summary: Facility Evaluation

raw_content:
Narrative:
On 08/28/2024 at 1:15 p.m., Licensing Program Analyst (LPA) Brenda Rodriguez conducted an announced visit to the licensed facility. The purpose of this visit was to conduct the SB Psychotropic Medications Inspection. LPA Rodriguez met with Terry Pace, Administrator. The facility currently has a census of two clients in care who meet the SB484 inspection criteria. At 2:55 p.m., LPA Rodriguez observed Cresenia Allen, Facility Manager to conduct a pill count of the psychotropic medications. LPA Rodriguez did not observe deficiencies with the pill counts. LPA observed that the medications were kept in a locked cabinet inside of a locked room. LPA Rodriguez received and reviewed four staff files. LPA Rodriguez found no deficiencies. LPA Rodriguez conducted two staff confidential interviews. The SB Psychotropic Medications Inspection is not currently finished, LPA Rodriguez will interview both clients at a later date and time. LPA Rodriguez conducted an exit interview with Terry Pace, Administrator at 3:20 p.m. The signature confirms the receipt of this document.


state: CA

facility_name: T&T HOUSE OF CHAMPIONS, INC

summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 9-13-24 10:30AM, Licensing Program Analysts George Karkazis conducted an unannounced Annual/Random inspection at listed facility. LPA met with Terry Pace, Administrator and toured the facility inside and out. The Short Term Therapeutic Program is licensed to serve 6 clients. Present during the inspection were 2 staff and 1 client. At 10:45AM LPA Karkazis reviewed client and staff files. During staff file review, S1 did not have LIC Health Screening Form. S1,S4,S5, did not have a current CPR Certificate. During client file review, C1 and C2 did not have updated needs and service plans. At 1:30PM, LPA Karkazis toured the facility. LPA Karkazis observed 3 bedrooms and 2 bathrooms. LPA observed facility license, personal rights, facility sketch, meal menu, and other forms posted on the walls throughout the facility. LPA Karkazis tested the water temperature and found it to be 110 degrees which is in range. The thermostat read 71 degrees which is within range. Sharps were locked and chemicals were safely stored. There were two days of perishable foods and seven days non-perishable foods present. The medication was also stored and locked in the locked office in a locked cabinet. The facility is in good repair and clean. LPA Karkazis interviewed 1 staff and no clients, client refused. At 2:00PM LPA Karkazis toured the backyard. There were no open bodies of water. The backyard was in good repair and clean. continued on LIC 809-C continued from LIC The facility is being cited for California Code of Regulations 80066(a)(10) Health Screening, Interim Licensing Standards 87065.1(d)(6) Supervision, Evaluation, and Training Requirements (CPR), and Interim Licensing Standards 87068.3(a) Modification To Needs and Service Plans. An exit interview was conducted, appeal rights discussed/provided and a copy of this report was given to Terry Pace, Administrator.

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

(a) The needs and services plan as described Sections 87068.2 and 87068.22, shall be updated at least every 30 days to determine the following

report_type: Facility Evaluation

visit_type: Annual

met_with: Terry Pace, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 9-13-24 2:45PM, Licensing Program Analyst (LPA) George Karkazis conducted an unannounced Case Management /Non-Compliance Conference (NCC) inspection at T&T House of Champions, and met with Terry Pace, Facility Administrator. On 6-30-23, Community Care Licensing held a Non-Compliance Conference. The purpose of the inspection was to review the progress of the facility since the facility had their NCC. The facility will be on NCC until 11-30-25. Inspections shall occur quarterly. The following conditions were stated and discussed during today's inspection and also during the NCC. There was no client present and three staff present during the inspection. Licensee agrees to do the following in order to bring the facility into compliance: 1. CRIMINAL RECORD CLEARANCE Ensure that all employees are fingerprint cleared, ( "Eligible Clearance", in Guardian ) no exceptions, before they begin employment at the facility. The facility to submit LIC 500 quarterly, starting 5-1-2023. LPA checked current LIC 500 against Guardian Roster. All staff have fingerprint clearance as of 9-13-24, updated LIC 500 provided. 2. SUPERVISION REQUIREMENTS Facility Manager shall be present on site at all times when Facility Administrator is not present. Staffing levels shall be maintained at 1:3 ratio, and increased based on clients' needs, in order to maintain client/staff safety as needed. A safety plan was implemented for a client with risky behavior until his departure. Plan has been received and is on file, LIC 500 indicates one facility manager on duty at all shifts and one direct care staff, except for overnight shift. 3. TRAINING REQUIREMENTS Quarterly training to begin June 1, 2023. in the following areas: trauma informed de-escalation techniques, restraint holds such as CPI or ProAct. . Quarterly training to be conducted by an outside company and not the Licensee. Training documents readily available on request by CCL. LPA observed training: continued on LIC 809-C continued from LIC Complex Trauma and Behaviors 5-30-24, Medication and MARS 6-9-24, Effective Communication 6-6-24, Active Listeninig 7-9-24, Trauma Informed Approach 7-11- PT1, Trauma Informed Approach 8-11- PT2, 8-8-24. 4. PROGRAM STATEMENT/PLAN OF OPERATION/ TO SUBMIT UPDATES Licensee shall update the Emergency Intervention Plan (EIP) within the T&T House of Champions Program Statement, and to include when to call 911 for assistance policy. Also, update all areas in PS/POO to reflect version 4 of PS/POO. Submitted and on file. Administrator Terry Pace sent LPA ILS 5 updates to LPA May 2024, on file. 5. STAFF SELECTION REQUIREMENTS Facility to create a plan to enhance screening process to hire employees to include: checking references, use of LIC Form, create a questionnaire that checks the interactions with clients, staff, work performance, create work simulation questions during interview process. Terry Pace has created an assessment sheet for the interview. They are simulation based questions, such as: What if a client calls swears at you and calls you a name? How do you handle it? If a client is breaking a house rule, how do you handle it? If a client doesn't want to go to school because they have no clean clothes, how do you handle it. What do you do if a client becomes violent and destroys property and is a danger to self and others? Terry Pace provided a copy of the simulation sheet. 6. INSPECTIONS The facility is subject to increased unannounced inspections to ensure compliance. 7. TSP Referral Used the service prior, T&T continues their improvements. The facility is clean and in good repair.

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
On 11-22-24 1:31PM, Licensing Program Analyst (LPA) George Karkazis conducted an unannounced Case Management /Non-Compliance Conference (NCC) inspection at T&T House of Champions, and met with Terry Pace, Facility Administrator. On 6-30-23, Community Care Licensing held a Non-Compliance Conference. The purpose of the inspection was to review the progress of the facility since the facility had their NCC. The facility will be on NCC until 11-30-25. Inspections shall occur quarterly. The following conditions were stated and discussed during today's inspection and also during the NCC. There was one client present and two staff present during the inspection. Licensee agrees to do the following in order to bring the facility into compliance: 1. CRIMINAL RECORD CLEARANCE Ensure that all employees are fingerprint cleared, ( "Eligible Clearance", in Guardian ) no exceptions, before they begin employment at the facility. The facility to submit LIC 500 quarterly, starting 5-1-2023. LPA checked current LIC 500 against Guardian Roster. All staff have fingerprint clearance as of 11-22-24, updated LIC 500 provided. 2. SUPERVISION REQUIREMENTS Facility Manager shall be present on site at all times when Facility Administrator is not present. Staffing levels shall be maintained at 1:3 ratio, and increased based on clients' needs, in order to maintain client/staff safety as needed. A safety plan was implemented for a client with risky behavior until his departure. Plan has been received and is on file, LIC 500 indicates one facility manager on duty at all shifts and one direct care staff, except for overnight shift, as of 11-22-24. 3. TRAINING REQUIREMENTS Quarterly training to begin June 1, 2023. in the following areas: trauma informed de-escalation techniques, restraint holds such as CPI or ProAct. . Quarterly training to be conducted by an outside company and not the Licensee. Training documents readily available on request by CCL. Continued on LIC 812-C continued from LIC LPA observed training: 10-17-24, Training on MARS, Reporting Requirements for Incident Reports-created scenarios when and how to report. Program Notes and STRTP Training Notes. 10-18- Behavioral Training/Violence in the Workplace. 4. PROGRAM STATEMENT/PLAN OF OPERATION/ TO SUBMIT UPDATES Licensee shall update the Emergency Intervention Plan (EIP) within the T&T House of Champions Program Statement, and to include when to call 911 for assistance policy. Also, update all areas in PS/POO to reflect version 4 of PS/POO. Submitted and on file. Administrator Terry Pace sent LPA ILS 5 updates to LPA May 2024, on file. 5. STAFF SELECTION REQUIREMENTS Facility to create a plan to enhance screening process to hire employees to include: checking references, use of LIC Form, create a questionnaire that checks the interactions with clients, staff, work performance, create work simulation questions during interview process. Terry Pace has created an assessment sheet for the interview. They are simulation based questions, such as: What if a client calls swears at you and calls you a name? How do you handle it? If a client is breaking a house rule, how do you handle it? If a client doesn't want to go to school because they have no clean clothes, how do you handle it. What do you do if a client becomes violent and destroys property and is a danger to self and others? Terry Pace provided a copy of the simulation sheet. Terry Pace hired a new clinician Francisco Bautista and Facility Manager Ronald Bernstien. Terry Pace stated that scenario based interview questions have helped in the hiring process, getting a better understanding of how prospective employees will react in situations. 6. INSPECTIONS The facility is subject to increased unannounced inspections to ensure compliance. 7. TSP Referral Used the service prior. Terry Pace stated that they are more selective in staff they choose to hire, and research the candidates further, making operations smoother. Terry Pace also stated that they will gather as much information on a perspective client, making sure the placement is mutually beneficial.


