summary: Facility Evaluation

raw_content:
Narrative:
On April 16, 2025, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Courage to Change located in Exeter, CA to conduct an unannounced complaint inspection and Program Director Gary Bonds and Lead Intake Coordinator/Case Manager Alex Gonzales. The purpose of the inspection was to clear a Plan of Correction (POC). LPA reviewed documentation to confirm that the POC was cleared. No deficiencies were issued or observed at this time. An exit interview was conducted, a copy of this report and the Letter of Deficiency citations cleared were provided to Gary Bonds at the conclusion of the inspection.


state: CA

facility_name: COURAGE TO CHANGE

summary: Facility Evaluation

raw_content:
Narrative:
On May 7, 2025, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Courage to Change located in Exeter, CA and met with Facility Representative Alex Gonzales. The purpose of this unannounced inspection was to conduct Case Management regarding an the program "write up" Incident report System. LPA conducted confidential interviews regarding the policy regarding clients "write-up" Incident report policy. LPA reviewed the client policy handbook. No deficiencies observed or citations on today's inspection. A copy of this report was provided to the Alex Gonzales at the conclusion of the inspection.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Alex Gonzales


summary: Facility Evaluation

raw_content:
Narrative:
On June 19, 2025, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Courage to Change located in Exeter, CA to conduct an unannounced complaint inspection and Program Director Gary Bonds and Lead Intake Coordinator/Case Manager Alex Gonzales. The purpose of the inspection was to clear a Plan of Correction (POC). LPA reviewed documentation to confirm that the POC was cleared. No deficiencies were issued or observed at this time. An exit interview was conducted, a copy of this report and the Letter of Deficiency citations cleared were provided to Gary Bonds at the conclusion of the inspection.

met_with: Gary Bonds and Alex Gonzales


summary: Facility Evaluation

raw_content:
Narrative:
On October 18, 2022, Licensing Program Analyst (LPA) Vanessa Galvan conducted a Case Management inspection at the Courage to Change in Exeter, CA and met with Administrator Susan Gambini and Program Director Gary Bonds. The purpose of the visit was to discuss an incident that occurred at the facility. LPA conducted confidential interviews. The confidential interviews disclosed that client 1 did have access to staff 1's magazine clip containing ammunition. It was determined through confidential interviews no firearm was accessible to client 1. (see 812 for details) Based on LPA's observation and confidential interviews, California Code of Regulations is being cited on the attached 809D. An exit interview was conducted, a copy of this report and appeal rights were provided to Gary Bonds and Susan Gambini at the conclusion of the inspection.

met_with: Susan Gambini & Gary Bonds


summary: Facility Evaluation

raw_content:
Narrative:
On February 9, 2023, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Courage to Change in Exeter, CA, and met with Program Director Gary Bonds. The purpose of this unannounced inspection is to conduct a Case Management regarding late incident reports that the facility submitted to Community Care Licensing. On January 26, 2023, the facility submitted an incident report for an incident that occurred on 12/26/2022. Based on the LPA's investigation and observation, it was determined that the facility has failed to submit an Incident Reports within the seven days the incident occurred. The facility is being cited for violation of the California Code of Regulations, Title 22, Division 6, regulation 80061(b) Reporting Requirements. An exit interview was conducted to discuss this report and appeal rights. A copy of this report and appeal rights were provided to Gary Bonds at the conclusion of the inspection.

