summary: Facility Evaluation

raw_content:
Narrative:
On 7/24/25, Licensing Program Analysts (LPAs) Jonathan Medina and Omar Sawyer conducted a quarterly case management inspection in accordance with the terms agreed upon during the January Noncompliance Conference (NCC). LPAs met with Administrator Carolyn Williams and explained the purpose of the visit. The NCC visits were extended for an additional two quarters due to continued non-compliance observed between April and June. As outlined in the NCC terms and during previous inspections, several requirements were reviewed. Documents observed on this visit indicated compliance, with all staff receiving the required training at the time of hire and additional training on a quarterly basis. LPAs reviewed an updated LIC 500 and supporting documentation for three staff-including LIC 501 forms, First Aid and CPI certifications, and current training records for the past 12 months. All other staff were already reviewed in a recent annual facility inspection completed on 5/15/2025 meeting this quarters requirements. Overnight staffing requirements have been consistently met, with two staff members present during each overnight shift, including one facility manager. During review of the June schedule, LPAs observed the use of nurses to cover staff ratio requirements. Further investigation is needed to determine whether the use of the nurse registry is being correctly implemented at the facility. Bed check logs were reviewed and found to be complete and organized. Although there were some discrepancies in the physical folder, proof that bed check rounds were conducted was found in the digital bed check log. Regarding administrative oversight, Carolyn Williams passed the Administrator examination on 11/27/24 and is now a certified Administrator. Administrator was confirmed to be only working at one home and meet the 20hr requirement of being at the home as reviewed on staff schedules. Continues on LIC809-C LPAs reviewed the facility's overall compliance over the past quarter. In recent months, the facility has experienced multiple compliance issues, particularly related to reporting requirements, staff conduct, adherence to the facility's Plan of Operation, and one instance of lack of supervision. On 1/13/2025, during a prior NCC visit, the facility was cited for failing to report unusual incidents. This deficiency was discovered during LPA's review of facility records. During the initial annual inspection conducted on 4/30/2025, the facility was cited for failing to develop Needs and Services Plans for the clients reviewed, and one client was found to be missing a TB test. On 5/5/2025, a complaint was received alleging that staff made inappropriate comments to a minor. This allegation was substantiated. On 5/12/2025, another complaint was filed alleging that staff spoke inappropriately to a minor in care. This allegation was also substantiated. Both complaints involved the same staff member, who has since been terminated. The related deficiencies were promptly addressed and cleared. On 5/14/2025, during the investigation of another complaint, LPAs discovered through confidential interviews that significant incidents had not been reported. As a result, a civil penalty was issued for a repeat deficiency related to reporting requirements. The home was referred to TSP services with Selena Hood and completed a training on reporting requirements and mandated reporting. LPA Medina observed that incident reporting had significantly improved following the TSP training. On 5/29/2025, the facility received two substantiated complaint allegations. The first stated that staff did not ensure a minor received therapy sessions. The second stated that staff forced minors to clean hazardous materials. Additionally, during the continuation of the annual inspection on 5/15/2025, LPA identified deficiencies related to the frequency of therapy sessions being provided. Staff interviews and client statements confirmed that only one individual and one family therapy session per week were being conducted. However, per the facility's Plan of Operation, each client is to receive two to three individual therapy sessions and two family therapy sessions per week. The facility is currently working on submitting an updated Plan of Operation to reflect the revised therapy schedule. Lastly, on 6/02/2025, the facility received a complaint alleging that the facility failed to provide supervision sufficient to meet clients' needs. This allegation was substantiated. The staff member involved in the incident has since been terminated and deficiency cleared immediately. All Plans of Corrections (POCs) for the above deficiencies have been cleared, with the exception of the updated Plan of Operation, which is still under review by LPA. Three confidential client interviews were conducted, and staff interview data has already been collected during the recent annual inspection. No deficiencies were observed on todays visit. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to Administrator Carolyn Williams.


state: CA

facility_name: CENTER FOR DISCOVERY, BRENTWOOD II

summary: Facility Evaluation

raw_content:
Narrative:
This is an amended report from the original report date of August 8, 2025. Licensing Program Analyst (LPA) Willy Ea and Celeste Aparicio conducted an unannounced case management inspection on 11/7/2025. The purpose of the amended report was to update the below report. See below. On August 8th, 2025 at 10:30AM, Licensing Program Analyst (LPA) Will Ea conducted an unannounced case management inspection at the above facility to follow up on an Incident Report. LPA met with the facility administrator, Carolyn Williams. At time of arrival, four staff members and four clients were present. The incident report in review was submitted regarding an incident that occurred on July 15th, 2025. According to the report, Client #1 (C1), please refer to LIC811 dated (8/8/2025) for confidential names, had an altercation with a staff member, which resulted in the facility contacting law enforcement and the youth being hospitalized. A few days after (C1) returned to the facility, C1 was discharged from the facility. LPA conducted two staff interviews, one client interview, and gathered additional evidence for LPA's investigation. Based off interviews and record review, it was determined staff reacted appropriately to protect the health and safety of clients in care. No deficiencies were observed or cited at this time. An exit interview was conducted, and a copy of this report was left with the facility.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Carolyn Williams, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
*This is an amended report from the original report date of November 7, 2025.* This report was created in error. *This is an amended report from the original report date of November 7, 2025.* This report was created in error.

met_with: Luis Farias, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 11/12/25, Licensing Program Analysts (LPAs) Celeste Aparicio and Hanako Primer made a visit to the facility to amend a report. LPA met with Facility Manager, Luis Farias and informed them on the purpose of the visit. The report was amended. An exit interview was conducted, and a copy of this report was left with the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On 12/23/2025, Licensing Program Analysts (LPAs) Will Ea and Jonathan Medina made a visit to the facility to amend a report. LPA met with Administrator, Carolyn Williams and informed them on the purpose of the visit. The report was amended. An exit interview was conducted, and a copy of this report was left with the facility.


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Investigation Findings:
On October 22nd, 2025, Licensing Program Analyst (LPA) Will Ea visited the facility for a follow-up complaint investigation visit regarding the above allegation. LPA met Behavioral Tech Montana Olson and informed of the purpose of the visit, to deliver findings for the investigation on the allegation above. During the course of the investigation, LPA Will Ea reviewed documentation and conducted confidential interviews. Based on record review and confidential interviews, statements received did not corroborate the events as described in the allegation. While some testimonials did allege possible instances of lapse of supervision, there were inconsistencies regarding key details of when and how lapse of supervision had occurred. None of the statements could point to a specific, verifiable event of supervision lapse and the majority of accounts were in agreement that supervision is properly maintained during staff meetings. 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: staff left clients unsupervised is UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was provided to Behavioral Tech Montana Olson . UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Willy Ea 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:

report_type: Complaint Investigation

met_with: Montana Olson, Behavioral Tech II

complaint_status: unsubstantiated


raw_content:
Narrative:
Staff not giving client medication on time Staff did not pick up client's medication on time Facility conducts body checks in an inappropriate location at the home Staff are not properly providing educational services to clients Facility did not follow proper discharge procedures Facility did not have a nurse available at the home These six allegations are unsubstantiated, and no Title 22 deficiencies were observed. An exit interview was conducted, appeal rights discussed, and a copy of this report was left with Administrator, Carolyn Williams, whose signature on this form confirms receipt

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: Administrator, Carolyn Williams


summary: Facility Evaluation

raw_content:
Narrative:
On January 15, 2026 at 12:10PM, Licensing Program Analysts (LPAs) Oliver Cole and Will Ea conducted an unannounced Plan of Correction (POC) inspection and met with Administrator, Carolyn Williams, who helped facilitate the inspection. LPAs disclosed the purpose of the inspection and were granted entry to the facility by the Administrator. At the time of the inspection there were 3 clients and 4 staff present in the facility. LPA's visit was regarding one citation issued on 12/4/25, 80061(b)(1)(E) Reporting Requirements, for which a POC was developed and due on 01/05/26. See LIC Case Management, dated 12/4/25. LPA confirmed with the Administrator that the POC had not been completed. LPA was unable to verify completion of the POCs during today's visit. LPA is assessing a civil penalty for the late POC, pursuant to California Code of Regulations, Title 22, Section 80054, of $100 per day beginning the POC due date for the POC not completed. The civil penalty comes to $1,000. LPA advises that this is an accruing penalty, and the POC should be submitted by the end of today (01/15/26) to avoid additional penalties. An exit interview was conducted, appeal rights were provided, an additional copy of the LIC 809, from 12/4/25 report was provided, and a copy of this report was provided to Administrator, Carolyn Williams.