summary: Facility Evaluation

raw_content:
Narrative:
On 2-25-25 1:15PM, Licensing Program Analyst (LPA) George Karkazis conducted an unannounced Case Management /Non-Compliance Conference (NCC) inspection at T&T House of Champions, and met with Terry Pace, Facility Administrator. On 6-30-23, Community Care Licensing held a Non-Compliance Conference. The purpose of the inspection was to review the progress of the facility since the facility had their NCC. The facility will be on NCC until 2-25-25. The following conditions were stated and discussed during today's inspection and also during the NCC. There were no client presents and one staff present during the inspection. 1. CRIMINAL RECORD CLEARANCE Ensure that all employees are fingerprint cleared, ( "Eligible Clearance", in Guardian ) no exceptions, before they begin employment at the facility. The facility to submit LIC 500 quarterly, starting 5-1-2023. LPA checked current LIC 500 against Guardian Roster. All staff have fingerprint clearance as of 2-25-25, updated LIC 500 provided. This condition has been met and fulfilled. 2. SUPERVISION REQUIREMENTS Facility Manager shall be present on site at all times when Facility Administrator is not present. Staffing levels shall be maintained at 1:3 ratio, and increased based on clients' needs, in order to maintain client/staff safety as needed. A safety plan was implemented for a client with risky behavior until his departure. Plan has been received and is on file, LIC 500 indicates one facility manager on duty at all shifts and one direct care staff, except for overnight shift, as of 2-25-25. This condition has been met and fulfilled. 3. TRAINING REQUIREMENTS Quarterly training to begin June 1, 2023. in the following areas: trauma informed de-escalation techniques, restraint holds such as CPI or ProAct. . Quarterly training to be conducted by an outside company and not the Licensee. Training documents readily available on request by CCL. Continued on LIC 812-C continued from LIC LPA observed training: Child and Adolescent Development / Program Structure, conducted 1-2-25. Terry Pace stated that on 2-26-25 will conduct Supervision & De-Escalation Tactics. This condition has been met and fulfilled. 4. PROGRAM STATEMENT/PLAN OF OPERATION/ TO SUBMIT UPDATES Licensee shall update the Emergency Intervention Plan (EIP) within the T&T House of Champions Program Statement, and to include when to call 911 for assistance policy. Also, update all areas in PS/POO to reflect version 4 of PS/POO. Submitted and on file. Administrator Terry Pace sent LPA ILS 5 updates to LPA May 2024, on file. This condition has been met and fulfilled. 5. STAFF SELECTION REQUIREMENTS Facility to create a plan to enhance screening process to hire employees to include: checking references, use of LIC Form, create a questionnaire that checks the interactions with clients, staff, work performance, create work simulation questions during interview process. Terry Pace has created an assessment sheet for the interview. They are simulation based questions, such as: What if a client calls swears at you and calls you a name? How do you handle it? If a client is breaking a house rule, how do you handle it? If a client doesn't want to go to school because they have no clean clothes, how do you handle it. What do you do if a client becomes violent and destroys property and is a danger to self and others? Terry Pace provided a copy of the simulation sheet. LPA asked Terry Pace about her success with staff and she attributes her success to weekly 1:1 chats with her employees. They discuss current issues with clients, how to handle and de-escalate. Increased staffing levels helps to better serve clients and staff interactions. This condition has been met and fulfilled. 6. INSPECTION The facility will no longer be subject to quarterly NCC Inspections. 7. TSP Referral Adminstrator Terry Pace's success is based on the use of the TSP Program. The TSP taught Terry Pace to be more selective in choosing staff and clients, and how to better adhere to regulations. The facility has met all conditions of the Non-Compliance Conference which started on 6-30-23. Quarterly inspections shall cease, and T&T House of Champions is no longer on Non-Compliance as of 2-25-25.


summary: Facility Evaluation

raw_content:
Narrative:
On 7/17/25 at 10:10 am, an unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Celeste Aparicio and Cole Oliver. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Aparicio and Oliver met with Cresensia Allen, Head of Service. No clients were present during the inspection. LPAs Aparicio and Oliver inspected facility inside and out. LPAs reviewed 2 client files on site at the facility. LPAs interviewed 0 clients. LPAs will conduct client interviews at another time when clients are available. LPAs reviewed 5 staff personnel files on site at the facility. LPA interviewed 1 of staff on site to discuss the facilities policies and procedures of operation. At 12:48 p.m., LPAs Aparicio and Oliver observed Cresenia Allen, Head of Service to conduct a pill count of the psychotropic medications. LPAs did not observe deficiencies with the pill counts. No deficiencies are being cited at this time. LPA conducted exit interview and provided a copy of this report to Cresensia Allen, Head of Service whose signature confirms receipt.

met_with: Cresensia Allen, Head of Service


summary: Facility Evaluation

raw_content:
Narrative:
On 7/23/25, an unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Celeste Aparicio. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Aparicio met with Cresensia Allen, Head of Service. The purpose of this inspection was to complete client interviews. At the time of the inspection, two clients were in care at the facility. LPA conducted 2 client interviews. No deficiencies are being cited at this time. LPA conducted exit interview and provided a copy of this report to Cresensia Allen, Head of Service whose signature confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 8/6/25, Licensing Program Analyst (LPA) Celeste Aparicio made an announced collateral visit to the facility to conduct a confidential interview. LPA met with Cresensia Allen, Head of Service and informed the Head of Service on the purpose of the visit. During the inspection, LPA conducted one client confidential interview related to an outside investigation. An exit interview was conducted, and a copy of this report was left with the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On 08/27/2025, 10: AM, Licensing Program Analysts (LPA) Cole Oliver and Simran Nayyar made an unannounced visit to the agency to LPA Oliver met with Head of Service, Cresensia Allen and informed them of the purpose of the visit. LPAs toured the facility. During the visit LPA Oliver cleared a Plan Of Corrections (POCs) that was created 08/12/2025 and due by 08/29/25. Cresensia Allen provided LPAs documentation that clears the POCs. An exit interview was conducted, appeal rights discussed, and a copy of this report was left with Head of Service, Cresensia Allen whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 6/27/22 at 12: PM, Licensing Program Analysts (LPA) Alyssa Ng and George Karkazis conducted an unannounced case management inspection at T&T House of Champions and spoke with Tracy Rawlins, Facility Manager. The purpose of the inspection was to follow up on an incident involving sexual interactions between two clients and the use of restraints. LPA Ng received a completed report from Investigations Branch (IB) regarding complaint # 14-CR-20220214120547. After reviewing the report, C2 and C3 disclosed a sexual interaction they had when a staff member went to the bathroom for 10-15 minutes. When IB reviewed camera footage, it shows that the staff was in the office from 1801 hours to 1959 hours talking on the phone. During confidential interviews conducted by IB, it was reported that staff would use improper restraints during escalated incidents. Based on a review of the facilities Program Statement under Precautions To Protect Child Or NMD And Others, it says, T&T utilizes restraints as a last resort. All staff are trained in CPI, in the event that youth is an immediate danger to self and others, and all de-escalation strategies did not work, then staff will engage in restraint procedures. FM stated that they had a recent training in regards to restraints. They watched videos, shared methods on effective ways to de-escalate youth before using restraint as their resort, and safety precautions. LPA Ng requested training to be sent by July 4th at 4: PM. Facility cited for violation of California Code of Regulations, Title 22, Division Six, Section 80078(a) Responsibility for providing care and supervision. One deficiency was cited. An exit interview was conducted, appeal rights provided, and sent to Tracy Rawlins, Facility Manager.

met_with: Tracy Rawlins


summary: Facility Evaluation

raw_content:
Narrative:
On 9-13-22 3: PM, Licensing Program Analysts George Karkazis and Alyssa Ng conducted an unannounced case management inspection. The purpose of the inspection was to obtain information regarding an incident that occurred on 8-17-22. Safety precautions were taken such as mask wearing and temperature checks. Present during the inspection were two clients and three staff. The reporting party stated that a staff worker came into the facility with a bottle of alcohol in her purse and was found to be under the influence LPA Karkazis toured the facility at 3: PM and found the facility to be in good repair and clean. Confidential interviews were conducted with 2 staff and 1 client. Facility is being cited for violation of California Code of Regulations (CCR): 807072 (c)(11) Personal Rights. Upon checking Guardian Roster, it was discovered that a staff worker present during the time did not have criminal background clearance. A Civil Penalty was assessed and the facility was cited for Title 22, Division 6, Chapter 1, Article 3, Section 80019(e)(1) Criminal Background Clearance. At this time, two deficiencies were cited today. A exit interview was conducted, appeal rights given, and a copy of this report was given to Terry Pace, Administrator.

met_with: Terry Pace, Facility Administrator


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 9/12/2023, at 11:00AM, Licensing Program Analyst (LPA) Alyssa Ng conducted an unannounced Psychotropic Medication Inspection to the listed facility. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Ng met with Terry Pace, Administrator. The facility currently has four clients. Of the four clients, three clients meets the criteria of foster youth currently prescribed psychotropic medications. LPA reviewed the medication, centrally stored medication log including the Medication Administration Record and Psychotropic Medication Administration Record. LPA interviewed three staff members on site to discuss the facility's policies and procedures of operation. Facility cited for Interim Licensing Standards 87068.3(a) Modifications to the Needs and Service Plan, Children's Records, and California Code of Regulations Health Related Services . At this time, three deficiencies were cited. LPA did not conduct any client interviews or review staff training. LPA Ng will come back on a later date. LPA conducted exit interview with Terry Pace, Administrator, at 6: PM whose signature confirms the receipt of this document.

