summary: Complaint Investigation - Substantiated - 1 deficiency - 1 allegation

raw_content:
Narrative:
unauthorized absences, per the consumer notes, which were not reported to Licensing, and which could not be confirmed as reported to the authorized representative due to lack of submission of written report: 3/3/21-3/4/21, 3/20/21-3/31/21, 4/25/21- 4/26/21, 4/28/21- 5/3/21, 5/4/21, 5/18/21 -5/19/21, 5/29/21, 5/31/21, 06/01/21. In addition, interviews and documented submitted to LPA indicated that the facility did not maintain in C1's file C1's valid work permit or work schedule, and authorized representative was not able to confirm C1's employment. Also, when C1 would leave on unauthorized absences, staff would check in on C1 via text, and C1 would check in with staff via phone or by text. However, on-site supervising staff did not always directly notify C1's case manager of unauthorized absences the night priors or authorized representative. It was reported that the facility would allow C1 to leave without a pass or authorization from authorized representative due to feeling that C1 was working hard at work and school. Per authorized representative, when they spoke to the school, they learned that C1 was failing their classes. LPA obtained a copy of (C1) school transcripts, report cards, and this was confirmed to be true. Also, obtained a copy of (C1) progress report from March and (C1) had a total of 9 unexplained absences from 02/22/2021 to 03/16/21. Based on the information obtained, there is a preponderance of the evidence to prove that the facility staff allowed the minor to AWOL, staff did not notify the minors authorized representative of the AWOLs, staff not meeting clients' needs, and staff not checking in on minors. Therefore, the above allegation is substantiated. Appeal Rights were provided and discussed with the facility and deficiencies were cited. Exit interview conducted and a copy of the report was left with the facility.

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

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

Deficiencies:
86065: 1
2
3
4
5
6
7

met_with: Frank Delgado and Deb Miller

title:
Personnel Requirements (a) Facility personnel shall be competent to provide the services necessary to meet individual participant needs and shall.....
This requirement is not met as evidenced by

description:
1
2
3
4
5
6
7


state: CA

facility_name: UNITY CARE GROUP

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Due to the insufficient information and interviews LPA Mendoza was unable to confirm if the above allegations happened. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that there was a violation of personal rights, and staff consuming alcohol while working therefore, the above allegation are Unsubstantiated. An exit interview was conducted, and a copy of the report was left with the facility.

Investigation Findings:
13On 5/4/22 at 9: AM, Licensing Program Analyst (LPA) Isabel Mendoza conducted a follow-up complaint inspection to the THPP administrative office and met with Program Manager Frank Delgado, and Director of Compliance Deb Miller. The purpose of the inspection was to deliver the findings for the above complaint allegations. During the course of the investigation LPA Mendoza, conducted interviews with staff members, participants, witnesses, and reviewed (P1's) file (Please refer to LIC 811, dated 05/4/22, for confidential names). The interviews and documentation revealed inconsistencies if participants personal rights were violated, and if staff (S1) is consuming alcohol while working. LPA Mendoza recieved a recording where (S1) was approached and accusations were made that (S1) was drinking and (P1) had proof. However, no photos were submitted to LPA Mendoza. (Please Refer to Lic 9099-c...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: Isabel Mendoza LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, TRAEGER AVE., SUITE FACILITY NAME: UNITY CARE GROUPFACILITY NUMBER: VISIT DATE: 05/04/2022

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

report_type: Complaint Investigation

met_with: Frank Delgado & Deb Miller

complaint_status: unsubstantiated


raw_content:
Narrative:
which did not corroborate the information obtained from the parties interviewed. On 11/29/21 there was an incident where their was a verbal altercation between (P1's roommates and (P1). Lastly, LPA reviewed (C1's) file and consumer notes and (P1) has a history of being verbally aggressive towards others, and has challenges engaging in positive relationships with others. Also, communicated having issues with a few participants. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove Foster youth is being bullied by other residents while in care. Facility staff smoke at the facility. Therefore, the above allegation is Unsubstantiated. An exit interview was conducted, and a copy of the report was left with the facility.

Investigation Findings:
13On 5/4/22 at 9: AM, Licensing Program Analyst (LPA) Isabel Mendoza conducted a follow-up complaint inspection to the THPP administrative office and met with Program Manager Frank Delgado, and Director of Compliance Deb Miller. The purpose of the inspection was to deliver the findings for the above complaint allegations. During the course of the investigation, LPA Mendoza conducted interviews with staff members, participants, and reviewed documentation. The interviews revealed inconsistencies in explanation if (P1) is being bullied by other residents while in care, and staff smoke at the facility. (Please refer to LIC 811, dated 05/4/22, for confidential names). In addition, LPA Mendoza obtained and reviewed (C1) file and incident reports, (please refer to LIC 9099-C..) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: Isabel Mendoza LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, TRAEGER AVE., SUITE FACILITY NAME: UNITY CARE GROUPFACILITY NUMBER: VISIT DATE: 05/04/2022

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


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
Licensing Program Analyst (LPA) Isabel Mendoza made an unannounced required Annual inspection to Unity Care's Administrative office. LPA met with Interim Lead Case Manager, Frank Delgado, and Deb Miller, Compliance Director arrived later during the inspection. This agency provides services to Minors and Non-Minor Dependents, licensed for 43 participants and currently have a census of 22 participants- (1) minor and (21) NMD's. At 9: AM, LPA inspected the premises, and did a walk through inspection with Case Manager, Frank. The office has sufficient space for confidential meetings. The facility only had 8 participant files in a locked cabinet in a secure location. All other participant files are being kept at each remote site. The agency has their license posted in their office. LPA spoke with Case Manager about the residential units, and obtained copies of all Certificate of Compliances. The facility currently has 4 sites. Compliance Director confirmed that all residential units have at least one toilet, sink and tub in working order. At 10: AM, LPA reviewed 3 participants files. LPA could not locate Needs and Service Plans for(C2 and (C3), (please refer to LIC 811, dated 09/08/21 for confidential names). The facility did not have personnel staff files or staff training at administrative office. LPA reminded the facility that all personnel records shall be at the administrative building. The Case Manager attempted to contact Human Resources but there was no response. All personnel files are stored electronically, and only HR has access. The facility informed LPA Mendoza that they will now request copies of all required documents and will start keeping them on file. During inspection, Case Manager located one staff file for (S1), however the file was incomplete and did not have all required documents. (Please Cont. To Lic 809-c) The facility informed LPA Mendoza, that they have found former Administrator replacement. The new Administrator will start on 9/16/21. Former Administrator, Dyese Hunt resigned, and her last day was on 8/30/21. The facility agrees to submit all LIC documents and letter from the board, no later than Friday 9/24/21. During inspection, LPA obtained copies of LIC 610, current client roster, and LIC 500. LPA Mendoza requested the facility to submit an updated LIC 309 (Administrative of Organization) later than Friday 9/17/21. The facility has been cited under Title Regulations, and a copy of the report was left with Compliance Director.

Deficiencies:
86168.3(c): Deficient Practice Statement
1
2
3
4Based on record reviews, the licensee did not comply with the section cited above in 1 out of 3 persons [C2 and C3] which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2021
Plan of Correction
1
2
3
4

report_type: Facility Evaluation

visit_type: Annual

met_with: Frank Delgado- Interim Lead Case Manager & Deb Miller, Compliance Director

title:
Needs and Services Plan

(c) The THPP administrator or social work personnel shall complete a Needs and Services Plan for a nonminor dependent that is consistent with the Transitional Independent Living Plan of the nonminor dependent.

