summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On February 24, 2025, at 11: AM, Licensing Program Analyst (LPA) Jacob Salem and Licensing Program Manager (LPM) Dawn Segura conducted a technical assistance meeting virtually, via Teams, with San Pasqual Treatment Center (STRTP) Executive Director (ED) Lawrence Howell, Regional Director (RD) Dana Centanni, and Business Manager (BM) Jennifer Stoops. Also present at the meeting were System of Care Branch Analyst, Ansar Mohammed, System of Care Branch Manager, Marjana Jackson, and San Diego County Representatives Eileen Marshall, Jimabeth Ramsey, and Christina Bradley. The Purpose of the meeting was to discuss and review the following pending Licensing forms, Plan of Operation (POO), and Program Statement (PS) revisions: Application and Supporting Documentation (LIC 281E) 1. Application for a Community Care Facility (LIC 200) - Meets Standards 2. Orientation Certificate (Reference CCR § 80018(b) - Proof of attendance on file/Meets Standards 3. County Letter of Recommendation (Reference HSC § 1562.01(f) ILS § 87018(c)(6)) - Pending 4. Applicant information (LIC 215) - Does Not Meet Standards 1. Photocopied signature was provided. Please provide the original wet signature or new forms with electronic signature (using Adobe). 4. Designation of Facility Responsibility (LIC 308) (Reference CCR § 80064) - Meets Standards 5. Affidavit Regarding Client Cash Resources (LIC 400) (Reference HSC § CCR § 80018) - Does Not Meet Standards 1. Wrong bond amount listed on the form. Based on the amount stated the facility will hold at one time, a surety bond of $5000 is required. Please correct. 2. Photocopied signature was provided. Please provide the original wet signature or new form with electronic signature (using Adobe). 6. Surety Bond (LIC 402) (Reference CCR § 80018(d)) - Pending CONTINUED... ...Continued 2 7. Monthly Operating Statement (LIC 401) (Reference HSC § 1520(c) CCR § 80018 - Does Not Meet Standards 1. Wrong number of clients listed under program revenue section at top of form. 2. Salary and wages is too low given the number of employees listed on the LIC Personnel Report. Please correct or provide break down of employee salary/wages. 3. Photocopied signature was provided. Please provide the original wet signature or new forms with electronic signature (using Adobe). 8. Supplemental Financial Information (LIC 401A) (Reference HSC § 1520(c) CCR § 80018) - Does Not Meet Standards 1. Please complete Part II of the form. 2. Photocopied signature was provided. Please provide the original wet signature or new forms with electronic signature (using Adobe). 9. Balance Sheet (LIC 403) (Reference HSC § 1520(c), CCR § 80018) - Does Not Meet Standards 1. Numbers not transferred over correctly from LIC 403a forms, specifically lines 8 & 13. Please correct or provide explanation of discrepancy. 2. Photocopied signature was provided. Please provide the original wet signature or new forms with electronic signature (Adobe). 10. Balance Sheet supplemental Schedule (LIC 403A) (Reference HSC § 1520(c), CCR § 80018) - Does Not Meet Standards 1. Numbers not transferred over correctly to LIC 403 forms, specifically lines 23 & 29. Please correct or provide explanation of discrepancy. 2. Photocopied signature was provided. Please provide the original wet signature or new forms with electronic signature (using Adobe). 11. Financial Information Release and Verification (LIC 404) (Reference HSC § 1520(c), CCR § 80018) - Pending 12. Personnel Report (LIC 500) (Reference HSC § 1522, CCR § 80018) - Does not Meet Standards 1. Staff are currently scheduled to work at the same time in both facilities. Please correct. 13. Health Screening Personnel (LIC 503) (Reference CCR § 80018(d)) - Meets Standards 14. Emergency Disaster Plan (LIC 610C) (Reference CCR § 80023) - Does not Meet Standards 1. Form is not signed by administrator. Please ensure wet or electronic signature is provided. Continued... ...Continued 3 2. Letters of approval from relocation sites are missing. Please include. 15. Fire Inspection Authority (LIC 9054) (Reference CCR § 80018(d)), CCR § 87018(d)) - Meets Standards 16. Board of Directors Statement (LIC 9165) contained in PUB 326) (Reference CCR § 87018(d)) - Meets Standards 17. Control of Property (Reference CCR § 80018(c) - Meets Standards 18. Bacterial Analysis of Water (Reference CCR § 80021) - Meets Standards 19. Application or Documentation of Accreditation (Reference ILS § 87089) - Does not Meet Standards 1. See below notes for Section 20 of Program Statement Plan of Operation Section A, Purpose and Goals - Meets Standards Section B, Administrative Organization - Does Not Meet Standards 1. Organizational chart on page 220 is outdated. Please update. 2. Administrator certificate pending. Section C, Facility Sketch - Meets Standards Section D, Staff Plan - Does Not Meet Standards 1. At a minimum, the following course should be included in the 16 minimum training plans: Health issues in foster care-missing (87065.1 (d)(3)(Z)). 2. Facility Manager training missing the following training: - Implementation of the assessment by the Qualified Individual, as specified in section 87022.1(b)(8)(A), and information about the Qualified Individual's assessment process pursuant to Sections 4096 and 11462.01 of the Welfare and Institutions Code. - Facilitation of participation of family members in child's treatment program and documentation of integration of family members into the treatment process, as specified in section 87022.1(b)(13)(A). - Facilitation of outreach to family members and documentation of outreach, as specified in section 87022.1(b)(13)(A). - A child's right to receive gender affirming sexual and reproductive health care and information. - A child's right to have their health information kept confidential. - The duties and responsibilities of the assigned case management worker and the licensee to ensure that children can obtain sexual and reproductive health services and information. Continued... ...CONTINUED 4 - Guidance about how to engage and talk with children about healthy sexual development and reproductive and sexual health in a manner that is medically accurate, gender affirming, age or developmentally appropriate, and trauma informed. - Information about current contraception methods and how to select and provide appropriate referral resources and materials for information and service delivery. 3. Please ensure required training below has been included in their training: - Prior to working with children, a peer partner shall be certified in cardiopulmonary resuscitation (CPR) and first aid and are required 16 of training prior to working with children and those training are required at minimum to include (87065.1(g)(1) and 87065.1 (f)(1)). i. The confidentiality of information and records relating to children in the short term residential therapeutic program. ii. Teamwork and interpersonal communication among facility personnel and children, children's family members, and the child and family team members. iii. The children's personal rights as specified in Welfare and Institutions Code section 16001.9 and section 87072, including, but not limited to, the right to have fair and equal access to all available services, placement, care, treatment, and benefits, and to not be subjected to discrimination or harassment on the basis of actual or perceived race, ethnic group identification, ancestry, national origin, color, religion, sex, sexual orientation, gender identity and expression, mental or physical disability, or HIV status. iv. Physical and psychosocial needs of children, including behavior management, de-escalation techniques, and trauma-informed crisis management planning, including the use of emergency interventions. v. Child and adolescent development, including sexual orientation, gender identity and gender expression. Section E, Policies Regarding Child Abuse Reporting - Meets Standards Section F, Administrative Policies and Procedures - Meets Standards Section G, Admission Determination Procedures - Does Not Meet Standards 1. Please also include how the licensee defines these characteristics (CSEC, fire starting) for the purposes of assessing appropriateness of fit (87068.05 (C)(3)). 2. Please clearly detail the timeframes for initial and final response to the county placing agency regarding referrals for placement. 87068.05(c)(4)(A). Continued... ...CONTINUED 5 - The established timeframes must include, but are not limited to, an initial response period in which the facility accepts, denies, or requires more information for the consideration of the referral for placement. The facility's initial response period shall not exceed 5 days following the receipt of referral for placement and-meets standards. - A final response period in which the facility accepts or denies the referral for placement. 3. Elevated review procedures: If the licensee determines that the program is not capable of meeting the child's needs without additional services and/or supports, the licensee shall request such assistance from the placing agency, Community Based Organization, or any other resource, and shall document this request. 87068.05 (g) please ensure to document this request. Recommend adding this on page 284, after "the Head of Service will make the support request." Section H, Intake Policies and Procedures - Does Not Meet Standards 1. Please mention that a needs and services plan will be completed within 30 days of intake. Page 289 mentions Needs and Services Plans for Non-minor dependents, but a Needs and Services Plan should be completed for all youth. 2. Please update procedures for child/youth emergency placement to include 87068.1(e): No later than 7 days after emergency placement, the administrator or social work staff shall review the intake documents to determine whether the facility can continue to provide the services necessary to meet the needs of the nonminor dependent. Section I, Admission Agreement - Meets Standards Section J, Removal or Transfer Policies and Procedures - Does Not Meet Standards 1. Please detail policies and procedures for removal or transfer of children and nonminor dependents during the following times (87022 (c)): After program goals have been reached. 2. Please include a description of how the licensee will mitigate against potential impacts to a child as a result of removal or transfer, including but not limited to 87068.4 (a): - how licensee will assist in preventing delays or gaps in delivery of services(please describe on page 302). - The program statement states "Maintain contact and provide aftercare support to the child after transfer (if applicable and not the responsibility of another STRTP)." Please describe the types of trauma-informed support and transition services to be provided. Continued... ...CONTINUED 6 - The program statement states, "San Pasqual Treatment Center will incorporate best practices for staff communication with the child and family prior to their transition." Please explain these best practices. As a reminder, the facility shall provide trauma-informed support and transition services to children/foster youth as part of a planned or unplanned removal or transfer, as specified in Subdivision (l) of Section 1562.01 of the Health and Safety Code (87068.4 (c)(1)). 3. If it is determined that the facility cannot meet the needs of the child, the licensee shall notify the authorized representative(s) of the determination and request that the child be placed elsewhere. The Requests shall be submitted to the county placing agency and shall contain the following information: 87068.4 (e)(2) - on page 304, please ensure the letter is submitted to the county placing agency and includes a request for the child to be placed somewhere else. Please ensure the following as well: - Date the county placing agency was informed of the concern pursuant to Section 87068.4 (e)(1)(B). - date the Child and Family Team meeting was held pursuant to Section 87068.4 (e)(1)(D). - Please ensure requests that the child be placed somewhere else shall be accompanied by a statement, signed by the facility's Mental Health Head of Service, providing an explanation of why the facility was unable to meet the needs of the child, including the following information: 4. Please include the procedures for an NMD to transfer from an STRTP in accordance 87068.4 (h): - Written notice to the NMD and placement agency; - Transfer shall state the reason for the transfer and request the NMD be placed elsewhere; and - Procedures for appropriately distributing the NMD's records. Section K, Rate Setting and Refunds - Meets Standards Section L, Handling Money, Personal Property, and or Valuables - Meets Standards Section M, Consultants and Community Resources to be Utilized - Meets Standards Section N, Trauma-informed Intervention and De-Escalation Techniques - Meets Standards Section O, Plan or Use of Delayed Egress Devices - Meets Standards Section P, Conflict of Interest Mitigation Plan - Meets Standards Section Q, Continuous Quality Improvement (CQI) - Does Not Meet Standards 1. Please detail how the CQI plan is developed based on the mission, vision, and values. (87081) 2. Please describe how direct input is used to inform program development and improvement. (87081 (b)(1)) CONTINUED... ...Continued 7 3. Please include a description of how outcome measures will inform Dignity of its program being trauma-informed and culturally relevant. 87081(c)(2) 4. Include collecting data on the numbers and types of complaints received and, if applicable, the resolution of each complaint. 87081(c)(7) 5. How the facility will take the data to inform and improve policies, practices, and programs. 6. After the facility has analyzed and interpreted the data, how does the facility use that data to improve polices, practices and programs? 