summary: Facility Evaluation

raw_content:
Narrative:
On November 13, 2025, at 10:45 a.m., Licensing Program Analyst (LPA) Brent Lockhart and Licensing Program Manager (LPM) Jean Herring, conducted an unannounced Post Licensing inspection (Continuation) at Ascend Behavioral Health Group Home (GH). LPA and LPM met with Monique Cleveland, Program Manager and Leroy Rickard, Clinical Supervisor. The facility currently has a provisional Group Home license and is licensed to serve six (6) ambulatory clients age 12 to 17 years old. There are currently 4 clients (1 male and 3 females) placed at the facility. LPAs and LPM reviewed the following domains of the Compliance and Regulatory Enforcement (CARE) tool: Client and Staffing Records, Emergency Intervention Plan, and completion of Operational Requirements. Client Records: LPA and LPM reviewed four (4) client records. All client records are available to the licensing agency to inspect, audit and copy upon demand. Client records reviewed include, but not limited to, consent forms, appraisal/needs and services plan, removal/discipline/complaint procedures; medical assessments; personal property and valuables; education records; personal rights forms; and medication administration records. Staffing Records LPA and LPM reviewed four (4) staff records. Staff records contain documentation of the required education and experience requirements and training. Emergency Intervention Plan LPA and LPM observed documentation of Emergency Intervention Training and on-going training. Operational Requirements Facility maintains a current, written plan of operation that meets licensing standards. Facility maintains a register of clients and the register is available upon request. Facility maintains and implements written complaint procedures and the procedures are posted in a publicly accessible location in the facility. During today's inspection, the facility was provided four (4) Advisory Note/Technical Violations (LIC9102TV), and one (1) Type B citation. An exit interview was conducted A signed copy of this report, Confidential Names list dated 10/30/25, LIC9102TVs, LIC809-D and Appeal Rights were provided to Leroy Rickard, Clinical Supervisor.


state: CA

facility_name: ASCEND BEHAVIORAL HEALTH

summary: Facility Evaluation

raw_content:
Narrative:
On 04/08/26 at 01:00 p.m., Licensing Program Analyst (LPA) Brent Lockhart and Licensing Program Manager (LPM) Jean Herring made an unannounced inspection at the above-named facility. LPA and LPM met with Amanda Lilly, Program Manager. The purpose of the inspection was to evaluate the licensee's request to increase the facility's licensed capacity from six (6) to eight (8), based on the application submitted for a capacity increase. This facility is licensed to serve clients, ages 12-17 years old. Currently, the facility has four (4) minors in placement. The staff to client ratio at the time of inspection was 5:4. LPA and LPM toured the facility with the Program Manager. The facility consists of: 4 bedrooms; therapy office; 2 full bathrooms for clients and 1 bathroom for staff; multipurpose room; dining room; kitchen; laundry area; 2-car garage being used as a clinical office; front porch, covered patio and swimming pool. Overall, the facility is clean, safe, sanitary, and in good repair. All passageways are unobstructed and all doors open freely. Sharps, disinfectants, cleaning solutions and other toxic materials are locked in a closet located in the laundry area. At the time of inspection facility temperature was 70 degrees (F). Hot water temperature was tested and measured at 107 degrees (F). Bedrooms# 1 & 3 are equipped with 2 beds each and Bedrooms 2 & 4 are furnished with one (1) bed each. All client beds have clean linens. The carbon monoxide and smoke alarm were tested and observed to be operable. (Continued on 809-C) The facility has non-perishable foods for at least one week and perishable foods for at least two days. A review of weekly menu indicates that the facility provides nutritious meals and snacks. Medications are locked in a closet located in the multipurpose room and accessible only to employees responsible for stored medications. A new fire clearance for a capacity of eight (8) has been received by the Department prior to this inspection. Based on observation, the following furniture need to be added in order to increase the facility capacity to eight (8); Bedrooms # 2 & 4 need one additional bed, and one additional night stand. Bedroom #1 needs one additional closet/armoire. Multipurpose/study room needs two (2) additional study desks and 2 chairs. Two (2) Technical Advisory Notes (LIC 9102) were provided. A signed copy of this report was provided to the Program Manager.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Amanda Lilly - Program Manager


facility_name: ASCEND HEALTHCARE

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview was completed and copy of the report and appeal rights were discussed and provided to Facility Manager, Stefan Zeljkovic.

Investigation Findings:
13On 08/13/25, at 9: AM, Licensing Program Analyst (LPA) Andrea Aceves and Licensing Program Manager (LPM) Lakescia Smith made an unannounced visit to the above facility to conclude the investigation and to deliver the findings on the above allegations. LPA and LPM met with Facility Manager, Stefan Zeljkovic. During the investigation, LPA Andrea interviewed all available parties and reviewed LIC500-Personnel Report, Needs and Services Plan. It was reported that (1) Staff did not ensure that minor's needs were met while in care, (2) Staff did not follow minor in care's treatment plan, and (3) staff harassed minor in care. Based on interview statements from staff and review of client treatment plan, LPA Andrea was able to confirm that minor was engaged in therapy throughout her entire program. LPA was unable to confirm if parent of C1 was harassed by the facility regarding financial responsibilities however, parent was signed the Admission Financial Package which identifies the program's financial expectations. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Andrea Aceves LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: ASCEND HEALTHCAREFACILITY NUMBER: VISIT DATE: 08/13/2025

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

report_type: Complaint Investigation

met_with: Facility Manager Stefan Zeljkovic

complaint_status: unsubstantiated


summary: Facility Evaluation

raw_content:
Narrative:
On January 26, 2023, at 9: AM, Licensing Program Analyst (LPA), Charmetha White arrived at Ascend Healthcare, for the purpose of conducting a Year Annual Inspection. LPA met with Facility Compliance Manager, Dave Trice and the Director of Facilities, Zackary Hale and was granted access into the facility. The facility was toured at 9: AM both inside and out. The facility is a private pay therapeutic treatment program licensed to provide care and supervision services for six (6) children, ages 12-17 years old, ambulatory only. The census at the time of the inspection was six (6). The facility is a two story, 3-bedroom, 5-bathroom house which includes a Living room, Dining room, Kitchen, Laundry room, Staffing/Medical office, a Garage, and a Backyard. The facility is set up as follows: Living room: is furnished with sectional sofa, 2 chairs, and has an non-operating fireplace equipped with an iron screen. Dining room: is furnished with a wooden table and six (6) chairs. Kitchen: is equipped with a 4-burner gas operated stove, a microwave, refrigerator/freezer, a dishwasher, and a toaster. Laundry room: is located in the garage and is equipped with a washer and dryer. Staffing/Medical office: is located on the first floor near the garage. The office is equipped with a computer, chair, and desk. LPA observed the room to have a locked cabinet which are used to stores medication, PPE supplies. Additionally, medications that require refrigeration is stored in a double locked refrigerator located inside the office. The office is locked and made inaccessible to clients in care. Pool: is located in the backyard and is equipped with a fence that meets regulations. Garages: is attached to the home and is equipped with a desk, chair, and gym equipment. There are also two (2) small rooms used staff and client meetings. Backyard: contained a swimming pool equipped with a five foot fence with a self-latching lock, a ping pong table, ½ court basketball, and a sitting area. The backyard was observed to be free of debris and hazardous materials. Report continued on LIC 809C (page 1 of 2) Bedroom 1: is named Warrior and it is equipped with 2 full size beds. There are adequate drawers, closet space, and lighting in this room. Bedroom 2: is named Sunrise and it is equipped with 2 full size beds. There are adequate drawers, closet space, and lighting in this room. Bedroom 1 & Bedroom 2 shares a Jack and Jill bathroom. Bedroom 3: is named Horizon and it is equipped with 2 full size beds. There are adequate drawers, closet space, and lighting in this room. The room also has a separate bathroom, and French doors, which remain locked at all times, leading to the backyard. All bedrooms were equipped with comfortable mattresses, clean linen, blankets, and pillows. Bathrooms: bathrooms had a toilet, sinks, tub/shower. The bathrooms were clean and in operating condition. Water temperature was observed to be within 105 - 120 degrees Fahrenheit. LPA observed the home to be clean, safe, sanitary, and in good repair. The home has a linen closet located on the second floor which stores additional towels and sheets. Knives are locked in box located under the stove and made inaccessible to the clients. Disinfectant and cleaning solutions are locked in a storage closet located off of the entrance and made inaccessible the clients. The first aid kit is located in the staff office and was found to be complete with scissors, tweezers, gauzes, antiseptic, 1st Aid Manual, and a thermometer. There are no firearms or dangerous weapons located in the home. The smoke alarms and carbon monoxide detectors were tested and found to be in working order. The home has 3 fire extinguishers. There are no security bars on the windows. There is a camera waiver on file. Facility operates within license conditions and limitations including capacity limitations. Facility has a current written plan of operation. All posting requirements were met. Clients are provided three nutritious meals and snacks per day. Clients in care are in accorded personal rights. Clients in care are supported, encouraged to participate in extracurricular activities. Clients in care can contact the licensing agency or Foster Care Ombudsman person in confidence without threats or punishment for making complaints. Clients in care are accorded dignity in personal relationships with others in the home. Clients in care are not restricted in telephone use except by court order. LPA will return at a later date to review Staff and Client flies. There were no deficiencies cited per California Code of Regulations, Title Regulations, Division 6, chapters 1 & 5. Exit interview was conducted and a copy of this report was left at the facility.