met_with: Gary Bonds


summary: Facility Evaluation

raw_content:
Narrative:
On June 23, 2023, Licensing Program Analyst (LPA) Vanessa Galvan traveled to the Courage to Change (CTC) Short-Term Residential Therapeutic Program in Exeter, CA, to conduct a Case Management and met with Program Director Gary Bonds. The purpose of the inspection is to discuss an incident report that was submitted to the department on 6/15/2023 regarding client 1 (C1) being administered incorrect medication by Staff 1. (See attached LIC 811) LPA Galvan reviewed medication files, medical incident reports, and staff file. LPA spoke to CTC's Program Direct regarding the concerns of staff administering C1 incorrect medication, the importance of staff verifying and confirming the correct medication is being administered and maintaining medication quality assurance. LPA spoke to facility representative (FR) Abagail Zavala, FR stated S1 is contracted Licensed Vocational Nurse to oversee medication and medical well being of all clients at CTC. S1 admitted to giving the incorrect medication to S1. S1 was given S1's evening medication dosage in the morning and missed a medication dosage. S1 caught the error while conducting a pill count and notified management of the error. S1 was directed on making sure to review and verify that the correct medication is being administered to clients. The medical case manager has been providing additional medication oversight to prevent medication error. Based on interviews and record review, the Agency is being cited for the Short-Term Residential Therapeutic Program Interim Licensing Standards, Chapter 7.5, Version 4, Section 87075(c) Health-Related Services. An exit interview was conducted to discuss this report and appeal rights. A copy of this report and appeal rights were provided to Gary Bonds at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On August 28, 2023, Licensing Program Analyst (LPA) Vanessa Galvan traveled to Courage to Change Short-Term Residential Therapeutic Program located in Exeter, CA, and met with Gary Bonds, Assistant Program Director, and Susan Gambini, Administrator. The purpose of this unannounced inspection is to conduct a Case Management regarding a late incident report that the facility submitted to Community Care Licensing. On August 14, 2023, the facility submitted an incident report for an incident that occurred on July 22, 2023. Based on document review and interviews, it was determined that the facility has failed to submit an Incident Report within the seven days the incident occurred. The incident report disclosed that there was a incident between staff and a youth in care; youth 1 (Y1) (See attached LIC 811) became hostile and cursed staff in which lead to staff cursing at the youth. Staff did admit to cursing at Y1. Based on interviews it was determined that staff did violate Y1's personal rights. The facility is being cited for violation of the California Code of Regulations, Title 22, Division 6, regulation 80061(b) Reporting Requirements and The Interim Licensing Standard (ILS) Section 87072(c)(11) Personal Rights. The facility was cited on 2/09/2023 for California Code of Regulations, Title 22, Division 6, regulation 80061(b) Reporting Requirements. Due to a repeated violation within a 12-month period, a civil penalty is being assessed. An exit interview was conducted to discuss this report, the civil penalty, and appeal rights. A copy of this report, the civil penalty, and appeal rights were provided to Gary Bonds, at the conclusion of the inspection.

met_with: Gary Bonds & Susan Gambini


facility_name: CREEKSIDE STRTP

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
more. Confidential interviews stated FC1 has never gone a long period of time without eating or drinking. Confidential interviews stated staff provides breakfast, lunch, dinner and snack. Confidential interviews stated C1 has access to unlimited food and drinks. Confidential interviews stated C1 went to the doctor due to concerns regarding C1's eating habits. LPA received conflicting information regarding the allegations. Based on confidential interviews, although the allegations stated that staff did not ensure that C1 is eating meals and staff did not ensure that C1 is drinking fluids while in care may have occurred, they are not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report was reviewed and provided to facility representative.

Investigation Findings:
13On April 7, 2022, at 12: PM Licensing Program Analyst (LPA) Shanae Pharaoh conducted and unannounced inspection to Creekside Short Term Residential Treatment Program (STRTP) and met with Program Supervisor, Yonique Bonner to deliver the findings for the allegations stated above. During the investigation, LPA interviewed two of five clients and one staff. On 3/16/2022, a safety inspection was conducted and there were no hazards or deficiencies observed. In addition, client records were reviewed on 4/4/2022. On March 7, 2022, Community Care Licensing (CCL) received allegations alleging staff did not ensure that minor is eating meals and staff did not ensure that minor is drinking fluids. It was specifically alleged that client #1 (C1) was dehydrated and had not eaten for two weeks. Confidential interviews stated C1 had a history of not eating enough food and vomiting. A confidential interview stated staff did not observe C1 not eating for two weeks, but staff did notice C1's lack of energy and explained that C1 needed to eat UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Shanae K Pharaoh 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 19-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, MAIN ST., SUITE FACILITY NAME: CREEKSIDE STRTPFACILITY NUMBER: VISIT DATE: 04/07/2022

