summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
Staff reported CSW could not provide transportation therefore, Y1's appointment was missed. CSW reported the facility did not tell the County about the appointment until the day of the appointment, April 20, 2021. CSW further stated that during the Child and Family Team Meeting on April 19, 2021, the facility did not mention Y1's appointment. CSW reported that if the facility had provided the County with more time, transportation could have been arranged. LPAs review of the program statement found the facility was following the transportation policy. However, the facility failed to inform the CSW about the appointment in a timely manner therefore Y1 did not have access to the medical appointment. Based on confidential interviews, there is a preponderance of evidence to prove staff (names unknown) did not provide resident (Y1) access to medical services. The facility is cited under the Interim Licensing Standards, Version 3, regulation 87072 (17) Personal Rights. An exit interview was conducted, a copy of this report and appeal rights were provided to the facility manager.

Investigation Findings:
13On June 29, 2021, Licensing Program Analyst (LPA) Kendal Zirbes met with Facility Manager Grace Williams to deliver the investigative finding for the above stated allegation. During the investigation, LPA interviewed two youth, the Administrator, a facility manager, three direct staff care staff members, and one County Social Worker (CSW). In addition, LPA completed a review of the facility records. On May 13, 2021 a safety inspection was conducted by LPA Zirbes, no deficiencies were observed. On May 7, 2021, the Department received information that unknown staff members, failed to provide youth 1 (Y1) with access to a medical appointment. Confidential interviews reported Y1 had a medical appointment scheduled for April 20, 2021. Confidential interviews reported the appointment was missed due to a lack of transportation. Additional confidential interviews reported there were no problems with transportation to medical appointments. Staff reported that on April 10, 2021, Y1 made an appointment without the consent of the facility. Staff further reported that Y1 was informed, that the facility could not provide transportation to the appointment as indicated by the program statement. Staff members reported that on April 19, 2021, Y1's CSW was informed that transportation was needed for the appointment on April 20, 2021. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Christina Barnes LICENSING EVALUATOR NAME: Kendal Zirbes 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 08-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, METROPOLITAN DR. # FACILITY NAME: REFUGE, THEFACILITY NUMBER: VISIT DATE: 06/29/2021

met_with: Facility Manager, Grace Williams


state: CA

facility_name: REFUGE, THE

summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Based on record review, there is a preponderance of evidence to prove the facility is not operating within their plan of operation. The facility is cited under the Interim Licensing Standards, Version 3, regulation 87022 (f) Plan of Operation. On June 7, 2021, the facility was cited under 87022 (f) Plan of Operation therefore, civil penalties will be assessed. An exit interview was conducted, a copy of this report and appeal rights were provided to the facility manager.

Investigation Findings:
13On June 29, 2021, Licensing Program Analyst (LPA) Kendal Zirbes met with Facility Manager Rachel Beck to deliver the investigative finding for the above stated allegation. During the investigation, LPA interviewed the one direct care staff, one facility manager and the administrator. In addition, LPA completed a review of the facility records. On June 16, 2021 at 04:15pm a safety inspection was conducted by LPA Zirbes, no deficiencies were observed. On June 10, 2021 the Department received information that on May 28, 2021 the facility conducted an intake interview with Youth 1 (Y1). On June 8, 2021, the authorized representative was notified that Y1 would not be accepted into the program. LPA review the facilities approved Plan of Operation which stated: "After the intake interview, our agency will communicate acceptance or rejection of the referral within five business days...". Information received from staff members confirmed the facility failed communicate acceptance or rejection within time allotted by the program statement. Therefore, the facility notified the authorized representative seven days after the intake interview instead of five days as required in the approved in the program statement. Report continued on page two SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Christina Barnes LICENSING EVALUATOR NAME: Kendal Zirbes 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 08-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, METROPOLITAN DR. # FACILITY NAME: REFUGE, THEFACILITY NUMBER: VISIT DATE: 06/29/2021

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

report_type: Complaint Investigation

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
***This is an amended document*** interviews and record review revealed S1 corroborated the purchases were intended for C1 and provided to C1. An additional allegation alleging Staff (S1) made inappropriate comments to minor (C1) in care was also received by CCL. Specifically, it was reported S1 made inappropriate sexual comments to C1 on at least two occasions. Confidential interviews provided consistent statements of S1 making sexual comments to C1 about C1 and other staff working at the facility. Based on confidential interviews and record review the allegations Staff (S1) purchased a vape pen for minor (C1) in care, Staff (S1) made inappropriate comments to minor (C1) in care, and Staff (S1) purchased alcohol for minor (C1) in care are substantiated. The preponderance of evidence standard has been met. Facility is cited for two violations Health and Safety Code 1550(c) Conduct Inimical: Conduct which is inimical to the health, morals, welfare or safety of either an individual in or receiving services from the facility or people of this state. A copy of the amended report and appeal rights was discussed and provided to Michele Hazelwood, House Manager of The Refuge

Investigation Findings:
13This is an amended report originally delivered on August 8, 2022. On August 8, 2022 at 2:07 pm Licensing Program Analyst (LPA), Nicole Strickland, met with Grace Williams, Executive Director of The Refuge to deliver the finding for the above stated allegations. The investigation was conducted by Special Investigator (SI) Rey Lyyjoki and LPA Strickland and included interviews with one of one foster youth, three staff members (Staff #1 [S1], Staff #2 [S2], and Staff #3 [S3]), San Marcos Sherriff's Detective and Executive Director (ExDir). In addition, county records and facility records were reviewed. On March 23, 2022, Community Care Licensing (CCL) received two allegations alleging Staff (Staff #1 [S1]) purchased a vape pen for minor (Child #1 [C1]) in care and S1 purchased alcohol for minor (C1) in care. Specifically, it was reported on March 4, 2022, S1 took C1 to the store where S1 purchased alcohol and a vape pen for C1. Confidential interviews, record review, and observation of photographs taken of the video surveillance from the store provided consistent accounts of S1 making the purchases. Confidential SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Nicole Strickland 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 08-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, FACILITY NAME: REFUGE, THEFACILITY NUMBER: VISIT DATE: 08/08/2022

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

met_with: Grace Williams


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
evidence. Confidential interviews denied allegations of a lack of supervision as well as staff not preventing child from self-harm. According to confidential interviews, Child # 1 (C1) and Child # 2 (C2) got into a verbal argument in which staff immediately intervened to de-escalate the situation and separated the clients, one in each bedroom. According to confidential interviews, despite staff intervention, C2 pushed thru staff and barged into C1's bedroom hitting C1 in the head with a closed fist. According to confidential interviews, staff stood in between C2 and C1, receiving the brunt of C2's blows. According to confidential information, there was proper supervision and adequate staff during all stages of this incident. Confidential interviews also denied that staff failed to prevent C1 from self-harming. According to confidential interviews, C1 became upset after hearing disappointing news and locked themselves in the bathroom while making suicidal threats. According to confidential information, staff was counseling C1 during the incident and subsequently contacted authorities to have C1 evaluated. According to confidential information, C1 had not engaged in self-harm during this incident, and only made verbal threats of self-harm. While other confidential information received by Licensing Office stated that these allegations of a lack of supervision and self-harm had occurred, and that there was an inadequate response by staff during these incidents. Based on confidential information obtained during the course of this investigation, the allegations a lack of supervision resulting in Child # 2 (C2) causing harm to Child # 1 (C1) , as well as staff not preventing C1 from causing self-harm while in care, may have occurred, however is not supported or proven by evidence. Therefore, the above allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report was provided.

