summary: Facility Evaluation

raw_content:
Narrative:
On July 27, 2021 at 11: AM, Licensing Program Analysts (LPA's) Anastasia Flores and Valerie Wilson conducted an unannounced case management inspection in regard to the inspection conducted by LPA Flores on July 1, 2021. LPA's met with (STRTP) Olive Crest Treatment Center -Saylor House, Residential Manager, Brittany Bounds During the inspection on 7/01/21, LPA Flores observed the STRTP monthly menu not posted for the clients in care. LPA Flores conducted interviews with five of six clients (C1, C2, C3, C4, C5), two staff and facility Administrator. Confidential interviews disclosed that the menu had not been posted for over a week and was not easily accessible for the staff to print and replace. Based on facility records and confidential interviews, the facility is being issued a citation violation of the STRTP Interim Licensing Standards (ILS), section 87076 (b) Food Service, the STRTP's menu readily available for clients or staff to view on at least one occasion. This poses a potential health, safety, or personal rights risk to the youth in care. Exit interview conducted, appeal rights and a copy of this report were provided to Brittany Bounds.


state: CA

facility_name: OLIVE CREST TREATMENT CENTERS - SAYLOR

summary: Facility Evaluation

raw_content:
Narrative:
On August 19, 2021 at 1: PM, Licensing Program Analyst (LPA) Jessica Rubio conducted an unannounced case management inspection in regard to an incident occurring 7/23/2021. LPA met with Olive Crest Treatment Center - Saylor House (STRTP), Residential Manager, Brittany Bounds. Record review revealed, that client 1 (C1) left the facility unauthorized on 7/23/2021 and returned on 7/26/2021, however a special incident report was not submitted to Community Care Licensing until 7/27/2021. Based on record review, the facility is being issued a citation violation of the STRTP Interim Licensing Standards (ILS), Section Reporting Requirements. Per record review the facility did not ensure client's unauthorized absence was reported timely. This poses a potential health, safety, or personal rights risk to the youth in care. Exit interview conducted, appeal rights and a copy of this report were provided to Brittany Bounds.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Brittany Bounds


summary: Facility Evaluation

raw_content:
Narrative:
On August 26, 2021 at 9: AM, Licensing Program Analysts (LPAs) Cindy Hamilton conducted an unannounced SB Psychotropic Medication Inspection. During the inspection, LPA Hamilton met with Program Supervisor Amy Aherni and inspected the facility inside and out. LPA reviewed six client psychotropic records at the facility site at 10: AM. During the review of client records, LPA observed two out of six children Needs and Services Plan were not signed by the child's Social Worker and three out of six were not signed by the client. A LIC Advisory Note was issued. LPA also observed Client #5 (C5) file did not have a JV-223 authorization. LPA will return at a later date to review staff personnel files that are kept at the facility's corporate offices.. LPA began two staff interviews at 1: PM LPA interviewed one of six children currently taking psychotropic medication at 2: PM. One client was at a medical appointment and three others were not available for interviews at the time of inspection. LPA conducted exit interview with Program Supervisor Amy Ahern at 3: PM. LPA provided the Summary Report, LIC 9102TA , LIC 8099-D and Appeal Rights, to Amy Ahern upon completion.

met_with: Amy Ahern, Program Supervison


summary: Facility Evaluation

raw_content:
Narrative:
On May 8, 2024, at 12:00 pm, Licensing Program Analyst (LPA) Guadalupe Munoz conducted an unannounced case management inspection of the facility. LPA conducted a walk through of the facility, and no deficiencies were observed. The purpose of the inspection was to conduct an Incident Report (IR) follow up visit. LPA Munoz met with Program Supervisor, Brenda Solano. Community Care Licensing (CCL) has only been provided with Incident Reports for clients who are placed by Orange County. The facility is required to report incidents for all clients placed in their care. The STRTP facility is being cited for violation of Title General Licensing Requirements, Section Reporting Requirements. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed to Brenda Solano, Program Supervisor.

met_with: Brenda Solano


summary: Facility Evaluation

raw_content:
Narrative:
On June 11, 2024, at 12:00 pm, Licensing Program Analyst (LPA) Guadalupe Munoz conducted an unannounced case management inspection of the facility. LPA conducted a walk through of the facility, and no deficiencies were observed. The purpose of the inspection was to conduct an Incident Report (IR) follow up visit. LPA Munoz met with Facility Administrator, Grace Coffman. No deficiencies were observed at this time. Community Care Licensing (CCL) became aware of an incident that occurred on 4/16/24 in which client was observed to be heavily intoxicated and bumping into walls after consuming an undetermined amount of alcohol and medical aid was not provided to client by facility. During the same incident, client was able to gain access to keys to facility vehicle which led to an accident that injured client and staff. The STRTP facility is being cited for violation of Title Division Chapter Article Buildings and Grounds 80087 (g) and Title Division Chapter Article Health Related Services 80075 (a). An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed to Emylee King, Residential Coordinator and facility designee.

met_with: Grace Coffman


summary: Facility Evaluation

raw_content:
Narrative:
On March 24, 2026, at 3: PM Licensing Program Analyst (LPA), Stefanie Mutialu, met with Olive Crest - Saylor Short-Term Residential (STRTP) Residential Coordinator (RC), Kathleen Beltran, to deliver a case management deficiencies report. Information obtained by Community Care Licensing (CCL) revealed a concern regarding Staff confiscating clients' phone chargers, staff not providing client' with transportation, and the Administrator not being present at the facility. LPA conducted interviews with five clients (C1- C5 ) and eight staff (S1 - S8). LPA viewed facility documents. Confidential interviews provided consistent statements that S1 confiscated phone chargers during intake and enforced a rule that clients must turn in their phone to the staff every night if clients want to have their cell phones charged. This is a violation of Interim Licensing Standards (ILS), version 6, Article 6, Section: 87072 (c)(8): Personal Rights - The licensee shall ensure that each child, regardless of whether the child is in foster care, is accorded the personal rights specified in Welfare and Institutions Code Section 16001.9, and below, as applicable: To be provided with and allowed to possess and use adequate personal items, consistent with Welfare & Institutions Code section 16001.9(a)(3). Confidential interviews provided consistent statements that S1 refused to drive clients to participate in off-site activities. ***Continued on the Next Page**** This is a violation of Interim Licensing Standards (ILS), version 6, Article 6, Section: 87074 (c)(3): Transportation - Unless other arrangements are specified in the needs and services plan or the Transitional Independent Living Plan for a child or nonminor dependent, a licensee shall ensure transportation is provided to the following: Extracurricular, personal enrichment, cultural, racial, ethnic, and social activities, in accordance with the reasonable and prudent parent standard specified in Section 87067. Confidential interviews provided consistent statements that the Administrator is not present at the facility at least 20 hours per week. In addition, LPA observed that the Administrator was not present at the facility on 5/14/25, 5/16/25, 12/17/25, 3/02/26, 3/04/26, 3/05/26, 03/11/26, and 3/24/26. This is a violation of Interim Licensing Standards (ILS), version 6, Section: 87064 (b)(1): Administrator Qualifications and Duties - All short-term residential therapeutic programs shall have a qualified and currently certified administrator. The administrator shall be on the premises for a minimum of 20 hours per week to manage and administer the short-term residential therapeutic program in compliance with applicable law and regulations. The STRTP is being cited three type B citations for violation of ILS 87072 (c)(8): Personal Rights, 87074 (c)(3): Transportation, 87064 (b)(1): Administrator Qualifications and Duties. A copy of the report was discussed and provided along with LIC 811, and appeal rights to Olive Crest - Saylor Short-Term Residential (STRTP) Residential Coordinator, Kathleen Beltran. Due to technical difficulties a copy of this report was emailed at the time of inspection.

met_with: Kathleen Beltran, Residential Coordinator


summary: Facility Evaluation

raw_content:
Narrative:
On April 2, 2026, at 9: AM, Licensing Program Analyst (LPA) Stefanie Mutialu returned to the Olive Crest - Saylor Short-Term Residential Therapy Program (STRTP), to follow-up on a Plan of Correction (POC) that has not been received by Community Care Licensing (CCL). LPA Mutialu met with the Youth Care Specialist (YCS), Rachel Anselmo, and conducted a walkthrough of the facility, and no deficiencies were observed. On March 24, 2026, the facility was cited for a type B violation of Interim Licensing Standards (ILS) standard 87064(b)(1) Administrator Qualifications and Duties- (b) All short-term residential therapeutic programs shall have a qualified and currently certified administrator. (1) The administrator shall be on the premises for a minimum of 20 hours per week to manage and administer the short-term residential therapeutic program in compliance with applicable law and regulations. When the citation was issued Olive Crest - Saylor's Residential Coordinator (RC), Kathleen Beltran stated the POC would be submitted via email by POC due date of 03/31/2026. On 03/30/2026, LPA Mutialu contacted Residential Manager (RM), Agustin Rojas by telephone at the facility and reminded RM of the upcoming POC due date of 03/31/2026. LPA advised RM to review email sent on 03/24/2026. LPA also notified RM that 03/31/2026 is a state holiday and LPA will be out of the office. As of 04/02/2026, CCL has not received the POC. The facility is receiving Civil Penalties for violation of California Code of Regulations, Title Division 6 regulation 80054(f) Penalties If any deficiency is not corrected by the date specified in the notice of deficiency, a penalty shall be assessed for each day following that date until compliance has been demonstrated. Civil Penalties are being assessed at $100 a day beginning on 04/01/2026 and will continue to accrue at $100.00 per day until deficiency is corrected. ****** A copy of this report along with the LIC 809D deficiency page, and appeal rights were provided to Youth Care Specialist, Rachel Anselmo. Due to technical difficulties a copy of this report was emailed at the time of inspection.