visit_type: Annual

met_with: Facility Compliance Manager - Dave Trice and Director of Facilities - Zackary Hale


summary: Facility Evaluation

raw_content:
Narrative:
On May 9, 2023 at 9: AM, Licensing Program Analyst (LPA) Charmetha White made an unannounced visit to Ascend Healthcare for the purpose of conducting a Case Management for Special Incident Report #05-2023-34-CM-01. The incident occurred 04/26/2023 and the incident report was received by the Department on 05/01/2023. LPA met Director of Operations, Jacqueline Marshall Waldron and discussed the incident. During this visit, confidential interviews were conducted. Additional interviews will be conducted on a later date. LPA requested a copy of the following documents: Current LIC 500, Staff #2's training records, and Client #1's intake paperwork. Additionally, LPA was informed that Client #1 is no longer in placement as of 04/29/2023. Based on interviews and information gathered, this case management needs further investigation. Exit interview was conducted, and a copy of this report was emailed to the Director of Operations.

met_with: Director of Operations - Jacqueline Marshall Waldron


summary: Facility Evaluation

raw_content:
Narrative:
On June 20, 2024, at 12: PM, Licensing Program Analyst (LPA) Regina Martin conducted a Case Management - Incident inspection at ASCEND HEALTHCARE Group Home, met with Facility Representative and later with Emely Hernandez, Facility Manager and Jack Waldron, Facility Director in response to an Incident Report submitted to Community Care Licensing (CCL) on June 12, 2024. The incident, reports in part alleged violation of personal rights as a youth was reportedly touched inappropriately by a staff member. During this inspection, LPA Martin informed the incident has been referred to CCL Investigations Branch, Investigator Lorraine Patterson for assignment. Upon completion of the investigation, the investigation findings will be delivered and discussed. LPA Martin requested and/or obtained the following documents from facility records and subject client files: Client Roster (obtained during visit), Personnel Report (Schedule) LIC500, Client Needs and Services Plan, discharge documentation and all incident reports concerning subject youth (if applicable). Please submit requested documents to LPA Regina Martin at regina.martin@dss.ca.gov The incident requires further investigation. Upon completion, the Department's findings will be issued and discussed. There are no deficiencies cited per California Code of Regulations, at this time. Exit Interview conducted, and a copy of this report was left with Facility Representative.

met_with: Facility Representatives


summary: Facility Evaluation

raw_content:
Narrative:
On 05/30/2025, Licensing Program Analyst (LPA) Andrea Aceves and Licensing Program Manager (LPM) Lakescia Smith, made an announced visit to Ascend Healthcare #1 for the purpose of a Case Management- Incident Report. LPA and LPM met with Acting Facility Manager, David Hurwitz to discuss an incident regarding the lack of supervision. The department received an incident report dated 05/22/25. The incident report disclosed that two clients engaged in inappropriate sexual behavior and staff was asleep during the incident. During the investigation LPA obtained copy of LIC 500, client roster, and interviewed Acting Facility Manager, David Hurwitz. Staff #1 was not available for an interview. Staff #1 will be contacted at a later date. LPA informed David Hurwitz that more information is needed. LPA will return at a later date to conclude the investigation. Exit interview was conducted and a copy of this report was provided to Acting Facility Manager, David Hurwitz.

met_with: Acting Facility Manager-David Hurwitz


summary: Facility Evaluation

raw_content:
Narrative:
On September 24, 2025 at 12:10pm, Licensing Program Analyst (LPA) Emelyn Sanchez P. conducted an unannounced visit to Ascend Healthcare for the purpose of conducting an Initial 10-day Complaint Investigation visit. LPA Sanchez P. met with Stefan Zeljkovic, Facility Manager who granted access into the facility. LPA Sanchez P. conducted a Health and Safety Risk assessment upon arriving at the facility. LPA Sanchez P. requested the LIC 500- Personnel Report and current client roster. After reviewing requested documents LPA Sanchez P. was able to confirm that the complaint investigation was recorded under the wrong facility. LPA Sanchez P. will be conducting a complaint investigation visit at Ascend Healthcare 3 #198209719. No deficiencies were cited at this time. An exit interview was conducted, and a copy of this report was left with Stefan Zeljkovic, Facility Manager

met_with: Stefan Zeljkovic, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 05/30/2025, Licensing Program Analyst (LPA) Andrea Aceves and Licensing Program Manager (LPM) Lakescia Smith, made an announced visit to Ascend Healthcare #1 for the purpose of a Case Management- Deficiency and met with Acting Facility Manager, David Hurwitz. While initiating a visit at the facility, LPA and LPM requested a copy of the LIC500-Personnel Report. LPA Andrea reviewed the Personnel Report and Guardian roster. LPA and LPM advised Acting Facility Manager, David Hurwitz that Staff #1 was not associated to the home per licensing regulations. In addition, LPM and LPA reminded Acting Facility Manager that all staff working in the home must obtain a criminal record clearance and associated to the facility prior to working in the home. Note: LPM informed staff regarding the Central Administrative Facility Waiver to designate one facility to associate all staff for clearance purposes. LPA will send instructions on submitting the waiver request via email. In addition, LPA will send Provider Information Notice regarding camera use in the facilities. Due to staff not being associated to the facility a deficiency is being cited. See LIC 809D. Exit interview completed and copy of the report and appeal rights were provided to acting facility manager, David Horwitz.

met_with: David Hurwitz-Acting Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 08/12/25, at 9: AM, Licensing Program Analyst (LPA) Andrea Aceves and Licensing Program Manager (LPM) Lakescia Smith made an unannounced visit to Ascend Healthcare for the purpose of conducting a Case Management for Incident Report dated 05/21/25 (#0001797-FN). LPA Andrea and LPM Lakescia met with Facility Manager, Stefan Zeljkovic. During the investigation, LPA Andrea interviewed all available parties, requested and received LIC500-Personnel Report and client roster. The incident occurred on 05/19/25 and the report was received on 05/22/25. Per Facility Manager and S1, LPA was able to confirm that a staff was asleep while on shift. However, due to conflicting statements, LPA was not able to confirm if two clients engaged in inappropriate sexual behavior as reported. No further investigation or interviews are required on the above incident. As a result, the facility is being cited (see LIC809D). Exit interview was completed and copy of the report and appeal rights were discussed and provided to Facility Manger, Stefan Zaljkovic.


facility_name: ASCEND HEALTHCARE 2

summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Evidence obtained from records noted that C1 was admitted to the facility with a belt that was stored in a designated storage area. Evidence obtained from records noted that on 04/19/24, C1 was permitted to wear a belt when they asked for it in the morning but had to return it to staff before bed. Statements obtained revealed C1 was given their belt either on 04/17/24 or 04/24/24. However, statements obtained could not corroborate if or when the belt was collected from C1 at the end of the day. The investigation revealed on the evening of 4/24/2024, during a designated supervised shower time, C1 was monitored with verbal communication by staff during a 7-minute time span for C1's shower. Statements revealed, C1 requested more time and was given an additional two minutes. After the two minutes passed, staff knocked on the door and did not get a response from C1. When staff opened the bathroom door, C1 was found unresponsive, with their neck hung with a belt on a shower rail. Staff on duty brought C1 down and performed cardiopulmonary resuscitation (CPR) until paramedics arrived. C1 was resuscitated, transported to the hospital, intubated, and diagnosed with Hypoxia. Statements obtained did not determine the length of time C1 was unresponsive to staff's knocks at the bathroom door, or length of time it took for staff to get C1 down. Statements revealed inconsistent accounts of staff conducting a search of C1 and bathroom areas prior to the incident. Statements revealed witness corroborating accounts of C1 wearing a belt the day of the incident and the days leading up to the incident on 4/24/2024. Based on confidential interviews, record review, and analysis of circumstances, the Department has determined that the preponderance of evidence standard has been met; therefore, the allegation that staff did not provide necessary care and supervision to C1 resulting in C1's attempted suicide by hanging with a belt while in care is substantiated. This poses an immediate health, safety, and personal rights risk of harm to clients placed in care. The facility is issued a citation in accordance with California Code of Regulations, Title 22, Division 6, Chapter 5, 84078(b) Responsibility for Providing Care and Supervision. See page LIC9099-D for the cited deficiency. An exit interview was conducted, and appeal rights discussed. A copy of this report and appeal rights was left with Administrator. An enhanced civil penalty determination is pending.