Investigation Findings:
13Licensing Program Analyst (LPA), Daniel Mena met with House Managers, Marcus Strong and Michele Hazelwood to issue the investigative findings for the above stated allegations. Licensing Program Analyst (LPA), Lorena Valenzuela conducted an inspection to the Short Term Residential Therapeutic Program (STRTP) on August 30, 2021 at 10:50am. No immediate hazards observed. LPAs Valenzuela and Mena interviewed Administrator (AD), six staff (S1, S2, S3, S4, S5 & S6), Current Social Worker (CSW), one of three foster children (C2), as well as reviewed client and facility records. LPA was unable to interview Children # 1 (C1) and # 3 (C3) due to them currently being on AWOL status and LPA not being able to obtain current contact information from social worker. Community Care Licensing received information on August 26, 2021 alleging a lack of supervision resulting in Child # 2 (C2) causing harm to Child # 1 (C1) , as well as staff not preventing C1 from causing self-harm while in care. Information obtained in confidential interviews did not corroborate the allegations with a preponderance of UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Daniel Mena 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 08-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, FACILITY NAME: REFUGE, THEFACILITY NUMBER: VISIT DATE: 08/18/2022

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

met_with: Michele Hazelwood

complaint_status: unsubstantiated


raw_content:
Narrative:
Confidential interviews also denied that any staff had ever physically or verbally harassed C1 while in care. According to confidential interviews, injuries observed on C1's arms were self-inflicted scratches or cuts that C1 had done to themselves while using a shaving razor inside the bathroom. While other confidential information received by Licensing Office stated that these allegations. LPA Mena spoke to C1's County Social Worker who stated that at this time they had no concerns regarding these allegations. Based on confidential information obtained during the course of this investigation, the allegations that facility staff was harassing and had sexually abused Child # 1 (C1), and that C1 has also sustained unexplained injuries while in care, may have occurred, however is not supported or proven by evidence. Therefore, the above allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report was provided C1 while in care.

Investigation Findings:
13Licensing Program Analyst (LPA), Daniel Mena met with Staff Member, Destinee Jaime to discuss the investigative findings for the above stated allegations. LPA Daniel Mena conducted an inspection to the facility on August 18, 2022, at 11:21am. No immediate hazards observed. Special Investigator (SI), Ernestina Belluco and LPA Mena interviewed four Staff (S1, S2, S3 & S4), one of one foster children (C1), County Social Worker (CSW), County Investigator (COI), as well as reviewed client and facility records. Community Care Licensing received information on August 08, 2022, alleging that facility staff was harassing and had sexually abused Child # 1 (C1), and that C1 had also sustained unexplained injuries while in care. Information obtained in confidential interviews did not corroborate the allegations with a preponderance of evidence. IB investigator and LPA Mena obtained conflicting information during interviews. Confidential interviews denied allegations that Staff # 1 (S1) or any other staff had sexually abused C1 while in care. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Daniel Mena 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 08-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, FACILITY NAME: REFUGE, THEFACILITY NUMBER: VISIT DATE: 03/03/2023

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

met_with: Destinee Jaime


raw_content:
Narrative:
The preponderance of evidence standard has been met, therefore the allegation S1 interacted inappropriately with C1 is found to be Substantiated. This posed an immediate Health, Safety or Personal Rights risk to the children in care. The facility is being issued a citation for violations of the Interim Licensing Standards, Chapter 7, Version 4, Sections 87078 (b) Responsibility for Providing Care and Supervision. See attached LIC 9099D for cited deficiency. An exit interview was conducted, appeal rights explained and a copy of this report was provided to Wanni Mena, along with the LIC 811.

Investigation Findings:
13On April 18, 2023, at 10:46 am, Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera conducted an unannounced inspection to the facility to deliver the findings of the above allegation. LPA met with Wanni Mena . LPA Nicole Strickland conducted an inspection of the facility on September 06, 2022 at 04:18 pm and no immediate deficiencies were observed. Three of three clients (C1, C2, C3), three staff and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that on August 30, 2022, C1 was suicidal and wrapped a belt around the neck in attempts to commit suicide. Confidential staff interviews reported that staff #1 (S1) was able to get the belt off of C1's neck. Confidential staff interviews reported that staff did not seek any medical attention for C1 after the incident until the following day. All of the persons interviewed including C1 corroborated this information. Based on record review and interviews staff did not seek medical attention for C1 on August 30, 2022, after a suicidal attempt, and therefore C1's mental health needs were not met in a timely manner. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Darlene Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-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, FACILITY NAME: REFUGE, THEFACILITY NUMBER: 374603969

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

met_with: Wanni Mena


raw_content:
Narrative:
The interviews that were provided to the LPA were not consistent regarding the allegations that staff are not properly supervising C1 and did not provide any further specific details regarding staff supervision. Based on interviews and record reviews the allegations that staff kicked and yelled at C1 and S1 used inappropriate language towards C1, may have occurred, however is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Destinee Gastelum.

Investigation Findings:
13On May 2, 2023 at 11:10 am, Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera conducted an unannounced inspection to the facility to deliver the findings of the above allegations. LPA met with Destinee Gastelum. LPA conducted an inspection of the facility on November 30, 2022, at 09:10 am and no immediate deficiencies were observed. Three of four children (C1, C2, C3, C4), four staff and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that staff #1 (S1) kicked and yelled at C1 and S1 used inappropriate language towards C1. Confidential staff interviews reported that S1 attempted to wake up C1, to get ready because C1 had pre-scheduled therapy appointment. Confidential staff interviews reported that staff#2 (S2) attempted to wake up C1 but again refused. Confidential interviews reported that C1 then woke up upset and broken the facility phone. Confidential staff interviews reported that C1 was provided space to calm down, in which C1 had no further issues. Other interviews reported that staff did not uses any physical restraint with C1 and staff did not use any inappropriate language towards C1. LPA attempted to interview C1 on two separate occasions, however C1 refused to be interviews. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Darlene Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-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, FACILITY NAME: THE REFUGE, CHILDREN OF THE IMMACULATE HEARTFACILITY NUMBER: VISIT DATE: 05/02/2023

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

met_with: Destinee Gastelum


raw_content:
Narrative:
Confidential interviews reported that C1 was placed at the facility on December 20, 2022, and C1 was enrolled and attending school on January 06, 2022, due to the schools being on winter break. All of the persons interviewed including C1 corroborated this information. Other confidential information received stated that the allegations were true. The interviews that were provided to the LPA were not consistent regarding the allegations. Based on interviews and record reviews the allegations that staff did not have the appropriate training to care for the clients in care, staff did not ensure that C1 was receiving mental health services, staff did not ensure that C1 attended medical appointments and C1 was not enrolled in school in a timely manner, may have occurred, however is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Grace Williams.

Investigation Findings:
13On May 24, 2023, at 10:10am, Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera conducted an unannounced inspection to the facility to deliver the findings of the above allegations. LPA met with Grace Williams. LPA Belinda Torres conducted an inspection of the facility on June 10, 2022, at 10:38 am and no immediate deficiencies were observed. Two of two clients (C1, C2), three staff and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that staff did not have the appropriate training to care for the clients in care, staff did not ensure that C1 was receiving mental health services, staff did not ensure that C1 attended medical appointments and C1 was not enrolled in school in a timely manner. Confidential staff interviews and record review indicated that staff is given appropriate training to care for the clients prior to employment and annual training. Confidential staff interviews reported that staff did seek mental health services for C1, however, C1 did need more intensive treatment. Confidential staff interviews reported that staff made several medical appointments for C1, but C1 refused and staff had to reschedule several of the appointments. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Darlene Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-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, FACILITY NAME: REFUGE, THEFACILITY NUMBER: VISIT DATE: 05/24/2023

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


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Other confidential interviews stated that the allegations were true. The interviews that were provided to the LPA were not consistent regarding the allegations that S1 did not pick up C1 from school in a timely manner and that S1 grabbed C1 by the arm. Based on interviews and record reviews the allegations, may have occurred, however is not supported, or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Grace Williams.

Investigation Findings:
13On August 14, 2023, 2023 at 09:15am Williams Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera met with facility Grace Williams to discuss the findings of this investigation. LPA conducted an inspection of the facility on February 14, 2023, at 10:15 am and no immediate deficiencies were observed. Three of three children (C1, C2, C3), four staff and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that staff #1 (S1) did not pick up C1 from school in a timely manner and S1 grabbed C1 by the arm. More specifically S2 received a phone call from C1's school. C1 needed to be picked up from school, due to C1 being intoxicated. Confidential staff interviews reported that S2 then notified S1 that S2 was at another school and was unable to pick up C1. Confidential staff interviews reported that S1 went to pick up C1 from school, within 30 minutes of receiving the phone call. Confidential interviews reported that C1 had attempted to run out of the school and S1 then blocked the door, as the ambulance was arriving. Confidential staff interviews reported that S1 never grabbed C1's arm or handled C1 in an inappropriate manner. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Darlene Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-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, FACILITY NAME: THE REFUGE, CHILDREN OF THE IMMACULATE HEARTFACILITY NUMBER: VISIT DATE: 08/14/2023


raw_content:
Narrative:
Confidential interviews revealed that staff confiscated marijuana and alcohol and reported this incident to all appropriate parties. Other information received stated that the allegations were true. Other confidential interviews stated that the allegations were true. The interviews that were provided to the LPA were not consistent regarding the allegations that S1 made an inappropriate comment to C1, S2 inappropriately restrained C1 and S1 allows the minors to drink and smoke at the facility. Based on interviews and record reviews the allegations, may have occurred, however is not supported, or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Grace Williams.

