summary: Facility Evaluation

raw_content:
Narrative:
On August 10, 2021 at 7:50 pm Licensing Program Analyst (LPA) Nicole Strickland returned to the facility to follow- up on multiple Plan of correction's (POC)'s that has not been received by Community Care Licensing (CCL). LPA Strickland met with Sojourners Haven Group Home Executive Director LaTresse Armstrong. The Short Term Residential Therapeutic Program (STRTP) was cited on July 23, 2021 at 2:49 pm for Fixtures, Furniture, Equipment, and Supplies: (e)The following facilities shall maintain a signal system... (2) All facilities having separate floors and not providing full-time staff on each floor whenever children are present. When the citation was issued Sojourners Haven Group Home, Facility Manager III (FM) Sherrae Smith whom LPA met with in person and Executive Director (ED) Latresse Armstong who FM had on speaker phone stated the POC would include the facility policy of staff remaining upstairs when residents are upstairs will be reviewed with all staff at their next All staff meeting August 3rd. FM/ED will have staff sign acknowledging retraining on facility policy. Outline of training along with staff signatures was to be provided to LPA via email by POC date of 8/6/2021. ED stated random spot checks will also be conducted to ensure staff compliance with facility policy. CCL has not received the POC. The STRTP was cited on July 23, 2021 for Training Requirements: (a)(8)(A) Completion of cardiopulmonary resuscitation and first aid training shall be demonstrated by current and valid CPR and first aid cards issued... an accredited college or university. When the citation was issued the STRTP FM and ED stated the POC would include the new hire orientation log being revamped to include verification of all required on boarding documents with initials of reviewer to include both 1st aid and CPR certificates. FM was to provide LPA a copy of the updated new hire orientation log by POC date 8/6/2021. CCL has not received the POC. The STRTP was cited on July 23, 2021 for Training Requirements: (c)(1) 8-hour training (C) The 8-hour training shall include trauma-informed training as specified in Section 87078.2(a)(3). When the citation was issued the STRTP FM and ED stated the POC would include the new hire orientation log being revamped to include trauma informed care during initial 8-hour training. FM was to provide LPA a copy of the updated new hire orientation log by POC date 8/6/2021. CCL has not received the POC. The STRTP was cited on July 23, 2021 for Training Requirements: (c)(1) 8-hour training (D) A maximum of 4 hours of the training requirement may be satisfied by successful completion of job shadowing. When the citation was issued the STRTP FM and ED stated the POC would include the new hire orientation log being revamped to include documentation of date and number of hours spent job shadowing, and what was reviewed in the job shadowing. FM was to provide LPA a copy of the updated new hire orientation log by POC date 8/6/2021. CCL has not received the POC. The STRTP was cited on July 23, 2021 at 2:49 pm Training Requirements: (c)(1)(D)(4) Successful completion of job shadowing shall be verified by a statement completed by the experience facility personnel... by the job shadowing activity. When the citation was issued the STRTP FM and ED stated the POC would include the new hire orientation log being revamped to include all training requirements and to note that assessment was completed and is in personal record along with date of assessment. FM was to provide LPA a copy of the updated new hire orientation log by POC date 8/6/2021. CCL has not received the POC. The STRTP was cited on July 23, 2021 at 2:49 pm Training Requirements: (c)(1)(E) Within 7 calendar days of completion of the 8-hour training the administrator or administrator's designee shall assess...staff understands and can apply the training. When the citation was issued the STRTP FM and ED stated the POC would include the new hire orientation log being revamped to include all training requirements and to note that assessment was completed and is in personal record along with date of assessment. FM was to provide LPA a copy of the updated new hire orientation log by POC date 8/6/2021. CCL has not received the POC. The STRTP was cited on July 23, 2021 at 2:49 pm Training Requirements (c)(1)(E)(2) The assessment shall be documented in each direct care staff personnel record. When the citation was issued the STRTP FM and ED stated the POC would include the new hire orientation log being revamped to include all training requirements and to note that assessment was completed and is in personal record along with date of assessment. FM was to provide LPA a copy of the updated new hire orientation log by POC date 8/6/2021. CCL has not received the POC. ****** The STRTP was cited on July 23, 2021 at 2:49 pm Training Requirements (c)(2)(B) Within 30 days of completion of the 16-hour training, the administrator or administrator's designee shall assess... staff understands and can apply the training. When the citation was issued the STRTP FM and ED stated the POC would include the new hire orientation log being revamped to include all training requirements and to note that assessment was completed and is in personal record along with date of assessment. FM was to provide LPA a copy of the updated new hire orientation log by POC date 8/6/2021. CCL has not received the POC. The STRTP was cited for Training Requirements: (c)(2)(B)(2) The assessment shall be documented in each direct care staff personnel record When the citation was issued the STRTP FM and ED stated the POC would include the new hire orientation log being revamped to include all training requirements and to note that assessment was completed and is in personal record along with date of assessment. FM was to provide LPA a copy of the updated new hire orientation log by POC date 8/6/2021. CCL has not received the POC. The STRTP was cited for Training Requirements: (c)(3) Training shall include... (E) Direct care worker's self-awareness and appropriate boundaries for physical and verbal interactions with children or nonminor dependents who have a history of abuse, neglect or other trauma. When the citation was issued the STRTP FM and ED stated the POC would include the new hire orientation log being revamped to include all training requirements to meet ILS section 87065.1(c)(3)(A) through (X). FM was to provide LPA a copy of the updated new hire orientation log by POC date 8/6/2021. CCL has not received the POC. The STRTP was cited for Training Requirements: (c)(3) Training shall include... (F) Role of other facility personnel in service delivery, including case staffing and the designated staff member(s) applying the reasonable and prudent parent standard. When the citation was issued the STRTP FM and ED stated the POC would include the new hire orientation log being revamped to include all training requirements to meet ILS section 87065.1(c)(3)(A) through (X). FM was to provide LPA a copy of the updated new hire orientation log by POC date 8/6/2021. CCL has not received the POC. The STRTP was cited for Training Requirements: (c)(3) Training shall include... (H)Disaster response. When the citation was issued the STRTP FM and ED stated the POC would include the new hire orientation log being revamped to include all training requirements to meet ILS section 87065.1(c)(3)(A) through (X). FM was to provide LPA a copy of the updated new hire orientation log by POC date 8/6/2021. CCL has not received the POC. ****** The STRTP was cited for Training Requirements: (c)(3) Training shall include... (I) Medical emergency response. When the citation was issued the STRTP FM and ED stated the POC would include the new hire orientation log being revamped to include all training requirements to meet ILS section 87065.1(c)(3)(A) through (X). FM was to provide LPA a copy of the updated new hire orientation log by POC date 8/6/2021. CCL has not received the POC. The STRTP was cited for Training Requirements: (c)(3) Training shall include... (L) The role of placement workers. When the citation was issued the STRTP FM and ED stated the POC would include the new hire orientation log being revamped to include all training requirements to meet ILS section 87065.1(c)(3)(A) through (X). FM was to provide LPA a copy of the updated new hire orientation log by POC date 8/6/2021. CCL has not received the POC. The STRTP was cited for Training Requirements: (c)(3) Training shall include... (N) Short-term residential therapeutic program children's adjustment to congregate care. When the citation was issued the STRTP FM and ED stated the POC would include the new hire orientation log being revamped to include all training requirements to meet ILS section 87065.1(c)(3)(A) through (X). FM was to provide LPA a copy of the updated new hire orientation log by POC date 8/6/2021. CCL has not received the POC. The STRTP was cited for Training Requirements: (c)(3) Training shall include... (P) Recreation activities and resources. When the citation was issued the STRTP FM and ED stated the POC would include the new hire orientation log being revamped to include all training requirements to meet ILS section 87065.1(c)(3)(A) through (X). FM was to provide LPA a copy of the updated new hire orientation log by POC date 8/6/2021. CCL has not received the POC. The STRTP was cited for Training Requirements: (c)(3) Training shall include... (U) An overview of the children welfare and probation systems. When the citation was issued the STRTP FM and ED stated the POC would include the new hire orientation log being revamped to include all training requirements to meet ILS section 87065.1(c)(3)(A) through (X). FM was to provide LPA a copy of the updated new hire orientation log by POC date 8/6/2021. CCL has not received the POC. The STRTP was cited for Training Requirements: (c)(3) Training shall include... (V) Awareness and identification of commercial sexual exploitation and best practices for providing care and supervision to ****** commercially sexually exploited children. When the citation was issued the STRTP FM and ED stated the POC would include the new hire orientation log being revamped to include all training requirements to meet ILS section 87065.1(c)(3)(A) through (X). FM was to provide LPA a copy of the updated new hire orientation log by POC date 8/6/2021. CCL has not received the POC. The STRTP was cited for Training Requirements: (c)(3) Training shall include... (W) The federal Indian Child Welfare Act... and connection to the tribal community and traditions. When the citation was issued the STRTP FM and ED stated the POC would include the new hire orientation log being revamped to include all training requirements to meet ILS section 87065.1(c)(3)(A) through (X). FM was to provide LPA a copy of the updated new hire orientation log by POC date 8/6/2021. CCL has not received the POC. The facility is receiving Civil Penalties for violation of California Code of Regulations, Title Division Six regulation 80054(f) Penalties which poses a potential health, safety or personal rights risk to foster children in care. Civil Penalties are being assessed at $100 a day per violation beginning on August 7, 2021 and will continue to accrue at $100 a day per violation, until deficiencies are corrected. A copy of this report along with LIC 809D deficiency page, LIC Civil Penalty Assessment and appeal rights were provided to Sojourners Haven Group Home Executive Director, LaTrese Armstrong.

