raw_content:
Investigation Findings:
13At 11:46AM, Licensing Program Analyst (LPA) Madi Fremont traveled to Paradise Home to conduct an unannounced Complaint Investigation Inspection and to deliver findings for a complaint received on 05/11/2021. (See LIC811 - Confidential Names dated 11/24/2021). On 05/11/2021, the San Jose Children's Residential Program Regional Office received a complaint for Paradise Home with two allegations: (1) "Staff mishandled a minor while in care," and (2) "Staff did not seek timely medical attention for a minor while in care." On 06/04/2021, LPA AmyLe Tran traveled to the home to notify the licensee of these allegations and to request relevant documentation. LPA Fremont returned to the home on 11/18/2021 to collect additional documentation and to conduct interviews with staff and clients. Regarding these allegations, LPA Fremont conducted interviews with 2 clients and 5 staff. LPA obtained the following information: According to all those who were interviewed, if a client expresses to staff that they are feeling sick or injured, the staff protocol is to immediately offer the client medical attention, either by making an appointment at the nearest urgent care during normal business hours or by taking the client to the closest emergency room if no appointments are available. All those interviewed stated there was no reason that staff would ever deny a client medical attention, although clients were able to refuse treatment if they wanted. Neither of the clients who were interviewed were living at the home when these allegations were reported, and could not speak to the incident in question. All staff who were interviewed stated that the client named in this complaint (C1) had a history of aggression and making false allegations about staff. All staff stated that C1 had been the aggressor for the duration of the incident on 05/07/2021, and had been making verbal threats and exhibiting physical aggression toward the staff involved. It was reported that San Ramon Police responded to this incident after C1 called 911, and both officers agreed with staff that the client had been the aggressor, and they did not feel the need to make a report for the incident. It is noted in the incident report dated 05/07/2021 and in staff shift notes for the same day that C1 had taken a video of the incident, but upon showing the video to the police, C1 was told that it only showed her being the aggressor toward staff, and that she needed to go to bed. All staff interviewed corroborated this information, but did not know where a copy of this video could be found as it was never provided to the licensee. All staff stated that the client had reported their foot was injured during the incident, but the client did not report this to the responding officers, and the client did not mention an injury or request medical attention at all in the days following the incident. The staff involved stated they would have offered the client medical attention if they had requested it, but did not because the client did not show any observable signs of injury. These statements are corroborated by an incident report dated 05/07/2021, as well as the staff shift notes for the day of the incident. LPA Fremont attempted to contact the client involved, the responding officers, and the complainant several times over the course of this investigation, but was ultimately unsuccessful in getting a response. This agency has investigated the allegations (1) "Staff mishandled a minor while in care," and (2) "Staff did not seek timely medical attention for a minor while in care," and has found that althought the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, appeal rights discussed, and a copy of this report was emailed to the licensee. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Madeleine Fremont 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: Facility Manager Ashaki Gregory


state: CA

facility_name: PARADISE HOME

summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Investigation Findings:
13On 9/21/22 at 12:30, Licensing Program Analyst (LPA) Alyssa Ng conducted a complaint inspection at Paradise Home and spoke with Sabrina Shelton, Care Coordinator. The purpose of the inspection was to deliver the findings for the above complaint allegation. During investigation, interviews were conducted, and incident reports were reviewed, and it was determined that a minor attacked another minor while in care. Based on LPA's interview with staff, clients, and record review(s), the preponderance of evidence standard has been met, therefore the above allegations, Minor attacked minor while in care is found to be SUBSTANTIATED. Facility is being cited for violation of California Code of Regulations (CCR), Title 22, Division 6 & Chapter 1: 80078(a) Responsibility for Providing Care and Supervision. Please refer to attached 9099D. At this time, one deficiency was given. An exit interview was conducted, appeal rights provided and discussed, and a copy of this report was given to Sabrina Shelton, Care Coordinator. SubstantiatedEstimated 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 Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, TRAEGER AVE., SUITE FACILITY NAME: PARADISE HOMEFACILITY NUMBER: 075600345

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

report_type: Complaint Investigation

met_with: Sabrina Shelton

complaint_status: SUBSTANTIATED


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Investigation Findings:
13On 11/3/22 at 3: PM, Licensing Program Analyst (LPA) Alyssa Ng conducted a complaint inspection at Paradise Home and spoke with Ashaki Gregory, Facility Manager. The purpose of the inspection was to deliver the findings for the above complaint allegations. During investigation, interviews were conducted, photos obtained, and incident reports were reviewed, and it was determined that facility did not provide proper supervision and the facility menu was not being followed. Based on LPA's interview with staff, clients, and record review(s), the preponderance of evidence standard has been met, therefore the above allegations, Facility not providing proper supervision and Facility menu is not being followed is found to be SUBSTANTIATED. Facility is being cited for violation of California Code of Regulations (CCR), Title 22, Division 6 & Chapter 1: 80078(a) Responsibility for Providing Care and Supervision and 80076 (a)(5) Food Services. Please refer to attached 9099D. At this time, two deficiencies were given. An exit interview was conducted, appeal rights provided and discussed, and a copy of this report was given to Ashaki Gregory, Facility Manager. SubstantiatedEstimated 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 Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, TRAEGER AVE., SUITE FACILITY NAME: PARADISE HOMEFACILITY NUMBER: 075600345

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: Ashaki Gregory

complaint_status: unsubstantiated


raw_content:
Investigation Findings:
13On 9/20/23 at 10: AM, Licensing Program Analyst (LPA) Alyssa Ng conducted a complaint inspection at listed facility and spoke with Ashaki Gregory, Facility Manager. The purpose of the inspection was to deliver the findings for the above complaint allegation. During the investigation, LPA Ng reviewed documents and conducted interviews with clients and staff. In addition to the confidential interviews, LPA also reviewed incident reports and shift notes, and found no evidence of staff not providing adequate supervision to minor(s) in care. Although, the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that facility staff are not providing adequate supervision to minor(s) in care. Therefore, the above allegation are unsubstantiated. Exit interview was conducted and a copy of the report will be emailed to Ashaki Gregory, Facility Manager. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn 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 3

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


raw_content:
Investigation Findings:
13On 1-12-24 1:19PM, Licensing Program Analyst (LPA) George Karkazis conducted an unannounced inspection at Paradise Home, and met with Ashaki Gregory, Facility Manager, who helped with the inspection. The purpose of the inspection was to deliver the complaint findings. The complaint alleged that staff are not providing adequate supervision to the youths while in care. During the course of the investigation, LPA conducted confidential interviews and document research, which provided conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove staff are not providing adequate supervision to the youths while in care. Therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given to Ashaki Gregory, Facility Manager. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lidia Tinoco LICENSING EVALUATOR NAME: George Karkazis 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: Ashaki Gregory, Facility Manager


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

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

met_with: Ava Ballard, Shift Supervisor


investigation_findings: UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

allegations: UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:


facility_name: PARADISE OAKS - ANTELOPE

summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
One of the individuals involved in the incident provided different details than the reporting party and the other person involved in the incident only spoke with the reporting party about the incident in question. Not having consistent information or corroboration, the allegations are determined to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted, and a copy of the report and appeal process was provided.

