) after several attempts. The LPA reviewed Updated Monthly Report, Children's Mental Health Assessment, Qualified Individual Report, Placement Preservation Plan, Treatment Recommendations, Child and Family Team Meeting (CFTM) Summary and Action Plan, Needs and Services and Treatment Plan, Timeline since placement, Individual Education Program (IEP), and Special Incident Report. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Yan Yeung LICENSING EVALUATOR NAME: Caitlin Chambers LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200a Monterey Park, CA Facility Name: James Penny House INC.FACILITY NUMBER: VISIT DATE: 05/13/2025

met_with: Facility Manager, Aeesha Bell


raw_content:
Narrative:
...page Complainant was interviewed August 6, 2024. CSW was unable to be interviewed. C2 was unable to be interviewed C1, C3 and S1-S3 (See confidential names list LIC 811 dated June 6, 2025) were interviewed August 27, 2024. The investigation revealed the following: It was alleged that staff did not prevent a minor from being sexually abused by another minor. In confidential interviews it was revealed that a youth consented to a sexual act by another youth in the STRTP. The youth said that it occurred because of peer pressure. Youth revealed that staff was unaware of the incident occurring. Further, youth admitted that staff was present in the facility and reported the incident to staff. Youth said that she called the police. Confidential interviews with staff show a history of police activity in the home for fights and youth leaving without permission. Staff did not confirm police activity for any sexual activity between youths. Staff did not confirm that sexual activity between youths was seen, or staff made aware of it. Staff revealed that there have been consensual relationships between youths in the facility, but it has since ended. LPA reviewed requested documents and did not observe any activity to prove the allegations. Based on the information gathered, although the allegations may have happened or is valid, the preponderance of evidence to prove the allegations was not met, therefore the allegation is unsubstantiated. A copy of this report and Appeal Rights were provided to facility manager. Exit interview was conducted.

Investigation Findings:
13On June 6, 2025, at 3: P.M. Licensing Program Analyst (LPA) Demetris Teal conducted an unannounced visit to James Penny House INC. for the purpose of concluding the above identified complaint investigation. LPA met with Melissa Luevano-Facility Manager and discussed complaint findings. The investigation consisted of the following: On August 6, 2024, LPA met with Adrien Jackson- Facility Manager. LPA requested a copy of the LIC 500, list of current clients, needs and services plans, staff notes for review, police reports and incident reports. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Demetris Teal LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200a Monterey Park, CA Facility Name: James Penny House INC.Facility Number: Visit Date: 06/05/ Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32...page Complainant was interviewed August 6, 2024. CSW was unable to be interviewed. C2 was unable to be interviewed C1, C3 and S1-S3 (See confidential names list LIC 811 dated June 6, 2025) were interviewed August 27, 2024. The investigation revealed the following: It was alleged that staff did not prevent a minor from being sexually abused by another minor. In confidential interviews it was revealed that a youth consented to a sexual act by another youth in the STRTP. The youth said that it occurred because of peer pressure. Youth revealed that staff was unaware of the incident occurring. Further, youth admitted that staff was present in the facility and reported the incident to staff. Youth said that she called the police. Confidential interviews with staff show a history of police activity in the home for fights and youth leaving without permission. Staff did not confirm police activity for any sexual activity between youths. Staff did not confirm that sexual activity between youths was seen, or staff made aware of it. Staff revealed that there have been consensual relationships between youths in the facility, but it has since ended. LPA reviewed requested documents and did not observe any activity to prove the allegations. Based on the information gathered, although the allegations may have happened or is valid, the preponderance of evidence to prove the allegations was not met, therefore the allegation is unsubstantiated. A copy of this report and Appeal Rights were provided to facility manager. Exit interview was conducted. SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Demetris Teal LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 2 of 2