met_with: LaTresse Armstrong


state: CA

facility_name: SOJOURNERS HAVEN GROUP HOME

summary: Facility Evaluation

raw_content:
Narrative:
On August 11, 2021, at 10: AM, Licensing Program Analysts (LPAs) Cindy Hamilton and Babatunde Aborchie, and Licensing Program Manager (LPM) Abdoulaye Traore arrived at facility and met with Administrator Gina Melendez. The purpose of the visit was to review staff and client files. LPAs and LPM reviewed seven staff files and two of three client files. LPAs and LPM observed client #2's (C2) file was missing a signed copy of the facility's discipline policy. It was also observed that C2 did not receive Tuberculosis (TB) testing within 30 days of placement. In addition, the centrally stored medication form in C2's file did not have all the required information per Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS). In regard to staff file reviews, LPA's and LPM observed staff #7's (S7) file did not contain the required first aid and Cardiopulmonary Resuscitation training. Based on client file reviews, the facility is being cited for violation of STRTP ILS Chapter 7.5, Version 3.1 section 87070(c)(2) Children's Records. The facility is also being cited for violation of California Code of Regulations, Title 22, Division 6, section 80075(k)(7)(B through H) Health-Related Services and section 80069 ( c)(1) Client Medical Assessments. Based on staff file review, the facility is being cited for violation of STRTP ILS Chapter 7.5, Version 3.1, section 87065.1(8)(A) Training Requirements. A copy of this report along with appeal rights were discussed and provided to Administrator Gina Melendez.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Gina Melendez, Administrator


facility_name: SOUTH COUNTY GROUP HOMES, INC I

summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
For the allegation that facility allowing smoking on the property, confidential interview with staff confirms that the staff is smoking at least two times during each shift in front of the garage located on the facility property. Based on the interview the allegation is found to be substantiated California Code of Regulations, Title 22, Division Chapter 5, 84087(c) - Buildings and Grounds is being cited on the attached LIC9099D. At the time of the complaint LPA reviewed the Program Statement/Plan of Operations and noted that the section on Neighbor Complaints had not been reviewed since 12/31/1998 when the facility was named Country House. Revision of the Neighbor Complaint section was discussed with the Administrator and Licensee on 03/17/2021 during the opening of this investigation. Based on conversation with the Licensee and Administrator on 03/17/2021, the Licensee had not updated this section nor was the Administrator familiar with the policy the allegation is found to be substantiated California Code of Regulations, Title 22, Division Chapter 5, 80022(k) - Plan of Operation is being cited on the attached LIC9099D. As a result of this visit, there were two California Code of Regulations, Title 22, Division Chapter 5 deficiencies observed (See 9099D dated 08/25/2021). Exit interview was conducted and a copy of this report was provided to Dr. Shacy Rivera, Administrator whose signature on this form confirm receipt of these documents

Investigation Findings:
13Licensing Program Analyst (LPA) Carolyn Flynn made and unannounced visit to the above list facility at 11: AM on 08/25/2021. LPA was met by Dr. Shacy Rivera, Administrator (Adm). LPA explained the purpose of the visit was to deliver findings for the above listed allegations. At the time of the visit there were zero clients and one staff. Adm gave LPA a tour of the outside. LPA did not go inside due Adm being informed this AM of a COVID exposure of a client in care. During this investigation LPA Flynn and LPA AmyLe Tran conducted confidential interviews with the reporting party (RP), Adult Protective Services Social Worker, three staff, four parents, one county social worker, and three service coordinators from the San Andreas Regional Center between March and July 2021. LPA Flynn also reviewed six client behavior plans, staff roster and staff schedule from February and March 2021 that the Administrator sent to LPA via email on Mach 10, 2021. LPA reviewed the Neighborhood Section of the Program Statement for the facility from 12/31/1998. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Carolyn Flynn 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: SOUTH COUNTY GROUP HOMES, INC IFACILITY NUMBER: VISIT DATE: 08/25/2021

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

report_type: Complaint Investigation

met_with: Dr. Shacy Rivera

complaint_status: SUBSTANTIATED


summary: Complaint Investigation - Substantiated - 3 allegations

raw_content:
Narrative:
Facility cited for violation of California Code of Regulations, Title 22, Division Six, Section 84065(j)(2) Annual Training and Responsibility for Providing Care and Supervision. An exit interview was conducted and a copy of this report will be sent to administrator Anelise Toedoro.

Investigation Findings:
13Licensing Program Analyst (LPA) Shikya Belfield conducted an unannounced inspection at the above facility on 7/13/2021 at 9: AM. The purpose of this inspection is to deliver the findings regarding the above complaint allegations. LPA Belfield met with administrator Annelise Teodoro, who assisted with the inspection. Based on confidential interviews, obtained documentation to include but not limit; staff roster, staff schedule, client roster, client files, and incident reports. Clients leave the facility without interventions from staff when running away, staffing ratio is out of compliance and crisis interventions are unsuccessful because of this. Based on obtained documentation, staff have not had sufficient training and training hours and topics are out of compliance. The preponderance of the evidence has been met. Therefore, this allegation is Substantiated. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Shikya Belfield 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: SOUTH COUNTY GROUP HOMES, INC IFACILITY NUMBER: VISIT DATE: 07/13/2022

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Estimated Days of Completion: 90

visit_type: Annual

met_with: Anelise Teodoro


raw_content:
Narrative:
Facility cited for violation of the California Code of Regulations Title 22, Division Six, Section Responsibility for Providing Care and Supervision and 84065(j)(2) personnel requirements. An exit interview was conducted and a copy of this report will be sent to Maria Gado and administrator Anelise Teodoro.

Investigation Findings:
13Licensing Program Analyst (LPA) Shikya Belfield conducted an unannounced compliant inspection at the above facility on 8/30/2022 at 10:40AM. The purpose of this inspection is to deliver the findings regarding the above complaint allegations. LPA Belfield met with Maria Gado, who assisted with the inspection. Based on confidential interviews conducted and obtained supportive documentation to include but not limited to; staff schedules, staff training records, needs and service plans, and staff phone roster. On at least six occasions the facility failed to provide sufficient staffing ratios for the clients in care. Due to the insuficient staffing ratios, there was no coverage for persons who were to receive additional staffing support. Based on obtained documentation, staff have not had sufficient training and training hours. The preponderance of the evidence has been met. Therefore, these allegations are Substantiated. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Shikya Belfield 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: SOUTH COUNTY GROUP HOMES, INC IFACILITY NUMBER: VISIT DATE: 08/30/2022

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Estimated Days of Completion: 90

met_with: Maria Gado


summary: Complaint Investigation - Unsubstantiated - 3 allegations

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Shikya Belfield conducted an unannounced compliant inspection at the above facility on 8/30/2022 at 10: AM. The purpose of this inspection is to deliver the findings regarding the above complaint allegations. LPA Belfield met with Maria Gado, who assisted with the inspection. Based on confidential interviews conducted and obtained supportive documentation to include but not limited to; staff schedules, staff training records, needs and service plans, and staff phone roster. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, these allegations are Unsubstantiated. There were no violations cited of the California Code of Regulations Title 22, Division Six. An exit interview was conducted and a copy of this report will be sent to Maria Gado and administrator Anelise Teodoro. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Shikya Belfield 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 3

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 90

complaint_status: unsubstantiated


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Shikya Belfield conducted an unannounced complaint inspection at the above facility on 1/6/2023 at 10: AM. The purpose of this inspection is to deliver the findings regarding the above complaint allegation. LPA Belfield met with staff Gilbert Abilay, who assisted with the inspection. Based on confidential interviews conducted and obtained supportive documentation to include but not limited to; staff schedules, staff training records, needs and service plans, and staff phone roster. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, this allegation is Unsubstantiated. There were no violations of the California Code of Regulations Title 22, Division Six cited during this inspection. An exit interview was conducted and a copy of this report will be sent to administrator Anelise Teodoro. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Shikya Belfield 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 3

