summary: Facility Evaluation

raw_content:
Narrative:
On 04/23/ Licensing Program Analyst (LPA) Chad Cabigon arrived unannounced at this Enhanced Behavioral Supports Home - GH (Group Home) to conduct its Required/Annual Inspection. LPA was met by Harrisha Willis, Lead Staff II, who gave a tour of the interior and exterior grounds of the facility's physical plant; Ms. Willis also facilitated client interviews as well as the start of the records review. More time is required to complete the inspection; a copy of this report is being provided to the facility.

met_with: Harrisha Willis


state: CA

facility_name: MERAKEY - TENAYA

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Although the allegation may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No title 22 regulations were cited during today's inspection. An exit interview was conducted, a copy of this report and appeal process was reviewed and provided to the Administrator and the Shift Lead DSP.

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

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

report_type: Complaint Investigation

met_with: Shift Lead DSP

complaint_status: unsubstantiated


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
During interviews, C1 stated that S1 hits him and has sat on him on at least one occasion. C1 identified S2, S3 and S4 as witnesses. All staff including witnesses identified by C1 deny observing S1 placing her hands on C1. Two staff state that C1 can't be restrained due to Individual Program Plan IPP. However, two staff (S2 and S6) corroborate that S1 sat on him. S2 stated that she observed S1 entering C1's room and C1 running out of the room stating that S1 sat on him. S6 stated that C1 told her that S1 sat on C1. Additionally, S6 stated observing C1 hiding from S1 on several occasions. One staff out of 5 stated that C1 has been restrained one time. Two staff state that C1 can't be restrained due to Individual Program Plan (IPP). The Needs and Services Plan does state , "Due to Hevanne's heart condition, physical containment is not recommended." As a result of the information obtained and the confidential interviews conducted, the allegations that a minor was shoved in care and improperly restrained are substantiated. Based on the information obtained there is preponderance of the evidence to prove the facility staff shoved the minor in care and improperly restrained minor. On this date, the facility is being cited for the following violations of Title 22, Division 6, Chapter 5 found during complaint investigation conducted from 1/4/22- 2/9/22: Personal Rights 84072 (d) (11) and Needs and Services Plan 84078 (b) . An exit interview was conducted and a copy of appeal rights was left with the facility.

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

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

met_with: Jronesha Brown DSP Lead II

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
Allegation: Personal Rights- To be free from physical, sexual, emotional or other abuse, and corporal punishment. The allegation is staff caused injury to minor in care. Although minor did present with an injury, (5 inches by 4 inches bruise on right thigh with diamond and triangle marks) Licensing Program Analyst unable to determine where injury occurred and who was responsible. Clients in facility are all non-verbal and unable to be interviewed. Facility staff interviewed all corroborate that they did not observe any behavior by clients and/or staff that would have caused the injury. School did report restraint of client on 06/16/2022 but, was transparent with photos and did not observe the injury in question. Interview with school staff corroborate that injury did not occur during restraint and school staff identified the injury the following day. Based on the investigation, records reviewed and interviews conducted, the complaint finding is UNSUBSTANTIATED at this time meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Client not being provided with PRN medication as needed. The allegation is staff mismanaged minor's medication. Review of daily medication chart indicates client received PRN medication on 05/19/2022. 05/21/2022, 05/25/2022 and 05/28/2022 for watery eyes and runny nose visible symptoms. Photos taken on 05/22/2022 provided to the Department show minor with a crusty nose and chapped lips and face. LPA unable to identify if PRN's were provided as soon as symptoms began which may have prevented chapping to nose and face. Interviews with staff corroborate PRN's are given based on visible symptoms as client does not have a way to communicate need for allergy medication. Based on the investigation, records reviewed and interviews conducted, the complaint finding is UNSUBSTANTIATED at this time meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. LPA Goldie conducted exit interview at 2: PM and provided and discussed a copy of this report and a copy of appeal rights to the facility.

Investigation Findings:
13Licensing Program Analyst (LPA) Connie Goldie arrived at the agency to conduct an unannounced complaint investigation inspection on 09/09/2022 at 1: PM PM. LPA Goldie spoke with Kylie Leblanc, Program Administrator(in training) and Robyn Cheeskiewicz Director of Program Assistance to discuss the findings of the complaint investigation and allegations stated above. LPA Goldie informed facility staff this case was investigated by LPA Goldie. The initial 10-day complaint investigation inspection was conducted by LPA Connie Goldie at the facility on 06/24/2022. LPA Goldie toured the facility and an interview was conducted with facility staff J'Ronesha Brown, Lead Staff II. Copies of facility documentation provided to LPA Goldie included :Client register, one client's individual personalized plan and IBST notes, one client's PRN medication sheets for May and June, daily shift log-hygiene, restraint log, cleaning schedule log and pest control reports/receipts for 6 months, Staff Roster, staff schedule month of June and staff contact Information. Confidential interviews were conducted with eight staff, three witnesses, co-complainant, VMRC supervisor and Program Administrator between 06/24/2022 and 09/07/2022. Records review of documents and photos obtained was completed on 07/07/2022 and 09/07/2022. Continued on LIC9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Connie Goldie LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: MERAKEY - TENAYAFACILITY NUMBER: VISIT DATE: 09/09/2022

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

met_with: Robyn Cheskiewicz Director of Program Assistance Kylie LeBlanc Program Administrator in Training


raw_content:
Narrative:
Allegation: Reporting Guidelines not met. The allegation is staff did not report child's injury as required. Special incident report was written and provided to Community Care Licensing on 06/21/2022, five days after incident occurred which does not meet the regulation requirement of reporting within the agency's next working day. Based on LPA's observations and record reviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Title 22, Division 6, Chapter Article 6 80061 (b) (1) (G) Reporting Requirements is being cited on the attached LIC 9099D Allegation: Hygiene needs of minor not being met. The allegation is staff did not ensure that minor's hygiene needs were met. Multiple photos were provided to the Department indicating hygiene needs not being met. Photos included dirty feet on multiple occasions and long fingernails. Daily logs also indicate inconsistencies in teeth brushing. Interviews corroborated that youth's hygiene needs are not being consistently met. Based on LPA's observations, record reviews and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Title 22, Division 6, Chapter Article 6 84072 (d) Personal Rights is being cited on the attached LIC9099D. Allegation: Unsanitary conditions at facility. The allegation is the staff did not keep the facility sanitary. Records review of mopping calendar for facility reflects that between April 2022 and June 2022 there were 7 days the facility was not mopped at all. LPA observed unsanitary conditions in the backyard on 08/23/2022 during inspection. Sandbox 4'by 6' intended for use by clients had multiple animal feces inside. Based on LPA's observations, record reviews and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Title 22, Division 6, Chapter Article 7 80087 (a) Buildings and Grounds is being cited on the attached LIC9099D. Exit interview completed at 2: PM . A copy of this report and appeal rights were discussed and provided to the facility.

Investigation Findings:
13Licensing Program Analyst (LPA) Connie Goldie arrived at the agency to conduct an unannounced complaint investigation inspection on 09/09/2022 at 1: PM. LPA Goldie spoke with Robyn Cheskiewicz Director of Program Assistance and Kylie LeBlanc Program Administrator in Training , to discuss the findings of the complaint investigation and allegations stated above. LPA Goldie informed facility staff this case was investigated by LPA Goldie. The initial 10-day complaint investigation inspection was conducted by LPA Connie Goldie at the facility on 06/24/2022. LPA Goldie toured the facility and an interview was conducted with facility staff J'Ronesha Brown, Lead Staff II. Copies of facility documentation provided to LPA Goldie included :Client register, one client's individual personalized plan and IBST notes, one client's PRN medication sheets for May and June, daily shift log-hygiene, restraint log, cleaning schedule log and pest control reports/receipts for 6 months, Staff Roster, staff schedule month of June and staff contact Information. Confidential interviews were conducted with eight staff, three witnesses, co-complainant, VMRC supervisor and Program Administrator between 06/24/2022 and 09/07/2022. Records review of documents and photos obtained was completed on 07/07/2022 and 09/07/2022. Continued on LIC9099C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Connie Goldie LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: MERAKEY - TENAYAFACILITY NUMBER: VISIT DATE: 09/09/2022