This requirement is not met as evidenced by


summary: Facility Evaluation

raw_content:
Narrative:
On Thursday, March 24, 2022, at PM, Community Care Licensing (CCL) conducted an office meeting virtually via Microsoft Teams. The following individuals attended the Teams meeting: Licensing Program Managers (LPMs) Carolyn Flynn, Helga Wong, Licensing Program Analyst (LPA's) Isabel Mendoza, Vaishali Singh-Sood, Jennifer Baca, Tamara Hill, and Mary Shelton. In addition, CCL met with Deb Miller, Alexander William, Sander Trent, and Frank Delgado. This meeting aimed to discuss the "SF Resident Deduction" sheet that LPA Mendoza observed posted in one of the THPP's remote sites on 2/14/22. Unfortunately, our department has not approved the deduction sheet. After further discussion with LPM Jodean Hall, LPA Hill informed the facility the above deduction sheet was not approved or included in the facilities revised program statement which is under review. CCL informed the facility that it was determined that the listed items in the SF deduction sheet were all violations of the client's Personal Rights. All parties on the call agreed that CCL would not accept this, and the facility will no longer use the above deduction sheet. Currently, the facility is working on their final revisions for all three THPP sites out of the Sacramento office. Once the program statement has been approved, the facility will submit a hard copy and an electronic copy to the San Jose regional office (SB and SJ). An exit interview was conducted, and a copy of the report was emailed to Deb Miller for signature.

met_with: Deb Miller & Alexander William


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Britanee Windom and Licensing Program Manager (LPM) Angela King conducted a case management inspection on September 27, 2022 at 10: 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, 7 out of Direct Care Staff and 6 out of 7 youth files were reviewed. 2 out of Direct Care Staff and 3 out of 7 youth were interviewed.(See the Confidential Names List, LIC 811, September 27, 2022). The Plan of Operation including policies and procedures were reviewed. Based on the analysis of the confidential interviews and youth file review including the Transitional Independent Living Plan & Agreements and Safety 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 Windom and LPM 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 as required. The licensee is contacting law enforcement in accordance to their policies and procedures 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 THP Program Manager Frank Delgado and Director of Compliance Deb Miller.

visit_type: Case Management

met_with: Frank Delgado, THP Program Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 1/6/23, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility office for a case management visit. LPA met with Program Manager Frank Delgado and Director of Compliance Deb Miller and informed of the purpose of the visit. The purpose of the visit was to meet to discuss recently submitted incident reports regarding a participant bringing dangerous contraband on the grounds and engaging in inappropriate activities, and a participant permitting a disallowed guest on the grounds. LPA obtained additional information about the incidents from Deb and Frank and obtained resident documentation and case worker information. No deficiencies have been found during this visit. An exit interview was conducted, and a copy of this report was left with Program Manager Frank Delgado, whose signature on this form confirms receipt.

met_with: Program Manager Frank Delgado; Director of Compliance Deb Miller


raw_content:
Narrative:
An exit interview was conducted, and a copy of this report was left with Program Manager, Deandra Doyle.

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

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

visit_type: Complaint Investigation

met_with: Deandra Doyle, Program Manager


summary: Facility Evaluation

raw_content:
Narrative:
The purpose of this report is to correct the discrepancy with multiple facility numbers for Unity Care Group. The facility moved from one suite in the building located at Enterprise Way, to a suite with the address of Enterprise Way. The effective date of facility # 317006116 is 06/01/2020.

visit_type: Prelicensing


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
(page 2) It is alleged that client funds are mismanaged. The investigation revealed that clients do not know how much their stipend payments will be until they receive the funds or the money is deposited in their account. The clients report the amount of payments are never the same which makes budgeting hard. The clients state they do not get an explanation or supporting documents showing what deductions are made or the date of the deduction. When LPA requested accounting documents for additional clients, with details on deductions, staff stated it would take while as they had to gather the data to create a spreadsheet each time a client statement was requested. LPA observed client stipend checks with "pay to the order of" in a staff's name and staff's address. Staff stated the checks are made payable to them until a client has a direct deposit set up. Staff cashes the check, gets the client's signature, and then gives the money to the client. Two clients and two county social workers reported money was withheld from emancipation funds after clients exited the program. Staff state that deductions for excessive cleaning or damages to the living units may be withheld from emancipation funds. The facility withholds $100 for non-minor dependents (NMD) and $50 for minors, per month, from their total monthly stipend amount. The facility Plan of Operation does not include a section on emancipation funds. The Plan of Operation does not describe how the facility will account for or handle funds held in a client emancipation account. Client housing agreements indicate deductions may be taken for infractions of the housing policies and cleaning fees may be withheld from an emancipation fund or the monthly stipend. It is alleged that the regional program director (RD) made derogatory remarks to a client. A Placer County Supervisor (PCS) stated that during a Child and Family Team (CFT) meeting the RD made several statements that escalated the youth. PCS stated RD was accusatory and hostile and the youth was escalated by this. PCS stated, "at one point (the youth) even called RD on her attitude saying she had been rude and disrespectful to others in the meeting by constantly interrupting and negating what they were saying." PCS intervened in the CFT meeting because RD said the youth put other residents at risk and was endangering their safety by leaving after curfew. PCS challenged the statement by RD because the other residents were non-minors without a curfew and therefore not at risk by a minor leaving. Two other participants confirm hearing RD speak in a demeaning manner and confirm the youth called RD out about being rude. A Placer County worker (PCW) stated that the lack of professionalism is troubling at best. PCW stated, "their lack of support is continued trauma and emotional upheaval for participants. There is long-term harm to the youth participating in the program." One facility staff and RD deny derogatory remarks were made. One CFT participant refused to speak on the matter. It is alleged that a minor was not provided supervision after a dental sedation procedure. The investigation revealed that a minor was sedated for a tooth extraction and bone graft procedures on 8/28/21. The minor was transported to and from the appointment by a Placer county worker. The facility did not make arrangements for adult supervision at the housing unit the day of the procedure. The regular live-in staff was on a scheduled vacation. Staff stated that the youth only had a tooth pulled and did not think sedation was necessary. A CFT meeting on 5/11/2021 indicates the need for a tooth extraction and bone grafting. CFT meeting notes from 8/11/2021 state dental needs still need to be addressed. (continued on p3) (page3) CSW stated that the minor had high anxiety leading up to the procedure and Unity Care was well informed of the date and the sedation. The facility offered to arrange a Lyft ride. CSW stated staff was reminded that minor would be fully sedated and could not take Lyft. CSW knew staff was on vacation but RD would get a fill-in. Staff knew that minor was struggling with serious mental health issues and had stopped taking medications prior to the dental procedure. The minor was left in the house with two other residents and an on-call phone number written on a white board. Minor stated they were in excruciating pain. Minor went to the refrigerator for something to eat and ended up throwing food and causing destruction all over the house. Help was called and it was determined that minor required hospitalization for a psych evaluation the evening of 8/28/21. Based on the information from interviews conducted and documents obtained the allegations, that client funds are mismanaged, Regional program director made derogatory remarks to a client, and a minor was not provided supervision after a dental sedation procedure, are substantiated. The facility is cited for California Code of Regulations Title 22, division 6, chapter 7, Transitional Housing Placement Program for Minor Foster Children and Non-Minor Dependents Responsibility for Providing Care and Supervision and Personal Rights. Although the allegation that client funds are mismanaged is substantiated no citation is issued at this time due to a citation issued on 11/18/21 for this violation. An exit interview was conducted and a copy of this report and appeal rights discussed and will be emailed to Mr. Johnson and Ms. Miller.

Investigation Findings:
13On 12/23/21 at 4: PM, Licensing Program Analyst (LPA) Robin Sullivan contacted the facility for the purpose of delivering findings for the allegations that client funds are mismanaged, Regional Director made derogatory remarks to a client, minor was not provided supervision after a dental sedation procedure. LPA met with Devin Johnson, Supervisor and Deb Miller, Compliance Officer, via teleconference due to technology issues, to discuss the findings. During the investigation LPA interviewed three clients, two Placer County Children's System of Care managers, two Placer county social workers (CSW), 2 facility staff and the regional program director between 8/30/21 and 12/09/21. LPA reviewed the following documents: facility program statement and plan of operation, Face Sheets and emergency contacts for youths, client needs and services plans, admission agreements, incident reports, financial payment and deduction information, copies of payment stubs, PEX account statements, THP Orientation booklet, and Transitional Independent Living Plans. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Robin Sullivan 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 23-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, NATOMAS PARK DR., STE FACILITY NAME: UNITY CARE GROUPFACILITY NUMBER: VISIT DATE: 12/23/2021

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

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
It is alleged that a client's needs and services are not met. The investigation revealed that clients are offered therapeutic services once per week or more often if determined necessary. According to a confidential interview the client was participating in therapy and then stopped going. It was stated that the client withdrew from facility workers which made providing additional services challenging. The client's case manager stated the client refused in-house therapy and refused to participate when another option was scheduled. Case manager stated that the client was a no show for their weekly meetings 75% of the time. Client did not participate in monthly Independent Living Skills. Client refused to complete a dental appointment due to provider not offering nitrous oxide. Placer County authorized dental sedation however the facility was unable to support a Saturday appointment. It is alleged that incident reports are not sent to authorized representatives. One social worker reports only receiving incident reports on a client after a 14-day notice to move the client was submitted. One social worker stated getting phone calls and emails from the case manager if there are concerns about a client but did not get regular written reports. Case managers state that staff are trained to write reports when an incident occurs while they are on shift or when they are notified of a situation. The reporter submits the initial incident report to their supervisor or the regional program director who in turn submits the report to CCL and authorized representatives. The facility is participating in a Technical Advisory Program addressing issues with reporting requirements. Based on interviews conducted and documents reviewed the allegations that a client's needs and services are not met and incident reports are not sent to authorized representatives are unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and a copy of this report, appeal rights, and the LIC811 were discussed and emailed to Mr. Johnson and Ms. Miller. .