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 90

met_with: Gilbert Abilay


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Shikya Belfield conducted an unannounced inspection at the above facility on 4/17/2023 at 9: AM. The purpose for this inspection is to inform the facility representative of the findings for the above allegations. LPA met with Anelise Toedoro who assisted with the inspection. Based on a review of staff schedule and observation while visiting the facility, there was one staff who did not have criminal record clearance to work in the facility and they were a live-in staff. facility was cited and issued a civil penalty during the inspection on 3/6/2023. Based on review of staff schedule, it was observed that at least one client (C1, see LIC 811 dated 4/17/2023) did not have one to one support staff as required. The preponderance of the evidence has been met. Therefore, these allegations are Substantiated. Facility cited for violation of the California Code of Regulations, Title 22, Division Six, Section 84065.5(c) staffing/child ratios, as described on the following form LIC 9099D. An exit interview was conducted a copy of this form along with appeal rights will be sent to administrator Anelise Toedoro. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Shikya Belfield 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: SOUTH COUNTY GROUP HOMES, INC IFACILITY NUMBER: 435200178

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

met_with: Anelise Toedoro


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Shikya Belfield conducted an unannounced inspection at the above facility on 4/17/2023 at 9: AM. The purpose for this inspection is to inform the facility representative of the findings for the above allegations. LPA met with Administrator Anelise Toedoro who assisted with the inspection. Based on observations during a walk through on 4/17/2023 and photos taken in the facility, there are nails that prohibit the window from being opened in the middle bedroom and third bedroom windows and sliding door and the window in the first bedroom that is not able to be opened. Facility cited for violation of the California Code of Regulations, Title 22, Division Six, Section 80072(a)(7) Personal rights, as described on the follow page LIC 9099D. An exit interview was conducted a copy of this form along with appeal rights will be sent to administrator Anelise Toedoro. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Shikya Belfield 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: SOUTH COUNTY GROUP HOMES, INC IFACILITY NUMBER: 435200178

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Estimated Days of Completion: 90

met_with: Anelise Toedor


summary: Facility Evaluation

raw_content:
Narrative:
At 9:15AM, Licensing Program Analysts (LPAs) Madi Fremont and Selena Hood traveled to the home above for the purpose of conducting an unannounced Require Annual Inspection. LPAs met with Administrator Anelise Teodoro who helped facilitate this inspection. Currently in care are 6 ambulatory clients. anelise.claire@gmail.com (408) 832- During this inspection, LPAs toured the facility inside and out. The home is one story with 3 double bedrooms for clients, and one single bedroom for live-in staff. All bedrooms were comfortably furnished with adequate lighting. All windows were in good repair. The home has two full bathrooms, both of which were observed to be clean and free from hazards. The home also has a kitchen, living room, family room, laundry room, and a garage. The kitchen was observed to be clean and free of hazards. Sharps are kept locked and inaccessible to clients. LPA's observed at least 2 days of perishable food and 7 days of nonperishable food, stored in two refrigerators, two freezers, and cabinets in the kitchen. The thermostat was set to a comfortable temperature. Hot water from the kitchen sink was measured two separate times, first measuring 135 degrees Fahrenheit, and then measuring 139 degrees Fahrenheit. A deficiency was cited per Title 22 regulations, Division 6, Chapter 1, Article 7, Section 80088(e)(1) - Furniture, Fixtures, Equipment, and Supplies. Please see LIC809D for details. All cleaning supplies, chemicals, and pesticides are kept locked and inaccessible to clients. No firearms on the property. No bodies of water on the property. LPA's observed a fire extinguisher in the kitchen, and carbon monoxide/smoke detectors located throughout the home. (Continued on Lic809-c) LPAs observed all required postings in the living room of the home, except for the facility license. Staff explained the reason for this was it had repeatedly fallen of the wall. LPAs explained the license needed to be posted where the public could view it. The facility was issued an Advisory Note - Technical Advisory for Title 22, Division 6, Chapter 5, Article 2, Section 84009(a) - Posting of License. Please reference LIC9102 for details. LPA's toured the backyard of the home and observed it to be free of hazards. There is a large concrete pad in the backyard which clients can use to play basketball and other games. There is a trampoline on an area of artificial grass, which LPAs observed was not anchored to the ground. The facility was issued an Advisory Note - Technical Advisory for Title 22, Division 6, Chapter 5, Article 7, Section 84088.3(a) - Outdoor Activity Equipment. Please reference LIC9102 for details. LPA's observed all medications were centrally stored and locked from client access. There are two first aid kits in the kitchen, which had all required elements except for tweezers. The facility was issued an Advisory Note - Technical Advisory for Title 22, Division 6, Chapter 1, Article 6, Section 80075(g)(1)(F) - Health Related Services. Please reference LIC9102 for details. While in the kitchen, LPA's observed that the waste basket was not equipped with a tight-fitting lid. Upon inspection, LPAs observed the waste baskets in the bathrooms also did not have tight-fitting lids. The facility was issued an Advisory Note - Technical Advisory for Title 22, Division 6, Chapter 1, Article 7, Section 80088(f)(1) - Furniture, Fixtures, Equipment, and Supplies. Please reference LIC9102 for details. LPA Shikya Belfield will return to the home at a later date to complete the remainder of the home's Required Annual Inspection. At this time, 1 deficiency was cited and Advisory Notes were issued. An exit interview was conducted, Appeal Rights Provided and discussed, and a copy of this report was emailed to Administrator Anelise Teodoro, whose signature on this form confirms receipt.

met_with: Administrator Anelise Teodoro


summary: Facility Evaluation

raw_content:
Narrative:
On 05/12/2022 at 10:50AM, Licensing Program Analyst (LPA) Selena Hood conducted an announced visit to the above facility for the purpose of conducting a psychotropic medications inspection. LPA met with Anelise Teodoro, Administrator (ADM), and Leticia Soriano, Direct Care Staff (DC). DC and ADM conducted a pill count of the psychotropic medications. DC and ADM did the pill count for four clients, one of the clients medications was elsewhere while they are on a 5250 hold. There were no errors when comparing the Psychotropic Medications Administration Record (PMAR) and the pill count. No deficiencies were cited at this time. LPA conducted an exit interview with Anelise Teodoro, Administrator, at 11:30AM, whose signature confirms the receipt of this document.


summary: Facility Evaluation

raw_content:
Narrative:
On 7/22/2022 at 12:00PM, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the above facility. The purpose of this visit is to finish the required annual inspection. LPA met with Gilbert Abilay, Direct Care Staff and Marilyn Gado, House Manager, and conducted a walk through of the facility. At the time of the inspection, there were two staff members and one client present. LPA observed the home to be tidy, clean, and in good repair. LPA observed that there was a sufficient amount of food in the fridge and pantry. LPA observed that medications and files were kept in locked cabinets. LPA reviewed ten staff files. LPA found that two of the staff members had expired CPR/First Aid certificates. LPA cited Title California Code of Regulations 84065(i)(6) (see LIC 809D). LPA also found that one of the staff files did not contain current training hours for the previous year. LPA delivered a Technical Violation for 94065(j)(6) (see LIC 9102). LPA reviewed the files of five clients. LPA observed that the files were missing compatibility agreements for the clients that share rooms. LPA cited Title California Code of Regulations 84087(e) (see LIC809D). LPA noted that one client was missing the signatures on their Needs and Services Plan (NSP) and their NSP was not updated within the last six months. LPA delivered a Technical Violation for 84068.3(a). No further deficiencies were cited. LPA conducted an exit interview with Administrator Anelise Teodoro at 3:30PM. LPA will be providing this document to Administrator virtually to sign and return.


summary: Facility Evaluation

raw_content:
Narrative:
On 06/15/2023 at 9: AM Licensing Program Analyst (LPA) Shikya Belfield conducted an announced visit to the above licensed facility. The purpose of this visit is to conduct a case management inspection regarding incidents received by the department. Present during this inspection were two staff and one client. All other clients were at school and one client was in the hospital. During this inspection LPA interviewed S1 ( see LIC 811 dated 6/15/2023) and obtained copies of one client files. At this time the inspection cannot be complete as more information is needed regarding the staff and clients. No violations were cited during this inspection. An exit interview was conducted and a copy of this form was left with facility manager Maria Gado.