met_with: Melissa Luevano-Facility Manager


summary: Complaint Investigation - Unsubstantiated - 3 allegations

raw_content:
Narrative:
Page The Department received a complaint alleging a client (C1) (See Confidential Names list LIC811 dated 6/5/25) sustained injuries as a result form and altercation with a staff (S1). LPA Larios was unable to obtain a statement from S1 due to expired contact information. However, record review revealed S1 denied physically abusing C1 to another agency's investigator. The victim maintained she was hit on the face and scratched on her neck by S1 resulting in injuries. Statements obtained from confidential interviews conducted did not support the allegation. Witnesses reported C1's behavior prompted two staff to initiate multiple restraints during the afternoon of 1/5/25. However, none of the facility clients or other staff present reported observing S1 physically abuse or hit C1. Furthermore, witnesses reported observing an altercation between C1 and another youth during the incident, where the other youth was observed hitting C1 on her head. In addition, a social worker met with C1 on 1/8/25 and described the reported eye injury as "not fresh" and a scratch on C1's neck as "closing and healing". The social worker reported the injuries could have occurred prior to the reported incident. Based on information gathered from interviews conducted and record review the allegation is unsubstantiated. Although the allegation may have happened or is valid, the standard of the preponderance of evidence was not met. A copy of this report and LIC811 dated 6/9/25 were given to the above-mentioned facility representative. Exit interview conducted. No deficiencies were cited.

Investigation Findings:
13An unannounced follow up complaint inspection was conducted by Licensing Program Analyst (LPA) Christopher Larios was conducted on 6/9/25 at 9: AM. During the inspection LPA Larios met with Administrator Raeanna Howard. The purpose of the inspection was to deliver findings regarding the above-mentioned complaint allegation. During the course of the investigation LPA Larios conducted interviews with five facility clients, two facility staff and a social worker between 1/15/25 and 6/4/25. In addition, on 1/15/25, LPA Larios conducted a record review and obtained copies of the LIC500 and staff contact information, a staff termination report, LIC9020, client medical records, shift log, incident reports and daily progress notes. Also, on 6/3/25, LPA Larios obtained another agency's investigation narrative. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Christopher Larios LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200a Monterey Park, CA Facility Name: James Penny House INC.FACILITY NUMBER: VISIT DATE: 06/09/2025

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0


raw_content:
Narrative:
It was alleged that Staff handled minor in a rough manner and Staff spoke inappropriately about minor to other children in care. All relevant parties denied the allegations. Confidential interviews were consistent and did not collaborate the allegation. Based on the information gathered during confidential interviews the allegations are unsubstantiated. Although the allegations may have happened or are valid, the standard of the preponderance of evidence was not met. An exit interview was conducted, and a signed copy of this report was provided to the facility licensee along with LIC9099C. Appeal rights explained.

Investigation Findings:
On July 11, 2025, Licensing Program Analyst (LPA) Angelina Garibaldo conducted an unannounced follow up complaint inspection visit at James Penny (STRTP) and met with Administrator, Raeanna Howard for the purpose of delivering findings for the above allegations. During the course of the investigation, LPA Garibaldo interviewed the Administrator and two (2) Clients (C2, and C3) on 06/13/25, County Social Worker (CSW) and Client 1 (C1) on 07/07/25, Former Client (FC), and on 07/09/ Client 4 (C4) on 07.11.25. LPA also reviewed documents including but not limited to staff training and certificates, special incident reports (SIRs), Needs and Services Plans (NSPs), and case notes. LPA also reviewed Department databases for past and current complaints. (Reference Confidential Names list LIC811 dated 07/11/25). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Angelina Garibaldo LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200a Monterey Park, CA Facility Name: James Penny House INC.FACILITY NUMBER: VISIT DATE: 07/11/2025