Investigation Findings:
13On 12/23/21 at 4: PM, Licensing Program Analyst (LPA) Robin Sullivan contacted the facility for the purpose of delivering findings for the allegations that client funds are mismanaged, Regional Director made derogatory remarks to a client, minor was not provided supervision after a dental sedation procedure. LPA met with Devin Johnson, Supervisor and Deb Miller, Compliance Officer, via teleconference due to technology issues, to discuss the findings. During the investigation LPA interviewed three clients, two Placer County Children's System of Care managers, two Placer county social workers (CSW), 2 facility staff and the regional program director between 8/30/21 and 12/09/21. LPA reviewed the following documents: facility program statement and plan of operation, Face Sheets and emergency contacts for youths, client needs and services plans, admission agreements, incident reports, financial payment and deduction information, copies of payment stubs, PEX account statements, THP Orientation booklet, and Transitional Independent Living Plans. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Robin Sullivan 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 23-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, NATOMAS PARK DR., STE FACILITY NAME: UNITY CARE GROUPFACILITY NUMBER: VISIT DATE: 12/23/2021

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

met_with: Devon Johnson, Supervisor and Deb Miller, Compliance Officer


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
The Department has investigated the facility denied access to client's personal belongings. The County Social worker wanted to pick up C1's belongings with C1. However, due to an incident involving C1 the facility did not want C1 returning. The facility, County Social Worker and Conflict Manager decided the Conflict Manger would pick up Cl's belonging. However, it took longer than expected due to the Conflict Manager experiencing a brief illness and the County placing C1's belongings in storage. C1 stated the belongings were returned. C1 was removed by Law Enforcement and did not return to the facility after being released from the hospital. Based on the investigation, records reviewed, and interviews conducted, the complaint findings are UNSUBSTANTIATED at this time meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report and appeal rights were given to the agency. No title 22 regulations were cited during today's inspection.

Investigation Findings:
13Licensing Program Analyst (LPA) Mary Shelton conducted a visit at the agency on 2/2/2022, and LPA spoke with Pam Carter, N. Cal Regional Program Director to deliver findings of the investigation on the complaint allegations as stated. LPA Shelton informed the complaint investigation included a tour of the facility on 10/15/2021. The initial 10-day complaint inspection was conducted by LPA Robin Sullivan, at the agency on 10/15/2021. Photos pertaining to the complaint were provided as well as a statement from the County Social worker and Conflict Manager. LPA Shelton interviewed C1, County Social worker and Conflict Manager. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Mary Shelton 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 23-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, NATOMAS PARK DR., STE FACILITY NAME: UNITY CARE GROUPFACILITY NUMBER: VISIT DATE: 02/02/2022


raw_content:
Narrative:
The Department has investigated the allegation that staff is smoking inside a remote site residence. The County Social worker could not confirm it was staff smoking marijuana. However, the smell was coming from an area in the house that a live-in staff occupies. The staff's room is right inside the front door. The Client's interviewed stated that they have never smelt or seen staff using marijuana. All staff interviewed stated that they have never smelt or seen staff using marijuana . Based on the investigation, records reviewed, and interviews conducted, the complaint findings are UNSUBSTANTIATED at this time meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report and appeal rights were given to the agency. No title 22 regulations were cited during today's inspection.

Investigation Findings:
13Licensing Program Analyst (LPA) Mary Shelton conducted a visit at the agency on 2/14/2022, and LPA spoke with Devin Johnson, Case Management Supervisor to deliver findings of the investigation on the complaint allegation as stated. LPA Shelton informed the complaint investigation included a tour of the facility on 10/21/2021. The initial 10-day complaint inspection was conducted at the agency on 10/21/2021. LPA did not request documents and stated documents may be required later. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Mary Shelton 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 23-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, NATOMAS PARK DR., STE FACILITY NAME: UNITY CARE GROUPFACILITY NUMBER: VISIT DATE: 02/14/2022


raw_content:
Narrative:
C1 is the victim and declined to be interviewed regarding the investigation. C1 and C2 both orally copulated each other. Both C1 and C2 are the same sex. C2 stated the sexual interaction only occurred once and was consensual. C1 signed an "Unity Care Group Admission Agreement" it states Dating: Participants in single site setting are prohibited from dating one another and physical contact is prohibited between residents. C1 is a minor and C2 is over the age of 18. The Case Manager at Unity Care interviewed both C1 & C2 and at that time they both denied ever engaging in any sexual activity. However, the victim C1 later reported the incident to the Police and then declined to be interviewed. C1 is currently living out of the state. Based on information the investigator obtained during the investigation; the facility staff have no expectation of supervision for residents regardless of age. The residents of the facility are mostly adults and come and go from the facility as they please but must be back at the facility prior to curfew at 2200 hours Sunday through Thursday and 2300 hours Friday and Saturday. As a result of the investigation conducted, the allegation that minor was sexually assaulted in care is UNSUBSTANTIATED at this time meaning the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with the Program Manager, and document/appeal rights were provided. No citations were issued on this date.

Investigation Findings:
13Licensing Program Analyst (LPA) Mary Shelton made an unannounced complaint inspection on 7/20/2022 at 9: AM and met with the Program Manager to discuss the findings of the complaint allegation. LPA informed the Progaram Manager, that the complaint investigation included an initial inspection of the facility on 9/29/2021 by LPA Robin Sullivan which included a walk-through of the facility and LPA requested the following documents: 1. Client Roster (names, DOBs, DOPs, DODs, authorized representative name and phone numbers), 2. Staff Roster (with title and phone numbers), 3. Staff Schedule March - September 2021. 4. Needs and Services Plans, TILP, Admission agreements, therapeutic services, for Clients 1-4 (see LIC811 confidential names list), 5. Case notes for past six month, clients 1-4. review of documentation provided by the facility for staff and previous staff, clients, and previous clients. LPA Robin Sullivan informed the Regional Director that the Department's Investigation Branch would be investigation the complaint. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Mary Shelton 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 23-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, NATOMAS PARK DR., STE FACILITY NAME: UNITY CARE GROUPFACILITY NUMBER: VISIT DATE: 07/20/2022