887071(c)(5) 7. Describe how CQI program will be culturally relevant, trauma-informed, and age and developmentally appropriate. For example, input is received from all levels of staff, children and CQI objectives and plan is directly tied to trauma informed principles of safety, permanency, and trauma informed services/supports. Program Statement Section 1, Population Served - Does Not Meet Standards 1. Please describe the treatment modalities aimed at addressing the needs of youth in the population served by your facility (probation youth/ survivors of commercial sexual exploitation/various diversities/LGBTQ/probation/substance abuse). ILS 87022.1 (b)(2)(A) - page 349 "all interventions will be evidence based and trauma informed", integrated core practice. 2. Can you describe programs and services specific to assisting an NMD in preparing for the transition to independent living? 3. Does the facility plan to serve youth with special heath care needs? Section 2, Emergency Disaster Response Procedures - Meets Standards Section 3, Transportation Arrangements - Meets Standards Section 4, Core Services and Supports - Does Not Meet Standards 1. Please describe the core services and supports offered to youth at the facility to include the following 87078.1 (a)(1-5): Services to achieve permanency, including supporting efforts to reunify or achieve adoption or guardianship and efforts to maintain or establish relationships with parents, siblings, extended family members, tribes, or others important to the child or nonminor dependent, as appropriate. Please describe in depth what the services/supports to achieve permanency look like, for example family therapy sessions, transportation to visits. Continued... ...Continued 8 2. Does the facility plan to contract (or hold any current contracts) with any community-based providers/agencies/organizations to provide core services and supports? If so, please attach the agreements and ensure documentation of agreements with other agencies shall be maintained by a short-term residential therapeutic program and be available upon request by the licensing agency. 87078.1(b)(2) 3. Please provide the names of any existing relationships with community and county-based providers and describe the core services secured through agreements (87078.1(b)(2)). This may include local parks and recreation to support extracurricular activities, LGBTQ centers to support clients, colleges for NMD support in academic continuation, linkages to TAY programs, American Indian centers/programs, regional centers. Section 5, Culturally Relevant Interventions, Practices, Services, and Supports - Meets Standards 1. Recommend describing any specific services for CSEC, African American, Latino. Does the facility work with any specific culturally relevant community-based organizations or agencies? In addition to discussion of services and supports pg. 390, recommend describing how these services are implemented. Section 6, Trauma Informed Interventions and Treatment Practices - Does Not Meet Standards 1. The trauma-informed prevention services, interventions, practices, services and supports must demonstrate the following: maximization of physical and psychological safety for the child or nonminor dependent; recommend describing examples. 2. Please provide the procedures for how the provider will access and make referrals for evidence-based and/or promising services and practices that are trauma informed. 3. Please provide the procedures for maintaining consistency with TILPS (when applicable). Section 7, Development, Implementation, and Modification of Needs and Services Plan - Meets Standards Section 8, Planned Activities - Meets Standards 1. Please include a written plan for indoor and outdoor activities including, but not limited to, the following: - Activities which meet the training, money management, and personal care, grooming needs, and any other independent living skills identified in the children's needs and services plans, as specified in Section 87068.2(b)(3) through (5) and Section 87068.22(c)(1); recommend describing the money management planned activities: credit recovery, how to open a bank account, etc. Fake monopoly is a great way to help learn financial management, but since you already have classes to teach these things, could it be more age appropriate to allow the "younger" youth access to the classes instead? Continued... ...CONTINUED 9 - As a reminder, a schedule of the planned activities shall be posted on at least a weekly basis in a central facility location readily accessible to children, relatives, and representatives of placement. 87079(e) Section 9, Services During Placement and After Discharge - Does Not Meet Standards 1. Please use this section to list any agencies or community-based organizations that the facility has identified or commonly uses to provide additional services during care and after care. Please add the name, location, and the services. You can also include a statement that references another section where this information can be found. Section 10, Plan of Participation in the Child and Family Team - Does Not Meet Standards 1. How often will CFTM be held after the initial CFTM? Please see ILS § 87022.1(b)(11); ILS § 87001(c)(4). 2. Repetitive language. Recommend condensing. Section 11, Identification of Home-Based Care - Meets Standards Section 12, Participation of Family Members in Treatment & Outreach to Family - Meets Standards Section 13, Complaints and Grievances - Meets Standards Section 14, Participation and Assistance in Initiatives to Improve the Child Welfare System - Meets Standards Section 15, Family Visitation - Meets Standards Section 16, Children and Non-minor Dependents Personal Rights - Meets Standards Section 17, House Rules for Children and Non-minor Dependents - Does Not Meet Standards 1. What is the actual curfew time? 2. Please detail house rules on alcohol, drugs, weapons, smoking, room search/search of personal belongings. Section 18, Positive Discipline Policies - Does Not Meet Standards 1. Please include a copy of the code of conduct. 2. Please include a description on how discipline policies are trauma informed and include a description on how discipline policies account for specialized populations (CSEC youth). 3. Please ensure Staff, children, and authorized representatives shall sign and receive copies of discipline policies and procedures and the Signed copies shall be maintained in the child's record 87072.1(a)(3-4) Section 19, Storage of Medication - Meets Standards Section 20, Documentation of Accreditation - Does Not Meet Standards CONTINUED... ...Continued 10 1. The facility has included a copy of an accreditation. Please demonstrate that this is the accreditation for this specific facility's location. 2. New applicants should submit a declaration of accreditation status including what accrediting entity was chosen and a description of steps the applicant has taken to acquire accreditation. 87089 (c)(1). The applicant shall submit documentation of accreditation/a copy of its application for accreditation (87089(c)). 3. Please include a statement that the facility will provide documentation to the Department reporting its accreditation status at 12 months and 18 months after the date of provisional licensure (87089 (d)). 4. Please include a statement that the facility will provide a copy of final accreditation summary report to the licensing agency within 30 days of its release date (87089 (f)) 5. Please include a statement that if a corrective action is required by the accrediting entity in response to the final accreditation summary report, or at any other time following accreditation, a short-term residential therapeutic program shall provide documentation of its corrective action to the ..licensing agency Department within 30 days of its completion date (87089(g)) Section 21, Mental Health Program Approval - Meets Standards 1. Please update section if Mental Health approval has been received since submitting application. Section 22, Nursing Services - Does Not Meet Standards 1. Page 547 states "The ROP Nurse oversees multiple STRTP homes and is not based solely at one home." Is this nurse employed/hired by ROP or contracted? If so, please detail and include any MOU/contracts. Section 23, Food and Nutritional Plan/Sample Menus/Schedule - Meets Standards Section 24, Emergency Intervention Plan - Does Not Meet Standards 1. Please include the following in runaway plan: - Procedure for complying with Reporting Requirements specified in Section 87061(i). - Procedures for management review of incident reports, policies, and practices to determine the cause of, and to develop strategies to address, runaway children, both on an individual and facility-wide level. Procedures must include regular management reviews to be conducted at least once a year.*n - How staff respond to runaway child(ren) and child(ren) outside of the facility property without permission, but who are within view of the staff. Continued... ...CONTINUED 11 i. The section stated "If a client is outside the facility without permission in view of staff, they will be immediately informed they must ask to return to the facility," is this what was intended to have been said? When reporting incidents, please ensure all report requirements specified in Section 87061(I) are also maintained Incident Reports documenting a runaway situation must include the following: - (A) When, how, and by whom was the child's absence first noted. (B) The child's last known activities. (C) What were the circumstances surrounding the child's absence. (D) What action did the facility personnel take to discourage the child from leaving and what interventions were utilized. (E) What action was taken by facility personnel to locate the child. If a manual restraint was used, and if it is determined by the post incident review, as required in Section 87095.68, that facility personnel did not attempt to prevent the manual restraint, a description of what action should have been taken by facility personnel to prevent the manual restraint incident. (F) Describe what corrective action that will be taken or will not be taken against thefacility personnel and why. (G) If law enforcement was involved in the incident, a detailed description of the events involving the law enforcement contact, including a - police report number if available. (H) Documentation that the child's authorized representative has been notified of the incident. 2. Please specify whether the youth are being supervised during the 15 min cool down. 3. Please describe the procedures for determining and using age and size appropriate emergency intervention techniques. 4. Please include criteria for assessing when an emergency intervention plan needs to be modified or terminated, along with the procedures for terminating the plan or making any necessary modifications. 5. The section stated, "Manual restraints shall not be longer than 15 minutes." Please describe in-depth what the facilities' intervention process is after 15 minutes. If the youth is unable to remain calm, what are the facilities' policies? If the facility will use restraints longer than 15 mins, please describe the procedures. Recommend detailing these procedures if the facility plans to use restraints past 15 mins. 6. The following required detail in the descriptions of the monthly restraint log was left out: result of licensee review. Please include. 7. Please include if facility will use separation rooms. Continued... ...Continued 12 8. Please state that the admissions agreement will include a written statement regarding the types of emergency interventions the licensee has been approved to use and must be reviewed with the child/NMD and authorized representative at the time of admission, and that a copy of the interventions used will be provided to the authorized rep upon request. (87095.22(i)(1)(A)) 9. Please state that the facility will follow the reporting requirements for each use of manual restraints of a child/NMD (87061(i)(7), which are: - Date and time of other manual restraints involving the same child in the past 24 hours. - A description of the child's behavior that required the use of manual restraints, and description of the precipitating factors which led to the intervention. - Description of what manual restraints were used and how long the child was restrained. - Description of what non-physical interventions, trauma-informed practices, or de-escalation techniques were utilized prior to the restraint and an explanation of why more restrictive interventions were necessary. - Description of any injuries sustained by the child or facility personnel, including what type of medical treatment was sought and where the child was taken. Provide an explanation if medical treatment was not sought for injuries. - Name(s) of facility personnel who conducted the manual restraint. - Name(s) of facility personnel who witnessed the child's behavior and the restraint. - The child's verbal response and physical appearance, including a description of any injuries at the completion of the restraint. - If it is determined by the post incident review, as required in Section 87095.68, that facility personnel did not attempt to prevent the manual restraint, provide a description of what action should have been taken by facility personnel to prevent the manual restraint incident. Describe the corrective action that will be taken or will not be taken against the facility personnel and why. - If law enforcement was involved, a detailed description of the events involving the law enforcement contact, including a police report number if available. - Documentation that the child's authorized representative has been notified of the incident. General Notes: -Correction of "The Southern California Treatment Programs" used on page 564. A copy of this report was sent to Lawrence Howell, Executive Director for signature. The original signed copy will be maintained in the facility file in the San Diego Regional Office.