summary: Facility Evaluation

raw_content:
Narrative:
On 06/15/2023 at 9: AM Licensing Program Analyst (LPA) Shikya Belfield conducted an announced visit to the above licensed facility. The purpose of this visit is to conduct a Annual inspection regarding incidents received by the department. Present during this inspection were two staff and one client. All other clients were at school and one client was in the hospital. A walk through was conducted with facility manager Maria and this LPA. At this time the inspection is not complete and will be completed on a later date. An exit interview was conducted a copy of this report was left with Facility manager Maria Gado.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Shikya Belfield made an unannounced inspection to the above facility on 12/21/2023 at 8: AM. The purpose of this inspection is obtain the license of the previous facility type. On 11/8/2023 the facility transitioned to an adult residential facility and the children's facility is no longer in operation. LPA met with facility manager Maria Gado who assisted with this inspection. There were three staff and one client present during this inspection. There were no deficiencies observed. The license was given to this LPA and the inspection was concluded. This children's residential facility is now closed and an adult facility is now in operation.


summary: Facility Evaluation

raw_content:
Narrative:
On 04/29/2022 at 9:30AM, Licensing Program Analyst (LPA) Selena Hood and LPA Madi Fremont conducted an announced visit to the above licensed facility. The purpose of this visit was to conduct the Psychotropic Medications inspection. LPAs met with Anelise Teodoro, Administrator, and conducted a walk through of the facility. At the time of the inspection, there were four staff members and two clients present. LPAs reviewed the files of the four staff members who are trained to administer psychotropic medications, all staff files had the appropriate training records and required reports. LPA Hood interviewed two staff members and one client. The current census is six clients, five of which are currently prescribed psychotropic medications. LPAs reviewed the files of the the five clients on psychotropic medications. LPAs also reviewed the centrally stored medical binders. Based on record review, LPAs observed that all medications, including psychotropic medications, are being documented on the same Medication Administration Record. This is a violation of California Code of Regulations (CCR) 84070(b)(13). LPAs delivered a Type B citation, with a Plan of Correction due date of 5/27/2022 (see LIC 809D). During the record review of the client files, LPAs observed that four of the five clients were missing parent authorization for their psychotropic medications. LPAs delivered a Type B citation for CCR 84070(b)(12) with a Plan of Correction due date of 5/27/2022 (see LIC809D). LPA Hood conducted an exit interview with Anelise Teodoro, Administrator, at 2:00PM whose signature confirms the receipt of this document. Appeal rights were read and discussed.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst's (LPA) Shikya Belfield made an unannounced case management inspection to the above facility on 3/6/2023 at 9: AM. The purpose for this inspection is to conduct a case management regarding a deficiency observed by LPA. LPA Belfield met with Administrator Anelise Toedoro who assisted with the inspection. Based on a review of the guardian background check and a review of agency staff files and schedules, it was observed by LPA Belfield that S1(see LIC 811 dated 3/6/2023) who works for the facility, have not been criminally record cleared to work in the facility. Agency is being cited for violation of the California Code of Regulations, Section 80019(e)(1): Criminal Record Clearance. (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. Civil Penalty is being issued. During a review of the guardian background check, LPA observed that S1 process started in August 2022. An exit interview was conducted and a copy of this report along with appeal rights will be sent to administrator Anelise Toerdoro.


summary: Facility Evaluation

raw_content:
Narrative:
On 04/17/2023 at 9: AM Licensing Program Analyst (LPA) Shikya Belfield conducted an announced visit to the above licensed facility. The purpose of this visit is to conduct the Psychotropic Medications inspection. LPA met with Anelise Toedoro and conducted a walk-through of the facility. At the time of the inspection, three staff, administrator, and licensee were present. All clients were at school during this inspection. LPA reviewed the files of two staff who are trained to administer psychotropic medications and administrator file. Staff files had the appropriate training records and required reports. LPA Belfield interviewed two staff members. The current census is six clients, four of which are currently prescribed psychotropic medications. One client file was reviewed as three files did not meet the criteria for review. LPA also reviewed the centrally stored and medication binders. Based on record review, LPA observed that all psychotropic medications, are being documented on the same Medication Administration Record. This is a violation of California Code of Regulations (CCR) 84070(b)(13) as described on the attached LIC 809D. Staff conducted a pill count of the psychotropic medications. There were no errors when comparing the Psychotropic Medications the pill count. During a review of the Psychotropic Medication Record, it was observed that the medications are missing required information such as date of prescroiption, quantity, and space for documenting refusal and missing doses.This is a violation of California Code of Regulations (CCR) 84070(b)(13)(G) and 84070(b)(13)(c). Technical Violation Advisory issued. LPA Belfield conducted an exit interview with Anelise Teodoro, Administrator, at 2:00PM whose signature confirms the receipt of this document. A copy of Appeal rights were left along with this report.


summary: Facility Evaluation

raw_content:
Narrative:
On 9/13/2023 at 9: AM Licensing Program Analyst (LPA) Shikya Belfield conducted an unannounced inspection to the above licensed facility. The purpose of this visit is to conduct a case management inspection regarding an incident report received by the department regarding C1 (see LIC 811 dated 9/13/2023) . Present during this inspection were three staff. All clients were at school. During this inspection LPA interviewed S1 (see LIC 811 dated 9/13/2023) and obtained copies of client / staff ratio schedule. LPA spoke to administrator Anelise Toedoro regarding the incident and it was determined that due to, the two staff ( S2 and S3) leaving client unsupervised, the client was able to leave the facility and police were contacted. Facility cited for violation of California Code of Regulations, Title 22, Division Six, Section 80078(a) Responsibility for Providing Care and Supervision, as described on the following page LIC D. A civil penalty is being assessed. An exit interview was conducted and a copy of this form along with appeal rights will be sent to S1 and Administrator Anelise Toedoro.


facility_name: SOUTHWEST KEY PROGRAM

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Investigation Findings:
13On 11/3/22 at 10: AM, Licensing Program Analyst (LPA) Alyssa Ng conducted a complaint inspection at Southwest Key and spoke with Kavita Sharma, Administrator. The purpose of the inspection was to deliver the findings for the above complaint allegations. During confidential interviews and documents reviewed, staff do not discriminate against youth(s) in care and staff provides activities for youth(s) in care. Although the allegation may have happened or is valid, there is not a preponderance of the evidence that staff discriminate against youth(s) in care and staff not providing activities for youth(s) in care, therefore the above allegations is UNSUBSTANTIATED. An exit interview was conducted, and a copy was sent to Kavita Sharma, Administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Alyssa Ng 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: Kavita Sharma


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Ng made an unannounced inspection to Southwest Key Program group home. During the inspection, LPA Ng met with Kavita Sharma, Program Director and inspect the facility inside and out. LPA reviewed files with Program Director. The group home is licensed to served 30 clients ages 6-17. Present during the inspection was 17 clients and 7 staff. The CARE Inspection Tool was used to conduct the inspection. The facility and grounds are clean, tidy, and free of obstructions. There are no hazards on the premises and no firearms, per Administrator. Bedrooms are double-occupancy, and beds have clean linens and mattress pads. There is enough storage for residents' personal belongings. Food is of good quality, within date, and stored properly. First aid kit was observed to be complete. Room temperature was 70 degrees maintained at a comfortable temperature within permitted range. Water temperature measured at 113.7 which is in the permitted range. LPA conducted 2 confidential staff interviews and 2 confidential client interviews. The facility consists of 14 bedrooms with each room having a individual bathroom inside. The facility is licensed for 30 residents (all must be ambulatory) and currently 17 clients reside in facility. No more than two clients share a bedroom. Client files and 5 staff files were reviewed. LPA observed all client files and found no deficiencies. The documentation in the clients file are complete. LPA observed all staff files to be complete all correct documentation and all staff were up to date with their 20 hours of training for the year. At this time, no deficiencies were cited. An exit interview was conducted, and a copy of this report was emailed to Kavita Sharma, Program Director whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 12/13/2022 at 10: AM, Licensing Program Analyst (LPA) Alyssa Ng conducted an unannounced case management inspection with listed facility and spoke with Catherine Galindez, Executive Assistant. The purpose of the inspection was to follow up on an incident involving sexual abuse between clients. LPA Ng reviewed the incident report that came in on 12/6/22. Both clients were sitting on the couch during the time of the incident. One client placed their hand on the other client's knee. Then their hand proceeded to move closer to the other client's groin area. Staff immediately redirected client and reminded them that it is not okay to touch other clients in an inappropriate manner and to respect others' space and boundaries. LPA Ng asked Catherine Galindez, Assistant Program Manager the procedures for incidences like this and how staff use prudent parenting/trauma informed care to ensure clients are feeling safe and comfortable. What kind of services, what staff are communicating to clients, and how often they check in with clients regarding personal space and boundaries were asked during the time of inspection. Assistant Program Director stated that both clients were seen by a clinician after the incident to ensure that the clients were okay and if they needed additional support LPA was also provided with documentation. Documents included training to all clients regarding sexual harassment, personal space, and the prevention of sexual abuse. Both clients also took a refresher course on the same topics. No deficiencies were cited today. A copy of this report was given to Catherine Galindez, Executive Assistant.