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

met_with: Devin Johnson, Program Manager


raw_content:
Narrative:
The Department has investigated the complaint that the participants are not properly supervised to meet their needs and facility is in disrepair. There is one staff from 3: PM until 12: AM, weekdays at the home. There needs to be a staff who lives on site for minors placed in the home. According to the Program statement "Staffed Sites: Participant (Minors and/or NMD) live in an independent setting in a Unity Care home and do not require constant (24-hour X7 day) supervision. Our Staff Sites are separate for male and female participant. Staffed Sites have Residential Advisors who live at the site." This states that Unity Care is not following the Program Statement. There is not a staff available on site during the weeknight and none on weekends. The non-minor dependents are not properly being supervised. Most of the clients in the home are 18 years old. However, there have been incidents of clients sneaking in friends and family members that intrude on other clients in the house. In addition, the Department has investigated the complaint that the facility is in disrepair and found no one in the home have witness or heard of yard fighting, someone being taken to jail on a warrant, cars being broken into, the fire department and ambulance was called for a resident with a medical emergency and the front gate was replaced due to erosion. It was also stated the home could be more organized and cleaner due to clients not cleaning up after themselves. However, it was founded that garbage is being left outside on the side of the home and not properly placed in a trash can. The residents sometimes forget to take out the trash and it piles up. The trash is picked up once a week. Based on LPA's interviews which were conducted and record reviews(s), the preponderance of evidence standard has been met, therefore the above allegation(s) (ARE) found to be Substantiated. The facility is cited on the attached LIC 9099D under the California Code of regulations, 86078(B) RESPONSIBILITY FOR PROVIDING CARE AND SUPERVISION: The licensing agency retains the authority to require additional staff, including social workers when the agency determines it is necessary to provide for the appropriate care and supervision of the participants and Buildings and Grounds(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. A copy of this report was reviewed and given to the Administrator with appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA) Mary Shelton conducted a visit at the agency on 11/7/2022 and LPA spoke with Devin Johnson, Administrator to deliver findings of the investigation on the complaint allegations as stated. LPA Shelton informed the complaint investigation included a tour of the facility on 7/20/2022. The initial 10-day complaint inspection was conducted at the agency on 7/20/2022 and included a review of the facility and obtaining of relevant documents: LPA requested the following client and staff information: 1. Client Roster (names, DOBs, DOPs, DODs, authorized representative name and phone numbers), 2. Staff Roster (with title and phone numbers), Needs and Services Plans, Admission agreements, therapeutic services, for Clients, Case notes for the past six month and a log of house repairs. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Mary Shelton 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 23-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, NATOMAS PARK DR., STE FACILITY NAME: UNITY CARE GROUPFACILITY NUMBER: VISIT DATE: 11/07/2022

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

met_with: Devin Johnson, Administrator


raw_content:
Narrative:
C1stated that there is no drugs or alcohol being used in the home to C1's knowledge. C2 stated another client is using drugs but that person keeps to self. C3 stated that "C3 has smelled marijuana outside of the home and it's rare and does not know where the smell was coming from" and C4 stated that the former roommate was a drug addict and is no longer in the house/program. The agency's Program Directed stated if there were drugs or alcohol being used in the homes an incident report would be filed. The agency staff would communicate with the youth that was using and remind them of program rules. In addition, during confidential interviews it was determined that at least one client is not receiving their monies on the 1st and 16th and at times takes up to one week, this happens randomly. However, all residents agreed they received two payments a month in the sum of $500.00. According to the agency the clients at the homes are given monies twice a month. That will be every 1st and 16th unless it falls on a non-business day or holiday. If a client does not have a bank account, then UCG signs them up for a PEX account. They are able to use it like a credit card. Monies are transferred to the client's PEX account. If the client has a bank account, then the monies are sent to the client's account. The agency was cited on 11/18/2022 for client funds are mismanaged. Based on the investigation, records reviewed, and interviews conducted, the complaint findings are UNSUBSTANTIATED at this time meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report was reviewed and given to the Administrator and no title 22 regulations were cited during today's inspection.

Investigation Findings:
13Licensing Program Analyst (LPA) Mary Shelton conducted a visit at the agency on 12/13/2022 and LPA spoke with Devin Johnson, Administrator to deliver findings of the investigation on the complaint allegation as stated. LPA Shelton informed the complaint investigation included a tour of the facility on 7/20/2022. The initial 10-day complaint inspection was conducted at the agency on 7/20/2022 and included a review of the facility and obtaining of relevant documents: Client Roster (names, DOBs, DOPs, DODs, authorized representative name and phone numbers), Staff Roster (with title and phone numbers), Needs and Services Plan, Admission agreements, therapeutic services, for Clients and Case notes for past six month. The Department has investigated the complaint drugs and alcohol are being used in the home and Clients are not being provided their monies. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Mary Shelton 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 23-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, NATOMAS PARK DR., STE FACILITY NAME: UNITY CARE GROUPFACILITY NUMBER: VISIT DATE: 12/13/2022

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


raw_content:
Narrative:
The Department has investigated the complaint that the agency is not providing a safe environment for minor(s) in care and lack of supervision for minor(s) in care. Both C1 and C2 declined to be interviewed for the purpose of this complaint. C3 stated that there is supervision in the home on both weeknights and weekends. C3 stated that no drugs or alcohol or being used in the home "not that I know of". However, C3 stated that C3 has smelled marijuana outside of the home. C3 last saw a dentist a month ago and had a medical physical two months ago. The agency also provided a medical visit log. C3 stated there have been no adult males in the home or coming over to party. C3 stated if this did occur the agency would have them removed. Agency staff interviewed felt the home was a safe environment for clients and supervision was in place for the clients in care. The agency was cited (86078(B) RESPONSIBILITY FOR PROVIDING CARE AND SUPERVISION) on 11/7/2022. Based on the investigation, records reviewed, and interviews conducted, the complaint findings are UNSUBSTANTIATED at this time meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report was reviewed and given to the Administrator and no title 22 regulations were cited during today's inspection.

Investigation Findings:
Licensing Program Analyst (LPA) Mary Shelton conducted a visit at the agency on 1/24/2023 at 8: AM and LPA spoke with Atila Tilly Farr, Administrator Specialist to deliver findings of the investigation on the complaint allegation as stated. LPA Shelton informed the complaint investigation included a tour of the facility on 11/21/2022. Program Director, Jeffery Jefferson also attened the discussion via intercom. The initial 10-day complaint inspection was conducted at the agency on 11/21/2022 and included a review of the facility and obtaining of relevant documents: Needs and Service Plans for Clients, Client Roster and a Staff Roster (with title and phone numbers). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Mary Shelton 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 23-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, NATOMAS PARK DR., STE FACILITY NAME: UNITY CARE GROUPFACILITY NUMBER: VISIT DATE: 01/24/2023

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


facility_name: UNITY CARE GROUP, INC

raw_content:
Narrative:
Based on the information obtained from records and interviews, the allegation that staff did not report youth's absence from the facility is SUBSTANTIATED. The facility is cited for violation of Title Transitional Housing Placement Program (THPP) Regulation Reporting Requirements.

Investigation Findings:
13On 8/8/ Licensing Program Analyst (LPA) Robin Sullivan went to the facility to deliver findings for the allegation that staff did not report youth's absence from the facility and met with Pam Carter, Regional Director. LPA conducted interviews with three staff (S2, S3, S4, see confidential names LIC811);S3 on 6/7/21, S2 on 7/15/21, S4 on 7/27/21, the county social worker on 7/13/21, and probation officer on 7/27/21. The following documents were reviewed: Transitional Independent Living Plan (TILP), admission agreement, Needs and Services Plan, client Health and Education Passport, dental appointment confirmation, an accounting of balances paid to youth, and incident reports. A foster youth's county social worker (CSW) reported not receiving notification when the youth did not return to the facility after an approved overnight. The CSW stated the reporting issue has been resolved and she is now getting reports. The probation officer (PO) stated the facility contacted him on about day six of the youth missing. Community Care Licensing (CCL) has no report indicating the youth was missing for six days. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Robin Sullivan 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 23-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, NATOMAS PARK DR., STE FACILITY NAME: UNITY CARE GROUP, INCFACILITY NUMBER: VISIT DATE: 08/09/2021

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

met_with: Pam Carter, Regional Director


raw_content:
Narrative:
C1 stated he was greeted by an unidentified male saying something about heard you ordered me up and the male touched C1's waist. S2 stated he may have put his hands up, about stomach high, as a means to motion hey it's okay calm down. S1 stated S2 grabbed the client by the hips. S1 and S2 verify it was meant to be funny but the client reacted in anger. C1 stated S2 made other comments about his attractive appearance and beautiful blue eyes which made C1 feel uncomfortable. S2 confirmed he spoke to C1 about becoming a model. S3 and S4 stated they independently wrote an incident report detailing the above event. CCL did not receive an incident report detailing the interactions between S1, S2 and C1. CCL received an incident report stating S1 had boundary issues and used vulgar language. A verbal report from RD to LPA Sullivan indicated the interactions and language were in the presence of other staff members but did not involve a client. The facility was advised to send a written incident report to CCL and refer the staff's behavior to human resources. Based on the interviews conducted and incident reports reviewed the allegations that staff inappropriately touched minor, staff made sexual advances towards minor, and the facility did not notify licensing of an incident are SUBSTANTIATED. The facility is cited for violations of Interim Licensing Standards AB Nonminor Dependents, THPP Article 6, Personal Rights. A violation of Reporting Requirements is substantiated, however no citation is issued at this time. A citation was issued on 8/9/21 for this violation. An exit interview was conducted and a copy of this report and appeal rights discussed and emailed to Devin Johnson.