Deficiencies:
87070: (13)A separate log for each psychotropic medication prescribed to a child documenting all of the following..

met_with: Terry Pace

title: Childrens Records


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
"Unauthorized staff are transporting the clients in care" which violates Interim Licensing Standards Article 06. Section Transportation (e). LPA Oliver discussed with the program manager, Stevonna "Stevi" Gordon that all staff needed to be fully cleared on Guardian before employees could work with the clients in care. LPA discussed the resources available and provided the resources to the program manager. LPA is issuing two type A citations; California Code of Regulations (CCR), Title 22, Section 80019 (e)(2) Criminal Record Clearance and Interim Licensing Standards Article 06. Section Transportation (e) (Refer to LIC9099-D) Additionally, as mandated in Section 80019, LPA is assessing an immediate civil penalty of $100 for a maximum of 5 days in violation, in which staff worked on site, for a total of $500. LPA print and complete the LIC 421BG and provide a copy to Facility Manager, Stevi Gordon. An exit interview was conducted, appeal rights were discussed, and a copy of this report was printed and left with Facility Manager, Stevi Gordon. Whose signature confirms receipt.

Investigation Findings:
13On 02/04/2026 at 10: AM, Licensing Program Analyst (LPA) Cole Oliver initiated a complaint investigation at the facility. The LPA met with Program Manager, Stevonna "Stevi" Gordon to inform them of the purpose of the visit. The LPA conducted a walkthrough of the facility inside and outside. During the visit, there were one (1) staff members, and two (2) clients present at the facility. Based on LPA's confidential interviews, observations, and record review, during the visit. The preponderance of evidence standard has been met. Therefore, the following allegations are found to be substantiated: "Uncleared staff are working in the facility" which violates California Code of Regulations (CCR), Title 22, Section 80019 (e)(2) Criminal Record Clearance. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Benjiman Oliver LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN JOSE RO, N. First Street, Ste. FACILITY NAME: T&T HOUSE OF CHAMPIONS, INCFACILITY NUMBER: VISIT DATE: 02/04/2026

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

report_type: Complaint Investigation

met_with: Program Manager, Stevonna Gordon

complaint_status: SUBSTANTIATED


summary: Facility Evaluation

raw_content:
Narrative:
On February 19, 2026, Licensing Program Analyst (LPA) Celeste Aparicio conducted an unannounced complaint inspection and met with Administrator, Terry Pace. The purpose of the inspection was to deliver findings related to the complaint investigation. During the inspection there were no clients and two staff present in the facility. During the course of an investigation, LPA Aparicio conducted a comprehensive review of the facility's records. Based on this review, it was determined that the facility does not document clients' dietary restrictions within their Needs and Services Plans. As a result, LPA Aparicio issued a Technical Violation pursuant to STRTP Interim Licensing Standards (ILS), Section 87076(d), Food Service. The facility was advised to ensure that any special dietary needs or practices recommended by a child's physician are clearly documented in the client's Needs and Services Plan moving forward. An exit interview was conducted, and a copy of the report was given to the facility.

met_with: Administrator, Terry Pace and Program Manager, Stevonna 'Stevie' Gordon


summary: Complaint Investigation - Unsubstantiated - 3 allegations

raw_content:
Narrative:
is unsubstantiated, and no Title 22 deficiencies were observed. An exit interview was conducted, appeal rights were discussed with Facility Manager Erasmo Ortiz whose signature confirms receipt. A copy of this report was emailed to Administrator Terry Pace, and Program Manager Stevonna "Stevi" Gordon.

Investigation Findings:
UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion: 0

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0

met_with: Facility Manager, Erasmo Ortiz

complaint_status: unsubstantiated


raw_content:
Narrative:
are UNSUBSTANTIATED, and no Title 22 deficiencies were observed. An exit interview was conducted. Appeal rights were discussed, and a copy of the report was provided to Program Manager Stevi Gordon, whose signature confirms receipt.

Investigation Findings:
UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion: 0

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0

met_with: Administrator, Terry Pace


summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13On February 19, 2026, Licensing Program Analyst (LPA) Celeste Aparicio conducted an unannounced complaint inspection and met with Administrator, Terry Pace. The purpose of the inspection was to deliver findings related to the complaint investigation. During the inspection there were no clients and two staff present in the facility. Regarding the allegation that staff threatened minor, LPA Aparicio conducted confidential interviews and reviewed available documentation. Due to inconsistencies in interview statements, discrepancies noted during the records review, the absence of witnesses, and the lack of available camera footage, the LPA was unable to determine whether staff threatened the minor. Although the allegation may have happened or is valid, based on LPA's observations, interviews, and record review, there is not a preponderance of the evidence to prove the alleged violation did or did not occur. Therefore, the allegation is found to be unsubstantiated. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Celeste Aparicio LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2


summary: Facility Evaluation

raw_content:
Narrative:
On March 19, 2026, Licensing Program Analyst (LPA) Cole Oliver conducted an unannounced case management visit and met with Senior Facility Manager Tracy Rawlins. The purpose of the visit was to issue a deficiency for late Incident Reports (IR) received by the Department. LPA Oliver toured the facility, both inside and outside. At the time of the inspection, no clients were present, and two (2) staff members were on site. The facility received an email from LPA Oliver on March 4, 2026, reminding the facility that incident reports must be submitted within seven days of the incident. On March 13, 2026, LPA Oliver received two late incident reports from the facility. Additional details (Refer to LIC812) As a result of this visit, LPA Oliver issued one Type B deficiency pursuant to the California Code of Regulations (CCR), Title 22, Division 6, Chapter 1, Article 06, Section 80061(b), Reporting Requirements. (Refer to LIC809-D) An exit interview was conducted, and a copy of the report was provided to MHRS, Dannika Carroll whose signature confirms receipt.

met_with: Senior Facility Manager, Tracy Rawlins


summary: Facility Evaluation

raw_content:
Narrative:
On 04/16/2026, 10: AM Licensing Program Analysts (LPA) Cole Oliver and Simran Nayyar conducted an unannounced case management visit to the facility. The purpose of this inspection is to conduct a case management regarding review of the facilities program statement and emails from the facility received by LPA Oliver. LPA met with Erasmo Ortiz, Facility Manager and explained the purpose of the visit. The LPA conducted a physical plant at the facility. During the visit, there was two (2) staff member, and one (1) client present at the facility. The facility had informed LPA Oliver on 01/07/2026 that cameras in the facility have been set to record continuously in all common areas of the home via email. The facilities Program Statement and Plan of Operations does not mention the use of cameras in the facility. During the visit LPA Oliver observed cameras in the facility. LPA issued one Type B deficiency under California Code of Regulation (CCR) Section - Plan of Operation 80022(k). (Refer to LIC809-D) (Cont. on LIC809-C) Addition details (Refer to LIC812) LPA conducted an exit interview; LPAs provided a copy of this report to Stevonna Gordon, Program Manager whose signature confirms receipt.

met_with: Erasmo Ortiz


facility_name: UNICORN GARDEN #1

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
It was alleged that a facility staff kicked a client resulting in an injury. Confidential information obtained did not corroborate the allegation. Confidential information obtained indicated that the allegation was later denied, and there were no witnesses to the alleged incident. The facility staff, Reference #1, who allegedly hit the client denied the allegation. Other staff indicated that they have never witnessed Reference #1 hit any of the clients. Other staff also denied ever hitting any of the clients or witnessing other staff hit clients. Based on the information gathered, although the allegation may have happened or is valid, the preponderance of evidence to prove the allegation was not met, therefore the allegation is unsubstantiated. A copy of this report, Confidential Names Form and Appeal Rights were provided to the facility representative. There were no deficiencies cited during this inspection.