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
*** Amended on 04/02/26-LPA met with Youth Care Specialist, Rachel Anselmo*** Confidential interviews indicated that staff were placing cash in the client's binders for them to use at a later time, even when the client's asked for the money. Confidential interviews revealed that the discipline included multiple restrictions for single actions; no Wi-Fi, no television, no outings, no store runs, if sick must be on bed rest, and not providing transportation as a form of discipline/punishment which is not in alignment of the facility's Program Statement and House Rules. Based on confidential interviews and record reviews the allegations alleging the staff is refusing to give client(s) allowance and staff are utilizing unusual punishment are substantiated. The complaint allegations are valid because the preponderance of evidence standard has been met. Facility is cited for two type B violations of Interim Licensing Standards (ILS), Version 6, Article 06: Section 87072 (c)(11)- Personal Rights: (c) The licensee shall ensure that each child, regardless of whether the child is in foster care, is accorded the personal rights specified in Welfare and Institutions Code Section 16001.9, and below, as applicable: (11)To possess and use their own cash resources except as specified in Section 87026, and to maintain bank account and manage personal income consistent with the child's age and developmental level, unless prohibited by the case plan. Also, Section 87072 (c)(16) Personal Rights The licensee shall ensure that each child, regardless of whether the child is in foster care, is accorded the personal rights specified in Welfare and Institutions Code Section 16001.9, and below, as applicable: (16) To be free of physical, sexual, emotional, or other abuse, and from corporal or unusual punishment, exploitation, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature including, but not limited to, interference with the daily living functions of eating, sleeping, or toileting, or withholding of shelter, clothing, or aids to physical functioning. (See LIC 9099D). A copy of the report was discussed and provided along with appeal rights to Residential Manager, Agustin Rojas. Due to technical difficulties, a copy of this report was emailed to Program Director, Grace Coffman, and Residential Manager, Agustine Rojas at the time of inspection.

Investigation Findings:
13*** Amended on 04/02/26-LPA met with Youth Care Specialist, Rachel Anselmo*** On March 24, 2026, at 11: AM Licensing Program Analyst (LPA), Stefanie Mutialu met with Olive Crest Saylor Short Term Residential Therapeutic Program Facility, Residential Manager, Agustin Rojas, to deliver the finding for the above stated allegations. A Health and safety inspection of the facility was conducted on March 24, 2026, and no immediate hazards were observed. The investigation included interviews with four clients (C1, C2, C3, C5) and three staff (S1, S2, S3). In addition, facility records and client records were reviewed On December 8, 2025, Community Care Licensing (CCL) received allegations alleging the staff is refusing to give client(s) allowance and staff are utilizing unusual punishment. Specifically, it was reported that client is refused allowance and client is grounded for no reason. Confidential interviews provided consistent statements that staff are withholding allowance; staff did not disburse the money to the clients. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Stefanie Mutialu 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 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: OLIVE CREST - SAYLORFACILITY NUMBER: VISIT DATE: 03/24/2026

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

report_type: Complaint Investigation

met_with: Agustine Rojas, Residential Manager

complaint_status: SUBSTANTIATED


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
*** Amended on 04/02/26-LPA met with Youth Care Specialist, Rachel Anselmo** Confidential interviews revealed that clients are given access to Wi-Fi and provided a Wi-Fi voucher for use when clients follow their program. Therefore, the complaint alleges that staff do not provide client Wi-Fi are unsubstantiated because the preponderance of evidence standard has not been met. A copy of the report was discussed and provided along with appeal rights to Kathleen Beltran, Residential Coordinator Due to technical difficulties, a copy of this report was emailed to Program Director, Grace Coffman, Residential Manager, Agustine Rojas, and Residential Coordinator, Kathleen Beltran at the time of inspection.

Investigation Findings:
13*** Amended on 04/02/26-LPA met with Youth Care Specialist, Rachel Anselmo ** On March 24, 2026, at 12: PM Licensing Program Analyst (LPA), Stefanie Mutialu met with Olive Crest Saylor Short Term Residential Therapeutic Program Facility, Kathleen Beltran, Residential Coordinator, to deliver the finding for the above stated allegation. A Health and safety inspection of the facility was conducted on March 24, 2026, and no immediate hazards were observed. The investigation included interviews with four clients (C1, C2, C3, C5) and three staff (S1, S2, S3). In addition, facility records and client records were reviewed On December 8, 2025, Community Care Licensing (CCL) received an allegation alleging staff do not provide clients with Wi-Fi. Confidential interviews provided inconsistent statements. Confidential interviews revealed that Wi-Fi is accessible via a code that changes every couple of hours. Confidential interviews entailed that vouchers are given when clients are following the program and when Wi-Fi is needed for schoolwork. Other confidential interviews revealed that S1refused to provide C1 with any vouchers. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Stefanie Mutialu 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 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: OLIVE CREST - SAYLORFACILITY NUMBER: VISIT DATE: 03/24/2026

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

complaint_status: unsubstantiated


summary: Facility Evaluation

raw_content:
Narrative:
On April 15, 2026, at 12:30PM, Licensing Program Analyst (LPA) Stefanie Mutialu returned to the Olive Crest - Saylor Short-Term Residential Therapy Program (STRTP), to follow-up on a Plan of Correction (POC) that has been received by Community Care Licensing (CCL). LPA Mutialu met with Residential Manager, Agustin Rojas, and conducted a walkthrough of the facility, and no deficiencies were observed. On March 24, 2026, LPA opened a case management for a missed POC date of 03/31/2026 and advised the facility, civil penalties of $100 a day would be assessed until POC was received by CCL. On April 2, 2026, RM sent an email that did not meet the POC agreed upon. Per POC the facility will ensure Administrator will be on premises at least 20 hours a week and will provide LPA Mutialu with Administrator regular hours at the facility and monthly timesheet/schedule showing Administrator was at the facility. The email did not include Administrator schedule or monthly time sheets/schedule. LPA responded to RM's email on April 6, 2026, with a copy of the POC that was agreed upon. On April 6, 2026, RM responded to the email and asked for the timeframe and LPA requested the last three months. RM replied and stated the facility does not keep track of the actual hours worked by Administrators or the locations that they worked. On April 7, 2026, LPA replied to RM and asked for actual hours worked as agreed upon or a Statement of Declaration to be written and signed by the Program Director (PD) as the PD stated the Administrator works at the facility for 20 hours every weekend. *** *** On April 7, 2026, LPA received Statement of Declaration that the Administrator was on-site at the facility during the week and on weekends and the POC was cleared. continue. The facility is receiving Civil Penalties for violation of California Code of Regulations, Title Division Regulation 80054(f) Penalties: If any deficiency is not corrected by the date specified in the notice of deficiency, a penalty shall be assessed for each day following that date until compliance has been demonstrated. Civil Penalties are being assessed in the amount of $700 ($100 x 7) from 04/01/2026 to 04/07/2026. A copy of this report along with the LIC 809D deficiency page, and appeal rights were provided to Residential Manager, Agustin Rojas. A copy of this report was emailed at the time of inspection.