raw_content:
Narrative:
Special Incident Reports (SIRs). LPA also reviewed Department databases, and reports from other agencies. On June 11, 2025, the Department received a complaint alleging that lack of staff supervision resulted in a minor engaging in inappropriate activity. It was also alleged that staff did not prevent minor from AWOLing. And lastly, it was alleged that staff did not report incident. Interviews with facility staff resulted in denials of all allegations. Staff stated that they conducted their room checks as per protocol, and that the door to the minors' rooms are usually ajar unless someone is changing in the room, allowing for extra visibility. Staff denied seeing any inappropriate activity being done by clients. Staff stated that they could not control what happened while minors were on unauthorized leave away from the facility, but that they did caution all minors against leaving for that same reason. Staff stated that redirection is used when minors attempt to leave unauthorized, but that they cannot forcibly stop any client from leaving, so they do what they can and then report accordingly to law enforcement, the client's authorized representatives and community care licensing (CCL). Staff stated that they did report what the client revealed to them upon the client's return from an unauthorized absence to appropriate authorities. Confidential interviews conducted by LPA revealed contradicting statements regarding the allegations, including whether client revealed to staff what happened during their unauthorized leave and also statements that staff do try to discourage clients from leaving through redirection, and that staff cannot place hands on clients to prevent them from leaving. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the allegations are determined to be Unsubstantiated. No deficiencies were cited at this time. Exit interview conducted. A signed copy of this report, LIC9099-C, and LIC811 were provided to Raeanna Howard, Administrator. Appeal rights provided.

Investigation Findings:
13On August 26, 2025, at 10:50 a.m., Licensing Program Analyst (LPA) John Bonilla conducted a follow-up complaint investigation at James Penny House Inc., a Short-Term Residential Therapeutic Program (STRTP), for the purpose of delivering findings on the above allegations. LPA met with Raeanna Howard, Administrator LPA's investigation consisted of the following: On 06/10/25, LPA Brent Lockhart interviewed an adult. On 06/16/25, LPA interviewed an adult. On 06/17/24, LPA conducted 10 day at STRTP, interviewd two staff, and interviewed one client. On 06/18/25, LPA interviewed one client. On 06/19/25, LPA interviewed one staff and one client. On 06/24/25, LPA interviewed an adult. On 08/12/25, LPA interviewed three professional contacts and attempted to interview two additional professional contacts. On 08/18/25, LPA Lockhart interviewed a staff. On 08/25/25, LPA interviewed two staff, reviewd the STRTP's complaint history, and reviewed documents collected throughout the investigation including but not limited to LIC Personnel Report, LIC Register of Clients, Staff Contact Numbers, Needs and Service Plans (NSPs) for Clients 1 through 5 (See LIC Confidential Names list dated 06/17/25), and relevant (Continued next page...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: John Bonilla LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200a Monterey Park, CA Facility Name: James Penny House INC.FACILITY NUMBER: VISIT DATE: 08/26/2025

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


raw_content:
Narrative:
Page The Department received a complaint alleging a client was sexually assaulted due to inadequate supervision by staff, staff did not seek medical attention for a minor, and staff does not prevent a minor from AWOLing. The facility administrator denied the allegations. Information gathered during the investigation did not support the allegations. Statements obtained from confidential interviews conducted indicate the alleged sexual assault occurred when the client was AWOL from the facility. The client was able to AWOL due to the presence of other clients at the facility who required supervision. The facility contacted law enforcement and reported the AWOL. Law enforcement records revealed three interviews were attempted with the client before the assault was disclosed. After the disclosure, staff transported the client to the hospital to have a medical exam completed. Based on interviews and records review conducted by SI Lomeli and LPA Larios, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED. A copy of this report and Confidential Names form LIC811 dated 9/15/25, were provided to the above-mentioned facility representative. Exit interview conducted. No deficiencies were cited.

Investigation Findings:
13A follow up complaint inspection was conducted by Licensing Program Analyst (LPA) Christopher Larios on 9/15/25, at 12: PM. During the inspection LPA Larios met with Administrator Raeanna Howard. The purpose of the inspection was to deliver findings regarding the above-mentioned complaint allegations. The investigation was conducted by Community Care Licensing Division (CCLD) Investigations Branch (IB) State Investigator (SI) Mariana Lomeli and LPA Larios. During the course of the investigation SI Lomeli conducted interviews with the facility administrator on 5/22/25 and a client on 5/27/25 (See Confidential Names list LIC811 dated 9/15/25). In addition, LPA Larios interviewed a social worker on 9/11/25. LPA Larios attempted to interview one staff, but the staff separated from the facility during the investigation and contact information is out of service. (Continued on page 2) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Christopher Larios LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200a Monterey Park, CA Facility Name: James Penny House INC.FACILITY NUMBER: VISIT DATE: 09/15/2025

