raw_content:
Narrative:
Confidential interviews revealed conflicting statements as to whether or not S1 did not allow C1 to have access to their backpack when requested. In addition, there were no witnesses to the alleged incident. Based on confidential interviews, that staff (S1) did not ensure that minor has access to their belongings while in care may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Head of Service, Brittany Kelly on the phone and in person with Associate Social Worker, Sarah Hoover-Castorena.. A copy of this report, LIC 811, and appeal rights was provided to the facility designee. that youth were expected to ask for food when needed during this period of time. Interviews further confirmed that the clients had to request snacks and the staff could not readily provide the clients with the snack due to attending to other clients. LPA observed the kitchen refrigerator to only contain half a gallon of milk, half a loaf of bread, several slices of cheese and a couple of condiments. Community Care Licensing (CCL) received an additional allegation that staff are emotionally abusive to minor in care. Specifically, it was reported that S1 is agonistic towards youth and calls C1 names like "bitch". Confidential interviews revealed that C1 had submitted a grievance regarding S1's behavior towards C1 to Program Director (PD). Interviews further revealed that other facility staff witnessed S1 speaking inappropriately to minors in care and that staff also reported this behavior to facility management. Interviews confirmed that S1 was addressed for this behavior by PD and supervisor. Interviews further confirmed that PD facilitated a meeting between S1 and C1 to address this concern and S1 underwent retraining. Based on confidential interviews, the preponderance of evidence standard has been met and the allegations that staff do not ensure that minor has access to food while in care, and staff (S1) are emotionally abusive to minor (C1) in care are substantiated. The STRTP facility is being cited for violation of the Title 22, Division 6, Chapter 1, Article 06, Continuing Requirements regulation 80076(a)(4) Food Services, and Interim Licensing Standards Version 5, Article 06, Continuing Requirements regulation 87072(c)(1) Personal Rights. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Head of Service, Brittany Kelly on the phone and in person with Associate Social Worker, Sarah Hoover-Castorena. . A copy of this report, LIC 811, and appeal rights was provided to the facility designee..

Investigation Findings:
13On November 1,2024, at 11: AM, Licensing Program Analyst (LPA) Guadalupe Munoz arrived unannounced at the facility and met with Head of Service, Brittany Kelly on the phone and in person with Associate Social Worker, Sarah Hoover-Castorena to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 3/25/24 at 10:45 am and no deficiencies were observed. LPA Interviewed four staff (S1-4) and two clients(C1-2). LPA obtained and reviewed the following documents: Needs and Service Plan, Staff Schedule, Client Roster and Incident Reports, facility Training and Development Documentation for S1, and Client Grievance Form. On 03/18/2024, Community Care Licensing (CCL) received an allegation that staff do not ensure that minor has access to food while in care. Specifically, it was reported that that staff is not getting youth food. Confidential interviews revealed that for 10 days the youth at the facility did not have access to food because it was being stored in the locked garage. Interviews revealed that the food was removed due to a client that had been taking the food and throwing it on the beds of their peers when in crisis. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE This is an official report of an unannounced visit/investigation of a complaint received in our office on 03/18/2024 and conducted by Evaluator Guadalupe Munoz COMPLAINT CONTROL NUMBER: 22-CR- FACILITY NAME:ROP ATCS JOANN HOUSEFACILITY NUMBER: ADMINISTRATOR:JOSEPH M ALVARADOFACILITY TYPE: ADDRESS: JOANN STREETTELEPHONE: (949) 631- CITY:COSTA MESASTATE: CAZIP CODE: CAPACITY:6CENSUS: 5DATE: 11/01/ UNANNOUNCEDTIME BEGAN: 10: AM MET WITH:Sarah Hoover-CastorenaTIME COMPLETED:01: PM 9Staff do not ensure that minor has access to their belongings while in care. INVESTIGATION FINDINGS: 13On November 1, 2024, at 11: AM, Licensing Program Analyst (LPA) Guadalupe Munoz arrived unannounced at the facility and met with Head of Service, Brittany Kelly on the phone and in person with Associate Social Worker, Sarah Hoover-Castorena to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 3/25/24 at 10:45 am and no deficiencies were observed. LPA Interviewed four staff (S1-4) and two clients(C1-2). LPA obtained and reviewed the following documents: Needs and Service Plan for C1, Staff Schedule, Client Roster, Incident Reports, facility Training and Development Documentation for S1, and Client Grievance Form. On 03/18/2024, Community Care Licensing (CCL) received an allegation that staff do not ensure that minor has access to their belongings while in care. Specifically, it was reported that S1 would not open the door for C1's backpack. Confidential interviews revealed that school backpacks are kept hanging on hooks in the living room area and that backpacks used for other activities were kept locked in storage area designated for clients' personal property. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 3 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: ROP ATCS JOANN HOUSEFACILITY NUMBER: VISIT DATE: 11/01/2024

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


state: CA

facility_name: ROP ATCS JOANN HOUSE

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Specifically, it was reported that on 3/27/ C1 had been dysregulated for most of the day and that the mental health assessment team was not contacted for several hours in which time C1 bit their tongue, banged their head against the wall and that C1 had cuts to their lips and had some red marks around their head. It was also reported that other "residents came in and started to taunt" C1. Confidential interviews confirmed that C1 was in mental health distress for several hours of the day starting around lunch time and ending around 7:30 pm at which time C1 was transported via ambulance to the local hospital. Interviews further revealed that throughout the day C1 asked to be taken to the hospital on multiple occasions because C1 reported that they did not feel safe and repeatedly banged their head against the wall and floor and bit their lip which caused blood to spill onto the floor of the living room. Interviews also revealed that other residents began to taunt and trigger one another which led to multiple physical altercations which included clients climbing out of windows and running out the doors to attack C1. Law enforcement arrived to assist facility with ensuring safety of clients. Furthermore, interviews also confirmed that C1 was pushed by S2 into the wall when C1 was running towards S2 during the crisis. Based on confidential interviews, the preponderance of evidence standard has been met and the allegations that facility did not prevent minor from self-harming, that facility did not provide a safe environment for a minor in care, that staff did not seek medical attention in a timely manner for a minor in care and that staff pushed a minor while in care are substantiated. The STRTP facility is being cited for violation of the Interim Licensing Standards Version 5, Article 06, Continuing Requirements regulation 87072(C)(16) Personal Rights and Title Division Chapter Article Health Related Services 80075 (a). An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Brittnie Peluso. . A copy of this report, LIC 811, and appeal rights was provided to the Administrator. Confidential interviews revealed conflicting statements as to whether S1 did not allow C1 to use the bathroom when requested. In addition, C1 was unable to be interviewed. Based on confidential interviews, that staff (S1) did not allow minor to use the bathroom. may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights were explained, and a copy of this report and LIC 811 was provided to facility designee.

Investigation Findings:
13On December 20, 2024, at 10: AM, Licensing Program Analyst (LPA) Guadalupe Munoz arrived unannounced at the facility and met with ,Brittnie to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 04/03/24 at 10:15 am and no deficiencies were observed. LPA interviewed five Staff (S1, S3-6), and three Clients (C2-4). LPA was unable to interview S2 due to their termination of employment at the facility. LPA also attempted to interview C1. LPA obtained and reviewed the following documents: Needs and Service Plan for C1, Staff Schedule, Client Roster, Incident Reports, and Employee Termination notice. On 03/27/2024, Community Care Licensing (CCL) received multiple allegations that facility did not prevent minor from self-harming, that facility did not provide a safe environment for a minor in care, that staff did not seek medical attention in a timely manner for a minor in care and that staff pushed a minor while in care. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: ROP ATCS JOANN HOUSEFACILITY NUMBER: VISIT DATE: 12/20/2024

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

report_type: Complaint Investigation

met_with: Brittnie Peluso

complaint_status: unsubstantiated


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Confidential interviews confirmed that C1 was in mental health crisis and was displaying aggression towards facility staff. Interviews further revealed that C1 was physically restrained due to their aggressive behavior and once released from a five-minute containment, C1 ran towards S1 and flicked a cup of water from S1's hand. S1 responded by pushing C1 to the ground and grabbing C1's leg when they were attempting to get up and holding C1's leg to drag them to their bedroom. Based on confidential interviews, the preponderance of evidence standard has been met and the allegation that facility staff handled youth in a rough manner is substantiated. The STRTP facility is being cited for violation of the Interim Licensing Standards Version 5, Article 06, Continuing Requirements regulation 87072(C)(16) Personal Rights. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Brittnie Peluso. A copy of this report, LIC 811, and appeal rights was provided to the Administrator.