met_with: Residential Manager, Agustin Rojas


summary: Facility Evaluation

raw_content:
Narrative:
On April 21, 2026, at 11: AM, Children's Residential Program (CRP) Licensing Program Manager (LPM) Ann Valenzuela, Licensing Program Analyst (LPA) Guadalupe Munoz, and LPA Stefanie Mutialu met with Olive Crest Saylor Short Term Residential Therapeutic Program (STRTP) Regional Program Director, Tina Chang, Program Director/ Administrator, Grace Coffman, and Administrator, Michael Cabrera in the CRP Orange Local Office for an informal office conference. Also present was, Senior Social Services Supervisor, Rocio Vaca, Supervising Probation Officer, Denise Simmons, Senior Social Worker, Sheri McCluskey, Deputy Probation Officer Rebecca Lozano, and Deputy Probation Officer Placement Supervisor, Shyra Metcalf from the Orange County Social Services Agency (OCSSA). The purpose of the meeting was to discuss the following concerns with Olive Crest Saylor STRTP regarding Administrative oversight and Clarification of Information Provided to Community Care Licensing. Since January 2026, there have been three complaint allegations substantiated. Also, the facility has received a total of eight citations. Since January 2026, the Facility has been cited for six type A violations: Three Personal Rights one Administrator Qualifications and Duties, and one violation of Transportation, and three type B violations: Buildings and Grounds and two repeat violations with civil penalties assessed. LPM Ann Valenzuela explained that an Administrator who is also a Facility Manager cannot be over multiple facilities. ****** In addition, there needs to be a Facility Manager on site at all times when clients are present. LPM discussed Administrator Qualifications, and asked Olive Crest representatives to explain what their plan is to get back into compliance with Title Regulations. Regional Program Director and Program Director stated they are committed to working in collaboration with CCL and OCSSA. OCSSA stated the concern about the challenges with the Residential Manager, difficulties with placement, Personnel Roster not being updated, and transparency. On 4/21/26 the following plan was developed: Facility will have Brenda Solano be the Administrator over Saylor and Wheeler Facilities. Grace was reminded that Brenda Solano's Administrator's Certificate is expiring on 4/26/2026, who stated that she has completed all required courses and will notify CCL once submitted. Facility will label Personnel Roster with an asterisks and label designee for Facility Managers. CCL will refer Technical Assistance to Residential Manager Augustine Rojas. Olive Crest is in the process of updating their Program Statement and will provide the updated version when completed. A copy of this report was reviewed and provided to Program Director, Grace Coffman. The signed report will be placed in the facility file.

met_with: Program Director, Frace Coffman


raw_content:
Narrative:
Based on confidential interviews and record reviews, the allegations alleging that the staff (S1) speak inappropriately to clients (C1, C2) in care and staff (S2) use inappropriate discipline with clients (C1) in care are substantiated. The complaint allegations are valid because the preponderance of evidence standard has been met. The facility is cited for two type B violations of the Interim Licensing Standards-STRTP, Article 06. 87072 (c)(1)-Personal Rights: (c)The licensee shall ensure that each child, regardless of whether the child is in foster care, is accorded the personal rights specified in Welfare and Institutions Code Section 16001.9, and below, as applicable: (1)To live in a safe, healthy, and comfortable home where they are treated with respect. If the child is an Indian child, to live in a home that upholds the prevailing social and cultural standards of the child's Indian community, including, but not limited to, family, social, and political ties. 87072 (c)(16)-Personal Rights: (c)The licensee shall ensure that each child, regardless of whether the child is in foster care, is accorded the personal rights specified in Welfare and Institutions Code Section 16001.9, and below, as applicable: (16) To be free of physical, sexual, emotional, or other abuse, and from corporal or unusual punishment, exploitation, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature including, but not limited to, interference with the daily living functions of eating, sleeping, or toileting, or withholding of shelter, clothing, or aids to physical functioning. Civil Penalties are being assessed in the amount of $250 for a Repeat Violation within 12 months of a previous citation for CCR Section 87072 (c)(16) on 03/24/2026. (See LIC 9099D). A copy of the report was discussed and provided along with appeal rights to Residential Facility Manager, Agustin Rojas. Due to technical difficulties, a copy of this report was emailed to Program Director, Grace Coffman, and Residential Facility Manager, Agustin Rojas at the time of inspection.

Investigation Findings:
13On April 17, 2026, at 3: PM Licensing Program Analyst (LPA), Stefanie Mutialu met with Olive Crest Saylor Short Term Residential Therapeutic Program (STRTP) Facility, Residential Facility Manager, Agustin Rojas, to deliver the finding for the above stated allegations. Administrator was not on site at the time of inspection. A Health and safety inspection of the facility was conducted on April 1, 2026, and no immediate hazards were observed. The investigation included interviews with two clients (C1, C2), five staff (S1- S5), one School Nurse (SN), and one School Senior Support Supervisor (SS). In addition, facility records and client records were reviewed. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Stefanie Mutialu 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 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: OLIVE CREST - SAYLORFACILITY NUMBER: VISIT DATE: 04/17/2026

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


raw_content:
Narrative:
Based on confidential interviews, records reviewed and photo taken, the allegation that the staff left pepper spray accessible to minor in care is substantiated. The complaint allegations are valid because the preponderance of evidence standard has been met. Facility is cited for one type B violation of California Code of Regulations (CCR), Title 22, Division 6, Chapter Article 07 -Physical Environment: Section 80087 (g)- Buildings and Grounds: Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. Civil Penalties are being assessed in the amount of $250 for a Repeat Violation within 12 months of a previous citation for CCR Section 80087 (g) on 05/14/2025 (See LIC9099D). A copy of the report was discussed and provided along with appeal rights to Residential FacilityManager, Agustin Rojas. Due to technical difficulties, a copy of this report was emailed to Program Director, Grace Coffman, and Residential Manager, Agustine Rojas at the time of inspection.

Investigation Findings:
13On April 17, 2026, at 3: PM Licensing Program Analyst (LPA), Stefanie Mutialu met with Olive Crest Saylor Short Term Residential Therapeutic Program (STRTP) Facility, Residential Facility Manager, Agustin Rojas, to deliver the finding for the above stated allegations. Administrator was not onsite. A Health and safety inspection of the facility was conducted on April 17, 2026, and no immediate hazards were observed. The investigation included interviews with two clients (C1, C2) and five staff (S1- S5). In addition, facility records, client records, and photos were reviewed On March 18, 2026, Community Care Licensing (CCL) received allegations alleging staff left pepper spray accessible to minor in care. Specifically, it was reported that S1 left their vehicle keys on a desk with pepper spray on the key chain while a youth was present in the office. Confidential interviews provided consistent statements and photo submitted provided evidence that S1 left personal keys with pepper spray attached on staff desk accessible to C1 in care. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Stefanie Mutialu 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 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: OLIVE CREST - SAYLORFACILITY NUMBER: VISIT DATE: 04/17/2026

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


facility_name: OLIVE CREST TREATMENT CENTERS - WHEELER

raw_content:
Narrative:
A confidential interview revealed staff did not care if C1 took C1's medication and also that S1 would not offer C1 their medication due to C1 refusing medication often. That same interview revealed that C1 asked S1 to take C1's medication however S1 did not provide it due to C1 refusing medication often. Other confidential interviews revealed there were no known issues with S1 withholding or not offering C1 medication. Record review revealed C1 was placed in the STRTP from 3/2/2020 - 5/27/2020 and was prescribed three different medications: Melatonin, Fluoxetine and Adderall. Record review indicated C1 started Melatonin and Fluoxetine on 4/8/2020 and Adderall on 5/16/2020. One confidential interview revealed it was believed there had been an issue with staff not obtaining C1's medication around April or May 2020 however, no additional details could be provided. Another confidential witness interview revealed blank entries on clients' MAR logs were often observed and appeared medication had not been provided to some clients, however, no observations were recalled regarding C1's MAR entries specifically. Other confidential interview revealed there was a lapse from when C1's Adderall was prescribed to when it was initially filled, however there were no missed doses once C1 began the medication. Additionally, a confidential interview and record review revealed that C1's Adderall was not started at the same time as the other medications due to C1 not being on any medication for several months prior. Record review corroborated and stated C1's treatment plan indicated re-initiating the medication as "staggered and gradual" to see how C1 adjusted to and was affected by the medication. Furthermore, CSW1 had no concerns of staff withholding medication from C1. At one point in April 2020, CSW2 was made aware by C1 that C1 was not yet receiving Adderall, however, CSW2 explained to C1 that it was likely due to the psychotropic medication evaluation process and C1's current assessment. Based on record review and conflicting statements, the allegation staff did not ensure minor received medications may have occurred however is not supported or proven by evidence. Therefore, the above allegation is unsubstantiated. An exit interview was conducted and a copy of this report, LIC 811 and appeal rights were provided to Youth Care Specialist Aisea Tongilava.

Investigation Findings:
13On September 15, 2021 at 4:53 pm, Licensing Program Analyst (LPA), Jessica Rubio arrived at Olive Crest Treatment Center (STRTP). LPA received a verbal authorization over the phone from Residential Manager David Owens to deliver the investigative finding for the above stated allegation to Youth Care Specialist Aisea Tongilava. On 2/22/2021 at 11:00 am, LPA Ann Valenzuela conducted a safety tele-inspection of the STRTP and no safety concerns or deficiencies were observed. During the investigation, LPA Rubio interviewed one client (C1), three current staff (S2, S3, S6), one former staff (S5) and two county social workers of C1 (CSW1 and CSW2). LPA attempted interviews with additional former staff (S1 and S4) however was unsuccessful due to no responses from those individuals. LPA Rubio also reviewed the client and staff rosters, the medication administration records (MAR) and special incident reports for C1. On 2/12/2021, Community Care Licensing (CCL) received an allegation staff did not ensure minor received medications; specifically, that the STRTP withheld psychotropic medication from C1. (Continued on LIC 9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Jessica M Rubio 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 22-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, THE CITY DR., SUITE FACILITY NAME: OLIVE CREST TREATMENT CENTERS - WHEELERFACILITY NUMBER: VISIT DATE: 09/15/2021

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

met_with: David Owens


raw_content:
Narrative:
Confidential interviews revealed that S1 would antagonize C1 by bringing up topics that were trauma triggers for C1. Confidential interviews also confirmed that S1 was aware that C1 was easily triggered by certain topics and S1 continued to make the comments. Due to unknown whereabouts, LPA was unable to interview C1, therefore LPA was unable to view the video that showed S1 speaking inappropriately to C1. Based on confidential interviews and records reviewed, the preponderance of evidence standard has been met and the allegation that staff spoke inappropriately to minors in care is substantiated. The Short-Term Residential Treatment Program (STRTP) facility is being cited for violation of Interim Licensing Standards version 5, Article 6, Continuing Requirements: 87072(c)(15) Personal Rights. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Residential Manager, Ruta Peterson. A copy of this report, LIC 811, and appeal rights was provided to the Residential Manager.