Investigation Findings:
13On August 5, 2021 at 11: AM, Licensing Program Analyst (LPA) Joshua Rarela conducted a follow-up inspection to deliver the findings of a complaint investigation concerning the allegation above. LPA Rarela discussed the findings with the facility representative named above. During the course of the investigation, LPA Rarela contacted the complainant on 2/4/21, the placing agency social worker on 2/4/21, facility administrator on 2/4/21, and facility staff on 8/5/21 (see Confidential Names Form dated August 5, 2021). LPA also reviewed documents on 2/4/21 and 8/4/21 including the Placing Agency Records, Staff Job Duty Statement, Facility Client Roster and School Information, and Facility Client's Needs and Services Plan child's Needs and Services Plan. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Joshua Rarela LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: UNICORN GARDEN #1FACILITY NUMBER: VISIT DATE: 08/05/2021

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

met_with: Kristina Villalpando, Manager


raw_content:
Narrative:
Confidential statements obtained during the investigation were unable to corroborate the allegations as there were no statements obtained to support the allegations. Facility staff denied the allegations. A tour of the facility showed that facility clients had ample supply of clothes in their bedrooms and closets. Based on the information gathered, the allegations are unsubstantiated as the preponderance of evidence to prove the allegations was not met even though the allegations may be valid. A copy of this report, Confidential Names Form and Appeal Rights were provided to the facility representative. There were no deficiencies cited during this inspection.

Investigation Findings:
13On December 15, 2021 at 12: PM, Licensing Program Analyst (LPA) Joshua Rarela conducted a follow-up inspection to deliver the findings of a complaint investigation concerning the allegations above. The complaint was investigated LPA Rarela. LPA Rarela discussed the findings with the facility representative named above. During the course of the investigation, LPA Rarela interviewed facility staff and facility clients on 12/15/21 (see Confidential Names Form dated December 15, 2021). LPA Rarela also reviewed documents on 12/14/21 including placing agency records and service logs. It was alleged that staff failed to provide medications for a client during an overnight visit, a facility client was left alone at the facility without staff supervision, and a facility client did not have clothing that fit him. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Joshua Rarela LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: UNICORN GARDEN #1FACILITY NUMBER: VISIT DATE: 12/15/2021

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

met_with: Paul Crews, Program Director


raw_content:
Narrative:
Additionally, the clients were unable to provide supportive documentation to support that they complained to anyone and clients denied ever observing anyone being mishandled while in a restraint. Interviews conducted with another client had similar statements of an incident occurring where they observed a child being restrained by staff. However, this third client was unable to specify the details of why staff restrained the client or if client was in distress based on the restraint. Another client stated that one staff did grab and restrained them till the point of almost breaking their arm. Client identified two staff members who conducted the restraint; however, client was unable to provide any witnesses that could attest to how the staff handled them during the restraint or when it specifically happened. Staff stated that multiple incidents have occurred with one client where client was having an issue of acting out causing harm to others and client was not listening to staff's redirection. Staff had similar recollections in stating that in these incidents that occurred client was restrained with their arms placed behind their back and staff asked client if they had calmed, client stated they had calmed so staff released them from the hold. However, staff stated once client was released client started attacking staff again. Client was placed back in the same restrained position until client in fact was calmed down. Staff stated client was checked over and did not express any discomfort or present with any injury. Staff stated that when clients are acting out in self injurious or harmful behaviors to others, they do place clients in restrained positions of holding the client's arms behind their back till they are calmed and listening for redirection. However, staff denied twisting a client's arm to the point of breaking or almost breaking client's arm. Staff had similar statements in that if a client calls out in distress of any sort during the restrained period staff release the client. Staff further stated that they consistently ask client if they have calmed to release them from the restrained position. LPA reviewed incident reports and supportive documents provided by facility and no complaints were made or incidents documented where a client was taken to the hospital for injuries after being placed in a restraint. LPA was unable to contact county social worker, but no documents identified a problem with clients placed in the home or facility staff. Based on the information gathered, although the allegation may have happened or is valid, the preponderance of evidence to prove the allegation was not met, therefore the allegation is unsubstantiated. An exit interview was conducted. A copy of this report Confidential Names Form, and Appeal Rights were provided to the facility representative. There were no deficiencies cited during this inspection.

Investigation Findings:
13On 03/30/ Licensing Program Analyst (LPA) Claudia Portillo made an announced visit to the Unicorn Garden 1 facility on behalf of LPA Dawn Mahecha to deliver the findings to the above identified complaint investigation. LPA Portillo spoke with Administrator (NAME) and informed Administrator of investigative findings. Investigation consisted of the following: On 12/20/ LPA Janeth Chavez conducted 10-day inspection to facility (see LIC 811 confidential names, dated December 20, 2021). Between 2/22/22 and 3/9/ LPA Elnora Smith interviewed four (4) children and five (5) staff. Additionally, LPA attempted to contact social workers and additional staff. On 2/23/ LPA reviewed documents received and on 3/10/ LPA Mahecha reviewed interviews and information provided. Investigation revealed the following: It was alleged that facility staff twisted a client's arm. Interviews conducted with two clients were unclear as they were unable to provide a specific date, week, or time of occurrence of a child being mishandled by staff. (continued on page 2) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Claudia Portillo LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: UNICORN GARDEN #1FACILITY NUMBER: VISIT DATE: 03/30/2022

met_with: Ranice Dodson, Facility Manager


raw_content:
Narrative:
It was alleged that C1 was hit, handled in a rough manner, and spoken to inappropriately by S2 during an alleged physical altercation. Information obtained from confidential interviews with the above individuals revealed that an incident did occur involving S2 and C1. S2 denied the alleged allegations stating that C1 was questioned regarding C1's soiled garments and the feces left in the washer. S2 indicated that C1 was verbally redirected to C1's room after being belligerent and giving S2 the middle finger. S2 indicated that C1 walked towards the room and started breaking items in the room and attempted to stab S2 with a pencil. S2 further indicated that a standing MAB hold was attempted however C1 dropped to the floor and at this point, S2 was replaced by S3 to de-escalate the situation. Information obtained from S3 and S4 indicated that C1 has behavioral and defiant difficulties, which are addressed via a plan to assist C1 with finding alternative ways to self-deescalate. S1 denied the allegations further stating that the information reported to the hotline by (S1) was not accurately documented by the screener due to having S2 as the aggressor and punching C1 which is not accurate. S2 provided LPA with several SIR's involving C1 and notating aggressive behavior, as well as a letter from the Head of Services to the Department of Human Services, expressing concerns due to C1's conduct and its effect on staff and other residents' safety. Information obtained from C2, C3, and C4 denied the alleged allegation indicating that C1 was the aggressor. During interviews with C2, C3, and C4, it was further disclosed that staff are very professional with them and provides whatever is needed. Therefore, based on the information received, the above allegations are determined to be unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the allegations are found to be unsubstantiated. Appeal Rights were provided and discussed with the Facility Representative. There are no deficiencies to be cited at this time. An exit interview was conducted and a copy of the report along with the (LIC 811) was left with the Facility Representative.

Investigation Findings:
13On September 23, 2022, at 12: PM, Licensing Program Analyst (LPA), Karen McGee, delivered the findings of a Complaint investigation conducted by LPA Winston Moroney. The LPA met with Direct Care Staff, Deborah Jackson. On March 23, 2022, the California Department of Social Services Community Care Licensing Division received a complaint from Centralized Complaint and Information Bureau (CCIB) with the following allegations: Staff hit minor while in care; Staff handled minor in a rough manner; Staff spoke to minor in an inappropriate manner. The investigation of the above allegations was conducted by this LPA and it consisted of, but was not limited to a review of records, including the client's needs and services plans, medical records, and interviews with four staff members (S1, S3, S4) on 3/30/22, S4 on 4/21/22, and two clients (C2, C3,) on 3/30/22. LPA was unable to obtain a statement from C1 due to being removed by Law Enforcement on day of initial visit.. (Reference Confidential Names Form LIC 811, dated September 12, 2022). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Karen McGee LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: UNICORN GARDEN #1FACILITY NUMBER: VISIT DATE: 09/23/2022

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

met_with: Deborah Jackson


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
Based on information obtained from interviews conducted and records reviewed the allegation was Substantiated. C1's personal rights were not afforded as required by the Interim Licensing Standards (ILS) Ver. 3. Sec. 87072(d)(11). The allegation is valid because the standard of the preponderance of evidence has been met. Facility cited for violation of Interim Licensing Standards (ILS) Ver. 3. Sec. 87072(d)(11): Personal Rights. Statements obtained from interviews conducted corroborated the allegation that a staff mishandled a minor in care. An exit interview was conducted, and a signed copy of this report was provided to the facility licensee along with LIC9099C, LIC9099D, and LIC811. Appeal rights explained.