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


raw_content:
Narrative:
Allegation # Staff did not ensure supervision of youth in care. Regarding the allegation that staff did not ensure supervision of youth in care, statements made during interviews by 5 of 7 staff corroborated that emergency ratios are utilized at minimum 1-2 times a week. Emergency ratios were defined as 2:1 ratio clients going to 1:1 and 1:1 ratio client going to general supervision. One staff stated facility is never out of ratio but, did refer to emergency ratio. One staff stated the facility is never out of ratio. The Regional Center determines the level of supervision needed based upon the needs of the clients. These fluctuating ratios were not approved by the Regional Center or Community Care Licensing. All clients are unable to be interviewed because they are non-verbal. Based on LPA's observations and interviews which were conducted, and record reviews of time sheets, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Title Division Chapter 5 84078 (b) Responsibility for Providing Care and Supervision is being cited. Allegation # Needs and Services plans not being adhered to for minor in care. Regarding the allegation that Needs and Services plans are not being adhered to for minor in care, statements made during interviews were corroborated. Two of three staff present corroborated that the definition of imminent danger was reached during a client behavior when client hit his eyes with closed fists and slammed his head into the wall but, a restraint was not conducted as outlined in the Individual Emergency Intervention Plan resulting in injuries to clients face- bruising and swelling to eyes and bridge of nose. One of the staff stated the restraint was not done because a staff was uncomfortable with doing a restraint. One staff does not recall how client received injuries. Based on interviews and record review of incident report and photographs submitted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Title Division Chapter Article 8 84300(c) Emergency Intervention in Group homes is being cited. An exit interview was conducted, a copy of this report and appeal process was reviewed and provided to the Board Certified Behavior Analyst Blair Greenberg at 12: PM.

Investigation Findings:
13Licensing Program Analyst (LPA) Connie Goldie arrived at the agency to conduct an unannounced complaint investigation inspection on 12/09/2022 at 11: AM. LPA Goldie spoke with, Blair Greenberg, Board Certified Behavior Analyst to discuss the findings of the complaint investigation and allegations stated above. LPA Goldie informed facility staff this case was investigated by LPA Goldie. The initial 10-day complaint investigation inspection was conducted by LPA Connie Goldie at the facility on 09/21/2022. LPA Goldie toured the facility and interviewed two facility staff. Copies of facility documentation provided to LPA Goldie included: Client register, one client's individual personalized plan and IBST notes for 2 months, Staff Roster, staff schedules July-September and staff contact Information. Confidential interviews were conducted with six staff, VMRC supervisor and Program Administrator between 09/21/2022 and 11/29/2022. No client interviews were conducted as all clients are non-verbal. Records review of documents obtained was completed on 09/20/2022 , 11/03/2022 and 11/10/ SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Connie Goldie LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: MERAKEY - TENAYAFACILITY NUMBER: VISIT DATE: 12/09/2022

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


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Regarding the allegation that youth in care was touched inappropriately, statements made during interviews by 6 of 6 staff corroborated that C1 is capable of toileting independently but, does require prompting. 4 staff of 6 staff stated they were unaware of a client being touched inappropriately. Two staff stated that C1 was struggling with diarrhea on 09/16/2022 when S6 assisted C1 in the bathroom. S6 stated "I put on gloves and gently guided his penis into the toilet to avoid a mess." S1 confirmed that S6 communicated this was done "as urine was shooting out." Although S6 did touch youth, it was done to assist youth and therefore, not with negative intent. Record review of Individual Program Plan, indicates C1 is toilet trained, however does have occasional inappropriate urinations. Based on lack of observation and information provided by interviewees, the LPA found that while this allegation may have occurred or is valid, there was not a preponderance of evidence to prove that it did or did not occur, therefore LPA has found it to be unsubstantiated. An exit interview was conducted, a copy of this report and appeal process was reviewed and provided to the Administrator.

Investigation Findings:
13Licensing Program Analyst (LPA) Connie Goldie arrived at the agency to conduct an unannounced complaint investigation inspection on 04/06/2023 at 04: PM. LPA Goldie spoke with,Jronesha Brown, Program Administrator to discuss the findings of the complaint investigation and allega stated above. LPA Goldie informed facility staff this case was investigated by LPA Goldie. The initial 10-day complaint investigation inspection was conducted by LPA Connie Goldie at the facility on 01/19/2023. LPA Goldie toured the facility and interviewed five facility staff. Copies of facility documentation provided to LPA Goldie included: Client roster, one client's individual personalized plan, September 2022 communication notes log for 1 client, Staff Roster, staff schedules for January and February, and staff contact Information. Confidential interviews were conducted with six staff, VMRC supervisor and Program Administrator between 10/08/2022 and 03/30/2023. No client interviews were conducted as all clients are non-verbal. Records review of documents obtained was completed on 01/30/2023. Continued on LIC9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Connie Goldie LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: MERAKEY - TENAYAFACILITY NUMBER: VISIT DATE: 04/06/2023

met_with: Jronesha Brown Program Administrator


raw_content:
Narrative:
The Department investigated the allegation, "Staff utilized inappropriate discipline to keep client in bedroom." One staff stated that a water gun was used to keep a resident in their bedroom. Six of seven staff interviewed denied using a water gun to squirt a client and stated they did not observe any other staff do so. Two of seven staff stated water guns were used for an art activity with the behaviorist. All staff stated C1 does not sleep well at night and is frequently awake but, he is allowed to come out of the bedroom to get water, snacks and utilize the bathroom and is redirected to bedroom afterwards to rest. Therefore, it is not possible to determine whether the allegation occurred or not. Based on the investigation, records reviewed, and interviews conducted, the complaint finding is UNSUBSTANTIATED at this time meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted. A copy of all reports and appeal rights were provided to the facility.

Investigation Findings:
13Licensing Program Analysts (LPAs) Connie Goldie and Michelle Silvas arrived at the agency to conduct an unannounced complaint investigation inspection on 10/11/2024 at 02: PM. LPA Goldie spoke with Jessica Kutsoginis, Program Administrator to discuss the findings of the complaint investigation and allegation stated above. The initial 10-day complaint investigation inspection was conducted by LPA Goldie at the facility on 08/20/2024. LPA conducted a record review of two staff and one youth files. LPA received the following documentation: Register of facility clients, LIC500, Activity schedules August 2024, staff schedule for week 07/14/2024-07/20/2024, C1's IPP plan, behavioral plan and internal review of allegation report . Interviews were conducted with seven facility staff and service coordinator from 08/20/2024- 10/09/2024. C1 was unable to be interviewed due to cognitive disabilities. Continued on LIC9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Connie Goldie LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: MERAKEY - TENAYAFACILITY NUMBER: VISIT DATE: 10/11/2024

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

met_with: Jessica Kutsoginis Program Administrator


raw_content:
Narrative:
The Department investigated the allegation," Staff speaks inappropriately to client in care." Five of seven staff corroborate that staff have spoken inappropriately to clients in care. Staff comments made were, "staff speaks harshly to clients", 'staff made rude comments to a client" and "staff aggressively yelled at clients more than three times." Therefore, the allegation is determined to be substantiated. Based on LPA's observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 5, 84072(d)(1) Personal Rights, are being cited on the attached LIC 9099D." An exit interview was conducted. A copy of all reports and appeal rights were discussed and provided to Ms. Taylor.