summary: Facility Evaluation

raw_content:
Narrative:
On May 14, 2025, Licensing Program Analyst (LPA) Jonathan Medina conducted a visit to the facility in connection with an incident that came to light during interviews conducted on a prior visit on May 7, 2025. LPA met with Carolyn Williams, Program Administrator, and informed her of the reason for the visit. The incident involved a client being discharged from the facility due to inappropriate physical contact with other clients. The Administrator confirmed that the incident occurred and stated that law enforcement had been contacted. The facility discharged the client immediately in accordance with proper follow-up procedures. Reported client was transferred to higher-level of care. However, because the facility failed to report an incident that is considered reportable, a citation is being issued for a violation of the California Code of Regulations (CCR), Title 22, Division 6, Chapter 5, Section 80061(b)(1) - Reporting Requirements. The Administrator explained to LPA that there had been a mix-up in the spelling of the email address to which the incident report was sent. At this time, one deficiency has been issued. Additionally, a civil penalty of $250 was assessed for a repeat deficiency. An exit interview was conducted, appeal rights were provided and discussed, and a copy of this report was given to Carolyn Williams, Administrator.

met_with: Carolyn Williams - Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On November 7, 2025 at 10:15AM, Licensing Program Analysts (LPAs) Celeste Aparicio and Will Ea conducted an unannounced case management inspection and met with Facility Manager, Luis Farias who helped facilitate the inspection. LPAs disclosed the purpose of the inspection and were granted entry to the facility by the Facility Manager. At the time of the inspection there were (6) clients and (3) staff present in the facility. The purpose of this visit is to discuss an incident that occurred at the facility on November 2nd, 2025. It was reported that on November 2nd, 2025, three clients in care were left unattended at the facility, three clients in care were left unattended at a park, clients in care were not transported with authorized facility vehicles, and clients in care were offered illegal substances by staff contracted through the Meledy Agency. During the inspection, LPAs requested the following documentation: LIC500, staff schedule, client roster with authorized representative information, shift notes, staff contacts, training materials, and facility activity calendar. LPA's learned that the facility utilizes a third party staffing agency known as Meledy Agency, at this time the Department needs to further investigate the contract between the facility and Meledy Agency. LPAs conducted (2) staff interviews with S1 & S2, (2) client interviews with C4 and C7, and attempted (2) client interviews with C1 and C2 who refused. Based on interviews and records reviewed, it was found that the two staff working on November 2, 2025 (S5 & S6) were working with the clients in care while lacking Guardian clearance. {Reference LIC Confidential Names list dated 11/7/25}. Additionally, it was found that S5 drove their personal vehicle to transport the clients which is against facility protocol per plan of operation/ program statement and temporarily left the clients C1,C4, and C6 unsupervised at the facility. Based on LPAs' observations, interviews, and records reviewed, LPAs are issuing the following citations under California Code of Regulations (CCR), Title 22, Division 6, Chapter 1, 80019(e)(2)Criminal Record Clearance, Sections 80022(k) Plan of Operations, and Chapter 5, 84065.2 (b)(1) Personnel Duties. (See attached LIC809-D page). During todays inspection LPAs observed S3 working in the facility who lacks Guardian clearance. LPAs are assessing an immediate civil penalty of $100 for a maximum of 5 days in violation, in which S3, S5, and S6 worked on site, for a total of $1,500. LPAs had to print and complete the LIC 421BG and provide a copy to Facility Manager, Luis Farias. An exit interview was conducted, appeal rights discussed, and a copy of this report was left with the Facility Manager, whose signature on this form confirms receipt.


summary: Facility Evaluation - 3 deficiencies

raw_content:
Narrative:
***This is an amended report with original date 11/21/2025, LPA has corrected the POC due dates, and included relevant information to the below report rather than LIC 809-D page.*** On November 21, 2025, at 10:30AM, Licensing Program Analysts (LPAs) Jonathan Medina and Will Ea conducted an unannounced case management inspection and met with Administrator Carolyn Williams. During the inspection, there was 1 client and 2 staff on site. The purpose of this visit was to follow up and continue an investigation into an incident report that occurred at the facility on November 2nd, 2025. It was reported that on November 2nd, 2025, three clients (C1-C3, please refer to LIC 811 for confidential names) in care were left unattended at the facility, three clients in care were left unattended at a park (C4-C6), clients in care were not transported with authorized facility vehicles, and clients in care were offered illegal substances by staff contracted through the Medely Agency. For additional information, please refer to the inspection dated 11/7/25. During today's inspection, LPA requested to see personnel and staff training files for the two staff involved in this incident from 11/2/25, (S1) and (S2). During today's inspection, the administrator, Carolyn Williams, was unable to provide those items to LPA Ea. Administrator Carolyn Williams informed LPAs that the facility has ceased usage of the Medely agency effective the date after the last case management inspection on 11/7/25. () (page 2 of 2) List of citations: (1) 84065(i) Personnel Requirements: not ensuring S1 and S2 received the minimum required 24 hours of initial training, (2) 80065(a) Personnel Requirements: for S1 and S2 lacking competency to provide services necessary according to clients' needs and services plan, (3) 84065(d) Personnel Requirements for not ensuring a facility manager is on site when clients are on site at the facility, (4) 80066(a) Personnel Records: for not maintaining personnel records for S1 and S2, (5) 84066(b) Personnel Records for not maintaining personnel records with required docs, and (6) 80022(k) Plan of Operation on November 2nd, not adhering to the Plan of Operation regarding requisite supervision ratio (1:6). Please refer to LIC809-D for full details regarding the above citations. LPAs cleared a POC from a case management citation that occurred on November 7th, 2025 for an incident that occurred on November 2nd, 2025. A copy of the plan will be taken back to the Regional Office to file within the facility folder. Licensee sent LPAs evidence regarding the facility discontinuing use of Medely staffing agency as of 11/12/2025. An exit interview was conducted, appeal rights were provided, and a copy of this report was provided to Administrator Carolyn Williams, whose signature on this form confirms receipt.

Deficiencies:
84065(i): Notwithstanding Sections 80065(f)(1) through (6), new child care staff ... shall complete a minimum of 24 hours of initial training comprised of the 8 and 16-hour training as specified in (1) and (2) below:
80065(a): Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
84066(b): 1
2
3
4
5
6
784066(b)	 Personnel Records
The licensee shall maintain the following personnel records

title:
1
2
3
4
5
6
784065(i) Personnel Requirements

title:
1
2
3
4
5
6
780065(a) Personnel Requirements


summary: Facility Evaluation

raw_content:
Narrative:
On November 21, 2025, Licensing Program Analysts (LPAs) Jonathan Medina and Will Ea conducted a quarterly case management inspection in accordance with the terms established during the Noncompliance Conference (NCC) held in January 2023. LPAs were initially greeted by Mental Health Technician Jonathan Gonzalez, who was informed of the purpose of the visit. Approximately 30 minutes later, LPAs met with Administrator Carolyn Williams and continued the inspection. The NCC visits were extended for two additional quarters due to continued noncompliance observed between April and June 2025 during previous quarterly visit. This visit concludes the final quarter of NCC monitoring. Due to continued non-compliance a follow-up meeting with the Department will be scheduled to address final quarter. LPAs requested the LIC 500 to verify staff fingerprint and Guardian clearance. All staff listed were confirmed to be cleared. It was also verified that the Administrator is assigned to only one facility. At 11:00 a.m., LPAs conducted a walk-through of the facility. Two staff members and one client were present. The facility had sufficient food supplies, which were properly labeled. The environment was clean; however, the perimeter fence was observed to be broken due to a recent client-related incident. The facility will be cited under (CCR) Title 22, Section 80087(a) - Buildings and Grounds. Please refer to LIC809-D for further details. At 12:00 p.m., LPAs reviewed staff schedules from August to the present. Per the LIC Noncompliance Summary, the facility is required to have two overnight staff, including at least one facility manager. This requirement was not consistently met during the quarter due to staffing challenges. The Administrator acknowledged that the requirement was not fulfilled and that management was aware of the noncompliance. LPAs also reviewed bed check logs beginning in August. Logs were complete, signed, and included valid explanations for any missing entries (e.g., hospital visits, off-site activities, or client discharges). Continued on LIC 809-C At 1:00 p.m., LPAs reviewed staff training records. Staff had completed the required training on supervision procedures, mandated reporting, and incident documentation, as outlined in the LIC 9111. Facility kept incident report and mandated reported training in a program named Day Force and Supervision training is on a program named Navex. Additionally, the facility was referred to Technical Support Program (TSP) services last quarter with Selena Hood and completed a training focused on reporting requirements and mandated reporting. LPA Medina noted an improvement in incident reporting practices following the TSP training. Any training's not available during todays visit are to be emailed to LPA by Monday 11/24/2025. During this quarter several incident reports were submitted, including reports of inappropriate contact between clients and an incident in which clients were left unsupervised and offered vape pens by a contracted staff member. This staff member was associated with a concern previously identified during an earlier NCC visit. The Administrator stated that the facility contracts with Meledy, a staffing agency for Licensed Vocational Nurses (LVNs). Some contracted LVNs were observed working in direct care roles without the required training or fingerprint clearance and were left alone with clients. As a result, the facility has discontinued its contract with this agency and agreed to comply with all regulatory requirements related to staffing. This issue was cited under a separate case management report dated today, titled "Case Management - Deficiencies". At 3:00 p.m., LPAs discussed the facility's compliance for the current quarter with the Administrator. On November 7, 2025, a case management incident follow-up resulted in one Type A citation and two Type B citations. The Type A citation was issued for contracted staff working in direct care roles without Guardian clearance, in violation of Title 22, Section 80019(e)(2). One Type B citation was issued for failure to follow the transportation policy outlined in the Plan of Operation (Section 80022(k)). The second Type B citation was issued for failure to provide adequate supervision and care to clients, in violation of Section 84065.2(b)(1). During this visit one deficiency was cited. NCC quarterly visits are now concluded. An exit interview was held with Administrator Carolyn Williams. Appeal rights were discussed, and a copy of this report was provided.