Deficiencies:
90086: 02/24/2025 Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32...Continued 10 1.

title: Visit Date


state: CA

facility_name: SAN PASQUAL TREATMENT CENTER - MALE PROGRAM

summary: Facility Evaluation

raw_content:
Narrative:
On October 9, 2025 at 1: PM, Licensing Program Analyst (LPA) Jacob Salem conducted an unannounced visit to the above facility for the purpose of conducting a post-licensing inspection and met with Frank Simmons, Administrator. LPA inspected the facility's physical plant, including personal rights postings, health-related services, buildings and grounds, food services, telephones, indoor and outdoor activity space, and furniture, fixtures, equipment and supplies. Their are currently no clients in care. The home is a one story building with three client bedrooms and two client bathrooms which are set up as follows: Bedroom #1 has two twin beds and can sleep two clients, bedroom #2 has two twin beds and can sleep two clients, and bedroom #3 has two twin beds and can sleep two clients. There is a kitchen and living room, separate office garage for client visitation and therapy, laundry room and locked storage closets, and backyard/patio area. Due to time constraints, the annual is being extended to complete file reviews and interviews. An exit interview was conducted and a signed copy of this report was provided to Frank Simmons, Administrator.

report_type: Facility Evaluation

met_with: Frank Simmons, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On October 10, 2025 at 10: AM, Licensing Program Analyst (LPA) Jacob Salem conducted an unannounced visit to the above facility and met with Monica Gastelum, Designee. The purpose of this Case Management inspection is to conduct an annual continuation from 10/09/2025. LPA conducted two staff interviews. LPA reviewed five staff files (S1-S5), which contained the required demographic information, background clearances, and qualifications. Based on observations made during the inspection, there were no deficiencies cited at this time. An exit interview was conducted with Monica Gastelum, Designee and a signed copy of this report was provided.

visit_type: Case Management

met_with: Monica Gastelum, Designee


summary: Facility Evaluation

raw_content:
Narrative:
On October 10, 2025, at 2: PM, Licensing Program Analyst (LPA) Jacob Salem made an unannounced visit to the facility and met with Frank Simmons, Administrator. The purpose of the visit was to discuss a case management inspection. During an inspection of the facility on 10/09/25, LPA reviewed psychotropic medication administration records for former client (C1) and observed that two days in July 2025 had not been initialed by staff while C1 was away from the facility. Based on records reviewed, the facility is being cited for violation of Interim Licensing Standards 87070(b)(14) Children's Records. An exit interview was conducted and a copy of this report, LIC 809D, LIC 811, and appeal rights were provided to Frank Simmons Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On February 23, 2026, at 11: AM, Licensing Program Analyst (LPA) Jacob Salem conducted an unannounced visit to the above facility for the purpose of conducting an annual inspection and met with Frank Simmons, Administrator. LPA initiated an inspection of the facility's physical plant and a review of clients files. LPA conducted two staff and two client interviews. Due to time constraints, the annual is being extended to review client and staff files. An exit interview was conducted and a signed copy of this report was provided to Frank Simmons, Administrator.

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
On February 24, 2026 at 10: AM, Licensing Program Analysts (LPAs) Jacob Salem and Stephanie Arreola conducted an announced visit to the above facility and met with Frank Simmons, Administrator. The purpose of this Case Management inspection is to conduct an annual continuation from 2/23/2026. LPA Salem inspected the facility's physical plant, including personal rights postings, health related services, buildings and grounds, food services, indoor and outdoor activity space, and furniture, fixtures, equipment and supplies. The home is clean, in good repair, and free from observable risks to clients' health, safety, and personal rights. The home is a one story building with three client bedrooms and two client bathrooms which are set up as follows: Bedroom #1 has two twin beds and currently sleeps one client, bedroom #2 has two twin beds and currently sleeps two clients, and bedroom #3 has two twin beds and currently sleeps no clients. There is a kitchen and living room, storage closets, and back and front patio and separate garage used as an administrative office or for visitation. LPAs Salem and Arreola reviewed five staff files (S1-S5), which are kept locked in a separate HR building next door. The staff files reviewed contained the required demographic and hiring information, criminal background clearances, and health screenings. During the review, LPAs observed that S3's file did not contain documentation of the required annual training. LPAs reviewed three client files (C1-C3), which are kept locked in the administrator's garage office. Continued... ...CONTINUED The client files contained the required demographic information, physical health assessments, and medication logs and court authorizations. Based on observations during staff file review, the facility is being issued a citation (see LIC 809D) for violating Interim Licensing Standards Version 5 section 87065.1(e)(1) Supervision, Evaluation, and Training Requirements. An exit interview was conducted with Frank Simmons, Administrator and a signed copy of this report, LIC 811, LIC 809D and appeal rights was provided.