Investigation Findings:
13On July 12, 2024, at 10: AM, Licensing Program Analyst (LPA) Guadalupe Munoz arrived unannounced at the facility and met with Residential Manger, Ruta Peterson, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 11/13/2023 at 1:00 pm and no deficiencies were observed. LPA Interviewed three staff (S1-3), interviewed four clients (C2-5), LPA attempted to interview Client #1 (C1), however was unsuccessful due to no contact information available. During the investigation, the following documents were reviewed: staff schedule, communication logs, grievance forms, and needs and services plans for minors in care. On 11/08/2023, Community Care Licensing (CCL) received an allegation that staff spoke inappropriately to minors in care. Specifically, it was reported that that there was a video made that showed S1 speaking inappropriately to C1 and that S1 antagonizes the youth in care. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz 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 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: OLIVE CREST - WHEELERFACILITY NUMBER: VISIT DATE: 07/12/2024

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

met_with: Ruta Peterson


raw_content:
Narrative:
C1 allowed C3 to spend the night in their bedroom by climbing in through the bedroom window. Confidential interviews further revealed that C1 and C3 slept in the bedroom for several hours without facility staff conducting room checks inside of the client bedroom. Confidential interviews confirmed that S3 did not routinely conduct room checks of client's bedroom and did not follow agency policy of communicating client information on digital shift log. Based on confidential interviews and records reviewed, the preponderance of evidence standard has been met and the allegation that there was a lack of supervision of clients in care. is substantiated. The Short-Term Residential Treatment Program (STRTP) facility is being cited for violation of Interim Licensing Standards version 5, Article 6, Continuing Requirements: 87065.2 (b)(1)Personnel Duties An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with XXX. A copy of this report, LIC 811, and appeal rights was provided to the Administrator.

Investigation Findings:
13On September 13, 2024, at 1: PM, Licensing Program Analyst (LPA) Guadalupe Munoz arrived unannounced at the facility and met with Administrator,Brenda Solano and Residential Manager, Ruta Peterson, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 2/7/2024, at 12:00 pm and no deficiencies were observed. LPA Interviewed two staff (S1-2) and attempted to interview S3. IB Investigator Smith and LPA interviewed two clients C1 and C3. Investigator Smith attempted to interview C2, however was unsuccessful due to no contact information available. and interviewed C4. During the investigation, the following documents were reviewed: staff schedule, communication logs, community pass form, needs and services plans, and Investigative Branch Report. On 01/31/2024, Community Care Licensing (CCL) received an allegation that there was a lack of supervision of clients in care. Specifically, it was reported that C1 was able to have C3, a client from another facility, spend the night in their bedroom without any facility staff being aware. Confidential interviews revealed that SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz 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 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: OLIVE CREST - WHEELERFACILITY NUMBER: VISIT DATE: 09/13/2024

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

met_with: Ruta Peterson and Brenda Solano


summary: Facility Evaluation

raw_content:
Narrative:
On June 29, 2021, at 3:45PM Licensing Program Analysts (LPA's) Adrian Mendez and Jesus Cervantes, conducted an unannounced Required Annual inspection of the facility. The facility converted from a Group Home to STRTP (Short Term Therapeutic Program) on June 4, 2018. LPA's were met at the facility by Youth Care Specialists Andrew Bertalan, and Aisea Tongilavea, and Program Supervisor Amy Ahern. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster, the Emergency Disaster Plan was also posted. Medications are locked and centrally stored in the staff office. Medication records were reviewed and observed to be completed with dates and staff initials on dispensing records. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. Three bedrooms contained two twin beds. The facility has two bathrooms. The water temperature in one of the client bathrooms was tested at 4:03pm and registered at 119.3 degrees which is within the appropriate range of 105 degrees to 120 degrees. Per facility staff, no firearms or weapons are allowed in the facility. Cont. on 809-C The facility employs three Clinical Support Staff, four facility managers and seven direct care staff that are used in accordance with regulatory requirements. Licensee obtained Mental Health (MH) Certification in June 2019. Licensee has obtained National Accreditation through COA. The Accreditation is valid through October 30, 2021. All the client files are stored and locked in the file cabinet in the staff office. LPA's reviewed a sample of four client's files during the time of inspection. No deficiencies were found. Due to time constraints and employee files being housed in their corporate office, LPA will return to the facility to conduct a continuation of staff file reviews and staff and client interviews. No deficiencies were found. Exit interview was conducted and a copy of this report was provided to Program Supervisor Amy Ahern.

visit_type: Annual

met_with: Amy Ahern


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Dahl Larios and Licensing Program Manager Angela King conducted a case management inspection July 27, 2022 at 9:05 am based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection 9 out of Direct Care Staff and 5 out of 5 youth files were reviewed. 5 out of Direct Care Staff and 5 out of 5 youth were interviewed. (See the Confidential Names List, LIC 811, dated July 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 care plan, and Child Family Team Meeting records, 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 Dahl Larios observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Program Supervisor Amy Ahern.

met_with: Program Supervisor - Amy Ahern


summary: Facility Evaluation

raw_content:
Narrative:
On January 30, 2023, at 3: PM Licensing Program Manager (LPM) Ann Valenzuela arrived at the facility to conduct an interview with a client regarding an incident that occurred at their previous placement. LPM met with Aisea Tongilava, Youth Care Specialist.. LPM conducted an inspection of the facility and no deficiencies were noted. Exited interview was conducted and a copy of this report was emailed to David Owens.

met_with: Aisea Tongilava


summary: Facility Evaluation

raw_content:
Narrative:
On April 17, 2023, at 10: AM Licensing Program Analyst (LPA) Sarah Lo, conducted an unannounced annual inspection of the facility. The facility converted from a Group Home to STRTP (Short Term Therapeutic Program) on June 4, 2018. LPA was met at the facility by Residential Coordinator, Eriyan Odom and at 11: AM Administrator/Residential Manager, David Owens arrived at the facility and continued with the annual inspection. LPA began a physical plant inspection at 10: AM and included the following checks: Facility grounds are clean, free of debris and hazards free. There is adequate indoor and outdoor activity space. Sports equipment, books, games were observed for client's recreation time. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster, the Emergency Disaster Plan was also posted. Medications are locked and centrally stored in the staff office inside the staff restroom. Medication records were reviewed and observed to be completed with dates and staff initials on dispensing records. Chemicals/poisons are locked in a closet in the hallway and sharp objects are locked and stored in the staff office inside the staff restroom. First Aid Kits are also stored in the staff office and are complete. Contraceptives are available in the staff office and is available to be held individually by clients. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. Three bedrooms contained two twin beds. The facility has one bathroom for the client to use. The hot water in the client's bathroom was deemed safe and measured between 105 degrees to 120 degrees Fahrenheit. (Continued on LIC 809-C). Per Residential Manager, no firearms or weapons are allowed in the facility. Administrator/Residential Manager, David Owens is present at the facility a minimum of 20 hours a week, as verified by staff schedule. Appropriate staff/client ratios were verified during this inspection. The facility employs one facility manager, five direct care staff, and two therapists. Licensee has obtained National Accreditation, The Accreditation is valid through October 31, 2025. Annual Fees are current. Licensee has mental health approval from May 20, 2022, until May 20, 2023. LPA reviewed two out of two client files to ensure they contained all required documentation per Title Regulations. Client files are maintained in a locked cabinet inside staff office (See Confidential Names List (LIC 811) dated April 17, 2023) were also completed. Per review, Client 2 is missing the initial medical assessment, per CCR 80069(a) Except for licensees of ARFs, prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client, as specified in Section 80069(c), which enables the licensee to determine his/her ability to provide necessary health related services to the client. The assessment shall be used in developing the Needs and Services Plan. Per review, Client 1 and Client 2 is missing the TB test result, per CCR 80069(c)(1) The medical assessment shall include the following: The results of an examination for communicable tuberculosis and other contagious/infectious diseases. LPA reviewed five personnel files to ensure they contained all required documentation per Title Regulations. Personnel files are maintained off-site in a locked cabinet in staff corporate office in Santa Ana, and the Administrator brought over the files and were available for review. CPR/First Aid Certificates were observed and were valid. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. No deficiencies were found during this inspection. LPA interviewed two staffs and one client. The client interviewed deemed that their needs were being met and they feel safe and secure in the facility. Staffs and client have no issues or concerns regarding the facility. Based upon the inspection of facility records and interviews with staff and clients, the Licensee appears to be meeting CFT and Core Services/Supports requirements. An exit interview was conducted, a copy of this report was discussed and will be provided to Administrator/Residential Manager, David Owens.