Investigation Findings:
13On 08/04/2022 at 11:15am, Licensing Program Analyst (LPA), Tana Kinder conducted an unannounced inspection for the purpose of delivering findings with the Facility Administrator. Prior to the meeting, LPA Kinder reviewed the agency's file at the licensing office, including the complaint history, criminal background check, incident reports and facility personnel report summary. LPA Shelton conducted an inspection of the facility inside and out on 5/2/22 and no citations were issued. LPA Kinder conducted 5 confidential interviews between 7/25/22-7/26/22. LPA attempted to conduct an additional 3 interviews but they were either declined or calls not returned. LPA obtained and reviewed the following documents: Needs and services Plan for 1 client, Treatment Plan for 1 client, Case Notes, Placement History, Staff Training Records, and a staff/client roster. Based on 5 confidential interviews conducted, there is conflicting information provided by the reporting party who heard about the alleged concerns second hand. It is unclear as to the nature of comment as whether the comment was misheard. Regarding staff being verbally argumentative, again there is a difference of interpretation about the tone of the conversation. Continue.... UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Tana Kinder LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: PARADISE OAKS - ANTELOPEFACILITY NUMBER: VISIT DATE: 08/04/2022

met_with: Facility Administrator


raw_content:
Narrative:
On the allegation that staff failed to keep youth safe following a youth brandishing a weapon and threatening other youth, corroborating statements and documentation detail staff doing a search of the suspected youth's room immediately after the first verbal threat by that youth was reported by another youth to staff. Additionally, a search of the youth's person was conducted where the youth was asked to empty their pockets-no "pat-down" search is allowed in the facility. Law enforcement was also called and responded-this first search yielded no discovery of a weapon. After a second time that the threat was purportedly made again and upon this being reported to staff, another search was conducted with the involvement of law enforcement, at which time a folding knife was found on the suspected youth's person-that youth was then detained by the responding officers. No other youths interviewed attested to seeing the suspected youth actually brandishing the weapon, nor did any of the interviewed staffers state that they saw the weapon before it was discovered. Beyond threats made by the suspected youth, no other youths were actually harmed due to this ordeal. On the allegation that there are Altercations between youths at the facility, though physical fights sometimes took place in the facility, no youths interviewed reported non-action on the part of the staff. The youths corroborated that staff do intervene when a physical fight breaks out between youths. Reviewed training records show that staff are educated on de-escalation techniques and, when needed, application of restraints. It is not a reasonable expectation that no altercations between youths happen in the facility-only that facility staff attempt to de-escalate situations or intervene when a physical fight does occur. Corroborating statements by youths indicate that staff do their part in this regard. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are UNSUBSTANTIATED. No citations are being issued as a result of this investigation; a copy of this report along with a copy of the Appeal Rights are being provided to the facility.

Investigation Findings:
13On 10/21/ Licensing Program Analyst (LPA) Chad Cabigon communicated with this facility's administrator, Jovan Metoyer, to deliver the findings of the complaint investigation. On 06/22/ LPA opened the investigation and conducted an onsite inspection of this facility's physical plant. At this time, LPA also requested the Needs & Services Plans for youths; the following records were also obtained and reviewed as part of this complaint investigation: a client roster with County Social Worker names and numbers, the clients' dates of birth, corresponding school and/or summer school information, all staffs' names, titles, personal contact numbers, the and staff training documents for the past full calendar year plus year-to-date. Confidential interviews were conducted by LPA with five Paradise Oaks Youth Services (POYS) staffers, four foster youths (all interviewed off the facility's premises), one case-carrying County Social Worker, and a youth's adoptive grandparent. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Chad Cabigon LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: PARADISE OAKS - ANTELOPEFACILITY NUMBER: VISIT DATE: 10/21/2022

met_with: Jovan Metoyer, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 06/18/21 at 1: PM, the second collaborative a quarterly meeting with Paradise Oaks Youth Services (POYS) was held to provide technical assistance and collaborative support to assist with and ensure POYS operates a successful program. The first meeting was held on March 19, 2020. POYS consists of nine locations: Olivine, Rosa Vista, Hazel, Hickory, Antelope, Mariposa, Old Auburn, Madison, and Sunset. The current census at all locations is 28. Two locations have closed, Linda Creek on 2/3/21 and Violets on 5/11/21. The following were present on an MS Teams virtual meeting: · CCL: Margo Castaneda, Regional Manager, Jodean Hall, Licensing Program Manager, Robin Sullivan, Licensing Program Analyst. · System of Care (SOC): Marjana Jackson, Stacie Kinney. · Sacramento County: Linda Abdelbaki · Department Health Care Services (DHCS): Brian Keefer · POYS: Robert Pye, CEO, Laynee Kuhn, Executive Director, Stephanie Fisher, Program Director, Thomas Harrer, Clinical Director POYS provided a status update of the CARF evaluation stating the accreditation approval is over two months out due to backlogs from covid. An extension of approval is in effect. The Mental Health review by Dept. of Health Care Service (DHCS) was completed in April 2021 and at this time POYS is working with DHCS in providing the plan of corrections. POYS reports numerous clients recently graduated from high school. Some graduates are enrolled in community college, some are working, some are seeking transitional housing programs, and some are still figuring things out. Distance learning challenges were reported to be with band-width issues both from the schools and at the facilities. Distance learning was embraced by about half of the clientele, with the other half preferring in-person learning. CCL reported a decrease in complaints and incident reports. POYS attribute the decline to a more deliberate intake process and screening for better compatibility with the current clients. They also reported they were revamping their level system. In addition, POYS is training house staff to participate more closely with each client and their overall treatment plan. Staff are eliciting more input from youth on what is working/not working with the program. Youth have responded with more engagement. POYS reported they are resuming a higher level of training for staff as more in-person training become available. They have contracted with Relias Learning for staff training. When asked about the status of overnight staff, POYS reported, they have two roamers that are assigned to three homes each. They also have one floater that helps out as needed or if someone calls out. This model is used both for the day shift and nighttime shift. The roamers and floaters meet regularly with staff to discuss client behaviors and needs. Sacramento County had no specific areas of concern. They complimented the discussed areas of change and the graduation of youth. DHCS discussed the pros/cons of the virtual Mental Health review and was appreciative for POYS' feedback on the process. Clarification on mask wearing requirements for POYS clients and staff will be provided as the Department receives details. POYS will submit an electronic Program Statement to include recent revisions. They next meeting is scheduled for September 17, 2021. A copy of this report will be emailed for signatures to Laynee Kuhn.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Executive Management


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Marla Horne and Tamara Hill conducted an unannounced annual inspection on 7/26/21 at 10: AM. LPAs toured the facility inside and out and observed that the facility has three dual occupancy rooms and two bathrooms accessible to clients in care. LPAs observed the facility license and foster youth rights posted in a prominent area. Medications were locked in a box in a file drawer in the staff office. LPAs observed and tested the smoke/carbon monoxide detector. LPAs observed the refrigerators and freezers to be well stocked with perishable and non-perishable items. Fresh fruit was observed on the kitchen counter, a menu was posted on the refrigerator. LPAs observed the bedrooms to have required furniture and bedding. LPAs observed cleaning supplies and chemicals in a locked closet. The fire extinguisher was last serviced June 2021. The water in the kitchen and bathroom sinks warmed up to a required temperature. The shower and toilets functioned properly. Soap and paper towels were observed in the kitchen and hallway bathroom. The back bathroom was observed during the inspection as well but was not clean although it was cleaned prior to LPAs leaving the facility. Facility was cited for 80087(a) Buildings and Grounds as the facility shall be clean, safe, sanitary and in good repair and LPAs observed that the back client bathroom was not clean during the inspection but was cleaned while LPAs were present in the facility. An exit interview was conducted with Jovan Metoyer.

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Marla Horne and Tamara Hill conducted and unannounced annual inspection at the administrative offices for Paradise Oaks Youth Services located at Sunrise Vista Drive, Citrus Heights 95610. LPAs reviewed staff files during the inspection and the required documents were observed in the files reviewed although LPAs were unable to complete the file review. A continuation of the file review is needed to conclude the annual inspection. No citations were issued during this inspection. Exit interview conducted with Executive Director, Laynee Kuhn.

met_with: Laynee Kuhn, Executive Director


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Marla Horne conducted an unannounced annual inspection at the Paradise Oaks Youth Services administration office located at Sunrise Vista Drive at 10: AM on 7-29-21. The inspection was a continuation on the inspection from 7-26-21. LPA completed the file reviews for the Antelope location. All required documents were observed to be in the files. No citations were issued during this inspection. An exit interview was conducted with Human Resources Director, Lisa Garceau.