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

report_type: Complaint Investigation

met_with: Program Supervisor, Yonique Bonner

complaint_status: unsubstantiated


raw_content:
Narrative:
evidence of an approval for C1 to get tongue pierced. Confidential interviews reported C1 returned to the facility and showed Licensee C1's tongue. Licensee reported S5 was written up for this incident and other issues in preforming S5's position. Record review revealed S5 was written up on December 25, 2021 and placed as "on call" position with facility. Based on confidential interviews and record review the allegation staff member (Staff #5 [S5]) arranged for minor (Child #1 [C1]) to have their tongue pierced is substantiated. The preponderance of evidence standard has been met. Facility is cited for violation of Interim Licensing Standards (ILS) standard 87065.2(b)(8) Personal Duties (b)Direct care staff shall perform the following duties: (8) Any other duties that may be necessary to ensure the health and safety of children in the facility. A copy of the report was discussed and provided along with appeal rights to Creekside Short Term Residential Therapeutic Program (STRTP) Administrator,Daryl Monteilh. Based on record review and confidential interviews the allegations staff member (Staff #2 [S2]) is buying marijuana for minors in care, Staff member (S2) is buying inappropriate items for minors (Child #1 [C1] and Child #2 [C2]) in care, Staff member (S2) allows minors (C1 and C2) to have inappropriate sleeping arrangements, Staff (S2) allows minors (C1 and C2) to sleep at other locations, Staff member (licensee) made inappropriate comment to minors (unknown) and staff member (licensee) dropped minors (unknown) off at undisclosed locations may or may not have occurred, however they are not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of the report was provided along with appeal rights to Creekside Short Term Residential Therapeutic Program (STRTP) Administrator, Daryl Monteilh. Two additional allegations were received by CCL alleging Staff member (Staff #2 [S2]) is buying inappropriate items for minors (Child #1 [C1] and Child #2 [C2]) in care and Staff member (S2) allows minors (C1 and C2) to have inappropriate sleeping arrangements. Specifically, it was reported S2 bought C1 and C2 a tent and allowed C1 and C2 to use the tent to sleep with unknown individuals. Confidential interviews provided conflicting statements as to how C1 obtained the tent. Confidential interviews reported C1 returned from a family visit with a tent while other confidential interviews reported not knowing how C1 obtained the tent. Confidential interviews also provided conflicting statements of how and when C1 and C2 utilized the tent. Confidential interviews and record review reported C1 and C2 left the facility with the tent to meet with unknown individuals. Record review was unable to confirm or dispute confidential statements of C1 and C2 being AWOL at the time the tent was being used. CCL received an additional allegation alleging Staff (Staff #2 [S2]) allows minors (Child #1 [C1] and Child #2 [C2]) to sleep at other locations. Specifically it was reported C1 and C2 were at a motel with unknown individuals. Confidential interviews provided conflicting reports as to C1 and C2 being AWOL from the facility at the time they were at the motel. Record review of the facility's communication log notes that C1 and C2 returned to the facility on January 25, 2022 stating that their friends had gotten a room and they were leaving. Record review revealed staff reported they discussed leaving the facility with C1 and C2 however, facility records were unable to confirm C1 and C2 were considered AWOL at the time of their motel stay. Two additional allegations were made to CCL, alleging Staff member (licensee) made inappropriate comment to minors (unknown) and staff member (licensee) dropped minors (unknown) off at undisclosed locations. Specifically it was reported when licensee would become angry with the resident's licensee would tell residents to pack up their belongings. It was also reported licensee would take residents (unknown) and drop them off somewhere (unknown). Confidential interviews provided conflicting reports of licensee getting angry and telling residents to pack their stuff. Confidential interviews reported licensee uses a loud stern voice when speaking to residents which may seem threatening and/or inappropriate to some individuals. Confidential interviews reported the only transportation that is done by the facility is to drop off residents for approved family visits or court order appointments. Confidential interviews reported it is possible that licensee made the statement to pack a resident's stuff when licensee was preparing to take a resident for an approved visit or appointment. Other confidential interviews could not confirm or dispute that they had ever heard or seen licensee tell residents to pack their stuff and/or drop residents off at undisclosed locations. ******