met_with: David Owens, Residential Manager


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Guadalupe Munoz on May 24, 2024 at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Munoz met with Administrator Brenda Solano and Program Manger, Ruta Peterson and inspected the facility inside and out. LPA reviewed one of one child's records and two of staff personnel files on site at the facility. LPA reviewed one of child's psychotropic medications and medication records. LPA interviewed three of staff on site to discuss the facilities policies and procedures of operation. LPA will interview one of one youth currently prescribed psychotropic medication at a later time. During the inspection the LPA,.no deficiencies are being cited at this time. The facility was provided with a Technical Assistance (TA) note. LPAs conducted exit interview with Administrator, Brenda Solano and a copy of this report, LIC 811 dated 5/24/24 and the TA were provided to administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On April 28, 2025, at 10: AM, Licensing Program Analyst (LPA) Stefanie Mutialu made an unannounced visit for the for the purpose of conducting an annual inspection of the facility. LPA met with Residential Manager, Ruta Peterson. The Facility is licensed to serve six (6) ambulatory children ages 12-17 years old. Facility also provides services to nonminor dependents pursuant to W&I Code 16501.1(c)(1), The current census is five (5) children. The facility is a one story three-bedroom, two-bathroom home. A physical plant inspection was completed with Residential Manager and included the following checks: three client bedrooms, one client bathroom, one staff bathroom, kitchen, living room, dining area, family room, office, garage, and backyard. All required forms are posted including Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster, the Emergency Disaster Plan was also posted. Currently there a no clients in care taking medications at this time. Clients' medications are inaccessible and stored in medication room when clients in care are taking medication. Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. Facility carbon monoxide detectors were tested and observed to be in working order; fire extinguisher is properly charged and serviced on 11/15/2024. Fire clearance inspection is to be completed today 04/28/25. ****Continued on Page 2***** Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. LPA observed a minimum seven-day non-perishable and two-day perishable supply of food. Individual beds were observed with clean linens, pillows, comforters, and mattress in good repair. All three bedrooms contain two twin beds. The facility has one client bathroom. . LPA conducted two staff interviews and one client interview. Two of the three clients home refused interview or were not available to interview. The Short Term Residential Therapeutic Program is accredited through Council on Accreditation valid through October 31, No deficiencies cited. Due to time constraints and client/staff records located at the main office LPA will visit main office on another day to review staff records and complete inspection. Per facility staff, no firearms or weapons are allowed in the facility. The licensing fee payments are current. An exit interview was conducted, and a copy of this report, LIC811 (confidential names), and appeal rights were discussed and provide to Ruta Peterson. A copy of this report will be placed in the facility file.

met_with: Residential Manager, Ruta Peterson


summary: Facility Evaluation

raw_content:
Narrative:
On May, 5 2025, at 12: PM, Licensing Program Analyst (LPA), Stefanie Mutialu continued the unannounced annual inspection, which was started on April 28, 2025. LPA met with Program Director, Grace Coffman, Human Resource Manager, Maria Orona and Human Resource and Program Supervisor, Brenda Solano at Olive Crest main office in Santa Ana, where client and staff files are kept. . Five out of five staff files reviewed contain documented verification of Department of Justice, Federal Bureau of Investigations, and Child Abuse Index Check clearances. Five out of five staff files contain documentation acknowledging confidentiality and mandated child abuse reporting requirements, completed physical exam/tuberculosis testing and results on file, and met the required education and experience requirements. Five out of five staff files reviewed contain current cardiopulmonary resuscitation (CPR) and first aid training. The facility is operating within the social worker/client ratio. Due to time constraints and client records located at the main office LPA will visit main office on another day to review client records and complete inspection. LPA reviewed five staff files (S1-S5). No deficiencies cited. An exit interview was conducted, and a copy of this report, confidential names (LIC811), and appeal rights were discussed and provided to Program Director, Grace Coffman A copy of this report will be placed in the facility file.

met_with: Human Resource Manager, Maria


summary: Facility Evaluation

raw_content:
Narrative:
On May 15, 2025, at 1: PM, Licensing Program Analyst (LPA), Stefanie Mutialu continued the unannounced annual inspection, which was started on April 28 ,2025. LPA reviewed scanned client records received by Program Supervisor, Brenda Solana. LPA reviewed five client (C1-C5) files. Five out of five client records reviewed had required documents including admission agreements, signed personal rights, medical/dental exam, immunization records, medical consent forms, an initial and updated needs and services plan on file, and met the minimum requirements per Interim Licensing Standards. During the time of inspection on April 28, 2025, LPA requested Emergency Disaster Drill Log from Resident Manager, Ruta Peterson. Per Residential Manager, they do not have access to Emergency Disaster Drill Log as it is on the secured database, and they do not have access to secure database to obtain Emergency Disaster Drill Log. LPA requested Emergency Disaster Drill Log from Program Director, Grace Coffman and Program Supervisor, Brenda Solana. LPA did not receive Emergency Disaster Drill Log. As a result, the facility is receiving a type B citation. Facility cited for violation of California Code of Regulations, Title Division six, regulation 1565(c): Other Provisions. An exit interview was conducted, and a copy of this report, Confidential Names List (LIC811), and appeal rights were discussed and emailed to Program Director, Grace Coffman. A signed copy of this report will be placed in the facility file.

met_with: Program Supervisor, Brenda Solana


summary: Facility Evaluation

raw_content:
Narrative:
On July 29, 2025, at 10: AM, Licensing Program Analysts (LPA) Guadalupe Munoz and Stefanie Mutialu conducted an unannounced inspection at the facility and met with the Residential Coordinator, Roberto Elloquim. LPAs conducted a walkthrough of the facility, and no deficiencies were observed. The purpose of the inspection was to conduct a case management regarding facility's failure to correct plan of correction (POC). LPAs requested an updated Personnel Roster and a Client Roster. LPAs conducted one staff (S1) interview, please refer to Confidential Names List (LIC 811) dated July 29, 2025. On May 15, 2025, LPA Munoz conducted a case management inspection, and the facility was not in compliance. The facility received a type B violation, 87072(c)(21) Personal Rights with a POC of 06/16/2025. As of this date, the facility has not submitted POC, LPA Munoz has made several attempts to contact Residential Supervisor, Ruta Peterson, and has not received a response. Therefore, the Short Term Residential Therapeutic Program failed to correct and Civil Penalties of $600 ($ X 6 days) will be assessed. An exit interview was conducted with Residential Supervisor, Ruta Peterson. A copy of this report and confidential names (LIC811) dated 7/29/2025, and appeal rights was provided to Residential Supervisor, Ruta Peterson.


summary: Facility Evaluation

raw_content:
Narrative:
On May 15,2025, at 9:30 am, Licensing Program Analyst (LPA) Guadalupe Munoz conducted an unannounced case management inspection of the facility. LPA conducted a walk-through of the facility with Youth Care Specialist, Christopher Huerta while waiting for Residential Manager to arrive. LPA observed the following deficiencies during the tour: broken kitchen cabinet, broken front door panel, rust/damage to water dispenser on fridge, and patch on bedroom wall that needs to be painted. The purpose of the visit was to conduct an Incident Report (IR) follow up visit. LPA Munoz met with Residential Manager (RM), Ruta Peterson. Community Care Licensing (CCL) became aware of an incident that occurred on 04/30/25 in which S1 noticed items from a locked storage closet were taken out of the cabinet. S1 began to ask other staff if they knew who had taken out the property. S1 then observed client (C1) take keys out of their pocket that looked like the facility keys to the locked storage cabinets in the garage. C1 refused to tell S1 how they got the key to storage room. C1 confirmed that they had taken out the property from locked cabinet earlier when C1 was alone in garage because they wanted their confiscated property. Confidential interviews revealed that C1 was able to enter unlocked staff office unsupervised and gained access to facility storage keys. Interviews also confirmed that the box where the facility keys are stored was unlocked inside the staff office that C1 was able to access. The STRTP facility is being cited for violation of Title Division Chapter Article Buildings and Grounds 80087 (g), Title 22, Division Chapter 1, Article 07. Physical Environment: 80087(a) Buildings and Grounds and Interim Licensing Standards version 5, Article 7, Continuing Requirements: 87072(c)(21) Personal Rights. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to RM.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA) Jessica Rubio arrived at Olive Crest Treatment Center - Wheeler (STRTP) to discuss records reviewed. LPA contacted Residential Manager David Owens via telephone. Mr Owens provided verbal authorization to deliver this report to Youth Care Specialist Aisea Tongilava. LPA reviewed April 2020 and May Medication Administration Record (MAR) log for C1 and discovered there were entries of medication refusals for C1's Fluoxetine recorded on 4/16/2020, 5/10/2020, and 5/24/2020. LPA reviewed the Special Incident Reports (SIR) that STRTP submitted to Community Care Licensing (CCL) during that time and no SIRs were submitted to CCL documenting C1 refused medication on those dates. LPA also discovered there was a blank entry on the MAR for 4/16/2020 for Melatonin. After LPA reviewed records it was determined that C1 was absent without leave (awol) at the time medication would have been administered however, there was no mention of the missed dose of medication written in the SIR reporting the awol nor was there another SIR submitted for the missed dose. The facility is being cited for Title General Regulation Section 80061 (b) (1) (E) Reporting Requirements. Based on record review the facility did not ensure C1's medication refusals or missed dose of medication due to awol were reported to CCL which poses a potential health, safety or personal rights risk to clients in care. An exit interview was conducted and a copy of this report, LIC 811 and appeal rights were provided to Youth Care Specialist Aisea Tongilava.