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0


raw_content:
Narrative:
Confidential interviews were completed on 04/04/25 with R1, C2,04/16/25 with C3,C5, (Reference Confidential Names Form LIC 811, dated September 19, 2025). The investigation revealed the following: At the time of the investigation, five youth were placed in the home. Three youth agreed to be interviewed, while one declined to provide statements. and one had been discharged before the follow-up interview attempt. The youth interviewed denied that alcohol was present or consumed in the facility. They also denied that staff failed to intervene in fights or assaults, or that staff allowed inappropriate sexual behavior or mistreatment to occur. The youth stated that staff are present when issues arise, that they feel safe in the home, and that they can bring concerns to staff who respond when needed. Staff interviews supported these statements. Staff denied allowing alcohol in the facility or observing youth drinking. Interviewed staff also denied failing to prevent youth from being attacked or engaging in inappropriate sexual behavior. Staff stated that youth are encouraged to share concerns and that staff address issues as they come up. A collateral contact further confirmed that youth placed in the home had not reported any concerns about safety, supervision, or peer conflict. The collateral contact reported that youth spoke positively about the facility, felt safe, and described the environment as supportive. Based on the confidential interviews, the complaint is unsubstantiated. An unsubstantiated determination means the allegation lacks a preponderance of the evidence to prove that the violation occurred. There are no deficiencies to be cited at this time. LPA Martinez conducted an exit interview and provided a signed LIC 9099 to the facility representative.

Investigation Findings:
13On 09/19/25, Licensing Program Analyst (LPA) Joe Martinez conducted a follow-up complaint inspection at the Short Term Residential Therapeutic Program (STRTP). LPA Martinez met with the facility representative named above. The inspection aims to deliver the finding for the above allegation(s). On 04/02/25, the Community Care Licensing Division of the California Department of Social Services received a complaint from the Centralized Complaint and Information Bureau (CCIB) with the following allegation(s): Staff do not prevent the minors from drinking alcohol while in care, Staff do not prevent the minors from attacked from other minors while in care, Staff did not prevent a minor from engaging in inappropriate sexual behavior while in care, Staff do not prevent the minors from being mistreated while in care. LPA Martinez investigated the above allegation. The investigation included a review of records and confidential interviews, but it was not limited to these. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Yan Yeung LICENSING EVALUATOR NAME: Joe Martinez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200a Monterey Park, CA Facility Name: James Penny House INC.FACILITY NUMBER: VISIT DATE: 09/19/2025