Investigation Findings:
13On 10/5/21 at 12: PM, Licensing Program Analyst (LPA) Robin Sullivan went to the facility and met with Devin Johnson, Supervisor, to deliver findings for the allegations that staff inappropriately touched minor, staff made sexual advances towards minor, and facility did not notify licensing of an incident. LPA interviewed one staff (S3) on 5/24/21, regional director (RD) on 6/17/21, Staff 1 (S1) on 8/12/21, S2 on 8/22/21 and C1, S3 and S4 on 10/1/21. LPA reviewed the following documents: incident report, Transitional Independent Living Plan, Needs and services plan, Transitional Housing Program (THP) rules and expectations, facility file review and program statement. The investigation revealed that two staff (S1 & S2) intended to play a joke on a non-minor dependent client (C1). C1 and S1 had a well-established staff-to-client relationship. S2 was a new employee meeting C1 for the first time. It is confirmed by S1 and S2 that S1 encouraged S2 to "punk" C1 by saying "is this what you ordered up", indicating himself, when C1 comes to the door. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Robin Sullivan 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 23-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, NATOMAS PARK DR., STE FACILITY NAME: UNITY CARE GROUP, INCFACILITY NUMBER: VISIT DATE: 10/05/2021

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

met_with: Devin Johnson, Supervisor


raw_content:
Narrative:
Based on interviews conducted the allegation that staff threw away resident's belongings is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and a copy of this report, appeal rights and the confidential names list, LIC811, were discussed and left with Devon Johnson.

Investigation Findings:
13On 11/18/21 at 2: PM, Licensing Program Analyst (LPA) Robin Sullivan made an unannounced complaint inspection for the purpose of delivering findings for the allegation that staff threw away resident's belongings. LPA met with Devon Johnson, Supervisor. During the investigation, LPA interviewed seven clients, three staff, one probation officer, and one social worker, between 4/27/21 and 11/1/21 and obtained the following documents: financial payment and deduction information for eleven clients, copies of payment stubs, Needs and Services Plans, THP Orientation booklet, and Transitional Independent Living Plans. The investigation revealed that a client left some belongings at a residential site after moving into an apartment. The client would not confirm that personal belongings where disposed of prior to the allowed period of time after exit date. The client indicated that his caseworker took care of getting the personal items and if anything was thrown out it occurred after the client left the residence. The facility has a policy that client's may retrieve their personal belonging within 30 days of moving out. After 30 days any remaining items will be removed from the premise. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Robin Sullivan 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 23-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, NATOMAS PARK DR., STE FACILITY NAME: UNITY CARE GROUP, INCFACILITY NUMBER: VISIT DATE: 11/18/2021

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

met_with: Devon Johnson, Supervisor


raw_content:
Narrative:
LPA obtained information that staff are trained to write incident reports when they are present during an incident or they obtain information that requires a written report. After the report is written, staff submits to their supervisor or regional manager for review. Management reviews the reports for thoroughness of content and accuracy and then enters the report into a computer system. It is alleged that the living units are not clean. LPA obtained photographs of one house with a sink full of dirty dishes and the kitchen trash can overflowing. During an unannounced inspection, LPA observed the same house to be clean and clutter free. The kitchen sink was clean, the floors were clean, the trash was half full, and the main living area was clean and tidy. LPA observed a client washing dishes at a second location upon entering the house. The client stated that chores rotate and this was his day to wash the dishes. Client stated that sometimes he lets the pots and pans stacked up and then washes them all at once. Client stated that everyone in the house rotates chore duties. It is alleged that client information is not being kept confidential. One staff reported that cabinets used for client files are not locked properly. One staff reported that one drawer of a file cabinet was broken but no client files were stored in the broken drawer. LPA has observed all client files to be locked and secure in the regional office. It is alleged that clients are not receiving necessary services. Clients have access to weekly individual counseling, group counseling, and case management sessions. Two clients confirm they go to individual counseling. One client stated not needing anything. Two clients declined to talk about using services or if services are offered. One case manager had concerns for two clients that present with mental health issues but may not be getting additional services. One of the two clients verified he attends therapy sessions and the probation officer confirmed the client's attendance. The other client stated there is no need for additional services. Based on interviews and observations the allegations that staff are falsifying incident reports, living units are not clean, clients are not receiving necessary services, and client information is not being kept confidential are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted and a copy of this report, appeal rights and the LIC811 were discussed and left with Devon Johnson.

Investigation Findings:
13On 11/18/21 at 4: PM, Licensing Program Analyst (LPA) Robin Sullivan went to the facility for the purpose of delivering findings for the allegations that staff are falsifying incident reports, living units are not clean, clients are not receiving necessary services, and clients information is not being kept confidential. During the investigation six clients, four staff, one probation officer, and one social worker were interviewed between 4/14/21 and 10/26/21. LPA obtained and reviewed the following documents Needs and Services Plans, Transitional Independent Living Plans, physician reports, medical and dental reports, budget plans, and photographs. It is alleged that staff are falsifying incident reports. LPA obtained information from two staff that when they wrote incident reports they were submitting the reports directly into an electronic reporting system. Both staff indicated that procedures changed and they now submit their written reports to their supervisor and/or the regional manager. The staff were concerned that some reports may get modified or not reported to the proper authorities because they can no longer track reports in the system. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Uchenna Ajaero 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 23-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, NATOMAS PARK DR., STE FACILITY NAME: UNITY CARE GROUP, INCFACILITY NUMBER: VISIT DATE: 11/18/2021

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


facility_name: UNITY CARE GROUP, INC. THPP/THP+FC

raw_content:
Narrative:
The clients that resided at the home are no longer participants with this agency. LPA Raissi could not make further contact with the witness. Based on interviews and a inspection at the residence (THPP staff site) there is no further information that could be obtained. Therefore, the complaint findings are Unsubstantiated. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation(s) are Unsubstantiated. No deficiencies were cited. Exit interview conducted, appeal rights discussed, and a copy of the report was left at the agency with Administrator, Kenya Kennedy.

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

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

met_with: Kenya Kennedy


raw_content:
Narrative:
On 09/23/2021, LPA Raissi interviewed W1, who stated that these allegations were not true, and that police had responded to an incident at the facility site for an incident in which the victim named in the complaint was the one who had pushed staff, and not staff pushing a resident as it is stated in allegation #1. This information is corroborated by an incident report dated 09/13/2021 which was submitted to this department. LPA Fremont attempted to contact several other witnesses over the course of this investigation, but was ultimately unsuccessful in recording other witness statements. LPA also attempted to contact the police department in jurisdiction of this facility site, but was unable to obtain a police report to corroborate or disprove these allegations. This agency has investigated the allegations (1) "Facility staff pushed a resident," and (2) "Resident is not accorded dignity in relationship to staff," and has determined that although the allegations may be true or are valid, the preponderance of evidence standard has not been met, therefore the allegations are found to be unsubstantiated, based on records review and witness interviews. At this time, no deficiencies were observed or cited. An exit interview was conducted, Appeal Rights provided, and a copy of this report was emailed to Compliance Officer Deepa Bhat, whose signature on this form confirms receipt.