Investigation Findings:
13On 10/15/2024, at 12: PM, Licensing Program Analyst (LPA), Regina Martin conducted a complaint inspection at ASCEND HEALTHCARE 2 to deliver findings concerning the above-mentioned allegation. LPA Martin met with David Hurwitz, Clinical Director and Emely Hernandez, Facility Manager and discussed the investigative outcome. On 5/13/2024, Community Care Licensing Division (CCLD) received an allegation that on 4/24/2024, Client (C1) was transported to the hospital following an attempted suicide by hanging with a belt (refer to LIC811, dated 10/15/2024). The allegation was referred and investigated by CCLD Investigations Branch, Investigator Laarni Santiago. The investigation included confidential interviews with six former clients, including C1, nine staff members, associated parties, and witnesses. The investigation further included review of facility and medical reports. The investigation revealed C1 was placed at ASCEND HEALTHCARE 2 on 4/16/2024. Records reviewed revealed C1's history of multiple hospitalizations and suicide attempts including a prior attempt made with a belt. (Continued on page 9099-C) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Regina Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: ASCEND HEALTHCARE 2FACILITY NUMBER: VISIT DATE: 10/15/2024

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

met_with: David Hurwitz, Clinical Director

complaint_status: SUBSTANTIATED


raw_content:
Investigation Findings:
13On 01/29/2025 at 9: AM, LPA Jarmin arrived at Ascend Healthcare 2 to deliver the findings regarding the allegation. LPA met with the facility manager and discussed the investigative outcome. LPA explained that the investigation concluded on 01/23/2025 at 6: PM. During the investigation, LPA conducted confidential interviews, performed health and safety assessments, and reviewed relevant documents. The investigation revealed conflicting statements and a lack of material evidence to substantiate the allegation that minors in care engaged in inappropriate interactions. Attempts to contact the foster child and collateral individuals connected to the incident were unsuccessful. Document reviews found no evidence or sufficient information to support the claim and confirmed that the facility continues to follow its established policies and procedures. Based on the investigation, LPA's finding for this allegation is Unsubstantiated, meaning that while the allegation may have occurred or is valid, there is not a preponderance of evidence to prove a violation. An exit interview was conducted with the Facility Manager, and a copy of this report was provided. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Enrique M Hernandez LICENSING EVALUATOR NAME: Dennis Jarmin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B This is an official report of an unannounced visit/investigation of a complaint received in our office on 02/08/2024 and conducted by Evaluator Dennis Jarmin COMPLAINT CONTROL NUMBER: 34-CR- FACILITY NAME:ASCEND HEALTHCARE 2FACILITY NUMBER: ADMINISTRATOR:GOLDBERG,EPHRIAMFACILITY TYPE: ADDRESS: MAGNOLIA BLVD.TELEPHONE: (747) 247- CITY:ENCINOSTATE: CAZIP CODE: CAPACITY:6CENSUS: DATE: 02/26/ UNANNOUNCEDTIME BEGAN: 01: PM MET WITH:Stefan ZeljkovicTIME COMPLETED:03: PM INVESTIGATION FINDINGS: UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Enrique M Hernandez LICENSING EVALUATOR NAME: Dennis Jarmin 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: 2 of 2

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

met_with: Stefan Zeljkovic


summary: Facility Evaluation

raw_content:
Narrative:
On 01/31/2022 at 10:45am, Licensing Program Analyst (LPA) arrived at the facility for the purpose of conducting re required annual inspection. LPA Karnsrithong met with Facility Manager, who granted access and tour to the facility. The facility is licensed to provide care and supervision up to six (6) children ages 12 to 17 and non-minor dependents. There is a swimming pool located in the premises. The facility is a two-story residential home. During the visit, LPA Karnsrithong has reviewed three (3) client files and two (2) staff files. LPA Karnsrithong has interviewed two (2) staff and two (2) clients during the inspection. Administrator Certification is valid until 10/25/2022.All smoke detectors and carbon monoxide detector were tested and operable at the time of inspection. LPA Karnsrithong observed multiple fire extinguishers throughout the facility that were fully charged. During the inspection LPA Karnsrithong has observed the following: Bedrooms: There are three (3) client bedrooms (Summit, Apex, Valor). All rooms are equipped full-size beds, adequate closet and drawer space, and sufficient lighting. LPA observed clean linens, blankets, and pillows. All client's beds are in good repair and equipped with a sturdy spring mattress. All bedroom windows are in good working condition. Bedroom temperatures meet regulations at 69 degrees Fahrenheit. Each bedroom has a copy of the facility sketch plan and COVID-19 safety cough guidelines. Bathrooms: There is a total of four (4) bathrooms in the facility. There are two (2) located upstairs and two (2) located downstairs. The Summit Bedroom has its own bathroom that is equipped with a toilet, sink, and shower. It has a tub but is currently non-operational. The client bathroom upstairs has a double sink, toilet, and shower. Staff's bathroom is located downstairs next to the Education Room. It has a toilet, sink, and shower in good working condition. Shower is not being used by staff but is available if needed. There is a half-bathroom downstairs that is used by guests, clients, and staff. It has a toilet and sink that is in good working condition. (Page 1 of 3) Office Room: The staff office is located upstairs. This room is equipped with a desk, couch, and chairs. It has a computer and Covid-19 supplies to be used by staff and clients. The First Aid Kit and client medications are stored in this room. Medications are inaccessible to clients, and accessible to only authorized employees. There is also an office area located upstairs that are used by staff that has a computer and printer. There are cabinets next to the office area that are used to store contraband items, linens, and hygiene supplies and are always kept locked. There is a furnace in a locked cabinet located upstairs next to the office area. Dining Area: Equipped with a large table with 8 chairs and is connected to the Kitchen. Clients were observed to be eating meals in the dining area during the visit. Kitchen: There is a large kitchen located downstairs. It has four burner stove, oven range, microwave, and a dishwasher. It has a double sink and enough cabinet storage for utensils, cups, plates, pots, and pans. Knives and sharp objects are kept in a locked cabinet and is inaccessible to clients. There is a private chef that comes to the facility and prepares all meals for the clients. There is a refrigerator in the kitchen. There is a cabinet that stores the facility's dry goods and non-perishable food items. Menus and snack schedule are also posted in the kitchen. There is also a chore list posted in the refrigerator. At the other side of the kitchen is a Kosher Kitchen space dedicated for clients who have a Kosher diet. It has a designated microwave and coffee maker and other small appliances and supplies designated for Kosher food preparation. There is a double door pantry that contains ample supply of non-perishable food in the facility. Therapy Rooms: There are two (2) rooms designated for therapeutic services. There are coffee tables and ample seating for clients. There is a rug and a computer desk and an office chairs for therapists to use. The facility has a therapy dogs that provides emotional support to clients that is being cared for by the licensed therapists. Hallway Closet: Cleaning solutions, disinfectants, and cleaning supplies are stored in a closet underneath the stairway and is kept locked and inaccessible to clients. (Page 2 of 3) Creative Learning Space: This is a converted garage space that is being use for education and art. It is located downstairs. It has computers, tables, chairs, cabinets, and shelves. Cabinets are used to store art and incentive supplies for clients. This space is well maintained by staff and is kept locked when education and art activities are not in session. The electric and water shut off valves are in this area and is kept locked and inaccessible to clients. There is also another furnace located here in a locked cabinet. Indoor Common Areas: There are two (2) living room areas located downstairs. One is located next to the entrance that is equipped with ample seating, a coffee table, rug, and a television. There is a non-operable fireplace here that is kept covered and inaccessible to clients. Another living room area is located next to the dining room. It has couches, a rug, and a coffee table. Laundry room: There is a washer and dryer. Laundry supplies and detergent are stored in locked cabinets above the washer and this room is also kept locked when not in use. Clients are permitted to use the laundry room supervised with a staff. Outdoor space: The outdoor space is completely fenced in. There is gate that leads to the driveway. There are ample trees and shrubs throughout the facility. There is an enclosed patio area that is being used for group activities. There is a Ping-Pong table and exercise equipment located outside that is being used by clients. There is adequate patio seating furniture located throughout the garden. There is a Tennis/Basketball court located outside as well. There is a fenced in pool that is well maintained and free of debris. LPA Karnsrithong has observed the gate door to swing away from the pool, with self-close and self-latching device located no more than six inches from the top of the gate. The Gas Shut off valve is located outside. There are three (3) storage sheds located outside. One is used for facility supplies such as extra chairs and table. One is being used for storing client's personal items such as luggage. One is being used to store extra perishable and non-perishable food items. This shed has a refrigerator and a freezer and is maintained by the chef. The outdoor space is free of debris and any hazards. There are no deficiencies cited at this time. Exit interview was conducted with the facility manager. A copy of this report will be provided to the facility.

met_with: Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 04/26/2022 at 9am, Licensing Program Analyst (LPA) Bernice Karnsrithong and Associate Governmental Program Analyst (AGPA) Leosha Eves arrived at the facility for the purpose of conducting required annual inspection. LPA Karnsrithong met with Jaq Waldron, Director of Operations who granted access and tour to the facility. Health and safety risk assessment was conducted upon arriving at the facility. The facility is licensed to provide care and supervision up to six (6) children ages 12 to 17 and non-minor dependents. The facility is located in residential neighborhood. It is a two-story home and is completely fenced in. Currently there are six (6) clients in care and five (5) staff at the time of the visit. During the visit, LPA Karnsrithong has toured the physical plant and observed the following: Common Areas: There are two (2) common room areas located downstairs. One is located next to the entrance that is equipped with ample seating, a coffee table, rug, television, and sports equipment. There is a non-operable fireplace here that is kept covered and inaccessible to clients. Another living room area is located next to the dining room. It has couches, a rug, coffee table, musical instruments, and art supplies. It also has a shelf that is use to store board games and facility activity supplies. Therapy Rooms: There are two (2) rooms designated for therapeutic services. There are coffee tables and ample seating for clients. There is a rug and a computer desk and an office chairs for therapists to use. Hallway Closet: There is a hallway closet room downstairs. This room is used to store cleaning solutions, disinfectants, and cleaning supplies. This room also has the main alarm box for the facility. This room is kept locked and inaccessible to clients. (Page 1 of 2) Kitchen/Dining Area: There is a large kitchen/dining area located downstairs. It has four burner stove, French Door Refrigerator, oven range, microwave, and a dishwasher. It has a double sink and enough cabinet storage for utensils, cups, plates, pots, and pans. Knives and sharp objects are kept in a locked cabinet and is inaccessible to clients. There is a private chef that comes to the facility and prepares all meals for the clients. Menus are posted in the kitchen area that includes menus for lunch, breakfast, dinner, and snacks. There is a cabinet that stores the facility's dry goods and non-perishable food items. There is also a chore list posted in the refrigerator. At the other side of the kitchen is a Kosher Kitchen space dedicated for clients who have a Kosher diet. It has a designated microwave and coffee maker and other small appliances and supplies designated for Kosher food preparation. There is a double door pantry that contains ample supply of non-perishable food in the facility. The dining area is next to the kitchen. It is equipped with a large table and dining chairs. School Room: This is a converted garage space that is being use for education and art. It is located downstairs. It has computers, tables, chairs, cabinets, and shelves. Cabinets are used to store art and incentive supplies for clients. This space is well-maintained by staff and is kept locked when education and art activities are not in session. The hot water heater and furnace are stored here in a locked cabinet. Office Room: The staff office is located upstairs. This room is equipped with a desk, couch, and chairs. It has a computer and Covid-19 supplies to be used by staff and clients. The First Aid Kit and client medications are stored in this room. Medications are inaccessible to clients, and accessible to only authorized employees. This office room also serves as a nursing station for the group home. Laundry room: There is a washer and dryer. Cleaning supplies and detergent are stored in locked cabinets above the washer and this room is also kept locked when not in use. Cleaning supplies are also stored in the cabinets here but is kept locked and inaccessible to clients. Toiletries and other supplies are also store in the laundry room cabinets. There is sink in the laundry room as well. There are no deficiencies cited at this time. Exit interview was conducted with Director of Operations, Jaq Waldron. (Page 1 of 2)