Investigation Findings:
13Licensing Program Analyst (LPA) Connie Goldie arrived at the agency to conduct an unannounced complaint investigation inspection on 11/27/2024 at 12: PM. LPA Goldie spoke with Tiauna Taylor, Facility Manager to discuss the findings of the complaint investigation and allegation stated above. The initial 10-day complaint investigation inspection was conducted by LPA Goldie at the facility on 09/04/2024. LPA conducted a health and safety check assessment of the facility inside and outside, LPA interviewed one staff and conducted a record review of a staff file and two youth files. LPA received and reviewed the client register, staff schedules for October 2024, A Quality and Compliance Report dated 08/01/2024 and an Individualized Program Plan for two youth- C1 and C2. Seven interviews were conducted during the course of the investigation. The clients in care, C1, C2, C3 and C4 are unable to be interviewed as they are non-verbal. Continued on LIC9099C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Connie Goldie LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: MERAKEY - TENAYAFACILITY NUMBER: VISIT DATE: 11/27/2024

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

met_with: Tiauna Taylor Facility Manager


facility_name: MOSAIC MANOR

raw_content:
Narrative:
Based on record review and confidential interviews, the youth has managed to elope from care, caused property damage, and caused injury to staff. Also based on record review and interviews, staff have followed facility protocols of de-escalation. Although the allegation that facility does not have control of minor may or may not be true, the allegation has not met the preponderance of doubt. Therefore the allegation is unsubstantiated. LPA conducted an exit interview with George Grant, Administrator at 3:00PM whose signature confirms the receipt of this document.

Investigation Findings:
13On 2/7/2023 at 1:06PM, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the facility. The purpose of this visit is to deliver the findings for the listed allegations. LPA met with Arden Pedrasa, Shift Lead. At the time of the visit, there was one youth and five staff present. One youth was at the hospital, accompanied by another staff member and another youth is staying offsite accompanied by another staff member. During the course of the investigation, LPA Hood conducted eight interviews between 1/9/2023 and 2/6/2023. LPA reviewed incident reports from 2023 regarding the youth involved. The youth involved declined to interview, LPA Hood conducted observations of the home interactions. LPA reviewed the youth's intake paperwork, including a compatibility analysis of the housemates. Based on record review, the youth has 2:1 staffing ratio and staff maintains supervision of the youth at all times. Based on confidential interviews, staff mitigate elopement and property damage. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Selena Hood LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: MOSAIC MANORFACILITY NUMBER: VISIT DATE: 02/07/2023

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

met_with: Arden Pedrasa


raw_content:
Narrative:
and Ukeru trainings. There was a restraint done, and there was a restraint debriefing after the incident to discuss. Based on the facility's program plan, restraints will be done if there is imminent danger to staff or other clients. The youth was actively assaulting staff members prior to the restraint. At the time of the incident, there were seven staff involved and/or observing. Based on an internal review and LPA Hood's interviews, the staff did not see any other staff hit the client in care. Although the allegations that staff hit client in care and staff wrongfully restrained a client in care may or may not be true, the allegations have not met the preponderance of doubt and thus the allegation is unsubstantiated. LPA conducted an exit interview with George Grant, Administrator, at 3:25PM whose signature confirms the receipt of this document.

Investigation Findings:
13On 2/22/2023 at 11:45AM, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the facility. The purpose of this visit is to deliver the findings for the listed allegations. LPA met with Arden Pedrasa, Lead on Shift. During the course of the investigation, LPA conducted eight confidential interviews. LPA conducted observations of the home. The youth involved declined to interview multiple times. LPA reviewed pertinent incident reports, Needs and Services Plans for all youth, training records of staff, the staff schedule, and facility's Program Statement. Based on review of the staff schedule and incident reports, the staffing was within ratio. The youth involved in the allegations has a staffing ratio of 2:1. All staff that were present at the time had current Pro-Act UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Selena Hood LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: MOSAIC MANORFACILITY NUMBER: VISIT DATE: 02/22/2023

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

met_with: George Grant


raw_content:
Narrative:
The allegations that staff speak inappropriately to youth in care, staff engage in inappropriate sexual discussions in front of youth, and staff are smoking in the facility may or may not be true. The allegations have not met the preponderance of doubt and are therefore unsubstantiated. No deficiencies were cited at this time. LPA conducted an exit interview with George Grant, Administrator, at 4:15PM.

Investigation Findings:
13On 3/15/2023 at 4:05PM, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the licensed facility. The purpose of this visit was to deliver the findings on the above allegations. LPA met with George Grant, Administrator. During the course of the investigation, LPA Hood conducted twelve interviews between 2/22/2023 and 3/10/2023. The two youth involved declined to interview. LPA reviewed the administrator clock-in schedule, incident reports, and employee expectations documentation. Based on confidential interviews, eleven out of twelve of the interviewees stated that they had never heard staff curse or say inappropriate things in front of the youth. Eleven of the twelve interviewed stated that they had not heard staff talking about their personal sexual experiences in front of the youth. Eleven of the twelve interviewed said they had not suspected any staff of smoking on the premises. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Selena Hood LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: MOSAIC MANORFACILITY NUMBER: VISIT DATE: 03/15/2023

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


raw_content:
Narrative:
Based on confidential interviews and incident reports, staff was visually observing both residents while they were watching the content. At the time of the incident, the facility was in appropriate staff-to-resident ratio. Based on program statement and case management notes, the protocol for both residents is to not intervene unless there is imminent danger. Prior to this, the non-minor dependent was showing staff appropriate videos on their phone, so the staff did not assume it was an inappropriate video. Based on confidential interviews, the residents were watching the content for less than one minute, and staff immediately intervened after one resident told them what type of content they were watching. After learning about the nature of the content on the phone, the staff separated the two residents. Although the incident did happen, the allegation that due to staff not intervening, resident was exposed to inappropriate content on a phone from another resident in the home may or may not be true. The allegation has not met the preponderance of doubt and therefore the allegation is unsubstantiated. LPA conducted an exit interview with George Grant at 2:47PM whose signature confirms the receipt of the document.

Investigation Findings:
13On 3/30/2023 at 2:32PM, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the licensed agency. The purpose of this visit was to deliver the findings for the above allegations. LPA met with Administrator, George Grant. During the investigation, LPA Hood conducted seven confidential interviews between 2/6/2023 to 3/27/2023. LPA reviewed the residents' Individual Behavior Service Plan, case management summaries, incident reports, and the facility program statement. Based on confidential interviews and incident report, an incident did occur on 1/29/2023 where a non-minor dependent resident showed a minor resident inappropriate content on their cell phone. Per confidential interviews and the recent IBSP, sexualized behavior was not a core support for the non-minor dependent because there had not been sexualized behavior from their time in the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Selena Hood LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: MOSAIC MANORFACILITY NUMBER: VISIT DATE: 03/30/2023

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


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with George Grant, Administrator (ADM) at 1: PM on 4/30/24. Based on confidential interviews conducted and observations it was determined that the allegations listed above are Unsubstantiated. Witnesses interviewed stated that the facility has a two staff to one client ratio and that clients are supervised at all times. They mentioned that staff are always present to deescalate any peer-to-peer aggression. Witnesses stated that staff always attempts to encourage clients to go to school and that some clients decline. LPA observed a safe environment for clients while visiting the facility unannounced multiple times. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was provided to ADM. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: George Grant, Administrator


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with George Grant, Administrator (ADM) at 11: AM on 5/24/24. Based on confidential interviews conducted it was determined that the allegations listed above are Unsubstantiated. Based on witnesses interviewed, LPA was unable to find evidence that staff were abusing clients or treating clients in care in an agressive manor. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was provided to ADM. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with George Grant, Administrator (ADM) at 10: AM on 6/26/24. Based on confidential interviews conducted it was determined that the allegations listed above are Unsubstantiated. Based on witnesses interviewed, LPA was unable to find evidence that staff were not providing adequate supervision. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was provided to ADM UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility main office to inform them of the findings for the above listed allegations. LPA met with George Grant, Administrator (ADM) at 12: PM on 8/15/24. Based on confidential interviews conducted and record reviews it was determined that the allegation listed above is unsubstantiated. There was not enough evidence to determine if the facility violated any regulations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. As a result of this visit, there were no title 22 deficiencies observed. Exit interview was conducted and a copy of this report was provided to ADM. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Paul Simien LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: George Grant, Administrator (ADM)


facility_name: PEOPLE'S CARE 116TH STREET

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward made an unannounced licensing visit to conduct the annual/required inspection. The inspection began at 3: PM and was conducted with the assistance of administrator Azeez Lamina. The following was observed. The facility is implementing COVID Screening as required. This is three bedroom, two bathroom home located in the City of Inglewood, CA. There are currently two clients in care. Both clients are non-verbal and considered non-ambulatory although they are both capable of walking. Children's records were complete. The parents of both clients maintain medical rights, therefore no JV 220 paperwork is required. There are no bodies of water, firearms or fireplaces on the premises. There are no security bars on windows. The yard area is free of visible hazards. LPA observed a generator in the backyard, All bedrooms are equipped with one full sized bed each, including all required linens. The windows in bedroom #2 are covered in decorative paper rather than blinds or curtains due to the resident's tendency to tear down window coverings. There is a complete supply of first aid items. Smoke detectors and carbon monoxide detectors are working and properly placed. There is a fire extinguisher near the kitchen; it is recommended that this unit be recharged. All knives, household chemicals and medicines are stored under lock and key. The following were posted as required: Notice if Personal Rights, employee schedule, COVID 19 postings, and floor plan. There is a current menu; However the menu is not posted. The last disaster drill was conducted 11/23/21. There were no deficiencies cited on this date. LPA will return at a later date to review staff records.