Investigation Findings:
13On December 27, 2024, at 10: AM, Licensing Program Analyst (LPA) Guadalupe Munoz arrived unannounced at the facility and met with Brittnie Peluso, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 04/03/24 at 10:15 am and no deficiencies were observed. LPA interviewed four Staff (S2-4), and three Clients (C1-3). LPA was unable to interview S1 due to their termination of employment at the facility. LPA obtained and reviewed the following documents: Client File and Facility Files. On April 2, 2024, Community Care Licensing (CCL) received an allegation that facility staff handled youth in a rough manner. Specifically, it was reported that on 03/29/ C1 had been dysregulated and in crisis during which C1 was aggressive towards S1. S1 then "grabbed C1 by one of their legs causing them to fall to the ground face down. S1 then dragged C1 while they were face down to their bedroom". ***Conitnued on Next Page*** SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: ROP ATCS JOANN HOUSEFACILITY NUMBER: VISIT DATE: 12/27/2024

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

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
**Continued from LIC9099** LPA Marquez was able to watch a video of the alleged incident recorded by C1, the recording entailed S5 and S6 telling C1 "you gonna go to jail" multiple times. Based on confidential interviews and review of the video, the allegation that staff (S5 and S6) threatened minor (C1) in care is substantiated. The preponderance of evidence standard has been met. The Facility is being cited for violation of Interim Licensing Standards version 5, Section 87072(c)(16) Personal Rights, please refer to LIC9099D. A previous licensing report was issued on 12/27/2024 giving notice of the same violation. Because this facility has been cited for repeating the same violation within 12 months, a civil penalty shall be assessed today. An exit interview was conducted, a plan of correction was made, and appeal rights were explained. A copy of this report along with appeal rights, Confidential Names List, and Civil Penalty Assessment was provided to Program Manager David Owens. **Continued from LIC9099** Confidential interviews revealed conflicting statements. Confidential interviews revealed that C1 had scratches on their arm and leg, but it was undetermined when the injuries occurred, and no bruises were observed. There were no witnesses and no recording to the alleged incident. Based on confidential interviews, the allegation that staff pushed minor in care causing the minor to hit a dresser may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights were explained, and a copy of this report along with appeal rights was provided to Program Manager David Owens.

Investigation Findings:
13On 09/26/2025 at 11: AM, Licensing Program Analysts (LPAs) Gilbert Marquez and Guadalupe Munoz met with Rite of Passage (ROP) ATCS Short Term Residential Treatment Program (STRTP) Joann House Program Manager David Owens. The purpose of the visit is to deliver findings for the above stated allegation. On 08/07/ LPA Marquez and Sarah Lo inspected the Facility, and no immediate health and safety hazards were observed. The investigation included confidential interviews with Staff (S1-S7), Clients (C1 - C5), Probation Officer (PO) and County Social Worker (CSW), please refer to Confidential Names List dated 09/26/2025. In addition, LPA reviewed client's needs and services plans, child and family team meeting notes, photos and videos. On 07/30/2025, Community Care Licensing (CCL) received a complaint regarding an incident that occurred on 7/29/2025 alleging staff threatened minor in care. Specifically, it was alleged that staff observed C1 vaping in their bedroom and staff began to verbally attack C1.**Continued LIC9099** SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Gilbert Marquez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: ROP ATCS JOANN HOUSEFACILITY NUMBER: VISIT DATE: 09/26/2025

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

met_with: David Owens, Program Manager


summary: Facility Evaluation

raw_content:
Narrative:
On December 20, 2023 at AM, Licensing Program Analysts (LPAs) Guadalupe Munoz and Jacqueline Garcia conducted an announced pre-licensing inspection and completed Component III. LPAs met with Facility Administrator, Dana Butler. The facility is a three client bedroom one client bathroom single-family, two-story home. The applicant is applying for a Short Term Residential Treatment Program (STRTP) with the capacity of six ambulatory clients aged between 9-17 years old. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. Clients will use a cordless telephone to make and receive confidential telephone calls. The water temperature in bathroom #1 located in the hallway measured to be Degrees Fahrenheit. The facility smoke detectors and carbon monoxide detectors tested and were observed to be in working order; the fire extinguishers are properly charged and serviced. The facility has a fully equipped first aid kit and first aid manual. The applicants stated there were no weapons in the facility. Disinfectants and cleaning solutions will be stored and locked. Sharp knives will be stored in a locked kitchen cabinet. Medication will be locked in the locked cabinet in the attached garage that is used as a staff office. The staff files and client files will be kept on a digital database. LPA's advised Facility Administrator, Dana Butler, that staff and client files to be accessible to Community Care Licensing (CCL) at any time. ****** The following required forms were posted in the facility: Personal Rights form, Foster Care Ombudsmen Poster and Disaster plans were posted. There is adequate indoor and outdoor activity space. The downstairs area is set up as follows Open living room that flows into the dining area and attached kitchen. There are three client bedrooms with two clients per room with twin sized beds dresser and closet space for each client. Bedroom #1 is designated for two clients, two twin beds, one dresser with four drawers, and closet space. . Bedroom #2 is: designated for two clients, two twin beds, one dresser with four drawers, and closet space. Bedroom #3 is designated for two clients, two twin beds, one dresser with four drawers and closet space. Each room has adequate clean linens, pillows, blankets, comforters, mattress pads, and mattresses. . The downstairs also includes an attached garage that is designated as a staff office. It has locked cabinets for facility logs, client medications. The upstairs area set up as follows: Clinician office, staff office and staff bathroom. Clients use clinical office for therapy sessions. The Backyard is set up as follows: Large open area that is free of debris. There is a detached storage shed for overflow items and large containers for client storage items. ****** Facility Vehicles: The facility has two vehicles for client needs, a facility van and a sedan. The sedan is currently being repaired for broken windshield. Vehicle logs were current with valid registration and proof of insurance. Vehicles contained emergency backpack with required items. All special incident reports (SIR's) will be sent via e-mail to: cclpaccr@dss.ca.gov. The reporting requirements were reviewed with the Applicant on this date. LPA explained that once the license is approved, all employees shall have an approved criminal record clearance for CCL and be associated to this facility. LPAs observed the following areas that need to be corrected: Bedroom #2 had dresser with missing drawers that need to be repaired. Blinds in dining room need to be repaired. Disaster Logs that need to be updated monthly. Monthly Manual Restraint log is needed. Based on the facility pre-licensing inspection, the facility will make the corrections and once completed submit proof of correction to LPA.