met_with: Jaq Waldron, Director of Operations


summary: Facility Evaluation

raw_content:
Narrative:
On 04/27/2022 at 9:30am, Licensing Program Analyst (LPA) Bernice Karnsrithong arrived at the facility and met with Jaq Waldron, Director of Operations for the purpose of continuing the annual inspection. Health and safety risk assessment were conducted upon arriving the facility. During today's inspection, LPA Karnsrithong had interviewed two (2) clients and two (2) staff. LPA Karnsrithong also reviewed three (3) staff and three (3) client files. Facility conducts safety drill training for clients and staff once a month. LPA Karnsrithong had observed that all client medications are properly stored and is inaccessible to clients. Client's medication administration are properly documented in the facility's medication binder and online database. The passageways and stairways are unobstructed. All clients are accorded personal rights. Clients are provided telephone service in the facility. Clients are provided with appropriate supplies when needed and have access to indoor and outdoor activities. Educational activities are provided to children regularly and is being supervised by staff. Cash resources and personal belongings of clients are locked and securely stored in a safe. The facility's accreditation from the Joint Commission is valid until April 23, 2024. During the inspection LPA Karnsrithong has observed the following: Bedrooms: There are three (3) client bedrooms (Summit, Apex, Valor). All rooms are equipped full-size beds, adequate closet and drawer space, and sufficient lighting. LPA observed clean linens, blankets, and pillows. All client's beds are in good repair and equipped with a sturdy spring mattress. All bedroom windows are in good working condition. Bedroom temperatures meet regulations at 69 degrees Fahrenheit. Each bedroom has a copy of the facility sketch plan and client schedules are posted. There are two (2) clients assigned per bedroom. (Page 1 of 2) Bathrooms: There is a total of four (4) bathrooms in the facility. There are two (2) located upstairs and two (2) located downstairs. The Summit Bedroom has its own bathroom that is equipped with a toilet, sink, and shower. It has a tub but is currently non-operational. The client bathroom upstairs has a double sink, toilet, and shower. Staff's bathroom is located downstairs next to the Therapy Room. It has a toilet, sink, and shower and is in good working condition. Shower is not being used by staff but is available if needed. There is a half-bathroom downstairs that is used by clients. It has a toilet and sink that is in good repair. Outdoor space: The outdoor space is completely fenced in. There is gate that leads to the driveway. There are ample trees and shrubs throughout the facility. There is an enclosed patio area that is being used for group activities. There is a ping-pong table, boxing and exercise equipment located outside that is being used by clients. There is adequate seating furniture located throughout the garden. There is a fire pit with patio seating throughout as well. There is a Tennis/Basketball court located outside. There is a fenced in pool that is well-maintained and free of debris. LPA Karnsrithong has observed the gate door to swing away from the pool, with self-close and self-latching device located no more than six inches from the top of the gate. Utility shut off valves are located outside. There are three (3) storage sheds outside. One is used for facility supplies such as extra chairs and table. One is being used for storing client's personal items such as luggage. One is being used to store extra perishable and non-perishable food items. This shed has a refrigerator and freezer and is maintained by the chef. The outdoor space is free of debris and any hazards. The facility has at least two (2) Direct Care Staff that supervises clients at all times. Clients have regular outings and activities such as Equine and Surfing. LPA Karnsrithong has observed clients doing educational activities in the school room. There are no deficiencies cited at this time and exit interview was conducted with Jaq Waldron, Director of Operations. A copy of this report will be provided to the facility. (Page 2 of 2)


summary: Facility Evaluation

raw_content:
Narrative:
On 7/31/2024, at 2: PM, Licensing Program Analyst (LPA) Regina Martin conducted a Case Management - Incident inspection at ASCEND HEALTHCARE and met with Emily Hernandez Facility Manager, to deliver findings concerning Incident Report submitted to Community Care Licensing (CCL) on 6/12/2024. The incident report reported that a youth resident, reported being "fondled" in their private area under their clothing, by an unidentified staff member while in care. The incident was referred to CCL Investigator, Lorraine Patterson for investigation assignment. The investigation revealed as of 6/12/2024, Youth #1 no longer resides at the facility following a voluntary discharge. The investigation further revealed a lack of evidence to prove the alleged as Youth #1 declined to be interviewed by CCL Investigator or provide additional information concerning the incident. Confidential interviews revealed no details, information, evidence, and/or witnesses to support the alleged. Based on the statements gathered, and records reviewed the Department has concluded there is not enough evidence to prove that the alleged violation occurred. The Department's finding is therefore determined Unsubstantiated. There are no deficiencies per California Code of Regulations cited at this time. Exit interview completed. A copy of this report was provided to Facility Manager during this visit.


summary: Facility Evaluation

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Narrative:
On 11/19/2024 at 12: PM, Licensing Program Analyst (LPA) Regina Martin met with Emely Hernandez, Facility Manager (Empress location), to assess an Enhanced Civil Penalty (ECP). On October 15, 2024, the Department concluded a complaint investigation alleging that Facility Staff did not provide care and supervision resulting in Client's attempted suicide by hanging while in care. The allegation was determined substantiated, and the Group Home was cited for violation of the California Code of Regulations, Title 22, 84072(b) Responsibility for Providing Care and Supervision (See the Confidential Names List, LIC 811, dated 11/19/2024. Based on an analysis of the interviews and documentary evidence, the Department has determined that an enhanced civil penalty is warranted for Staff not providing necessary care and supervision causing a serious injury for which a child was hospitalized, required intubation, and was placed under extensive care. Serious bodily injury is defined in Penal Code section 243 as "a serious impairment of physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of function of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement." Pursuant to the Enhanced Civil Penalty law, Health & Safety Code section 1548(f)(1)(C)(ii), the Department issues an immediate civil penalty of $2,500.00. An exit interview was completed, and appeal rights discussed. A copy of this report, the Confidential Names List, and a Civil Penalty Assessment - Serious Bodily Injury/Physical Abuse (Form 421-D) was provided to the Facility Manager and Administrator (via e-mail). The signed copy will be retained in the facility file.