Investigation Findings:
13On 09/13/2022 at 1:45PM, Licensing Program Analyst (LPA) Madi Fremont traveled to the facility above to conduct an unannounced complaint investigation inspection. The purpose of this inspection was to deliver findings for the allegations listed above. LPA met with Compliance Officer Deepa Bhat, who helped faciliate this inspection. On 09/14/2021, the San Jose Children's Residential Program Regional Office received a complaint for the facility above with two allegations: (1) "Facility staff pushed a resident," and (2) "Resident is not accorded dignity in relationship to staff." This complaint was investigated by LPAs Sam Raissi and Madi Fremont. (CONTINUED ON LIC9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Madeleine Fremont 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 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. San Jose, CA Facility Name: Unity Care Group, INC. THPP/THP+FCFACILITY NUMBER: VISIT DATE: 09/13/2022

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

met_with: Compliance Officer Deepa Bhat


raw_content:
Investigation Findings:
13On 2/24/25 at 3: PM, Licensing Program Analyst (LPA) Vaishali Singh-Sood conducted an unannounced inspection to the above facility. The purpose of the inspection was to inform the facility representative of the findings for the above listed allegation. LPA Singh-Sood met with Diane Braz, , who assisted with the inspection. During the investigation of the aforementioned allegations, confidential interviews were conducted, as well as a review of supportive documentation. However, the program statement clearly indicated that stipends are only provided to clients who successfully discharge from the program. Addtionally, the program statement also indicated that they recommend no one to store any expensive items at the facility due to the property being unable to be fully safeguarded. Although the allegation above may have happened, there is not enough of the evidence to support that they are true. Therefore, this allegation is Unsubstantiated. At 4; PM, an exit interview was conducted, and copy of this report was provided to Ms. Braz. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Vaishali Singh-Sood LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Diane Braz


summary: Facility Evaluation

raw_content:
Narrative:
On June 10, 2021, at 11: AM, Licensing Program Analyst (LPA) Sam Raissi was met by Administrator, Kenya Kennedy at the agency listed above this report (announced visit due to COVID-19 precautions). The purpose of the case management was regarding an incident involving a resident at the Transitional Housing Placement Program (THPP) residential apartment. Refer to ( Confidential Names list, dated June 10, 2021). On May 17, 2021, Eddie Brown, property manager texted (911) at 9: PM to Samara Lacapa, case manager. Samara called Eddie and informed her that Client 3 (C3) called him stating that his roommate, Client 2 (C2), raped his girlfriend, Client 1 (C1). All clients are residents of the THPP. Eddie was advised to call San Jose Police Department (SJPD). Samara and Kenya went to the residential apartment (UP1) to wait for SJPD to arrive on the scene. SJPD arrived and took statements from staff C1, and C3. C2 was not at his apartment when the report was made and when the SJPD came to the apartment. C1 reported to SJPD that C2 raped her on Saturday, May 15, 2021. SJPD transported C1 to the hospital for observation. A restraining order was put on C2. SJPD communicated C2 was able to return to the house. Due to the circumstances Unity Care THPP representatives moved C2 to another THPP residential site, were there is increased staff supervision. On June 9, 2021, C2 moved back to residential apartment (UP1). The above agency is monitoring the situation and will keep this LPA informed of any developments. No citation was given for this visit. A copy of this report was given to Kenya Kennedy for review and signature.


summary: Facility Evaluation

raw_content:
Narrative:
On July 29, 2021, at 11: AM, Licensing Program Analyst (LPA) Sam Raissi was met by Administrator (Admin), Kenya Kennedy at the agency listed above this report. The purpose of the case management was regarding an incident involving a resident at the Transitional Housing Placement Program (THPP) residential apartment. Refer to ( Confidential Names list, dated July 28, 2021). On Saturday, July 24, Client 1 (C1) and his girlfriend were arguing/yelling for a lengthy period. Per Admin, PM called the police. PM arrived at the property; the police cars were lined across the block. PM was told by the police officers that C1 said his girlfriend stabbed him with a knife. When police arrived C1 told the police officers that he did not want to press charges. C1 told the police officers that his girlfriend had a seizure. The police officers requested to speak with the girlfriend. C1 ran into his room, locked the door, and barricaded themselves. After several verbal requests, C1 opened the door and pulled out the girlfriend. C1 proceeded to charge towards the police officers. The police eventually took C1 into custody, on a gurney (handcuffed). C1 was taken to the hospital. The girlfriend was also taken to the hospital. Per Admin, C1 was released from custody and discharged from the THPP program. Admin said she does not have any more information and wants to see the police report before she describes what accurately happened. Admin notified C1's Alameda County Social Worker. The girlfriend is not placed with Unity Care THPP. Admin sent an Incident Report (IR) describing what had taken place. An updated IR will be submitted following the police report. Admin will update LPA regarding this matter. No citation was given for this visit. A copy of this report was given to Kenya Kennedy.


summary: Facility Evaluation

raw_content:
Narrative:
On today's date, this Licensing Program Analyst (LPA) was met by Property Manager, Eddie Brown, at the facility listed above. The purpose for this case management inspection was regarding an incident involving a client at the Transitional Housing Placement Program (THPP) residential apartment. Refer to ( Confidential Names list, (dated 5/23/22). On May 18, 2022, facility staff called and submitted a death report to the Department reporting the death of an 18 year-old male client, possible suicide. Facility case manager went to client's apartment on May 18, 2022 for their visit. When the client did not answer the door, the property manager provided entry to the case manager and they found him deceased. There is no additional information provided regarding the cause of death or when this happened. Unity Care Group Chief Executive Officer notified the death to the San Jose Police Department and Santa Clara County Coroner's Office and will investigate the cause of death. On May 19, 2022, this matter was referred to Department of Social Services, Investigative Branch (IB) Investigator McIntosh,, and accepted as an assignment. No citation was given for this inspection. A copy of this report was emailed to Mr. Trent Saunders, and the inspection was concluded at 12: PM

met_with: Eddie Brown


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Vaishali Singh-Sood made an unannounced case management inspection to the above facility on March 28, 2023, at 10: AM. LPA Singh-Sood met with Apartment Manager, Eddie Brown, who assisted with the inspection. The purpose of this inspection was to discuss the detailed information regarding an incident report which was received by Community Care Licensing (CCL) on March 28, 2023. The report indicated one participant (refer to confidential names list on LIC 811 dated 3/28/2023) had a gun that was found in a shoe box in her room. It was noted that the participant, as well as the participant's roommate both had young children who also reside in the apartment. Due to the severity of the incident, San Jose Police Department was contacted, and the gun was confiscated by Police. LPA Singh-Sood interviewed Mr. Brown regarding the incident. The interview has been attached on an LIC 812 form dated 3/28/2023. Due to the facility following all protocols, no citation was given for this inspection. An exit interview was conducted at 12: PM, and copy of this report were emailed to Mr. Saunders.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Vaishali Singh-Sood made an unannounced case management inspection to the above facility on October 4, 2023, at 1: PM. LPA Singh-Sood met with Apartment Manager, Eddie Brown, who assisted with the inspection. The purpose of this inspection was to discuss the detailed information regarding an incident report which was received by Community Care Licensing (CCL) on October 3, 2023. The report indicated one client (refer to LIC 812 dated 10/3/2023) had stabbed another client. Due to the severity of the incident, San Jose Police Department was contacted, and arrived on scene. Subsequently, one client was arrested, and taken into custody. LPA Singh-Sood interviewed Mr. Brown regarding the incident. The interview has been attached on an LIC 812 form dated 10/3/2023. Due to the facility following all protocols, no citation was given for this inspection. An exit interview was conducted at 4: PM, and copy of this report were emailed to Ms. Miller


facility_name: UNITY TRANSITIONAL HOUSING INC.

summary: Facility Evaluation

raw_content:
Narrative:
On December 18, 2023, a virtual Component II Orientation was conducted by LPA (Licensing Program Analyst) Vanessa Galvan with Program Director, Mary Beth Irons and Board Member/Administrator, Rose Churchill. The following was addressed and discussed: The program expectation/review. An overview of the first revision letter. Requirements for the physical plant and pre-licensing inspection will provide tool to applicants. Informed the applicants of corrections needing to be made to the application. Revisions to the Plan of Operation (POO)/Program Statement (PS) to meet regulatory standards. Unity Transitional Housing transferring and associating employees and board members in Guardian. Unity Transitional Housing foster care rates has submitted application, LPA will submit Program Statement to Rate consultant. Letter of Documentation for correction and missing paperwork. Tentatively corrections will be submitted the week of 01/18/2022. The location of the Pre-licensing inspection will be conducted at W. Cambridge Ave, Visalia, CA, 93277, and is scheduled for 01/08/2023 at 12: PM

met_with: Mary Beth Iron & Rose Churchill


summary: Facility Evaluation

raw_content:
Narrative:
On February 6, 2024, Licensing Program Analyst (LPA) Vanessa Galvan traveled to the Unity Transitional Housing office located in Visalia CA. LPA was met by Administrator, Rose Churchill, Program Director, Mary Beth Irons, and ILP Specialist Noe Lara for the purpose of a scheduled pre-licensing inspection. A general overview of their program and a tour of the facility was provided. This facility has a reception area, waiting area, and office space for staff. Observed fixtures and furniture, equipment and supplies necessary for this operation. Also observed locked cabinets for client and staff files in order to ensure confidentiality. Discussed daily ongoing functions including incident reports. There is ample confidential space for meeting with clients on an as needed basis. The above licensee meets the requirements to be licensed as a THPP serving clients age 18-21 within a two hour driving radius pending approval of updates requested during the component II orientation. Once licensed the applicant will submit updated version of the program statement to Rates. On a quarterly basis, facility is to submit a roster of THPP clients that includes client names, dates of birth, county worker and current address of placement.