report_type: Facility Evaluation

visit_type: Annual

met_with: Azeez Lamina


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward made an unannounced licensing visit to conduct the annual/required inspection. The inspection began at 3: PM and was conducted with the assistance of administrator Azeez Lamina. The following was observed. The facility is implementing COVID Screening as required. This is three bedroom, two bathroom home located in the City of Inglewood, CA. There are currently two clients in care. Both clients are non-verbal and considered non-ambulatory although they are both capable of walking. There are no bodies of water, firearms or fireplaces on the premises. There are no security bars on windows. The yard area is free of visible hazards. LPA observed a generator in the backyard. All bedrooms are equipped with one full sized bed each, including all required linens. The windows in bedroom #2 are covered in decorative paper rather than blinds or curtains. The administrator was advised to obtain drapes or blinds for the window. There is a complete supply of first aid items. Combination smoke detectors and carbon monoxide detectors are installed. However the home needs a carbon monoxide detection unit that makes a distinct sound as required by Title 22. Facility was advised to obtain a CO unit that meets regulations, There is a fully charged fire extinguisher in the dining area All knives, household chemicals and medicines are stored under lock and key. The following were posted as required: Notice of Personal Rights, employee schedule, COVID 19 postings, and floor plan. There are two current menus because one client has food allergies. The last disaster drill was conducted on 03/08/22. LPA will view client and staff records at a later date. There were no deficiencies cited as a result of this inspection


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst met with lead staff Vera Adidi to complete the annual inspection by reviewing staff and client files. In total 2 client and 3 staff files were reviewed. LPA also noted that the previous smoke detectors were replaced by combination smoke/CO detectors that meet the requirements of the Health and Safety code 13262 and that there were new blinds place over the window in bedroom # Parents maintain medical rights over each client, therefore no medical court orders are required. There were no deficiencies cited as a result of this investigation.

visit_type: Case Management

met_with: Vera Adidi, RBT


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward made an unannounced licensing visit to conduct the annual/required inspection. The inspection began at 9: AM and was conducted with the assistance of administrator Azeez Lamina. The following was observed. The facility is still implementing full COVID Screenings upon entry. This is three bedroom, two bathroom home located in the City of Inglewood, CA. There are currently two clients in care. Both clients are non-verbal and considered non-ambulatory due to lack of awareness. However, they are both capable of walking. There are no bodies of water, firearms or fireplaces on the premises. There are no security bars on windows. The yard area is free of visible hazards. LPA observed a generator in the backyard. All bedrooms are equipped with one full sized bed each, including all required linens. All windows are operational and covered with blinds in good condition. There is a complete supply of first aid items. There are working smoke and carbon monoxide detectors in the home. There is also a fully charged fire extinguisher. All knives, household chemicals and medicines are stored under lock and key. The following were posted as required: Notice of Personal Rights, employee schedule, COVID 19 postings, floor plan and grievance procedurs. The last disaster drill was conducted on 09/30/23 at 10: AM & 3: PM There are two current menus because one client has religious based dietary requirements. There are separate food storage areas and a separate microwave oven to accommodate these requirements. The facility van passed visual inspection of tires, headlights, tail lights, turn signals, horn and seat belts. LPA reviewed the records of both clients and five staff members. The parents of both children hold medical rights. Therefore there were no court orders for psychotropic medications. LPA interviewed three staff members. Both clients are non-verbal. This completes the Annual Inspection. There were no deficiencies cited.

met_with: Azeez Lamina, administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward made an unannounced licensing visit to conduct the annual/random inspection. The inspection began at 11: AM and was conducted with the assistance of administrator Tiffany Murguia. The following was observed. This is three bedroom, two bathroom home located in the City of Inglewood, CA. There are currently three clients in care. All clients are non-verbal and considered non-ambulatory due to lack of awareness. However, they are all capable of walking. There are no bodies of water, firearms or fireplaces on the premises. There are no security bars on windows. LPA observed a generator in the backyard. All bedrooms are equipped with one full sized bed each, including all required linens. All windows are operational and covered with blinds in good condition. There is a complete supply of first aid items. There are working smoke and carbon monoxide detectors in the home. There is also a fully charged fire extinguisher. All knives, household chemicals and medicines are stored under lock and key. The following were posted as required: Notice of Personal Rights, employee schedule, floor plan and grievance procedures. The last disaster drill was conducted on September 4, 2024 at 1: PM. LPA observed that there were two separate menus because one client can only eat the food that his parents prepare at home and bring to the facility. Employee file review and staff interviews will be conducted at a future date. The licensee was cited under Title 22, Section 84088.3(e)

met_with: Tiffany Murguia, administrato


summary: Facility Evaluation

raw_content:
Narrative:
On October 14, 2025, Licensing Program Analyst Connie Jones-Steward met with lead staff Elizabeth De La Torre and LVN Zully Chan to follow-up on the special incident report of October 7, 2025. The Department received an incident report that S1 had placed C1's medications in his food on the morning of October 7th. LPA reviewed C1's Client Face Sheet which confirmed that C1 is non-verbal. LPA reviewed C1's medication record and noted that on the morning of October 7th, C1 was administered 4 medications. One of which should not be crushed, chewed or split. However, there was a letter from the prescribing doctor Stacy Shuai stating that C1 should be allowed to take his medication with food if he refuses it otherwise. Per Ms. De la Torre and Nurse Chan, the medication was never hidden and client indicated his agreement to take the medication on peanut butter. LPA suggested that the letter be updated to specify soft foods that do not require chewing in order to prevent an accidental overdose. LPA also spoke with administrator Tiffany Murguia, who stated that S1 was cleared to return to work after the doctor stated that it was safe for client to take his medication in food. However she has not yet been back to work. Ms. Murguia stated that she will send a copy of the investigation to the Dept. At this time no violation was cited. However LPA still needs to speak to the clients Regional Center Coordinator.

met_with: Lead Staff Elizabeth De la Torre, Zully Chan LVN


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward met with administrator Tiffany Murguia regarding a concern raised by the Department of Developmental Services that the facility does not always have a lead staff on duty. Ms. Murguia explained that there is always someone on duty with the qualifications of a lead staff. However in the past, sometimes a qualified lead staff, including herself, has had to act as a direct care staff as well. In those situations, the schedule is clear on who is in charge so that there is no confusion on whom the other staff are to take direction from. Per Ms. Murguia, there are currently only two clients in care. One is under 2:1 ratio 24/7 while the other is under 2:1 ratio during daytime hours. Therefore the facility does not currently have a staffing issue. Furthermore, before another client is accepted, the administrator will inquire about the necessary supervision level to insure that the facility can maintain adequate staffing. The facility is also in the process of hiring additional full-time and on-call lead staff so that they can maintain ratio according to Department of Developmental Services requirements LPA reviewed the work schedules for the Jan 2026 and December 2025 as well as the facility's job description for lead staff. At this time no deficiency is found in the areas of staffing per CCL requirements

met_with: Tiffany Murguia, administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward met with administrator Tiffany Murguia to conduct an investigation of an incident report concerning a medication error. The IR Follow-up case number is 0001671-FN. Per the incident report, two staff in charge of administering medications failed to give a client her medication because they did not notice that it was lodged in the bubble pack. The missed medication was discovered and reported by a member of the nursing staff as she was reviewing the medications. Per Ms. Murguia, the two staff who caused the error have undergone a medications administration hands on review and are in the process of completing five additional classes on the subject of medication handling. LPA Jones-Steward collected a photo of the missed medication, copies of the disciplinary write-ups, a copy of the hands-on medication review, and proof of completion for the trainings that have been completed. Per Ms. Murguia, the staff are not allowed to handle medications until they have completed all trainings. The facility was cited under Title 22 84775(b)(2).