Investigation Findings:
13On July 20, 2022 at 9:54 am Licensing Program Analyst (LPA), Nicole Strickland, met with Creekside Short Term Residential Therapeutic Program (STRTP) Administrator, Daryl Monteilh to deliver the finding for the above stated allegation. The investigation was conducted by Special Investigator (SI) Georgina Tallagua and LPA Strickland and included interviews with six foster youth (Child #1 [C1], Child #2 [C2], Child #3 [C3], Child #4 [C4], Child #5 [C5], and Child #6 [C6]) five staff members (Staff #1 [S1], Staff #2 [S2], Staff #3 [S3], Staff #4 [S4], and Staff #5 [S5]), four County Social Workers (CSW1, CSW2, CSW3, and CSW4) and licensee. In addition, county records and facility records were reviewed. On January 27, 2022, Community Care Licensing received an allegation alleging staff member (Staff #5 [S5]) arranged for minor (Child #1 [C1]) to have their tongue pierced. Confidential interviews reported Staff #5 (S5) took Child #1 (C1) to get C1's tongue pierced. Confidential interviews reported C1 had told S5 it was approved and therefore S5 arranged for C1 to have it done. Record review was unable to provide SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Nicole Strickland 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 19-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, MAIN ST., SUITE FACILITY NAME: CREEKSIDE STRTPFACILITY NUMBER: 367900029

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: Daryl Monteilh


raw_content:
Narrative:
and C6 began verbally threating to "jump" C5, resulting in C5 barricading self in C5's room by placing a dresser against the door. Confidential interviews reported staff attempted to de-escalate C2 and C6. Confidential interviews reported C2 and C6 continued to threaten C5 and attempted to push their way into C5's room causing the dresser to fall alerting staff to C2 and C6's continued attempts to assault C5. Confidential interviews reported when staff, C2 and C6 entered C5's room they found the window open leading all to believe C5 had AWOL'd. Confidential interviews reported C5 was heard later screaming from the shed/barn located on the property where C5 had been hiding. Confidential interviews and record review revealed C2 and C6 had located C5 in the facility's shed/barn and began to kick, punch, and bang C5's head on a propane tank. Confidential interviews reported 9-1-1 was called and C5 was transported to the hospital where C5 was treated for lacerations to the head, abrasions, contusion, bloody nose and rug burns. Record review revealed C2 and C6 were arrested for violation of Penal Code 243(D) - Battery with Serious Bodily Injury-Hands; Fist: Feet. Based on confidential interviews and record review the allegation of resident (Child #5 [C5]) was assaulted by other residents (Child #2 [C2] and Child #6 [C6]) resulting in injuries is substantiated. The preponderance of evidence standard has been met. Facility is cited for violation of Interim Licensing Standards (ILS) standard 87072(c) Personal Rights (c) The licensee shall ensure that each child, regardless of whether the child is in foster care, is accorded the personal rights specified in Welfare and Institutions Code Section 16001.9 as applicable. In addition, the licensee shall ensure that each child is accorded the following personal rights. The facilities violation of ILS 87072(c) which resulted in injury to C5 requires the facility to be assessed an immediate civil penalty per Health and Safety Code 1548(c)(1). An Enhanced Civil Penalty (ECP) determination is pending. If an ECP is assessed a Community Care Licensing (CCL) representative will return to the facility to deliver the penalty assessment. A copy of the report was discussed and provided along with Civil Penalty assessment and appeal rights to Creekside Short Term Residential Therapeutic Program (STRTP) Administrator,Daryl Monteilh. Confidential interviews were unable to confirm or dispute licensee's loud, stern tone when speaking to residents is used in a threatening manner. Confidential interviews were unable to confirm, or dispute licensee was speaking to C5 in a threatening manner when licensee told C5 "you're going to be okay." Based on record review and confidential interviews the allegation of staff (unknown) spoke to resident in an inappropriate way, may or may not 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, and a copy of the report was provided along with appeal rights to Creekside Short Term Residential Therapeutic Program (STRTP) Administrator, Daryl Monteilh