summary: Facility Evaluation

raw_content:
Narrative:
On 09/17/21 at 1: PM, the third collaborative quarterly meeting with Paradise Oaks Youth Services (POYS) was held to provide technical assistance and collaborative support to assist with and ensure POYS operates a successful program. POYS consists of nine locations: Olivine, Rosa Vista, Hazel, Hickory, Antelope, Mariposa, Old Auburn, Madison, and Sunset. The current census at all locations is 27. Three locations: Madison, Sunset and Old Auburn currently have no foster youth placed. The following were present on an MS Teams virtual meeting: · CCL: Jodean Hall, Licensing Program Manager, Robin Sullivan, Licensing Program Analyst (LPA), Cindy Johnson, LPA, Tammy Hill, LPA · System of Care (SOC): Marjana Jackson, Stacie Kinney. · Sacramento County: Linda Abdelbaki · Department Health Care Services (DHCS): Brian Keefer · POYS: Robert Pye, CEO, Laynee Kuhn, Executive Director, Stephanie Fisher, Program Director POYS reported a staff and family moved into Sunset after their home burned down approximately 2 weeks ago. Annual inspections were completed for all their facilities in June and July, resulting in Technical Advisory/Advisory Notes and no deficiencies cited. CCL will provide the electronic program statement revisions to System of Care. Program statement revisions for the SAY population was submitted but still needs to be reviewed and approved. LPA Marla Horne will review by October 20, 2021. Incident reports regarding smoking on grounds was discussed. Both trauma-informed practices and harm reduction protocols were discussed. Harm reduction practices have not been approved by the Department. POYS is reminded that incident reports should document interventions including staff discouraging youth from smoking. CCL pointed out youth smoking in the backyard is still smoking on grounds which may require additional case management inspections. CCL requested program statement revision to Transportation services to add details of exceptions to provide transportation to youth when extreme weather, youth not feeling well or after hours. CCL requested incident reports be typed due to the difficulty of reading the handwritten reports. At this time there are multiple POYS staff that still hand write reports. This has been an ongoing conversation between POYS and CCL. CCL requests all reports be typed by November 1, 2021. POYS declined this request. CCL requested all youths' names be included in one incident report rather than referring to other involved youth as "peer". CCL recommended using a legend to submit the report to CCL and redacting the names for POYS purposes. POYS declined the request due to confidentiality. The CCL request was requested and approved through upper management and noted not to be a HIPPA violation. CCL requested incident reports and time-frames be more specific. Antecedent information is specific and thorough, yet more follow up details or resolution information is needed and requested. CCL recommended POYS to Technical Support Program (TSP) for incident report writing. POYS approved the recommendation. Sacramento County had no specific areas of concern. DHCS had no specific areas of concern. Due to the upcoming impact of FFPSA on program statements, a deadline for the revisions was not determined and will be included at the time of the FFPSA changes. No further meetings are scheduled.

met_with: Robert Pye, CEO, Laynee Kuhn, Executive Director, Stephanie Fisher, Program Director,


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced collateral inspection on 9/24/21 at 12: PM to the administrative office location for the agency located at Sunrise Vista Drive, Suite 2100, Citrus Heights 95610 and met with Laynee Kuhn, Chief Executive Officer for the agency. LPA made the visit to discuss the following incident reports for this facility: On 6/27/ C1 left to the store while staff was in the kitchen. While at the store youth was asking for cigarettes and customer called law enforcement who then returned youth to the facility. LPA inquired as to whether staff were even aware of youth's absence prior to law enforcement returning youth to the facility. Ms. Kuhn states that she believed On 5/5/ C2 threw a bowl of cereal at staff's back after one staff denied having a conversation C2 claimed to have had with C2. The incident appeared to possibly be confrontational between the C2 and staff. LPA learned that C2 has a history of being confrontation and volatile with staff and facility is working with C2 on tempers and reactiveness to situations as C2 could have responded the same if staff had not responded about the alleged conversation. Agency did not see this as confrontational or out of line for staff during this incident. On 4/23/21, C3 was playing with fire while in the facility living room. LPA asked Ms. Kuhn about contacting law enforcement following incidents of this nature and Ms. Kuhn states that they have historically contacted law enforcement but are typically told that they will not respond unless there is an active fire in progress. If staff are successful in putting out the fire, there is no need to respond. This was discussed during C3's child and family team meeting and youth is currently no longer in this placement. Facility typically will not accept youth with fire starting behaviors. LPA discussed with Ms. Kuhn the additional clarification needed on the reports to ensure all details including antecedents and follow up are captured appropriately. No citations were issued as a result of this inspection. Document provided to Ms. Kuhn.

met_with: Laynee Kuhn, Chief Executive Officer


facility_name: PARADISE OAKS - HAZEL

raw_content:
Narrative:
three to five days to receive the results. The facility did not attempt to obtain results until August 16, 2021. Documentation obtained during the investigation indicates that youth were tested August 12, 2021, and their results were ready as of August 14, 2021. Test results were obtained verbally from the clinic. Until a subsequent visit to the facility on January 27, 2022, the facility did not have any documentation of the test results in question. Facility Administrator went to the clinic during the LPA's visit and obtained the documentation because it was not obtained previously. Amongst the results, there was one positive youth and two youth's results indicate that COVID was "Not Detected" and the narrative of the results states "re-testing should be considered" but these two youth were not re-tested. During the time from the date of the test to the date of the receipt of the COVID results these youth were not isolating in their rooms and were potentially exposing staff and other youth. The youth that was in the hospital for another reason returned to the facility on August 15, 2022, was retested but was in isolation in their room until their test results were received August 17, 2022 indicating they were negative. As a result of the information obtained, interviews conducted and documentation received, the allegation that the facility did not obtain the youths' COVID test results in a timely manner is SUBSTANTIATED at this time meaning that the "preponderance of the evidence" standard has been met. Facility was cited for violation of California Code of Regulations, Title Division Six, regulation 80070(b)(9) Client Records. Licensees are required to maintain a separate, complete, and current record in the facility for each client that also includes, but is not limited to, record of any illness or injury requiring treatment... The facility took four youth for COVID testing on August 12, 2021, but did not obtain the written documentation of the COVID testing results as necessary to meet the intent of this regulation. The written documentation was not obtained from the clinic until January 27, 2022. Facility obtained the COVID testing results via phone on August 16, 2022, but the results of the verbal contact with the clinic was not documented in client files. Exit interview was conducted with Ms. Kuhn and documents provided along with appeal rights. When LPA interviewed staff about COVID-19 protocols, it was discussed that staff were not sure what part they play in mitigating the spread of COVID outside of cleaning multiple times throughout the facility and following Centers for Disease Control and Prevention (CDC) guidelines and protocols. Staff also confirmed that they feel that COVID is so new and ever-evolving that they aren't confident that they could be trained in a thorough manner either. Confidential interviews revealed that while staff some have been trained to clean, maintain social distancing, wear masks and wash their hands often, they feel that the agency could provide additional training on how all of these measures are helpful and what other things they could do. Some staff insisted that they have not received any training related to COVID mitigation and prevention at the facility. The allegation that the facility is not following their emergency plan to protect clients and staff is related to staff feeling that Paradise Oaks administrative staff asked at least one staff to return to work once their quarantine and/or isolation period was over regardless of still being symptomatic. LPA attempted to speak to this staff person about the circumstances but staff refused to be interviewed. Other confidential interviews revealed that a staff person reported to other staff that they were cleared to return to work regardless of still being symptomatic. This situation made staff question facility's policies to mitigate the spread of COVID, further creating the potential for additional spread of COVID. Confidential interviews revealed that said staff did not return to work and forfeited their position with the agency. Other interviews revealed that staff are trained and constantly reminded and trained that they are not to return to work if they are experiencing any COVID-related symptoms. As a result of the investigation, interviews conducted, and documentation reviewed, the allegations that facility staff are not properly training on COVID protocols, facility is not following their emergency plan, and facility failed to implement mitigating factors that created additional exposure to clients and staff are UNSUBSTANTIATED at this time meaning that the allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview was conducted with Ms. Kuhn and documents provided along with appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced visit on 1/27/22 at 11: AM and met with Laynee Khun, Executive Director to discuss the complaint allegations as stated for this facility. LPA informed Ms. Kuhn that the investigation included an initial inspection at the facility on 8/26/2021 by LPA Robin Sullivan where documents were requested via email. LPA Hill made a subsequent visit to the facility on 10/19/2021 where LPA Hill requested that the agency provide a copy of the COVID training plan for staff, protocols for youth and any other cleaning, sanitizing or other COVID protocols established for the mitigation of the spreading COVID within the facility. Another subsequent visit was conducted on 1/27/22 to the facility to obtain additional documentation. LPA Hill conducted interviews with clients and staff from 10/19/21 to 1/20/22. At least one staff did not respond to repeated requests for interview. The allegation that the facility did not obtain COVID test results in a timely manner is related to an incident on August 10, 2021, where one youth was taken to the hospital for another reason and was COVID tested. The hospital alerted the facility staff that youth had tested positive so all the remaining youth were taken to a clinic for tests on August 12, 2021. According to the administrator, the clinic's policy on testing is that the tests can SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: PARADISE OAKS - HAZELFACILITY NUMBER: VISIT DATE: 01/28/2022