met_with: Catherine Galindez


summary: Facility Evaluation

raw_content:
Narrative:
On 2/3/2023 at 10: AM, Licensing Program Analyst (LPA) Alyssa Ng conducted an unannounced case management inspection with listed facility and spoke with Kavita Sharma, Administrator The purpose of the inspection was to follow up on an incident involving sexual abuse between clients. LPA Ng reviewed the incident report that came in on 2/2/22. The incident report involved one female client and one male client. The female client reported to a staff member that she was uncomfortable with his comments and gestures. A staff member checked in with the male staff and denied the comments and gestures and reported bullying from the female client. Staff offered the youth to file a Prevention Sexual Abuse (PSA) report or grievance. A refresher PSA training was also given to both clients. LPA Ng stated that these incidences are becoming a common occurrence and asked how the facility can ensure that clients are safe and protected. Administrator stated that staff will create PSA refreshers for all clients and update the Risk Assessment for all clients. For example, if a client is high risk, Administrator will ensure there is an extra staff for elevated supervision. Administrator will hold a meeting with staff in regards to bullying, supervision, sexual abuse prevention, boundary violations, and red flag behaviors. Unannounced visits to all the shifts and interview youth and staff regarding the PSA and their understanding about it. Facility keeps a log/calendar on the unannounced visits to ensure they remain in compliance with CCL and Office of Refugee and Resettlement (ORR). No deficiencies were cited today. A copy of this report was given to Kavita Sharma, Administrator.

announced_status: Unannounced


summary: Facility Evaluation

raw_content:
Narrative:
On 07/23/2024 at 12:20 p.m., Licensing Program Analyst (LPA) Brenda Rodriguez conducted an unannounced Annual Inspection and met with Kavita Sharma, Program Director. LPA Rodriguez disclosed the purpose of the inspection and was granted entry into the facility. LPA Rodriguez used the CARE Inspection Tool. There were twenty (20) staff members, and thirteen (13) clients present at the time of inspection. The facility currently has a census of thirteen (13) non-minor dependent clients ages 13-17. The facility consists of fourteen (14) bedrooms with each room having an individual bathroom inside. No more than two clients share a bedroom. LPA Rodriguez reviewed five (5) staff files and five (5) client files. The documentation in the clients file is complete. LPA Rodriguez conducted two confidential staff interviews and one confidential client interview. During the physical plant inspection, no deficiencies were found. The facility and grounds are clean, tidy, and free of obstructions. There are no hazards on the premises and no firearms, per Administrator. Bedrooms are double-occupancy, and beds have clean linens and mattress pads. There is enough storage for residents' personal belongings. Food is of good quality, within date, and stored properly. Room temperature was 70 degrees maintained at a comfortable temperature within permitted range. At this time, the inspection is not complete. LPA Rodriguez will come back at a later day to complete the required Annual Inspection. No deficiencies were cited. An exit interview was conducted at 4:15 p.m., and a copy of this report was emailed to Program Director Kavita Sharma, whose signature on this form confirms receipt.

met_with: Kavita Sharma, Program Director


summary: Facility Evaluation

raw_content:
Narrative:
On 07/31/2024 at 2:15 p.m., Licensing Program Analyst (LPA) Brenda Rodriguez conducted an unannounced Annual Inspection and met with Ivonete Kim, Assistant Program Director. LPA Rodriguez disclosed the purpose of the inspection and was granted entry into the facility. LPA Rodriguez used the CARE Inspection Tool. There were twenty-four (24) staff members, and twelve (12) clients present at the time of inspection. LPA Rodriguez reviewed staff training that is done online, certificates, and everything is up to date. LPA Rodriguez conducted two confidential client interviews. LPA Rodriguez observed the locked cabinet where all medication is stored and kept. The required annual inspection is complete. No deficiencies were cited. An exit interview was conducted at 3:02 p.m., and a copy of this report was emailed to Assistant Program Director Ivonete Kim and Program Director Kavita Sharma, whose signature on this form confirms receipt.

met_with: Ivonete Kim, Assistant Program Director


summary: Facility Evaluation

raw_content:
Narrative:
*** Sent back to Administrator with correct amount of interviews conducted. *** *** Correct number of interviews was 15 not 18. *** On 10/16/24 at approximately 10: AM, Licensing Program Analysts (LPAs), Jonathan Medina and Lisette Valenzuela arrived unannounced to the facility and met with Kavita Sharma, Administrator for the purpose of conducting a Case Management inspection regarding sexual abuse claims related to Out of State Southwest Keys facilities. During this case management health and safety inspection, the LPAs conducted interviews with 0 clients and 15 staff. There were no clients in placement. LPAs conducted a walk through of the facility. In addition, LPAs met with Katherine Galandez, Veronica Navarro, and Monika Balley to review facility records, 5 most recent client files, and 58 staff files. Please see LIC811 confidential names list dated 10/16/24. No immediate deficiencies were observed or cited during today's case management inspection. An exit interview was conducted, and a copy of this report was provided to Kavita Sharma, Administrator.

met_with: Kavita Sharma - Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 10/15/2025 at 12: PM, Licensing Program Analyst (LPA) Jasmine Cardeno made an unannounced visit to the building of the former facility, Southwest Key Program. LPA arrived to the front entrance and observed maintenance staff moving storage boxes into a mini van. LPA introduced herself and informed maintenance staff the purpose of the inspection is to verify that Southwest Key Program is no longer operating as a Group Home or as a Licensed Children's Residential Facility. The maintenance staff stated that the Group Home is no longer operating and everything has been moved out and some things are in the process of being moved out. Maintenance staff informed LPA that Facility Administrator, Kavita Sharma, is present on-site. LPA met with Facility Administrator, Kavita Sharma, and presented her badge and introduced herself to Facility Administrator. LPA informed Facility Administrator the purpose of the inspection is to verify that Southwest Key Program is no longer operating as a Group Home or as a Licensed Chidren's Residential Facility. During the time of the inspection, zero youth were present as Facility Administrator informed LPA that there have been no youth present living in the facility since March 2025. At 12: PM, LPA conducted a walk-through tour of the facility, facilitated by Facility Administrator. Facility Administrator led LPA around the building to show different areas of the facility including kitchen, dining, living room common spaces, gym, and client bedrooms. LPA observed that there are no beds present in the building or signs of youth residing in the building. LPA observed empty filing cabinets that were put away in rooms for storage purposes. LPA had a discussion with Facility Administrator asking about where confidential files are located. Facility Administrator informed LPA that there are no longer confidential files located on-site at the facility and have been shipped away properly. (Continuation Page on LIC809-C form.) LPA observed the building of the former facility, Southwest Key Program, is not being used as a Group Home. LPA observed that there are no clients residing in the facility. An exit interview was conducted and a copy of this report was left with Facility Administrator, Kavita Sharma, whose signature on this form confirms receipt.

met_with: Facility Administrator, Kavita Sharma


summary: Facility Evaluation

raw_content:
Narrative:
On 6/27/2023 at 11: AM, Licensing Program Analyst (LPA) Alyssa Ng conducted an unannounced case management inspection with listed facility and spoke with Catherine Galindez, Executive Assistant. The purpose of the inspection was to follow up on an incident involving a staff member giving out their personal information to a youth in care. LPA Ng reviewed the incident report that came in on 6/23/23. A youth disclosed that a staff member gave out their personal email and stated that the staff said that another employee from listed facility is married to her father. Moreover, staff told youth that she had a boyfriend in their 30s. LPA Ng asked Catherine Galindez, the procedures for incidences like this and how the facility ensures that staff follow the facilities Code of Conduct (COC). LPA also asked how often staff get refreshers on the COC. Catherine stated that the client was seen by a clinician after the incident to ensure that the client was okay and if they needed additional support. LPA Ng interviewed both the client and the clinician who the client disclosed the information to. The staff that was involved in the incident is currently suspended pending investigation. Based on the interviews, reviewing related documents and video footage, the facility has been cited for 80065(f)(3) Personnel Requirements. At this time, one deficiency was cited, appeal rights were discussed, and a copy of this report was given to Catherine Galindez, Executive Assistant.


facility_name: SOUTHWEST KEY PROGRAMS SAN DIEGO

raw_content:
Narrative:
Confidential interviews revealed inconsistency as to whether the facility did not follow proper COVID-19 protocols. The facility's Corp office sent information to Public Health regarding COVID - 19 information however it was incomplete. Confidential interviews revealed that the facility did report COVID-19 however some of the information for the case log for public health was incomplete because the information was provided by the Corp office. Confidential interviews revealed that PD was out on medical leave when public health tried to contact PD about the facility's COVID information. Additional interviews revealed that ADP was available to provide additional information however ADP was not included in the emails there were sent to PD while PD was out. Based on record reviews and confidential interviews, the facility not following proper COVID-19 protocols and the facility not following reporting requirements related to COVID-19 cases are unsubstantiated. The details gathered for the incidents did not provide a preponderance of evidence to prove or disprove the allegations. LPA Meza-Gonzalez conducted an exit interview and provided a copy of this report along with appeal rights to APD Vega.