met_with: Youth Care Specialist Aisea Tongilave


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Eduardo Barragan on July 28, 2022 at 9: AM. During the inspection, LPA Barragan met with David Owens, Residential Manager and inspected the facility inside and out. LPA reviewed 1 of child's records on site at the facility at 9: AM. During the review of children's records, LPA Barragan observed Client 1 (C1) Psychotropic Medication Administration Records (PMAR) was missing dates of the administered medications. LPA Barragan noted that some of the PMAR sheets were missing the staff signature; the pill counts were not accurately counted as the pharmacy label identified; and certain medications were unaccounted for. All this would note on C1's PMAR sheet. LPA reviewed 2 of staff personnel files on site at the facility at 10: AM. LPA interviewed 2 staff on site at 11: AM. LPA interviewed 0 of children currently taking psychotropic medication at 12: PM. LPA conducted exit interview with David Owens, Residential Manager at 1: PM. LPA provided the Summary Report to David Owens, Residential Manager upon completion. One deficiency was observed (refer to LIC 809D) and cited from the California Code of Regulations, Title 22, and Health & Safety Codes during the inspection.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Leslie Covarrubias on August 10, 2023 at 11: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Covarrubias met with Administrator, Amy Ahern and inspected the facility inside and out. LPA reviewed two of child's records and three of staff personnel files on site at the facility. LPA reviewed two of child's psychotropic medications and medication records. LPA interviewed three of staff on site to discuss the facilities policies and procedures of operation. LPA interviewed two of children currently prescribed psychotropic medication. During the inspection the LPA observed deficiencies (see attached 809D), plan of corrections were discussed and appeal rights were provided. LPA provided a copy of this licensing report to Administrator, Amy Ahern.

Deficiencies:
87070: 1
2
3
4
5
6
7(13)	A separate log for each psychotropic medication prescribed to a child documenting all of the following

met_with: Administrator, Amy Ahern


raw_content:
Narrative:
Based on confidential interviews and documents reviewed, the allegation that minors ingested illegal drugs due to lack of supervision may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted with Residential Manager, Roberto Eulloqi. A copy of this report, Confidential Names List (LIC 811), and appeals rights were provided to Residential Manager, Roberto Eulloqi. Due to technical difficulties the report was emailed to Residential Manager, Roberto Eulloqi, Administrator, Brenda Solano, and Program Director, Grace Coffman at the time of inspection.

Investigation Findings:
13On April 2, 2026, at 8: AM, Licensing Program Analyst (LPA) Stefanie Mutialu arrived unannounced at the Short Term Residential Therapeutic Program (STRTP) facility and met with Residential Manager, Roberto Eulloqui, to discuss the investigative findings for the allegation noted above. On 12/09/ LPA Mutialu conducted an inspection of the facility; no deficiencies were noted. Investigative Branch Investigator Dennis Seng conducted the investigation. During the investigation the following interviews were conducted with five foster children (FC1-FC5), five staff (S1-S5), three county social workers (CSW1-CSW2), one probation officer (PO), and one charge nurse (CN). In addition, facility files and client records were reviewed. On 12/03/25, Community Care Licensing (CCL) received allegations that the STRTP staff allow minors to ingest illegal drugs in the facility. Confidential interviews and records reviewed indicated that C1 would return from approved absence from the facility in the possession of illegal substances and under the influence. Confidential interviews revealed that staff monitor C1 behaviors and attempt to confiscate the items however C1 does not consent to relinquishing contraband or any searches. There were no witnesses to the said events, therefore we cannot confirm or deny that the allegation occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Stefanie Mutialu 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 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: OLIVE CREST - WHEELERFACILITY NUMBER: VISIT DATE: 04/02/2026

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

met_with: Residential Manager, Roberto Eulloqui


facility_name: OPEN ARMS SAFE HAVEN-TRC

summary: Facility Evaluation

raw_content:
Narrative:
On December 30th, 2025 at 9:30AM, Licensing Program Analyst (LPA) Hanako Primer and Licensing Program Manager (LPM) Joel Segura met with Applicant representatives, Rhonda Jones, Chief Operating Officer, Taiwan Jones, Chief Executive Officer, Lanesha Morris, facility staff, Petrina Moreau, Director of Operations, and Akila Crane, Interim Director for the scheduled Component II face-to-face meeting. The meeting was held virtually via Microsoft Teams. The following items were discussed: - Ages served by the STRTP - Harm reduction techniques - Discipline methods - Needs and Services Plans - Medication administration procedures - Reporting Requirements - Policies on cameras - Administrator qualifications - Background Clearance/Guardian Process - Rates application process LPA described the next steps in the application process. Applicant sent the second revisions to LPA on 12/30/2025 via email. Component III was scheduled for 01/14/2026 from 9:30AM to 1:30PM. A copy of this report was provided to Applicant via email for digital signature.

met_with: Rhonda Jones - Chief Operating Officer


summary: Facility Evaluation

raw_content:
Narrative:
On January 21st, 2026, at 11:00AM Licensing Program Analysts (LPAs) Hanako Primer and Celeste Aparicio conducted a scheduled prelicensing inspection at the facility site. LPAs met with Rhonda Jones, Chief Operating Officer and Lanesha Morris, staff member. There no clients at the facility. LPA conducted a tour of the facility site, reviewed operating requirements with applicant representatives, and discussed the pending items to be completed prior to licensure. LPAs discussed Technical Support Program and provided informational pamphlet. Facility was clean and in good repair. LPAs inspected three bedrooms and three bathrooms. Bedrooms had storage space and beds with sheets and linens, with extra linens/towels in upstairs cabinet. Lights were functioning. LPAs observed two days of perishable foods and seven days of non-perishable foods. There are kitchen utensils, silverware, and dishes in the kitchen cabinets. The trashcans have tight-fitting lids. The backyard is clean and free of hazards. LPAs observed client rights, grievance procedures, activity schedule, and food menu posted in the facility. There are locked storage areas for medications, sharps, and toxic substances. Cleaning compounds were stored separately from food supplies. Client files and staff files will be stores in the staff office. The following items need to be completed prior to licensure. Office of the Foster Care Ommbudsperson Client Rights poster will be ordered. Licensee will send photo to LPA. Disaster and Emergency Preparedness Plan should include medication procedures and storage of refrigerated medication during an emergency. Licensee will send updated plan to LPA. Updated administrator qualifications exception request. Lanesha Morris's CPR/first aid certificate. Complete and submit to LPA the following program statement revisions. (see notice of incomplete application for details) 1. Revise staff training plan chart (pg. 77) to reflect trainings described in body paragraphs (pg. 74). On-hire trainings should be labeled. 2. Revise staff qualifications in job descriptions (pgs. 19-53) to reflect qualifications described in body paragraphs (pg. 55 and on). 3. Policies regarding security cameras per PIN 24-09-CRP. 4. Revised LIC200, LIC401, LIC500, LIC9165. 5. Revise intake policies/procedures section. 6. Include agreements with other agencies in core services and supports section. 7. Population to be Served: clarify, and keep consistent with LIC200. 8. Needs and Services Plan: Include listed elements. 9. Update components of centrally stored medication records. 10. Ensure allowance disbursements day is consistent throughout application. An exit interview was conducted with Rhonda Jones, Chief Operating Officer, and a copy of this report was provided to applicant representatives.

visit_type: Prelicensing


facility_name: OPEN LINE - THE OAKS

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

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

met_with: Debi Nunes, Administrator


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
Three clients reported a staff member solicited nude photos from one client who was Absent Without Leave (AWOL) from the facility. The facility was informed of the alleged solicitation, and promptly terminated the staff, who was already on leave for other unprofessional conduct. In addition to soliciting nude photos, the clients reported the staff member allowed the clients to use the staff member's cell phone to access social media, which went against facility policy. The staff member also visited a client while the client was AWOL, brought the client food, and took the client to the staff member's home. Per facility administration, the staff member did not notify the facility of being in contact with the AWOL youth, nor was the probation officer contacted regarding the client's location. Based on the preponderance of evidence that was met through interviews, observation, and record review, the allegation of: Staff solicited pornographic images from client is therefore SUBSTANTIATED. Facility is issued one citation from Interim Licensing Standards, Article 06. Section 87072 (C )(11): Personal Rights: (c) The licensee shall ensure that each child... is accorded the personal rights specified in Welfare and Institutions Code Section 16001.9, as applicable. In addition, the licensee shall ensure that each child is accorded the following personal rights: 11) To be free of physical, sexual, emotional, or other abuse, and from corporal or unusual punishment, exploitation, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature..." A signed copy of this LIC-9099, LIC-9099C, and LIC-9099D were provided to the facility. Appeal Rights were given. An exit interview was conducted.