met_with: Emely Hernandez, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 05/22/2025, Licensing Program Analyst (LPA) C. White arrived at the facility for the purpose of conducting a Year Required inspection. LPA met with Director of Operations, Jaq Waldron who granted access to the facility and tour of the interior and exterior was conducted. Ascend Healthcare #2 is a therapeutic treatment program designed to accept Private Placements. The facility is licensed to provide care and supervision for up to six (6) children ages 12 to 17 years old; ambulatory only. Currently the census is six (6). The facility is set up as follows: This is a two-story home, located in a residential neighborhood and the property is completely fenced in. There are three (3) bedrooms, four (4) bathrooms, living room, dining room, kitchen, staff office/medication room, therapy offices, a laundry area, an attached garage, and outdoor/backyard area. Living Room: Is located to the right of the entrance and is used as a group therapy area. The room is equipped multiple chairs, a coffee table, rug, mounted television, and sports equipment. The room has a non-operable fireplace that is kept covered and made inaccessible to clients. Dining Room: Is located next to the kitchen. The room is equipped with a couch, coffee table, musical instruments, and art supplies. The room has a non-operable fireplace that is kept covered and made inaccessible to clients. Kitchen: Is equipped with refrigerator/freezer, a gas stove with four (4) burners, microwave, coffee maker, dishwasher, and a wooden table with six (6) chairs. The facility has a chef that prepares all meals for the clients. There is a Kosher Kitchen space dedicated for clients who have a Kosher diet. LPA observed the menu was posted and the trash can has a fitted lid. There were ample plates, cups, and eating utensils. Sharp knives are stored within a locked box kept in a locked cabinet under the stove. Facility had ample non-perishable and perishable food items. Snacks are kept in a locked double door pantry next to the kitchen. License ensures clients in care receive three (3) meals and snacks per day. Report continued on LIC 809C (Page 1 of 3) Staff office/Medication Room: This room is located on the second floor. This room is equipped with a desk, computer, and chairs. The room has a double door closet that stores the First Aid supplies, client medications, and a small refrigerator for medications. The closet remains locked and made inaccessible to clients. Medications are accessible to authorized employees. Therapy Rooms: There are two (2) rooms designated for therapeutic services. Both rooms are located on the first floor. The rooms are equipped with coffee tables, ample seating for clients, computer desks and an office chairs for therapists to use. Laundry Area: There is a washer and dryer. Cleaning supplies and detergent are stored in a locked cabinet opposite the washer and dryer. This area has a door that leads the backyard. Attached Garage: The garage has been converted into the classroom. It contains computers, tables, chairs, cabinets, and shelves. Cabinets are used to store school and art supplies. The area also has a locked cabinet that contains the hot water heater and furnace. Backyard Area: There is a covered patio with a grill and dining table, a basketball court, a fenced pool (fence meets regulation standards). LPA observed the gate door to swing away from the pool and has a self-close and self-latching lock. There are two locked sheds, one contains extra food, and one is used for storage. Bedrooms: There are three (3) bedrooms all located on the second floor. All bedrooms are equipped with two full sized beds, adequate drawer space, lighting and have windows. All bedrooms have comfortable mattresses, clean linen, blankets, and pillows. Bathrooms: There are four (4) bathrooms. Two bathrooms are located on the first floor, and two bathrooms are located on the second floor. All bathrooms have a toilets and sink; three (3) bathrooms have a shower; and one bathroom room has a shower and stand-alone tub (the water supply to the tub has been shut off). All bathrooms were checked and found to be clean and in operating condition. The water temperature was measured and found to between 105-120 degrees. LPA observed the facility to be clean, safe, sanitary and in good repair. Cleaning solutions, disinfectants, and cleaning supplies are stored in a locked hallway closet and made inaccessible to clients. The outdoor spaces were clean and clear of hazards. Passageways, open porches, and all exits were observed to be unobstructed. Licensee ensures that individuals supervising children in the pool area are Water Safety trained. The facility operates within license conditions and limitations including capacity limitations. LPA discussed and advised facility staff to ensure the following: Children are afforded their Personal Rights. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. Report continued on LIC 809C (Page 2 of 3) All posting requirements for Group Home Licensure, including the Emergency Plan, and grievance procedure were met and posted on the wall. The LPA reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. Licensee will ensure to utilize the Unusual Incident Report LIC 624, and LIC 624LE to document incidents. Transportation: The facility uses a Honda, Odyssey to transport children in care. LPA inspected the vehicle and found it to be in good repair. LPA observed the vehicle to have current registration and valid insurance. Facility staff provided LPA with a copy of the Personnel Report (LIC 500) and Current Client Roster (LIC 9020). Clients Records are electronically stored in the facilities online Portal with Kipuworks.com and Staff Records are electronically stored in the facilities online iSolve system. LPA will return at a later date to review staff and client files. There are no deficiencies observed or cited at this during this inspection. An exit interview was conducted with the Director of Operations, and a copy of this report was left at the facility. (Page 3 of 3)

met_with: Jaq Waldron - Director of Operations


facility_name: ASCEND HEALTHCARE 3

raw_content:
Narrative:
During the investigation there was inconsistent statements the schedule of the Administrator/Director. Interviews stated that due to COVID-19 outbreaks staff was doing hybrid schedules to reduce the spread of the virus. LPA Rosas conducted facility inspection on 10/19/2021, 10/21/2021, and 12/17/2022. LPA Rosas reviewed and obtained copy of Personnel Report (LIC 500). LPA observed ratio and administrator to be in compliance with regulations. Results from the Department's investigation, consisting of interviews with related parties, inspections, and review of records. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. The Department has decided that the allegations of Other are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There were no deficiencies observed or cited at this time. Exit interview was conducted with S1 and a copy of this report was left at the facility.

Investigation Findings:
13On April 26, 2022, at 1:30pm Licensing Program Analyst (LPA) Olivia Rosas made an announced inspection to Ascend Healthcare 3 for the purpose of concluding the investigation on the above allegations and to deliver the findings. LPA Rosas met with Staff#1 (S1) and together discussed the investigation details. Individuals mention in this complaint are identify on the Confidential Names List (LIC811) dated April 26, 2022. During the investigation, LPA Rosas inspected the facility, interview pertinent parties and reviewed supportive documentation. Based on gathered information, investigative interviews, record reviews and other supportive evidence the finding concerning program director does not work at the facility are unsubstantiated. LPA Rosas conducted facility inspection on 10/19/2021, 10/21/2021, and 12/17/2022. Report continues LIC9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Olivia Rosas LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: ASCEND HEALTHCARE 3FACILITY NUMBER: VISIT DATE: 04/26/2022

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

met_with: Staff#1 (S1)


summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13Licensing Program Analyst Connie Jones-Steward investigated the allegation that client was wrongfully discharged from the facility. LPA reviewed Ascend's discharge policies as written in their program statement and reviewed the admissions agreement and the discharge summary that were signed by both the complainant and C1, The facility states that C1 was discharged for violating the admissions agreement. However the complainant asserts that C1 was discharged due to a dispute between the facility and the insurance company. Due to conflicting accounts, LPA Jones-Steward was not able to substantiate nor disprove the allegation. Therefore it is resolved as unsubtantiated. Unsubstantiated means that although an allegation may have happened or is valid, there is not a preponderance of evidence that it did happen. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Connie Jones-Steward LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B This is an official report of an unannounced visit/investigation of a complaint received in our office on 03/13/2025 and conducted by Evaluator Connie Jones-Steward COMPLAINT CONTROL NUMBER: 34-CR- FACILITY NAME:ASCEND HEALTHCARE 3FACILITY NUMBER: ADMINISTRATOR:BRITTANY COHENFACILITY TYPE: ADDRESS: IRON CANYON ROADTELEPHONE: (661) 347- CITY:SANTA CLARITASTATE: CAZIP CODE: CAPACITY:6CENSUS: DATE: 03/26/ UNANNOUNCEDTIME BEGAN: 01: PM MET WITH:Brenda Reyes, Facility Manager/Jaq Waldron, Director of OperationsTIME COMPLETED:02: PM Facility did not properly report that C AWOLED. INVESTIGATION FINDINGS: 13Licensing Program Analyst Connie Jones-Steward met with Brenda Reyes & Jaq Waldron to discuss the allegation that Ascend did not report an AWOL by C1. LPA Jones-Steward searched the Special Incident Report (SIR) database and did not find an SIR regarding an AWOL by C1 on March 2, 2025. Ms. Reyes & Ms. Waldron checked their records and found notice of the incident. However there was no Special Incident Report made to Community Care Licensing, most likely due to an oversight. Ms. Reyes sad that she was out that week. However she wiil ensure that a report regarding the incident is filed. Ms. Reyes received the report from her staff and forwarded it to the Department during this visit. The facility was cited under Title 22, Section 80061(b)(1)(E) for faliure to report the absence of a client. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Connie Jones-Steward 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: 2 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: ASCEND HEALTHCARE 3FACILITY NUMBER: 198209719

met_with: Brenda Reyes, Facility Manager/ Jaq Waldron, Director of Operations


raw_content:
Narrative:
Client interviews shared that while the facility is on a farm, the facility is not dirty nor does it have an odor. Clients testified that a professional cleaning crew come at least twice a week, and that there are no complaints of a smell. Clients also shared during their interviews that while the facility was prepared to evacuate in January, they never left the facility. The evacuation was canceled, the area was safe, and no clients ever left the facility. Clients also stated that the outside facility grounds are generally well lit even at night. LPA interviewed several facility staff members who also testified that the facility does provide onboarding training to new hires, specifically called the "Ascend Academy". All staff shared that they attended the training prior to starting their work at the facility. LPA performed record reviews and observed that the training happened monthly and never took a break or was postponed. All staff confirmed that there are also monthly trainings provided by the facility, with reminders actively sent leading up to the trainings. LPA was also informed by staff interviews that mentor shadowing is provided beforehand for new hires to learn and ask questions about their work. Staff interviews also stated that the facility has professional cleaners come 2-4 times a week, while clients do chores regularly, and staff also perform general housekeeping duties. Staff interviews shared that there has never been a complaint or issue with odors in the house. Staff interviews testified that the facility has exterior lights all around the grounds, including the porch. LPA performed a facility walkthrough and specifically observed the porch lights to be in working condition. Staff shared that they have never heard of any on-the-job injury recently, and that there is no workers' comp case open at the moment. Staff interviews also corroborated that the facility never had to evacuate in January during the fires. LPA reviewed receipt records showing that the facility was prepared to evacuate to a local Hyatt hotel for emergency procedures, not an unlicensed facility. LPA received multiple conflicting testimonies regarding all the allegations against the facility. Interview evidence and records review of the roster for the previous "Ascend Academy" meetings show that the training was being provided and was never canceled or postponed. Interview evidence from the client and staff shared that the facility is free of odors due to weekly professional and general house cleaning. Interview and observation evidence showed that the facility's exterior lights were in working condition. Interview evidence and records review in the form of the hotel receipts show that the facility never evacuated to an unlicensed location, and if the facility needed to evacuate they were prepared to go to an approved emergency location. Based on the available information LPA gathered from interviews, records review, and observation evidence the preponderance of the evidence standard has not been met; therefore, the allegations that the "Facility did not ensure that staff are trained, Facility has an odor, Staff did not ensure that facility has adequate lighting, & Facility served clients at an unlicensed location." is found to be unsubstantiated. An exit interview was conducted, during which LPA provided the Facility Manager with a copy of this report and a copy of their appeal rights.