met_with: Tiffany Murguia, Administrator


facility_name: POLARIS HOME

raw_content:
Narrative:
The agency has investigated the complaint allegations that the Youth was handled in a rough manner while in care and youth was slapped while in care. The incident was reported by staff and after the administrator viewed the video the staff was immediately terminated. The video footage that was submitted on March 22, 2021 shows the youth being handed in a rough manner and being slapped in the back of the head with an open palm by Staff 9. Based on video footage, LPA's observations, interviews which were conducted and record reviews(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is (ARE) found to be Substantiated. The facility is cited on the attached LIC 9099D under the California Code of Regulations, for Personal Rights ILS 88487.8(b)(2) A copy of this report and appeal rights were emailed to the agency. No title 22 regulations were cited during today's inspection.

Investigation Findings:
13Licensing Program Analyst (LPA) Mary Shelton conducted a tele visit at the agency on June 9, 2021 and LPA spoke with Fenina Pham, Administrator to deliver findings of the investigation on the complaint allegations as stated. LPA Shelton informed the complaint investigation included a tour of the facility on 3/16/2021. The initial 10-day complaint inspection was conducted by LPA Mary Shelton, at the agency on 3/16/2021 and included a review of the facility and obtaining of relevant documents: Needs and Services, monthly treatment plan, supervised visit log, certificate of approval, facility sketch, staff training records and staff roaster. LPA Shelton interviewed the facility administrator on 3/16/2021. Additional interviews were conducted by LPA Mary Shelton, which included Sheriff Deputy Neri, C1's Social Worker and Staff. between 3/16/2021 and 6/2/2021. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Mary Shelton LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: POLARIS HOMEFACILITY NUMBER: VISIT DATE: 06/09/2021

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

met_with: Fenina Pham, Administrator


raw_content:
Narrative:
Regarding the allegation that staff called minor inappropriate names, statements made during interviews by 4 of 4 staff corroborated that staff and C1 joked back and forth and often client called staff names but, staff did not. Additionally, C1 denied being called names by staff. However, one out of four staff stated that one time they called C1 fat. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 , Chapter 5 84072 (d) (10) , are being cited on the attached LIC 9099D." An exit interview was conducted at 11: PM, a copy of this report and appeal process was reviewed and provided to the Administrator.

Investigation Findings:
13Licensing Program Analyst (LPA) Connie Goldie arrived at the agency to conduct an unannounced complaint investigation inspection on 12/13/2022 at 10: AM. LPA Goldie spoke with, Andrew Nguyen, Interim Program Administrator, to discuss the findings of the complaint investigation and allegation stated above. LPA Goldie informed facility staff this case was investigated by LPA Goldie. The initial 10-day complaint investigation inspection was conducted by LPA Connie Goldie at the facility on 09/26/2022. LPA Goldie toured the facility and interviewed one facility staff. Copies of facility documentation provided to LPA Goldie included: Client register, one client's individual personalized plan, Staff Roster, staff schedules for September and staff contact Information. Interviews were conducted with one client, four staff, Regional Center worker and C1's mother between 09/26/2022 and 11/08/2022. Two clients were not interviewed as they are non-verbal. Records review of documents obtained was completed on 09/26/2022 and 10/19/2022. Continued on LIC9099C. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Connie Goldie LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: POLARIS HOMEFACILITY NUMBER: VISIT DATE: 12/13/2022

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

met_with: Andrew Nguyen Interim Program Administrator


raw_content:
Narrative:
Regarding the allegation that staff refused to provide minor with a snack, statements made during interviews all corroborate that snacks are scheduled but, clients can request and receive food at unscheduled times. The LPA found that while this allegation may have occurred or is valid, there was not a preponderance of evidence to prove that it did or did not occur, therefore LPA has found it to be unsubstantiated. An exit interview was conducted at 11: PM, a copy of this report and appeal process was reviewed and provided to the Administrator.

Investigation Findings:
13Licensing Program Analyst (LPA) Connie Goldie arrived at the agency to conduct an unannounced complaint investigation inspection on 12/13/2022 at 10 : AM. LPA Goldie spoke with, Andrew Nguyen, Interim Program Administrator, to discuss the findings of the complaint investigation and allegation stated above. LPA Goldie informed facility staff this case was investigated by LPA Goldie. The initial 10-day complaint investigation inspection was conducted by LPA Connie Goldie at the facility on 09/26/2022. LPA Goldie toured the facility and interviewed one facility staff. Copies of facility documentation provided to LPA Goldie included: Client register, one client's individual personalized plan, Staff Roster, staff schedules for September and staff contact Information. Interviews were conducted with one client, four staff, Regional Center worker and C1's mother between 09/26/2022 and 11/08/2022. Two clients were not interviewed as they are non-verbal. Records review of documents obtained was completed on 09/26/2022 and 10/19/2022. Continued on LIC9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Connie Goldie LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: POLARIS HOMEFACILITY NUMBER: VISIT DATE: 12/13/2022

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


raw_content:
Narrative:
The Department investigated the complaint that a minor sustained unexplained bruises while in care. Although minor did present with an injury, ( 6 inches long by 2 inches in width of multiple small red circle bruises in a row and scratch marks under his left under arm-), Licensing Program Analyst was unable to determine where injury occurred and who was responsible. Clients in facility are all non-verbal and unable to be interviewed. Facility staff and school staff interviewed all corroborate that C1 demonstrates self injurious behavior. Facility staff stated they did not observe any behavior by clients and/or staff that would have caused the injury. An investigation was completed at C1's school and staff did not observe behavior that would indicate how the injury in question occurred. Additionally, RP stated they are 95% certain the bruising did not occur at the facility based on "how fresh injuries looked" and C1 had been at school all day prior to injury being observed. Based on the investigation, records reviewed, and interviews conducted, the complaint finding is UNSUBSTANTIATED at this time meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No Title 22 deficiencies were cited. LPA Goldie provided a copy of report along with appeal rights and discussed with Administrator.

Investigation Findings:
13Licensing Program Analyst (LPA) Connie Goldie arrived at the agency to conduct an unannounced complaint investigation inspection on 05/23/2023 at 3: PM. LPA Goldie spoke with Andrew Nguyen, Program Administrator to discuss the findings of the complaint investigation and allegation stated above. LPA Goldie informed facility staff this case was investigated by LPA Goldie. The initial 10-day complaint investigation inspection was conducted by LPA Connie Goldie at the facility on 04/05/2023. LPA Goldie toured the facility and interviews were conducted with five facility staff. Copies of facility documentation provided to LPA Goldie included: Client roster, Staff roster, staff schedule for 03/19/2023-04/14/2023, one client's individual personalized plan, one client's body check logs, and incident reports for C1 for March 2023. Confidential interviews were conducted with eight staff, three witnesses, North Bay Regional Center coordinator between 04/03/2023 and 05/19/2023. Records review of documents and photos obtained was completed on 04/13/2023. Continued on LIC9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Connie Goldie LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: POLARIS HOMEFACILITY NUMBER: VISIT DATE: 05/23/2023

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

met_with: Program Administrator, Andrew Nguyen


raw_content:
Narrative:
The Department investigated the complaint that a minor sustained unexplained bruises while in care. Although minor did present with an injury, (a linear bruise on his thigh above the top of his knee about 2 inches long and ½ inch thick and a bruise to the kneecap about 3 inches wide, both were purple, brown in color.) C1 is non-verbal and non-ambulatory. C1 engages in self-harm behaviors. Both the school and home stated that C1 has SIB (Self Injury Behavior) The reporting party stated that C1 likes to hit his head with his leg but that this injury is different and was concerned about C1 receiving 1:1 care at home. The reporting party stated that the injury was noticed at approximately 10: AM on 7/24/2024 at C1's school. Facility staff and school staff interviewed all corroborate that C1 demonstrates self injurious behavior. The increase in C1's SIB (Self-injury-behavior) behavior could be the result of a medication change according to the Administrator. During confidential interviews with staff at the home C1 is receiving 1:1 care during the day and 1:2 care at night. This is also noted in C1's Needs and Service Plan. At school C1 is receiving 1:1 care. LPA Shelton observed C1 at school on 7/31/24 and notice a red mark on C1's noise and the injury to C1's was no longer purple or brown in color. Based on the investigation, records reviewed, and interviews conducted, the complaint finding is UNSUBSTANTIATED at this time meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No Title 22 deficiencies were cited. LPA Shelton provided a copy of the report along with appeal rights and discussed with Administrator.