met_with: Carolyn Williams -


summary: Facility Evaluation - 2 deficiencies

raw_content:
Narrative:
On 12/4/25 at 10:15am, Licensing Program Analyst (LPA) Will Ea and Celeste Aparicio conducted an unannounced case management inspection and met with Luis Farias, Facility Manager who helped facilitate the inspection. LPAs disclosed the purpose of the inspection and were granted entry to the facility by staff. At the time of the inspection there was three clients and five staff present in the facility. In October 2025 an incident report was received by the department for the incident date of 10/2/25, the submitted incident report was in regards to a disclosure of unwanted and inappropriate physical contact between (C1) and (C2) (See confidential names list LIC-811 dated 12/4/25). This incident report was referred to the Investigations Bureau (IB). During the course of their investigation, IB conducted confidential interviews, obtained records, and LPA Will Ea reviewed additional records. Based on confidential interviews, observations, and record review, it was discovered that between the dates of 10/02/2025 and 10/16/2025, C2 made unwanted sexual advances towards C1. (Report continued on LIC809-C dated 12/4/25) In addition, based on confidential interviews and records reviewed, it was discovered that C2 had left the facility grounds on approximately 10/16/25; however, no incident report of the unexcused absence or contact with law enforcement was submitted to the Department. Also, it was discovered that there were multiple instances of supervision lapsing due to (S1) falling asleep while on duty. S1 was a contracted staff member through the Medely staffing agency, as a result of this incident the facility is no longer contracting staff through Medely agency. LPAs are issuing the following citations under California Code of Regulations (CCR), Title 22, Division 6, 84065.2 (b)(1) Personnel Duties, 84072 (d)(1) Personal Rights, and 80061 (b)(1)(E) Reporting Requirements. (See LIC809-D pages dated 12/4/25). An exit interview was conducted, appeal rights were provided, and a copy of this report was provided to Luis Farias, Facility Manager whose signature on this form confirms receipt.

Deficiencies:
84065.2: Child care staff shall perform the following duties: Supervision, protection and care of children individually and in groups at all times.
80061: "...a report shall be made to the licensing agency...Events reported shall include the following:.. Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.

title:
1
2
3
4
5
6
784065.2 (b)(1) Personnel Duties

title:
1
2
3
4
5
6
780061 (b)(1)(E) Reporting Requirements


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 12/08/2025, at 11: AM, Licensing Program Analyst (LPA) Cole Oliver conducted an unannounced case management visit to the facility. LPA met with Administrator, Carolyn Williams who assisted with the visit. Executive Director, Shawn Krack assisted via phone. A tour of the facility was conducted. During the visit there were (7) staff and (3) clients present. The purpose of this visit was to request the facility update their Program Statement to avoid any personal right violations. During the visit it was found that the Program Statement does not reflect the program methods being performed at the facility. The facility is receiving a type B citation Title 22. Division 6, Chapter 1, Article 03. Plan of Operation 80022 (b)(1) Refer to LIC809-D An exit interview was conducted, and a copy of this report was provided to Administrator, Carolyn Williams, whose signature confirms receipt.

Deficiencies:
80022: 1
2
3
4
5
6
7

title:
(b)(1)
Statement of purposes, and program methods and goals.
This requirement is not met as evidence by

description:
1
2
3
4
5
6
7


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On Thursday 5/5/22 at 11:15AM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility for a continuation of the 2-year required inspection initiated on 4/27/22. LPA met with Program Director Virginia Parish and Assistant Milieu Manager Cecily Smith and informed of the purpose of the visit. Safety precautions were taken, including mask-wearing and pre-visit screening call. During the 4/27/22 inspection, the physical plant was inspected and resident/patient files were reviewed. During today's inspection, LPA inspected resident/patient medications and personnel records and conducted staff and resident interviews. No deficiencies were found during medication record and storage review. During review of personnel records, which are stored electronically, it was observed that four (4) staff [S1, S2, S3, and S4] (See LIC Confidential Names, dated 5/5/22) had no LIC Criminal Record Statement in their personnel records. Licensee's Human Resources Department stated that the form was not maintained in the records for staff hired prior to the program switching to a new electronic filing service. LPA is issuing a citation of California Code of Regulations, Title 22, Section 80066(A)(12)(a) Personnel Records. Staff S4 is also missing the LIC Personnel Record. LPA is issuing an advisory of Title 22, Section 80066(a)(6). An exit interview was conducted, appeal rights provided, and a copy of this report was left with Program Director Virginia Parish, whose signature on this form confirms receipt.

Deficiencies:
80066: (12)(A) A signed statement regarding their criminal record history as required by Section 80019(d).

met_with: Program Director Virginia Parish, Assistant Milieu Manager Cecily Smith

title:
Personnel Records
(a)...Each personnel record shall contain the following information


summary: Facility Evaluation

raw_content:
Narrative:
On 10/24/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a quarterly inspection (case management), per the agreed upon terms of the January 2023 noncompliance conference (NCC). LPA met with Administrator Sara Stokes and informed of the purpose of the visit. Per the NCC terms and previous inspection(s), the following was required and reviewed: (2) Ensure staff were fully trained, per applicable regulations, at hire and additionally on no less than a quarterly basis. | LPA reviewed five personnel records and observed all staff to have background clearances and up to date training, either surpassing required training hours or on track to complete training hours. (3) Designate two overnight staff each night with at least one being a facility manager. | The facility has continued to maintain two overnight staff, and staff conduct 15 minute rounds during the overnight shift and document them on paper and electronically. LPA reviewed rounds documentation at visit. (4) Designate an administrator to oversee only one facility. | The licensee has a candidate who has completed the administrator training and will be taking the exam soon. During file review, LPA observed that one incident report was not submitted to the licensing agency. LPA is issuing a citation of California Code of Regulations, Title 22, Section Reporting Requirements. See attached LIC 809-D. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Sara Stokes, whose signature on this form confirms receipt.

met_with: Administrator Sara Stokes


summary: Facility Evaluation

raw_content:
Narrative:
On 3/6/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit in order to deliver notice of deficiencies found during the course of an investigation or inspection at the facility. LPA met with Administrator Sara Stokes and Lead Tech Carolyn Williams and informed of the purpose of the visit. It was learned that two residents of different genders were allowed to share a bedroom. One resident identifies as a boy and one as a girl. An investigation of a report that one of these residents sexually assaulted the roommate found that the incident occurred in part due to the residents sharing a bedroom. LPA is issuing a citation of California Code of Regulations (CCR), Title 22, Section Personal Rights. Additionally, no documented bedroom sharing arrangement could be supplied upon request. Therefore, LPA is issuing a citation of CCR, Title 22, Section Buildings and Grounds. See attached LIC 809-D. An exit interview was conducted, appeal rights were provided, and a copy of this report was left with Administrator Sara Stokes, whose signature on this form confirms receipt.