Investigation Findings:
13On August 14, 2023, at 09:31am, Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera met with facility Grace Williams to discuss the findings of this investigation. LPA conducted an inspection of the facility on April 18, 2023, at 10:00 am and no immediate deficiencies were observed. Three of three children (C1, C2, C3), four staff and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that staff #1 (S1) made an inappropriate comment to C1, S2 inappropriately restrained C1, S1 allows the minors to drink and smoke at the facility. More specifically, C1 was agitated and threatened to hit staff. Confidential staff interviews reported that S1 told C1 that S1 would hit C1 back if C1 hit S1. Confidential staff interviews reported that C1 was attempting to attack C2 and S2 stood at the doorway to prevent C1 from attacking C2. Confidential interviews reported that C1 was never restrained, and law enforcement was contacted for assistance. Confidential interviews reported that S3 was allowing C1, C2 and C3 to drink and smoke while at the facility. Confidential interviews reported that C1 and C2 had returned to the facility with alcohol and marijuana hidden in their belongings. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Darlene Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-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, FACILITY NAME: THE REFUGE, CHILDREN OF THE IMMACULATE HEARTFACILITY NUMBER: VISIT DATE: 08/14/2023


raw_content:
Narrative:
However, C2 rushed through the staff and attacked C1, resulting in C1 having a black eye. Confidential staff interviews reported that law enforcement and the paramedics were called for assistance and C1 refused any medical attention. Confidential interviews reported that an incident report was completed and sent to all of the clients' authorized representatives. Confidential staff interviews reported that C1 was offered and scheduled therapeutic appointments, however C1 would refuse to attend. Other confidential interviews stated that the allegations were true. The interviews that were provided to the LPA were not consistent regarding the allegations that the facility did not ensure that C1 had access to mental health, due to lack of supervision C1 was physically assaulted by C2, C1 did not receive any medical attention, front door window was in disrepair, and the facility did not report an incident that occurred to C1's authorized representative. Based on interviews and record reviews the allegations, may have occurred, however is not supported, or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Grace Williams.

Investigation Findings:
13On August 14, 2023, at 09:47am, Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera met with Grace Williams facility to discuss the findings of this investigation. LPA conducted an inspection of the facility on May 2, 2023, at 11:46 am and no immediate deficiencies were observed. Three of three children (C1, C2, C3), four staff and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that the facility did not ensure that C1 had access to mental health, due to lack of supervision C1 was physically assaulted by C2, C1 did not receive any medical attention, front door window was in disrepair, and the facility did not report an incident that occurred to C1's authorized representative. More specifically, C1 was observed on April 28, 2023, with a black eye and the front door window/glass was broken. Confidential interviews reported that on April 26, 2023, C2 was behaving very defiantly and broke the front door glass with a fire extinguisher that was hanging on the wall. Staff was verbally counseling C2 but C2 was not receptive. Staff were standing in between C1 and C2. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Darlene Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-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, FACILITY NAME: THE REFUGE, CHILDREN OF THE IMMACULATE HEARTFACILITY NUMBER: VISIT DATE: 08/14/2023


summary: Facility Evaluation

raw_content:
Narrative:
On October 8, 2021, at 2: PM, an office tele-conference was held with representatives from The Refuge Short Term Residential Therapeutic Program (STRTP) via Microsoft Teams video platform. In attendance were: STRTP representatives Licensee Grace Williams, Administrator Amaneece Harrison. Also in attendance were: Community Care Licensing (CCL) Regional Manager (RM) LaCresha Cook, Licensing Program Manager (LPM) Christina Barnes, Licensing Program Analyst (LPA) Lorena Valenzuela, from the Department of Health Care Services (DCHS) David Gutierrez and Alexandria Valencia, from Harm Reduction unit Kelly Hartman, from System of Care (SOC) Marjana Jackson. The following was discussed with the facility: · Mental Health contract and Medi-Cal certification for the STRTP. · Compliance with HSC 1520.1(a)(2)(C). · HSC 1520.1(a)(2)(C) states: "... The short-term residential therapeutic program requires additional time to complete the mental health program approval as set forth in Section 1562.01. The department may require ongoing documentation to ensure progress toward mental health program approval. The department may also require ongoing documentation that the provider is ensuring access to specialty mental health services during provisional licensure." · Although it is preferred to have a mental health contract in the same county where the facility is located, The Refuge can obtain a mental health contract from any county and is not limited to San Diego County. · Complaint investigation. · Harm Reduction referral. During the meeting, Regional Manager (RM) LaCresha Cook asked about the facility's status in obtaining a county mental health contract. Licensee Grace Williams stated the facility attempted to obtain a mental health contract with San Diego county but was told mental health contracts are only offered to STRTP's who have a contract with County Welfare System (CWS) of San Diego County. Currently, per Ms. Wlliams the facility does not have a CWS contract with San Diego county. (continued on 809-c) Ms. Williams added that the facility will continue to purse a mental health contract with San Diego county. Ms. Williams stated the facility also contacted Riverside county and will continue to pursue obtaining a contract from Riverside county. Ms. Williams stated she will be contacting other counties regarding obtaining a mental health contract, including: Fresno, San Luis Obispo and Los Angeles. RM inquired about a timeframe in which Ms. Williams will reach out the counties. Ms. Williams stated she would reach out to the counties by the end of the week. Ms. Williams stated she will provide updates to LPA Valenzuela regarding their mental health contract status. During the meeting, David Gutierrez and Alexandria Valencia from DCHS informed the facility about Specialty Mental Health Services which are to provide to children in care. DCHS representatives provided the facility with a website link to DCHS STRTP Regulations(https://www.dhcs.ca.gov/Documents/STRTP-Regulations-version-II.pdf) and an email address for the facility to send any questions they may have about the Mental Health Approval Process. During this meeting, Kelly Hartman from Harm Reduction advised the facility of the support, resources and training available to the help the facility meet the needs of the population they serve. Ms. Hartman provided the facility with an email address for the facility to contact Harm Reduction for consultation. In addition, System of Care (SOC) Marjana Jackson provided and email address for the facility to contact SOC to help in obtaining the contacts needed for their mental health contract and program. During the meeting, LPA Valenzuela provided information regarding substantiated complaint investigations involving the facility not following their Plan of Operation and lack of supervision. RM Cook inquired about the steps the facility has taken to ensure the facility is following their Plan of Operation. Ms. Williams stated the facility provided staff training on the intake and admission process and has recently trained her staff on how to recognize suicidal ideations, eating disorders and supervision. RM Cook inquired about newly hired staff, Ms. Williams stated there was an additional five staff recently hired. RM Cook asked if they are meeting client to staff ratios, Ms. Williams stated yes. At the conclusion of the conference, RM Cook thanked the facility representatives. LPM Barnes reminded the facility that a provisional license was issued through 12/08/2021, and the in order to continue to be licensed the facility must demonstrate progress being made toward obtaining a mental health contract and mental health program approval. A copy of this report was emailed to Licensee Grace Williams for signature. Original signed report in facility file.