summary: Facility Evaluation

raw_content:
Narrative:
On April 9, 2026, at 11: AM, Licensing Program Analyst (LPA) Jacob Salem made an unannounced visit to the facility and met with Frank Simmons, Administrator. The purpose of the visit was to assess a civil penalty for failure to correct a deficiency cited on 2/24/26. An exit interview was conducted and a copy of this report, LIC 421FC, and appeal rights were provided to Frank Simmons Administrator.


facility_name: SANCTUARY RECOVERY FOR TEENS

summary: Facility Evaluation

raw_content:
Narrative:
On October 21, 2020 at 11: AM, Licensing Program Analyst (LPA) Belinda Torres conducted a Short Term Residential Therapeutic Program (STRTP) pre-licensing inspection. The LPA met with Lauri Burns, Executive Director, Anasheh Safarian, Director of Operations, and Morgan Salmans, Facility Manager. The facility is a one story residential building with five bedrooms, four bathrooms, living room, staff office, family room, dining room, kitchen, laundry room and a two car attached garage. A physical plant inspection was completed and the following was observed by the LPA: The facility stores personnel files, client files, client cash resources, and medications in the staff office. The door to the staff office has a keyed locked. The office is kept locked when not in use and is only accessible to the facility staff. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris, observable hazards, and insects. There is adequate indoor and outdoor activity space. A television, board games, books, and puzzle were observed for client's recreation time. The family room will be used for clients to use for relaxation and visits with family and friends. The following required forms were posted in the facility: Weekly Menu, Personal Rights form, and Complaint Procedures. Each of the four client bedrooms has proper lighting, adequate drawer space, all six beds were observed with appropriate clean linens, pillows, blankets, comforters, mattress pads, and mattresses in good repair. The facility has telephone service on premises. The hot water was tested and measured to be 113 degrees Fahrenheit which is in the required range of 105-120 degrees Fahrenheit. The facility has a fully equipped first aid kits and a current first aid manual approved by the American Red Cross. Smoking is prohibited in the facility and on the grounds. *** *** Per Executive Director, no firearms or weapons are kept or allowed in the facility and smoking is prohibited. Licensee has previously been accredited through the Joint Commission, and once the facility is licensed the licensee will notify the commission to make them aware of the program change to update the certification. Current staff have caregiver background checks and have received criminal record and child abuse index clearance. LPA discussed the following: Reporting requirements, facility manager requirements, personnel rights and Assembly Bill 388 requirements. The LPA was provided Criminal Record Transfer documents for Lauri Burns, Anasheh Safarian and Morgan Salmans during this inspection. . The licensee will ensure that LIC 503s Health Screening Report-Facility Personnel are submitted for Lauri Burns and Anasheh Safarian. After final review of the application, the program will be submitted for licensure. The facility will be notified once they are provisionally licensed as a Short Term Residential Therapeutic Program (STRTP). A copy of this report was provided to Lauri Burns.

visit_type: Prelicensing

met_with: Lauri Burns, Anasheh Safarian & Morgan Salmans


summary: Facility Evaluation

raw_content:
Narrative:
On December 1, 2022 at 10:14am, Licensing Program Analysts (LPA's) Adrian Mendez and Eduardo Barragan arrived unannounced at the facility to conduct an Required Annual inspection of the facility. LPA's met with Case Manager Lora Caldwell and Head of Service Mariam Mott. LPA Barragan inspected the facility inside and out with Head of Service Mariam Mott. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. There are five bedrooms in the facility. Four bedrooms are single rooms, one bedroom is set up for two clients. There is adequate shelf and closet space for client's belongings. Each bed room contained one desk as well. The bathrooms were clean and in good repair. The hot water in the client bathrooms were measured at 116 degrees, which is within regulatory requirements. All hazardous items have been properly made inaccessible. The medications were stored and locked in the staff office. Cleansers/chemicals are locked and stored in a locked closet in the hallway. Sharp knives are inaccessible and stored in a locked staff office. The First Aid Kit is located in the staff office and contained all required supplies. The facility's smoke/carbon monoxide detectors in the hallways were checked and were operable. There are no guns or weapons in the facility as stated by Head of Service Mariam Mott. The following required posted items were observed accessible to clients: Facility License, Grievance Procedures, Personal Rights, Visitation policies, Emergency Disaster Plan and current menu. The facility outside grounds was also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. LPA discussed and reviewed the following inspection components; Operational Requirements, Emergency Disaster Preparedness, and the Emergency Intervention Plan. Cont. on 809-C A sample of two client files were reviewed during the inspection. All client files had the required documents per Title Regulations. All client files are maintained on a secured internet database. All of the staff records are accessible and maintained at an off-site location. LPA's reviewed 5 staff files. All the staff have met the training and qualification requirements per regulation requirements. Per a review of the Community Care Licensing Information System (LIS), all staff met DOJ/FBI criminal record clearances and Child Abuse Index Check requirements. LPA's conducted a Post-Licensing inspection as well. Mental Health Program Approval for the facility is still currently pending. Based on the facility inspection, and files reviewed there are no deficiencies found at this time. An exit interview was conducted, and a copy of this report was explained to Case Manager Lora Caldwell. Due to printer malfunction, this report will be emailed to Case Manager Lora Caldwell.

met_with: Lora Caldwell, Mariam Mott


summary: Facility Evaluation

raw_content:
Narrative:
On 04/26/22 at 1: PM Licensing Program Analyst (LPA), Belinda Torres, met with Andrea Carmona, Administrator. The LPA was informed by Andrea that she started working as the administrator at the facility on 04/11/22 in preparation for the facility's first placement. Andrea worked for the corporation in their adult rehabilitation program facilities across the street from this facility. The LPA obtained a copy of the LIC Personnel Report, dated 04/15/22, which shows an employment date of 10/08/20 for Andrea and job title of Administrator. The Administrator on file with the Department is Anasheh Safarian. The LPA spoke by telephone with Lauri Burns, CEO, and received verbal authorization from Lauri for Andrea to sign for this licensing report. Lauri informed the LPA that the change of administrator notification was sent to the Department at the end of February of 2022. The LPA informed her that the notification was not received. Based upon a record review as of today's date, the licensee failed to notify the Department, in writing, within ten calendar (10) days of the hiring of a new administrator. The facility is cited for violation of the Interim Licensing Standards STRTP Article 6 87061(h) Reporting Requirements. A copy of this report, LIC Proof of Correction and appeal rights were provided to Andrea.

met_with: Andrea Carmona


facility_name: SANTA FE STATION

summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Lidia Tinoco conducted an unannounced visit to the Creative Alternatives main office in Merced in order to deliver the findings of the above allegations regarding Stanta Fe Station and met with Director Brandi Boehme. During the course of the investigation, Community Care Licensing (CCL) conducted interviews with facility staff and foster youth as well as conducted a review of records. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation occurred. Therefore, the allegation that the group home staff did not provide appropriate supervision resulting in inappropriate interactions is UNSUBSTANTIATED at this time. LPA Tinoco conducted exit interview with Brandi Boehme. A copy of this report was provided to the Facility Representative. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lidia Tinoco LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2

report_type: Complaint Investigation

met_with: Brandi Boehme

complaint_status: unsubstantiated


raw_content:
Investigation Findings:
13Complaint Specialist C.K. Kinney(CS) traveled to the facility and met with Amanda Fantazia to deliver findings of investigation. CS conducted investigation that included review of documentation, interviews of staff, clients and witnesses. CS was not able to come to a preponderance of the evidence that the allegations occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation occurred. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No deficiencies cited or observed during this inspection. Copy of this report and LIC Appeal Rights left at the facility at conclusion of inspection. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Charles Kinney LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2

met_with: Amanda Fantazia


raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Lidia Tinoco traveled to the Creative Alternatives-Mereced office due to the Santa Fe Station House being closed and met with Program Director, Brandi Boehme to deliver the findings on this complaint. During the course of investigating the allegations, LPA conducted file reviews and interviews. The interviews revealed inconsistencies in explanations of the above allegations. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the above allegations occurred as reported, therefore the above allegations are unsubstantiated at this time. No deficiencies were cited. A copy of the report was left with Brandi Boehme. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lidia Tinoco LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3


summary: Facility Evaluation

raw_content:
Narrative:
On 05/26/2021, Licensing Program Analyst (LPA) Tamara Melikian conducted a case management with Assistant Program Director Monica Alexander to discuss an incident that occurred on May 24, 2021 between staff (#1) and client (#2) resulting in a restraint that is not approved by the agency. Due to restrictions of Covid-19, this case management was conducted by teleinspection with this report being scanned to Ms. Alexander with a request for signature and a scan back to this LPA. Staff (#1) states that he did not intend to do a prone restraint, however, when assaulted by client (#2), staff (#1) attempted a childrens' control position and they both fell resulting in a prone restraint as staff (#1) attempted to gain control of the incident. The clinician was present and staff (#1) has been counseled by the agency. In addition, all clients were interviewed by the agency. Ms. Alexander will forward the memo of record for the discussion with staff (#1) and this LPA will request the report from law enforcement. There are no deficiencies to be cited on this date.