Investigation Findings:
13On July 20, 2022 at 11:50 am Licensing Program Analyst (LPA), Nicole Strickland, met with Creekside Short Term Residential Therapeutic Program (STRTP) Administrator, Daryl Monteilh to deliver the finding for the above stated allegation. The investigation was conducted by Special Investigator (SI) Georgina Tallagua and LPA Strickland and included interviews with six foster youth (Child #1 [C1], Child #2 [C2], Child #3 [C3], Child #4 [C4], Child #5 [C5], and Child #6 [C6]) five staff members (Staff #1 [S1], Staff #2 [S2], Staff #3 [S3], Staff #4 [S4], and Staff #5 [S5]), four County Social Workers (CSW1, CSW2, CSW3, and CSW4) and licensee. In addition, county records and facility records were reviewed. On February 2 2022, Community Care Licensing (CCL) received an allegation alleging resident (Child #5 [C5]) was assaulted by other residents (Child #2 [C2] and Child #6 [C6]) resulting in injuries. Specifically, it was reported on January 31, 2022, C5 was found unconscious after being assaulted by C2 and C6 in a shed on the grounds of the facility. Confidential interviews and record review revealed on 1/31/ C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Nicole Strickland 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 19-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, MAIN ST., SUITE FACILITY NAME: CREEKSIDE STRTPFACILITY NUMBER: VISIT DATE: 07/20/2022

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


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
On July 20, 2022, at 10: AM, LPA Enriquez and LPA Strickland initiated the investigation at the STRTP and obtained documents from the files and conducted a safety inspection. There were no immediate hazards observed. LPA was unable to contact the County Social Worker. On August 04, 2022, LPA Enriquez conducted collateral interviews at the STRTP. LPA interviewed S1 and S2. On December 15, 2022, LPA conducted a collateral interview with FC1, FC2, FC3, FC4 and FC5. Regarding the allegation that facility staff made minor attend school when ill, it was specifically alleged that FC1 was sent to school sick on 07/15/22. Confidential interview stated that staff denied sending any child to school when sick. It was added that if staff is notified that a child is feeling sick and there are symptoms, they have them take a COVID-19 test. Staff added that they will ask child if they want to go to urgent care. Additionally, confidential interview denied that foster children are forced to go to school. It was added that staff let foster children stay home if the tell them they fell sick and will ask children if they want to go to urgent care. Other confidential interview didn't witness staff sending any minor to school when illness was disclosed. Based on confidential interviews, the allegation that facility staff made FC1 attend school when ill, may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, this allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this report was reviewed and provided to facility representative.

Investigation Findings:
13On December 21, 2022, Licensing Program Analyst (LPA) Rafael Enriquez arrived at Creekside Short Term Therapeutic Program (STRTP) and met with CEO- Darryl Monteilh to discuss the finding for the allegation stated above involving the STRTP staff and foster children (FC1, FC2, FC3, FC4 and FC5) as listed on the Confidential Names List (LIC 811) dated December 21, 2022. On July 18, 2022, Community Care Licensing (CCL) received a complaint alleging facility staff made minor attend school when ill. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Rafael Enriquez 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 19-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, MAIN ST., SUITE FACILITY NAME: CREEKSIDE STRTPFACILITY NUMBER: VISIT DATE: 12/21/2022

met_with: CEO- Darryl Monteilh


raw_content:
Narrative:
On August 04, 2022, LPA Enriquez interviewed S1 and S2. On December 15, 2022, LPA conducted a collateral interview for FC1, FC2, FC3, FC4 and FC5. Regarding the allegation that staff were not providing a safe environment for children, it was specifically alleged that FC6 was threatening children and staff. Confidential interview stated that staff denied that the home is an unsafe living environment. Confidential interviews indicated that there was always a staff member with the children and that they were always asking the children how the foster children were feeling or what is going on with the foster children. It was added that if a child starts to get hostile staff intervene immediately and begin to redirect them. Confidential interviews stated that staff document every time a foster child tells them they feel unsafe and that they gave a daily check in where staff ask the foster children how they are doing. Additionally, other confidential interviews denied that staff were not providing a safe environment in the home. It was added that if someone is acting up the foster children tell staff and staff would try to resolve the matter immediately. Based on confidential interviews, the allegations that staff are not providing a safe environment for foster children, may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, this allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this report was reviewed and provided to facility representative.