Investigation Findings:
13Licensing Program Analyst (LPA) Misty Valencia arrived at the facility on this date for the purpose of delivering findings for the complaint investigation. LPA met with Orion Vasilas, Administrator. LPAs Hillary Hall and Misty Valencia conducted the complaint investigation. LPA Hall was assigned the complaint on 9/14/22, after the initial 10 day due date. LPA Valencia opened the investigation with the facility on 9/15/2022. During the course of the investigation, LPAs Hall and Valencia interviewed five current and former clients, three staff, two social workers, and a Probation Officer. LPA Hall reviewed records including: Employee termination report, Staff training log, Placement Roster, Serious Incident Reports, Prior Complaints, and Needs and Service Treatment Plans for clients. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Daniel Allmon LICENSING EVALUATOR NAME: Misty Valencia LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 25-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CHICO - RESIDENTIAL, COHASSET RD., STE. FACILITY NAME: OPEN LINE - THE OAKSFACILITY NUMBER: VISIT DATE: 11/17/2022

met_with: Orion Vasilas, Administrator


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Two Serious Incident Reports were documented by the facility, regarding two separate incidents within one week. One incident report documented an assaultive altercation between three clients. Staff attempted to de-escalate the clients using Emergency Intervention procedures. Law enforcement was called and responded. The events outlined in the law enforcement report correspond to the events in the report from the facility. The second Serious Incident Report documented verbally inappropriate behavior by one client toward another client. The staff responded to the clients by providing counsel, support, and additional supervision. Confidential interviews determined inconsistent information regarding the level of staff supervision during these two incidents. Based on LPA's observations, interviews which were conducted, and records reviewed, although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove the violation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED. A signed copy of this LIC-9099 report, the LIC-9099C, and appeal rights were provided to the facility. An exit interview was conducted.

Investigation Findings:
13Licensing Program Analyst (LPA) Misty Valencia and MIndy Pope arriveded unannounced at the facility on this date for the purpose of delivering findings for the complaint investigation. LPA met with Leanna Montgomery, Facility Manager. LPA McKinley conducted the complaint investigation. LPA opened the investigation with the facility on 8/22/2023 and the administrator and two staff were interviewed. LPA conducted a health and safety check of the facility on 8/22/2023 and no deficiencies were observed. During the course of the investigation, LPA Lyta Vue interviewed one client. LPA McKinley interviewed one client, two County Social Workers, and conducted three additional confidential interviews. LPA reviewed relevant records from the facility including, Placement Roster, Serious Incident Reports, Needs and Services Plans, CFT notes, Staff schedules, staff training log, and law enforcement reports. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Hillary Hall LICENSING EVALUATOR NAME: Misty Valencia LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 25-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CHICO - RESIDENTIAL, COHASSET RD., STE. FACILITY NAME: OPEN LINE - THE OAKSFACILITY NUMBER: VISIT DATE: 11/17/2023

met_with: Leanna Montgomery, Facility Manager


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
Based on IB findings, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations, staff had inappropriate interactions with client in care and staff absconded with client across state lines are SUBSTANTIATED, Facility is cited per Health and Safety code 1558 (a)(2) Conduct Inimical. A signed copy of this LIC-9099 report, the LIC-9099C, and LIC 9099D were provided to the facility, along with appeal rights. An exit interview was conducted.

Investigation Findings:
13On 2/16/ Licensing Program Analyst (LPA) Kellie McKinley arrived unannounced at the facility on this date for the purpose of delivering findings for the complaint allegations. LPA met with Rachel Gale- Residential Director. LPA McKinley opened the complaint on 8/18/23. The Investigation Branch (IB) conducted the investigation. LPA McKinley conducted a Health and Safety Inspection of the facility, and no deficiencies were observed. During the course of the investigation, IB conducted 14 confidential interviews and reviewed documentation, video, photos, texts and law enforcement records. One staff absconded from the facility with a minor in care, across state lines. Interviews were consistent that a staff was found behind closed doors with a client, which is against facility policy. Other behaviors were reported that corroborate an inappropriate relationship between the staff and client at the facility. continued on 9099-C page SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Hillary Hall LICENSING EVALUATOR NAME: Kellie McKinley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 25-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CHICO - RESIDENTIAL, COHASSET RD., STE. FACILITY NAME: OPEN LINE - THE OAKSFACILITY NUMBER: VISIT DATE: 02/16/2024

met_with: Rachek Gale- Residential Director


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
the minor to drive the staff's vehicle during the crime, while the staff was still employed at the facility, contributing to the delinquency of the minor. The minor was arrested. When the facility was notified of the incident two days later , the staff was terminated. Based on IB investigators interviews which were conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. A Citation is being issued for violating Interim Licensing standards Section # Personal Rights (c) (16). A signed copy of this LIC-9099 report, the LIC-9099C, and LIC-9099D were provided to the facility. An exit interview was conducted. Appeal rights were provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Kellie McKinley arrived unannounced at the facility on this date for the purpose of delivering findings for the complaint investigation. LPA met with Tyson Poso- COO. IB investigator Juan Barajas conducted the complaint investigation. LPA opened the investigation with the facility on 8/30/24 and conducted a Health and Safety Inspection. During the course of the investigation, IB investigator Barajas interviewed two current and one past staff , four clients, a parent, one past and one current administrators, the probation officer, and a police detective. IB investigator reviewed records from the facility including: Placement Roster, staff schedules, client mental health assessments, Needs and Services plan, staff and client files, progress notes, complaint history, and law enforcement reports. A staff member confirmed being involved in an incident in which a client in care engaged in criminal activity. Law enforcement reports detail the staff's involvement in the incident. The staff member allowed SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Hillary Hall LICENSING EVALUATOR NAME: Kellie McKinley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 25-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CHICO - RESIDENTIAL, COHASSET RD., STE. FACILITY NAME: OPEN LINE - THE OAKSFACILITY NUMBER: VISIT DATE: 11/14/2024

met_with: Tyson Poso - Chief Operating Officer


raw_content:
Narrative:
Based on interviews which were conducted, and records reviewed, although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove the violation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED. A signed copy of this LIC-9099 report, the LIC-9099C, and appeal rights were provided to the facility. An exit interview was conducted. Appeal Rights were given at the time of the delivery.

Investigation Findings:
13Licensing Program Analyst (LPA) Kellie McKinley arrived unannounced at the facility on this date for the purpose of delivering findings for the complaint investigation. LPA met with Tyson Poso COO. IB investigator Juan Barajas conducted the complaint investigation. LPA opened the investigation with the facility on 8/30/24 and conducted a Health and Safety Inspection. During the course of the investigation, IB investigator Barajas interviewed two current and one past staff , four clients, a parent, one past and one current administrators, the probation officer, and a police detective. IB investigator reviewed records from the facility including: Placement Roster, staff schedules, client mental health assessments, Needs and Services plan, staff and client files, progress notes, complaint history, and law enforcement reports. Fourteen out of fifteen interviews did not report knowledge of, or information about, a romantic relationship between a client and a staff member. Both the client and the staff member denied having any romantic relationship. No evidence was obtained through the record review regarding the alleged romantic relationship. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Hillary Hall LICENSING EVALUATOR NAME: Kellie McKinley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 25-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CHICO - RESIDENTIAL, COHASSET RD., STE. FACILITY NAME: OPEN LINE - THE OAKSFACILITY NUMBER: VISIT DATE: 11/14/2024

met_with: Tyson Poso- Chief Operating Officer


raw_content:
Narrative:
this incident or any other similar incidents involving staff vaping with the client. The staff observed in the incident did have a history of vaping, and staff and clients confirmed many of the clients smoke or vape. However, all interviewed agreed that clients obtain contraband from school or friends and never from staff at the facility. Both the client and the staff observed by the witness in the incident, denied sharing a vape or interacting inappropriately with each other. The staff has since resigned from employment at the facility. Based on LPA's observations, interviews which were conducted, and records reviewed, although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove the violations did, or did not, occur. Therefore, the allegations are UNSUBSTANTIATED. A signed copy of this LIC-9099 report, the LIC-9099C, and appeal rights were provided to the facility. An exit interview was conducted.