met_with: Monica Alexander


summary: Facility Evaluation

raw_content:
Narrative:
On this date, Licensing Program Analyst (LPA) Lidia Tinoco traveled to the Creative Alternatives Main Office in Merced and conducted an unannounced Case Management for the Santa Fe and met with Director Brandi Boheme. The purpose of the inspection is to discuss multiple incident reports regarding medication errors by Staff. LPA Tinoco reviewed incident reports from the Santa Fe facility. It was discovered that there have been 2 medication errors due to staff for this facility (See LIC812 for details) in 2021. LPA Tinoco discussed with Director Brandi the concerns with the amount of incident reports regarding medication errors being received, LPA also addressed what the licensee has been done at the agency level to prevent this from happening, and what the ongoing plans are moving forward to minimize these incidents. Director Brandi stated that a company wide training on administration of medication. An exit interview was conducted, and a copy of the report and appeal rights were provided to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by LPA (Licensing Program Analyst) Lidia Tinoco on at Santa Fe Station. LPA met with Hermilo Gandarilla Facility Administrator and inspected the facility, inside and out. Currently the facility is inactive and has been inactive since September 16, 2021. All facility smoke detectors were tested and appear to be in appropriate working order, fire extinguisher is properly charged. The facility currently keeps their food supply at an off site warehouse where they store non-perishables, fresh foods, and dairy that would be ready to be transported to the home would they choose to become active again. Individual beds were observed with appropriate clean linens and are in good repair. The facility is maintained at 72 degrees. No bodies of water were observed. No firearms or weapons are allowed in the facility. Licensee has obtained Mental Health Certification Including the following: Mental Health Program Approval valid through September 24, 2021, Medical certification effective January 1, 2019 and a county contract since September 1, 2019. Licensee has obtained National Accreditation through CARF. The Accreditation is valid through September 30, 2023. Due to the facility being inactive no records of personnel/ staff members were reviewed and no records of clients were reviewed. There were no deficiencies to be cited on this date. A copy of this report was left with Hermilo Gandarilla.

met_with: Hermilo Gandarilla


facility_name: SANTA LUCIA PROGRAM

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
come back under the influence at the facility. Two staff were interviewed on 01/08/2021. The facility manager Leann Leon was interviewed at around 10:45am. The interview revealed and confirmed client statements that the facility staff do supervise clients at all times and check on them every 15 minutes over night. An interview was also conducted with the facility head of services Carolina Cortez at around 11:45 am. Interviews with the Carolina and LeeAnn revealed that as soon as the facility became aware of the allegation of inappropriate contact with clients the facility staff separated the youth in question and for the duration of their stay at the facility. The incidents of inappropriate contact allegedly occurred overnight between roommates C1 and C2 (Clients 1 and 3, see confidential names list LIC 811, dated 05/26/2021) at an unknown date. Clients reported using marijuana when they leave the facility on an unauthorized basis and do come back under the influence; however, they report that staff not only discourage that behavior they are asked to empty their possessions to search for contraband. An interview was conducted with C1 on 04/20/2021 at around 3:30pm. The interview further confirmed the statements clients made on 01/08/2021. Client confirmed that upon learning of the allegations staff separated client from C2 and shared a room with a different roommate. The C1 reported that C2 did not share a room with anyone else. The client stated that they pretended to sleep when staff were checking on them only to get up for the 15 minutes between when staff would come and check on them. C1 stated they were quiet when the incident happened and they were using a vape pen; which they hid after using. C1 reported this incident took place in the span of 3 -4 minutes. Interview with C2 on 01/08/2021 did not result with any information, the client denied participating or knowing anything about the allegations. Note that C2 was accused of being the perpetrator of the inappropriate contact and one of the instigators of using marijuana at the facility. An interview was also conducted with direct care staff Karolina Redondo on 05/13/2021 at approximately 3:30pm. The interview confirmed the staff check on clients every 15 minutes over night. Karolina indicated she was supervising clients when one of the incidents of inappropriate conduct occurred. Karolina stated that she had supervised the clients the whole time while at a car wash. She had taken clients to assist with washing the facility van as and activity and chore. Karolina was also cleaning the van with clients. She stated that nothing was reported to her or observed during the activity. It was alleged C2 had used the vacuum at the car wash to place near the C3's buttocks. Karolina stated that yes, clients used the vacuum but did not observe or hear the clients using the vacuum in an inappropriate manner. Although the allegations may have occurred or are valid, there is not a preponderance of the evidence that they occurred as a result of lack of supervision by staff; therefore, the allegations above are unsubstantiated. Appeal Rights were provided and discussed with the administrator Victoria Shannon. No deficiencies were cited. Exit interview conducted and a copy of the report was emailed for a signature to Victoria Shannon.

Investigation Findings:
13Licensing Program Analyst (LPA) Joel Segura conducted a follow-up complaint inspection to the STRTP (Short Term Residential Therapeutic Program) and met with the administrator Victoria Shannon via Microsoft Teams. The purpose of the inspection is to deliver the findings for the above complaint allegations. During the course of investigating these complaint allegations, LPA Segura conducted interviews with staff and clients. LPA interviewed three clients on 01/08/2021 at the facility at around 11:30-2pm. Interviews with these clients revealed that staff do supervise clients and did not report incidents where staff were not supervising clients. Clients reported that staff check on them every 15 minutes over night including searches of their personal belongings when contraband is suspected. Clients further reported that their marijuana usage usually doe not occur at the facility and sometimes Continued on 812c UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Joel Segura LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: SANTA LUCIA PROGRAMFACILITY NUMBER: VISIT DATE: 05/26/2021

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

met_with: Victoria Shannon


raw_content:
Narrative:
On November 15, 2021, the Department received a complaint alleging facility staff do not prevent clients from bringing drugs into the home, and staff does not provide a safe environment for clients and staff does not treat clients equally. Based on confidential interviews, clients would come back to the facility already on drugs, not necessarily bring drugs into the facility. Staff did not ask the police to leave during an incident with a client. The client refused to talk with police. Staff treat clients as equally as possible. Some clients open up more to staff than others and this may lead to feelings of inequality. Based on confidential interviews conducted, the above allegations may have happened or are valid, however, there is not a preponderance of the evidence to prove that staff did not prevent clients bringing drugs into the facility, staff does not provide a safe environment and staff does not treat clients equally; therefore, the above allegations are unsubstantiated.

Investigation Findings:
13Investigations Branch (IB) Investigator (Inv) Maria Barragan and Licensing Program Analyst (LPA) Monica Pavia conducted a complaint investigation. Licensing Program Manager (LPM) Carolyn Flynn and LPA Selena Hood initiated a complaint investigation at the facility on November 18, 2021, at 12:30pm. The facility was toured, and records were reviewed, on this date. Inv Barragan and LPA Pavia conducted confidential interviews with staff, clients, and social workers. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Monica Pavia LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: SANTA LUCIA PROGRAMFACILITY NUMBER: VISIT DATE: 03/03/2022

met_with: Steve Duran


raw_content:
Narrative:
received the requested Progress Notes. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was provided to Nic Briseno.

Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegation. LPA met with Nic Briseno, Administrator (AD) at 10: AM on 1/12/ Over the course of the investigation, LPA conducted confidential interviews and reviewed files during this investigation. Based on confidential interviews conducted it was determined that the allegations listed above are unsubstantiated. Most staff and clients feel like the facility does provide a safe enviorment. An individual was able to sneak a cell phone into the facility, which was against court orders, but was able to do it without staff knowing. When staff learned of this they attempted to locate the cell phone but the individual already removed the cell phone from the facility. The facility had to delay sending incident reports (IR) to the social worker due to IT issues. The social worker eventually recieved the IRs. Based on confidential interviews, the facility has policies staff use to prevent AWOLs. The delay in the Social Worker recieving progress notes was a misunderstanding with the facility. Once the misundersstanding was cleared up the social worker eventually UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: SANTA LUCIA PROGRAMFACILITY NUMBER: VISIT DATE: 01/12/2023

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

met_with: Nic Briseno, Administrator


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with Nic Briseno, Administrator at 11: AM on 9/22/23. Based on confidential interviews conducted it was determined that the allegations listed above are Unsubstantiated. Witness interviewed stated that there was appropriate supervision at the time of the incident. The individual injured during the incident confirmed that the facility offered medical treatment and to go to the local hosipital but declined that offer. LPA made multiple attempts to contact the other indivdual involed in the incident but as 9/22/23 has not gotten a response. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was provided to Nic Briseno, Administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