Investigation Findings:
On 07/11/25, Licensing Program Analyst (LPA) Angelina Garibaldo conducted a follow up complaint inspection and met with Kim Hudnall,Administrator. The purpose of the inspection was to deliver findings for the above-mentioned complaint allegation. During the course of the investigation LPA Garibaldo conducted a records review on 3/25/21 and obtained staff contact information, special incident reports, and clients' needs and services plans. LPA Garibaldo conducted interviews with two facility staff and three clients on 5/14/25, one staff and County Social Worker on 6/9/25, and one Staff on 7/9/25. (Reference Confidential Names list LIC811 dated 7/11/25). It was reported S1 mishandled C1 by physically picking C1 up and bringing back to the facility while C1 was attempting to AWOL. S1 denied physically picking up C1 but admitted he grabbed C1 by the arm and brought him back to the facility. Statements obtained from interviews conducted with clients collaborated the allegation. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Angelina Garibaldo LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: UNICORN GARDEN #1FACILITY NUMBER: VISIT DATE: 07/11/2025

met_with: Kim Hudnall - Administrator


raw_content:
Narrative:
The staff members (S1, S2, and S3) refuted the allegations, asserting that all staff members are trained in trauma-informed care and have completed a sixteen-hour course on the Management of Assaultive Behavior (MAB) focused on crisis negotiation and intervention. The staff indicated that the facility is hands-off and will only use MAB intervention to prevent clients from self-harming or to prevent bodily injuries to others. The staff further disclosed that on the day of the alleged incident, S2 did restrain C1 from behind due to C1 attempting to strike S1 in the face with a closed fist, and in doing so, slipped and fell to the ground with C1. S2 noted that they remained on the floor for no more than ten to fifteen seconds before S1 assisted them in getting back on their feet and escorted C1 to their room without further incident. S2 indicated that no injuries were sustained, and the incident was reported promptly to all supporting agencies. The statement received from C1 revealed that they became aggressive towards the staff and tried to hit S1 in the face with a closed fist after being instructed to return to their room because of their inappropriate conduct at school. C1 denied sustaining any injuries during the incident and subsequently retracted the allegations during the interview. Information gathered from C2 and C3 confirmed that they were present during the incident and corroborated the details provided by the staff. C1, C2, and C3 expressed that they feel safe living in the facility and believe that the staff is helping them achieve their personalized plans. Additionally, CSW1 mentioned that the facility staff are highly attentive and supportive, frequently communicating with them about matters concerning C1. CSW1 further disclosed that they have no concerns regarding the care and supervision provided by the facility staff for their client. Therefore, based on the information received, the above allegation(s) is determined to be unsubstantiated. Although the allegation(s) may have happened are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the allegations are found to be unsubstantiated. Appeal Rights were provided and discussed with the STRTP Administrator. There are no deficiencies to be cited at this time. An exit interview was conducted and a copy of the report along with the (LIC 811) was left with the STRTP Facility Administrator.

Investigation Findings:
13On July 30, 2024, at 11: AM, Licensing Program Analyst (LPA) Winston Moroney conducted a complaint inspection at the above Short-Term Residential Therapeutic Program (STRTP) and met with Kim Hudnall. The inspection aimed to deliver the finding(s) regarding the complaint allegation(s). On April 24, 2025, the Community Care Licensing Division of the California Department of Social Services received a complaint from the Centralized Complaint and Information Bureau (CCIB) with the following allegation(s): The staff member handled a minor in care in a rough manner; The staff members caused injury to a minor in care. This LPA conducted the investigation of the above allegation(s) and it consisted of but was not limited to a review of records, including the client's needs and services plans, medical records, and interviews with three staff members (S2) on 4/29/25, S3 on 5/6/25, (S1) on 5/23/25, 3 of 4 clients (C1, C2 and C3) on 4/29/25, and one Kern County Social Worker (CSW1) on 4/25/225. C4 chose not to participate in an interview, thus no statement was acquired from them. (Reference Confidential Names Form LIC 811, dated July 30, 2025). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Winston Moroney LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: UNICORN GARDEN #1FACILITY NUMBER: VISIT DATE: 07/30/2025

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

met_with: Kim Hudnall


summary: Facility Evaluation

raw_content:
Narrative:
On June 2, 2021 at 09: AM, Licensing Program Analysts (LPAs) Claudia Portillo and Jenny Mundo conducted a Case Management (SB Psychotropic Medications) tele-inspection of the facility via Microsoft Teams Meeting app. Remote "tele-inspections" of facilities are a part of Community Care Licensing Division's emergency response to the spread of Coronavirus Disease 2019 (COVID-19). During this tele-inspection, LPAs spoke with Kim Hundnall, Executive Director/Administrator, Paul Crews, Program Director/Administrator and Rosemary England, Facility Manager/Rehab Specialist. All pertinent staff and client records were scanned and emailed to LPA Portillo prior to the tele-inspection. LPA Portillo reviewed the facility's Plan of Operation on 5/19/2021. Four clients at the facility take psychotropic medications. LPA Portillo reviewed 1 staff record and 3 client records, LPA Mundo reviewed 2 staff and 1 client records prior to the tele- inspection and continued review of records during the tele-inspection to obtain and/or clarify missing information. LPAs conducted a facility tour with Paul Crews at 09: AM. LPA Portillo and LPA Mundo inspected medications at 09: AM. LPA Portillo interviewed 1 staff member at approximately 7: AM and 2ND staff member at 11: AM LPA Portillo interviewed 1 client at 1:30 and another client at 1: PM. LPA Mundo interviewed 1 client at 2: PM, 2nd client at 3: PM and 1 staff member at 3: PM. LPA provided Advisory Notes - Technical Assistance to the licensee. There were no deficiencies issued during the tele-inspection. LPA conducted an exit interview with Kim Hundnall 4: PM. A copy of this licensing report was provided to the facility via email on 06/02/21 along with Confidential Names' list (LIC 811) and Advisory Notes (LIC 9102TA).


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Jenny Mundo and Pamela Silva on February 3, 2022 at 9:30am. During the inspection, LPAs met with Kim Hudnall, Administrator. LPAs and Administrator inspected the facility inside and out. LPAs reviewed four (4) children's records on site at the facility at 10:05 am. LPAs reviewed two (2) staff personnel files on site at the facility at 11:10 am. LPAs interviewed two (2) staff on site at 11:30 am. LPAs were unable to interview children at the time of the inspection due to the children being at school. LPAs provided the Summary Report to Kim Hudnall, Administrator upon completion. No deficiencies are being cited at this time. LPAs conducted exit interview with the administrator at around 12:10 pm.

met_with: Kim Hudnall, Administartor


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Pamela Silva, Juliet Robles and Joe Martinez on 02/07/23 at 9: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs met with Kim Hudnall, Administrator, and inspected the facility inside and out. LPAs reviewed four (4) of children's records and three (3) of staff personnel files on site at the facility. LPAs reviewed four (4) of children's psychotropic medications and medication records. LPAs interviewed three (3) of staff on site to discuss the facility's policies and procedures of operation. LPAs were unable to interview children currently prescribed psychotropic medications due to clients were in school at the time of inspection. LPAs provided a copy of this licensing report to Kim Hudnall, Administrator. No deficiencies are being cited at this time. LPAs conducted exit interview with Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On March 30, 2023, Licensing Program Analysts (LPAs) Johanna Lofton and Claudia Portillo conducted an unannounced Annual Inspection at the facility and met with Facility Administrator Paul Crews. LPAs stated the purpose of the inspection to the STRTP representative. During the inspection a copy of the Register of Facility Clients was provided upon request. The following topics were inspected: LPA obtained and reviewed the following: · LIC Personnel and client roster · LIC C Emergency Disaster Plan · Accreditation, allowance, complaint procedures · Board of Directors report, Continuous Quality Improvement data report and program statement The annual review consisted with the compliance of the following (5) domains: physical plant, operations, disaster preparedness plan, emergency intervention and core-therapeutic services. An exit interview was conducted and the STRTP Administrator, who agreed with the annual review findings and recommendations. LPAs provided a signed copy of this report LIC809, technical advisory notes.

met_with: Paul Crews-Administrator


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On April 14, 2023, Licensing Program Analysts LPAs) Johanna Lofton and Demetris Teal conducted an unannounced Annual Inspection continuation at the facility and met with Paul Crews, Facility Administrator. . LPAs stated the purpose of the inspection to the STRTP representative. During the inspection a copy of the Register of Facility Clients and Personnel Report was provided upon request. The following documents were inspected: During the inspection the following domains were inspected today: Four (4) Clients' files and (5) Employees' files Citations: One (1) Type B citation was given One (1) Technical Violation An exit interview was conducted and a signed copy of this report was provided to the facility representative along with LIC 809C, LIC 809Ds, and LIC 811 (Confidential Names/ list). Appeal rights explained.