met_with: Administrator Sara Stokes; Lead Tech Carolyn Williams


summary: Facility Evaluation

raw_content:
Narrative:
On 1/23/25, Licensing Program Analyst (LPA) Jonathan Medina conducted a quarterly case management inspection in accordance with the terms agreed upon during the January Noncompliance Conference (NCC). LPA met with Administrator Carolyn Williams and explained the purpose of the visit. As outlined in the NCC terms and previous inspections, several requirements were reviewed. Staff training records showed compliance, with all staff fully trained at the time of hire and receiving additional training on a quarterly basis. The Administrator agreed to submit an updated LIC 500 along with specific documents for all Staff, including LIC 501 forms, First Aid and CPI training certifications, and current training records for the past 12 months, by end of today. Overnight staffing requirements have been met consistently, with two staff members present each night, including at least one facility manager. Bed check logs were complete and organized, though some discrepancies were noted. The Administrator clarified these issues and described the corrective actions taken promptly. Regarding administrative oversight, the facility has transitioned leadership roles. The former administrator has been promoted, and the previous lead facility manager has assumed the administrator position. Carolyn Williams passed the Administrator exam on 11/27/24 and now is a certified Administrator. LPA reviewed the facility's overall compliance over the past quarter. Although no reports requiring follow-up had been submitted, it was discovered during the inspection that some reportable incidents had occurred in recent months. These were determined to be high-priority incidents that could require a follow-up. LPA provided guidance on proper reporting procedures and requirements and was assured by Administrator that the incident reports will be submitted by tomorrow. Facility is being cited for violation of California Code of Regulations (CCR), Title 22, Division 6, Chapter 5, Section 80061(b)(1). The facility has received two complaints, but no deficiencies in the past quarter. One deficiency was cited during todays inspection. An exit interview was conducted, and a copy of this report was provided to Administrator, Carolyn Williams.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On January 26, 2026, Licensing Program Analyst (LPA) Celeste Aparicio conducted an unannounced visit to the facility and met with Administrator, Carolyn Williams. LPA explained the purpose of the visit and was granted entry by staff. The purpose of the visit was to conduct a case management inspection to address reporting requirements with the facility. During the course of an investigation, LPA Aparicio conducted confidential interviews and reviewed facility records. Based on the information obtained, it was determined that an incident involving a client on November 16, 2025, which resulted in a head injury requiring medical attention, was not reported to the Department as required. No incident report was submitted, and during today's inspection, staff were unable to provide documentation verifying that the incident had been reported. LPA is issuing the following citation under California Code of Regulations (CCR), Title 22, 80061(b)(1)(E) Reporting Requirements. (See LIC809-D pages dated 1/26/26).The facility was previously cited with this regulation on 12/04/2025. LPA assessed a civil penalty for $250 due to the repeat violations. An exit interview was conducted, appeal rights were provided, and a copy of this report was provided to Administrator, Carolyn Williams whose signature on this form confirms receipt.

Deficiencies:
80061: "...a report shall be made to the licensing agency...Events reported shall include the following:.. Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.

title: (b)(1)(E) Reporting Requirements


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13On January 26, 2026, Licensing Program Analyst (LPA) Celeste Aparicio conducted an unannounced complaint inspection and met with Administrator, Carolyn Williams. LPA explained the purpose of the visit and was granted entry by staff. The purpose of the inspection was to deliver findings related to the complaint investigation. LPA Aparicio investigated the allegation that staff utilized inappropriate forms of discipline with minors. LPA reviewed facility documentation and conducted confidential interviews. The investigation determined that on two occasions, a minor was directed by staff to wear a weighted backpack as a intervention in response to negative self-statements. This intervention was not approved by the Department for use as a behavioral or disciplinary practice within the facility. The preponderance of evidence standard has been met, and therefore the above allegation is found to be Substantiated. LPA is issuing citation for California Code of Regulations, Title 22, Section 84072 (d)(19) Personal Rights. An exit interview was conducted, appeal rights provided, and a copy of this report left with the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Celeste Aparicio LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., SUITE FACILITY NAME: CENTER FOR DISCOVERY, BRENTWOOD IIFACILITY NUMBER: 075650142

met_with: Administrator, CAROLYN WILLIAMS

complaint_status: SUBSTANTIATED


narrative: Staff not giving client medication on time Staff did not pick up client's medication on time Facility conducts body checks in an inappropriate location at the home Staff are not properly providing educational services to clients Facility did not follow proper discharge procedures Facility did not have a nurse available at the home These six allegations are unsubstantiated, and no Title 22 deficiencies were observed. An exit interview was conducted, appeal rights discussed, and a copy of this report was left with Administrator, Carolyn Williams, whose signature on this form confirms receipt

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:


summary: Complaint Investigation - Substantiated - 1 deficiency - 3 allegations

raw_content:
Narrative:
At this time, one deficiency was issued, which includes a civil penalty of $250. An exit interview was conducted, appeal rights were provided and discussed, and a copy of this report was emailed to Administrator, Carolyn Williams. Whose signature confirms receipt. LPA was unable to print the report.

Investigation Findings:
13On 02/17/2026 at 10: AM, Licensing Program Analyst (LPA) Cole Oliver conducted an unannounced complaint inspection at facility. LPA Oliver met with Administrator, Carolyn Williams. The purpose of the inspection was to deliver the findings for the above complaint allegation. At the time of the visit, there were seven (7) staff members and three (3) clients present. Based on the Investigation Bureau's (IB) confidential interviews, observation and record review, the preponderance of evidence standard has been met. Therefore, the allegation- Staff did not provide adequate supervision resulting in minor inappropriately touching another minor. -is SUBSTANTIATED. This is a violation of California Code of Regulations (CCR), Title 22, Division 6, Chapter 1, Section 80078(a) - Responsibility for Providing Care and Supervision. A repeat violation citation of $250 was assessed as a result. (Refer to LIC9099-D) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Benjiman Oliver LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN JOSE RO, N. First Street, Ste. FACILITY NAME: CENTER FOR DISCOVERY, BRENTWOOD IIFACILITY NUMBER: VISIT DATE: 02/17/2026

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Estimated Days of Completion: 0

Deficiencies:
80078(a): 1
2
3
4
5
6
7

title:
Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the client's needs.
This requirement is not met as evidenced by

description:
1
2
3
4
5
6
7


summary: Facility Evaluation

raw_content:
Narrative:
On 04/09/2026 at 9: AM, Licensing Program Analyst (LPA) Cole Oliver conducted an unannounced random annual inspection at Center for Discovery Brentwood II. LPA met with Milieu Manager Luis Farias and toured the facility, both inside and out. The group home is currently licensed to serve six (6) clients; however, the facility is only serving three (3) due to management decisions. During the inspection, there were six (6) staff and three (3) clients present in the facility. The CARE Inspection Tool was used to complete this inspection. During the visit, LPA verified that all staff listed on the staff schedule have background clearances, as reflected in Guardian. At 9: AM, LPA Oliver toured the facility. LPA Oliver observed a total of six (6) beds arranged in three (3) double-occupancy bedrooms. All bedrooms had clean linens and sufficient storage space. LPA observed the facility license, personal rights, facility sketches, meal menu, and other forms posted on the walls throughout the facility. LPA Oliver tested the water temperature and found it to be 118 degrees, which is within range. The thermostat read 72 degrees Fahrenheit, which is also within range. Sharps were locked, and chemicals were safely stored in multiple locked closets and cabinets. There were two days' worth of perishable foods and seven days' worth of non-perishable foods present. Medications were stored and locked in the therapist's office in a locked medicine cart. The facility was in good repair and clean. LPA Oliver toured the backyard; there were no open bodies of water, and the backyard was in good repair and clean. (Cont. on LIC 809-C) At 10: AM, LPA Oliver interviewed five (5) staff members and three (3) clients. LPA Oliver also reviewed three (3) client files and five (5) staff files; all files were complete and in good order. The facility maintains staff records across multiple platforms, including the internal Dayforce website and the Dayforce training program. Board of Director meeting minutes were provided by Human Resources via email during the visit. As a result of this inspection, one Type B deficiency is being cited in accordance with California Code of Regulations, Title 22, Section 80061(e)(4) - Reporting Requirements. (refer to LIC 809-D) One technical assistance was provided in accordance with California Code of Regulations, Title 22, Section 80087(a) - Buildings and Grounds. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to Milieu Manager, Luis Farias, whose signature confirms receipt.

visit_type: Annual

met_with: Milieu Manager, Luis Farias


facility_name: CENTER FOR DISCOVERY, FRESNO

summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13Complaint Specialist C.K. Kinney(CS) traveled to Center for Discovery, Fresno and met with Ciara Armstead. CS conducted confidential interviews and delivered findings of investigation. Based on review of documentation and confidential interviews CS was able to find a preponderance of the evidence that the allegation occurred. This facility is being cited for violation of Title XXII Division Article Chapter 1 section 80075(b)(5)(B) Health Related Services. Copy of this report, citation, and appeal rights provided to facility at conclusion of inspection SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Charles Kinney LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, E SHAW AVE This is an official report of an unannounced visit/investigation of a complaint received in our office on 06/01/2022 and conducted by Evaluator Charles Kinney PUBLICCOMPLAINT CONTROL NUMBER: 24-CR- FACILITY NAME:CENTER FOR DISCOVERY, FRESNOFACILITY NUMBER: ADMINISTRATOR:PRISCILLA LYNCHFACILITY TYPE: ADDRESS: W BLUFF AVETELEPHONE: (559) 412- CITY:FRESNOSTATE: CAZIP CODE: CAPACITY:6CENSUS: 5DATE: 10/04/ UNANNOUNCEDTIME BEGAN: 01: PM MET WITH:Ciara ArmsteadTIME COMPLETED:03: PM 9Staff do not meet the qualifications. Staff yell at the youth. Staff say inappropriate things to the youth in care. Youth are threatened. Youth are not given privacy. INVESTIGATION FINDINGS: 13Complaint Specialist conducted investigation that included review of documentation and confidential interviews. Due to inconsistencies in the information obtained CS was not able to find a preponderance of the evidence the allegations occurred as reported so allegations are deemed unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove the alleged violations did or did not occur, therefore the allegations are deemed unsubstantiated. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Charles Kinney LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 2 of Control Number 24-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, E SHAW AVE FACILITY NAME: CENTER FOR DISCOVERY, FRESNOFACILITY NUMBER: 107207165

met_with: Ciara Armstead


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Daiquiri Boyd and Charles Kinney conducted an unannounced inspection to the facility for the purpose of conducting an Annual/Required inspection. LPAs met with Katee Wheaton Milieu Manager and Program Director Roshonda Cureton A tour of the facility was conducted. The Group Home (GH) currently has 5 clients in placement. A file review was conducted, no prior deficiencies were found within the past 12 months. LPAs asked for updated copies of LIC Designation of Administrative Responsibility, LIC Adminstrative Organization, and a copy of the new lease to be presented to Licensing by October 1, 2021. A review of Licensing Information System on September 16, 2021 indicates that all facility staff associated to the GH have DOJ, FBI, and child abuse index check clearances. No citations issued on today's visit. A copy of the report was provided to the GH at conclusion of inspection.