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


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility to inform them of the findings for the above listed allegations. LPA met with Nic Briseno, Adminstrator (ADM) on 1/26/24. Based on confidential interviews conducted by IB Investigator Ruben Munoz it was determined that the allegations listed above are Unsubstantiated. An individual interviewed gave multiple inconsistent statements to school staff, facility staff, and investigators. The individual denied being drugged and stripped of their clothes. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was emailed to Nic Briseno, ADM. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Nic Birseno, Administrator


raw_content:
Investigation Findings:
Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility to inform them of the findings for the above listed allegations. LPA discussed this with Joyce Ponton, Administrator at AM on 6/20/25. Based on confidential interviews conducted it was determined that the allegations listed above are Substantiated. Most individuals interview stated that the perpetrator didn't speak and treat victim with respect. They also stated that the perpetrator didn't utilize trauma-informed and evidence-based de-escalation techniques. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. As a result of this visit, there are two Interim Licensing Standards violations ( Personal Rights (c)(1) and Personal Rights (c)(32)). The facility will be cited (see 809-Ds for details). Appeal rights were discussed and provided. Exit interview was conducted and a copy of this report was provided to Joyce Ponton, Administrator. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN JOSE RO, N. First Street, Ste. FACILITY NAME: SANTA LUCIA PROGRAMFACILITY NUMBER: 275202098

met_with: Joyce Ponton, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 2/23/22 at 11:03 am, Licensing Program Analyst (LPA) Paul Simien conducted an unannounced visit to the above facility. The purpose of this visit was to conduct the required annual inspection. LPA met with Steve Duran, Administrator, at the above facility to conduct the required annual inspection. LPA Simien proceeded to Administration office and met with Chris Shannon, Executive Director at 11:28 am. LPA Simien requested staff files, client files, and staff schedule. LPA reviewed three staff files and staff schedule. No deficiencies were cited at this time. LPA conducted an exit interview with Steve Duran, Administrator, at 2:45 pm.

met_with: Steve Duran, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 4/13/22 at 11:45 am, Licensing Program Analyst (LPA) Paul Simien conducted an unannounced visit to the above facility. The purpose of this visit was to continue the required annual inspection started on 2/23/22. LPA met with Lacisha Zapata-Smith , Facility Manager (FM), at the above facility to conduct the required annual inspection LPA interviewed two staff members. No deficiencies were cited at this time. LPA conducted an exit interview with Lacisha Zapata-Smith, facility manager, at 3:35 pm.

met_with: Lacisha Zapata-Smith


facility_name: SANTA MARIA HOME

raw_content:
Narrative:
that some facility staff are aware that specific clients may be using and bringing vape pens into the facility when the contraband is found. Per confidential interviews, staff will make an effort to prevent clients from using vape pens and bringing vape pens into the facility by having regular small group meetings with the clients to address these issues. Confidential interviews reported that if staff were concerned about a specific client and their use of vape pens and bringing vape pens to the facility, then the in-house therapist would be advised to address these issues in therapy. Confidential interviews reported that if a client has shown a history of bringing in contraband or is suspected of bringing in contraband, then facility staff will conduct a search of their room. Confidential interviews reported that vape pens had been found during room searches. Per facility policy, when clients return from leaving without permission and they were recently caught with vape pens or have a history of bringing back vape pens, the staff will search their items such as shoes, dresser drawers, closets, bags, and ask the clients to empty their pockets. In addition, confidential interviews stated that staff would knock on bathroom doors if clients were taking too long in the bathrooms from what the client stated the purpose for them to be in the bathrooms. Confidential interviews also reported that these concerns were addressed in clients' updated needs and service plans. Other confidential interviews reported that when facility staff encounters a client using a vape pen, they address the behavior immediately and confiscate the contraband. Based on inconsistent confidential interviews, the allegation that staff do not prevent minors in care from using nicotine vapes in the facility is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted. A copy of this report and appeal rights were explained and given to Administrator Francine Haynes.

Investigation Findings:
13On 1/11/2024, at 11: AM, Licensing Program Analyst (LPA) Joon Choi conducted an unannounced visit to Santa Maria Home Short Term Residential Treatment Program (STRTP) to deliver the investigative findings for the allegation listed above. On 10/10/2023, LPA Joon Choi conducted a health and safety inspection at the STRTP, and no immediate health and safety hazards were observed. On 12/26/2023, LPA Joon Choi conducted a follow-up visit to the facility to gather additional information. During the investigation, LPA Choi obtained documents pertinent to the investigation and interviewed Clients 1 - 6 (C1-C6) and Staff 1-7 (S1-S7). On 10/05/2023, Community Care Licensing received an allegation that staff (S1-S6) do not prevent minors (C1-C6) in care from using nicotine vapes in the facility. Confidential interviews reported that C1 uses nicotine vaporizers in the facility. Confidential interviews reported that some facility staff have not seen clients bringing vape pens into the facility and using vape pens in the facility. Other confidential interviews reported CONTINUED ON THE NEXT PAGE UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Joon R Choi 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 19-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, MAIN ST., SUITE FACILITY NAME: SANTA MARIA HOMEFACILITY NUMBER: VISIT DATE: 01/11/2024

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

met_with: Francine Haynes, Administrator


raw_content:
Narrative:
**Continued From Previous Page** called them a crybaby. C1 feels bullied and intentionally targeted by S1 who allegedly lies in order to get C1 in trouble. Confidential interviews and documentation review could not confirm or deny that C1 and/or any client was called a crybaby by S1. Confidential interviews and documentation review provided conflicting evidence of bullying occurring in the facility. Confidential interviews and record review could not provide consistent accounts of the alleged incident(s) occurring. Record review revealed staff have been trained to "hand off" the client to another staff to ensure redirection by staff does not result in a client feeling bullied and/or picked on. Confidential interviews could not confirm or dispute this training was used when S1 was working with C1. Confidential interviews and documentation review could not confirm or dispute that staff's behavior poses a risk to minor. Based on confidential interviews and documentation review the preponderance of evidence standard has not been met and the allegations that, staff verbally abuses a minor while in care, staff bullies a minor while in care and staff behavior poses as a risk to a minor, may have happened or are valid, but there is not a preponderance of evidence to prove that the alleged violations occurred. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of the report was provided along with appeal rights to Santa Maria Home STRTP,Tina Carrillo, Facility Coordinator.

Investigation Findings:
UnsubstantiatedEstimated Days of Completion: 90-Days Estimated Days of Completion: 90-Days Estimated Days of Completion: 90-Days

Allegations:
- UnsubstantiatedEstimated Days of Completion: 90-Days Unsubstantiated Estimated Days of Completion: 90-Days Unsubstantiated Estimated Days of Completion: 90-Days

met_with: Tina Carrillo, Facility Coordinator


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
**Continued from Previous Page** occurring at the facility, C1 was taken to the hospital and upon C1's release from the hospital facility staff refused to C1 back into care. Confidential interviews reported consistent statements that confirmed staff did not take C1 back into care. Confidential interviews reported that facility staff met and agreed to deny C1 reintegration to the facility. Further confidential interviews and records review revealed that facility staff did not follow their Program Statement. Based on confidential interviews and records review, the preponderance of evidence standard has been met, and the allegation that Staff (Unknown) refused to take minor, Foster Child (C1) back into care is substantiated. The facility is being cited for violation of Short-Term Residential Treatment Programs, Interim Licensing Standards, (ILS) Version 5, Program Statement 87022.1(d). The facility shall operate in accordance with the terms specified in the plan of operation. An exit interview was conducted, a copy of this report, confidential names report (LIC 811) along with appeal rights were given to Santa Maria Facility Coordinator Lavonta King.

Investigation Findings:
13On May 15, 2025, at 1: PM, Licensing Program Analyst (LPA), Jason Dalton met with Santa Maria Short Term Therapeutic Program (STRTP) Facility Coordinator Lavonta King, to deliver the investigation finding for the above stated allegation. On November 12, LPA Dalton, arrived unannounced to Santa Maria STRTP to initiate an investigation of the above stated allegation. A health and safety inspection was conducted, and no immediate health and safety concerns were observed. The investigation included interviews with eight facility staff members [Staff #1-Staff #6 (S1-S6), one Administrator (Admin), one Facility Coordinator (FC)] and one of two County Social Worker(s) (CSW1). In addition, facility and county records were reviewed. LPA's attempts to interview Foster Child (C1 and C2), County Social Worker 2 (CSW2) and Reporting Party (RP) were unsuccessful. On 11/07/2024, Community Care Licensing received an allegation that Staff (Unknown) refused to take minor, Foster Child (C1) back into care. Specifically, it was reported that after a behavior episode SubstantiatedEstimated Days of Completion: 90-Days SUPERVISORS NAME: Nicole Strickland LICENSING EVALUATOR NAME: Jason Dalton 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 61-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE N CRP RO, MAIN ST., SUITE FACILITY NAME: SANTA MARIA HOMEFACILITY NUMBER: VISIT DATE: 05/15/2025