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


summary: Facility Evaluation

raw_content:
Narrative:
On August 9, Licensing Program Analysts (LPAs) Jean Herring, Juliet Robles and Raymond Wu conducted an unannounced inspection at the facility at 10: AM. LPAs met with Danielle Bell, Facility Manager (FM). The purpose of the inspection was to conduct an Annual/Required inspection of the facility. The facility currently has a provisional Short Term Residential Therapeutic Program (STRTP) license. The STRTP's Mental Health Program Application is pending approval. The STRTP has not submitted an application for National Accreditation. This STRTP is licensed to serve up to six (6) ambulatory children ages 11-17 years of age. The facility also provide services to non-minor dependents pursuant to W&I Code 16501.1 (C)(1). There are four (4) ambulatory minors and one(1) ambulatory non-minor dependent currently in placement. This facility is a one-story home with three (3) bedrooms, two (2) bathrooms, one (1) office, kitchen, dining, formal living rooms, and family room. Physical Plant The license is posted in a prominent, publicly accessible location in the facility. Disinfectants, cleaning solutions and sharps are locked in a walk-in closet located in the office. Facility has non-perishable foods for at least one week and perishable foods for at least two days. Facility provides at least three(3) meals per day. Medications are centrally stored and locked in the office. All kitchen, food preparation, and storage areas are kept clean and free of rodents and other vermin. Facility has one or more carbon monoxide detectors in the facility. Facility provides basic laundry services. Room temperatures are maintained at 76 degrees F. The hot water temperature was tested and measured at 115 degrees F. All toilets, handwashing and bathing facilities are maintained in safe and sanitary operating condition and meet the requirements. No more than 2 children share a bedroom. All beds are in good repair; equipped with good springs and a clean mattress; and supplied with pillows which are clean and in good repair. Facility provides age-appropriate clothing items and hygiene products. Overall, facility is clean, safe sanitary and in good repair. Operations Facility maintains a current, written plan of operation that meets licensing standards. Facility maintains a register of clients and the register is available upon request. Facility maintains and implements written complaint procedures and the procedures are posted in a publicly accessible location in the facility. The board of directors regularly conducts meeting to review and discuss the STRTP's operation. Cash resources are kept on the facility premises in a locked and secure location. Client Records All client records are available to the licensing agency to inspect, audit and copy upon demand. Client records contain required information including, but not limited to, consent forms, court orders, needs and services plan, removal/discipline/complaint procedures; medical assessment; safeguards for cash resources, personal property and valuables; education records; personal rights forms; and medication administration records. LPAs interviewed two(2) clients during the inspection. Core/Therapeutic Services Facility provides core services and supports to children and non-minor dependents as appropriate or necessary that are trauma informed, culturally relevant, age and developmentally appropriate and include the following: Medi-Cal specialty mental health services; transition support services; educational and physical, behavioral, and mental health supports; activities to support children and non-minor dependents and services to achieve permanency. One(1) Type A Deficiency cited during this inspection. LPAs provided three (3) Advisory Notes-Technical Violation (LIC9102TV) and one (1) Advisory Notes-Technical Assistance (LIC 9102TA). Appeal rights provided. An Annual/Required Continuation inspection is required. An exit interview was completed and a signed copy of this report was provided to the facility representative.

met_with: Danielle Bell, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On August 10, Licensing Program Analysts (LPAs) Jean Herring and Raymond Wu conducted an unannounced inspection of the facility at 9: AM. LPAs met with Danyelle Jones, Unit Coordinator and Robert Carter, STRTP Director. The purpose of the inspection was to conduct a Case Management - Annual Continuation inspection of the facility. During this inspection, LPAs reviewed the Emergency Intervention Plan, Emergency and Disaster Preparedness Plan, and Staff Records. Emergency Intervention Plan Facility maintains a monthly log of each use of manual restraints that contains all required information. The log is available for review by the Department upon request. LPAs observed documentation of Emergency Intervention Training and on-going training. Disaster Preparedness Plan Facility maintains a current, written disaster and mass casualty plan of action. Facility conducts disaster drill at least quarterly for each shift. The drills are documented and the documentation is maintained in the facility for at least a year. Facility maintains an emergency and disaster plan, register of clients, Needs and Services Plan for each client, medication records, and contact information for each client's responsible party and physician. Staff Records LPAs reviewed seven(7) personnel records. All individuals subject to criminal records review have been fingerprinted and signed a Criminal Record Statement. Personnel records are maintained on the licensee, administrator and each employee. The administrator meets the required qualifications and/or experience. Documentation of the required education and experience requirements are maintained in the personnel file. Facility Managers meet requirements. Personnel records contain documentation of 24-hour initial training, and 40-hour annual training in addition to CPR and First Aid. This inspection reveals that seven (7) out of 7 personnel records reviewed by LPAs, do not contain health screening and TB test documents. There are two(2) Type B deficiencies cited and two (2) Advisory Notes-Technical Violation (LIC9102TV) provided during this inspection. Appeal rights provided. An exit interview was conducted and a signed copy of this report was provided to the facility representative.


summary: Facility Evaluation

raw_content:
Narrative:
On August 10, Licensing Program Analysts (LPA) Jean Herring conducted an unannounced inspection of the facility at 2: PM. LPA met with Danyelle Jones, Unit Coordinator and Robert Carter, STRTP Director. The purpose of the inspection was to verify proof of correction to the deficiency cited on 8/9/21 re: Fire Clearance violation. During today's inspection, licensee submitted a Local Fire Inspection Authority Information required by the Department (LIC 9054). The deficiency is cleared. LPA provided a Plan of Correction (POC) Clearance letter along with this report. Appeal rights provided.