Investigation Findings:
13On 7/18/25 at 11: AM, Licensing Program Analyst (LPA) Reagan Cohen arrived at the above facility and met with Facility Manager for the purpose of delivering complaint findings regarding the above allegation. During the course of the investigation, LPA interviewed involved staff, clients, and witnesses. LPA also requested, received, and reviewed records evidence. LPA also toured the facility and observed the building and grounds. Witness testimony asserted that the facility was not providing the proper training to its staff, specifically the onboarding training, which resulted in ill-prepared staff and unsafe working environments. Witness testimony also alleged that the facility has an odor and is not properly cleaned. Witness interview stated that the facility is not properly lit outside, specifically the front porch, which resulted in an on-the-job injury. Witness interview also shared that during the fires in the area earlier in the year, the facility had to evacuate and did not evacuate to an approved emergency site like a nearby hotel, but went to another facility that had not been licensed yet to serve and care for clients. LPA also interviewed clients from the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Reagan Cohen LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: ASCEND HEALTHCARE 3FACILITY NUMBER: VISIT DATE: 07/18/2025

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

met_with: Brenda Reyes Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Olivia Rosas made an announced inspection to the Ascend Healthcare 3 on 10/19/21 at 10:00am for the purpose of conducting Annual Inspection. LPA Rosas met with Staff#1(S1), Staff#2(S2), Staff#3(S3) who granted access to the facility and an inspection of the facility was conducted together. The Ascend Healthcare 3 is a therapeutic treatment program that's designed to accept "Private Placement's" for a length of 45 - 90 days and is licensed to provide care supervision for six (6) youths, ages 12-17 years; ambulatory only. Individuals mention in this report are identify on the Confidential Names List (LIC811) dated 10/19/21. The S1 states that there are no guns or weapons on the premises. This is a one-story four (4) bedrooms. There are three (3) bathrooms, living room, dining room, outdoor Equine Therapy farm, and pool. LPA inspected the following: The Laundry room: The laundry room is enclosed adjacent to the kitchen. The laundry detergent is distributed to children individually according to the load of their laundry. Living Room/Dining room/Kitchen: Observed to be clean and organized; equip with living room furniture including a dining table. The Kitchen stove is gas operated with 4 burners and a grill flat top. The sharp knives and chemicals are made inaccessible locked in container in the staff office. There is one (1) extra refrigerator in the outdoor detached garage used for extra storage. LPA observed coverage trash cans in the kitchen, bathroom and staff office. LPA observed ample perishable food items in the refrigerator and the pantry is fully stocked with non-perishable food items. LPA observed enough perishable and Non-perishable food items for seven (7) days. The applicant will to ensure that three (3) nutritious meals, snacks, and special snacks will be provided to the youth. All disinfectant/ poisons chemicals are properly stored inaccessible. There is a private chef that comes to the facility and prepares all meals for the youth. Report continues on LIC 809-C Bedroom #1: Is occupied by Youth#1(Y1) and Youth#2 (Y2). There is two full size bed, adequate closet and drawer space. Bedroom #2: Is occupied by Youth#3(Y3) and Youth#4(Y4).. There is two full size bed, adequate closet and drawer space. Bedroom# 3: Is currently is not occupied but it reserved as the Quarantine room and Twin-size day bed available. Bedroom #4: Is occupied by Youth#5(Y5) and Youth#6 (Y6). There is two full size bed, adequate closet and drawer space. There is a bathroom in the room. Bathrooms: The bathrooms were inspected and found to be clean. LPA tested the water temperature, bathroom sinks and ensured that all toilets flushed. Bathroom #1 is shared by four (4) youths; has two (2) sinks; walk in shower and a separate tube that is not operable. Bathroom #2 sink toilet and a shower and inside of Bedroom#4. Bathroom #3 identified as the staff's bathroom equipped with a sink and a toilet. Staff Office: All the children prescribed medications are locked in the staff office and children files are store in a KIPU software system. Staff office is located inside the main facility. LPA observed a large key locked cabinet that stored hygiene supplies, separate containers for medication, various file folders to maintain the youth's records. The First Aid kit has the required items inside (age-appropriate, and scissors, tweezers, thermometer, and gauzes, antiseptic and First Aid Manual Guide. All windows were in good condition with screens and blinds. There were no security bars on the windows. LPA observed ample towels and linen closet. Back yard area: There is propane grill in good condition also observed to be secure and safe. The facility has a pool with a fence that is at least five feet high and has a fence does not obscure the pool from view. LPA Rosas and S1, S2, and S3 observed the gate door to swing away from the pool, with self-close and self-latching device located no more than six inches from the top of the gate. There is a pond located in the backyard of the facility completely covered with a sturdy net. The pool area is pending waiver from the Department. Report continues on LIC 809-C Garages: The attached garage is used as storage and is kept locked. The detached garage by the side of the house is used for storage, staff office, and has extra refrigerator. S1 stated the detached garage will be removed within three (3) months. LPA asked for safety plan for the removal of the detached garage. The outdoor perimeter front yard, side yard and backyard were inspected and found cleared of debris and hazards materials. LPA observed animals on the premises two (2) Goats; one (1) pig and three (3) miniature horses, and three (3) bunnies. All animals are gated in a barn style white picket fence. LPA verify that the animals are used for Specialist Equine Therapy. LPA observed two storage bins approximately 50 to 60 feet in distance. Storage bin #1 is utilized for the Equine storage animal food and supplies. Storage bin #2 is utilized for bunnies food and supplies. The two (3) chair swings; a Wood burning BBQ pit. All windows, screens and blinds from the inside and outside of the facility were observed to be in good condition. The passageways and porches are unobstructed. All posting requirements were met, (food menu, regulations, licenses, emergency disaster plan, Children's Personal Rights, and Ombudsman). The facility has a working telephone and youths can use the telephone unless restricted by court order. The Emergency Evacuation Plan is posted on the walls throughout the facility. There is a designated entrance for the staff to immediately wash their hands and have temperature tested prior to coming in direct contact with the youth. The Facility operates within license conditions and limitations including capacity limitations. Facility has a current, written plan of operation. Facility personnel are instructed to report violations of personal rights. Licensee will report changes in the plan of operation affecting service to youths. Licensee will report youth injuries requiring medical treatment. LPA-observed a camera in view of the perimeter; common areas of house (living room, dining room and hallways) that are not activated. There is a wood burning double sided fireplace; operable but not being utilized. The facility uses NEST electronic combined Smoke detector and Carbon Monoxide. Report continues on LIC 809-C On 08/26/2021, facility was informed that currently Community Care Licensing (CCL) are not approving camera waivers. S1 verbally ensured that all exterior and internal cameras are not activated. On 08/26/2021, LPA provided the S1 with a Declaration page (form LIC855), in order to declare under penalty and perjury that the facility security cameras will not be operable and will be unplugged, until a camera waiver has been approved by Community Care Licensing (CCL). CCL will conduct in person physical inspection in order approve the waiver in the future. The facility currently has no camera waiver or is granted to use video recording cameras. Fire Clearance granted on 6/22/2020 indicates that "The Garage is not permitted or to be used as a living space". LPA Rosas inspected and discussed the use of the garage is only to be used for storage or for cars. During inspection the garage is being used as storage and the detached garage will be removed. Facility will submit safety plan to LPA Rosas before removing the garage. The facility has one (1) chime in the exit door that is pending waiver from the Department. In addition, the facility is pending pool waiver from the Department. LPA Rosas discussed with and advised If any changes or modifications to the program or facility physical plant need to be submitted to the Department for review and approval before implementing the new changes. A review of Facility's Personnel Report Summary on 10/18/2021 indicates that all personnel have criminal record clearance has obtain the necessary clearances with DOJ, FBI, and Child Abuse Response. LPA Rosas was not able to review client or staff files during this visit and will return to continue with the annual inspection. There were no deficiencies observed or cited at this time. Exit interview was conducted with S2 and a copy of this report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Olivia Rosas made an announced inspection to the Ascend Healthcare 3 on 10/19/21 at 10:00am for the purpose of conducting Post-licensing Inspection. LPA Rosas met with Staff#1(S1), Staff#2(S2), Staff#3(S3) who granted access to the facility and an inspection of the facility was conducted together. The Ascend Healthcare 3 is a therapeutic treatment program that's designed to accept "Private Placement's" for a length of 45 - 90 days and is licensed to provide care supervision for six (6) youths, ages 12-17 years; ambulatory only. Individuals mention in this report are identify on the Confidential Names List (LIC811) dated 