met_with: Katie Wheaton


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Daiquiri Boyd and Charles Kinney conducted an unannounced inspection to the facility for the purpose of conducting an Annual Continuation inspection. LPAs met with Katee Wheaton Milieu Manager and Program Director Roshonda Cureton The Group Home (GH) currently has 6 clients in placement. LPAs asked for updated copies of LIC Designation of Administrative Responsibility, LIC Adminstrative Organization, and a copy of the new lease to be presented to Licensing by email. Interviews of all clients were completed at this visit. A Technical Violation was issued at this visit for one staff due to a CPR expired date of 09/13/21. A copy of the report was provided to the GH at conclusion of inspection.

met_with: Katee Wheaton


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Corina Carrillo conducted a case management inspection 7/13/22 at 10:30am based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection,10 out of Direct Care Staff and 3 out of 3 youth files were reviewed. 4 out of Direct Care Staff and 1 out of 3 youth were interviewed. (See the Confidential Names List, LIC 811, July 13, 2022). The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings were reviewed. Based on the analysis of the confidential interviews and youth file review including the safety plans and Needs and Services Plan the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Carrillo observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Katee Wheaton.

met_with: Katee Wheaton & Ciara Armstead


summary: Facility Evaluation

raw_content:
Narrative:
On 3/1/22, Licensing Program Analyst (LPA) Lisa Slusher conducted an unannounced annual inspection. Met at the facility by Facility Manager Ciera Armstead. Additionally present are two mental health techs and a Therapist. A facility physical plant was conducted upon arrival to the facility. 1. Facility Grounds were inspected. 2. Outdoor space observed. No bodies of water observed. 3. Chemicals are generally stored in locked garage cabinets. A few cleaning chemicals were observed under kitchen counter- a technical advisory was issued on this date. 4. Locked and centrally stored medications were observed on this date 5. First aid kit complete with appropriate manual was present upon inspection. 6. Adequate storage space observed. 7. Individual beds in good repair observed. 8. The house has 4 bedrooms, single or double occupancy, all located on one single level. Bedrooms are accommodating of all required furnishings. At this time, because there are only 3 clients, each client has their own bedroom. 9. Adequate food storage space observed. 2 days of perishable foods and 7 days of non-perishable foods observed 10. Weekly menu observed 11. Dining room observed. Table and seating provided for all clients.. 12.Facility has two full restrooms, both for client use. Water temperature was within the regulatory range. 13. Licensee has a vehicle for use at the facility. insurance and registration are both current. Resident (Client) files reviewed from 1:30-2:30. 3 resident files reviewed. Files were substantially complete. The current Program Director (Administrator) has recently left employment. The facility has a plan in place for a new certified administrator. A Technical Advisory note is provided to the facility on this date to note required documents for a change of Administrator. Facility is directed to work with their assigned Analyst, Charles Kinney (Charles.Kinney@dss.ca.gov). LPA Reviewed 6 (six) personnel records with assistance from HR personnel Accessing online files. As well as reviewed fingerprint/association records for all personnel. Review conducted between 2:30 pm and 3:30 pm. LPA will return at a later time to discuss and issue report regarding personnel records. Information regarding CPI Certifications Requested.

met_with: Ciera Armstead


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On the above date, LPA (Licensing Program Analyst) continued the Annual Inspection started on 3/1/23. Met with Facility Manager Ciera Armstead upon arrival at the facility. Robert Thomas, Regional Director was present for the inspection as well. During this inspection, LPA continued the review of personnel records, and completed reports, including technical violation and Technical Advisory. On this date, Citations are noted in the following areas, pursuant to CCR, Title 22, division 6, General Licensing or Group Home Regulations: Emergency Intervention Staff Training 84365(d)(1)(C) Personnel Records (84065(d)) Health Related Services 80076(f) On this date, advisory notes are provided in the following areas: Buildings and Grounds 80087(g) Administrator Qualifications 84065(d) Criminal Record Clearance 80019(e) Safeguards for Cash Resources, Personal Property and Belongings 80026(k) Licensee is requested to update and submit the following forms: LIC 308 (Designation of Facility Responsibility), LIC 309 (Administrative Organization) by 3/16/23

Deficiencies:
84065(d): Personnel Requirements

(d) The licensee shall designate at least one facility manager to be present at the facility at all times when children are present

met_with: Ciera Armstead, Robert Thomas


facility_name: CHILDREN'S CRITICAL SUPPORT HOME

raw_content:
Narrative:
During the investigation, there was no corroborating evidence to support the above allegation. Records reviewed indicated that C1 did fall on the ground, however, due to C1 being unable to verbally communicate with LPA, it is unknown if S6 caused C1 to fall to the ground. C1 was seen by a nurse that did not observe any marks or bruises. There were no witnesses to the alleged incident. Thus, confidential interviews did not corroborate the allegation with a preponderance of evidence. Based on confidential interviews and records reviewed the allegation that S6 physically attacked C1 while in care, which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Anna Liang. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights was emailed to the Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On July 23, 2024, at 10:10 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Anna Liang, Facility Representative, to discuss the investigative finding for the allegation noted above. LPA Guadalupe Munoz conducted an inspection of the facility on November 9, 2023, at 11:00 am and no deficiencies were observed. LPA Linley was unable to interview one of one client (C1) due to C1 being unable to verbally communicate with LPA, LPA interviewed C1's Biological Mother (BM), five staff (S1-3, S5-6), and LPA was unable to interview one staff (S4), despite multiple attempts to contact them. The following documents were reviewed during the investigation: Staff Schedule, Law Enforcement Report, S6's Personnel Application, S6's Resignation Letter, General Event Reports, and Shift Notes. On November 6, 2023, Community Care Licensing (CCL) received an allegation that staff physically attacked a minor while in care. It was reported that C1 bit S1, S1 left the room, and S6 "kneed" C1 in the ribs. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley 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 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: CHILDREN'S CRITICAL SUPPORT HOMEFACILITY NUMBER: VISIT DATE: 07/23/2024

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

met_with: Anna Liang


raw_content:
Narrative:
history of self-injurious behaviors, which resulted in self-inflicted bruises and scratches. Due to C1 being unable to verbally communicate with LPA, and no documentation that notated C1 causing the specific injuries, it could not be determined how or when C1 sustained injuries while in care. Thus, confidential interviews did not corroborate the allegation with a preponderance of evidence. Based on confidential interviews and records reviewed the allegation that due to lack of supervision C1 is sustaining injuries from unknown sources while in care, which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Anna Liang. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights was emailed to the Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On July 23, 2024, at 10:30 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Anna Liang, Facility Representative, to discuss the investigative finding for the allegation noted above. LPA Babatunde Aborchie conducted an inspection of the facility on August 28, 2023, at 10:20 am and no deficiencies were observed. LPA Linley was unable to interview one of one client (C1) due to C1 being unable to verbally communicate with LPA, LPA interviewed C1's Biological Mother (BM), five staff (S1-3, S5-6), and LPA was unable to interview one staff (S4), despite multiple attempts to contact them. The following documents were reviewed during the investigation: Personnel Report, Nursing Notes, Nursing Report, Individual Program Plan (IPP), Body Check Forms "General Event Reports." On August 18, 2023, Community Care Licensing (CCL) received an allegation that due to lack of supervision youth is sustaining injuries from unknown sources while in care. Confidential interviews indicated C1 had a UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley 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 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: CHILDREN'S CRITICAL SUPPORT HOMEFACILITY NUMBER: VISIT DATE: 07/23/2024