Investigation Findings:
13On May 3, 2023, at 3: PM, Licensing Program Analyst (LPA) Gloria Meza-Gonzalez conducted an unannounced complaint inspection at Southwest Key - San Diego. LPA Meza-Gonzalez met with Assistant Program Director (PD) Luis Vega. The purpose of the inspection was to deliver the findings for the above complaint allegations. LPA Carol Anderson conducted an inspection of the facility on September 15, 2022, and no deficiencies were noted. During the investigation, LPA Meza-Gonzalez reviewed PD and Assistant Program Director (ADP). LPA Meza-Gonzalez reviewed the following documentation: emails and a special incident report. On September 8, 2022, the Department received a complaint report, with the allegations that the facility not following proper COVID-19 protocols and the facility not following reporting requirements related to COVID-19 cases. See Page 2 - LIC9099c UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Gloria Meza-Gonzalez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, METROPOLITAN DR. # FACILITY NAME: SOUTHWEST KEY PROGRAMS SAN DIEGOFACILITY NUMBER: VISIT DATE: 05/03/2023

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

met_with: Luis Vega


raw_content:
Narrative:
During the investigation, confidential interviews indicated when there are call outs, staff from the current shift are asked to stay to cover the next shift; staff from the next shift are called if they can report sooner; or asked additional staff to cover shifts. Confidential interviews reported that education and security monitors are asked for support in providing supervision if there was a shortage in staffing. Regarding the allegation that staff leaves facility in unsanitary conditions, it was specifically reported that when the facility was aware that licensing was to conduct an inspection, the facility got everything fixed. Confidential interviews stated that maintenance staff mop and sweep, take out the trash and do laundry. Confidential interviews continued stating that clients also participate in cleaning their room and picking up after themselves. Confidential interviews did not provide consistent statements. Based on confidential interviews and record review, the allegation that staff does not provide adequate supervision to minors in care and staff leaves facility in unsanitary conditions, may have occurred, however, there was not a preponderance of evidence to support or deny the allegations. Therefore, the above allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this signed report was provided to Luis Vega, Program Director.

Investigation Findings:
13On March 22, 2024, at 1: PM, Licensing Program Analyst (LPA) Lucero Jauregui conducted an unannounced complaint inspection and met with Luis Vega, Program Director and Diana Pelosa, Assistant Program Director. The purpose of the inspection is to deliver the finding for the above allegations. LPA conducted an inspection of the facility on September 18, 2023, and no deficiencies were observed. During the investigation, LPA conducted five staff interviews (S1- S5), obtained program summary for 9/16/23, and reviewed facilities program statement. On September 18, 2023, Community Care Licensing (CCL) received the allegations that staff does not provide adequate supervision to minors in care and staff leaves facility in unsanitary conditions. It was specifically reported that on September 16, 2023, the facility was operating out of ratio with five staff supervising 50 clients and facility was short staffed on the weekends due to call outs. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: SOUTHWEST KEY PROGRAMS SAN DIEGOFACILITY NUMBER: VISIT DATE: 03/22/2024

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


raw_content:
Narrative:
It was reported that C1 did not lock the door and C2 reported to S1 that C2 saw C1's buttocks and genitals. Confidential interviews indicated S2 was assigned as the restroom monitor. Confidential interviews indicated C2 was in class and asked for permission to use the restroom. Confidential interviews indicated C2 was given permission to use the restroom and didn't knock on the restroom door due to receiving permission from S2. Conflicting confidential interview indicated C2 knocked on the door, did not hear anyone inside and opened the door. Confidential interview indicated C1 was inside and C1 did not hear anyone knock on the door. Record review indicated C1 did not lock the restroom door, and C2 did not knock before opening the door. Confidential interviews indicated staff followed up with C1 and C2 and both agreed they were comfortable to be around each other. However, LPA received conflicting statement that C2 did not feel comfortable around C1 after the incident. Confidential interviews indicated clients were reminded to knock on the door before entering and to lock the restroom door. Confidential interview did not reveal any other incident of a client walking into the restroom while another client was using the restroom. Based on confidential interviews the allegations that staff did not ensure that minor was provided with privacy while using the restroom may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this signed report and appeal rights were provided to Diana Peloso, Assistant Program Director.

Investigation Findings:
13On December 19, 2024, at 09: AM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Diana Peloso, Assistant Program Director to discuss the investigative finding for the allegation noted above. LPA Jauregui conducted an inspection of the facility on May 8, 2024, and no deficiencies were noted. During the investigation, LPA Jauregui interviewed five staff (S1-S5) and two clients (C1-C2) and reviewed Special Incident Report. On May 6, 2024, Community Care Licensing (CCL) received an allegation that staff did not ensure that minor was provided with privacy while using the restroom. It was reported that S2 failed to ensure proper supervision of C1 and C2 which led to the alleged incident. It was reported S2 was assigned to supervise the restroom area and forgot there was a youth, C1, inside the bathroom. Reportedly, S2 instructed C2 they could use the restroom, which led to C2 opening the bathroom door and seeing C1. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: SOUTHWEST KEY PROGRAMS SAN DIEGOFACILITY NUMBER: VISIT DATE: 12/19/2024

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


raw_content:
Narrative:
Confidential interviews indicated staff supervise and interact well with the clients. Confidential interviews indicated there is nothing out of the ordinary in staff's behavior. Confidential interviews indicated Southwest Key Headquarters conducted random drug and alcohol tests of staff. Confidential interviews and record review indicated there were two staff whose drug tests came out positive, and disciplinary action was taken in response to the staff's positive drug test results. However, it is not known whether either of the staff ever worked under the influence. Confidential interview and record review did not produce evidence that intruders gained access to the facility during the month of May, and no corroborating witnesses to the alleged event were discovered during the investigation. Based on confidential interviews and records review, the allegations that staff provide care under the influence of drugs and alcohol and minors are not being supervised properly may have occurred, however, the allegations are not supported or proven by evidence. Therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this signed report and appeal rights were provided to Diana Peloso, Assistant Program Director.

Investigation Findings:
13On December 19, 2024, at 09: AM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Diana Peloso, Assistant Program Director to discuss the investigative findings for the allegations noted above. LPA Jauregui conducted an inspection of the facility on May 29, 2024, and no deficiencies were noted. During the investigation, LPA Jauregui interviewed seven staff (S1-S7) and five clients (C1- C5) On May 23, 2024, Community Care Licensing (CCL) received the allegations that staff provide care under the influence of drugs and alcohol and minors are not being supervised properly. It was reported that during the month of May there were two incidents when an intruder gained access to the facility. It was reported that many staff come to work under the influence of drugs or alcohol, and it is visible that they are working under the influence. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: SOUTHWEST KEY PROGRAMS SAN DIEGOFACILITY NUMBER: VISIT DATE: 12/19/2024

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


raw_content:
Narrative:
Confidential interviews indicated staff conduct a second round to ensure clients have woken up. Confidential interviews indicated if clients have not got out of bed, staff advise clients staff will be turning on the light. Confidential interviews indicated S9 has prompted clients to wake up by tapping their walkie- talkie on the clients' bed rails. Additionally, confidential interview indicated a client was not awake and S9 grabbed a broom and began hitting the bed frame of the client until the client got up. Based on confidential interviews, the allegation that staff does not treat minors with respect is SUBSTANTIATED because the preponderance of the evidence has been met. This posed potential health, safety, or personal rights risk to child in care. The facility is being cited for violation of Title 22, Division Chapter Article 06. Continuing Requirements 84072(d)(1) Personal Rights. [See Lic9099d]. An exit interview was conducted and plan of correction was developed with Luis Vega, Program Director. A copy of this signed report, LIC 9099D, and appeal rights were provided to Luis Vega, Program Director. Confidential interviews indicated S1 has a loud voice and maintains the same tone of voice all day. Confidential interviews indicated clients are comfortable and get along well with S1. Confidential interviews denied S1 yell at the clients in an aggressive manner or tone. Confidential interviews denied the allegation. Based on confidential interviews, the allegation that staff yell at minors may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this signed report and appeal rights were provided to Luis Vega, Program Director.