report_type: Facility Evaluation

met_with: Grace Williams, Licensee and Amaneece Harrison, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On March 24, 2022 an informal conference was held with The Refuge Short-Term Residential Therapeutic Program (STRTP) to discuss current Mental Health Program Approval status and permanent licensure. Present at the meeting were: LaCresha Cook, Regional Manager (RM), Christina Barnes, Licensing Program Manager, Cheraki Davis, Licensing Program Manager, Lorena Valenzuela, Licensing Program Analyst, Grace Williams, Licensee, Cesar Argueta, Facility Administrator, Heather Flores, Consultant, and Marjana Jackson, System of Care Branch. The following information was discussed: · Mental Health Program Approval status · Mental health contract · Application withdraw · Facility closure plan During the meeting, RM Cook stated the meeting was to follow up on the facility status in obtaining a mental health contract. RM Cook stated that the STRTP provisional License expiration date is June 10, 2022. Licensee Grace Williams stated they have not had a county say yes to wanting to establish a mental health contract with the facility, and that Orange county has shown interest. Facility consultant Heather Flores stated she has contacted several counties regarding getting a mental health contract and most have said no but Ms. Flores is waiting to hear back from Imperial county. (continued on page 2) RM Cook inquired about the facility's plan in the case the facility is not able to ensure they have a mental health contract with a county prior to the license expiration date. RM Cook inquired as to whether the facility has a plan to operate a different facility type or withdraw their application. RM Cook stated that in addition to obtaining the mental health county contract, the facility would also have to get Medi-Cal certification, which is part of the Mental Health Program Approval process. RM Cook stated the process can take several months to complete. RM Cook stated that if the facility is not able to get a Mental Health Program approval, and the application is denied, the facility cannot re-apply to be licensed as an STRTP for 2 years. Ms. Williams asked RM Cook to explain further regarding not being able to reapply for 2 years. Ms. Williams stated she had received information that stated she could re-apply right away. RM Cook stated that if the facility withdrew their application for licensure the facility could apply at any time. RM Cook stated that if the Department denied the application, then the facility could not apply for 2 years. RM Cook inquired about what the facility would choose to do in case the facility was not able to meet the licensing requirements which includes having a mental health contract. Ms. Williams states the facility would choose to withdraw the application. Ms. Williams added that she understood that that meant the facility would have to close. RM Cook clarified that per statute, the maximum time a facility has to obtain a Mental Health program approval is 24 months, and that there are no extensions. Marjana Jackson from System of Care inquired about the facility's census and whether the facility has a closure plan. Ms. Williams stated the facility did not have a closure plan at this time. RM Cook stated LPA Lorena Valenzuela would be providing the licensee with information about a closure plan. A copy of this report was emailed to Grace Williams for original signature. A copy of Children's Residential Program, Provider Information Notice (PIN)-18-03, "Closure Plan for Community Care Licensing" was emailed to Grace Williams.

met_with: Grace Williams, Licensee


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Nicole Strickland arrived unannounced to the facility. While at the facility LPA gathered documents from staff records, staff schedule, and facility records. LPA set a meeting with licensee Grace Williams for Monday August 8, 2022 at 12:00pm.

visit_type: Case Management

met_with: Sophia Pappas


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Nicole Strickland arrived unannounced to The Refuge to deliver amended findings originally delivered to the facility on August 8, 2022.

met_with: Michelle Hazelwood, House Manager


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Nicole Strickland arrived unannounced to the facility to deliver an amended report originally delivered to the facility August 8, 2022.

met_with: Marcus Strong


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Nicole Strickland arrived to The Refuge to deliver an amended report initially delivered on August 8, 2022.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by Licensing Program Analysts (LPA) Kendal Zirbes and Danielle Garcia on June 7, 2021 at 11:00am. During the inspection, LPA's met with facility manager Nika Nettles. LPA's inspected the facility inside and out. The facility was licensed as a Short Term Residential Therapeutic Program (STRTP) on June 10, 2020. The facility is a two-story building with three bedrooms, three and a half bathrooms, a school room, staff office, kitchen, dining area, and prayer/meditation/quiet room located on the upper floor. The lower floor includes a therapy office, laundry room, and a two-car garage that is used as a recreational room. A physical plant inspection was completed and included the following checks: Facility grounds were clean and free of debris. LPA's observed one hole in the wooden patio that was twelve inches long and three inches wide. In addition, LPA's observed three additional wooden planks which had exposed nails and felt unstable when walked upon. The facility has a hot tub which was equipped with a cover that is locked on each corner. There is adequate indoor and outdoor activity space. Video games/books/games were observed for youth's recreation time. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. Medications are locked and centrally stored in a locked closest in the locked staff office. Six individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. At 4:30pm, LPA observed hot water temperature in the bathroom registered 107 degrees F. The facility has a fully equipped first aid kit and first aid manual. The facility does not have cameras. Per facility staff, no firearms or weapons are allowed in the facility and smoking is prohibited. Personnel Files and youth files were maintained on-site in a locked cabinet in the locked staff office. LPA reviewed six staff files and three youth files. All staff have caregiver background checks have received criminal record and child abuse index clearance. LPA's observed that the staff training did meet the staff training matrix per the plan of operation. Report continued on page two This is an amended document When LPAs arrived to the facility, the staff training records were not in the staff files. LPA's were advised that the training records were located on the Extended Reach System. LPA advised the facility that the training records must be available to the Department. Per the Facility Manager the training records will be added to the staff files or LPA's will be granted access to the Extended Reach system. Staff/client ratios were verified during this inspection and they were in accordance with the regulations. Based on LPA's observation the facility failed to ensure a safe outdoor area and failed to follow the approved program statement/ plan of operation. This poses potential risk to the youth in care. The facility was cited for a violation of STRTP interim licensing standard version 3.1 regulation 87087.2 (a) and 87022 (f). An exit interview was conducted with Facility Manager Rachel Beck and the Administrator. A copy of this report was emailed to the facility.

visit_type: Annual

met_with: Facility Manager Rachel Beck


summary: Facility Evaluation

raw_content:
Narrative:
On August 8, 2022 at 4:00 pm Licensing Program Analyst (LPA), Nicole Strickland, met with The Refuge, Executive Director, Grace Williams to deliver a case management deficiencies report. According to information obtained by Community Care Licensing (CCL) the facility hired Staff #1 (S1) on March 2, 2022 to fulfill the role of Administrator. Record review revealed S1 worked on site at the facility on both 3/4/2022 and 3/9/2022 prior to S1 being associated to the facility on 3/16/2022. This is a violation of California Code of Regulations (CCR) regulation 80019(e)(2). The facility is being cited for violation California Code of Regulations (CCR) regulation 80019(e)(2) CRIMINAL RECORD CLEARANCE (e)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing, or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in section 80019(f). The facility will be assessed an immediate civil penalty per CCR regulation 80019(g) CRIMINAL RECORD CLEARANCE (g) an immediate assessment of civil penalties for violations of CCR Section 80019(e). A copy of the report was discussed and provided along with Civil penalty assessment and appeal rights to The Refuge, Executive Director, Grace Williams.


summary: Facility Evaluation

raw_content:
Narrative:
On August 8, 2022 at 3:32pm Licensing Program Analyst (LPA), Nicole Strickland, met with The Refuge, Executive Director, Grace Williams to deliver a case management deficiencies report. According to information obtained by Community Care Licensing (CCL) the facility has been operating without a qualified and currently certified administrator. This is a violation of Interim Licensing Standards (ILS) standard 87064(b). The facilities operation without an approved qualified and currently certified administrator as described in the facility's Plan of Operation approved by Community Care Licensing (CCL) is a violation of Interim Licensing Standards (ILS) standard 87022(f). The facility is being cited for violation of ILS 87064(b) ADMINISTRATOR QUALIFICATIONS AND DUTIES (b) All short-term residential therapeutic programs shall have a qualified and currently certified administrator, and ILS 87022(f) PLAN OF OPERATION (f) The facility shall operate in accordance with the terms specified in the plan of operation and may be cited for not doing so. A copy of the report was discussed and provided along with appeal rights to The Refuge, Executive Director, Grace Williams.