met_with: Mary Beth Irons, Rose Churchill, Noe Lara


summary: Facility Evaluation

raw_content:
Narrative:
On May 29, 2024, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Unity Transitional Housing located in Visalia, CA, and met with Administrator/Social Worker Supervisor, Rose Churchill and Program Director, Mary Beth Irons. The purpose of the inspection is to conduct a post-licensing inspection. LPA Galvan conducted a physical plant inspection and included the following observation and checks: client and staff files are kept in locked filing cabinets. The agency has adequate confidential meeting space, space for Social Worker and Case Manager to complete job duties. The facility has a current copy of the license, Facility Sketch, Client Personal Rights, LIC 610C, posted in a common area. The agency has a client register roster LIC 9120, with all required information. The agency's office is located within two hours of travel time of the THPP participants living units. The agency employs (1) Administrator/Social Worker Supervisor, (1) Program Director, and (1) Case Manager. LPA Galvan reviewed three staff files. A review of the staff files on this date indicates that all facility staff has received child abuse index and fingerprint clearances. Agency staff meets the requirements of respective job descriptions. Staff files meet regulatory standards. The agency currently has (6) THPP NMD participants. LPA Galvan reviewed (5) THPP NMD Participant files on this date. Client files meet regulatory standards. LPA reviewed an updated LIC 500, roster of clients, board meeting minutes, and certified THPP units certificated. LPA discussed the client's medical assessments and domains in the client's Needs and Services Plan. LPA provide LIC 625, LIC 9108, and LIC 621 forms to the agency's Administrator and Program Director. No deficiencies were issued on this date. An exit interview was conducted, and a copy of this report was provided to Rose Churchill at the conclusion of the inspection.

met_with: Mary Beth Iron and Rose Churhill


summary: Facility Evaluation

raw_content:
Narrative:
On June 4, 2024, Licensing Program Analysts (LPAs) Vanessa Galvan and Angelica Borja traveled to Unity Transition Housing located in Visalia, California and conducted an unannounced visit. The purpose of the visit was to complete the inspection that was started on 5/29/2024. LPAs met with Program Director, Mary Beth Irons and Administrator, Rose Churchill. LPAs conducted interview (3) staff interviews. No deficiencies were issued or observed at this time. A copy of this report was provided to Rose Churchill at the conclusion of this inspection.

met_with: Mary Beth Irons and Rose Churchill


summary: Facility Evaluation

raw_content:
Narrative:
On June 20, 2024, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Unity Transitional Housing located in Visalia, CA, and met with Program Director, Mary Beth Irons (PD). The purpose of the inspection is to provide PD with the LIC 200 for updated capacity. PD added the capacity on the LIC 200 for a capacity increase. No deficiencies observed or cited during today's inspection. A copy of this report was provided to the Mary Beth Irons at the conclusion of the inspection.

met_with: Mary Beth Irons


summary: Facility Evaluation

raw_content:
Narrative:
On March 4, 2025, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Unity Transitional Housing located in Visalia, CA, and met with Administrator/Social Worker Supervisor Rose Churchill, Program Director Mary Beth Irons, and Case Manager Noe Lara. The purpose of the inspection is to conduct an Annual/Required inspection. LPA conducted a physical plant inspection and included the following observation and checks: clients and staff files are kept in locked filing cabinets. The agency has adequate confidential meeting space, space for Social Worker and Case Manager to complete job duties. The facility has a current copy of the license, Facility Sketch, Client Personal Rights, LIC 610C, fire clearance, and "Let Us No" reporting hotline poster posted in a common area, . The agency has a client register roster LIC 9120, with all required information. The agency's office is located within two hours of travel time of the THPP participants living units. The agency employs (1) Administrator/Social Worker Supervisor, (1) Program Director, and (1) Case Manager. LPA reviewed three staff files. A review of the staff files on this date indicates that all facility staff has received child abuse index, DOJ, and FBI clearances. Agency staff meets the requirements of respective job descriptions. Staff files meet regulatory standards. The agency currently has (15) THPP Non-Minor Dependent (NMD) participants. LPA reviewed (6) THPP NMD Participant files on this date. Client files meet regulatory standards. LPA reviewed an updated LIC 500, roster of clients, certified THPP units certificated, and Disaster Preparedness Plan. No deficiencies were issued on this date. An exit interview was conducted, and a copy of this report was provided to Rose Churchill at the conclusion of the inspection.

met_with: Rose Churchill, Mary Beth Irons, Noe Lara


summary: Facility Evaluation

raw_content:
Narrative:
On February 5, 2026, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Unity Transitional Housing located in Visalia, CA, and met with Administrator Mary Beth Irons. The purpose of the inspection is to conduct an Annual/Required inspection. LPA conducted a physical plant inspection and included the following observation and checks: clients and staff files are kept in locked filing cabinets. The agency has adequate confidential meeting space, space for Social Worker and Case Manager to complete job duties. The facility has a current copy of the license, Facility Sketch, Client Personal Rights, LIC 610C, fire clearance, and "Let Us No" reporting hotline poster posted in a common area. The agency has a client register roster LIC 9120, with all required information. The agency's office is located within two hours of travel time of the THPP participants living units. The agency employs (1) Administrator (1) Program Director, and (2) Social Workers. LPA reviewed four staff files. A review of the staff files on this date indicates that all facility staff have received child abuse index, DOJ, and FBI clearances. Agency staff meets the requirements of respective job descriptions. Staff files meet regulatory standards. The agency currently has (12) THPP Non-Minor Dependent (NMD) participants. LPA reviewed (5) THPP NMD Participant files on this date. Client files meet regulatory standards. LPA reviewed an updated LIC 500, roster of clients, certified THPP units certificated, and Disaster Preparedness Plan. On 02/05/2026, LPA reviewed Guardian Roster and confirmed all staff have a background clearance. No deficiencies were issued on this date. An exit interview was conducted, and a copy of this report was provided to Mary Beth Irons at the conclusion of the inspection.


raw_content:
Narrative:
Valor staff denied the alleged allegations further indicating that C1 was fully supported and various accommodation were made to support C1. Staff indicated that due to C1's frequent medical visits and in the best interest of C1, a seven-day notice was given due to Valor program not being able to meet C1's mental health needs; however were willing to work out a plan if provided with more services by Kern Behavioral Health & Recovery Services (KBHRS). Information obtain from CSW corroborated the above information further disclosing that the initial seven-day notice was issued on 5/7/21, however it was retracted due to KBHRS providing further mental health services. 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. There are no deficiencies to be cited at this time. A copy of the report along with the (LIC 811) was sent by courier to the address on file, Due to the above facility permanently closing.