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

met_with: Laynee Khun, Executive Director


raw_content:
Narrative:
S1 contacted S2 to inform S2 that the school was requesting that C1 be picked up due to illness. S2 contacted the school to discuss reasons for C1 needing to be picked up. During that discussion, school personnel were not able to confirm seeing or hearing C1 vomiting. S2 informed the school that because there was no physical evidence of C1 being ill, the facility would not pick up C1. C1 then contacted their probation officer to inform them that they were walking home since the facility would not pick them up. C1 then walked off the school campus and walked home. Upon arrival to the facility, C1 was taken to urgent care. While C1 had reported being ill, the facility is aware that C1 has a history of lack of attendance in school due to unauthorized absences at school or leaving the school grounds after being dropped off by facility staff. Upon the school personnel not being able to confirm C1's illness, facility staff refused to pick up C1 as a tactic to encourage C1 to stay in school. As a result of the interviews conducted, the allegation that staff abandoned minor at school is UNSUBSTANTIATED meaning the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted with Carla Izzarelli, Facility Manager and documents were provided. S1 contacted S2 to inform S2 that the school was requesting that C1 be picked up due to illness. S2 contacted the school to discuss reasons for C1 needing to be picked up. During that discussion, school personnel were not able to confirm seeing or hearing C1 vomiting. S2 informed the school that because there was no physical evidence of C1 being ill, the facility would not pick up C1. C1 then allegedly contacted their probation officer to inform them that they were walking home since the facility would not pick them up. School personnel indicated that they had spoken to the probation officer and was told that they were aware of C1 walking home. CEO states that she has proof via email that the probation officer would not have allowed C1 to leave the school grounds to walk to the facility. C1 then walked off the school campus and walked to the facility. Upon arrival to the facility, C1 was taken to urgent care. While C1 had reported being ill, the facility is aware that C1 has a history of lack of attendance in school due to unauthorized absences at school or leaving the school grounds after being dropped off by facility staff. Upon the school personnel not being able to confirm C1's illness, facility staff refused to pick up C1 as a tactic to encourage C1 to stay in school. As a result of the interviews conducted, the allegation that staff abandoned minor at school is UNSUBSTANTIATED meaning the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted with Ms. Kuhn and documents were provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Uchenna Ajaero conducted an unannounced complaint inspection on 6/3/22 at 12: PM and met with Laynee Kuhn, Chief Executive Officer to discuss the allegation as stated. LPA Ajaero informed Ms. Kuhn that the complaint investigation included a facility health and safety inspection conducted on 5/9/22. C1's client file (see LIC 811 dated 5/9/22) was obtained on 5/9/22. Interviews were conducted with reporting party on 5/9/22, three school personnel 5/9/22, agency staff (S1, S2) on 5/9/22 and 5/19/22, client (C1) on 5/9/22. During interviews conducted with school personnel, C1 reported that they were not feeling well while in school and C1 requested that the school contact the facility to be picked up on 5/3/22. School personnel contacted the facility to request that facility staff pick up C1 as it had been reported that other youths in the classroom heard C1 tell a teacher that they had vomited and was ill. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Uchenna Ajaero LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: PARADISE OAKS - HAZELFACILITY NUMBER: VISIT DATE: 05/31/2022

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


raw_content:
Narrative:
before the altercations escalate. Interview with RP and FFY both stated FFY was not treated with respect while at the house. As a result of the investigation and interviews conducted regarding the staff allowing minors to engage in physical altercations with another minor, this allegation has been found to be UNSUBSTANTIATED meaning that allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. During the investigation LPA Baca investigated the complaint that staff did not safeguard minors personal property. Interviews with A1 and S1 both stated that when a youth comes into the facility a safeguard property list is given to list all the youths belongings. LPA observed this document for FFY. Interview with FY1 and FY2 both stated that there has not been an issue with their belongings being taken or messed with at the facility. Due to the FFY being discharged from the facility quickly and a relative putting FFY belongings in multiple bags to take, staff was unable to conduct a safeguard of property form during discharge. Interview with FFY stated that a staff had accidentally dropped a fidget spinner that belonged to the FFY. As a result of the investigation and interviews conducted regarding the allegation that staff did not safeguard minors personal property, this allegation has been found to be UNSUBSTANTIATED meaning that allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. During the investigation LPA Baca investigated the complaint that staff did not treat minor with respect. During interviews with FY1 and FY2, both stated they feel they are treated with respect by staff at the house. S1 and A1 both stated they do their best to treat all clients with respect and try to teach the clients respect as well. Interviews with FFY and RP both stated that FFY was not treated with respect while at the facility. As a result of the investigation and interviews conducted regarding the allegation that staff did not treat minor with respect, this allegation has been found to be UNSUBSTANTIATED meaning that allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. End of report.

Investigation Findings:
13On 4.11..2023 at 1:45 p.m. Licensing Program Analyst (LPA) Monica Roberts arrived at the agency to conduct an unannounced complaint inspection. LPA Roberts spoke with Carla Izzarelli, Administrator to discuss the findings of the complaint investigation and allegations stated above. LPA informed agency staff this case was investigated by LPA Baca. The initial 10-day complaint investigation inspection was conducted at the agency on 3.20.2023. Documents obtained on 3.20.2023 included trainings, facility sketch, staff schedule and Incident reports pertaining to complaint allegations. and the foster youth's needs and services. Interviews were conducted with Reporting Party (RP) on 3.16.2023, Former Foster Youth (FFY) 3.16.2023, Foster Youth 1 (FY1) on 3.20.2023, Foster Youth 2 (FY2) on 3.16.2023, Staff 1 (S1) on 3.16.2023, Administrator (A1) on 3.20. 2023. LPA Baca investigated the complaint that staff allowed minors to engage in physical altercations with another minor. Interview with FY1 and FY2 stated that staff will stop any altercations that happen between the youths in the house. S1 stated that when he sees any altercation that he will separate the youths. Interview with A1 stated that staff are to break up any altercations that they see with the youths UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Monica Roberts LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION NO. Cal Cr/res., Natomas Park Dr., STE FACILITY NAME: PARADISE OAKS - HAZELFACILITY NUMBER: VISIT DATE: 04/11/2023

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


raw_content:
Narrative:
LPA Crass investigated the above allegations. Based on video footage provided by the reporting party, LPA Crass observed staff member (S2) casually eating and on their cell phone, while clients had put a chair on a table, to climb on to an awning, to get on to the roof. While the children were on the roof, the staff member was looking down at their cell phone, and then was watching a youth on the roof, while eating. The staff member did not appear to be preventing the child from being on the roof, or verbalizing for them to get down. The staff member eventually walks back inside the house. Additionally, two youth can be seen vaping in the video, one of which vaped right in front of the staff member, with no intervention from S2 being observed. Based on record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Interim Licensing Standards, Article 6, 87065.2(b)(1) is being cited on the attached LIC 9099D. An exit interview was conducted with Carla Izzarelli. A copy of this report and appeal rights were given. It was reported that sometime in 2021 or 2022, youth in care were hiding from the fire department at night, and that staff had locked the back door so the youth could not enter the facility. LPA Crass investigated the above allegation. Based upon information obtained during the investigation, LPA received conflicting statements from interviews, and was not able to observe youth being locked out of the home in video footage, therefore this allegation has been found to be UNSUBSTANTIATED meaning that the allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted with Carla Izzarelli. A copy of this report and appeal rights were given.