summary: Facility Evaluation

raw_content:
Narrative:
On August 18, 2022, at 1:38pm Licensing Program Analyst (LPA), Nicole Strickland, met with Michelle Hazelwood, House Manager of The Refuge to deliver a case management deficiencies report. According to information obtained by Community Care Licensing (CCL) the facility has been operating without a qualified and currently certified administrator and was cited for violation of Interim Licensing Standards (ILS) standard 87064(b) on August 8, 2022. On this date, the facility remains out of compliance with ILS 87064(b) and is being cited for violation of ILS 87064(b) ADMINISTRATOR QUALIFICATIONS AND DUTIES (b) All short-term residential therapeutic programs shall have a qualified and currently certified administrator. This is a repeat violation and the facility is being issued a civil penalty for the repeat violation. A review of the facilities board meeting minutes dated 3/26/2022, 4/8/2022, 5/23/2022, and 7/23/2022 revealed no documentation of review and discussion of incidents occurring at the facility involving contact with law enforcement. This is a violation of ILS standard 87063(8)(A) ACCOUNTABILITY (A)Review and discussion of short-term residential therapeutic program's operation shall include the incidents concerning a child in the facility involving contact with law enforcement that were reported to the department as specified in Section 87061(k). The review of board meeting minutes dated 3/26/2022, 4/8/2022, 5/23/2022, and 7/23/2022 revealed two additional violations regarding accountability. These violations include the boards accountability in ensuring that the facility employs an administrator who meets the requirements of ILS section 87063. Documentation obtained by CCL revealed that the facility has been operating without an approved Administrator. The board meeting minutes provided no evidence regarding this violation and did not include how the facility planned to come into compliance with the regulation. This is a violation of ILS 87063(5) ACCOUNTABILITY (5) Employ an administrator who meets the requirements of Section 87064, and 87063(a)(11) ACCOUNTABILITY (11) Ensure that oversight of program operations and internal controls are adequate and effective for the management of short-term residential therapeutic program and provide reasonable assurance of ****** compliance with applicable laws and regulations. Additional information obtained by CCL revealed a violation of 87061(i)(9) REPORTING REQUIREMENTS (i) Incident reports must include the following: (9) The licensee shall not interfere with the Department's investigation of an incident reporting requirements or any duties imposed pursuant to any provision of federal or state law or regulation. Record review occurring on August 16, 2022 revealed the facility conducted its own investigation into a complaint received by CCL. The facilities investigation included having staff go to a gas station to observe video footage and obtain photographs and gather written declarations from staff not present during the incident, these actions went beyond what was necessary to report the incident to the appropriate authorities. Staff records for Staff #1 (S1) provided by the facility to CCL revealed S1 was hired January 24, 2022 as a childcare worker. Record review of the LIC 500 dated August 4, 2022 submitted to CCL revealed S1 is listed as the Facility Manager. S1 fulfilling the role of facility manager which is not included in S1s job description is a violation of ILS 87065(k) PERSONNEL REQUIREMENTS (k)The staff assignment information specified in Section 87066(b)(2) shall be provided to all applicants during interviews for employment; to all staff during orientation or when changes are made which affect job assignments; and upon request to placement agencies. Also revealed during the record review was S1 does not have a current negative TB test on file, this is a violation of California Code of Regulation (CCR) regulation 80066(a)(11) PERSONNEL RECORDS (a)The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information: (11)Tuberculosis test documents as specified in Section 80065(g). A review of Staff #2 (S2)s staff record revealed no health screening for S2 and no Tuberculosis test for S2. These are violations of CCR regulation 80066(a)(10) PERSONNEL RECORDS (a)The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g) and CCR regulation 80066(a)(11) PERSONNEL RECORDS (11) Tuberculosis test documents as specified in Section 80065(g). ****** A review of Staff #3 (S3)s staff record revealed a copy of S3's state identification card and number are in staff's record however, no evidence of a driver's license which is required for staff who transport residents. On August 5, 2022, Licensing Program Analyst (LPA) Nicole Strickland arrived to the facility as S3 was preparing to transport two residents to therapy. Due to LPA's arrival S3 did not transport the residents on this date. S3's staff record not containing S3's driver's license information is a violation of CCR 80066 (a)(2) PERSONNEL RECORDS (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information: (2)Driver's license number if the employee is to transport clients. A copy of S3's job description was not observed to be in S3's record. This is a violation of CCR regulation 80066(a)(8) PERSONNEL RECORDS (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information (8) Duties of the employee. On August 5, 2022, Licensing Program Analyst (LPA) Nicole Strickland arrived to the facility and was greeted by Staff #1 (S1) and Staff #3 (S3). Upon entry to the facility LPA asked to speak to the Administrator and was informed that there was no administrator on site. LPA then asked to speak to Executive Director (ExDir) and was told by S1, ExDir was on maternity leave. S1 and S3 stated House Manager (Staff #4 [S4]) was not present. S3 stated she would call S4 to inform S4 of LPA's presence at the facility. S3 stated that S4 did not answer the phone so S3 was going to text S4. After texting S4, S3 made another attempt to contact S4 which was successful. S3 was informed that Staff #5 (S5) was on his way to the facility and would be able to assist LPA. A review of S1 and S3's personnel record provided no evidence of S1 or S3 being designated to fulfil the role of House Manager when House manager is not present. Therefore the facility is being cited for violation of Interim Licensing Standards (ILS) standard 87065(f) PERSONNEL REQUIREMENTS (f) the licensee shall designate at least one facility manager to be present at the facility at all times when one or more children are present: A copy of the report was discussed and provided along with civil penalty assessment LIC 421 and appeal rights to The Refuge House Manager Michelle Hazelwood.


summary: Facility Evaluation

raw_content:
Narrative:
On October 26, 2022, at 12:35 pm Licensing Program Analyst (LPA), Nicole Strickland, met with The Refuge, Children of the Immaculate Heart Administrator Peter Airewele and Executive Director Grace Williams to deliver a case management deficiencies report. The facility was initially issued a citation for violation of Interim Licensing Standards (ILS) standard 87064(b) ADMINISTRATOR QUALIFICATIONS AND DUTIES on August 8, 2022. The facility created a plan of correction which included Executive Director hiring a temporary administrator who meets the qualifications to fulfil the role until newly hired staff (Staff #1 [S1]) could. On August 18, 2022, the facility was issued a repeat citation for ILS standard 87064(b) which included an immediate civil penalty. On August 19, 2022 the facility sent LPA Strickland an email noting the plan of correction created and submitted to Community Care Licensing (CCL) was the facilities hiring of S1 to fulfill the role. On August 30, 2022, the facility was provided notification that S1 did not meet the qualifications for administrator based upon the information submitted to CCL on August 19, 2022. On September 23, CCL received an revised version of S1's resume for use in consideration of S1 meeting the qualifications as outlined in ILS 87064(b). The period between the repeat citation being issued, August 18, 2022 and the submittal of the revised resume September 23, 2022 the facility continued to operate without an approved certified administrator as required by ILS 87064(b). Therefore a civil penalty of $100 per day is being assessed for the period August 19, 2022 through September 23, 2022, as required by Health and Safety Code (HSC) 1548(b)(1). A copy of this report, LIC 421 with civil penalty assessment, and appeal rights were discussed with and provided to The Refuge, Children of the Immaculate Heart Administrator Peter Airewele and Executive Director Grace Williams Due to technical issues LPA was unable to obtain electronic signatures. Signed reports and paper copy of LIC 421 was signed and will be placed in facility file.