report_type: Facility Evaluation

visit_type: Prelicensing

met_with: Dana Butler


summary: Facility Evaluation

raw_content:
Narrative:
On 03/14/24 at 10: AM, Licensing Program Analyst (LPA) Guadalupe Munoz met with Brittnie Peluso, ffor the purpose of conducting a post licensing inspection of the facility. A physical plant inspection was completed and included the facility's building and grounds, kitchen area, refrigerator/freezers, food storage areas, client bedrooms, bathroom/showers and facility vehicles used to transport clients. The facility grounds were clean and free of debris and observable hazards. Sports equipment, toys, books, games, computers were observed for children's schooling and recreation time. There is adequate indoor and outdoor activity space. Facility smoke detectors and carbon monoxide detectors are in appropriate working order. Licensee maintains an adequate supply of perishable and non-perishable foods and the menu was posted. All other required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights, Emergency Disaster Plan and Foster Care Ombudsperson poster. Medications are locked and centrally stored inside staff's office. The facility ensures that there is one client per bed with appropriate linens, pillows, comforters, and mattresses in good repair. All bedrooms have individual beds and drawer space for each client. The hot water in the client's bathrooms was measured to be between 103 and 116 degrees. Per designee, no firearms or weapons are allowed in the facility. Chemicals and/or poisons are locked in the hallway closet. The LPA reviewed LIC 610C Emergency Disaster Plan, completed disaster training for staff and clients and completed emergency drills. LPA interviewed 1 client and 1 client declined and 2 staff during visit. Staff files are located at corporate office and therefore inspection will need to be continued at a later date. An exit interview and a copy of this report was provided to Brittnie Peluso, facility representative.


facility_name: ROP ATCS JOHNSON HOUSE

summary: Facility Evaluation

raw_content:
Narrative:
On December 20, 2023 at 12: PM, Licensing Program Analysts (LPAs) Guadalupe Munoz and Jacqueline Garcia conducted an announced pre-licensing inspection and completed Component III. LPAs met with Administrator, Dana Centanni, Compliance Manager Sylvia Arballo,, Facility Administrator, Dana Butler, Cynthia Nandino, QA Manager for Behavioral Health and Head of Service, Brittany Kelly. The facility is a four client bedroom one client bathroom single-family, single-story home. The applicant is applying for a Short Term Residential Therapeutic Program (STRTP) with the capacity of six ambulatory clients aged between 10-20 years old. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. Clients will use a cordless telephone to make and receive confidential telephone calls. The water temperature in bathroom #1 located in rose room measured to be Degrees Fahrenheit. The facility smoke detectors and carbon monoxide detectors tested and were observed to be in working order; the fire extinguishers are properly charged and serviced. The facility has a first aid kit that needs a thermometer and first aid manual. The applicants stated there were no weapons in the facility. Disinfectants and cleaning solutions will be stored and locked. Sharp knives will be stored in a locked kitchen cabinet. Medication will be locked in the locked cabinet in the attached garage used as a staff office. . ****** The staff and client files will be maintained on a digital database. LPA's advised Administrator that staff and client files need to be accessible to Community Care Licensing (CCL) at anytime The following required forms were posted in the facility: Personal Rights form, Foster Care Ombudsmen Poster and Disaster plans were posted. There is adequate indoor and outdoor activity space The facility is set up as follows The entry hallway has an attached garage that is designated as a staff office. It has locked cabinets for facility logs, client files and medications. The hallway leads to an open living room that flows into the dining area and attached kitchen. There are four client bedrooms with two single rooms that maybe used for non-minor dependents and two bedrooms for two clients per room with twin sized beds dresser and closet space for each client. Bedroom #1 is designated for one client, one twin bed, one dresser with four drawers, and closet space. . Bedroom #2 is: designated for one clients, one twin bed, one dresser with four drawers, and closet space. Bedroom #3 is designated for two clients, two twin beds, one dresser with four drawers and closet space. Bedroom #4 is designated for two clients, two twin beds, one dresser with four drawers and closet space. Each room has adequate clean linens, pillows, blankets, comforters, mattress pads, and mattresses. and a medication office. ****** LPAs observed the following areas that need to be corrected: Kitchen sink has broken dishwasher faucet. Adequate amount of Emergency disaster supply of food and water First Aid Kit needs thermometer Kitchen seating has two tears that need to be repaired Based on the facility pre-licensing inspection, the facility will make the corrections and once completed submit proof of correction to LPA. All special incident reports (SIR's) will be sent via e-mail to: cclpaccr@dss.ca.gov. The reporting requirements were reviewed with the Applicant on this date. LPA explained that once the license is approved, all employees shall have an approved criminal record clearance for CCL and be associated to this facility.

met_with: Dana Centanni


summary: Facility Evaluation

raw_content:
Narrative:
On 04/08/24 at 1: PM, Licensing Program Analyst (LPA) Guadalupe Munoz met with Dana Centanni Program Director (PD), for the purpose of conducting a post licensing inspection of the facility. Currently there are no residents in the home. LPA advised PD to communicate with CCL and report when residents begin to move into STRTP. Facility is pending Mental Health Certification and will provide CCL with copy once certified. A physical plant inspection was completed and included the facility's building and grounds, kitchen area, refrigerator/freezers, food storage areas, client bedrooms, bathroom/showers and facility vehicles used to transport clients. The facility grounds were clean and free of debris and observable hazards. Sports equipment, toys, books, games, computers were observed for children's schooling and recreation time. There is adequate indoor and outdoor activity space. Facility smoke detectors and carbon monoxide detectors are in appropriate working order. All other required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights, Emergency Disaster Plan and Foster Care Ombudsperson poster. Medications will be locked and centrally stored inside staff's office. The LPA reviewed LIC 610C Emergency Disaster Plan. The facility will ensure that there is one client per bed with appropriate linens, pillows, comforters, and mattresses in good repair. All bedrooms have individual beds and drawer space for each client. The hot water in the client's bathrooms was measured to be between 103 and 116 degrees. Per designee, no firearms or weapons are allowed in the facility. Chemicals and/or poisons will be locked in the hallway closet. An exit interview and a copy of this report was provided to Dana Centanni, Program Director.


summary: Facility Evaluation

raw_content:
Narrative:
On January 8, 2025, at 11:00 aM, Licensing Program Manager (LPM) Ann Valenzuela and Licensing Program Analyst (LPA) Gilbert Marquez met with Mishaun Marshall, Administrator, for the purpose of conducting an annual inspection of the facility. The Facility is licensed to serve six ambulatory children ages 10-17 years-old. The current census is six children. Facility has obtained Mental Health Certification which expires on March 23, 2025, and has been accredited by CARF which is valid through February 28, 2025. The Facility is a single story dwelling that consists of four bedrooms, two bathrooms (one staff, one client), kitchen, living room, dinning room, a study nook, and a therapist room adjacent to the living room. A physical plant inspection was completed and included the facility's building and grounds, and vehicle inspection. Client bedrooms consisted of two single occupancy rooms which housed a single twin bed with a closet and dresser, two other bedrooms had a double occupancy which had two twin beds, two closets and two dressers. All beds had required linins. The kitchen was observed to be clean with sufficient cooking/eating supplies, the refrigerator/freezers, food storage areas contained two days of perishable foods and seven days of non-perishable items. Bathroom was clean, toilet and shower were in working order and the water temperature was measured to be 114.3 degrees which is within the regulated temperature. Extra towels were observed to be stored in the hall closet. The dinning room lies in between the living room and the kitchen and the study nook is adjacent to the dinning room, which is adjacent to the hallway connecting the bedrooms. The areas were clean and free of debris and free of observable hazards. Books, games, computers, and movies were observed for children's schooling and recreation time. Outdoors were also clean and free of debris and was observed to have a table and chairs for clients to use. There is adequate indoor and outdoor activity space. ****Continued on Page 2*** ***CONTINUED FROM PAGE 1**** The Facility smoke detectors and carbon monoxide detectors are are located in each bedroom, one in the hallway, one in the dinning room, and another in the garage, and were all in working order. Cleaning supplies are maintained in a lock cabinet in the laundry area, and also in a locked cabinet in the garage which is also utilized as a staff office. Medications were locked in the garage in a separate locked cabinet. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights, Emergency Disaster Plan and Foster Care Ombudsperson poster. The LPA reviewed LIC 610C Emergency Disaster Plan. Two staff interviews and two client interviews were conducted at time of inspection. However, due to facility files being housed at the Corporate Office the inspection will be continued. An exit interview and a copy of this report was provided to Mishaun Marshall.