Deficiencies:
87095.61(f): Documentation and Reporting Requirements

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


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Pamela Silva and Juliet Robles on 04/23/24 at 9: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs met with Debra Jackson, Facility Manager, and inspected the facility inside and out. LPAs reviewed two (2) of the children's record and three (3) of staff personnel files on site at the facility. LPAs reviewed two (2) of children's psychotropic medications and medication records. LPAs interviewed two (2) staff on site to discuss the facility's policies and procedures of operation. LPAs will conduct client interviews at a later date due to no clients being available during the time of inspection. No deficiencies are being cited at this time. LPAs conducted exit interview with Debra Jackson, Facility Manager, and provided a copy of this licensing report.

met_with: Debra Jackson


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Pamela Silva and Timika Martin on 05/08/25 at 9: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs met with Kim Hudnall, Administrator, and inspected the facility inside and out. LPAs reviewed three (3) of children's records and three (3) of staff personnel files on site at the facility. LPAs reviewed three (3) of children's psychotropic medications and medication records. The three (3) clients taking psychotropic medications were unavailable for interview at the time of inspection. LPAs will attempt to conduct client interviews at a later date. LPAs interviewed 2 of staff on site to discuss the facility's policies and procedures of operation. LPA provided a copy of this licensing report to Kim Hudnall, Administrator. No deficiencies are being cited at this time. A Technical Advisory was issued (see LIC 9102).


summary: Facility Evaluation

raw_content:
Narrative:
On Wednesday September 17, 2025, at 4:20PM, Licensing Program Analyst (LPA), Humberto Flores, conducted an unannounced Case Management inspection at Unicorn Short Term Residential Therapeutic Program (STRTP) and met with Rosemary England. The purpose of the inspection was to gather information about the incident below reported via Special Incident Report (SIR). The STRTP reported that on 08/15/2025, Child Ref #1 (C1) (see Confidential Names form LIC811 dated 09/17/2025) was restrained 3 times. According to the SIR, the total amount of time that C1 was placed in a manual restraint was for approximately 23 minutes. LPA Flores will investigate these incidents. Interviews and documentation review will be conducted at a later day. A copy of this report and LIC811 were provided to the STRTP representative. Exit interview conducted.

met_with: Rehab Specialist, Rosemary England


summary: Facility Evaluation

raw_content:
Narrative:
On Wednesday October 15, 2025, at 5:10PM, Licensing Program Analyst (LPA), Humberto Flores, conducted an unannounced Case Management inspection at Unicorn Short Term Residential Therapeutic Program (STRTP) and met with Odalys Espinoza. The purpose of the inspection was to interview Child Ref #1 (C1) (see Confidential Names form LIC811 dated 10/15/2025). LPA Flores arrived at the STRTP and C1 was playing video games. C1 refused to be interviewed. A copy of this report and LIC811 was provided to the STRTP representative. Exit interview conducted.

met_with: Facility Manager, Odalys Espinoza


summary: Facility Evaluation

raw_content:
Narrative:
On Tuesday October 21, 2025, at 2:30PM, Licensing Program Analyst (LPA), Humberto Flores, conducted an unannounced Case Management inspection at Unicorn Short Term Residential Therapeutic Program (STRTP) and met with Kim Hudnall. The purpose of the inspection was to obtain copies of files. LPA Flores conducted a review of Child Ref #1 (C1) (see Confidential Names form LIC811 dated 10/21/2025) and Staff Ref #1 (S1) files, copies were provided upon request. Further inspection is needed to complete this inspection. A copy of this report and LIC811 were provided to the STRTP representative. Exit interview conducted.

met_with: Executive Director, Kim Hudnall


summary: Facility Evaluation

raw_content:
Narrative:
On July 11,2025, Licensing Program Analyst (LPA) Angelina Garibaldo conducted a case management inspection at the STRTP and met with Kim Hudnall, Administrator The purpose of the inspection was to address violations that were revealed during the investigation of complaint 32-CR- During the investigation it was discovered that an incident report was not submitted to the Department regarding C AWOL. It was also revealed that facility uses an internal Behavioral/AWOL report form to document incidents, but after review of documents and Department database it was determined that facility failed to submit Serious Incident Reports (SIRs) to the Department. This is in violation of Title Division Chapter Article 6, 80061(b)(1)(E) on Reporting Requirements. A deficiency citation is being issued, see LIC809D. An exit interview was conducted, and a signed copy of this report was provided to the facility licensee along with LIC809C, LIC809D, and LIC811. Appeal rights explained.


summary: Facility Evaluation

raw_content:
Narrative:
On Wednesday December 3, 2025, at 11:50AM, Licensing Program Analyst (LPA), Humberto Flores, conducted an unannounced Case Management inspection at Unicorn Short Term Residential Therapeutic Program (STRTP) and met with Facility Manager (FM) Debra Jackson. The purpose of the inspection was to deliver the findings for the incidents/restraints below reported via Special Incident Report (SIR). The STRTP reported that on 08/15/2025, around 6:20PM, Child Ref #1 (C1) (see Confidential Names form LIC811 dated 09/17/2025) was restrained 3 times. According to the SIR, the total amount of time that C1 was placed in a manual restraint was for approximately 23 minutes. LPA Flores investigated the restraints and conducted interviews with C1 and Staff Ref #1 (S1). A review of C1's file was conducted, and copies were provided upon request. The information revealed that on 08/18/2025, around 6:20PM, C1 displayed aggressive behavior towards his peers while playing outside of the STRTP front yard area. C1 grabbed a chair and threatened to hit a child. According to the SIR, C1 was re-directed and asked to put the chair down. Right after C1 put the chair down he went into his room and continued to act aggressively towards staff and tried to harm himself. Due to the C1's unsafe behavior and attempts to harm himself and others, C1 was restrained 3 times, for a total of approximately 23 minutes. cont.# After a review of the SIR, LPA Flores observed that the SIR did not state who and how the 1st and 3rd restraint were conducted. The SIR only specified that the 2nd restraint was conducted by S1, but it did not report how the 1st restraint was conducted. The SIR also reported that 6:20PM was the time when C1 started to act aggressively with his peers, but at the same time the STRTP reported that this was the time when the initial restraint started, this is not consistent with the information that was provided to LPA Flores during the interviews. The SIR did not report the starting time of when the 2nd and 3rd restraints occurred. At the time that this report was issued, the STRTP did not provide LPA Flores documentation that corroborates that a debriefing was offered neither to C1 nor it was discussed with the staff involved and the mental health head of service no later than the next working day following the incident. Two (2) citations Type B were issued. A copy of this report, citation page, LIC811 and appeal rights were provided. Appeal rights explained. Exit interview conducted.

met_with: Facility Manager, Debra Jackson


summary: Facility Evaluation

raw_content:
Narrative:
On Wednesday December 3, 2025, at 2:00PM, Licensing Program Analyst (LPA), Humberto Flores, conducted an unannounced Case Management inspection at Unicorn Short Term Residential Therapeutic Program (STRTP) and met with Facility Manager (FM) Debra Jackson. The purpose of the inspection was to address the below issue/incident. While conducting an inspection at the STRTP, LPA Flores observed a rodent (little mice) in the kitchen area. This is a violation of the regulations and the Health and Safety Code that, if not corrected, have a direct and immediate risk to the health, safety or personal rights of those in care. A citation type A was issued. LPA Flores explained to the facility representative that they have only 24hrs to hire a mice removal service. A copy of this report, citation page, LIC811 and appeal rights were provided. Appeal rights explained. Exit interview conducted.


summary: Facility Evaluation

raw_content:
Narrative:
On April 23, 2026, 11:10AM, Licensing Program Analyst (LPA) Humberto Flores conducted an unannounced Annual Inspection at Unicorn Short Term Residential Therapeutic Program (STRTP) and met with Executive Director Kim Hudnall. LPA Flores stated the purpose of the inspection to the STRTP representative. LPA Flores conducted the inspection accompanied by Executive Director Kim Hudnall and Facility Manager (FM) Debra Jackson. The inspection was not completed. It will continue tomorrow Friday 04/24/26 and a final report will be issued. A copy of this report was provided to the facility representative. Exit interview conducted.


facility_name: UNICORN GARDENS #2

raw_content:
Narrative:
It was alleged that an unknown facility staff had a sexual relationship with a client. Confidential statements obtained did not provide sufficient information to corroborate the allegation of sexual abuse by staff at the facility. All facility staff interviewed denied the allegation of subjecting a client to sexual abuse or witnessing any abuse at the facility. Based on the information gathered, although the allegation may have happened or is valid, the preponderance of evidence to prove the allegation was not met, therefore the allegation is unsubstantiated. A copy of this report, Confidential Names Form and Appeal Rights were provided to the facility representative. There were no deficiencies cited during this inspection.

Investigation Findings:
13On September 1, 2021 at 11: AM, Licensing Program Analyst (LPA) Joshua Rarela conducted a follow-up complaint inspection to deliver the findings of a complaint investigation concerning the allegation above. The complaint was investigated by Community Care Licensing, Investigations Branch, Investigator Maria Barragan. LPA Rarela met with the facility representative named above and discussed the findings. During the course of the investigation, Investigator Barragan interviewed the facility client on 5/5/21, and the placing agency investigator on 5/6/21; LPA Rarela interviewed facility staff on 8/5/21 (see Confidential Names Form dated September 1, 2021). Investigator Barragan also reviewed documents on 5/3/21 including placing agency records, the client's Needs and Services Plan, and facility personnel files. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Joshua Rarela LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: UNICORN GARDENS #2FACILITY NUMBER: VISIT DATE: 09/01/2021

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


raw_content:
Narrative:
Confidential statements obtained during the investigation were unable to corroborate the allegations as there were no statements obtained to support the allegations. Facility staff indicated that facility clients are separated as a form of intervention if a fight among clients occur. A tour of the facility showed that food is readily available at the facility. Based on the information gathered, the allegations are unsubstantiated as the preponderance of evidence to prove the allegations was not met although the allegations may have happened or are valid. A copy of this report, Confidential Names Form and Appeal Rights were provided to the facility representative. There were no deficiencies cited during this inspection.