Investigation Findings:
13Licensing Program Analyst (LPA) Kellie McKinley arrived unannounced at the facility on this date for the purpose of delivering findings for the complaint investigation. LPA McKinley met with Mike Hernandez Administrator. LPA McKinley conducted the complaint investigation. LPA Wendy Brown opened the investigation with the facility on 9/10/24, met with Kalina McCarty- Facility Manager and conducted a Health and Safety Inspection. During the course of the investigation, LPA McKinley interviewed two clients and attempted to interview two other clients, who declined. LPA interviewed an administrator, a former staff, and the Chief Operating Officer. LPA Lyta Vue interviewed the reporting parties, a program director, facility manager, and the clinical director. LPA reviewed relevant records from the facility including: Training logs, staff schedules, a staff file, complaint history, Serious Incident Reports, CFT notes, and Needs and Service Plans for foster youth. It was alleged that a staff member engaged in inappropriate interaction and shared a vape with a client in care. One witness reported observing a staff member stand close to a client and vape with the client on one occasion, away from the facility. Subsequent staff and client interviews indicated no knowledge of continued on 9099-C page UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Hillary Hall LICENSING EVALUATOR NAME: Kellie McKinley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 25-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CHICO - RESIDENTIAL, COHASSET RD., STE. FACILITY NAME: OPEN LINE - THE OAKSFACILITY NUMBER: VISIT DATE: 11/22/2024

met_with: Mike Hernandez Administrator


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
An incident report was submitted to the Department indicating a staff member had been horseplaying with a client. The staff member meant to tap the client on the arm with a rubber ruler, but the ruler instead made contact with the side of the client's face. The staff apologized to the client. Interviews and documentation support that the incident was accidental on staff's part. No medical treatment was necessary for the client. The facility immediately responded by suspending, then terminating, the staff. The client was provided with additional staff support after the incident. Based on LPA's interviews which were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. No citation issued due to prompt response by the facility with corrective action already completed. A signed copy of this LIC-9099 report, the LIC-9099C, and appeal rights were provided to the facility. An exit interview was conducted. A copy of the Appeal right was given.

Investigation Findings:
13Licensing Program Analyst (LPA) Kellie McKinley arrived unannounced at the facility on this date for the purpose of delivering findings for the complaint investigation. LPA met with Tyson Poso, CEO. LPA McKinley conducted the complaint investigation. LPA initiated the investigation with the facility on 4/30/25 and met with Rachel Underwood- Residential Director, and conducted a Health and Safety Inspection. During the course of the investigation, LPA interviewed five clients, a County Social Worker, three past and current staff and one outside service provider. LPA reviewed records including: Placement Roster, staff file, prior complaint history, Serious Incident Reports, Child Welfare Records, staff schedule, and the Needs and Service Plans for clients. continued on 9099-C page SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Hillary Hall LICENSING EVALUATOR NAME: Kellie McKinley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 25-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CHICO - RESIDENTIAL, COHASSET RD., STE. FACILITY NAME: OPEN LINE - THE OAKSFACILITY NUMBER: VISIT DATE: 05/29/2025

met_with: Tyson Poso- Chief Executive Officer


summary: Facility Evaluation

raw_content:
Narrative:
On /21/ LPA met with Tyson Poso administrator for an annual inspections at 10: AM. The Oaks currently has no youth living at the facility, nor staffing. The facility has one care taker who lives at facility to maintain and assure property is not vandalized or broken into while vacate. LPA observed kitchen to be clean and clear of debris. Refrigerator in function condition and at an appropriate temperature. Bathrooms were observed to be in functioning order with water temperature slightly above required limit. Tyson Poso will have maintenance check the water temperature is not above 120 degrees. Locked closet in hall is where chemical and supplies are kept when staff and children are present. Bedrooms were observed to have twin bed frames Medications are locked in the office cabinet when clients are in care and their is staff. Garage housed locked refrigerator for any medication that would require refrigeration. Garage had boxes, washer and dryer in good condition. First aid kit was observed with First Aid booklet dated 2016, bandages, gauze, tweezers and scissors. The backyard was observed as being large with lots of mature trees and dead grass. The exterior of the house needed minor maintenance issue fixed from previous repairs and to fill siding holes. LPA observed back area of yard where fencing needs to be taken down in one section and the fence corner repaired. Administrator stated he would have his maintenance person out this week. Administrator stated this is the reason they got a care taker as they were having issues with people breaking in or teens coming and having parties here at the facility. No citation is given as their are not clients in care. LPA reviewed all applicable areas of the CARES tool that applied including Operations, Disaster preparedness, Emergency intervention plan and training, and Core Therapeutic Services. LPA could not review any client files or staff files as the house has not current clients in care. These section will not apply at the time of the annual inspection. No citations were given at the time of the inspection.

met_with: Tyson Poso- Administrator


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA), Stefanie Whitlow, on 11/19/21 at 11: AM. During the inspection, LPA met with Mike Hernandez, Administrator and inspected the facility inside and out. The facility (The Oaks) house is located at Alta Mesa. Redding, Ca. There are currently no children residing in the home, therefore, no clients were interviewed and no PMAR's reviewed. LPA also did not conduct a medication count. LPA interviewed one staff, medical coordinator, at The Oaks house, at the time of inspection. LPA arrived at administrative office with address of Mountain Lake Blvd. Redding, Ca at 1: PM LPA met with Administrators, Debi Nunes and Mike Hernandez. One staff was interviewed and four staff records were reviewed. The staff members who will be staffing the Oaks Home when children are moved in, currently work at the Westgate Home which has address of Westgate Avenue. Redding, Ca. LPA met and interviewed two additional staff at the Westgate facility. LPA reviewed 0 child's records on site at the facility. LPA reviewed 4 staff personnel files on site at the facility at 1: PM. LPA interviewed 4 staff on site at 12: PM, 1: PM, and 4: PM. LPA interviewed 0 children currently taking psychotropic medication. No deficiencies are being cited at this time. LPA conducted exit interview with Mike Hernandez, Administrator at 6: PM, who signed Summary Report, which was emailed upon completion.

met_with: Mike Hernandez


summary: Facility Evaluation

raw_content:
Narrative:
On 11/17/2022, Licensing Program Analyst (LPA) Misty Valencia conducted an unannounced inspection at the facility and met with the Orion Vasilas, Administrator (Admin) regarding a Special Incident Report (SIR) that was submitted to Community Care Licensing on November 10, 2022. The SIR was regarding the AWOL (Absence Without Official Leave) of Youths #1, #2, and #3 (see confidential name list LIC 811 dated 11/17/22) On 11/08/2022 the Youth #1 that resides at the Woodcliff Facility (lic. 455001037) reported that when he, Youth #3, and Youth #2 were AWOL from the facility, that Youth #2 was trading sexual favors to an adult for drugs, alcohol and a place to stay. Youth #1 also reported that he believes that Youth #3 may have also been involved. A Suspected Child Abuse Claim was filed, the police were notified, and SIR was submitted. Youth #2 likes to AWOL a lot. He is in a very negative stated right now in his mind. And has been for the last year. He has just been wanting to go home so he has been having behavior issues. LPA asked Admin was happened before the youth AWOL'd from the facility. Admin reported; On Oct 28, Youth #1 had a court date and thought he was going to be released to his family member, but that did not happen. The family member is not ready for Youth #1 to come home just yet. The judge also encouraged the social worker to find a lower level of care for him, but Youth #1 does not want to go anywhere except with grandma. The other two (2) youth we don't have any issues with usually. This was their first time leaving the facility without permission. On 11/05/2022 all three (3) youths left the facility. When they returned Youth #1 told me that Youth #2 was doing sexual favors for vape pens, marijuana, and a place to sleep. I asked Youth #3 what happened while they were gone and he denied anything had happened. I contacted Child Protective Service Worker (CPS) , then Law Enforcement (LE). Youth #1 should me where they were staying and I let LE know. The next day LE went to the apartment and picked up Youth #2 and Youth #3 and brought them back to the facility. They were then interviewed by LE. None of the youth has disclosed any other information to me. continued on 809-C continued form We have a Case Manager at the Facility that will be working with the youth. They are also encouraged to come to us to talk if they need to as well as their counselors. We are going to move Youth #2 to another facility to see if that alleviates him and the other two (2) youth from leaving. We thought maybe the change of environment would be good for Youth #2 to help turn things around. The other two (2) youths we have had no issues leaving without permission, so moving Youth #2 may help them not leave. Facility took appropriate actions therefore no citations will be issued. Based on the information obtained through interview, there is no evidence of any Interim Licensing Violations. There were no deficiencies cited at this time, and a copy of this report was given to the facility representative.

met_with: Orion Vasilas, Administrator (Admin)