visit_type: Annual

met_with: Mishaun Marshall, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On January 17, 2025, at 9: AM Licensing Program Analyst (LPA) Guadalupe Munoz and LPA Gilbert Marquez conducted an unannounced annual continuation inspection from inspection that began on January 8,2025.. LPA met with Sylvia Arballo, Compliance Manager. The purpose of the visit is to complete client and staff file reviews in order to complete the annual inspection that started on 01/08/25. LPAs conducted five staff file reviews. LPAs conducted five client file reviews. . No deficiencies were noted during time of inspection. An exit interview was conducted and a copy of this report and LIC 811 dated 01/17/25 was provided to Sylvia Arballo, Compliance Manager.

visit_type: Case Management

met_with: Sylvia Arballo, Complaince Manager


summary: Facility Evaluation

raw_content:
Narrative:
On March 7,2025, at 10:00 am, Licensing Program Analyst (LPA) Guadalupe Munoz conducted an unannounced case management visit of the facility. LPA conducted a walk through of the facility, and no deficiencies were observed.. LPA Munoz met with Facility Administrator, Mishaun Marshall. LPA informed facility that an investigation will be conducted regarding an incident that was reported on 03/03/25. On 03/03/25, Community Care Licensing (CCL) was notified of two concerns regarding clients at the facility. Concern #1 reported that C1 missed a mandatory court ordered meeting because staff were unable to transport them. Concern #2 reported that C2 ingested unknown substances and was transported to the hospital due to an overdose. LPA interviewed two staff during the visit. LPA obtained and reviewed documents and completed medication review. Further information and interviews are required to resolve the concern therefore this investigation is being extended. The outcome of the investigation will be provided to the Facility Administrator. The facility is reminded not to discuss the ongoing investigation with any interested parties. An exit interview was conducted with Residential Manger and copy of this report and LIC 811 dated 03/07/25 was provided to the designee.

met_with: Mishaun Marshall


summary: Facility Evaluation

raw_content:
Narrative:
On August 13,2025, at 9:30 am, Licensing Program Analyst (LPA) Guadalupe Munoz conducted an unannounced case management visit of the facility. LPA conducted a walk through of the facility, and no physical plant deficiencies were observed. LPA Munoz met with Child Care Worker (CCW), Emily Torres and was informed that Facility Administrator (FA) was not on site and could be contacted by telephone. LPA contacted FA by cellphone and notified them of the purpose of the visit. LPA informed facility that an investigation will be conducted regarding an incident that was reported on 08/04/25. On 08/04/25, Community Care Licensing (CCL) was notified of an incident regarding safety and supervision of clients at the facility. The incident reported that clients were drinking alcohol and smoking marijuana at the facility during the overnight shift. LPA interviewed two staff during the visit and two client. LPA requested and obtained documents needed for the investigation. Further information and interviews are required to resolve the concern therefore this investigation is being extended. The outcome of the investigation will be provided to the Facility Administrator. The facility is reminded not to discuss the ongoing investigation with any interested parties. An exit interview was conducted with CCW Torres and FA gave verbal consent for CCW to sign this report. A copy of this report and LIC 811 dated 08/13/25 was provided to the designee.

met_with: Emily Torres, Child Care Worker


summary: Facility Evaluation

raw_content:
Narrative:
On March 28, 2025, Licensing Program Analyst (LPA) Guadalupe Munoz conducted an unannounced case management follow up visit to the inspection that was conducted on 3/7/2025. LPA met with Purshay Harris, Senior Coach, and with Mishaun Marshall, Facility Administrator via telephone. LPA conducted a walk through of the facility, and no deficiencies were observed. The purpose of the inspection was to follow up on information reported to Community Care Licensing on March 3, 2025. On March 3, 2025, Community Care Licensing (CCL) received information that the facility did not transport C1 to a mandatory court ordered substance use treatment appointment. LPA interviewed one staff (S1) and reviewed client's (C1) Needs and Services Plan. Confidential interviews and records reviewed confirmed that C1 missed a court ordered health related services appointment. The STRTP is being cited for ILS v Article 06. Continuing Requirements Section 87074 (c)(1) Transportation. An exit interview was conducted with Mishaun Marshall via phone and a copy of this report and appeal rights were provided to administrator. Per administrator request, LPA will email report for to administrator for signature required. A copy of the signed report will be placed in the facility file.


summary: Facility Evaluation

raw_content:
Narrative:
On August 21, 2025, Licensing Program Analyst (LPA) Guadalupe Munoz conducted an unannounced case management follow-up inspection that was conducted on 8/13/25. LPA spoke with Mishaun Marshall, Facility Administrator via telephone. LPA conducted a walkthrough of the facility, and no deficiencies were observed. The purpose of the inspection was to follow up on information reported to Community Care Licensing on August 4, 2025. On 08/04/25, Community Care Licensing (CCL) was notified of an incident regarding safety and supervision of clients at the facility. On 8/13/ LPA observed that the facility did not have a Facility Manager (Senior Coach) onsite when children were present during the shift. LPA interviewed two staff (S1, S2) during the visit and two clients (C1, C2). LPA obtained and reviewed documents needed for the investigation. LPA observed that the Facility did not have a facility manager present at the time of the inspection. Based on confidential interviews and records reviewed, Community Care Licensing (CCL) has determined that the licensee does not have a designated facility manager present at the facility at all times when one or more children are present as per Title General Licensing Requirements Section 87065(f) Personnel Requirements. The Short-Term Residential Program (STRTP) facility is being cited for violation of Title General Licensing Requirements Section 87065(f) Personnel Requirements. An exit interview was conducted with Mishaun Marshall via phone and a copy of this report and appeal rights were provided to the Senior Coach, Frisco Taoete that arrived for evening shift. A copy of the signed report will be placed in the facility file.

met_with: MIshaun Marshall, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Rachel Vanegas on April 29, 2026 at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Vanegas met with Facility Administrator, Mishaun Marshall and Compliance Manager - Sylvia Arballo and inspected the facility inside and out. LPA reviewed 1 of 1 child's records and 5 of 5 staff personnel files on site at the facility. LPA reviewed 1 of 1 child's psychotropic medications and medication records. LPA interviewed 2 or 5 staff on site to discuss the facilities policies and procedures of operation. LPA interviewed 1 of 1 children currently prescribed psychotropic medication. During the inspection LPA Vanegas observed deficiencies (see attached 809D). Based on observation and record review the facility is cited one Type A violation in accordance with California Code of Regulations (CCR) Section 80019(e)(3) Criminal Record Clearance due to Staff 6 (S6) not having a transfer of a criminal record clearance at the time of this inspection. As a result of this violation, a civil penalty is being assessed for $500 ($100 per day for each day the violation occurred for maximum of 5 days). LPA conducted an exit interview and a copy of this report, LIC 421BG, and appeal rights were reviewed and provided to Facility Administrator, Mishaun Marshall.

met_with: Facility Administrator - Mishaun Marshall


raw_content:
Narrative:
In regard to the allegation that staff do not ensure facility has adequate food resources in the home for youth in care, confidential interviews revealed that multiple clients spend their own money to purchase food to cook in the home. In addition, facility menus were reviewed and reflect that meals that are provided to clients do not meet the daily quantity necessary to meet the needs of the clients per USDA Standards. Interviews confirmed that menus are used to complete the weekly grocery shopping for clients. Regarding the allegation that staff do not ensure facility is kept free of pests in the home, confidential interviews revealed that there was an ant infestation in client bedrooms and in the kitchen. Interviews further revealed that the clients reported the infestation on multiple occasions however clients were not offered support or assistance to clean and disinfect bedrooms because clients were taking food to their bedrooms which was blamed for the infestation. Confidential interviews also revealed that the kitchen also became infested with ants. Based on confidential interviews, the preponderance of evidence standard has been met and the allegations that staff do not ensure facility has adequate food resources in the home for youth in care and that staff do not ensure facility is kept free of pests in the home are substantiated. The STRTP facility is being cited for violation of Title 22, Division 6, Chapter Article 06. Continuing Requirements Section 80076(a) Food Services and Title 22, Division Chapter Article 07. Physical Environment Section 80087(a) Buildings and Grounds. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with facility representative. A copy of this report, LIC 811, and Appeal Rights was provided to the Administrator. Further interviews revealed that multiple clients may have been sending semi-nude photos of themselves to unknown individuals. However, interviews revealed conflicting statements about when and where these photos and videos were happening whether in the facility or when client's were away from the facility without permission. Interviews also revealed conflicting statements as to whether staff were aware of this behavior was taking place at the facility. There are no witnesses to support the allegation. Based on confidential interviews, the allegation that staff do not prevent youth from having access to inappropriate sexual content may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights were explained, and a copy of this report along with appeal rights was provided to Program Administrator.