Allegations:
- SubstantiatedEstimated Days of Completion: 90-Days Estimated Days of Completion: 90-Days Estimated Days of Completion: 90-Days

met_with: Facility Coordinator Lavonta King

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
staff do not prevent minors from having access to smoking products in the facility, staff do not ensure minor receives assistance with health care needs, staff do not ensure medications are dispensed as prescribed, and licensee does not ensure minor is enrolled and attending an educational program. It was specially alleged that staff speak to C1 inappropriately and try to put religion on C1, staff allow C1 to be picked on by other clients and staff say negative things about C1, staff do not ensure that clients do not use smoking products, staff is not ensuring C1 is treated for C1's mental health care needs, staff were not administering C1's medications as prescribed, and facility staff did not ensure that C1 was enrolled in school. Confidential witness statements revealed that staff did not speak to C1 in an inappropriate manner or put religion on C1. Furthermore, LPA was informed that C1 would speak to staff inappropriately at times. Also, disclosed to LPA was that C1 was religious and would ask staff questions regarding religion but staff did not put or force religion on C1. Another confidential witness informed LPA that staff would speak to C1 inappropriately and put religion on C1. Regarding the allegation that staff do not ensure that C1 was treated with dignity and respect by other clients and staff, confidential witnesses denied that occurred. LPA was provided with consistent statements that staff assured that C1 was not picked on by other clients and staff did not speak negatively regarding C1. Furthermore, LPA was informed that staff didn't allow C1 to be bullied. LPA was informed that C1 would act out and make other clients uncomfortable. Other confidential witnesses informed LPA that C1 was not treated respectfully by staff and staff would not always address when C1 was bullied. In reference to the allegation that staff do not ensure that clients do not use smoking products, confidential witnesses informed LPA that some clients placed at the facility smoked but staff did not allow it. Furthermore, LPA was informed that if staff found or suspected that a client was under the influence staff addressed it immediately and would write the client up and speak to the client about the negatives of smoking. Another confidential witness informed LPA that when some staff observed smoking devices, they would not confiscate the devices and allow clients to keep them. (...) Referring to the allegation that staff do not ensure minor receives assistance with health care needs, confidential witnesses informed LPA that C1 was seen by medical providers and provided with mental health treatment. Additionally, LPA was informed that all clients received therapy. Additional confidential witnesses informed LPA that though the clients received therapy at the facility they felt as though the therapist did not address the clients' mental health needs and clients needed more mental health treatment than they were provided. Pertaining to the allegation that staff were not administering C1's medications as prescribed. Confidential witnesses informed LPA that all clients that took medication were administered their medication appropriately. Additionally, LPA was informed that C1 did not arrive at the STRTP with medication and was taken to see medical professionals but was not prescribed medication. LPA received other information that staff were aware of C1's need to take medication but C1 did not have medication available. Concerning the allegation that licensee does not ensure minor was enrolled and attending an educational program, confidential witnesses informed LPA that C1 was enrolled in school but often refused school. Furthermore, LPA was informed that when clients refuse school, staff would encourage them not to refuse and attend school. Additionally, LPA was informed that there was confusion as to which grade C1 was in which delayed C1's school enrollment. An additional confidential witness informed LPA that when clients refused school staff did not encourage them to attend and allowed them to miss school. LPA received conflicting information regarding all allegations. Based on confidential interviews the allegations staff do not speak to C1 in an appropriate manner, licensee does not ensure C1 is treated with dignity and respect from staff and peers in the facility, staff do not prevent minors from having access to smoking products in the facility, staff do not ensure C1 receives assistance with health care needs, staff were not administering C1's medications as prescribed, and licensee does not ensure C1 is enrolled and attending an educational program, may have occurred, however, they are not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Courtney Brandon.

Investigation Findings:
13On October 16, 2025, at 12: PM Licensing Program Analyst (LPA) Michael Almaraz met with Santa Maria Home Short Term Residential Therapeutic Program (STRTP) Administrator, Courtney Brandon, to issue the finding for the above allegations involving client (C1) listed on the confidential names list (LIC 811) dated October 16, 2025. The complaint was jointly conducted by LPA Almaraz and LPA Jason Dalton. On January 21, 2025, at 8: AM LPA Dalton conducted a safety inspection of the facility, and no immediate health and safety hazards were observed. Furthermore, LPA Dalton conducted seven staff (S1, S2, S3, S4, S5, S6, S8) interviews, one county worker (CSW) interview, and five clients (C1, C2, C4, C5, C6) interviews. During the investigation LPA Almaraz interviewed six clients (C1, C2, C4, C5, C6, C7) and one staff (S9). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Michael Almaraz 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 61-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE N CRP RO, MAIN ST., SUITE FACILITY NAME: SANTA MARIA HOMEFACILITY NUMBER: VISIT DATE: 10/16/2025

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

met_with: Courtney Brandon


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
An unannounced annual inspection was conducted by Licensing Program Analyst (LPA) Val Wilson, Licensing Program Analyst (LPA) Lorena Valenzuela, and Licensing Program Manager (LPM) Christina Barnes, on 11/08/2021 at 9:00am, at Santa Maria Home Short Term Residential Therapeutic Program (STRTP). Prior to the visit the facility file was reviewed for annual fees due and no annual fees are past due. Upon arrival, LPAs and LPM met with Facility Administrator, Francine Haynes, who led a tour of the facility. The home is a one story residence with three bedrooms and three bathrooms. LPAs and LPM toured the inside and outside of the facility at 10:15am. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. Bedroom #1 has a wall puncture and an unfinished repair to the ceiling. Bedroom #3 had water damage to the ceiling. There is adequate shelf and closet space for client's belongings. The bathrooms were in good repair. The hot water in the client bathrooms was measured to be 106* F bathroom #1 and 105.5*F bathroom #2. Facility walls need an overall cleaning/painting due to LPA's and LPM observing paint chips and the walls being dirty with foreign matter smeared. The therapist office behind the garage has a broken window Cleansers/chemicals are locked and stored in laundry area and storage room in the garage. Chemicals were also found in the food pantry. Sharp knives are inaccessible and stored in a locked box in a locked cabinet in the staff office. The facility's Smoke and Carbon Monoxide Detectors were checked and were operable. There are no guns or weapons in the facility as stated by Administrator. LPAs and LPM observed facility posted items in the kitchen area that included: Child's Personal Rights, Emergency Disaster Plan, and Foster Care Ombudsman poster. Clients medications were observed to be inaccessible and stored in a locked file cabinet within a locked cabinet in the staff office. LPAs observed a minimum 7-day non-perishable and a 2-day perishable supply of food. However, snacks are locked in a cabinet inaccessible to clients. During the inspection, there was one client present. Refer to LIC 809C for the continuation of this report. Based on the facility inspection, observation, the LPAs observed paint chips and the walls dirty with foreign matter smeared. The facility is cited under Title 22, Division 6, Chapter 1, Article 06, Section 80087(a) Buildings and Grounds. Based on the facility inspection, observation, documents, and interviews, LPAs obtained unsigned, incomplete, required Board Meeting Minutes. LPA observed that the minutes did not reflect there was a review and discussion of the documents required per the Health and Safety Code 1520.1(f). The facility will be cited under STRTP Interim Licensing Standards, Version 4, Section 87063(a)(9) Accountability. Based on the facility inspection and interviews, the facility did not ensure monthly logs of each manual restraint use was documented as required. The facility will be cited under STRTP Interim Licensing Standards, Version 4, Section 87095.61(f) Documentation and Reporting Requirements. Due to time constraints, LPAs will return to complete the staff and children's record review at a later time. Exit interview conducted. A copy of this report LIC 809Ds and LIC9102TA was provided to Administrator, Francine Haynes. Appeal rights were provided. The facility outside grounds was also inspected. LPAs observed boards missing in the backyard wooden fence. In addition, multiple wood boards and plywood were observed to be leaning at the side of the home near the backyard gate. Emergency exits were free from obstruction. Facility Administrator was unable to provide signed Board Meeting Minutes for the past year. LPAs interviewed 2 staff on cite. Based on the facility inspection, observation, and interviews Chemicals were observed by the LPAs in the food pantry by the therapist office. The facility will be cited under Title 22, Division 6, Chapter 1, Article 06, Section 80076(a)(16) Food Service. Based on the facility inspection, observation, and interviews, snacks were not accessible to the children in care. The facility will be cited under Title 22, Division 6, Chapter 1, Article 06, Section 80076(a)(4) Food Service. Based on the facility inspection and observation, LPAs observed boards missing from the wooden backyard fence. The facility will be cited under STRTP Interim Licensing Standards, Version 4, Section 87087.2(a)(4)(A) Outdoor Activity Space. Based on the facility inspection, observation, and interviews, LPAs observed punctures in walls, water damage to the ceiling, and facility walls need an overall cleaning/painting. The facility will be cited under Title 22, Division 6, Chapter 1, Article 06, Section 80087(a) Buildings and Grounds. Based on the facility inspection and observation, LPAs observed one window broken in the Therapists office. The facility is cited under Title 22, Division 6, Chapter 1, Article 06, Section 80087(a) Buildings and Grounds. Refer to LIC 809C for the continuation of this report.