Investigation Findings:
13On December 21, 2022, Licensing Program Analyst (LPA) Rafael Enriquez arrived at Creekside Short Term Therapeutic Program (STRTP) and met with CEO- Darryl Monteilh to discuss the findings for the allegation stated above involving the STRTP staff and foster children (FC1, FC2, FC3, FC4 and FC5) as listed on the Confidential Names List (LIC 811) dated December 21, 2022. On July 28, 2022, Community Care Licensing (CCL) received a complaint alleging that staff are not providing a safe environment for children. On August 04, 2022, at 12: PM, LPA Enriquez initiated the investigation at the STRTP and obtained documents from the files and conducted a safety inspection. There were no immediate hazards observed. LPA was unable to contact the County Social Worker. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Rafael Enriquez 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 19-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, MAIN ST., SUITE FACILITY NAME: CREEKSIDE STRTPFACILITY NUMBER: VISIT DATE: 12/21/2022

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


raw_content:
Narrative:
Regarding the allegation that staff is not properly trained, it was specified that a staff was never trained from January to June 2022 and was often with clients and didn't know how to do anything for them. During investigation, confidential interview stated that staff received a minimal training. It was added that staff was only given a computer training, commercial sexual exploitation of children (CSEC) training, incident report training, and trauma informed care training. Another confidential interview indicated that staff stated they went through orientation with a group of new hires and received training on how to fill out documentation but was not provided 24-hour required training prior to working with the clients. Confidential interviews stated client thought that staff were good at interacting with clients but did not know how long staff had to train prior to supervising clients at the facility. LPAs were not available to receive documentation showing that the required training's were completed during inspection. Based on confidential interviews and record review the allegation that staff is not properly trained is substantiated. The preponderance of evidence standard has been met. Facility is cited for violation of Interim Licensing Standards (ILS) standard 87065. Supervision, Evaluation and Training Requirements (c)(2). The training plan shall address the initial 24-hour training for newly hired direct care staff. An exit interview was conducted, and a copy of this report along with the appeal right were provided to facility representative. Regarding the allegation that the facility drills are not being conducted, it was specifically alleged that the facility didn't conduct fire drills and had no logs. During investigation, confidential interview stated that fire drills were conducted and logged in a logbook in the staff office. Confidential interviews indicated that a fire drill was conducted when they were present at the facility. It was added that they did not know how often drills were conducted or if they were documented. Confidential interviews stated that the facility conducted a fire drill and all clients and staff went to the field during the drill. However, LPA received a conflicting information and LPAs observed the fire drills log was documented ahead and it was inconsistent. In regard to the allegation that residents are not being provided activities, it was specifically alleged that the clients don't get to do any activities. Confidential interviews disclosed that clients are provided with activities but could not provide a written plan for activities. Confidential interviews stated that clients were taken to movies and dinners, but she had not seen if they were documented. Confidential interviews stated that they did get taken out on outings like the movies and the carnival. It was added that they had water balloon fights and other activities around the facility. Based on confidential interviews, the allegations that facility drills were not being conducted and clients were not being provided activities, may have happened or valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, these allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report along with the appeal right were reviewed and provided to facility representative.

Investigation Findings:
13On February 08, 2023, Licensing Program Analyst (LPA) Rafael Enriquez arrived at Creekside Short Term Therapeutic Program (STRTP) and met with Program Supervisor- Elizabeth Pryer to discuss the finding for the allegation stated above involving the STRTP staff and clients (C1, C2) as listed on the Confidential Names List (LIC 811) dated February 08, 2023. On June 24, 2022, Community Care Licensing (CCL) received a complaint alleging that staff is not properly trained. On June 30, 2022, at 9: AM, LPA Almaraz initiated the investigation at the STRTP and obtained documents from the files and conducted a safety inspection. There were no immediate hazards observed. LPA conducted interviews for S1, S2, S3 & C1. On January 27, 2023, LPA Enriquez interviewed C2 at a collateral visit at the STRTP. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Rafael Enriquez 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 19-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, MAIN ST., SUITE FACILITY NAME: CREEKSIDE STRTPFACILITY NUMBER: VISIT DATE: 02/09/2023