Investigation Findings:
13Licensing Program Analyst (LPA) Mary Shelton arrived at the agency to conduct an unannounced complaint investigation inspection on 08/16/2024 at 1:00PM. LPA Shelton spoke with Margarita Hernandez, Shift Lead to discuss the findings of the complaint investigation and allegation stated above. LPA Shelton informed facility staff this case was investigated by LPA Shelton. The initial 10-day complaint investigation inspection was conducted by LPA Shelton at the facility on 07/31/2024. LPA Shelton toured the facility and interviews were conducted with the Administrator, reporting party, school staff and seven facility staff. Copies of facility documentation provided to LPA Shelton included: Client roster, Staff roster, staff schedule, C1's individual personalized plan, C1's body check log, and incident reports for C1 for July 2024. Confidential interviews were conducted with the Administrator, School Behavior Specialist, staff, and LPA Shelton observed C1 at school on 7/31/2024. Records review of documents and photos obtained was completed on 8/2/2024. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Mary Shelton LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: POLARIS HOMEFACILITY NUMBER: VISIT DATE: 08/16/2024

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

met_with: Margarita Hernandez, Shift Lead


raw_content:
Narrative:
The Department has investigated the allegation that a client sustained an unexplained injury while in care. During confidential interviews, it was revealed that five out of the five staff members interviewed, did not know how the client sustained bruises and scratches on both biceps. Record review indicated that on 10/15/24, the scratches were noted on the client's Injury Log, with the cause listed as, "unknown". The client has a history of self injurious behavior. Based on the investigation, records reviewed, and interviews conducted, the complaint finding is UNSUBSTANTIATED at this time meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted with Benjamin Rimorin. A copy of this report and appeal rights were provided.

Investigation Findings:
13On Wednesday, December 4th, 2024, Licensing Program Analyst (LPA), Brittany Crass, made an unannounced complaint investigation visit to deliver findings. LPA met with Benjamin Rimorin, Lead Staff. The initial 10-day complaint inspection was conducted at the facility by LPA Crass on 10/30/2024. On that date, LPA obtained copies of the client's Body Scan forms, Incident Log, and Staff Schedule. In between 10/30/2024 and 11/15/2024, LPA interviewed 5 staff members (S1-S5), the Licensee, three of the clients Teachers (T1-T3), and the Behavioral Specialist (S4). The client was unable to be interviewed as he is non-verbal. (Continued on LIC9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Brittany Crass LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: POLARIS HOMEFACILITY NUMBER: VISIT DATE: 12/04/2024

met_with: Benjamin Rimorin


raw_content:
Narrative:
LPA Silvas received an email from Administrator, Benjamin Rimorin, on 12/23/2024 indicating that the accused staff, Joha Thomas, will no longer be working at Polaris. Regarding the allegation that staff hit and kicked youth, staff yelled at youth and staff threw objects at youth, statements made during interviews by 2 of 6 staff and video footage of client pointing to alleged staff, corroborated that staff did hit and kick youth, staff yelled at youth and staff threw objects at youth. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. An exit interview was conducted, a copy of this report and appeal process was reviewed and provided to the Administrator.

Investigation Findings:
13Licensing Program Analyst (LPA) Michelle Silvas arrived at the agency to conduct an unannounced complaint investigation inspection on 1/16/2025 at 9: AM. LPA Silvas spoke with Benjamin Rimorin, Administrator, to discuss the findings of the complaint investigation and allegation stated above. LPA Silvas informed facility staff this case was investigated by LPA Silvas. The initial 10-day complaint investigation inspection was conducted by LPA Michelle Silvas at the facility on 12/16/2024. LPA Silvas toured the facility and interviewed six staff. Copies of facility documentation provided to LPA Silvas included: staff schedule for the next two weeks, contact information for the noc shift staff, daily shift notes for the child, daily notebook notes and body scan notes. Interviews were conducted with six staff and ongoing communication via email with Amir Cruz-Khalili from the Department of Developmental Services. Four clients were not interviewed as they are non-verbal. LPA Silvas observed all four clients on 12/16/2024. Records review of documents obtained was completed on 12/16/2024. Continued on LIC9099C. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Michelle Silvas LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: POLARIS HOMEFACILITY NUMBER: VISIT DATE: 01/16/2025

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

met_with: Benjamin Rimorin, Administrator


raw_content:
Investigation Findings:
13On 3/3/2025 at 3:25PM, Licensing Program Analyst (LPA) Michelle Silvas conducted an unannounced visit at the facility. The purpose of the visit was to Issue a citation that was inadvertently left out for the complaint delivered on 1/16/2025 which was found to be substantiated involving the allegations listed above. For details of this investigation, please see complaint number; 23-CR-20241216104956. LPA Silvas met with Benjamin Rimorin and discussed the citation. type A violation is being cited during today's visit. An exit interview was conducted, and reports discussed and provided to facility along with the appeal rights. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Michelle Silvas LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: POLARIS HOMEFACILITY NUMBER: 487006088

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


facility_name: TURNING POINT- AVALON

raw_content:
Narrative:
out of 11 interviews stated that the staff at the facility were being dignified and giving the youths at the facility respect. 2 of 3 youths placed at the facility state that the staff treat them well and that they have no complaints with the staff. Secondly, based on records review, it is noted that C1 does have a history of not telling the truth, attempting to control others, or manipulating others to get their way. Also, the Service Coordinator for the youth in question has no concerns for the treatment of the youth in the facility. Although the allegation may have happened or is valid there is not a preponderance of evidence to prove the alleged violation did occur therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted, and Appeal Rights were discussed with Shadayleon Walker, Facility Administrator Assistant. A copy of this report and Appeal Rights were left at the facility.

Investigation Findings:
13On 11/21/ Licensing Program Analysts (LPAs) Sara Luman-Gonzalez & Orlando Areizaga conducted an unannounced visit to the above agency to deliver the findings of a complaint investigation. LPAs met with Shadayleon, Walker, Facility Administrator Assistant and was granted entry. During the investigation, LPA Luman-Gonzalez conducted the 10-day inspection of the facility on 8/5/2024. LPA obtained Client Facesheet, Admission Packet, IBSPs, Email and Text Message correspondence between the Responsible Parties and the Facility, Staff Schedule, Contact information for all staff, and Case notes for the month of July 2024. 11 confidential interviews were conducted between August 2024 and November 2024 by LPA Luman-Gonzalez. Based on Interviews conducted during the investigation process, LPA received inconsistent statements on whether staff taunted youths in care. (Cont. on LIC 9099C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Sara Luman-Gonzalez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: TURNING POINT- AVALONFACILITY NUMBER: VISIT DATE: 11/21/2024