met_with: Peter Airewele


facility_name: TIFFANY'S PLACE

raw_content:
Narrative:
some group meetings or activities are conducted off site. It was advised that due to the location of the group, clients are expected to be ready to leave the facility 30 minutes prior to the beginning of the session. Staff members stated that clients are fully aware of the rules. Staff stated that that would be only reason that clients are not allowed to attend group. Information from confidential interviews stated that staff do not allow clients to attend group for small issues. It was advised that staff are too strict on the clients, even though the rules are often communicated. Information from additional witnesses stated no concerns have been advised regarding clients not being allowed to attend group. It was reported that participation is high for the facility. It was reported that a client was not allowed to be permitted back into the facility after they returned from AWOL. It was advised by Administrator that the client went on AWOL status during the Covid-19 pandemic and guidelines were put in place. It was advised that upon client's return to the facility, a mandatory quarantine must take place. It was advised that the client refuse to go on quarantine status until a negative Covid-19 test returned. It was stated that staff members contacted the probation department and was advised to transport the client to the juvenile facility in order for the client to be detained and quarantine at the facility. It was advised that the next day, the clients probation officer contacted the facility and did not agree with the decision; the client never returned to the facility. Information from confidential interviews stated thaty facility staff refused to allow client into the home and subsequently had to go to juvenile hall. No further information was advised. Additional witnesses stated they had no further concerns due to the facility being advised to act accordingly. Further information stated the decision was made to ensure the safety of the facility was not jeopardized. In regards to the mental and psychiatric needs of the clients not being met, it was advised that clients are referred to mental and psychiatric health to two outside clinics. It was reported that due to the pandemic, appointments were made slower than normal. It was advised that clients are allowed to speak with the facililty social worker and their own therapist. It was reported that clients are provided their psychotropic medication on a regular and scheduled basis. Information from confidential interviews stated clients did not feels supported during the pandemic by staff or therapist. It was also reported tha appointments took too long to schedule. It was also advised that some staff were sensitive to the needs of clients and ensured they were safe and comfortable. Probation officer and social worker stated there were no issues or concerns as clients are taken to therapeutic services regularly. It was also advised that no concerns were advised or addressed. In regards to staff being rough with minor, it was reported that a staff member "snatched" a jacket out of a client's hand. It was advised that no concerns were ever addressed pertaining to a staff member being rough or inappropriate with a client. It was advised that the facility is completely "hands off." Confidential interviews stated a staff member was rough with a client. It was reported that a staff member "snatched" a remote control out of a client's hand. Physical discipline and any other incident was denied. Additional witnesses stated no issues or concerns were advised regarding staff being "rough" with clients. It was reported that client did not have enough clothes and was not taken shopping. It was advised that San Diego County placements do not receive clothing allowance. It was reported that facility abides by the guidelines of San Diego County's clothing standard. It was advised that the inventory is conducted monthly and clients are allowed to shop with their peer counselor to meet the standard if the inventory is deficient. It was advised that due to the pandemic, shopping was conducted online. LPA Harris was provided clothing receipts and inventory documents. Confidential interviews stated that the clients have been placed at the facility and have not had any clothes purchased for them. It was reported that clients are also not allowed to do any online shopping with their peer counselor. It was reported that representatives are aware of the concerns. Information obtained from additional witnesses stated clients have an abundance of clothing. It was advised that clients always have clean and appropriate clothing on when observed; no concerns have been advised. In regards to the allegation that staff took minor's computer away, it was reported that staff do not allow clients to utilize their personal computers. Administrator advised that due to the CSEC population the facility houses, the clients are not allowed access to computers, phones, social media applications, etc. Administrator stated due to the Covid-19 pandemic, clients were required to utilize computers to complete schoolwork. It was reported that clients were abusing their computer privileges by downloading music and social media applications. Administration stated in order to combat the issues and ensure the clients are not being revictimized, the clients were switched to paper schoolwork packets. Administration stated therefore; the clients are no longer permitted to use computers. Confidential interviews stated staff took away thier computers due to clients not following the rules, but the computers were needed in order to complete school work. Information from the interviews also stated that it is not a privilege, but a right to have access to technology. Information from confidential interviews corroborated that due to the nature of the clients' past, clients are not permitted to have access to technological devices; no concerns. Based on interviews and information obtained, the allegations that staff did not allow minor to go to youth group, minor was not allowed back to the group home after minor had went on absent without leave (AWOL) status, mental and psychiatric needs of minors are not being met, minor does not have enough clothes, staff was rough with minor, and staff took minor's computer away, may or may not have occurred, however it is not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. Exit interview conducted and a copy of the report will be provided to the representative. Signed copies will be placed in the complaint file.

Investigation Findings:
13Licensing Program Analyst (LPA) Jazmond Harris provided the findings for investigation pertaining to the listed allegations to Facility Administrator, Briann Guillen via phone, due to the Covid 19 pandemic. On January 13, 2021 at 1: PM, LPA N. Strickland initiated the complaint investigation with CEO, Lynn Burgard and no immediate deficiencies or health concerns were noted. LPA Harris conducted interviews with Administrator, Facility Manager, Staff Members, Social Worker, Michelle White, Probation Officer, and two out of three clients (C1, C2, C3). One client refused to be interviewed by LPA Harris. On January 7, 2021, Community Care Licensing (CCL), received information which stated staff did not allow minor to go to youth group, minor was not allowed back to the group home after minor had went on absent without leave (AWOL) status, mental and psychiatric needs of minors are not being met, minor does not have enough clothes, staff was rough with minor, and staff took minor's computer away. In regards to staff not allowing minor to go to youth group, it was advised by administration and staff that UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Jazmond D Harris 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 08-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, FACILITY NAME: TIFFANY'S PLACEFACILITY NUMBER: VISIT DATE: 05/25/2021

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

met_with: Facility Administrator-Briann Guillen


raw_content:
Narrative:
CEO stated that she used the word for clarification, but never called Client #1 the term. Information obtained from confidential interviews stated that no client has been called the term, but information advised stated that staff has told clients to "stop having a black attitude." It was reported that the facility did not have any food and that clients were forced to eat biscuits for dinner. It was advised by administration and staff that the facility has more than enough food. It was advised that the facility's food supply is replenished on Tuesdays and Saturdays. It was also stated that the facility obliges by the Community Care Licensing Standard for perishable and non perishable foods. Confidential interviews revealed that the facility has enough food and clients are fed well, but a lot of the food is expired. It was reported that minors are denied television usage and are taken on inappropriate outings. It was stated that clients are only allowed to watch documentaries and were taken to a cemetery for an outing. It was stated that clients do have media education time where they do what documentaries, but are able to watch their own shows at another time. Confidential interviews did not reveal any issues or concerns regarding television time. It was also reported that clients were taken to a cemetery for an outing. Information obtained from administration and staff denied the allegation. It was reported that clients are taken to parks, beaches, movies, etc. Information from confidential interviews corroborated the information. It was reported that the facility is dirty and has pest. Information obtained stated that staff members and clients are responsible to clean the facility. It was also reported that a cleaning company cleans the facility once a month. It was reported that the facility can get messy, but never dirty. No information was advised of the facility having pest. Information obtained from confidential interviews stated that the facility is dirty; especially the kitchen and refrigerator. Information did advise that staff and clients are responsible for cleaning the facility. Confidential information did state that pest are in the facility as well. It was reported that a staff did not keep minors personal information confidential. It was reported that recently a client did advise that a staff member revealed their medical information. Information from administration and staff stated that Client #1 told a new client their medical information which was corroborated by the new client. All staff denied that they shared any personal information regarding any client. Information obtained from confidential interviews stated staff do share their information, but could not provide any specific details. Based on interviews and information obtained, the allegations that staff made inappropriate comments towards minor, staff did not maintain adequate food supply on premises, staff did not provide enough allowance to youth, minors denied tv usage, minors taken on inappropriate outings, facility is dirty and has pests, and staff did not keep minors personal information confidential may or may not have occurred, however it is not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. Exit interview conducted and a copy of the report will be provided the facility.

Investigation Findings:
13On June 16, 2021 at 5: PM, Licensing Program Analyst (LPA) Jazmond Harris met with Facility Social Worker, Michelle White to provide the findings for the investigation pertaining to the listed allegations. On January 15, 2021, at 1: PM, LPA Nicole Strickland initiated the complaint investigation with CEO and no immediate deficiencies were noted. LPA Harris conducted interviews with Administrator, Facility Managers, Probation Officer, and two out of four clients (See Confidential Names List (LIC 811) dated June 14, 2021. LPA Harris was not able to interview two clients due to no current contact information being available. On January 7, 2021, Community Care Licensing (CCL), received information which stated staff made inappropriate comments towards minor, staff did not maintain adequate food supply on premises, staff did not provide enough allowance to youth, minors denied tv usage, minors taken on inappropriate outings, facility is dirty and has pests, and staff did not keep minors personal information confidential. It was reported that a staff member called a client a "nigger." Information obtained from administration and staff stated that Client #1 uses the derogatory term often towards clients and staff. It was advised that CEO had a discussion with Client #1 and stated that the term should not be used towards anyone in the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Jazmond D Harris 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 08-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, FACILITY NAME: TIFFANY'S PLACEFACILITY NUMBER: VISIT DATE: 06/16/2021

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

met_with: Facility Social Worker-Michelle White


raw_content:
Narrative:
On May 10, 2021, the Department received allegations that facility did not notify clients and staff of exposure to COVID-19 and staff were not wearing face coverings inside the facility. Confidential interviews revealed that there was a COVID-19 positive individual in the facility, at which time the staff and the residents were not notify of possible exposure. Additional confidential interviews revealed that all in person appointments and outing were canceled, and clients were quarantine without any explanation. Confidential interviews revealed that staff have not been wearing face coverings since January of 2021. Additional interviews revealed that staff are told to wear face coverings when personnel from Child Welfare Services, Probations, and/or Community Care Licensing arrive to the facility. Based on confidential interviews and documentation reviewed the allegations that the facility did not notify clients and staff of exposure to COVID-19 and staff are not wearing face coverings in the facility are substantiated. This poses a potential health, safety and personal rights risk of harm to clients placed in care. The facility is being issued a citation in accordance with the Health and safety Code Health and safety Code section 1550 for conduct inimical . See page LIC809d for the cited deficiencies. An exit interview was conducted, and appeal rights discussed. Exit interview conducted and a copy of this report, LIC811 and appeal rights were given to the PA Guillen for signature.