Investigation Findings:
13On April 30, 2026, at AM, Licensing Program Analysts (LPA) Guadalupe Munoz met with Rite of Passage (ROP) ATCS Johnson House, Short Term Residential Treatment Program (STRTP) Facility Manager,Mishaun Marshall. The purpose of the visit is to deliver findings for the above stated allegations. On January 30, 2026, LPA inspected the STRTP, and no immediate health and safety hazards were observed. The investigation included confidential interviews with Staff (S1-S3) and Clients (C1 - C5). In addition, LPA obtained and reviewed the following documents: Special Incident Report, Emails, Menus, Grocery Receipts, Vendor Invoices, and Needs and Services Plans. On January 22, 2026, Community Care Licensing (CCL) received allegations that staff do not ensure facility has adequate food resources in the home for youth in care and that staff do not ensure facility is kept free of pests in the home. Specifically, it was reported that the facility lacks adequate food and had an infestation of ants throughout the facility. ***Continued on 9099C*** SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: ROP ATCS JOHNSON HOUSEFACILITY NUMBER: VISIT DATE: 04/30/2026

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

met_with: MIshaun Marshall


facility_name: ROP ATCS SIERRA RIDGE TREATMENT CENTER

raw_content:
Narrative:
Based on interviews with the Tracker, Administrator, Head of Service, five clients and staff, none reported that these allegations occurred. However, LPA was not able to interview the reporting party, therefore, the above allegations are UNSUBSTANTIATED, meaning that while the allegation may be valid or true, there was not enough evidence to prove that it did or did not occur. An exit interview was conducted with Head of Service. A copy of this report was emailed to Head of Service for signature, and he will email the signed document to LPA by email.

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

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

met_with: Gregory Brewer, Head of Service


raw_content:
Narrative:
Throughout the course of the investigation, IB interviewed former and current residents (R1, R2, R3, R4, R13, and R14), former and current staff members (S1, S2, S4, S5, S9, S10, and S11), and the Reporting Party (RP). Interviews were conducted on the following dates: 05/10/21, 06/07/21, 06/08/21, 06/09/21, 06/10/21, 07/15/21, and 07/19/21. During confidential interviews, there were consistent statements made by residents that an assault did occur at the facility which lasted around 10-20 minutes before staff intervened. This altercation, which occurred in 2018, resulted in a resident suffering from a fractured cheek bone. Confidential interviews with staff revealed that one staff who was on shift the day of the incident had walked away but was not gone for more than ten minutes. Upon their return to the hallway, this staff heard noises coming from a bedroom and when they went to open the door, they observed one resident being assaulted. During staff interviews, there was also statements that during this period, the facility was understaffed and they were times that one staff would be left alone with 15 residents. Based on IB's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations is found to be SUBSTANTIATED. The facility is cited on the attached LIC9099D under the California Code of Regulations, Title 22, Division Chapter 1, section 80078(a) Responsibility for Providing Care and Supervision: The licensee shall provide care and supervision as necessary to meet the client's needs. Exit interview conducted and a copy of this report and a copy of the appeal rights were left at the facility with Christopher Essary, Program Director. LPA Xiong investigated the allegation that "Staff are inappropriately restraining minors" while the allegation that "Staff are providing minors with drugs" was investigated by the Department's Investigation Branch and assigned to Investigator Sergio Guerra (IB). During the course of the investigation, IB interviewed the Reporting Party (RP), former and current Residents R1, R13, and R14 along with Current and Former Staff S9, S10, and S11. IB and LPA conducted joint interviews with Residents R2-R4, and Staff S1, S2, S4, and S5. LPA interviewed Residents R5, R7, R9-R12, Staff S3, and S6-S8. LPA attempted to interview Residents R6, R8, and R15 but they declined the interview. LPA attempted to interview Staff S12 but they did not respond back. Interviews were conducted on the following dates: 05/10/21, 06/07/21, 06/08/21, 06/09/21, 06/10/21, 6/30/21, 07/15/21, 07/19/21, and 7/26/21. During confidential interviews with former and current residents regarding the allegation that "staff are inappropriately restraining minors," two residents made consistent statements that staff used inappropriate restraints while nine other residents made consistent statements that staff do no inappropriately restrain residents and staff do not mistreat residents. In confidential interviews with staff members, one staff stated that some staff are more aggressive with residents so that residents will listen. However, consistent statements were made from nine other staff members that residents are not inappropriately restrained nor are handcuffs used as part of the restraint. During the investigation for the allegation that "Staff are providing minors with drugs", six residents (former and current) were interviewed. One resident stated that a male staff sold Marijuana to residents, a second resident stated they heard rumors of staff selling drugs but did not believe it, and a third resident stated that they did not witness staff selling drugs to residents but stated that staff "sometimes" sold drugs to residents. One resident stated that sometimes staff smoked with residents. Three other residents made consistent statements that they have not witnessed nor heard of staff selling drugs to residents. In confidential interviews with both former and current staff members, all staff made consistent statements denying any knowledge of staff selling drugs to residents. Based on IB and LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegations that Staff are inappropriately restraining minors and Staff are providing minors with drugs are found to be UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No title 22 regulations were cited during today's inspection. Exit interview conducted and a copy of this report along with Appeal Rights was left with Christopher Essary, Program Director.

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

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

met_with: Christopher Essary, Program Director


raw_content:
Narrative:
Throughout the course of the investigation, LPA also conducted interviews with the following individuals: County Social Worker (CSW) on 5/26/21, Sacramento County Emergency Response Social Worker (ER) on 5/28/21 and 7/20/21, Residents R2-R5, R7, and R9-R12, Staff members S1-S9. Interviews were conducted on 5/26/21, 5/28/21, 6/7/21, 6/30/21, 7/19/21, and 7/26/21. LPA attempted to interview Residents R1, R6, and R8 but they declined the interview. LPA attempted to interview Staff S10 but they did not respond to LPA's attempts at contact. During interviews with CSW and ER, they stated that Resident R1 informed them that staff had handled him roughly during a restraint. CSW and ER made consistent statements that R1 stated that staff held him down, pressing his face to the ground, were choking him out, and took his shoes off. LPA was unable to interview R1 as they declined to speak with LPA. During confidential interviews with nine residents, consistent statements were made that staff do not restrain residents roughly and do not take away their shoes during a restraint. During confidential interviews with 10 staff members, there were consistent statements indicating that staff do not restrain residents roughly or inappropriately. Three staff members made consistent statements that R1 had been combative and resisting the restraint, causing R1 to fall down on their own, but at no point did staff throw and hold R1 to the ground. Two staff members stated that by the time they reached the area where R1 had ran off to, R1's shoes were already off and they do not know how or when it occurred. All ten staff members made consistent statements that shoes are not taken away from residents during restraints. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegation is found to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No title 22 regulations were cited during today's inspection. Exit interview conducted and a copy of this report along with Appeal Rights was given to Christopher Essary, Program Director.