summary: Facility Evaluation

raw_content:
Narrative:
On 7/14/22 at 9:00am, Licensing Program Analyst (LPA) Stephanie Lor and Licensing Program Manager (LPM) Rosa Rodriouez conducted a Pre-Licensing Inspection, Component II and Component III at the above facility. LPA Lor and LPM Rodriguez met with the Regional Program Director and Cheryl Gutierrez. The facility consisted of a formal living room equipped with a set of 3 couches, a formal dining room equipped with a large table with 6 chairs. There is a resting area/second living room area equipped with a TV and board games. The kitchen was equipped with counter space with 4 stools, locked cabinets to store the sharp objects/knives and dish soaps, plates, utensils, cups, silverware, and a large trash can with lid on. 2 office rooms, one room will be used for staff and to lock the files and medication. The second office (the garage) will be utilized by the Administrator. There are 4 bedrooms equipped with a full size beds, closet (curtain will be installed) dresser, night stand, trash can with lid, 2 1/2 bathrooms, one bathroom is for ambulatory clients and the second bathroom is built especially for non-ambulatory clients. Laundry room equipped with a washer/dryer and lock cabinets to store the laundry soap. There is an open back patio, backyard with a basketball court, and a gated section in back for gardening, The front yard was clean and free of hazards. The telephone land line and internet service were in working order. The water temperature was tested and it was between 105 - 120 degrees. There was a little of perishable/non-perishable food available but more will be purchased prior the first placement. During the pre-inspection, LPA Lor and LPM Rodriguez observed the following: 1 first aid kit which was missing the thermometer, and instruction booklet, 2 fire extinguisher located by the main (see 2nd page) entrance, and kitchen area, carbon monoxide and smoke detector were built in throughout the entire house, system was tested and in working condition. Component II was completed during today's inspection and the following areas of the Program Statement were reviewed with the Regional Program Director: Program Description, Client Service, Emergency/Disaster Plan, and Exit Criteria. No additional modifications are needed for the Program Statement. Component III was also completed during today's inspection and the following forms were reviewed with the Regional Program Director: LIC198A -Child Abuse Central Index Check for State Licensed Facilities (family child care homes; children's residential homes and facilities; and adult residential facilities if, through an approved exception or a specialized license, they provide care to a person under age 18), LIC198B - Out-of-State Child Abuse/Neglect Report Request, · LIC 306-Reporting Requirements to Department. of Social Services, LIC 308 - Designation of Facility Responsibility, LIC 500 - Personnel Report, LIC 501 - Personnel Record, LIC 503 - Health Screening Report (including TB Clearance), LIC 508 -Criminal Record Statement, LIC 508D - Out-of-State Disclosure & Criminal Record Statement, LIC 613B - Personal Rights, LIC 624 -Unusual Incident/Injury/Death Report, LIC 627B - Consent for Medical Treatment, LIC 9058 - Applicant/Licensee Rights, LIC 9182 - Criminal Background Clearance Transfer Request, LIC Criminal Record Exemption Transfer Request, Appendix D - A Guide to Safeguarding Resident/Client Cash Resources, LIC 311B - Records to be Maintained in a Group Home, LIC 311E - Records to be Maintained in a Small Family Home, LIC 313 - Evidence of Program Consultant (Group Homes), · LIC Identification and Emergency Information, LIC 602 - Physician's Report for Community Care Facilities, LIC 603 - Preplacement Appraisal Information, LIC 622 - Centrally Stored Medication and Destruction Record, LIC 625 - Appraisal/Needs and Services Plan, LIC 9106 - Group Home Program Statement, LIC 9106A - Short-Term Residential Therapeutic Program (STRTP) Statement General Instructions, LIC 9128 - Foster Family Agency Program Statement, Neighborhood Complaint Policy (see 3rd page) Regional Program Director was instructed to obtain the following items: Thermometer, First Aid Instruction Booklet, and a small refrigerator to utilize if medication needs to be stored in the refrigerator. LPM Rodriguez informed the Regional Program Director that the facility cannot be licensed until CCL received certification from DDS and certification for the Administrator from the Regional Center. Exit interview conducted with Regional Program Director and a copy of the report will be emailed by 07/15/2022.

visit_type: Prelicensing

met_with: Alicia Caroll, Regional Program Director


summary: Facility Evaluation

raw_content:
Narrative:
On 8/10/23, Licensing Program Analyst (LPA) Stephanie Lor made an unannounced visit to the above facility for the purpose of conducting a Post Licensing Inspection. LPA met with the Program Administrator who provided LPA with a tour of the interior and exterior of the facility. LPA observed the following: This facility has 4 bedrooms, 2 living rooms, 2 staff office, kitchen, backyard and 3 bathrooms. LPA observed fixtures and furniture, equipment, and supplies necessary for this operation. LPA observed locked cabinets personnel files to ensure confidentiality. Facility was unable to test out smoke detectors due to the high ceiling, but showed proof of annual testing for the alarms. LPA observed chemicals and sharps to be locked. A first aid kit and fire extinguishers were on site. The water temperature was tested at a safe temperature. LPA Lor observed the agency's license posted in the front entrance. A Technical Assistant (TA) was provided to post up personal rights poster, complaint procedure, and emergency disaster plan in a common area. The agency currently employs one Administrator, one Administrative Assistant, and Direct Support Professionals. The agency currently has one client on site. LPA reviewed one client's file with all required documents. During today's inspection there are no deficiencies cited. An exit interview was conducted, and a copy of this report was provided to the Administrator at the conclusion of the inspection.

met_with: Cheryl Gutierrez, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 8/10/ Licensing Program Analyst (LPA), Stephanie Lor made an unannounced visit to conduct a case management regarding an incident report received by Community Care Licensing for an incident that occurred on 7/19/23 regarding missed medication. LPA met with the Administrator. LPA conducted interviews with the Administrator and provided LPA with copies of training certificate. An exit interview was conducted with the Administrator and a copy of this report will be emailed to the facility. No deficiencies cited. This case management investigation is closed.


summary: Facility Evaluation

raw_content:
Narrative:
On December 18, 2023 at approximately 08: AM, Licensing Program Analysts (LPAs), Farhaan Sarangi and Sara Luman-Gonzalez arrived unannounced at Turning Point-Avalon for the purpose of conducting a Case Management-Other inspection to verify training of facility staff members. During the Case Management-Other inspection, LPAs reviewed a sample of staff records and observed that 1 out of 6 staff members does not have an active First Aid/CPR Card (See LIC 9102-Technical Violation). The remaining 5 staff members have an active First Aid/CPR Card. In addition, LPA reviewed training and observed that 6 of 6 staff members have the required 40 hours of initial training and 20 hours of annual training as outlined in Title 22 regulations. LPA toured the facility and observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. However, LPA did observe a screen that was not on a clients window. Administrator stated that the client took off the screen and that staff members will reinstall it today (See LIC 9102-Technical Advisory) LPA observed sufficient perishable and non-perishable foods. LPA observed that all medications were centrally stored and locked as outlined in Title 22 regulations. Fire Extinguishers were last charged on May 2023. No deficiencies were cited during today's Case Management-Other inspection. Exit interview was conducted, and a copy of this report was signed and given to the Administrator.

met_with: Administrator, Cheryl Gutierrez


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Sara Luman-Gonzalez made an unannounced inspection on May 10, 2024 at 8: A.M. During the inspection LPA met with Cheryl Gutierrez, Facility Administrator who assisted with the inspection. LPA conducted a walk-through of the facility inside and out. There were 4 present and 0 clients as they were in school. LPA interviewed Staff and Clients at this time. LPA observed 3 bedrooms and 3 bathrooms. LPA inspected and/or reviewed the following: Physical Plant License, Personal Rights and other required documentation was posted throughout the facility. Disinfectants/Cleaning Solutions are locked away in the closet area where staff have keys to access but clients do not. Pantry, Fridge, and Freezer were adequately stocked with both perishable and non-perishable food. Facility also has a back stock ready for for emergencies. Menu's were posted on the fridge with snack choices available. Hot water was tested at 110 degrees F. All fire extinguishers were filly charged.Carbon Monoxide and Smoke Detectors were observed to be in working order. First Aid Kit with back up supplies was observed. Adequate bed linens were observed in the facility. Fixtures are in adequate repair. Multiple Common Areas are available for youths to utilize. Dining area was observed to have adequate seating with furniture in good repair. All bathroom fixtures were observed to be in good repair with adequate soap and towels. Laundry Facilities are available for clientele use with a rotating schedule observed. Medication is locked in the separate room in a separate cabinet. Office is also locked with files locked in drawers for privacy. Working telephones are available in the staff office that clients have access too. Facility's motor vehicle is observed to be properly maintained with current registration and insurance. There are no external structures at this facility. (Page 1 of 3) Operations Complaint Procedures were reviewed with the Facility. All previous incidents were adequately submitted. Restraint log was reviewed. Board Minutes were made available by Facility. Disaster Preparedness Disaster & Mass Casualty Plan is updated and available throughout the facility. Monthly drills are documented for the facility. Disaster preparedness supplies were verified. Back up food storage was observed to be adequate. Emergency Intervention Staff training was documented adequately with current trainings. Restrain Log was reviewed. Staffing/Volunteers Staff Files were Reviewed. All were currently First Aid/CPR Certified through American Red Cross. Job title & qualifications were verified. All Criminal Record Clearances and Exemptions were observed. Staff either has or is currently in training. Client Records Client files were reviewed. LPA observed the Needs and Services Plans were in place with Centrally Stored Medication log, Parental Authorization for medication. Psychotropic and Medication Administration Log was was reviewed. Cash Resources Log was reviewed. Compatibility Assessment was observed. Special Health Care Needs (SHCN) SHCN plan created with staff and psychiatrist and implemented as required. Staff have received training in regards to the individual health needs of each client. The following items were reviewed for compliance in the regional office prior to the facility inspection: (Page 2 of 3) ·Annual fees · Administrator Certificate for: Cheryl Gutierrez · Emergency Disaster Plan (per H&S Code 1565) · Annual Emergency Intervention Log · Personnel Roster, Facility Sketch, LIC 500, LIC 610C and LIC 308 · Waivers and Exceptions An exit interview was conducted with Cheryl Gutierrez and a copy of this report was left with facility.