Investigation Findings:
13On Friday, September 20th, 2024 at 12PM, Licensing Program Analyst (LPA) Brittany Crass conducted an unannounced visit at the facility to deliver findings for the investigation of the complaint allegation stated above. LPA Crass met with the Facility Administrator, Carla Izzarelli, who arrived at 12:20PM, and informed them of the purpose of today's visit. The initial 10-day complaint inspection was conducted by LPA Crass and LPA Tamara Hill, at the facility on 8/29/2024. At the facility, LPA Crass and LPA Hill conducted a health and safety tour, interviewed C1, C2, the facility administrator, and reviewed video footage and documentation. On 8/26/24, LPA Crass interviewed the reporting party. On 9/17/24, LPA Crass reviewed additional video footage. (Continued on LIC 9099-C). SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Brittany Crass LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: PARADISE OAKS - HAZELFACILITY NUMBER: 347006002

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: Carla Izzarelli


summary: Facility Evaluation

narrative: On 06/18/21 at 1: PM, the second collaborative a quarterly meeting with Paradise Oaks Youth Services (POYS) was held to provide technical assistance and collaborative support to assist with and ensure POYS operates a successful program. The first meeting was held on March 19, 2020. POYS consists of nine locations: Olivine, Rosa Vista, Hazel, Hickory, Antelope, Mariposa, Old Auburn, Madison, and Sunset. The current census at all locations is 28. Two locations have closed, Linda Creek on 2/3/21 and Violets on 5/11/21. The following were present on an MS Teams virtual meeting: · CCL: Margo Castaneda, Regional Manager, Jodean Hall, Licensing Program Manager, Robin Sullivan, Licensing Program Analyst. · System of Care (SOC): Marjana Jackson, Stacie Kinney. · Sacramento County: Linda Abdelbaki · Department Health Care Services (DHCS): Brian Keefer · POYS: Robert Pye, CEO, Laynee Kuhn, Executive Director, Stephanie Fisher, Program Director, Thomas Harrer, Clinical Director POYS provided a status update of the CARF evaluation stating the accreditation approval is over two months out due to backlogs from covid. An extension of approval is in effect. The Mental Health review by Dept. of Health Care Service (DHCS) was completed in April 2021 and at this time POYS is working with DHCS in providing the plan of corrections. POYS reports numerous clients recently graduated from high school. Some graduates are enrolled in community college, some are working, some are seeking transitional housing programs, and some are still figuring things out. Distance learning challenges were reported to be with band-width issues both from the schools and at the facilities. Distance learning was embraced by about half of the clientele, with the other half preferring in-person learning. CCL reported a decrease in complaints and incident reports. POYS attribute the decline to a more deliberate intake process and screening for better compatibility with the current clients. They also reported they were revamping their level system. In addition, POYS is training house staff to participate more closely with each client and their overall treatment plan. Staff are eliciting more input from youth on what is working/not working with the program. Youth have responded with more engagement. POYS reported they are resuming a higher level of training for staff as more in-person training become available. They have contracted with Relias Learning for staff training. When asked about the status of overnight staff, POYS reported, they have two roamers that are assigned to three homes each. They also have one floater that helps out as needed or if someone calls out. This model is used both for the day shift and nighttime shift. The roamers and floaters meet regularly with staff to discuss client behaviors and needs. Sacramento County had no specific areas of concern. They complimented the discussed areas of change and the graduation of youth. DHCS discussed the pros/cons of the virtual Mental Health review and was appreciative for POYS' feedback on the process. Clarification on mask wearing requirements for POYS clients and staff will be provided as the Department receives details. POYS will submit an electronic Program Statement to include recent revisions. They next meeting is scheduled for September 17, 2021. A copy of this report will be emailed for signatures to Laynee Kuhn.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced annual inspection 7/22/21 at 10: AM using the Compliance and Regulatory Enforcement (CARE) tools and met with Carla Izzarelli, Administrator. LPA toured the facility inside and out during the inspection today. LPA observed three dual occupancy client bedrooms, that had all of the required furniture as required. LPA observed that there are two bathrooms available to clients and that the bathrooms were appropriately equipped with toilet paper and paper towels. LPA observed that the bathrooms had warm water as required. LPA observed that the showers and toilets functioned as required and showers had hot water as required. LPA observed that the facility had an adequate supply of perishable and nonperishable food for the clients in care. LPA observed that there is a fire extinguisher in the facility and it was last inspected in June 2021. LPA observed that there is a carbon monoxide detector in the hallway near the client bedrooms. LPA observed that the smoke detectors functioned as required. LPA observed that the facility appliances, fridge and freezer appeared to be clean and function as required. LPA observed that sharps and disinfectants and cleaning supplies were appropriately stored where not accessible to clients in care. LPA observed a menu posted in the facility. LPA observed that the facility has laundry services available for each youth to complete their own laundry. LPA observed that the facility has a functioning telephone in the facility. LPA observed that the facility vehicles appeared to be in good operating condition. No citations were issued during the inspection today and exit interview was conducted with Ms. Izzarelli and document was provided.

met_with: Carla Izzarelli, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPA) Tamara Hill and Marla Horne made an unannounced annual continuation inspection on 7/27/21 at 9: AM at the administrative offices for Paradise Oaks Youth Services located at Sunrise Vista Drive, Citrus Heights 95610. The purpose of the visit to this location is to review the staff files at the administrative office. LPAs reviewed staff files during this inspection and no citations were issued during the inspection today. Exit interview with Laynee Kuhn, Executive Director.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced annual continuation inspection on 7/30/21 at 10: AM at the facility and met with Misha Scott, Case Manager The purpose of the visit to this location is to review the client files at the facility. LPA reviewed client files during this inspection. No citations were issued but LPA did experience some technical difficulties while in the facility that were ultimately resolved the Department's programmer via telephone. Exit interview with Ms. Scott.

met_with: Misha Scott, Case Manager


facility_name: PARADISE OAKS - HICKORY

summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
According to corroborating staff and client statements, the minor in question was first reported as unresponsive as early as around PM on the evening of the incident. Per medical records, an ambulance was dispatched at about 11: PM, which meant that for approximately four hours the facility did not seek medical attention for what later proved to be an acute condition--an adverse reaction--that the minor was experiencing. Based on interviews and a records review, the preponderance of evidence standard has been met; therefore, the allegation is found to be SUBSTANTIATED. The facility is cited on the attached LIC 9099D, a violation of Personal Rights as set forth via the Interim Licensing Standards, Section 87072(c), and specified in the Welfare and Institutions Code, Section 16001.9(a). A copy of this report, and of the Appeal Rights, is being provided to the facility.

Investigation Findings:
13On 03/23/2022, at approximately AM, Licensing Program Analyst (LPA) Chad Cabigon conducted an unannounced inspection at this facility to deliver the findings of the complaint investigation. LPA met Carla Izzarelli, Administrator, with whom the report was discussed. Investigator Chris Krogstad of Community Care Licensing's (CCL) Investigations Branch (IB) conducted the investigation which was opened on 01/05/2022. Interviews were conducted with facility staff, administration, and clients; also done was a review of relevant documentation, including medical records. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Chad Cabigon LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: PARADISE OAKS - HICKORYFACILITY NUMBER: 347005962


raw_content:
Narrative:
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted with the Director. A copy of this report and the Appeal Rights will be emailed to the agency.

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

met_with: Laynee Kuhn, Director


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


raw_content:
Narrative:
Based on evidence gathered and confidential interviews conducted during the investigation, the allegation cannot be substantiated. 10 out of 11 confidential interviews confirmed they had never heard or witnessed the staff member discussing confidential information about clients with others in care. LPA Buchannan was informed that anyone who reported that the staff shared confidential information had done so based on what another client said, rather than from personal observation. Additionally, it was found that clients could overhear conversations in the Case Manager's office from their bathroom, creating a possibility that they may have inadvertently overheard confidential discussions about other clients in care. (See LIC TA) Although the allegation may have happened or may be valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, copy of this report and the Appeal Rights were discussed and sent to Licensee via email.