Investigation Findings:
13On March 24, 2022 at 11: AM, Licensing Program Analyst (LPA) Joshua Rarela conducted a follow-up complaint inspection to deliver the findings of a complaint investigation concerning the allegations above. LPA Rarela met and discussed the findings with the facility representative named above. During the course of the investigation, LPA interviewed facility clients on 3/23/22 and facility staff on 3/24/22 (see Confidential Names Form dated March 24, 2022). LPA Rarela also reviewed documents including the facility clients' placing agency service logs, referrals and client case plans. It was alleged that a facility client sustained an injury from a fight with another resident, facility clients engaged in physical fights at the facility, and that a foster child was not provided meals. (CONTINUED) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Joshua Rarela LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: UNICORN GARDENS #2FACILITY NUMBER: VISIT DATE: 03/24/2022

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

met_with: Rose England, Rehabilitation Specialist


raw_content:
Narrative:
Two staff denied the above allegations and stated that they never witnessed it and one staff admitted to threatening and making inappropriate comments to C1. LPA conducted an interview with one (1) client, the client stated that the above allegations occurred. Based on the observations, interviews and records reviewed, the preponderance of evidence standard has been met, therefore, the above allegations are found to be substantiated. Deficiencies are being cited in accordance with the California Code of Regulations, Title 22, Division 6, see LIC 9099-D. An exit interview was conducted and Plans of Correction were reviewed and developed with the licensee. A copy of this report and appeal rights were discussed and left with the facility representative whose signature on this form confirm receipt of these documents.

Investigation Findings:
13On January 19, 2023 at 9: AM Licensing Program Analyst (LPA) Timika Martin conducted a follow-up complaint inspection to deliver the findings of a complaint investigation concerning the allegations above. LPA Martin met with the facility representative named above and discussed the findings. During the investigation, LPA Timika Martin conducted a record review on 10/20/22 and obtained copies client's needs and services plan (NSP) and special incident reports (SIRs). LPA requested copies of the LIC 500, staff contact information, staff daily shift schedule and staff trainings. LPA Martin toured the facility and conducted interviews with 3 staff at the facility. Confidential interviews were conducted by LPA Martin with Reporting Party (RP), Client 1 (C1), Staff 1 (S1), Staff 2 (S2) and Staff 3 (S3) on 10/20/22 (See Confidential Names List Form LIC 811 dated January 19 2023). It was alleged that a facility staff threatened and made inappropriate comments to C1. LPA conducted interviews with three (3) staff. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Timika Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: UNICORN GARDENS #2FACILITY NUMBER: VISIT DATE: 01/19/2023

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


raw_content:
Narrative:
S1's eyesight (when attempting to leave the facility unauthorized) and therefore the authorized representative did not need to be called. Further, staff understand that they are to notify the clients authorized representative (placement agency social worker) when clients leave the facility unauthorized. Staff also communicated that they notify their administrator and their agency social worker. Additional interviews with BPDP1 revealed that C1 runs away from the facility very often and is not aware that the authorized representative was notified of C1 leaving the facility; as BPDP1 was unsure of who the authorized representative was. BPDP1 states the restaurant down the street found the child and called the police and BPDP1 called CPS. Based on information obtained by LPA Palmer, there is not a preponderance of evidence to support the allegation, therefore, the allegation(s) is unsubstantiated. No deficiency cited. Copies of the following reports were provided at the conclusion of the inspection: LIC 9099, LIC 9099-C.

Investigation Findings:
13On August 7, 2025 at 11: AM, Licensing Program Analysts (LPAs) Pamela Silva, Timika Martin and Amber Hunter conducted a follow-up complaint inspection with the above named facility and spoke to the Facility Manager, Ranice Dodson. The purpose of the visit is to deliver the findings for the above complaint allegation on behalf of LPA Carrie Palmer. During the course of the investigation, LPA Palmer reviewed facility records and conducted investigative interviews with S1, S2, S3 and S4 on 2/1/25, the complainant on 8/4/25, attempts to contact the authorized representative were made on 8/6/25 and 8/4/25, but were unsuccessful. LPA Palmer was unable to contact C1. (See Form 811 - Confidential Names List). During the investigation, it was revealed by facility staff that the authorized representative recommends that staff inform the authorized representative when clients leave the facility unauthorized. S1 states, S1 wasn't present at the time C1 left the facility unauthorized and that anytime S1 was present at the facility, C1 was in UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Pamela Silva LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: UNICORN GARDENS #2FACILITY NUMBER: VISIT DATE: 08/07/2025

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

met_with: Ranice Dodson


raw_content:
Investigation Findings:
13On August 8, 2025, Licensing Program Analyst (LPA) Johanna Aracena conducted a follow-up inspection at Unicorn Garden # STRTP with the purpose of delivering findings regarding the above complaint allegations. LPA Aracena spoke to Ranice Dodson and discussed the findings. During the investigation LPA Lofton made several attempts to reach the complainant on 7/18/25, 7/24/25 and 8/7/25. LPA interviewed four (4) clients and three (3) staff members on 7/17/25. The allegation was described and confirmed by the victim, however it was denied by the other three (3) interviewed clients who were present at the time of the incident. All the interviewed staff denied the allegations. Furthermore, both parties emphasized the victim's character of lying and aggressive behavior. The confidential interviews did not corroborate the allegations that happened at any time. Therefore, based on the interviews and records reviewed the allegations are found to be unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the allegations. Exit interview was conducted and a copy of this report was emailed to the Facility staff. There were no citations. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Johanna Aracena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Ranice Dodson-Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Jenny Mundo and Gilbert Gutierrez on May 23, 2022 at 10:05 am. During the inspection, LPAs met with Paul Crews, Administrator. LPAs inspected the facility inside and out. LPAs reviewed four (4) children's records on site at the facility at 10:30 am. LPAs reviewed two (2) staff personnel files on site at the facility at 12:50 pm. LPAs reviewed four (4) children psychotropic medications and medication records at 12:25 pm. LPAs interviewed two (2) staff at 1:15 pm. LPAs interviewed one (1) child on site at 2:00 pm.. LPAs provided the Summary Report to Paul Crews, Administrator upon completion. No deficiencies are being cited at this time. LPAs conducted exit interview with the administrator at around 1:35 pm.

met_with: Paul Crews, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On March 30, 2023, Licensing Program Analysts (LPAs) Johanna Lofton and Claudia Portillo conducted an unannounced Annual Inspection at the facility and met with Facility Administrator Paul Crews. LPAs stated the purpose of the inspection to the STRTP representative. During the inspection a copy of the Register of Facility Clients was provided upon request. The following topics were inspected: LPA obtained and reviewed the following: · LIC Personnel and client roster · LIC C Emergency Disaster Plan · Accreditation, allowance, complaint procedures · Board of Directors report, Continuous Quality Improvement data report and program statement The annual review consisted with the compliance of the following (5) domains: physical plant, operations, disaster preparedness plan, emergency intervention and core-therapeutic services. An exit interview was conducted and the STRTP Administrator, who agreed with the annual review findings and recommendations. LPAs provided a signed copy of this report LIC809, technical advisory notes.

met_with: Paul Crews- Administrator


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On April 14, 2023, Licensing Program Analysts LPAs) Johanna Lofton and Demetris Teal conducted an unannounced Annual Inspection continuation at the facility and met with Paul Crews, Facility Administrator. . LPAs stated the purpose of the inspection to the STRTP representative. During the inspection a copy of the Register of Facility Clients and Personnel Report was provided upon request. The following documents were inspected: During the inspection the following domains were inspected today: Two (2) Clients' files and (5) Employees' files Citations: One (1) Type B citation was given One (1) Technical Violation An exit interview was conducted and a signed copy of this report was provided to the facility representative along with LIC 809C, LIC 809Ds, and LIC 811 (Confidential Names/ list). Appeal rights explained.