summary: Facility Evaluation

raw_content:
Narrative:
On 8/17/21 at 8: AM, Licensing Program Analysts (LPAs) Jean Herring and Pamela Silva arrived at the facility named above for the purpose of conducting a SB Psychotropic Medication Inspection. LPAs met with Danyelle Jones, Unit Coordinator. There are two(2) clients on psychotropic medications placed in the home. LPAs conducted a facility tour at 9: AM. LPAs reviewed two(2) client records at 9: AM. Medications were also inspected. LPAs reviewed two(2) staff records at 10: AM. LPAs began interviewing staff at 10: AM. Both clients were not available to be interviewed at the time of inspection. LPA conducted an exit interview with Ms. Jones at 11: AM. No deficiencies to be cited at this time. A signed copy of this report was provided to the facility representative along with Confidential Name/s list (LIC 811.)

met_with: Danyelle Jones, Unit Coordinator and Robert Carter,


summary: Facility Evaluation

raw_content:
Narrative:
On 9/09/21 at 4: PM PM, Licensing Program Analyst (LPA) Jean Herring arrived at the facility named above for the purpose of interviewing two clients in order to complete the SB Psychotropic Medication Inspection initiated on 8/17/21. C1 and C2 were not available for interview during the previous inspection. (See Confidential Name/s list (LIC811) provided on 8/17/21.) LPA met with Raeanna Howard, Unit Coordinator. LPA completed SB 484 client interviews. A signed copy of this report was provided to the facility representative.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Dina Camara conducted a case management inspection on November 9, 2021 at 11: AM based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. 4 out of Direct Care Staff and 6 out of 6 youth files as identified on the LIC 811 confidential names dated November 9, 2021, were reviewed. 3 out of Direct Care Staff and 2 out of 6 youth were interviewed. The Plan of Correction including policies and procedure were reviewed A copy of this report was discussed and provided to Danyelle Jones, Unit Coordinator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Dina Camara and Licensing Program Manager Angela King conducted a case management inspection 08/09/22 at 9: AM based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 9 out of Direct Care Staff and 6 out of 6 youth files were reviewed. 2 out of Direct Care Staff and 4 out of 6 youth were interviewed. (See the Confidential Names List, LIC 811, dated 08/09/2022). The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments and youth case plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Dina Camara and LPM Angela King observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Calissa Walker, Administrator.

met_with: Robert Carter, Director and Calissa Walker, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Jenny Mundo on September 21, 2022 at 11: AM. During the inspection, LPA met with Raeanna Howard, Unit Coordinator 1. LPA and the Unit Cooedinator 1 inspected the facility inside and out. LPA reviewed four (4) child's records on site at the facility at 11: AM. LPA reviewed two (2) staff personnel files on site at the facility at 1: PM. LPA reviewed four (4) child's psychotropic medications and medication records at 11: AM. LPA interviewed one (1) staff on site at 1: PM. LPA interviewed two (2) child on site at 1: PM. LPA conducted exit interview with Raeanna Howard, Unit Coordinator 1 at 2: PM. LPA provided the Summary Report to the Unit Coordinator 1 upon completion. No deficiencies are being cited at this time.