10/19/21. The S1 states that there are no guns or weapons on the premises. This is a one-story four (4) bedrooms. There are three (3) bathrooms, living room, dining room, outdoor Equine Therapy farm, and pool. LPA inspected the following: The Laundry room: The laundry room is enclosed adjacent to the kitchen. The laundry detergent is distributed to children individually according to the load of their laundry. Living Room/Dining room/Kitchen: Observed to be clean and organized; equip with living room furniture including a dining table. The Kitchen stove is gas operated with 4 burners and a grill flat top. The sharp knives and chemicals are made inaccessible locked in container in the staff office. There is one (1) extra refrigerator in the outdoor detached garage used for extra storage. LPA observed coverage trash cans in the kitchen, bathroom and staff office. LPA observed ample perishable food items in the refrigerator and the pantry is fully stocked with non-perishable food items. LPA observed enough perishable and Non-perishable food items for seven (7) days. The applicant will to ensure that three (3) nutritious meals, snacks, and special snacks will be provided to the youth. All disinfectant/ poisons chemicals are properly stored inaccessible. There is a private chef that comes to the facility and prepares all meals for the youth. Report continues on LIC 809-C Bedroom #1: Is occupied by Youth#1(Y1) and Youth#2 (Y2). There is two full size bed, adequate closet and drawer space. Bedroom #2: Is occupied by Youth#3(Y3) and Youth#4(Y4).. There is two full size bed, adequate closet and drawer space. Bedroom# 3: Has a daybed and the room is used as a Quarantine room. Bedroom #4: Is occupied by Youth#5(Y5) and Youth#6 (Y6). There is two full size bed, adequate closet and drawer space. There is a bathroom in the room. Bathrooms: The bathrooms were inspected and found to be clean. LPA observed S1 test the water temperature, bathroom sinks and ensured that all toilets flushed. Bathroom #1 is shared by 4 youths; has 2 sinks; walk in shower and a separate tube that is not operable. Bathroom #2 sink toilet and a shower and inside of Bedroom#4. Bathroom #3 identified as the staff's bathroom equipped with a sink and a toilet. Staff Office: All the children prescribed medications are locked in the staff office and children files are store in a KIPU software system. Staff office is located inside the main facility. LPA observed a large key locked cabinet that stored hygiene supplies, separate containers for medication, various file folders to maintain the youth's records. The First Aid kit has the required items inside (age-appropriate, and scissors, tweezers, thermometer, and gauzes, antiseptic and First Aid Manual Guide. All windows were in good condition with screens and blinds. There were no security bars on the windows. LPA observed ample towels and linen closet. Back yard area: There is propane grill in good condition also observed to be secure and safe. The facility has a pool with a fence that is at least five feet high and has a fence does not obscure the pool from view. LPA Rosas and S1, S2, and S3 observed the gate door to swing away from the pool, with self-close and self-latching device located no more than six inches from the top of the gate. There is a pond located in the backyard of the facility completely covered with a sturdy net. The pool area is pending waiver from the Department. Report continues on LIC 809-C Garages: The attached garage is used as storage and is kept locked. The detached garage by the side of the house is used for storage, staff office, and has extra refrigerator. S1 stated the detached garage will be knocked out within 3 months. LPA asked for safety plan for the removal of the detached garage. The outdoor perimeter front yard, side yard and backyard were inspected and found cleared of debris and hazards materials. LPA observed animals on the premises (two (2) Goats; one (1) pig and three (3) miniature horses, and three (3) bunnies. All animals are gated in a barn style white picket fence. LPA verify that the animals are used for Specialist Equine Therapy. LPA observed two storage bins approximately 50 to 60 feet in distance. Storage bin #1 is utilized for the Equine storage animal food and supplies. Storage bin #2 is utilized for bunnies food and supplies. The two (3) chair swings; a Wood burning BBQ pit. All windows, screens and blinds from the inside and outside of the facility were observed to be in good condition. The passageways and porches are unobstructed. All posting requirements were met, (food menu, regulations, licenses, emergency disaster plan, Children's Personal Rights, and Ombudsman). The facility has a working telephone and youths can use the telephone unless restricted by court order. The Emergency Evacuation Plan is posted on the walls throughout the facility. There is a designated entrance for the staff to immediately wash their hands and have temperature tested prior to coming in direct contact with the youth. The Facility operates within license conditions and limitations including capacity limitations. Facility has a current, written plan of operation. Facility personnel are instructed to report violations of personal rights. Licensee will report changes in the plan of operation affecting service to youths. Licensee will report youth injuries requiring medical treatment. LPA-observed a camera in view of the perimeter; common areas of house (living room, dining room and hallways) that are not activated. There is a wood burning double sided fireplace; operable but not being utilized. The facility uses NEST electronic combined Smoke detector and Carbon Monoxide. Report continues on LIC 809-C On 08/26/2021, facility was informed that currently Community Care Licensing (CCL) are not approving camera waivers. S1 verbally ensured that all exterior and internal cameras are not activated. On 08/26/2021, LPA provided the S1 with a Declaration page (form LIC855), in order to declare under penalty and perjury that the facility security cameras will not be operable and will be unplugged, until a camera waiver has been approved by Community Care Licensing (CCL). CCL will conduct in person physical inspection in order approve the waiver in the future. The facility currently has no camera waiver or is granted to use video recording cameras. Fire Clearance granted on 6/22/2020 indicates that "The Garage is not permitted or to be used as a living space". LPA Rosas inspected and discussed the use of the garage is only to be used for storage or for cars. During inspection the garage is being used as storage and the detached garage will be removed. Facility will submit safety plan to LPA Rosas before removing the garage. A review of Facility's Personnel Report Summary on 10/18/2021 indicates that all personnel have criminal record clearance has obtain the necessary clearances with DOJ, FBI, and Child Abuse Response. The facility has three (3) chimes in the doors and windows that is pending waiver from the Department. In addition, the facility is pending pool waiver from the Department. LPA Rosas discussed with and advised If any changes or modifications to the program or facility physical plant need to be submitted to the Department for review and approval before implementing the new changes. There were no deficiencies observed or cited at this time. Exit interview was conducted with S2 and a copy of this report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Olivia Rosas made an announced inspection to the Ascend Healthcare 3 on 10/19/21 at 10:00am for the purpose of conducting Case Management- Licensee Initiated (Pool Waiver). LPA Rosas met with Staff#1(S1), Staff#2(S2), Staff#3(S3) who granted access to the facility and an inspection of the facility was conducted together. The Ascend Healthcare 3 is a therapeutic treatment program that's designed to accept "Private Placement's" for a length of 45 - 90 days and is licensed to provide care supervision for six (6) youths, ages 12-17 years; ambulatory only. Individuals mention in this report are identify on the Confidential Names List (LIC811) dated 10/19/21. The following items were inspected with S1, S2, S3: The facility has a pool with a fence that is at least five feet high and has a fence does not obscure the pool from view. LPA Rosas and S1, S2, S3 observed the gate door to swing away from the pool, with self-close and self-latching device located no more than six inches from the top of the gate. When LPA Rosas and S2 tested the door the gate and is self-close and has a self-latching device located no more than six inches from the top of the gate. The pool has a fence around the pool with two entree points. One of the entree doors is kept locked as it leads to the driveway, one of the doors is always to remain open. LPA Rosas received a copy of staff water safety certificates, and updated facility sketch. The pool waiver request is pending approval from Community Care Licensing Division (CCLD). There were no deficiencies cited at this time. Exit interview was conducted with S2 and a copy of this report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Olivia Rosas made an announced inspection to the Ascend Healthcare 3 on 10/19/21 at 10:00am for the purpose of conducting Case Management- Licensee Initiated (Chime Window/Door Waiver). LPA Rosas met with Staff#1(S1), Staff#2(S2), Staff#3(S3) who granted access to the facility and an inspection of the facility was conducted together. The Ascend Healthcare 3 is a therapeutic treatment program that's designed to accept "Private Placement's" for a length of 45 - 90 days and is licensed to provide care supervision for six (6) youths, ages 12-17 years; ambulatory only. Individuals mention in this report are identify on the Confidential Names List (LIC811) dated 10/19/21. The following items were inspected with S1, S2, S3: As indicated on the facility sketch, the facility has a total of one (1) chime alarm sensors installed on the exit glass door in Bedroom#4. LPA Rosas and S1, S2, S3 verified the alarm chime were operable during the inspection by testing the exit glass door. The alarm chime sensor waiver request is pending approval from Community Care Licensing Division (CCLD). There were no deficiencies noted or cited during this inspection. Exit interview was conducted with S2 and a copy of this report was left at the facility