Deficiencies:
87095.61(f): Documentation and Reporting Requirements

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


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Juliet Robles and Pamela Silva on 04/23/24 at 11: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs met with Kim Hudnall, Executive Director/Administrator and inspected the facility inside and out. LPAs reviewed three (3) of children's records and four (4) of staff personnel files on site at the facility. LPAs reviewed three (3) of children's psychotropic medications and medication records. LPAs interviewed one (2) of staff on site to discuss the facility's policies and procedures of operation. LPA interviewed 0 of children currently prescribed psychotropic medication due to children being unavailable. LPA will interview at a later time. LPA provided a copy of this licensing report to Executive/Administrator, Kim Hudnall. No deficiencies are being cited at this time. LPA Robles conducted exit interview with Executive/Administrator, Kim Hudnall.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Timika Martin and Pamela Silva on 05/08/25 at 11: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs met with Paul Crews, Administrator, and inspected the facility inside and out. LPAs reviewed three (3) of children's records and three (3) of staff personnel files on site at the facility. LPAs reviewed three (3) of children's psychotropic medications and medication records. The three (3) clients taking psychotropic medications were unavailable for interview at the time of inspection. LPAs will attempt to conduct client interviews at a later date. LPAs interviewed 2 of staff on site to discuss the facility's policies and procedures of operation. LPA provided a copy of this licensing report to Paul Crews, Administrator. No deficiencies are being cited at this time. A Technical Advisory was issued (see LIC 9102).


summary: Facility Evaluation

raw_content:
Narrative:
On July 22, 2025, at 12:45PM, Licensing Program Analyst (LPA) Humberto Flores, conducted an unannounced Case Management Inspection, at Unicorn Short Therapeutic Residential Treatment Program (STRTP) and met with Executive Director Kim Hudnall. The purpose of the inspection was to gather information about the below incident reported via Special Incident Report (SIR). The STRTP reported that on 03/10/2025, Child Ref #1 (C1) (see Confidential Names form LIC811 dated 07/22/2025) was restrained because he charged Staff Ref #1 (S1) at the STRTP. During interviews with Administrator Kim Hudnall and Head of Services Mike Lyons, it was reported that C1 was caught at school watching adult content in the school computer and once he arrived at the facility was informed that the incident will be reflected in his behavior chart. C1 got upset and started to use profanities and throw things at S1, after C1 charged S1, C1 was placed in a restrain. The SIR did not specify who the staff that conducted the restraint was, nor the starting time of the restraint. After a review of the SIR LPA Flores determined that the facility did not meet the requirements in Interim Licensing Standards (ILS) Version 5, Section 87061 (i) (7). An Advisory Note/Technical Violation was issued. A copy of this report, LIC9102 and LIC811 was provided to the facility representative. Exit interview conducted.


summary: Facility Evaluation

raw_content:
Narrative:
On July 22, 2025, at 1:45PM, Licensing Program Analyst (LPA) Humberto Flores, conducted an unannounced Case Management Inspection, at Unicorn Short Therapeutic Residential Treatment Program (STRTP) and met with Executive Director Kim Hudnall. The purpose of the inspection was to gather information about the incident below reported via Special Incident Report (SIR). The STRTP reported that on 03/08/2025, Child Ref #1 (C1) (see Confidential Names form LIC811 dated 07/22/2025) was banging on the walls and calling the staff names from his room. The staff had C1 come out to do a time-out in the kitchen, so he does not keep disturbing the other youth. C1 refused to go to the kitchen. The staff began to guide him to the kitchen for his time-out and C1 started to scratch and bite the staff. Due to C1 unsafe behavior and for staff protection the staff used a safety hold for approximately five minutes. The SIR did not state clearly who the staff that conducted the restraint was, how the hold was conducted and what part of C1's body was held by the staff involved, nor the starting time of the restraint. Staff Ref #1 (S1) and Ref #2 (S2) conducted the restraint. After a review of the SIR LPA Flores observed that the facility did not meet the requirements in Interim Licensing Standards (ILS) Version 5, Section 87061 (i) (7). An Advisory Note/Technical Violation was issued. The STRTP representative stated that a training regarding "Reporting Requirements" for restrain will be conducted. cont.# A copy of this report, LIC9102 and LIC811 was provided to the facility representative. Exit interview conducted.


summary: Facility Evaluation

raw_content:
Narrative:
On December 17, 2025, at 11:10AM, Licensing Program Analyst (LPA) Humberto Flores, conducted an unannounced Case Management Inspection at Unicorn Short Therapeutic Residential Treatment Program (STRTP) and met with Rehabilitation Specialist Rosemary England. The purpose of the inspection was to gather information about the incident below reported via Special Incident Report (SIR). The STRTP reported that on 09/18/2025, Child Ref #1 (C1) (see Confidential Names form LIC811 dated 12/17/2025) reported to Staff Ref #1 (S1) he has been having sexual intercourse with Child Ref #2 (C2), according to the SIR C1 did not state when these interactions started and how often it happened. LPA Flores investigated the incident and interviewed S1. C1 and C2 refused to provide information regarding these interactions. S1 disclosed that on 09/18/2025, while C1 was being transported from school he disclosed that he has been having sexual intercourse with C2, who at the time was his roommate. C1 disclosed to S1 that the sexual intercourse consensual from both of them. According to S1, Head of Mental Health Mike Lyons, Executive Director Kim Hudnall and Administrator Paul Crews, met with both children and they admitted that these sexual interactions happened at nighttime at the facility and it was consensual. S1 indicated that C1 and C2 signed documentation stating that the interactions was consensual. Copies of the documents will be sent to LPA Flores by Monday 12/22/2025. cont.# S1 stated that both children were informed that these types of behaviors are not permitted at the facility. The STRTP separated both children and they are no longer roommates. The level of supervision has been raised, and staff are aware that they cannot share the same room. No further action is needed at this time. No citation was issued. A copy of this report and LIC811 were provided to the facility representative. Exit interview conducted.


summary: Facility Evaluation

raw_content:
Narrative:
On Wednesday December 17, 2025, at 12:30PM, Licensing Program Analyst (LPA) Humberto Flores conducted an unannounced Case Management Inspection at Unicorn Short Therapeutic Residential Treatment Program (STRTP) and met with Rehabilitation Specialist Rosemary England. The purpose of the inspection was to gather information about the incident below reported via Special Incident Report (SIR). The STRTP reported that on 11/18/2025, Bakersfield Police Department (BPD) arrived at the facility and interviewed Child Ref #1 (C1) (see Confidential Names form LIC811 dated 12/17/2025) for an incident with a female student that occurred at the school during the 2024-2025 school year. According to the SIR, C1 he was interviewed by BPD, at C1 request, outside of the facility and without the supervision of a staff. The STRTP is not aware of what is being investigated and the status of it. The STRTP reported this Law Enforcement Contact with C1 to the licensing agency on 11/21/2025. An Advisory Note/Technical Violation will be issued due to the STRTP did not report this incident in a timely manner. No further action is needed currently. A copy of this report, LIC9102TV and LIC811 were provided to the facility representative. Exit interview conducted.


summary: Facility Evaluation

raw_content:
Narrative:
On Tuesday December 9, 2025, at 3:30PM, Licensing Program Analyst (LPA) Humberto Flores, conducted an unannounced Case Management Inspection, at Unicorn Short Therapeutic Residential Treatment Program (STRTP) and met with Director, Kim Hudnall. The purpose of the inspection was to gather information about the incident below reported via Special Incident Report (SIR). The STRTP reported that on 8/17/2025, Child Ref #1 (C1) (see Confidential Names form LIC811 dated 12/09/2025) was restrained. According to the SIR, on the date of the restraint C1 became upset when he was not allowed to watch a movie that staff did not consider age appropriate. According to the SIR, C1 went out of the facility and when he was redirected to go back inside, he threw punches at Staff Ref #1 (S1) stomach. Due to C1's behavior, C1 was restrained for approximately 15-30 seconds by S1. LPA Flores was not able to interview C1 because C1 has been relocated out of the State of California with his biological family. After a review of the SIR LPA Flores observed that the SIR did not report the starting time of the restraint. LPA Flores requested a copy of the debriefing form, Director Kim Hudnall disclosed that because C1 was discharged on 10/10/25, his file is not at the facility and she will provide the form tomorrow 12/10/2025. cont.# A citation type B was issued. A copy of this report, citation page, LIC811 and appeal rights were provided to the facility representative. Appeal rights explained. Exit interview conducted.

met_with: Director, Kim Hudnall


summary: Facility Evaluation

raw_content:
Narrative:
On Tuesday December 9, 2025, at 4:00PM, Licensing Program Analyst (LPA) Humberto Flores, conducted an unannounced Case Management Inspection, at Unicorn Short Therapeutic Residential Treatment Program (STRTP) and met with Director, Kim Hudnall. The purpose of the inspection was to gather information about the incident below reported via Special Incident Report (SIR). The STRTP reported that on 8/18/2025, Child Ref #1 (C1) (see Confidential Names form LIC811 dated 12/09/2025) was restrained. According to the SIR, at approximately 6: PM C1 was guided to his room after shoving another child for at the dinner table for allegedly "stealing" his seat (from his perspective). While in C1's room, Staff Ref #1 (S1) informed C1 that he needs to keep his hands to himself and that it is not appropriate to touch other children. C1 was not receptive to the advice. C1 then worked himself up blaming staff and other children for his actions. C1 tried to move S1 out of his way and began digging his nails into S1's arm, which resulted in bleeding. Due to C1's behavior, C1 was restrained for staff protection for 2 minutes. After C1 was released C2 was more receptive to staff instructions. C1 was guided through several coping skill exercises to ground himself and become regulated. LPA Flores was not able to interview C1 because C1 has been relocated out of the State of California with his biological family. cont.# After a review of the SIR LPA Flores observed that the SIR did not report the starting time of the restraint. LPA Flores requested a copy of the debriefing form, Director Kim Hudnall disclosed that because C1 was discharged on 10/10/25, his file is not at the facility and she will provide the form tomorrow 12/10/2025. A citation type B was issued. A copy of this report, citation page, LIC811 and appeal rights were provided to the facility representative. Appeal rights explained. Exit interview conducted.