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


summary: Facility Evaluation

raw_content:
Narrative:
On March 10, 2023 at 8: AM, Licensing Program Analyst (LPA) Babatunde Aborchie began a pre-licensing inspection for a Group Home license. Children's Critical support Homes was previously licensed and is relocating to the above address for a new license. LPA met with Leilani Whitfield, Orange county regional director who led a tour of the group home. The facility was toured both inside and out with the director. The group home will have four clients; two of the clients will reside the Mark lane and the other two clients at the Mark lane with a total capacity of four. The group home is a story building sharing the address 49- Mark lane with two bedrooms, one bath and three bedrooms, one bath respectively which is set up as follow: Mark lane · Bedroom #1 has a twin sized bed; it was vacant, it will sleep one client. · Bedroom #2 had a twin sized bed; it was vacant. It will sleep one client A living room, a kitchen, dining area, two storage, one bathroom, and the patio/backyard and a shared laundry room outside at the backyard. Mark lane · Bedroom #3 had a full sized bed; it was vacant. It will sleep one client. · Bedroom #4 had a full sized bed. It was vacant. It will sleep one client. · Bedroom #5 it was furnished with office furniture. It is currently used as an office A living room, a kitchen, dining area, storage, one bathroom, and the patio/backyard and a shared laundry room outside at the backyard. Bedrooms were arranged so that no more than two clients share a room, and there was one client per bed. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. There was adequate drawer and closet space for client's belongings. The smoke detectors and carbon monoxide detectors were checked, and they were working properly. Inside the facility there was no fireplace. Telephone service and appliances were in working order. All hazardous items have been properly made inaccessible to areas where clients will have access. Sharp knives and sharp objects were locked in a cabinet under the kitchen sink. Cleansers/chemicals were inaccessible and stored in a locked cabinet in the kitchen. There was adequate food storage space and a supply of two days of perishable foods and a week of non-perishable food. A proper storage of all food was discussed. Trash cans for storage of solid waste had tight fitting lids. The water temperature was observed to be at 107.5 degrees. First Aid kit were accessible with all required items and it was in the kitchen pantry. A Fire extinguisher was observed and properly charged. All the appropriate forms were posted in view of facility clients. As stated by the facility, there were no weapons/firearms and there were no pool or other body of water. The backyard where clients will have access to play was completely fenced and free of hazards. There are no deficiencies to be cited at this time. The request for relocation will be forwarded to Licensing Program Manager for final approval. An exit interview was conducted. A copy of this report was provided to Leilani Whitfield

visit_type: Prelicensing

met_with: Leilani Whitfield


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Joon Choi on 08/22/2023 at 09: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the visit, LPA Choi met with, Leilani Whitfied, Administrator and conducted a health and safety inspection of the facility. No immediate health or safety risks were observed. LPA reviewed 1 of child's records and 3 of staff personnel files on site at the facility. LPA reviewed 1 of child's psychotropic medications and medication records. LPA interviewed 2 of staff on site to discuss the facilities policies and procedures of operation. LPA attempted an interview of 1 of child currently prescribed psychotropic medication. (Child had severe developmental delays and could not participate in an interview competently). LPA provided a copy of this licensing report to Leilani Whitfield, Administrator. No deficiencies are being cited at this time. LPA conducted exit interview with Leilani Whitfield, Administrator and provided a copy of this report.

met_with: Leilani Whitfield, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On November 9, 2023, at 11: AM Community Care Licensing (CCL) Licensing Program Analyst(LPA), Guadalupe Munoz and Licensing Program Analyst (LPA) Jacqueline Garcia conducted an unannounced post licensing/ annual inspection. CCL were met at the facility by Administrator Nolette Untalan. The facility is a licensed group home to care for a capacity of four clients ages 13 -18 years old and currently have a census of three clients. One client resides in the Mark lane and the other two clients at the Mark lane with a total capacity of four. Licensing fee payments are current. The group home is a single story building sharing the address 49- Mark lane with two bedrooms, one bath and three bedrooms, one bath respectively which is set up as follow: Mark lane · Bedroom #1 has a full sized bed; Room is vacant. it sleeps one client. · Bedroom #2 had a full sized bed; It sleeps one client A living room, a kitchen, dining area, two storage, one bathroom, and the patio/backyard and a shared laundry room outside at the backyard. Mark lane · Bedroom #3 had a twin sized bed; It sleeps one client. · Bedroom #4 had a twin sized bed. It l sleeps one client. · Bedroom #5 it was furnished with office furniture. It is currently used as an office A living room, a kitchen, dining area, storage, one bathroom, and the patio/backyard and a shared laundry room outside at the backyard. ****** A physical plant inspection was completed using the Care Tools and included the following checks: Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children's recreation time. As stated by the facility, there were no weapons/firearms and there were no pool or other body of water. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguishers are properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and the Emergency Disaster Plan. Clients medications were observed to be inaccessible and stored in a locked cabinet. Medication records were reviewed and observed to be completed with dates and staff initials on dispensing records. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. There were dressers for each client and additional cabinet space for storage. All the client files are stored and locked in the file cabinet in the staff office. CCL reviewed a sample of three clients files during the time of inspection. Client files contained all required documents. CCL reviewed five staff files. All the staff have met the training and qualification requirements per regulations requirements. All staff met DOJ/FBI criminal record clearances and Child Abuse Index Check requirements. Two facility staff were interviewed during the inspection. No clients were interviewed due to being nonverbal and not able to participate in an interview. No deficiencies were found. An exit interview was conducted. A copy of this report was provided to facility administrator, Nolette Untalan.

met_with: Nolette Untalan


summary: Facility Evaluation

raw_content:
Narrative:
On September 4, 2024 at 10: AM Community Care Licensing (CCL) Licensing Program Analyst(LPA), Guadalupe Munoz conducted an unannounced required annual inspection. LPA was met at the facility by Administrator Nolette Untalan. The facility is a licensed group home with the capacity of four clients ages 0 -17 years old and currently has a current census of four clients. The group home is a single story building sharing the address 49- Mark lane which is set up as follow: Mark lane · Bedroom #1 has a full sized bed; It sleeps one client. · Bedroom #2 had a full sized bed; It sleeps one client A living room, a kitchen, dining area, two storage, one bathroom, and the patio/backyard and a shared laundry room outside at the backyard. Mark lane · Bedroom #3 had a twin sized bed; It sleeps one client. · Bedroom #4 had a twin sized bed. It sleeps one client. · Bedroom #5 it was furnished with office furniture. It is currently used as an office A living room, a kitchen, dining area, storage, one bathroom, and the patio/backyard and a shared laundry room outside at the backyard. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. There were dressers for each client and additional cabinet space for storage. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. Both kitchens had functioning appliances and secured cabinets for knives and cleaning supplies. A physical plant inspection was completed using the Care Tools and included the following checks: Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children's recreation time. As stated by the facility, there are no weapons/firearms and there were no pool or other body of water. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguishers are properly charged and serviced. Water temperature was within required range of 105-120 degrees and tested at 107.4 degrees. Clients medications were observed to be inaccessible and stored in a locked cabinet. Medication records were reviewed and observed to be completed with dates and staff initials on dispensing records. All the client files are stored and locked in the file cabinet in the staff office. CCL reviewed four clients files during the time of inspection. Client files contained all required documents. Two facility staff were interviewed during the inspection. No clients were interviewed because they were at school. Facility reports that all clients due are nonverbal and not able to participate in an interview CCL reviewed six staff files. LPA observed deficiencies in staff files, All staff have not met DOJ/FBI criminal record clearances and Child Abuse Index Check requirements. Facility is being cited for Type A deficiency for not meeting Title Continuing Care Requirements Section 1522(c)(1) Health and Safety Code. An exit interview was conducted. A copy of this report, LIC 811 dated 9/4/24, and Appeal Rights were provided to facility administrator, Nolette Untalan.


summary: Facility Evaluation

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Narrative:
An unannounced Psychotropic Medication Inspection was conducted on November 6,2024 at 10: AM by Licensing Program Analysts (LPA's) Guadalupe Munoz and Rachel Venegas This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the visit, LPA's met with Administrator Nolette Untalan.and conducted a health and safety inspection of the facility. No immediate health or safety risks were observed. LPA reviewed 1 of child's records and 3 of staff personnel files on site at the facility. LPA reviewed 1 of child's psychotropic medications and medication records. LPA interviewed 2 of staff on site to discuss the facilities policies and procedures of operation. LPAa unable to complete interview of 1 of child currently prescribed psychotropic medical. (Child had severe developmental delays and could not participate in an interview competently). No deficiencies are being cited at this time. A Technical Advisory was provided. LPAs conducted exit interview with facility Administrator. LPA provided a copy of this licensing report, LIC 811 dated 11/06/24 and Technical Advisory to facility Administrator.