Investigation Findings:
13On October 31, 2024 at 1: PM Licensing Program Analyst (LPA) Sarina Buchannan made an unannounced visit to deliver findings to the above Short Term Residential Therapeutic Program and met with Joanna Barnhill, Assistant Administrator. Prior to the meeting LPA Sarina Buchannan and Tatyana Shulz conducted the 10-day inspection of the Short Term Residential Therapeutic Program on 10/03/2024. No deficiencies were cited during that inspection. LPA Buchannan requested the following documents: The Needs & Services Plans/Individual Behavior Support Plan, client Face Sheets, client roster, staff roster/LIC 500, staff schedule with contact info, case notes, disciplinary files for staff in question, and staff training logs. LPA Buchannan attempted 1 confidential interview and conducted 11 interviews between 10/3/2024-10/15/2024. (Continued on LIC 9099C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Sarina Buchannan LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: PARADISE OAKS - HICKORYFACILITY NUMBER: VISIT DATE: 10/31/2024


raw_content:
Narrative:
Though there were substantive corroborating statements from those interviewed describing how a particular staffer's approach was not ideal when it came to providing care, supervision, and engagement to facility clients, there was insufficient evidence that the staff member failed to accord youth the right to live in a safe, healthy, and comfortable environment. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is Unsubstantiated. Exit interview conducted; a copy of this report and of the Appeal Rights is being provided to the facility. *This is an amended version of the original report issued on 10/31/2024.* Statements given by interviewed youth and staff were inconsistent as to whether there was improper and/or unsanitary preparation being done by a specific staff-person with food being served to clients. As for the purported emotional abuse, not enough evidence was found to support the claim; a video recording of a staff member's interaction with a client was also reviewed-and though the video showed poor judgement on the staff-person's part during a heated exchange between them and a youth, the recording does not show actions taken by that staffer that rise to the level of being abusive, emotionally or otherwise, to youth. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are Unsubstantiated. Exit interview conducted; a copy of this report and of the Appeal Rights is being provided Licensee via email.

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

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

met_with: Tasha Bradford, Facility Manager.


raw_content:
Narrative:
Consistently, interviewed youth reported that direct-care staff do a good job keeping an eye or maintaining visual of clients in care and that, if anything, the supervision might seem overbearing at times. The reporting youth only made staff aware of these unwanted advances later on in their placement. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is Unsubstantiated. Exit interview conducted; a copy of this report and of the Appeal Rights are being provided to the Licensee via email.

Investigation Findings:
13On October 31, 2024 at 1: PM Licensing Program Analyst (LPA) Sarina Buchannan conducted an unannounced inspection of this STRTP, Short Term Residential Therapeutic Program to close the complaint investigation. LPA met with Joanna Barnhill, Assistant Administrator to whom the following report was delivered. Community Care Licensing (CCL) investigated an allegation that there were Inappropriate interactions between youth in the facility. LPA Chad Cabigon officially opened the investigation on 07/23/2024, during which time a tour of the facility grounds was conducted and multiple youth as well as staff were interviewed. Though inappropriate interactions, in the form of touching, between youth were corroborated by at least two clients. These instances never happened in the presence of facility staff, according to the youth who corroborated these occurrences. (Continued on LIC 9099C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Sarina Buchannan LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: PARADISE OAKS - HICKORYFACILITY NUMBER: VISIT DATE: 10/31/2024

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

met_with: Joanna Barnhill,Assistant Administrator


summary: Complaint Investigation - Unsubstantiated - 5 allegations

raw_content:
Narrative:
Five out of the nine interviews conducted confirmed staff did not handle client's medication properly and staff did not report incidents to appropriate parties including Community Care Licensing (CCL) in a timely manner. The incident report for the missed medications was received on April 18, 2025 however, Community Care Licensing (CCL) did not receive any 24Hr reports regarding the multiple incidents. Interviews conducted confirmed that a staff member had given a client in care medication that seemed to be "moldy". Staff informed that the medication was not moldy but was wet, altering the appearance and client did not want to consume the medication. It was also confirmed by the facility administrator that the medication became wet due to the water cup dripping into the pill cup. In addition, medication was not administered correctly and a client in care was given an additional dose of medication on April 8, 2025, April 9, 2025, April 10, 2025, and April 11, 2025. Additionally, on April 25, 2025 the client was only given a single dose of a required double dosage of medication. Based on LPA Turner's observations and interviews which were conducted and records reviewed, there is a preponderance of evidence to prove the alleged violation occurred, therefore the allegations are found to be SUBSTANTIATED. Exit interview conducted, a copy of this report and the Appeal Rights were discussed and provided to the licensee. Seven out of the nine interviews conducted confirmed the allegations staff did not provide a safe environment for minor(s), staff did not safeguard minor's personal property, and staff made inappropriate comments in the presence of minor did not occur. During the investigation LPA Turner was informed by clients in care that they feel safe in the home. Several clients expressed their appreciation of staff members and how well taken care of they are in the facility. Staff informed LPA Turner that they provide a safe environment for clients in care and a safe place for client's belongings. Clients informed that they have space to keep personal belongings and that they have never heard staff making inappropriate comments around them. Three out of four clients stated that staff are very mindful of what they say around them while in care. During the interviews, LPA Turner was notified that clients in care misplace their personal belongings and they have seen other clients in care break or mishandle their belongings to try and get staff or other clients in trouble. Clients confirmed that they have removed some belongings from their room due to incontinence issues from other clients in care. Staff interviewed denied the above allegations regarding inappropriate comments and clients stated that staff only talk about the health and safety of clients in care. Lastly, LPA Turner was notified by staff and clients in care that a client in care has made allegations in the past to try and get staff and clients in trouble. Clients advised LPA Turner that they do not get along with this client in care because they like cause arguments in the house. Staff advised LPA Turner that they are working with this client in care so they can resolve their behavioral issues. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, a copy of this report and the Appeal Rights were discussed and provided to the licensee.

Investigation Findings:
13On May 30, 2025 at approximately 1: PM, Licensing Program Analyst (LPA) Zaria Turner made an unannounced visit to deliver findings to the above facility and met with Facility Administrator, Carla Izzarelli. Prior to the meeting LPA Turner initiated the complaint investigation on March 12, 2025. No deficiencies were cited during that inspection. LPA Turner requested the following documents: Staff and Client Roster, Staff Contact Sheet, Client Face Sheets, Medication Administration Records(MARS) and Psychotropic Medication Administration Records (PMARS) for the last 3 months, Inventory Log for one client in care, and Needs and Services Plans for all clients in care. LPA Turner conducted nine interviews between March 12, 2025 and May 14, 2025. Based on evidence obtained and confidential interviews conducted during the investigation process the above allegations are substantiated because there were consistent statements throughout the investigation process. Report continued on LIC 9099-C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Zaria Turner LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: PARADISE OAKS - HICKORYFACILITY NUMBER: VISIT DATE: 05/30/2025

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

met_with: MET WITH: Carla Izzarelli, Facility Administrator


summary: Complaint Investigation - Unsubstantiated - 3 allegations

raw_content:
Narrative:
Four out of the six interviews did not confirm the allegations, staff yell at the minor and staff did not meet minor's medical needs, occurred. During the investigation LPA Turner was informed that the youth in question often engages in behavior intended to provoke staff, including yelling at staff members in an attempt to elicit a reaction. The youth has attempted to record interactions with staff that manipulate the circumstances when staff are attempting to maintain structure and ensure safety within the home. The youth received medication after the behaviors ceased. The youth resists following facility procedures, particularly around medication administration. It was confirmed by staff and other youth in care that this youth in question wants the facility to comply with their personal preferences rather than the policies in place. They have stated that the youth's disruptive behavior causes tension in the facility. Lastly, LPA Turner was notified that the youth has been receiving additional support and advocacy and this has greatly impacted the youth's behavior. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, a copy of this report and the Appeal Rights were discussed and provided to the licensee.