Investigation Findings:
13On August 31, 2021 at 9: AM, Licensing Program Analysts (LPAs) Gloria Meza-Gonzalez and LPA Danielle Garcia conducted an unannounced complaint inspection at the facility. LPA Meza-Gonzalez met with program Administrator (PA) BriAnn Guillen to discuss and deliver the investigative findings for the allegations noted above. LPA Meza-Gonzalez conducted an unannounced inspection with the facility on May 19, 2021. No safety concerns were observed. During the investigation, LPA Meza-Gonzalez interviewed three clients (Client #1 [C1] , Client #2 [C2], Client #3 [C3]) and six out of seven staff (Staff #1 [S1], Staff #2 [S2], Staff #3 [S3], Staff #4 [S4], Staff #5 [S5], Staff #6 [S6]), Program Administrator (PA), Agency Social Worker, and County Social Worker (see confidential name list, LIC811, dated 08/31/2021), LPA Meza-Gonzalez reviewed the following documentation: Special Incident Reports (SIRs), staff roster, clients' face sheets, and needs and service plans. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Gloria Meza-Gonzalez 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 08-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, METROPOLITAN DR. # FACILITY NAME: TIFFANY'S PLACEFACILITY NUMBER: VISIT DATE: 08/31/2021

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

met_with: BriAnn Guillen


raw_content:
Narrative:
On May 17, 2021, Community Care Licensing (CCL) received an allegation that the S1 inappropriately grabbed C1 while in care. Confidential interviews revealed inconsistencies regarding S1 grabbing C1. Confidential interviews revealed that S1 grabbed C1 aggressively to get C1 out of the med closet. Additional confidential interviews reported that C1's arm touched S1's open hand as S1 was turning around from the med closet. There were no witnesses to this incident. Based on confidential interviews and record review, although the allegations that S1 inappropriately grabbed a C1 while in care may or may not have occurred, the allegation is not supported or proven by the evidence gathered. Therefore, the allegation is determined to be unsubstantiated. An exit interview was conducted, a copy of this report, the appeals and LIC 811 were given to PA Guillen.

Investigation Findings:
13On August 31, 2021 at 11: AM, Licensing Program Analysts (LPAs) Gloria Meza-Gonzalez and Danielle Garcia conducted an unannounced complaint inspection at the facility. LPA Meza-Gonzalez met with Program Administrator (PA) BriAnn Guillen to discuss and deliver the investigative findings for the allegations noted above. LPA Meza-Gonzalez conducted an unannounced inspection with the facility on May 19, 2021. No safety concerns were observed. During the investigation, LPA Meza-Gonzalez interviewed three clients (Client #1 [C1] , Client #2 [C2], Client #3 [C3]) and five out of six staff (Staff #1 [S1], Staff #2 [S2], Staff #3 [S3], Staff #4 [S4], Staff #5 [S5]), Program Administrator (PA), Agency Social Worker, and County Social Worker (see confidential name list, LIC811, dated 08/31/2021), LPA Meza-Gonzalez reviewed the following documentation: Special Incident Reports (SIRs), staff roster, C1's face sheet, and C1's needs and service plan. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Gloria Meza-Gonzalez 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 08-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, METROPOLITAN DR. # FACILITY NAME: TIFFANY'S PLACEFACILITY NUMBER: VISIT DATE: 08/31/2021

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


raw_content:
Narrative:
On 05/17/2021, Community Care Licensing (CCL) received an allegation that the S1 did not transport minor in a safe manner. Confidential interviews revealed that C1 and C3 were in the vehicle with S1, when S1 hit a parked vehicle while backing up. Additional information revealed that S1 did not stop to access the damages, wait for the owner of the vehicle or leave contact information. S1 contacted CEO once S1 arrived at the facility to inform CEO about the car accident. CEO went to the scene of the accident to access the damages and provide contact information. Based on confidential interviews and documentation reviewed the allegation that S1 did not transport minor in a safe manner is substantiated. This poses a potential health, safety and personal rights risk of harm to clients placed in care. The facility is being issued a citation in accordance with the Title 22, Division 6, Chapter 1: Responsibility for Providing Care and Supervision section code 80078 (a). See page LIC809d for the cited deficiencies. An exit interview was conducted, and appeal rights discussed. Exit interview conducted and a copy of this report, LIC811 and appeal rights were given to the PA Brooks for signature.

Investigation Findings:
13On 10/15/2021 at 9: AM, Licensing Program Analyst (LPA) Gloria Meza-Gonzalez conducted an unannounced complaint inspection at the facility. LPA Meza-Gonzalez met with Program Administrator (PA2) Rushel Brooks to discuss and deliver the investigative findings for the allegation noted above. LPA Meza-Gonzalez conducted an unannounced inspection with the facility on May 19, 2021. No safety concerns were observed. During the investigation, LPA Meza-Gonzalez interviewed three clients (Client #1 [C1] , Client #2 [C2], Client #3 [C3]) and four out of five staff (Staff #2 [S2], Staff #3 [S3], Staff #4 [S4], Staff #5 [S5]), Program Administrator (PA1) , Agency Social Worker (ASW), Chief Executive Officer (CEO) and County Social Worker (CSW) (see confidential name list, LIC811, dated 10/15/2021). LPA Meza-Gonzalez was not able to interview Staff #1 (S1). LPA Meza-Gonzalez reviewed the following documentation: Special Incident Reports (SIRs), staff roster, and C1 and C2's face sheet. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Gloria Meza-Gonzalez 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 08-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, METROPOLITAN DR. # FACILITY NAME: TIFFANY'S PLACEFACILITY NUMBER: VISIT DATE: 10/15/2021

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

met_with: Rushel Brooks


raw_content:
Narrative:
Confidential interviews revealed staff tried to intervene during the client-on-client altercation by trying to get in between the two clients creating space. Confidential interviews revealed other clients assisted staff by trying to pull one client off the other. Other interviews revealed that C1 did have a scab on their right knee but refused to seek medical treatment from staff. Confidential interviews revealed conflicting statements whether C2 refused, or the facility failed to provide medication on 10/12/21 and 10/13/21. A confidential interview indicated that C2 did not refuse their medications on 10/12/21 and 10/13/21, although the MAR's stated the client missed their medications. Based on interviews conducted and evidence gathered during the investigation, the allegations that staff failed to protect a client in care resulting in injuries and staff failed to give client medication may have occurred, however is not supported, or proven by evidence. Therefore, the allegations are unsubstantiated at this time. A copy of this report, LIC 811, and appeal rights were reviewed and explained to Administrator, Rushel Brooks.