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: Program Supervisor- Elizabeth Pryer


raw_content:
Narrative:
On October 04, 2023, at 02: PM, LPA Enriquez initiated the investigation at the STRTP and obtained documents from the files, conducted a safety inspection, and interviewed S1, S2, S3, C2 and C3. There were no immediate hazards observed. On December 28, 2023, LPA Enriquez attempted to conduct collateral interviews for C1, C5 and C6 but clients refused to speak to LPA. Regarding the allegation that staff do not ensure the facility has active smoke detectors, it was specifically alleged that the house has missing smoke detectors. During LPA's safety inspection smoke detectors were observed. Confidential interviews stated that the house did have smoke detectors. C1, C5 and C6 refused to be interviewed. LPA unable to gather additional information. In regard to the allegation that staff have not repaired the minor's beds while in care, it was specifically alleged that the children's beds look unsafe like they're breaking. During LPA's safety inspection client's beds looked safe and felt sturdy. Confidential interviews stated that the beds work properly and are comfortable. C1, C3, C5 and C6 refused to be interviewed. LPA unable to gather additional information. Concerning the allegation that staff are not meeting the mental health needs of the minors while in care, it was specified alleged that the mental health team is basically nonexistent. Confidential interviews stated that clients see an in-house therapist twice a week and an outside behavioral health therapist twice a week. C1, C3, C5 and C6 refused to be interviewed. LPA unable to gather additional information. Based on confidential interviews, the allegations that staff do not ensure the facility has active smoke detectors, staff have not repaired the minor's beds while in care and that staff are not meeting the mental health needs of the minors while in care may have occurred, however, there was not a preponderance of evidence to support or deny the allegations. Therefore, the above allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report along with the appeal right were reviewed and provided to facility representative.

Investigation Findings:
13On January 11, 2024, Licensing Program Analyst (LPA) Rafael Enriquez arrived at Creekside Short Term Residential Therapeutic Program (STRTP) and met with Program Supervisor Elizabeth Pryer to deliver the finding for the allegations stated above involving the STRTP staff and Client #1 (C1), Client #2 (C2), Client #3 (C3), Client #4 (C4), Client #5 (C5), Client #6 (C6), as listed on the Confidential Names List (LIC 811) dated January 11, 2024. On September 26, 2023, Community Care Licensing (CCL) received a complaint alleging that staff do not ensure the facility has active smoke detectors, staff have not repaired the minor's beds while in care and staff are not meeting the mental health needs of the minors while in care. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Rafael Enriquez 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 19-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, MAIN ST., SUITE FACILITY NAME: CREEKSIDE STRTPFACILITY NUMBER: VISIT DATE: 01/11/2024

met_with: Program Supervisor Elizabeth Pryer


raw_content:
Narrative:
On November 21, 2023, at 09: AM, LPA Enriquez initiated the investigation at the STRTP and obtained documents from the files, conducted a safety inspection, no interviews were conducted. There were no immediate hazards observed. On December 28, 2023, LPA Enriquez interviewed S1, S2 and attempted to conduct collateral interviews for C1, C2, C3, C4 and C5 but clients refused to speak to LPA. Regarding the allegation that staff did not ensure there was adequate amounts of food available at the facility for minors in care, it was specifically alleged that there were less than 10 times item in the fridge. Confidential interviews stated that there is enough food in the home. It was added that staff shop every Monday and will go to the store within the week if something runs out. C1, C2, C3, C4 and C5 refused to be interviewed. LPA unable to gather additional information. In regard to the allegation that staff did not ensure proper toiletries were available at the facility for minors in care, it was specifically alleged that the facility does not have hair care products for black children or feminine hygiene products. Confidential interviews stated that the clients are provided toiletries and feminine hygiene products. It was added that clients are taken to get their hair done professionally and get the products they need for their hair from the establishment. C1, C3, C5 and C6 refused to be interviewed. LPA unable to gather additional information. Based on confidential interviews, the allegations that staff did not ensure there was adequate amounts of food available at the facility for C1, C2, C3, C4, C5, and C6 in care and staff did not ensure proper toiletries were available at the facility for C1, C2, C3, C4, C5, and C6 in care may have occurred, however, there was not a preponderance of evidence to support or deny the allegations. Therefore, the above allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report along with the appeal right were reviewed and provided to facility representative.