Investigation Findings:
13On September 1, 2021 at 10: A.M., Licensing Program Analyst (LPA) Winston Moroney, conducted a teleconference inspection to the above Agency and met with Agency Administrator Randy Martin. The purpose of the teleconference was to deliver the findings for the above complaint allegations. On May 10, 2021, the California Department of Social Services Community Care Licensing Division received a complaint from Centralized Complaint and Information Bureau (CCIB) with the above allegations. The investigation to the above allegations was conducted by this LPA and it consisted of, but not limited to a review of records, including the clients' needs and service plan, medical records and interviews with Valor Administrator on 5/13/2021, C1 on 5/13/2021 and Kern County Social Worker (CSW) on 5/14/2021. (Reference Confidential Names Form LIC 811, dated September 1, 2021). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Deborah A Santos 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 CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: VALOR RESIDENTIAL & EDUCATIONAL SERVICESFACILITY NUMBER: VISIT DATE: 08/31/2021

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

met_with: Randy Martin - Administrator


raw_content:
Narrative:
On 03/23/2021, the Department received a complaint alleging that, there are individuals working at the facility without background clearance. Reporting Party alleged that on 03/19/21 there were two uncleared adults (A1) and (A2) reviewing clients files which contain personal information. Administrator denied the allegation stating that (A1) was hired as a bookkeeper consultant for the facility. That there were no clients present at the facility while (A1) was conducting bookkeeping duties. Administrator provided the Board of Director's Unanimous Written Consent dated 03/10/2021 to prove that (A1) was authorized to be present in the facility as a bookkeeper consultant. Administrator denies having any other unauthorized person present in the facility reviewing any type of documentation. After conducting confidential interview with Staff 1 (S1) it was determined that (S1) was laid-off before 03/19/21. Also, (S1) & (S2) confirmed that (A1) was present in the facility but did not witness any unauthorized person reviewing client's files and there were no client's present at the time. The facility is permanently closing effective July 15, 2021. All of the clients were sent to different facilities. 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. 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 sent via email and by courier to the address on file.

Investigation Findings:
On 09/16/2021 at 11:00AM, Licensing Program Analyst (LPA) Janeth Chavez conducted a follow up inspection for the purpose of providing findings for the above complaint allegation. LPA spoke with Randy Martin, Administrator. During the investigation, LPA conducted telephone interviews with Administrator (04/01/21), Agency Social Worker and Supervising Social Worker on. During the inspection LPA requested documents for review and obtained copy of LIC 500,Client's Roster, and Board of Director's Written Consent dated 03/10/21. Report Continues on Next Page UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Yan Yeung LICENSING EVALUATOR NAME: Janeth Chavez 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: VALOR RESIDENTIAL & EDUCATIONAL SERVICESFACILITY NUMBER: VISIT DATE: 09/16/2021

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

met_with: Randy Covenant


facility_name: VALOR RESIDENTIAL & EDUCATIONAL SERVICES

raw_content:
Investigation Findings:
13On 10/08/2021 at 1: AM, Licensing Program Analyst (LPA) Noubar Yerkatyan conducted a follow-up complaint inspection to the above facility and met with above staff. The purpose of the visit was to discuss and deliver findings for the above compliant allegations. While investigating the allegations, LPA Dawn Mahecha and LPA Yerkatyan conducted interviews with facility staff and county social workers (see Confidential Names LIC 811 dated October 08, 2021). Certain files were reviewed such as staff and client records. The facility has been closed and currently has no placements. LPA attempted to interview C1, however C1 refused. Due to inconsistency of information obtained during the investigation, it cannot be determined whether the above allegation occurred. Based upon the interviews, the complaint findings are unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the allegation occurred. No deficiencies were cited. An exit interview was conducted, and a signed copy of this report was left with above staff. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Noubar Yerkatyan LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Randy Martin, FFA Administrator


facility_name: VARSITY TEAM INC THP

summary: Facility Evaluation

raw_content:
Narrative:
On January 23, 2024, Licensing Program Analyst (LPA) Carol Anderson conducted an announced pre-licensing inspection to the above facility. LPA Anderson met with CEO Lance Hickman, CFO Drew Dahlstedt and THP Administrator Desmond Bryan. LPA Anderson toured the administrative office for the Transitional Housing Placement Plus Foster Care (THP+FC). The participants' apartment units will be within a two hour radius from the Administration office. LPA Anderson inspected the office. The following areas were observed: The Administrative Office is in executive office building. Within the administrative office, waiting area, four administrative offices, and break room. The participant records and personnel records will be locked in cabinet in one of the administrative offices. All documents have been received and the physical plant meets the minimum requirements of Title 22 regulations. The applicant has been informed that the address to this facility is available to the public. All special incident reports (SIR's) will be sent via e-mail to: cclpaccr@dss.ca.gov. Based on the facility pre-licensing inspection and facility records' review, no deficiencies were noted at time of the inspection Upon managers final review, the license will be provided. An exit interview was conducted, a copy of this report was discussed and left with the CEO Lance Hickman and CFO Drew Dahlstedt.

met_with: Lance Hickman


summary: Facility Evaluation

raw_content:
Narrative:
On February 28, 2025 at 9: AM, Licensing Program Analyst (LPA) Lucero Jauregui conducted an unannounced inspection at the above facility. LPA Jauregui met with Desmond Bryan, Adminsitrator and Lance Hickman, CEO. The purpose of the inspection is to conduct a annual inspection. The facility is licensed to provide transitional housing placement plus foster care for non-minor dependents for 36 participants ages eighteen (18) through twenty-one (21) years old. There are currently 5 participants in the program. The Administrative Office is located at Murphy Canyon Rd Suite 227, San Diego CA 92123. The administrative office is in a executive office building. LPA Jauregui inspected the administrative office. The office has a waiting area, four offices, and a break room. The participants' files are stored and locked in a cabinet located in administrators office. Five participants' files were reviewed. Staff files are stored and locked in CEO's office. Three staff files were reviewed. LPA Jauregui conducted one staff interview due to one staff being present. Based on todays inspection and review, there are no deficiencies cited at this time. An exit interview was conducted and a copy of this report was provided to Lance Hickman, CEO.

met_with: Desmond Bryan, Adminsitrator & Lance Hickman, CEO


summary: Facility Evaluation

raw_content:
Narrative:
On April 16, 2026, at 10: AM, Licensing Program Analyst (LPA) Cynthia Velasquez conducted an unannounced inspection at the above facility. LPA met with Desmond Bryan, Administrator. LPA was invited into the administrative office located in an executive office building. There were no blockages leading to the front entrance and the office was free from debris and well kept. The facility is licensed for 36 transitional housing placements and for providing foster care to non-minor dependents ranging from ages 18 through 21. There are currently 6 participants in the program. The office has four separate offices, a waiting area, and a break room. Postings of license and necessary documents were available. The participants' files are stored and locked in a cabinet located in administrators office, and six participants' files were reviewed. All client files contained identification, health screenings, needs and service plans, independent living plans, and placement documentation. Staff files are stored and locked in CEO's office, and all staff files were reviewed. All files had necessary documentation, identification, health screenings, and trainings. Based on today's inspection and file reviews, there were no deficiencies cited at this time. An exit interview was conducted, and a copy of this report was provided to Desmond Bryan, Administrator.

met_with: Desmond Bryan, Program Manager


facility_name: VICTORY FAMILY SERVICES

raw_content:
Narrative:
There is not enough evidence to prove the allegations; as the information provided during the investigation is conflicting. Based on information obtained by LPA Palmer, there is not a preponderance of evidence to support the allegation therefore, the allegation is unsubstantiated. No deficiency cited. Copies of the following reports were provided at the conclusion of the inspection: LIC 9099 and LIC 9099-C..

Investigation Findings:
13On May 28, 2025 at 1:20pm, Licensing Program Analyst (LPA), Carrie Palmer conducted a follow-up complaint inspection with the above named facility and spoke to the Director of Operations. The purpose of the visit is to deliver the findings for the above complaint allegation. During the course of the investigation, LPA Palmer reviewed facility records and conducted investigative interviews with S1 on 11/12/24 and C1 on 11/14/24 and S2 on 5/28/25. (See Form 811 - Confidential Names List Dated 5/28/25). During the investigation, confidential interviews revealed conflicting information. There was concern regarding the need to make repairs by the above named facility, and that the repairs were not completed by the facility and the repairs needed to be completed with the clients money. However, the facility was able to provide documentation regarding repairs completed on 10/05/24, 11/27/24, 1/24/2025, 4/07/25, 4/28/25, 4/30/25, via the maintenance log. Additional confidential interviews reveals that the facility does not clearly explain the rules resulting in a non compliance. However, the facilty provided a detailed intake package which consist of all of the rules of the facilty as well as a THPP Placement handbook, which they review with the client and have the client sign upon admission into the program. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Carrie Palmer 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: VICTORY FAMILY SERVICESFACILITY NUMBER: VISIT DATE: 05/28/2025

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

met_with: Petra Gil-Vigie, Director of Operations