Investigation Findings:
13On February 19, 2025 at 9: AM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Luis Vega, Program Director to discuss the investigative finding for the allegation noted above. LPA Jauregui conducted an inspection of the facility on October 2, 2024, and no deficiencies were noted. During the investigation, LPA Jauregui interviewed five clients (C1-C5) and eight staff (S1-S8). Pertinent documents were obtained. On September 30, 2024, Community Care Licensing (CCL) received an allegation that staff does not treat minors with respect. It was reported that staff force clients to wake up in the morning in an authoritarian manner. Confidential interviews indicated clients are woken up at 6 am. Confidential interviews indicated staff knock on their bedroom door and prompt clients it's time to get up. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: SOUTHWEST KEY PROGRAMS SAN DIEGOFACILITY NUMBER: VISIT DATE: 02/19/2025

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

met_with: Luis Vega, Program Director


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

raw_content:
Narrative:
It was reported that clients are always supervised, need to ask permission to go anywhere, and clients cannot walk around freely. It was reported that clients are not allowed to go out of their rooms without permission. Confidential interviews indicated staff follow clients when they move around inside the facility, and if they don't do so, the client is considered to be unsupervised. Confidential interviews indicated staff communicate through walkie-talkies with each other to watch when a client wants to step out of the classroom to use the bathroom in the hallway. Confidential interviews indicated clients have to ask for permission to walk around the facility, use the common bathroom in the hallway, and if they want to go out in the recreational area. Confidential interviews indicated clients are not allowed to go from one section of the facility to another without staff following. It was also reported that clients are not adequately fed. Confidential interviews indicated there are three meals and three snacks provided daily. Confidential interview indicated an alternative meal is not offered if a client doesn't like the meal being provided. Confidential interview indicated fruit is offered, if a client does not like the meal, but clients have to wait until the next meal is served to get something more than fruit. Confidential interview indicated that clients may have to wait some time to be provided fruit after requesting or indicating they are hungry between meal and snack times. Confidential interview indicated clients have also been denied access to salt and condiments when requested. Based on confidential interviews, the allegations that clients are not allowed out of their rooms without permission and staff are not ensuring that clients are adequately fed are SUBSTANTIATED because the preponderance of the evidence standard has been met. This posed potential health, safety, or personal rights risks to children in care. The facility is being cited for violation of Title 22, Division Chapter Article 06. Continuing Requirements 84072(d)(1) Personal Rights, and Title 22, Division 6, Chapter 1, Article 06. Continuing Requirements 80076 (a)(4) Food Services. [See Lic9099d]. An exit interview was conducted, and a plan of correction was developed with Program Director Luis Vega. A copy of this signed report, LIC 9099D, and appeal rights were provided to Program Director Luis Vega. It was reported that the soccer field is cement, uneven, and children are getting hurt because the ground is hard. It was reported that a child had wounds on their arms and sides as a result. Confidential interviews indicated the facility's outdoor recreational space is not appropriate for playing soccer. LPA observed the recreation area to be a black top. Confidential interviews indicated clients run and bump into each other while playing. Confidential interview indicated that while playing soccer a client attempted to kick the ball and kicked the ground instead. Confidential interviews indicated clients have fallen while playing and scraped their legs. Confidential interviews indicated clients received first aid onsite and further outside medical care when needed. Confidential interviews indicated staff are always present on the perimeter of the recreation area and supervising when clients are playing. It was reported that staff are not meeting the educational needs of clients in care. Confidential interview indicated all clients in care are taught at the same level. Confidential interviews indicated each time a new client is placed, all clients re-start at the lowest basic level. Confidential interviews indicated clients are taught in English and Spanish, and the material provided is in English. Confidential interviews indicated some clients in care do not speak English or Spanish. Confidential interviews indicated clients who speak a different language are provided with a pocket translator that is used to communicate with staff and other clients. Confidential interviews indicated there are tablets available for clients to translate classwork. Confidential interviews indicated clients could take a picture of class worksheets with the tablet, and the worksheets are translated into the client's preferred language. Confidential interviews indicated when videos are shown in class, subtitles are added. Confidential interviews indicated during lectures the work is being translated in different languages. Confidential interviews indicated clients are provided work for the week and clients can choose to work independently. Confidential interviews indicated youth care workers assist clients in completing classwork to the best of the staff's capabilities. Based on confidential interviews, the allegations that facility's outdoor space is unsafe for clients in care, due to lack of staff supervision clients are injured in care, and staff are not meeting educational needs of clients in care, may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this signed report and appeal rights were provided to Program Director Luis Vega

Investigation Findings:
13On April 11, 2025, at 11: AM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Program Director Luis Vega to discuss the investigative findings for the allegations noted above. LPA Jauregui conducted an inspection of the facility on September 25, 2024, and no deficiencies were noted. During the investigation, LPA Jauregui interviewed six clients (C1-C6) and seven staff (S1-S5, S8-S9). Pertinent documents were obtained. On September 18, 2024, Community Care Licensing (CCL) received allegations that clients are not allowed out of their rooms without permission, and staff are not ensuring that clients are adequately fed. It was reported that the facility restricts clients' freedom of movement; specifically, that clients regularly spend several hours locked in their bedrooms. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: SOUTHWEST KEY PROGRAMS SAN DIEGOFACILITY NUMBER: VISIT DATE: 04/11/2025

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

Deficiencies:
80076: (4) Between meal nourishment or snacks shall be available for all clients unless limited by dietary restrictions prescribed by a physician.

met_with: Program Director Luis Vega

title: (a) In facilities providing meals to clients, the following shall apply


raw_content:
Narrative:
Confidential interview indicated PSA training was conducted by S1 and provided to all staff and youths. Confidential interview indicated the training was provided to the youth every 15th of the month and if the youth had been in care more than 30 days. Confidential interviews indicated there was PSA training designed for different age ranges. Confidential interviews indicated that medical terminology was used to identify parts of the human body, and some youth expressed feeling uncomfortable with terms being used. Confidential interviews indicated the terminology used is not appropriate. Confidential interview indicated some youth come from rural areas or have not been exposed to the terms used. Other confidential interviews indicated the terms used are appropriate in for educating the youth in on sexual abuse. Confidential interview indicated prior to the training the youth are advised they can step out if they feel uncomfortable. It was also reported that minors are not accorded dignity in their relationship with staff. It was reported that S1 often yells, belittles, teases and challenges the youth and challenges them in at times where when the youth are extremely distressed. Confidential interview indicated S1 was not professional when conducting training. Confidential interviews indicated S1's tone was not unprofessional, but was direct and to the point. Confidential interviews indicated real life scenarios were used to provide the youth with examples of what is identified as sexual abuse. Other confidential interview denied that S1 spoke inappropriately to the youth in care. No other information was obtained during the investigation that indicated that S1 did not treat the clients with dignity. Based on conflicting confidential interviews, the allegations that staff are not provided with proper training and minors are not accorded dignity in their relationship with staff are unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of this signed report and appeal rights were provided to Luis Vega, Program Director.

Investigation Findings:
13On September 4, 2025 at 9: AM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Luis Vega, Program Director to discuss the investigative findings for the allegations noted above. LPA Jauregui conducted an inspection of the facility on March 14, 2025, and no deficiencies were noted. During the investigation, LPA Jauregui interviewed six staff (S1-S6). LPA Jauregui did not conduct client interviews due to zero clients in placement. Pertinent documents were obtained. On March 6, 2025, Community Care Licensing (CCL) received allegations that staff are not provided with proper training and minors are not accorded dignity in their relationship with staff. It was reported that S1 is unable to provide adequate training instructions regarding subjects dealing with sexual assault amongst the youth. It was reported that the PSA (Prevention of Sexual Abuse) Compliance Manager, S1, does not provide adequate training for staff. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: SOUTHWEST KEY PROGRAMS SAN DIEGOFACILITY NUMBER: VISIT DATE: 09/04/2025

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


summary: Facility Evaluation

raw_content:
Narrative:
On 02/04/2022 at 08: AM, Licensing Program Analysts (LPA) Gloria Meza-Gonzalez conducted unannounced inspection at the above facility. The purpose of the inspection is to conducted an annual 2 year required inspection. LPA Meza-Gonzalez met with Program Director (PD) Annahi Ruano and Regional Executive Director (RED) Ana Babudar. The facility serves ambulatory children, 6 to 17 years of age. LPA Meza-Gonzalez reviewed twelve staffs' files (see confidential list, dated: 02/04/2022). LPA Meza-Gonzalez observed the files to be completed and in order. Due to time constraints, the annual inspection is being extended to inspect the physical plant, ten clients' files, staff and clients' interviews. Based on observations made during the inspection, no deficiencies observed during today's visit. An exit interview was conducted, a copy of this report and LIC811 was given to PD Ruano.