Deficiencies:
87095.61(f): Documentation and Reporting Requirements

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

met_with: Facility Administrator, Francine Haynes


summary: Facility Evaluation

raw_content:
Narrative:
On November 9, 2021, at 11: AM, Licensing Program Analyst (LPA) Val Wilson, Licensing Program Analyst (LPA) Lorena Valenzuela, arrived at Santa Maria Home Short-Term Residential Therapeutic Program (STRTP). The purpose of the inspection was to complete the continuation inspection for STRTP annual inspection that was initiated on November 8, 2021. LPAs already completed the physical inspection of the facility on the first day of the annual inspection. The LPAs met with Facility Administrator, Francine Haynes, and Program Administrator, Denise Samano, and on the telephone Executive Director Larnel Jackson, PsychD. During this annual inspection continuation, LPAs reviewed ten personnel files to ensure they contained all required documentation per Title Regulations and Interim Licensing Standards (ILS). Personnel Files are maintained at the main office. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Eight of ten personnel files did not meet the annual training requirement for 2020. LPAs observed the training records for 2021 may not meet the training requirements. LPAs discussed that the Administrator is to ensure that the annual training requirements are met for 2021, which state all direct care staff shall complete a minimum of 40 hours annual training. Additionally, it could not be determined that staff 2 (S2) meets the direct staff personnel requirements based on education records and job history on file. Furthermore, four out of ten personnel records did not have valid CPR and first aid cards. Lastly, based on interviews, staff 3 (S3) and staff 4 (S4) are the designated Facility Managers. Based on training records review of S3 and S4, LPAs observed they did not meet the regulation training requirements. Based on the records review and interview, LPAs observed of S3 and S4 did not have the required training documentation needed to assume the role of a facility manager. The facility will be cited under STRTP Interim Licensing Standards, Version 4, Section 87065(f)(2) Personnel Requirements. Refer to LIC 809C for the continuation of this report. Based on the records review and interview, LPAs observed one of ten staff did not meet the direct staff personnel requirements based on education records and job history on file. The facility will be cited under STRTP Interim Licensing Standards, Version 4, Section 87065(g)(1)(A) Personnel Requirements. Based on the records review and interview, LPAs observed four of ten staff did not have a current and valid CPR and/or first aid cards. The facility will be cited under STRTP Interim Licensing Standards, Version 4, Section 87065.1(c)(6)(A) Training Requirements. Based on the records review and interview, LPAs observed eight of ten staff did not complete a minimum of 40 hours of annual training. The facility will be cited under STRTP Interim Licensing Standards, Version 4, Section 87065.1(d)(1) Training Requirements. Exit interview conducted. A copy of this report LIC809Ds and a copy of the appeal rights was provided to Administrator, Francine Haynes. Due to time constraints, LPAs will return at a later time to conduct a review of client records.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On November 18, 2021, at 09: AM, Licensing Program Analyst (LPA) Val Wilson, Licensing Program Analyst (LPA) Lorena Valenzuela, arrived at Santa Maria Home Short-Term Residential Therapeutic Program (STRTP). The purpose of the inspection was to complete the continuation inspection for STRTP annual inspection that was initiated on November 8, 2021. LPAs already completed the physical inspection of the facility on the first day of the annual inspection. The LPAs met with Facility Administrator, Francine Haynes, and Program Administrator, Denise Samano on the telephone. During this annual inspection continuation, LPAs reviewed five of five client files (Client 1- C1; Client 2- C2; Client 3- C3; Client 4- C4; Client 5-C5) to ensure they contained all required documentation per Title Regulations and Interim Licensing Standards (ILS). Client Files are maintained in the home and at the main office. There was five children present at the facility. LPAs conducted two children interviews, C1 and C4, the other three children refused to be interviewed, C2, C3, and C5. Based on the records review and interview, LPAs observed they did not meet the regulation and requirements.LPA's observed signed Copies of Child's removal/discharge and or transfer policies and procedures for C1, C2, C3, C4, and C5 are on file but did not reflect STRTP regulation standard and need to be updated. Additionally, discipline policy is not written to reflect STRTP regulation, including the facilities Emergency Intervention Plan not matching the facilities current crisis intervention program. Client's record for C1, C2, C3, and C5 do not document Tuberculosis results within 72 hours of the test. Client's cash record for C1, C2, C3, C4, and C5 did not include income, disbursement, balance, and receipts maintained in chronological order. Refer to LIC 809C for the continuation of this report. Based on Client's record and interviews allowance resources were taken in the form of fines by the facility for C1, C3, and C5 when there was property damage or loss made by the client. In addition, documentation of bedroom arrangement compatibility for C1, C2, C3, C4, and C5 are not maintained in the child's record. LPAs observed the Needs and Services Plan did not include educational needs and or goals for C1, C3, C4, and C5. LPA's also observed the Needs and Services Plan did not include money management needs and or goals, including maximum amount of money permitted in Client's possession at any one time for C1, C2, C3, C4, and C5. Lastly, the Needs and Services Plan for C1, C2, C3, C4, and C5's Client record did not include Needs and Services Plans updated at least every 30 days. Based on the records review and interview, signed copies of Child's removal/discharge and or transfer policies and procedures for C1, C2, C3, C4, and C5 are on file but did not reflect STRTP regulation and need to be updated. In addition, discipline policy is not written to reflect STRTP regulation, including the facilities Emergency Intervention Plan not matching the facilities current crisis intervention program. The facility will be cited under STRTP Interim Licensing Standards, Version 4, Section 87070(c)(2) Children's Records. Based on the records review and interview, client's record for C1, C2, C3, and C5 do not document Tuberculosis results within 72 hours of the test. The facility will be cited under Title 22, Division 6, Chapter 1, Article 06, Section 80069(c)(1) Client Medical Assessments. Based on the records review and interview, client's cash record for C1, C2, C3, C4, and C5 did not include income, disbursement, balance, and receipts maintained in chronological order. The facility will be cited under Title 22, Division 6, Chapter 1, Article 06, Section 80026(h)(1) Safeguards for Cash Resources, Personal Property, and Valuables. Refer to LIC 809C for the continuation of this report. Based on the records review and interview, client's record noted allowance resources were taken in the form of fines for C1, C3, and C5 on at least one occasion. The facility will be cited under STRTP Interim Licensing Standards, Version 4, Section 87026(c) Safeguards for Cash Resources, Personal Property, and Valuables. Based on the records review and interview, LPAs observed documentation of bedroom arrangement compatibility for C1, C2, C3, C4, and C5 are not maintained in the child's record. The facility will be cited under STRTP Interim Licensing Standards, Version 4, Section 87087(e) Buildings and Grounds. Based on the records review and interview, the Needs and Services Plan did not include educational needs and or goals for C1, C3, C4, and C5. The facility will be cited under STRTP Interim Licensing Standards, Version 4, Section 87068.2(b)(2) Needs and Services Plan. Based on the records review and interview, LPAs observed the Needs and Services Plan did not include money management needs and or goals, including maximum amount of money permitted in Client's possession at any one time for C1, C C3, C4, and C5. The facility will be cited under STRTP Interim Licensing Standards, Version 4, Section 87068.2(b)(5) Needs and Services Plan Based on the records review and interview, LPAs observed the Needs and Services Plan for C1, C2, C3, C4, and C5's Client record did not include Needs and Services Plans updated at least every 30 days. The facility will be cited under STRTP Interim Licensing Standards, Version 4, Section 87068.3(a) Modifications to The Needs And Services Plan. An LIC9102TA Technical Assistance was provided regarding ensuring the facility is planning and implementing activities with the children that meets their needs and includes the client's input. Exit interview conducted. A copy of this report LIC 809Ds, Appeal Rights, and LIC9102TA was provided to Administrator, Francine Haynes.

Deficiencies:
87068.3(a): Modifications to The Needs And Services Plan

(a) The needs and services plan specified in Section 87068.2 shall be updated at least every 30 days to determine the following


summary: Facility Evaluation

raw_content:
Narrative:
On December 8, 2021, Licensing Program Analyst's (LPA's) Lorena Valenzuela and Val Wilson arrived at Santa Maria Home and met with the Short-Term Residential Treatment Program (STRTP) Direct Care Staff, Sandra Alonzo. The Facility Administrator, Francine Haynes, arrived to the home around 3:15PM. The purpose of this case management is to discuss information received during a review of an incident that occurred at the facility. LPA's gathered additional information and obtained facility records. A copy of the LIC 809 was provided to Francine Haynes.

met_with: Francine Haynes, Facility Manager


facility_name: SARATOGA HOUSE

summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by LPA (Licensing Program Analyst) Lidia Tinoco on at Saratoga House STRTP. LPA met with Brandi Boehme and inspected the facility, inside and out. Currently the facility is inactive and has been inactive since May 2021. All facility smoke detectors were tested and appear to be in appropriate working order, fire extinguisher is properly charged. The facility currently keeps their food supply at an off site warehouse where they store non-perishables, fresh foods, and dairy that would be ready to be transported to the home would they choose to become active again. Individual beds were observed with appropriate clean linens and are in good repair. The facility is maintained at 72 degrees. No bodies of water were observed. No firearms or weapons are allowed in the facility. Licensee has obtained Mental Health Certification Including the following: Mental Health Program Approval valid through September 24, 2021, Medi-Cal site certification valid since 4/26/19 through 4/26/2022 and a county contract valid since September 1, 2019. Licensee has obtained National Accreditation through CARF. The Accreditation is valid through September 30, 2023. Facility has already gone through Annual Review with DHCS for 2021. Due to the facility being inactive no records of personnel/ staff members were reviewed and no records of clients were reviewed. There were no deficiencies to be cited on this date. A copy of this report was left with Brandi Boehme

met_with: Brandi Boehme