summary: Facility Evaluation

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Narrative:
On 03/26/2025 at 2: PM, Licensing Program Analyst (LPA) Gilbert Marquez attempted to conducted an unannounced annual visit to the facility listed above. LPA met with Nolette Untalan, Administrator. Due to technical difficulties, the Annual was unable to be conducted. LPA provided a copy of this report by email to Administrator Untalan due to printer malfunction.


summary: Facility Evaluation

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Narrative:
On 04/30/25 at 9: AM Licensing Program Analyst(LPA), Gilbert Marquez conducted an unannounced annual inspection. LPA was met at the facility by Veronica R, House Lead and Administrator Nolette Untalan. The facility is a licensed group home with the capacity of four clients ages 0 -17 years old and currently has a current census of four clients. The group home is a single-story building sharing the address 49- Mark Lane which is set up as follows: Mark Lane has two bedrooms (#1 and #2), there is only one client per bedroom. One bedroom has a queen bed, and the other has a twin bed, and storage space. There is a living room, a kitchen, dining area, two storages, one bathroom, a patio/backyard and a shared laundry room located in the backyard. Mark Lane has two bedrooms (#3 and #4), there is only one client per room and each room has a queen bed and storage room. There is an employee office, a living room, a kitchen, dining area, storage, one bathroom, and the patio/backyard with the shared laundry. Physical Plant inspect was completed with Veronica(S2). All required forms are posted including Grievance Procedures, Visitation Policies, Personal Rights form, and the Emergency Disaster Plan. Clients' medications were observed to be inaccessible and stored in locked cabinets. Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguishers are properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. LPA observed a minimum seven-day non-perishable and two-day perishable supply of food. **Continued on LIC809-C** Individual beds were observed with clean linens, pillows, comforters, and mattress in good repair. The water temperature was tested in bathroom one which measured 110.3F degrees Fahrenheit which is within the appropriate range of 105 degrees to 120 degrees Fahrenheit. The first aid kit was observed to have all required supplies. All client files are stored and maintained on a secure internet database. LPA reviewed four of four client files to ensure clients had all required documents per Title 22. LPA reviewed four client medication records. LPA reviewed five staff files out of 16 to ensure staff had all required documents per Title 22 regulations. Staff records are stored via a secured records portal. Per a review of Guardian, all staff have a criminal record clearance. LPA conducted three staff interviews (S1 - S3). Client interviews were not conducted as they have limited speech. Per facility staff, no firearms or weapons are allowed in the facility. Per Title 22, Division 6, Chapter 1, Article Limitations on Capacity and Ambulatory Status 80010(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation. This requirement is not met as evidenced by: Based on observation, interview, and client file review, one of four clients (C1) was 18 years of age. The current license for this facility only allows for children from 0 - 17 years of age. Therefore, a Type B violation is being given for C1 being placed beyond the license limitations. An exit interview was conducted, a plan of correction was created, appeal rights were discussed, and a copy of this report, plan of correction, confidential names list, and appeal rights were provided to Nolette Untalan. A copy of this report will be placed in the facility file.

met_with: Nolette Untalan, Administrator


summary: Facility Evaluation

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Narrative:
On March 23, 2026, at 9: AM Licensing Program Analyst (LPA) Gilbert Marquez conducted an unannounced annual inspection. LPA was met at the facility by House Lead Veronica Ruiz and Regional Manager Anna Liang. The facility is a licensed group home with the capacity of four clients ages 0 -17 years old. The group home consists of two single-story buildings sharing the address 49- Mark Lane which is set up as follows: Mark Lane has the following: Bedroom #1 - sleeps one client, has a queen bed, and drawer space Bedroom #2 - sleeps one client, has a twin bed, and drawer space Bathroom #1 - has a sink, toilet, and accessible shower There is a living room, a kitchen, dining area, two storage areas, a patio/backyard and a shared laundry room located in the backyard. Mark Lane has the following: Bedroom #3- sleeps one client, has a queen bed, and drawer space Bedroom #4 - sleeps one client, has a queen bed, and closet space outside the bedroom Bathroom#2 - has a sink, toilet, and accessible shower There is an employee office, a living room, a kitchen, dining area, storage room, and the patio/backyard with a shared laundry room. **Continued on LIC809C** **Continued from LIC809** Individual beds were observed with all the required linens, pillows, comforters, and mattress were in good repair. The water temperature was tested in bathroom #1 which measured 108.3 degrees Fahrenheit, and bathroom #2 which measured at 110 degrees Fahrenheit which is within the appropriate range of 105 degrees to 120 degrees Fahrenheit. The first aid kit was observed to have all required supplies and was located at Mark Lane dining room area. Knives are stored in locked kitchen cabinets and are inaccessible to clients. Medications are stored in locked kitchen cabinets and are inaccessible to clients. All required forms are posted including Grievance Procedures, Visitation Policies, Personal Rights, and the Emergency Disaster Plan. Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguishers are properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. LPA observed a minimum seven-day non-perishable and two-day perishable supply of food. All client files are stored and maintained on a secure internet database. LPA reviewed four of four client files (C1 - C4, see Confidential Names List LIC811) to ensure clients had all required documents per Title 22. LPA observed files had education records, physical examinations, Individual Person Plans, and psychiatric health notes. LPA reviewed four client medication records. All staff records are stored via a secured records portal. LPA reviewed five staff files (S1 - S5) to ensure staff had all required documents per Title 22 regulations. LPA observed files had a criminal record clearance or exemption, health screening and tb test, driver's license, personnel record LIC501 or job application, and all required training. LPA conducted three staff interviews (S1, S2, S6). LPA met and observed two clients (C1, C3) who were unable to communicate with LPA. Per facility staff, no firearms or weapons are allowed in the facility. An exit interview was conducted, and a copy of this report, confidential names list, and appeal rights were provided to Regional Manager Anne Liang. A copy of this report will be placed in the facility file.

met_with: Anna Liang, Regional Manager


facility_name: CHILDREN'S CRITICAL SUPPORT HOMES

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Narrative:
In regard to the complaint, it was specifically stated that "client came to school with a large bruise, about a size of a fist, under C1's left eye". During the investigation, a confidential interview denied C1 was hit causing bruising while in care. Confidential interview disclosed that C1 had self-injurious behaviors and known to make false statements. Another confidential interview denied hitting C1 and causing bruising in care. Another Confidential interview disclosed that C1 robbed C1's hand on C1's face until it was red. Confidential interview could not remember being hit in the face. Confidential interview added that the home was safe for C1. LPA received conflicting information regarding the allegation. Based on confidential interviews, the Department determined there was not sufficient information to determine that C1 was hit while in care, causing bruising. Although the allegation may have happened or may be valid, there was not a preponderance of evidence to support or deny the allegation, therefore, this allegation is unsubstantiated at this time. A copy of the report was discussed and provided along with LIC 811 to Children's Critical Support Homes' Facility Administrator.

Investigation Findings:
13On March 27, Licensing Program Analyst (LPA) Babatunde Aborchie arrived at Children's Critical Support Homes to deliver investigative findings for the above allegation involving the group home (GH) and clients listed in the Confidential Names List (LIC 811) dated 03/27/2023. LPA met with of the facility Administrator (FA) On September 1, 2022, Licensing Program Analyst (LPA) Babatunde Aborchie arrived at the GH to initiate investigation and met with facility Administrator (FA) Alvin Mallillin. LPA interviewed (FA) and staff 1 (S1). On March 8, LPA interviewed, client 1 (C1). LPA was unable to interview County Social Worker (CSW). On August 23, 2022, a complaint report was referred to Community Care Licensing (CCL) alleging resident was hit while in care, causing bruising. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Babatunde Aborchie 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 22-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, THE CITY DR., SUITE FACILITY NAME: CHILDREN'S CRITICAL SUPPORT HOMESFACILITY NUMBER: VISIT DATE: 03/27/2023