met_with: Ana Babudar and Annahi Ruano


summary: Facility Evaluation

raw_content:
Narrative:
On May 24, 2022, at 11: AM, Licensing Program Analyst (LPA) Gloria Meza-Gonzalez conducted an unannounced inspection. The purpose of the inspection is to conduct an annual continuation inspection. LPA Meza-Gonzalez met with Program Director (PD) Annahi Ruano. The facility serves ambulatory children, 6 to 17 years of age. LPA Meza-Gonzalez reviewed ten client files (see confidential name list, LIC 811, dated May 24, 2022). LPA Meza-Gonzalez observed the files to be complete and in order. LPA Meza-Gonzalez conducted four confidential client interviews. Due to time constraints, the annual inspection is being extended to inspect the physical plant, operations, disaster preparedness, and emergency intervention. Based on observations made during the inspection, no deficiencies were observed during today's visit. An exit interview was conducted, and a copy of this report and LIC811 was emailed to PA Ruano due to technical difficulties with the printer.

met_with: Annahi Ruano


summary: Facility Evaluation

raw_content:
Narrative:
On June 8, 2022, at 10: AM, Licensing Program Analyst (LPA) Gloria Meza-Gonzalez conducted an unannounced inspection at the above facility. LPA Meza-Gonzalez met with Assistant Program Director (ADP) Luis Vega. The purpose of the inspection is to conduct an annual continuation of the facility to inspect the physical plant, operations, disaster preparedness, emergency intervention, and staff interviews. The group home serves 59 unaccompanied ambulatory children from 6 to 17 years old. Currently, there are 31 children in care. LPA Meza-Gonzalez conducted five confidential staff interviews (see confidential name list, LIC811, dated: June 8, 2022). At 12: PM, LPA Meza-Gonzalez toured the facility inside and outside at 12: PM. The facility is a single-story building with two sides. The facility has living room, dining room and twenty-one bedrooms, and three multi-purpose rooms which are also utilized as classrooms. There are 18 bedrooms with three twin beds (waiver on file dated February 16, 2016), two bedrooms with two twin beds and one bedroom with one bed. One client bed has a nightstand and closet space. One client per bed. Each bedroom shares a bathroom with the adjoining bedroom. The bathroom were checked and appeared to be in working condition. The faucets that will be used by the youths were tested and measured 120 degrees Fahrenheit which are within regulatory requirements. The facility has a kitchen, laundry room, medical offices, and staff offices. The kitchen has three large refrigerators inside the kitchen and two refrigerators outside in the patio adjacent to the kitchen. There are three large freezer in the patio adjacent to the kitchen. There is a pantry in the kitchen and a large pantry closet outside in the patio adjacent to the kitchen. There is sufficient perishable and non-perishable food. Sharp knives are inaccessible and stored in a locked cabinet in kitchen area. See page LIC809c In the laundry room has three washers and three dryers as well as extra linen and bedding. The laundry soap is locked in the cabinet in the laundry room. Cleansers/chemicals are locked and stored in laundry room. All hazardous items have been properly made inaccessible to areas where clients will have access. Disinfectants and cleaning solution will be stored in the hallway closet. The facility has a two medical offices, one office is where medication are stored inside a locked cabinet. Medical log for medications are kept via computer. The second medical office is for youth exams and medical assistances. The First Aid Kit is located in the staff office and contained all required supplies. The facility has five first aid kits located throughout the facility including the medical office and kitchen. The facility has a security office, clinical office, supervisor offices, executive assistant office and staff lounge. There are additional clinician office and case manager offices in a building on the back of the property. There is another multipurpose room that is used for staff training in the back of the facility adjacent to the case managers' office There are five shed in the back of the property, three sheds are for overflow of youths' clothing, hygiene products and paper goods, one sheds is for maintenance, and the other for youths files. There are additional sheds in the side of the facility that had extra board games and supplies for recreational use such as soccer balls. In the middle of the property there a patio where youth can eat and play as well as in the back of the property there is space where the youth can play soccer. The smoke detectors/carbon monoxide (dual) were tested and operable. The entire facility also has water sprinklers throughout. Minors also have access to telephone privacy. There are no guns or weapons in the facility as stated by APD Vega. The following required posted items were observed accessible to clients: Grievance Procedures, Personal Rights, Ombudsman Poster, Visitation policies, and current menu. See page LIC809c The facility outside grounds was also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. There is a no swimming pool, or any spa/fountain located on the facility premises. All staff that work at the facility have Department of Justice and Child Abuse Clearance Index clearances. A review of administrative records indicate that the facility has paid their current licensing fees. According to Title Regulations and based on the facility inspection, there are no deficiencies found at this time. An exit interview was conducted, and a copy of this report emailed to APD Vega due to printer malfunction.


summary: Facility Evaluation

raw_content:
Narrative:
On March 22, 2024 at 08: AM, Licensing Program Analyst (LPA) Lucero Jauregui conducted an unannounced inspection at the above facility. The purpose of the inspection is to conducted an annual required inspection. LPA Jauregui met with Luis Vega, Program Director and Diana Pelosa, Assistant Program Director. The facility serves ambulatory children, 6 to 17 years of age. The facility is a single-story building with Sections A, B, C, kitchen, kitchen courtyard, recreational courtyard, laundry room and case managers offices. Section A consists of intake room, staff offices, medical office, medical room, utility room, break room, laundry room, four dorms for client use, one classroom and Telephone booth. Each dorm consist of three twin beds (waiver on file dated February 16, 2016). All beds were observed with appropriated linen. There was adequate dresser and closet space. Medications are stored in locked cabinets in Medical Room. Medical Room and Utility Room is maintained locked at all times. Section B consists of seven dorms and one classroom. Each dorm consist of three twin beds (waiver on file dated February 16, 2016). All beds were observed with appropriated linen. There was adequate dresser and closet space. Section C consists of eight dorms, one classroom, phone booth and one isolation dorm. Each dorm consist of three twin beds (waiver on file dated February 16, 2016) with the exception of isolation dorm with one twin bed. All beds were observed with appropriated linen. There was adequate dresser and closet space. The kitchen has one freezer chest, two commercial refrigerators, one commercial freezer, pantry and staff desk. LPA observed sufficient perishable and non-perishable food. Sharp knives are inaccessible and stored in a locked cabinet in the pantry. Continued.... The kitchen courtyard has one commercial refrigerator, pantry with snacks, and cleaning supplies. Chemicals were observed to be locked in cabinets. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguishers are properly charged and serviced, last date of services was 3/1/2024. The hot water temperature was measured in each section: Section A 139.8, Section B 121.2, Section C 129.2. The facility was advised water temperature should be between 105 to 120. Per facility staff, no firearms or weapons are allowed in the facility. There is 41 cameras located in hallways in the facility. LPA observed the following items posted in each section: Personal Rights, Vocational Schedule, Recreation Schedule, Physical Education Schedule and Program Schedule. LPA reviewed five out five staff files and five out five client files. LPA conducted two out of two staff interviews and two out of two client interviews. Based on today's observations there are no deficiencies at this time. LPA conducted an exit interview and a copy of this report was provided to Luis Vega, Program Director.


summary: Facility Evaluation

raw_content:
Narrative:
On October 25, 2024 at approximately 08: AM, Licensing Program Analyst (LPA) Lucero Jauregui, arrived unannounced to the facility and met with Diana Peloso, Assistand Program Director for the purpose of conducting a Case Management inspection regarding sexual abuse claims related to Out of State Southwest Keys facilities. During this case management health and safety inspection, the LPA conducted interviews with (2 of clients) and (13 of staff). In addition, facility records, 4 client files, and 13 staff files were reviewed. Please see LIC811 confidential names list dated 10/25/24. No immediate deficiencies were observed or cited during today's case management inspection. An exit interview was conducted, and a copy of this report was provided to facility representative.


summary: Facility Evaluation

raw_content:
Narrative:
On October 29, 2024 at approximately 09: AM, Licensing Program Analyst (LPA) Lucero Jauregui, arrived unannounced to the facility and met with Diana Peloso, Assistant Program Director for the purpose of conducting a Case Management inspection regarding sexual abuse claims related to Out of State Southwest Keys facilities. During this case management health and safety inspection, the LPA conducted interviews with (2 clients) and (3 staff). Please see LIC811 confidential names list dated 10/29/24. No immediate deficiencies were observed or cited during today's case management inspection. An exit interview was conducted, and a copy of this report was provided to facility representative.