Investigation Findings:
13On September 24, 2025 at approximately 9: AM, Licensing Program Analyst (LPA) Zaria Turner made an unannounced visit to deliver findings to the above facility and met with Facility Administrator, Carla Izzarelli, who granted LPA Turner access to the facility. Prior to the meeting LPA Orlando Areizaga initiated the complaint investigation on July 24, 2025. No deficiencies were cited during that inspection. LPA Turner requested the following documents: Staff and Client Roster, Staff Contact Sheet, Client Face Sheet, Needs and Services Plans for one client in care, and Incident Reports for the month of July for one client in care. LPA Turner conducted six interviews between August 6, 2025 and September 10, 2025. Based on evidence obtained and confidential interviews conducted during the investigation process the above allegations cannot be substantiated because there were inconsistent statements throughout the investigation process. Report continued on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Connie Goldie LICENSING EVALUATOR NAME: Zaria Turner LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: PARADISE OAKS - HICKORYFACILITY NUMBER: VISIT DATE: 09/24/2025

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

met_with: Carla izzarelli, Facility Administrator


facility_name: PARADISE OAKS - MADISON

raw_content:
Narrative:
The details in the initial allegation, staff sexually assaulted minors in care was lacking specificity. After obtaining additional information on 10/1/2020, the allegation in this case is already being investigating in other cases. For these reasons, the other investigations needed to be completed to determine if any additional investigation would be needed. After the other cases (23-CR-20200203171258 and Case Management Investigations on 12/31/2019, 2/12/2020, and 7/27/2021) concluded, no new information was obtained, and no additional investigation was needed. The previous cases investigated these same allegations and no further investigation is needed. Based on the investigation, interviews conducted and records reviewed in this investigation and the previous cases, the allegation is UNSUBSTANTIATED at this time, meaning that the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted. Facility signature is on hard copy. A copy of all reports and appeal rights were provided to the facility via email.

Investigation Findings:
13Licensing Program Analyst (LPA) Cindy Johnson arrived at Paradise Oaks Youth Services (POYS) Administrative Office on 7/27/2021 at 2: PM. LPA Johnson spoke with Laynee Kuhn, Executive Director to discuss the findings and concluding the investigation. LPA Johnson informed Ms. Kuhn this case was investigated by the Department's Investigator Jami Eaton and LPA Cindy Johnson. The investigation included: on 8/24/20, the initial 10-day complaint investigation inspection was conducted at POYS Administrative Office included: reviewing records of Former Resident 1 (FR1) and Former Staff 1 (FS1). (see LIC811 dated 7/27/2021). Copies of documentation of FR1 obtained include: Placement agreement, Contact List, Needs & Service Plan, & CFT Meeting Notes; for FS1: California Driver's license, Returned Mail, Personnel Action Form with termination date 12/20/2019, Address Change form, Communication Notes dated 12/19/2019, Incident Report dated 12/19/2019, Communication Notes dated 12/18/2019, Statement by FS1 dated 12/13/2019, Internal Investigation dated 12/13/2019, and Internal Investigation dated 2/13/2019 & 2/17/2019, Clearance Transfer Request, LIC 508, Signed Duty Statement, and training log. Interviews were conducted with Former Resident 2 (FR2) on 10/1/2020 (see LIC811 dated 7/27/2021). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Cindy Johnson LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: PARADISE OAKS - MADISONFACILITY NUMBER: VISIT DATE: 07/27/2021


summary: Facility Evaluation

raw_content:
Narrative:
On 06/18/21 at 1: PM, the second collaborative a quarterly meeting with Paradise Oaks Youth Services (POYS) was held to provide technical assistance and collaborative support to assist with and ensure POYS operates a successful program. The first meeting was held on March 19, 2020. POYS consists of nine locations: Olivine, Rosa Vista, Hazel, Hickory, Antelope, Mariposa, Old Auburn, Madison, and Sunset. The current census at all locations is 28. Two locations have closed, Linda Creek on 2/3/21 and Violets on 5/11/21. The following were present on an MS Teams virtual meeting: · CCL: Margo Castaneda, Regional Manager, Jodean Hall, Licensing Program Manager, Robin Sullivan, Licensing Program Analyst. · System of Care (SOC): Marjana Jackson, Stacie Kinney. · Sacramento County: Linda Abdelbaki · Department Health Care Services (DHCS): Brian Keefer · POYS: Robert Pye, CEO, Laynee Kuhn, Executive Director, Stephanie Fisher, Program Director, Thomas Harrer, Clinical Director POYS provided a status update of the CARF evaluation stating the accreditation approval is over two months out due to backlogs from covid. An extension of approval is in effect. The Mental Health review by Dept. of Health Care Service (DHCS) was completed in April 2021 and at this time POYS is working with DHCS in providing the plan of corrections. POYS reports numerous clients recently graduated from high school. Some graduates are enrolled in community college, some are working, some are seeking transitional housing programs, and some are still figuring things out. Distance learning challenges were reported to be with band-width issues both from the schools and at the facilities. Distance learnin CCL reported a decrease in complaints and incident reports. POYS attribute the decline to a more deliberate intake process and screening for better compatibility with the current clients. They also reported they were revamping their level system. In addition, POYS is training house staff to participate more closely with each client and their overall treatment plan. Staff are eliciting more input from youth on what is working/not working with the program. Youth have responded with more engagement. POYS reported they are resuming a higher level of training for staff as more in-person training become available. They have contracted with Relias Learning for staff training. When asked about the status of overnight staff, POYS reported, they have two roamers that are assigned to three homes each. They also have one floater that helps out as needed or if someone calls out. This model is used both for the day shift and nighttime shift. The roamers and floaters meet regularly with staff to discuss client behaviors and needs. Sacramento County had no specific areas of concern. They complimented the discussed areas of change and the graduation of youth. DHCS discussed the pros/cons of the virtual Mental Health review and was appreciative for POYS' feedback on the process. Clarification on mask wearing requirements for POYS clients and staff will be provided as the Department receives details. POYS will submit an electronic Program Statement to include recent revisions. They next meeting is scheduled for September 17, 2021. A copy of this report will be emailed for signatures to Laynee Kuhn.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Cindy Johnson arrived at Paradise Oaks Youth Services Main Office to initiate a Required Annual on 6/23/2021 at 10: AM with Laynee Kuhn, Executive Director, due to this facility not currently having any placements. Areas discussed: annual fees & outstanding fees, updated Administrator Certificate, waiver for 40 hours of annual staff training; and updated Emergency Disaster Plan (per H&S Code 1565). The status of other requirements was discussed, and current/updated version is being requested, for the following: · CARF International Accreditation was conducted 4/26/21-4/28/21, new certificate is pending · Mental Health Contract is renewed annually with Sacramento County · Mental Health Program approval- is currently in process of renewal and making corrections. · Emergency Intervention Log, via Board Meeting Minutes for the past 6 months, LPA Johnson followed Ms. Kuhn to the facility location and conducted the inspection. The following items were observed and evaluated by LPA Johnson: Posted items in the facility: Facility License, Emergency Mass Casualty Disaster Plan, Foster Youth Personal Rights, Foster Youth Ombudsman posters, exit routes, COVID-19 handwashing instructions with health & safety information. Kitchen- 4 refrigerators were present and tested below 45 degrees F, one frig was missing the door handles; 2 freezers were present and tested at zero degrees. Refrigerators and freezers had various areas that needed cleaning and/or removal of old food (onion). Area to post menus is available. Hot water temperature tested within the regulatory range of 105-120 degrees (120 degrees). Knives and Sharps will be stored and locked inside the staff office. However, none are currently present. Dishwasher is operable. There are no refrigerated medications. Trash can has a lid. Kitchen window is missing a screen. No disinfectants or cleaners are stored in the kitchen. Living Area- Furniture is clean and in good repair, except one couch to be disposed. Smoke & Carbon monoxide detectors are present and operable. Two windows were missing screens. Carpet was in good repair. Flooring in the staff office has two areas of damaged/ ripped linoleum. Bedrooms- There are 3 client bedrooms with double occupancy. All had the required furnishings, except Bedroom #2 only had one dresser. A drawer was missing exterior knobs. The facility has the required items for a bed: mattress pad, fitted sheet, top sheet, pillow and mattress in good repair, even if not on the bed; extra linen supply was present. Two windows were missing screens and window seal needed cleaning. Smoke detectors are operable. There are no staff bedrooms. Vent in hallway has dirt and rust. Bathroom- There are 2 client bathrooms (regular & master) and 1 staff bathroom. Hot water temperature tested exceeded the regulatory range of 105-120 degrees: 123, 122, and 127 respectively. The master bath: toilet was not operable & had no water; sink did not drain and needed cleaning. The shower rod in the regular bathroom is mostly rusted. Tub/showers were clean and operable. Buildings and Grounds- Fire extinguisher was serviced in 2021. Carbon monoxide detector and smoke detector were tested and working. Cleaning & Chemical Supplies were not accessible. Passageways are clean and free of obstructions. Facility has no bodies or water, cameras, or firearms on the premises. Outdoor fencing has a few areas that need additional support. Agency has engaged with the neighbors for repairs. Facility Telephone was not operable or present. Front door was replaced, but surrounding molding and exterior bricks is incomplete, needing repair. Detached structure (store) was inspected and does not store dangerous items. Medication- Medication is stored and locked in the filing cabinets inside the staff office, when it is present. Since no youth are currently placed, no medication or documentation were present to inspect. First aid kit was incomplete, missing adhesive tape and antiseptic solution. Since this facility is currently not occupied with clients and staff are not assigned to this location, file reviews and interviews were not conducted. Prior to resuming operations of this facility, the following items remain needed: Updated forms: LIC 308, 500, 610C If the administrator is changed, an updated board resolution and valid certificate. Adequate food supply- 2 days of perishable, 1 week of non-perishable and snacks Monthly menus and activity schedule need to be posted. Adequate dishware and cooking utensils. Hygiene supplies. Inspection of facility vehicle Beds have all required items No deficiencies are being cited due to no clients in placement. The agency should address all items prior to resuming the operation of the facility. Exit interview conducted and reports discussed with Laynee Kuhn, Executive Director; copies of documentation were provided to the facility, via email.