summary: Facility Evaluation

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Narrative:
On September 29, 2022 at 9: AM Licensing Program Analysts (LPA) Anne Visaya arrived at the facility to conduct an unannounced annual/required inspection. Lpa a. Visaya disclosed the purpose of the visit and met with Administrator Alvin Mallillin was granted access to the facility. The home is consist of 2 single story home, home # 48 and home # Upon entry to the facility, a living room with a locked closet that contains activities for the children, dining area with dining table and 4 chairs, a computer in a computer cart, and a small cabinet with counter top, and a kitchen area. Bedrooms are arranged so that no more than two children share a room and there is one child per bed. No room commonly used for other purposes. Used as a bedroom, and no bedroom serves as a passageway to another room. There is adequate shelf and closet space. Home # Bedroom #1, furnished with 1 full size bed, a closet and plenty storage and sleeps a 19 year old male client. Bedroom #2, furnished with 1 full size bed, a closet and plenty of storage space and sleeps a 17 year old male client. Bedroom #3, serves as office for the administrator and files are locked in this office. Bathroom number one hot water temperature measured to be 110.6 degrees Fahrenheit, Home # Bedroom #1, furnished with 1 full size bed, a closet and plenty of storage and sleeps a 19 year old male client Bedroom #2, furnished with 1 twin size bed, a closet and plenty of storage and sleeps a 16 year old male client Bedroom #3, is empty at this time and serves as storage. Bathroom number one hot water temperature measured to be 109.6 degrees Fahrenheit, Continue.... The Facility has a sufficient food supply which includes a sufficient supply of fresh fruits, vegetables, can goods, meat and staples. The smoke detectors and carbon monoxide detectors were checked and are working properly. All hazardous items have been properly made inaccessible to areas where children will have access. Medications are locked. Sharp knives, cleansers/chemicals are locked and stored in the bedroom hallway area. The first aid kit contains all required items. Telephone service and appliances are all in working order. There are no guns or weapons as stated by the administrator. The backyard where children will have access to play is completely fenced and free of hazards. There is no pool or other body of water. A review of the homes operation show that the facility is licensed to serve four developmentally disabled clients. Current census of clients in care is four at this time. The License, facility sketch, emergency disaster plan, personal rights poster, activity schedule, meal menu are posted at this time. A review of five of eleven staff records indicates that all facility staff have received criminal record and child abuse index check clearances and CPR and first aid is up to date except for the administrator expired on 03/06/2022. Administrator confirmed and will immediately undergo training and will provide the department of proof of correction. 80075 (f) (f) Staff is responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. A review of four of tour clients files are noted to have documents required per regulations in file. Children's records contained all medical history, immunization records, medical consent forms signed by their authorized representative and children's signed needs and services plans are up to date. LPA observed and reviewed medication records, a separate log for pyschotropic medications were not implemented. 84070(b)(13) (13) A separate log for each psychotropic medication prescribed to the child documenting all the following: A separate log for each psychotropic medication prescribed to the children.... LPA provided the correct LIC 622B to the administrator, stated that he was not aware of the form. Licensee updated the medication record to reflect the correct form (LIC 622B for Psychotropic Medication). Based on the facility inspection and file reviews this date, there is a deficiency found at this time. A copy of this report was reviewed and given to facility Administrator Alvin Mallillin. Exit interview conducted and a copy of this report and confidential names List (LIC 811) were given and explained to the administrator.

met_with: Alvin Mallillin


facility_name: CICADA-ALMOND

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Narrative:
LPA advised that the facility continue to carefully document all marks observed on R1's body, including any incident that could have caused marks, and to submit incident reports for all unusual incidents, especially if they cause an injury or bruising to R1. Although the allegation may have happened or is valid, based on LPA's observations and interviews with residents and staff, there is not a preponderance of the evidence to prove the alleged violation did or did not occur. Therefore, the allegation is Unsubstantiated. There are no citations. An exit interview was conducted with Facility Manager Patti Ioni, whose signature on this from confirms receipt.

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

met_with: Facility Manager Patti Ioni


raw_content:
Narrative:
LPA advised that the facility continue to carefully document all marks observed on R1's body, including any incident that could have caused marks, and to submit incident reports for all unusual incidents, especially if they cause an injury or bruising to a resident. Although the allegation may have happened or is valid, based on LPA's observations and interviews with residents and staff, there is not a preponderance of the evidence to prove the alleged violation did or did not occur. Therefore, the allegation is Unsubstantiated. There are no citations. An exit interview was conducted with Facility Manager Patti Ioni, whose signature on this from confirms receipt.

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


raw_content:
Investigation Findings:
13On 6/23/23 at 1: PM, Licensing Program Analyst (LPA) Alyssa Ng conducted a complaint inspection at Cicada- Almond and spoke with Patti Inouye, Administrator. The purpose of the inspection was to deliver the findings for the above complaint allegations. Part of this complaint was taken as an assignment by Community Care Licensing (CCL's) Investigations Branch (IB) on 03/08/2023. Two out of four allegations were upgraded to a full investigation on 03/08/2023 and assigned to Inv. Jorge Martinez. During investigation, interviews were conducted, photos obtained, and incident reports were reviewed, and it was determined that minor sustained multiple injuries while in care and staff does not ensure that minor is dressed in clean clothing. The preponderance of evidence standard has been met, therefore the above allegations, Minor sustained multiple injuries while in care and Staff does not ensure that minor is dressed in clean clothing, 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 80072(a)(2) Personal Rights. Please refer to attached 9099D. At this time, two deficiencies were cited, an exit interview was conducted, and a copy of this report was given to Patti Inouye, Administrator. 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: CICADA-ALMONDFACILITY NUMBER: 075600628

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: Patti Inouye


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

met_with: Facility Manager Patti Inouye


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On Friday 7/9/21 at 10:57AM, Licensing Program Analyst (LPA) Mariah Hawkins met with Co-Administrator / Facility Manager Patti Ioni for a required annual inspection. COVID-19 safety precautions were taken, including wearing masks, hand sanitizer, and pre-visit screening call. During inspection, LPA toured the facility site and grounds. There were no obstructions, hazards, or bodies of water on the grounds. Co-Administrator stated that there were no firearms on the premises, and LPA did not observe any. Room temperature was kept at a comfortable temperature within the permitted range. The kitchen was stocked with utensils and dishware to meet the needs to residents. Food storage was sanitary and organized, and the pantry was stocked with food to meet the 7-day nonperishable, 2-day perishable mandate. Medications were locked away and separated by resident. Sharps and knives were stored in a locked kitchen drawer, and chemicals were stored in locked cabinets in the locked laundry room. There is one male resident who has their own bedroom. Bedrooms were tidy, and linens were clean. All residents have their own bed and ample drawer space. Hygiene products are provided for the residents. During visit, LPA observed that staff engage with the residents and maintain appropriate staff-client ratios. LPA interviewed all present staff (3) and no residents, as residents were nonverbal and/or absent. The following issues were observed: The water temperature at the resident bathroom sink reached only to 100. F, which is below the minimum temperature allowed, F. An advisory was issued, per California Code of Regulations (CCR), Title 22, Section 80088. Foster youth rights were not posted in the facility. An advisory was issued, per CCR, Title 22, Section 84072. The resident roster was not up to date. An advisory was issued, per CCR, Title 22, Section 80071. Complaint procedures were not posted in the facility in a location visible to residents and authorized representatives. An advisory was issued, per CCR, Title 22, Section 84072.2. The following issues were observed (continued): Documentation of compatibility of residents sharing a room was not kept in the client files. An advisory was issued, per CCR, Title 22, Section 84087. The facility has not been submitting incident reports for every injury or manual restraint. An advisory was issued, per CCR, Title 22, Section 84061. The facility has not been logging instances of manual restraints in monthly logs. A citation was issued, per CCR, Title 22, Section 84361. An exit interview was conducted, appeal rights provided, and a copy of this report left with Co-Administrator / Facility Manager Patti Ioni, whose signature on this form confirms receipt.

Deficiencies:
84361(f): Documentation and Reporting Requirements

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

met_with: Co-Administrator Patti Ioni


summary: Facility Evaluation

raw_content:
Narrative:
On Thursday 07/07/2022 at 10:30AM, Licensing Program Analyst (LPA) Lisette Valenzuela made an unannounced visit to the facility to conduct a required annual inspection. LPA Valenzuela met with met with Co-Administrator/Facility Manager Patti Inouye and informed of the purpose of the visit. The facility is licensed to have a capacity of 6, and currently has 6 youth in placement. During inspection, LPA Valenzuela toured the facility site and grounds. There were no obstructions, hazards, or bodies of water on the grounds inside the house or in the backyard. LPA Valenzuela observed, the license, Emergency Disaster Plan, Weekly Menus, Personnel Report, and Group Planned Activities and appropriate posters were posted in an accessible location. LPA Valenzuela checked both the room temperature and the water temperature and observed it was kept at a comfortable temperature within the permitted range. The kitchen was stocked the adequate essentials to meet the residents needs. Sharps and knives were stored in a locked kitchen drawer, and chemicals were stored in locked cabinets in the locked laundry room. Food storage was sanitary and organized, and the pantry was stocked with food to meet the 7-day nonperishable, 2-day perishable mandate. Medications were locked away and separated by resident. Bedrooms were clean,linens were clean, and each resident has their own bed and closet/drawer space. In the resident bathroom, hygiene products are provided and separated by resident name for the residents. During visit, LPA Valenzuela observed that staff interact with the residents and maintain appropriate staff-client ratios. LPA Valenzuela interviewed one staff member (1) and no residents, as residents were in summer school. LPA Valenzuela reviewed 6 resident files and 6 staff files. All files were complete and contained all the correct documentation for both resident and staff files. At this time, per Title Regulations, no deficiencies were cited during this inspection. An exit interview was conducted, and a copy of this report was emailed to Co-Administrator/ Facility Manager Patti Inouye, whose signature on this form confirms receipt.

met_with: Co-Administrator Patti Inouye