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

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


raw_content:
Narrative:
A staffer stated it was their opinion that the way the facility was staffed throughout their tenure at ROP was inadequate, in general-whether it was in the number of coach counselors working, or in which staff were assigned to the dorms, citing specific examples of when they didn't get help at times. Although this LPA was not able to review the video footage culled from the security camera system because of the system's protocol that deletes messages older than a certain period, the San Bernardino County Probation Departments Investigation Report was taken into account for this CCL investigation. Within this report, the Officer articulates having observed in the video footage, over a period of time, that there was a lack of supervision by staff-this assessment was corroborated by the same staffer that the report references. Furthermore, one youth stated, though there have been no instances of staff who were present on campus not providing supervision, the facility as a whole could use more staff, in general, because of the various situations that could take place that sometimes do leave an insufficient number of staff or allow for a less-than-ideal staffing situation (female staff to monitor the youths taking showers and/or going in and out of the bedrooms, for example). Based on LPA's interviews and a review of the records, the preponderance of evidence standard has been met; therefore, the allegation is found to be SUBSTANTIATED. The facility is cited on the attached LIC 9099D under the California Code of Regulations, Title 22, Division 6, Chapter 1. The facility has provided documentation of the completed staff training prescribed by the San Bernardino County Probation's Investigation Report. No further corrective action is being required as of this time. A copy of this report is being provided to the facility.

Investigation Findings:
13On 10/01/2021, at approximately PM, Licensing Program Analyst (LPA) Chad Cabigon delivered the findings for this complaint investigation. LPA was met by Program Director Chris Essary and the report was discussed. LPA investigated the allegation that there was an overall Lack of Supervision of youths. On 06/25/20201 and 08/20/2021, Licensing Program Analyst (LPA) Chad Cabigon conducted unannounced onsite inspections of this facility, interviewing staff and youth residents on both occasions. Records obtained and reviewed were the following: Needs & Services Plans for the referenced youths, the facility's placement log or history of minor clients and a roster of facility staffers who worked for the time period of interest, a San Bernardino County Juvenile Probation Department STRTP Investigation Report dated 10/21/2020, and personnel files including documentation of the remedial training agreed upon as part of the corrective plan of action articulated in the aforementioned report. Interviews were conducted with the following individuals: three current student youth clients, a current ROP staffer, a former ROP employee, two involved Probation Officers (one from San Bernardino County, and one from Kern), and a biological mother to a former youth resident. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Chad Cabigon LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: ROP ATCS SIERRA RIDGE TREATMENT CENTERFACILITY NUMBER: VISIT DATE: 10/01/2021

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

met_with: Chris Essary, Program Director


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

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

met_with: Page Woodward, Deputy Program Director


raw_content:
Narrative:
Based on interviews with staff and residents, and LPAs not able to interview RP and S1, the preponderance of evidence standard has not been met, therefore the above allegation is found to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No title 22 regulations were cited during today's inspection. Exit interview was conducted with Program Director, Paige Woodward. A copy of this document will be emialed to Paige Woodward, Deputy Program Director.

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

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

met_with: Paige Woodward, Program Director


raw_content:
Narrative:
LPA Stidman reviewed two client files and one staff file and obtained documentation of the incident on 1/8/22, C1's Student statement form & Youth Grievance Form, C1's medical report dated 1/12/22, C1's & C2's Student intake forms, STRTP admission agreement, Student authorized contact list, Daily notes dated 12/1/21 to 1/11/22, California STRTP admissions review, CWS Case plan update, Needs and services plan. LPA Stidman reviewed five disciplinary actions for S3 from 5/4/21 to 12/31/21. Confidential interviews were consistent that S3 used an an inappropriate restraint on C1 resulting in C1 complaining of back and neck pain and the facility failed to seek medical attention for five days. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Facility cited for Version 4 of the Interim Licensing Standards, 87072(c)(10), (11) and (17) and Interim Licensing Standards, 87095.69(a)(3) Medical Examination on the attached LIC 9099D. Exit interview conducted with Ms. Woodard, Deputy Program Director and a copy of this report and appeal rights were provided to the facility.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 5/20/22 at 10: AM and met with Paige Woodard, Deputy Program Director, to discuss the findings of the complaint allegations as stated. LPA Hill informed Ms. Woodard that the complaint investigation included initial complaint inspection on 1/18/2022 by LPA Jean Stidman. During this inspection, three youth and one staff were interview and additional documentation was obtained related to the allegations. Additional staff were interviewed from 1/26/2022 to 5/12/2022. During the investigation that staff handled minor in a rough manner, minor sustained an inury while in care, staff spoke inappropriately towards a minor and staff did not seek medical attention for minor in care, LPA Stidman interviewed Paige Woodard Deputy Program Director (PD), staff PD, S2, S3, S5 and client C1 (see LIC811 dated 5/20/22). SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: ROP ATCS SIERRA RIDGE TREATMENT CENTERFACILITY NUMBER: VISIT DATE: 05/20/2022

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

met_with: Paige Woodard, Deputy Program Director


raw_content:
Narrative:
During this video conference, Ms. Woodard was able to share the video of the incident where it was observed that S1 left the dorm to make a phone call, leaving that wing of the dorm unsupervised for a period of approximately four minutes. In that time, it was observed that youth entered C1's room twice and subsequently reported that they had been assaulted by youth both times they entered C1's bedroom. This incident was investigated during a case management inspection conducted by LPA Hill on 5/20/2022. The allegation that facility staff did not supervise youth as required allowing minors to engage in physical fights in the facility is SUBSTANTIATED at this time meaning that the "preponderance of the evidence" standard has been met. The facility was cited during the case management inspection for violation of the Interim Licensing Standards Version 4, 87065.5(b)(1)(C): Direct Care Staff/Child Ratios and 87072(c): Personal Rights. Staff interviews, video surveillance review and client interview demonstrate that staff did leave the dorm unattended for approximately four minutes allowing two fights to take place in the dorm. In addition, the evidence supports that the facility was out of compliance on this night by having only three staff in the dorm with 14 youth. As a result of the case management inspection citations, the facility was not cited again on this complaint. Facility was assessed civil penalties for a violation of the same subsection within the previous 12 months. Exit interview with Ms. Woodard and documentation provided on 5/20/2022.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill was at the facility on 5/20/2022 at 4: PM when the complaint for this incident came in. LPA met with Paige Woodard, Deputy Program Director to discuss the allegation and findings for this allegation as this incident was already investigated during the case management inspecton on 5/20/2022. LPA Hill obtained documentation related to this incident and youth involved while at the facility on 5/20/2022. LPA conducted an interview with C1 (see LIC811 dated 5/20/2022) on 5/19/2022 and interviewed staff on 5/20/2022 while at the facility. LPA Hill and Ms. Woodard discussed the incident that happened at the facility on 5/18/2022 which included C1 (see LIC811 dated 5/20/2022) being beat up while in their room. LPA Hill, Jodean Hall, Licensing Program Manager, Ms. Woodard, Galey Betzler, ROP Compliance, and representatives from San Bernardino County Probation all met on 5/19/2022 to discuss the incident via video technology. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: ROP ATCS SIERRA RIDGE TREATMENT CENTERFACILITY NUMBER: VISIT DATE: 05/20/2022

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


facility_name: ROP EMANCIPATION HOME

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

raw_content:
Investigation Findings:
13On July 21, 2021 at 12pm LIcensing Program Analyst (LPA) Donald Martin arrived at the above facility to deliver finidings from the above allegation. LPA met with Raven Morrow, Facility Manager. During the investigation, LPA met with staff and clients and reviewed documentary evidence pertaining to the allegation. Staff #1 stated that during the time the incident occurred, she was alone supervising 4 clients. The clients interviews also supported Staff #1's statement. There was photo of the neighbor's broken window and an invoice provided for the repairs to LPA. As a result, the allegation is Substantiated. Facility is being Cited for violation of 87065. Direct Care Staff/Child Ratio's (a) In a facility with a licensed capacity of six or fewer children, there shall be coverage by direct care staff as follows: (1) During the hours of 7 am to 10 pm, there shall be one awake and on duty direct care staff for every three children, or fraction thereof, present, at a minimum. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: ROP EMANCIPATION HOMEFACILITY NUMBER: 198209644

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

Deficiencies:
87065.5: (1) 	During the hours of 7 am to 10 pm...one awake and on duty direct care staff for every three children, or fraction thereof...1
2
3
4
5
6
7Licensee is instructed to provide LPA proof of training on Supervision of Clients by submitting a sign off sheet after training is conducted.
8
9
10
11
12
13
14

met_with: Raven Morrow-Facility Manager

title: Direct Care Staff/Child Ratio's (a) six or fewer children, there shall be coverage by direct care staff as follows


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Due to lack of evidence and inconsistent information obtained during the investigation, LPA determines that the allegation is Unsubstantiated at the this time meaning, although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove or disprove a violation occurred. There were no deficiencies cited at this time. Exit interview was conducted and appeal Rights and a copy of this report will be emailed to Raven Morrow, Facility Manager.