met_with: Cheryl Gutierrez- Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On March 27, 2025 at approximately 9: AM, Licensing Program Analyst (LPA),Orlando Areizaga arrived unannounced at Turning Point-Avalon for the purpose of conducting a Case Management-Other inspection to follow up on a recent Department of Developmental Services (DDS) inspection. LPA met with Cheryl Gutierrez, Facility Administrator who granted LPA access. LPA conducted a walk through of the interior and exterior of the home, and no deficiencies were noted LPA requested and reviewed the follow documents: LIC 500 and 3 staff files. LIC 500: Reviewed: names, job titles, and specific duty hours. Staff Files: CPR and First-aid up to date via approved institution Training hours Identification cards Based on a file review, LPA Areizaga did not note any deficiencies during the time of the inspection. This case management is closed and no further interview are needed at this time. Exit interview was conducted with Cheryl Gutierrez, Facility Administrator and a copy of this report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On May 21, 2025 at approximately 9: AM Licensing Program Analyst (LPA) Orlando Areizaga and Licensing Program Manager (LPM) Rosa Rodriguez made an unannounced annual inspection to the above facility. LPA and LPM met with Administrator, Cheryl Gutierrez who assisted with the inspection. LPA conducted a walk-through of the facility interior and exterior of the facility . There were 6 staff present and 0 clients as they were in school. LPA interviewed Staff and Clients at this time. LPA observed 2.5 bedrooms and 4 bathrooms. LPA inspected and/or reviewed the following: Physical Plant: License, Personal Rights and other required documentation were posted throughout the facility. Disinfectants/Cleaning Solutions are locked away in the closet area where staff have keys to access, but clients do not. Pantry, Fridge, and Freezer were adequately stocked with both perishable and non-perishable food. Facility also has a back stock ready for emergencies. Menus were posted on the fridge with snack choices available. Hot water was tested at 111 degrees F. The temperature in the facility was set at 71 degrees. All, 3, fire extinguishers were filly charged. Carbon Monoxide and Smoke Detectors were observed to be in working order. First Aid Kit with back up supplies was observed. Adequate bed linens were observed in the facility. Fixtures are in adequate repair. Multiple Common Areas are available for youths to utilize. Dining area was observed to have adequate seating with furniture in good repair. 2.5 bathrooms were observed. 1 bathroom for non- ambulatory clients, 1 bathroom for ambulatory clients, and a half bathroom. All bathroom fixtures were observed to be in good repair with adequate soap and towels. (1 of 2) Laundry services are available for clients use with a rotating schedule observed. Medication were locked in the separate room in a separate cabinet. Office is also locked with files locked in drawers for privacy. Working telephones are available in the staff office that clients have access too. Facility's motor vehicle were observed to be properly maintained with current registration and insurance. The exterior of the facility has a shed with extra storage. LPA observed overgrown landscape in the front and back yard, a leak under the kitchen sink, and a loose cupboard above the stove. Operations: Complaint Procedures were reviewed with the Facility. All previous incidents were adequately submitted. Disaster Preparedness: Disaster & Mass Casualty Plan is updated and available throughout the facility. Monthly drills are documented for the facility. Disaster preparedness supplies were verified. Back up food storage was observed to be adequate. Emergency Intervention: Staff training was documented adequately with current trainings. Staffing/Volunteers: Staff Files were reviewed. All were currently First Aid/CPR Certified through American Red Cross. Job title & qualifications were verified. All Criminal Record Clearances and Exemptions were observed. Client Records: Client files were reviewed. LPA observed the Needs and Services Plans were in place with Centrally Stored Medication log, Parental Authorization for medication. Psychotropic and Medication Administration Log were reviewed. Administrator did talk about the petty cash funds that are used for clients. Special Health Care Needs (SHCN): SHCN plan created with staff and psychiatrist and implemented as required. Staff have received training in regards to the individual health needs of each client. The following items were reviewed for compliance in the regional office prior to the facility inspection: Outstanding annual fees: $1,362.00 will be sent via Fed ex overnight to the regional office by tomorrow. Administrator Certificate for: Cheryl Gutierrez Emergency Disaster Plan (per H&S Code 1565) Annual Emergency Intervention Log Personnel Roster, Facility Sketch, LIC 500, LIC 610C and LIC 308 Technical Violations are being issues. (1) for the overgrown landscape in the front and rear of the facility. (2) for a leak under the kitchen sink and a cupboard being loose above the stove. An exit interview was conducted with Administrator, Cheryl Gutierrez and a copy of this report was left with facility. (2 of 2)


facility_name: TURNING POINT OF CENTRAL CALIFORNIA INC.-ATLANTIS

summary: Facility Evaluation

raw_content:
Narrative:
On the date above a pre licensing visit was conducted at Turning Point of Central California-Atlantis by Licensing Program analyst (LPA) Les Inouye. I was met by Administrator Alicia Carroll and Rosemary Maurillio. A review of the Physical Plant was conducted including the Indoor Activity Space, Fixtures Furniture Equipment and Supplies and Outdoor Activity Space. The indoor space is an open floor plan with not hazards. Kitchen non-perishable items were observed in the pantry. Lockable drawers for sharps, cleaning supplies were observed. Bedrooms were observed, 4 single occupancy and a capacity of 4. All bedroom doors are key locked. All rooms were appropriately furnished with additional linens was observed and adequate space for clients. All chemicals and cleaning supplies were locked and secured. Smoke Alarms and Carbon Monoxide detectors, fire suppression system and fire extinguishers was observed and operating. Fire door between bedrooms and living room/kitchen was observed. Hot water temperature was measured at 118 degrees. Staff office was observed with medication cabinet and supples. The outdoor area is fee of hazards. There is a utility shed in the back yard which is secured. Back yard there is no pool or hot tub, yard consisted of a lawn area, basketball court and raised bed planting boxes. The back fence is metal and has a view of city walking path "Dry Creek Trail". The garage is converted to an office space for the administrator and Asst. Administrator. Garage doors are fully functional and central air conditioning has been added. Laundry room is open with no doors. The indoor activity spaces (2) had games. The facility does not use a Delayed Egress system. The physical plant review was observed to be clean, safe, and free of hazards. The physical plant has met. Other issues to be reviewed during the Plan of Operation submission will be updating the facility floor plan, mattress and box spring combination and Emergency Generator.

met_with: Alicia Carroll and Rosemary Maurillio


summary: Facility Evaluation

raw_content:
Narrative:
A Case Management visit was conducted to review questions about the Program Statement revisions. A review was conducted on Training requirements, Administration and responsibility for the program and confirmation on development of the Emergency Intervention Plan. Any further questions Alicia will call LPA and expected return date is May 9th.