summary: Facility Evaluation

raw_content:
Narrative:
On 09/17/21 at 1: PM, the third collaborative quarterly meeting with Paradise Oaks Youth Services (POYS) was held to provide technical assistance and collaborative support to assist with and ensure POYS operates a successful program. POYS consists of nine locations: Olivine, Rosa Vista, Hazel, Hickory, Antelope, Mariposa, Old Auburn, Madison, and Sunset. The current census at all locations is 27. Three locations: Madison, Sunset and Old Auburn currently have no foster youth placed. The following were present on an MS Teams virtual meeting: · CCL: Jodean Hall, Licensing Program Manager, Robin Sullivan, Licensing Program Analyst (LPA), Cindy Johnson, LPA, Tammy Hill, LPA · System of Care (SOC): Marjana Jackson, Stacie Kinney. · Sacramento County: Linda Abdelbaki · Department Health Care Services (DHCS): Brian Keefer · POYS: Robert Pye, CEO, Laynee Kuhn, Executive Director, Stephanie Fisher, Program Director POYS reported a staff and family moved into Sunset after their home burned down approximately 2 weeks ago. Annual inspections were completed for all their facilities in June and July, resulting in Technical Advisory/Advisory Notes and no deficiencies cited. CCL will provide the electronic program statement revisions to System of Care. Program statement revisions for the SAY population was submitted but still needs to be reviewed and approved. LPA Marla Horne will review by October 20, 2021. Incident reports regarding smoking on grounds was discussed. Both trauma-informed practices and harm reduction protocols were discussed. Harm reduction practices have not been approved by the Department. POYS is reminded that incident reports should document interventions including staff discouraging youth from smoking. CCL pointed out youth smoking in the backyard is still smoking on grounds which may require additional case management inspections. CCL requested program statement revision to Transportation services to add details of exceptions to provide transportation to youth when extreme weather, youth not feeling well or after hours. CCL requested incident reports be typed due to the difficulty of reading the handwritten reports. At this time there are multiple POYS staff that still hand write reports. This has been an ongoing conversation between POYS and CCL. CCL requests all reports be typed by November 1, 2021. POYS declined this request. CCL requested all youths' names be included in one incident report rather than referring to other involved youth as "peer". CCL recommended using a legend to submit the report to CCL and redacting the names for POYS purposes. POYS declined the request due to confidentiality. The CCL request was requested and approved through upper management and noted not to be a HIPPA violation. CCL requested incident reports and timeframes be more specific. Antecedent information is specific and thorough, yet more follow up details or resolution information is needed and requested. CCL recommended POYS to Technical Support Program (TSP) for incident report writing. POYS approved the recommendation. Sacramento County had no specific areas of concern. DHCS had no specific areas of concern. Due to the upcoming impact of FFPSA on program statements, a deadline for the revisions was not determined and will be included at the time of the FFPSA changes. No further meetings are scheduled


summary: Facility Evaluation

raw_content:
Narrative:
On January 27, Licensing Program Manger (LPM) Dara Campos, Regional Office Manager Margo Castaneda, and Licensing Program Analyst (LPA) Stephannie Verna held an Informal Conference Meeting from 1: PM to 2: PM to discuss concerns. The meeting was facilitated by LPM Campos. Attendees included (in-person) Paradise Oaks Youth Services staff, Laynee Kuhn (Executive Director), Stephanie Fischer (Administrator), Amanda Lee (administrator) and Board Member Al Werner, as well as (Via Teams Meeting), Shawn Wade Fresno County Social Worker, Julie Leong, Case Manager Mateo County Behavioral Health, Khoa Nguyen Stanislaus County Social Worker, and Tia Carter Sacramento County Social Worker. The topics discussed included: Absent without Permission Temporary Release (TR) Communication with local law enforcement Cancelling Missing Person reports Incident Report details No deficiencies were cited during today's meeting. A copy of this report was provided to Laynee Kuhn, Executive Director.


summary: Facility Evaluation

raw_content:
Narrative:
On 9/15/23, about 10: AM, Licensing Program Analyst, (LPA) Uchenna Ajaero attempted to conduct an annual visit at this facility. On arrival there was no one on site. LPA called the phone number listed, (916) 965-9469) but it went to voice mail which announced that LPA could not leave a message. LPA will retry another day.

met_with: Attempted Visit


summary: Facility Evaluation

raw_content:
Narrative:
On 9/28/23 about 10: AM, Licensing Program Analyst, (LPA) Uchenna Ajaero attempted for conduct a Randon Annual inspection visit but there was no staff or client present. A call to the office disclosed there is no placement at that location at this time and so there is no staff present. LPA Ajaero contacted Lynee Kuhn who agreed to have a staff, the Administrator of the Madison Location, Stephanie Piring meet LPA at the location tomorrow morning by 10: AM.


summary: Facility Evaluation

raw_content:
Narrative:
On 9/29/23, Licensing Program Analyst, (LPA) Uchenna Ajaero made an unannounced random annual investigation visit to this facility and met Stephanie Piring, Floating Administrator. The Administrator took the LPA on a tour of the facility. The building has a clothing closet which is a full room with clothes serving all the youths in all their other 5 facilities. At this time this facility is closed. There are no youths in the home now and there is no staff at the premises, and there is no plan in the near future to begin placement. This facility had youths at some point back in 2020. The facility has 3 bedrooms. One bedroom has a full bath and there is another full bath in the hall way. Each room has a closet. The facility has a kitchen, laundry, large living room area with boxes, and furniture, clothes storage room, and an overflow storage area. There is a van parked outside. During the tour LPA Ajaero observed: Fire extinguisher serviced 8/2/23; Working smoke alarm, carbon monoxide detector. Posted items in the facility: Facility License, Emergency Mass Casualty Disaster Plan, Foster Youth Personal Rights, Foster Youth Ombudsman posters, exit routes, floor plan, COVID-19 handwashing instructions with health, HIPPA Compliance notice & safety information. No interview was conducted of any youth or staff because there is no one at the facility at this time. Exit interview was conducted. No citation was issued.