Investigation Findings:
13On June 18, 2021 at 10am Licensing Program Analyst (LPA) Donald Martin conducted a follow-up complaint inspection and spoke with Raven Morrow, Facility Manager and delivered findings from the above complaint allegation. During the course of investigating the allegation for staff hit a minor while in care, LPA conducted interviews and collected several documents pertaining to the investigation. Interviews and documentary evidence did not produce corroborating evidence to support allegation. LPA was presented with Doctors visit information that shows the client complained about a back injury prior to stating he was struck by staff. The Doctors visit after the incident was inconclusive. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: ROP EMANCIPATION HOMEFACILITY NUMBER: VISIT DATE: 08/18/2021


raw_content:
Narrative:
Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or disprove that a violation occurred; therefore, the above allegation is Unsubstantiated. There are no deficiencies being cited at this time.

Investigation Findings:
13On October 28, 2022 at 1pm Licensing Program Analyst (LPA) Donald Martin arrived at the above facility. The Purpose of this visit is to deliver finding for the above allegations. LPA met with , Raven Morrow, Facility Manager and was allowed into the facility. During the course of investigating the allegations for facility staff provided alcohol to minor and facility staff are not properly supervising minors, interviews were conducted. The interview did not produce corroborating evidence to support said allegations. Interviews revealed inconsistent statements and no witnesses to suggest allegations occurred. There was no evidence that facility staff provided alcohol to a minor or that facility staff are not properly supervising minors. Child #1 recanted his story that staff provided alcohol to him. Staff was unable to supervise client due to allegation appearing to have occurred while client was on an approved mandatory outing. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: ROP EMANCIPATION HOMEFACILITY NUMBER: VISIT DATE: 10/28/2022


raw_content:
Narrative:
There was no evidence that facility is not meeting the health care needs of the children, facility does not have complete personnel files, facility does not have complete children's files, children in care were not advised of their personal rights, and facility is not in good repair. The facility was inspected by The Department of Los Angeles County Probation which prompted the allegations. The facility made all necessary repairs and file updates according to my inspection. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or disprove that a violation occurred; therefore, the above allegation is Unsubstantiated. There are no deficiencies being cited at this time.

Investigation Findings:
13On October 28, 2022 at 12pm Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for to deliver findings to the above faclity. LPA met with , Facility Manager and was allowed into the facility. During the course of investigating the allegations for facility is not meeting the health care needs of the children, facility does not have complete personnel files, facility does not have complete children's files, children in care were not advised of their personal rights and facility is not in good repair, interviews were conducted, files were reviewed and documents were obtained. The interview did not produce corroborating evidence to support said allegations. Interviews revealed inconsistent statements and no witnesses to suggest allegations occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: ROP EMANCIPATION HOMEFACILITY NUMBER: VISIT DATE: 10/28/2022

met_with: Facility Manager


raw_content:
Narrative:
Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or disprove that a violation occurred; therefore, the above allegation is Unsubstantiated. There are no deficiencies being cited at this time.

Investigation Findings:
13On October 28, 2022 at 12pm Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for to deliver findings to the above facility. LPA met with Charise Evans, Facility Manager and was allowed into the facility. During the course of investigating the allegations for staff did not prevent youths from engaging in altercations and staff is not providing a safe environment for youths, interviews were conducted. The interview did not produce corroborating evidence to support said allegations. Interviews revealed inconsistent statements and no witnesses to suggest allegations occurred. There was no evidence that staff did not prevent youths from engaging in altercations and staff is not providing a safe environment for youths. Child #1 refused to discuss with LPA the details of the altercation. No client interviewed expressed that they did not feel safe at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: ROP EMANCIPATION HOMEFACILITY NUMBER: VISIT DATE: 10/28/2022

met_with: Charise Evans-Facility Manager


raw_content:
Narrative:
Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or disprove that a violation occurred; therefore, the above allegation is Unsubstantiated. There are no deficiencies being cited at this time.

Investigation Findings:
13On November 17, 2023 at 1:30pm, Licensing Program Analyst (LPA) Donald Martin conducted a follow up complaint inspection and spoke with Facility Manager, Charise Evans. The purpose of this inspection was to deliver findings for the above complaint allegation. During the course of investigation the allegation for Staff did not ensure that sharp objects were inaccessible to minor, interviews were conducted. The interviews did not produce corroborating evidence to support said allegations. Interviews revealed inconsistent statements and no witnesses to suggest allegations occurred. There was no evidence that Staff did not ensure that sharp objects were inaccessible to minor. Child #1 sustained the cuts while on elopement from the facility. Facility keeps the sharps in a lock box in the office and document when sharps are distributed and returned to staff for disposal. Child #1 refused to speak with LPA. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: ROP EMANCIPATION HOMEFACILITY NUMBER: VISIT DATE: 11/17/2023

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


raw_content:
Narrative:
Confidential interviews, statements confirmed that S1 became intimately involved with C1 (former client) resulting in the birth of their child. Confidential statement revealed S1 and C1's relationship began after C1 left the ROP Emancipation Home. Statements further revealed S1's acknowledgement of violating ROP Emancipation Home policy and procedure (Anti-Fraternization Policy) as S1 was terminated in January 2024, for admitting to having a relationship with a former resident that resulted in the birth of a child. Based on confidential interviews and documentary evidence the preponderance of evidence standard has been met, and therefore the above allegation is Substantiated. The facility is cited per Health and Safety Code Persons prohibited from employment; dismissal or removal. The investigation including review of facility file/records, and confidential interviews of C1, S1, Program Manager, and contact with Department of Children and Family Services-Out of Home Care, revealed C1 resided at the facility from October 2021 to July 2022. S1 began employment with ROP Emancipation Home in March 2022 through January 2024. Information obtained from confidential interviews, revealed denial of sexual abuse by S1 towards C1. While statements disclosed confirmation of a sexual relationship between S1 and C1, statements maintain denial of C1 being underage or engaging in a sexual relationship or intimately involved while C1 resided in the facility. Confidential interviews revealed that S1 and C1 became intimately involved after C1 was discharged from the facility. Statements further contend that the intimate relationship between S1 and C1 was consensual. The Department's investigation determined, although the allegation may have happened or is valid, the allegation is not supported or proven by the evidence gathered. Therefore, the allegation that S1 sexually abused C1 while at ROP Emancipation facility, is determined unsubstantiated at this time. An exit interview was conducted, and a copy of this report was provided to the Facility Representative, Facility Senior Manager.