Investigation Findings:
13On 12/09/21 at 9: AM, Licensing Program Analyst (LPA) Danielle Garcia and LPA Gloria Meza-Gonzalez, met with Administrator, Rushel Brooks to deliver the findings regarding the allegations as stated above. During the investigation, Licensing Program Analyst (LPA) Danielle Garcia was able to interview four clients (C1, C2, C3, C4), four staff (S1, S2, S3, S4), the Administrator (A1), the CEO (CEO) of the facility and record review of facility documents (Staff Contact lists and all clients face sheets and needs and services plans, C2's Medications Administration Records (MAR) for 10/12/21 thru 10/13/21, and the Special Incident Reports). On 10/15/21, Community Care Licensing received the allegations that staff failed to protect a client in care resulting in injuries, staff failed to give client medication. ***Continued on Page 2*** UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Danielle Garcia 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 08-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, METROPOLITAN DR. # FACILITY NAME: TIFFANY'S PLACEFACILITY NUMBER: VISIT DATE: 12/09/2021

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


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

raw_content:
Narrative:
All confidential interviews revealed a client was sleeping in the therapy room because it was the only room the client felt safe due to the lock on the door. Confidential interviews revealed the facility implemented an "angry wall" where clients wrote other client's names and profanity on the wall and then used a plastic bat to punch holes into the wall. All interviews revealed conflicting statements on the rules and the purpose of the angry wall. Confidential interviews revealed only one client's name on the angry wall had holes. Based on confidential interviews and record review, the preponderance of evidence standard has been met and the allegations are substantiated. This posed a potential Health, Safety or Personal Rights risk to the clients in care, the facility is being cited for violation of Short Term Residential Therapeutic Program Interim Licensing Standards, Article 07. Physical Environment, Section 87087 (b) (4): Buildings and Grounds and Article 6. Continuing Requirements, Section 87072 (d)(11): Personal Rights. Confidential interviews and record reviews confirm a client was sleeping in a room for therapy and staff is making clients remain in a hostile environment. A copy of this report was reviewed and provided to Administrator Rushel Brooks, along with the Appeal Rights.

Investigation Findings:
13On 12/09/21 at 9: AM, Licensing Program Analyst (LPA) Danielle Garcia and LPA Gloria Meza-Gonzalez, met with Administrator, Rushel Brooks to deliver the findings regarding the allegation as stated above. During the investigation, Licensing Program Analyst (LPA) Danielle Garcia was able to interview four residents (C1, C2, C3, C4), four staff (S1, S2, S3, S4), the Administrator (A1), the CEO (CEO) of the facility and record review of facility documents (Staff Contact lists and all clients face sheets and needs and services plans, C2's Medications Administration Records (MAR) for 10/12/21 thru 10/13/21, and the Special Incident Reports). On 10/15/21, Community Care Licensing received the allegations that a client is sleeping in a room used for therapy and staff is making clients live in a hostile environment ***Continued on page 2*** SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Danielle Garcia 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 08-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, METROPOLITAN DR. # FACILITY NAME: TIFFANY'S PLACEFACILITY NUMBER: VISIT DATE: 12/09/2021

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

Deficiencies:
87087: Buildings and Grounds
No room commonly used for other purposes shall be used as a bedroom

title: (b) (4)


raw_content:
Narrative:
Specifically, it was reported S1 and S2 knew the C1 and C2 were bringing in alcohol [to the facility] and did nothing about it. Confidential interviews provided consistent reports of C1 and C2 bringing alcohol into the facility. Confidential interviews provided consistent statements of staff finding multiple empty bottles of alcohol in trash cans, in bushes, or other places at the facility. Confidential interviews also provided consistent statements regarding C1 and C2 drinking the alcohol in the presence of Staff #1 (S1), S2, and Staff #8 [S8] without staff intervention. CCL received and additional allegation alleging Staff (Staff #1 [S1]) provided minors (Child #1 [C1] and Child #2 [C2]) with vape pens. Confidential interview provided consistent statements regarding the use of vape pens by residents in the facility. Confidential interviews revealed consistent statements of S1 would vape with C1 and C2, and providing vape pens to C1 and C2. Based on confidential interviews the allegations of staff (Staff #2 [S2] and Staff #3 [S3]) negligence resulted in minors (Child #1 [C1] and Child #2 [C2]) consuming alcohol and Staff (Staff #1 [S1]) provided minors (Child #1 [C1] and Child #2 [C2]) with vape pens are substantiated. The preponderance of evidence standard has been met. Facility is cited for violation of California Code of Regulations regulation 80078(a) Responsibility for providing care and supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs, and Interim Licensing Standards (ILS) standard 87072(d) Personal Rights (d) The licensee shall ensure that each child, regardless of whether the child is in foster care, is accorded the personal rights specified in Welfare and Institutions Code Sections 16001.9 as applicable. In addition, the licensee shall ensure that each child is accorded the following personal rights. A copy of the report was discussed and provided along with appeal rights to Tiffany's Place Administrator (ADM), Rushel Brooks. regarding how residents AWOLing is handled by staff. Confidential interviews reported when a resident attempts to AWOL from the facility emergency intervention techniques are used by staff. Confidential interviews and record review revealed anytime a resident walks off or is out of staff sight while on outings this action is considered a resident AWOLing. Confidential interviews reported C1 had a history of walking off and/or being out of staff sight both from the facility and while on outings however, how staff handled the walk-offs is unknown. Confidential interviews could not confirm or dispute that staff followed emergency intervention plan when residents AWOLed. CCL received an additional allegation alleging Staff (Staff #3 [S3]) did not adhere to facility dress code allowing minors to wear provocative clothing. Confidential interviews provided conflicting reports of residents being allowed to wear provocative clothing. Confidential interviews reported when residents are leaving the facility for outings staff remind residents to adhere to dress code in order to participate in the outing. Additionally it was reported if residents are in the facility depending on which staff is working dress code may or may not be enforced. Based on confidential interviews and record review the allegations of staff (Staff #2 [S2] and Staff #3 [S3]) did not follow Emergency Intervention plan when minors (Child #1 [C1] and Child #2 [C2]) AWOL'd from the facility and Staff (Staff #3 [S3]) did not adhere to facility dress code allowing minors to wear provocative clothing, may or may not have occurred, however it is not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of the report was provided along with appeal rights to Tiffany's Place Administrator (ADM), Rushel Brooks.

Investigation Findings:
13On January 6, 2022 at 3:35pm Licensing Program Analyst (LPA), Nicole Strickland, met with Tiffany's Place Administrator (ADM), Rushel Brooks, to deliver the findings for the above stated allegations. LPA conducted an inspection of the facility on May 18, 2021 at approximately 4:00 pm and no immediate deficiencies were observed. The investigation was conducted by Special Investigator (SI) Lucius Charlemagne and LPA Strickland and included interviews with three of four foster children (Child #1 [C1], Child #2 [C2], and Child #4 [C4]), Probation Officer (PO) two current staff members (Staff #3 [S3], Staff #4 [S4]), five former staff member (Staff #2 [S2], Staff #5 [S5], Staff #6 [S6], Staff #7 [S7], and Staff #8 [S8]). Two confidential witnesses did not respond to SI and LPA's request for an interview and therefore were not interviewed. In addition, county records and facility records were reviewed. On May 12, 2021, Community Care Licensing (CCL) received an allegation alleging staff (Staff #1 [S1] and Staff #2 [S2]) negligence resulted in minors (Child #1 [C1] and Child #2 [C2]) consuming alcohol. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Nicole Strickland 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 08-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, FACILITY NAME: TIFFANY'S PLACEFACILITY NUMBER: VISIT DATE: 01/06/2022

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:


raw_content:
Narrative:
Confidential interviews reported that staff is following all proper protocols when dealing with the monitoring the minors. The interviews that were provided to the LPA were not consistent regarding the allegation of staff did not follow emergency intervention plan. Based on interviews and record reviews the staff did not follow emergency intervention plan, 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 provided to Carmen Powers.

Investigation Findings:
13On March 29, 2022 at 11:10 am, Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera conducted an unannounced inspection to the facility to deliver the findings of the above allegation. LPA met with program manager Carmen Powers. LPA Danielle Garcia conducted an inspection of the facility on November 04, 2021 at 09:30 am and no immediate deficiencies were observed. Three of three clients (C1, C2, C3), four staff and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that the facility did not prevent C1 from engaging in a physical altercation with adult #1 (A1). Confidential interviews reported that C1 saw A1 leaving in the vehicle and C1 ran towards A1's vehicle window and confronted A1 for making inappropriate comments about C1. Confidential interviews reported that A1 remained in the vehicle and A1 pushed C1 away from the window and C1 assaulted A1. Confidential interviews reported that staff immediately intervened, and law enforcement was contacted for assistance. Confidential staff interviews reported that C1 had previously picked up a pumpkin and placed back down from A1's property. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Darlene Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-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, FACILITY NAME: TIFFANY'S PLACEFACILITY NUMBER: VISIT DATE: 03/29/2022

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

met_with: Carmen Powers