met_with: Raeanna Howard, Unit Coordinator 1


summary: Facility Evaluation

raw_content:
Narrative:
On September 22, Licensing Program Analysts (LPAs) Dawn Mahecha and Tommy Davis conducted an unannounced inspection at the facility at 11: AM. LPAs met with Unit Coordinator Raeanna Howard (UC). The purpose of the inspection was to conduct an Annual/Required inspection of the facility. The facility currently has a provisional Short Term Residential Therapeutic Program (STRTP) license. The STRTP's Mental Health Program Application is pending approval. The STRTP has submitted an application for National Accreditation and is receiving their inspection on October 19,2022.. This STRTP is licensed to serve up to six (6) ambulatory children ages 11-17 years of age. The facility also provide services to non-minor dependents pursuant to W&I Code 16501.1 (C)(1). There are four (6) ambulatory minors currently in placement. This facility is a one-story home with three (3) bedrooms, two (2) bathrooms, one (1) office, kitchen, dining, formal living rooms, and family room. Physical Plant The license is posted in a prominent, publicly accessible location in the facility. Disinfectants, cleaning solutions and sharps are locked in a walk-in closet located in the office. Facility has non-perishable foods for at least one week and perishable foods for at least two days. Facility provides at least three(3) meals per day. Medications are centrally stored and locked in the office. All kitchen, food preparation, and storage areas are kept clean and free of rodents and other vermin. Facility has one or more carbon monoxide detectors in the facility. Facility provides basic laundry services. Room temperatures are maintained at 76 degrees F. The hot water temperature was tested and measured at 111.5 degrees F. All toilets, hand washing and bathing facilities are maintained in safe and sanitary operating condition and meet the requirements. No more than 2 children share a bedroom. All beds are in good repair; equipped with good springs and a clean mattress; and supplied with pillows which are clean and in good repair. Facility provides age-appropriate clothing items and hygiene products. Overall, facility is clean, safe sanitary and in good repair. During this inspection LPA Davis reviewed five (5) staff files including Administrator and STRTP Director and three (3) client files. . Exit interview was conducted, no deficiencies cited and a signed copy of this report was emailed to the Unit Coordinator.

met_with: Raeanna Howard, Unit Corrdinator 1


summary: Facility Evaluation

raw_content:
Narrative:
On 11/30/ Licensing Program Analyst (LPA) Dawn Mahecha made an unannounced visit to the James Penny House facility for the purpose of a case management incident. LPA met with Administrator and discussed the following: C1 having a gun pulled on them by another student. Administrator stated the following: Child informed staff that an unknown child at school pulled a gun on them. Staff followed up with school and school stated that child no longer attended school and that school would notify local law enforcement regarding incident. LPA requested a copy of the submitted incident report and any documentation from school or local law enforcement of what facility is doing to protect child in care. Child is no longer placed in home and no further information was provided regarding incident. Based on information received incident did not occur at facility and staff followed protocol in notifying school and ensuring incident was documented and child was being protected. Exit interview completed, no deficiencies cited or observed and a copy of this report was provided to Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On November 30, Licensing Program Analysts (LPAs) Dawn Mahecha and Tommy Davis conducted an unannounced inspection at the facility at 12:45PM. LPAs met with Administrator Raeanna Howard (Admin). The purpose of the inspection was to conduct an Annual/Required inspection of the facility. This STRTP is licensed to serve up to six (6) ambulatory children ages 11-17 years of age. The facility also provide services to non-minor dependents pursuant to W&I Code 16501.1 (C)(1). There are three (3) ambulatory minors currently in placement. This facility is a one-story home with three (3) bedrooms, two (2) bathrooms, one (1) office, kitchen, dining, formal living rooms, and family room. Physical Plant The license is posted in a prominent, publicly accessible location in the facility. Disinfectants, cleaning solutions and sharps are locked in a walk-in closet located in the office. Facility has non-perishable foods for at least one week and perishable foods for at least two days. Facility provides at least three(3) meals per day. Medications are centrally stored and locked in the office. All kitchen, food preparation, and storage areas are kept clean and free of rodents and other vermin. Facility has one or more carbon monoxide detectors in the facility. Facility provides basic laundry services. Room temperatures are maintained at 76 degrees F. The hot water temperature was tested and measured at 126.0 degrees F warning signs were posted of temperature being over 120 degrees F. All toilets, hand washing and bathing facilities are maintained in safe and sanitary operating condition and meet the requirements. No more than 2 children share a bedroom. All beds are in good repair; equipped with good springs and a clean mattress; and supplied with pillows which are clean and in good repair. Facility provides age-appropriate clothing items and hygiene products. Overall, facility is clean, safe sanitary and in good repair. During this inspection LPA Davis reviewed three (3) staff files including Administrator and STRTP Director and three (3) client files. . Exit interview was conducted, no deficiencies cited and a signed copy of this report was provided to the Administrator.