Investigation Findings:
13On August 27, 2024, at 11: AM, Licensing Program Analyst (LPA), Regina Martin conducted a subsequent complaint inspection to deliver findings concerning the above-mentioned allegation. LPA Martin met with Facility Manager and further spoke with facility Administrator by phone to inform the investigative outcome. The investigation was conducted by Community Care Licensing (CCL) Investigations Branch, Investigator Laura Garcia. On February 14, 2024, CCL received an allegation alleging that Staff (S1) engaged in a sexual relationship with a former resident resulting in staff becoming pregnant. The investigation including review of facility file/records, and confidential interviews of former client (C1) former staff member (S1), Program Manager, and contact with Department of Children and Family Services-Out of Home Care, revealed C1 resided at the facility from October 2021 to July 2022. S1 began employment with ROP Emancipation Home in March 2022 through January 2024. (Continued on page LIC9099-C) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Regina Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: ROP EMANCIPATION HOMEFACILITY NUMBER: VISIT DATE: 08/27/2024

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

met_with: Facility Representative #1


summary: Facility Evaluation

raw_content:
Narrative:
Report Amended to change the facility Name On July 26, 2021, Licensing Program Analyst, LPA Donald Martin made an inspection visit to ROP Emancipation Home for the purpose of concluding a Case Management Investigation. LPA met with Raven Morrow, Facility Manager. The Department received notification from the Department of Children and Family Services requesting a follow up on a CAP put in place for the ROP facilities. Referral Number: 1355-1304-5004-1047667 which was investigated by LPA Regina Martin. The "Second Floor Interactive Supervision Policy" was put in place by ROP to be in compliance with ILS regulation 87088 (e)(2) which states: The following facilities shall maintain a signal system which meets the requirements specified in (e) and (f) below. Such system shall be used by children to summon staff during an emergency: (2) All facilities having separate floors and not providing full-time staff on each floor whenever children are present. During the investigation process, LPA reviewed ROP's Second Floor Interactive Supervision Policy and also walked around the facility. The Policy and home are in compliance at the time of this LPA's visit. No further incident has been reported. A staff re-training on interactive supervision was completed by staff and submitted to the department.


facility_name: ROP HARBOR CITY HOME

raw_content:
Narrative:
review of medical records, facility internal investigation and review of related reports from the Los Angeles Police Department (LAPD) did not provide enough evidence to support allegation. Information provided by Client #1 to LAPD, Investigator Hector and facility staff show a pattern of inconsistency. Moreover, staff members working on the alleged date of the incident confirm no incidents occurred. Residents corroborate denial of witnessing alleged incident and agree that staff provide continual supervision and monitoring in the facility. Client #2 denied the allegation. There were no witnesses or documentary evidence to support or prove that the allegation occurred. As to claims of Client #3 being AWOL since August 2020, a review of records indicates on 08/21/2020, Client #3 left the facility without permission. At that time, staff followed procedures and AWOL Protocols were completed including, but not limited to, notifying required parties. Due to a lack of evidence, alleged lack of supervision leading to sexual abuse, and client AWOL cannot be substantiated. Therefore, it has been determined that the allegation is Unsubstantiated at this time meaning, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or disprove that a violation occurred. There were no deficiencies cited during the investigation. Exit interview conducted. A copy of this report and appeal rights was emailed to Facility Administrator.

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

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

met_with: Tamia Tolson, Facility Manager


raw_content:
Narrative:
Child one was unable to produce the actual name the overnight staff that slept on duty. Due to lack of evidence and inconsistent information obtained during the investigation LPA determines that the allegations are Unsubstantiated at this time meaning, although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove or disprove that a violation occurred. There were no deficiencies cited at this time. Exit interview was conducted and appeal Rights and a copy of this report will be left with Raven Morrow, Facility Manager.

Investigation Findings:
13On August 18, 2021 at 12pm Licensing Program Analyst (LPA) arrived at the above facility to conduct a follow-up complaint inspection and spoke with Raven Morrow, Facility Manager and delivered findings for the above complaint allegations. During the course of investigating the allegations for staff not allowing resident to retrieve personal belongings, staff sleeping during shift, staff threatened minor and lack of supervision resulting in a minor having access to another minor's personal belongings, LPA conducted interviews. Interviews did not produce corroborating evidence to support allegations. Child #1 was a client at the facility between June 2020 and August 2020. The complaint was filed in march. Child #1 belongings were retrieved by someone from Orange County September 17, 2020. Clients said to be involved were no longer residents of the above facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: ROP HARBOR CITY HOMEFACILITY NUMBER: VISIT DATE: 08/18/2021


raw_content:
Narrative:
There were no deficiencies cited at this time. Exit interview was conducted and appeal Rights and a copy of this report will be left with Tamia Tolson, Facility Manager.

Investigation Findings:
13On September 29, 2022 at 12pm LIcensing Program Analyst (LPA) Donald Martin arrived at the above facility. The purpose of the visit is to deliver findings for a Complaint investigation. LPA met with Tamia Tolson, Facility Manager and was allowed into the facilty. During the course of investigating the allegations for staff are not providing adequate supervision to minors, LPA conducted interviews. Interviews did not produce corroborating evidence to support allegations. Clients said to be involved were no longer residents of the above facility. Due to lack of evidence and inconsistent information obtained during the investigation LPA determines that the allegations are Unsubstantiated at this time meaning, although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove or disprove that a violation occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: ROP HARBOR CITY HOMEFACILITY NUMBER: VISIT DATE: 09/29/2022

met_with: Tamia Tolson-Facility Manager


raw_content:
Narrative:
There was no evidence that facility is not meeting the health care needs of the children, facility does not have complete personnel files, facility does not have complete children's files, children in care were not advised of their personal rights, and facility is not in good repair. The facility was inspected by The Department of Los Angeles County Probation which prompted the allegations. The facility made all necessary repairs and file updates according to my inspection. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or disprove that a violation occurred; therefore, the above allegation is Unsubstantiated. There are no deficiencies being cited at this time.

Investigation Findings:
13On December 16, 2022 at 12pm Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for to deliver findings to the above faclity. LPA met with Raven Morrow, Administrator and was allowed into the facility. During the course of investigating the allegations for facility is not meeting the health care needs of the children, facility does not have complete personnel files, facility does not have complete children's files, children in care were not advised of their personal rights and facility is not in good repair, interviews were conducted, files were reviewed and documents were obtained. The interview did not produce corroborating evidence to support said allegations. Interviews revealed inconsistent statements and no witnesses to suggest allegations occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: ROP HARBOR CITY HOMEFACILITY NUMBER: VISIT DATE: 12/16/2022

met_with: Raven Morrow-Administrator


raw_content:
Narrative:
There was no evidence that staff made inappropriate comments about residents. There was no name of the actual staff involved provided. Staff interviewed denied the allegation. There was no evidence that staff do not follow menu. Menu was provided to LPA and reasons for meal substitution. Although Child #1 was injured and was involved in a physical altercation, there was no evidence that staff instigated the fight or caused the injury to Child #1. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or disprove that a violation occurred; therefore, the above allegation is Unsubstantiated. There are no deficiencies being cited at this time.

Investigation Findings:
13On February 2, 2023 at 10am Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for the purpose of delivering findings for the above complaint allegations. LPA was met by and allowed into the facility. During the course of investigating the allegations for, resident sustained injury while in care, youth engaged in physical altercation, staff make inappropriate comments about residents and staff do not follow menu interviews were conducted, files were reviewed and documents were obtained. The interview did not produce corroborating evidence to support said allegations. Interviews revealed inconsistent statements and no witnesses to suggest allegations occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: ROP HARBOR CITY HOMEFACILITY NUMBER: VISIT DATE: 02/02/2023


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
Facility cited for violation 84172 (5)(2) The licensee shall ensure that every child admitted to a community treatment facility is informed and afforded the personal rights as specified...To be free from physical, sexual, emotional, or other abuse, or corporal punishment. A copy of this report is being left with Administrator, Raven Morrow.

Investigation Findings:
13On February 2, 2023 at 9am Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for the purpose of delivering findings for the above complaint allegation. LPA was met by Administrator, Raven Morrow and allowed into the facility. During the course of investigating the allegation of staff spoke inappropriately to residents, interviews were conducted and documentation collected. Interviews determined that staff in fact did speak inappropriately to a client in care which is a violation of his personal rights. Staff #1 admitted to speaking inappropriately and did receive a write up and mandatory training. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: ROP HARBOR CITY HOMEFACILITY NUMBER: VISIT DATE: 02/02/2023