summary: Facility Evaluation

raw_content:
Narrative:
On September 22, 2022 at 9: AM, Licensing Program Analyst (LPA) Charmetha White arrived at Ascend Healthcare 3, for the purpose of conducting a Annual/Required inspection. LPA met with Brenda Reyes, Facility Manager and was granted access into the facility. The facility was toured at 10: AM both inside and out. The facility is a private pay therapeutic treatment program licensed to provide care and supervision services for six (6) children, ages 12-17 years old, ambulatory only. The census at the time of the inspection was four (4). The facility is a one story, 4-bedroom, 3-bathroom house which includes a Living room, Dining room, Kitchen, Laundry room, Staffing/Medical office, Equine Therapy farm, a Pool, Garages, and a Backyard. The facility is set up as follows: Living room: is furnished with sectional sofa, chairs, and has a operable wood burning fireplace equipped with an iron screen. Dining room: is furnished with a wooden table and six (6) chairs, and has a operable wood burning fireplace equipped with a screen. Kitchen: is equipped with a 4-burner gas operated stove with a flat top grill, a microwave, refrigerator/freezer, a dishwasher, and a pantry. Laundry room: is located next to the kitchen and is equipped with washer and dryer. Staffing/Medical office: is located inside the main facility. The office is equipped with a computer, chair, and desk. LPA observed the room to have locked cabinets which are used to stores files, hygiene supplies, and client medications. Additionally, medications that require refrigeration is stored in a double locked refrigerator located in the office. The office is locked and made inaccessible to clients in care. Equine Therapy Farm: is gated and houses 2 goats, 1 pig, and 3 miniature horses. There are 2 storage bins next to the farm; one contains animal food and supplies; the other is used for storage. Pool: is located in the backyard and is equipped with a fence and pool cover which meet the regulations. Garages: one garage is attached to the home and was observed to be used as a classroom; the room had multiple computers tables and chairs. The second garage was observed to have an extra refrigerator used by staff, a staff restroom, storage shelves, and two separate therapy offices equipped with desk, chairs, and a sofa. Report continued on LIC 809C. Backyard: is equipped with a propane grill, a cement wood burning barbeque pit, a fire place equipped with a screen, volleyball net, ping pong table, yoga mats, a wooden table with seven (7) chairs, a swing, and multiple seating areas. Bedroom #1: is furnished with two twin size beds, closet space, two multi-shelve hanging organizers, and a working light. Bedroom #2: is furnished with two twin size beds, closet space, two multi-shelve hanging organizers, and a working light. Bedroom #3: is furnished with a twin-size day bed, closet space, a small three drawer dresser, and a working light. Bedroom #4: is furnished with two twin size beds, closet space, two multi-shelve hanging organizers, a working light, and has an attached bathroom. Bathrooms: All bathrooms were checked and found to be in good repair and working order. The hot water temperature was tested and found to be between 105-120 degrees (F). The carbon monoxide and smoke detectors were tested and found to be in working order. First Aid Kit was checked and found to be complete. The facility has 4 regulation fire extinguishers. The facility has a working telephone readily accessible. Menu is posted in kitchen area and facility has non-perishable foods for one-week, and perishable foods for two days. All meals are prepared off site and brought over the facility and clients are provided nutritious between meals snacks. Overall LPA observed the facility to be clean, safe, sanitary and in good repair. The front yard and outdoor recreation area were clean and free of debris. Passageways, stairways, inclines, ramps and open porches were unobstructed. There are no firearms or dangerous weapons in the facility. Temperatures in client rooms and common areas were found to be between 68 - 85 degrees (F). Disinfectants/cleaning solutions and poisons are stored and inaccessible to clients. The facility operates within license conditions and limitations including capacity limitations. LPA discussed and advised the Licensee to ensure the following: Children are supported and encouraged to participate in extracurricular activities. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. LPA reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. All posting requirements for Group Home Licensure and Emergency Plan were met. LPA observed a camera in the living room, dining room, hallways, and outside perimeter. There is no camera waiver on file and facility has not been granted the use of cameras. Facility Manager ensured LPA cameras are not activated. Facility Manager provided LPA with a copy of the Personnel Report (LIC 500). LPA will return at a later time to review client and staff records. There are no deficiencies observed or cited at this during this inspection. An exit interview was conducted with the Facility Manager, and a copy of this report was left at the facility.

met_with: Facility Manager - Brenda Reyes


facility_name: ASCEND HEALTHCARE 4

raw_content:
Investigation Findings:
13On 08/25/2022 at 12pm, Licensing Program Analyst (LPA) Bernice Karnsrithong arrived at the facility for the purpose of delivering findings for the above complaint investigation. Health and safety risk assessment was conducted upon arriving at the facility. LPA Karnsrithong met with Brenda Reyes, Facility Manager who granted access to the facility. During the investigation of the allegations, Staff inappropriately searched a minor while in care and Staff did not prevent a minor from wandering while in care; LPA Karnsrithong conducted confidential interviews and reviewed documentary evidences. There was no sufficient evidence that supports that staff inappropriately searched a minor and staff did not prevent a minor from wandering while in care. Admission Policies on Reasonable Search was provided to clients before enrollment to the facility. Statements were consistent that AWOL/Runaway communication system and policies were implemented when client goes on runaway. There was no corroborating witness. LPA determines that the allegations are unsubstantiated at this time meaning, although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. Exit interview was conducted with Facility Manager and a copy of this report will be provided. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Bernice Karnsrithong 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: Brenda Reyes, Facility Manager


raw_content:
Investigation Findings:
13On 08/25/2022 at 12pm, Licensing Program Analyst (LPA) Bernice Karnsrithong arrived at the facility for the purpose of delivering findings for the above complaint investigation. Health and safety risk assessment was conducted upon arriving at the facility. LPA Karnsrithong met with Brenda Reyes, Facility Manager who granted access to the facility. During the investigation of the allegation, Minor was not allowed to receive phone calls; LPA Karnsrithong conducted confidential interviews, conducted on-site inspections, and reviewed documentary evidences. Statements from confidential interviews were consistent that clients are not permitted to receive or make phone calls within the first seven days of admission to the facility. Facility has been cited for California Code of Regulations, Title Division Six, Chapter Article 06. Continuing Requirements Personal Rights: (8) To make and receive confidential telephone calls, unless prohibited by court order. Plan of correction, appeals and exit interview was conducted with Brenda Reyes, Facility Manager SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Bernice Karnsrithong LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: ASCEND HEALTHCARE 4FACILITY NUMBER: 198209744

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


raw_content:
Investigation Findings:
13On 02/26/2025 at 11: AM, LPA Jarmin arrived at Ascend Healthcare 4 to deliver findings on the allegation. LPA met with the Clinical Director and Facility Manager and explained that the investigation concluded on 02/03/2025. During the investigation, LPAs conducted confidential interviews, a health and safety assessment, and reviewed relevant documents. Findings revealed insufficient evidence to substantiate that a staff member engaged in inappropriate contact with a former youth in care. Interviews and records confirmed that the licensee took immediate action when made aware of the issue. The staff member, reassigned pending investigation, voluntarily left before the process was completed and was terminated. The facility followed policies and procedures, including staff training on client interactions and complaints. The allegation is unsubstantiated, meaning there was not enough evidence to support or disprove it. An exit interview was conducted, and a copy of the report will be provided. Amended from 02/26/ Findings. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Enrique M Hernandez LICENSING EVALUATOR NAME: Dennis Jarmin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B This is an official report of an unannounced visit/investigation of a complaint received in our office on 09/08/2023 and conducted by Evaluator Dennis Jarmin COMPLAINT CONTROL NUMBER: 34-CR- FACILITY NAME:ASCEND HEALTHCARE 4FACILITY NUMBER: ADMINISTRATOR:BRITTANY COHENFACILITY TYPE: ADDRESS: LORJEN ROADTELEPHONE: (661) 309- CITY:CANYON COUNTRYSTATE: CAZIP CODE: CAPACITY:6CENSUS: 6DATE: 02/26/ UNANNOUNCEDTIME BEGAN: 11: AM MET WITH:Do not useTIME COMPLETED:01: PM INVESTIGATION FINDINGS: UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Enrique M Hernandez LICENSING EVALUATOR NAME: Dennis Jarmin 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: 2 of 2

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

met_with: Kathryn Castronovo


summary: Facility Evaluation

raw_content:
Narrative:
On September 30, 2021 at 10:00am, Licensing Program Analyst (LPA) Olivia Rosas conducted a Component II- Face to Face with Ascend Healthcare 4 on Microsoft Teams. The purpose of the meeting was to discuss the Plan of Operation, Program Statement and supporting documents due to the facility opening a Group Home. The Ascend Healthcare 4 is a therapeutic treatment program that's designed to accept "Private Placement's" for a length of 45 - 90 days and will provide care supervision for six (6) clients, ages 12-17 years; ambulatory only. Attendees: Olivia Rosas, Licensing Program Analyst Effie Goldberg/CEO Jaq Waldron, Facility Manager The following matters were discussed: A Fire Safety Inspection Request (Form STD 850) was submitted on 05/26/2021 to the Los Angeles County Fire Department Schools, Churches & Institutions Unit. The fire safety inspection was completed on 06/23/2021 and noted "The facility renders no care to clients. This facility is used for drug and alcohol rehabilitation only. Garages are to be used for stated and vehicle use only, no habitation permitted. The Department is currently not accepting or approving camera/monitoring equipment waivers. Unless prior written licensing agency approval is received and approved no use of cameras/monitoring equipment can be used. PIN 21-03-CRP: Senate Bill 1264 (Committee on Human Services) Chapter 367, Statutes of 2020. Update emergency and disaster preparedness plan. (Continued on LIC809-C) The following is needed for License approval: LIC 309- Administrative organization- Update section 10. LIC308- Designation of Facility Responsibility LIC500- Personnel Form: Update Administrator, Facility Manger LIC 999- Facility Sketch- Update to include pool, label rooms, name rooms be used by staff/residents/clients. LIC610C Emergency Disaster Plan- Update section V. LIC501, LIC503- Personnel Record: Missing CEO, Administrator, Facility Manager with Criminal Clearance Transfer Request for personnel (CEO, Administrator, Facility Manager, Clinical Director, Nurse Manager, Education Manager). Water Safety Certificate for staff is needed because a pool was added Mention of the use of animals for therapeutic therapy Personnel Requirements: Application, Resume, Health Screening (Form LIC503 / TB test) are needed for Administrator, Facility Manager, Clinical Director, Nurse Manager, Education Manager. Section 16- Update CCLD information Section 21- LIC500 update Section 22- Staff Qualifications Section 28- update facility sketches Community Relations and Neighbor Complaints- Update to include dates/times Facility Manger or Administrator is available for neighbors. Include contact information. Each section of the Plan of Operation and Program Statement were reviewed, and LPA discussed the changes and revisions that need to be modified to meet Licensing Standards. LPA Rosas and the facility schedule pre-licensing visit for Wednesday, October 20, 2021 and Comp-III. LPA Rosas provided a copy of LIC Notification of Incomplete Application with items that need to be submitted by 11/29/2021. Exit interview completed and a copy of the report was mail to the Administrator.

met_with: CEO