Investigation Findings:
13On January 11, 2024, Licensing Program Analyst (LPA) Rafael Enriquez arrived at Creekside Short Term Residential Therapeutic Program (STRTP) and met with Program Supervisor Elizabeth Pryer to deliver the findings for the allegations stated above involving the STRTP staff and Client #1 (C1), Client #2 (C2), Client #3 (C3), Client #4 (C4), Client #5 (C5), Client #6 (C6), as listed on the Confidential Names List (LIC 811) dated January 11, 2024. On November 13, 2023, Community Care Licensing (CCL) received a complaint alleging that staff did not ensure there was adequate amounts of food available at the facility for minors in care and staff did not ensure proper toiletries were available at the facility for minors in care. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Rafael Enriquez 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 19-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, MAIN ST., SUITE FACILITY NAME: CREEKSIDE STRTPFACILITY NUMBER: VISIT DATE: 01/11/2024


raw_content:
Narrative:
Regarding the allegation that staff do not prevent youth from having physical altercations with other youth while in care, it was specifically alleged C4 said other children has pushed C4 and threw C4 against a wall. Confidential interviews stated that there was an incident with C4 and C1. It was added that it only occurred once, and staff talked to both clients. It was added that C1 and C4 became good friends afterwards. LPA unable to gather additional information due to clients refusing to be interviewed. In regard to the allegation that staff do not ensure adequate supervision is provided to youths in care, it was specifically alleged that C1 often tells C4 to go absent without leave (AWOL) with her. Confidential interviews stated that staff talk to clients if they suspect that they want to AWOL and follow protocol if they do leave. Additional confidential interview stated that staff tell clients if they want to AWOL then AWOL. C1, C2, C3, C5 and C6 refused to be interviewed LPA unable to gather additional information. Concerning the allegation that there was an Illegal eviction, it was specified alleged that C4 stated that the facility is going to be kicking C4 out. Confidential interviews stated that C4 was not kicked out. Additional confidential interviews corroborated that C4 was not told that C4 was being kicked out. C1, C2, C3, C5 and C6 refused to be interviewed. LPA unable to gather additional information. Based on confidential interviews, the allegations that staff do not prevent youth from having physical altercations with other clients while in care, staff do not ensure adequate supervision is provided to clients in care and illegal eviction may have occurred, however, there was not a preponderance of evidence to support or deny the allegations. Therefore, the above allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report along with the appeal right were reviewed and provided to facility representative.

Investigation Findings:
13On January 25, 2024, Licensing Program Analyst (LPA) Rafael Enriquez arrived at Creekside Short Term Residential Therapeutic Program (STRTP) and met with Administrator Darryl Monteilh to deliver the findings for the allegations stated above involving the STRTP staff, Client #1 (C1), Client #2 (C2), Client #3 (C3), Client #4 (C4), Client #5 (C5) and Client #6 (C6) as listed on the Confidential Names List (LIC 811). On October 17, 2023, at 9: AM, LPA Enriquez initiated the investigation at the STRTP, obtained documents from the files and conducted a safety inspection, no immediate hazards observed. LPA interviewed S2, S3 and C4. LPA attempted to interview C1, C2, C3, C5 and C6 but interviews were declined. On October 11, 2023, Community Care Licensing (CCL) received a complaint alleging that staff do not prevent youth from having physical altercations with other youth while in care, staff do not ensure adequate supervision is provided to youths in care and illegal eviction. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Rafael Enriquez 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 19-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, MAIN ST., SUITE FACILITY NAME: CREEKSIDE STRTPFACILITY NUMBER: VISIT DATE: 01/25/2024

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

met_with: Administrator Darryl Monteilh


raw_content:
Narrative:
Regarding the allegation that staff member threatened minor while in care, it was specifically alleged that S3 threatened to hit C2. During investigation, a confidential interview stated that S3 threatened to hit C2. Additional confidential interviews denied S3 threatening C2, and staff was not aware of the incident. LPA was unable to gather additional interview due to client's refusal to be interviewed. In regard to the allegation that staff member handled minor in a rough manner, it was specifically alleged that S3 grabbed C2 by C2's arm. A confidential interview stated that S3 grabbed C2's by the arm aggressively. Additional confidential interviews denied S3 handled C2 in a rough manner. It was added that nothing had been reported to the facility and C2 may fabricate stories. LPA was unable to gather additional interview due to client's refusal to be interviewed. Concerning the allegation that staff left minor unsupervised, it was specified alleged that C2 and C1 were dropped off in an area of the school where there were no staff present. Confidential interviews stated that C1 and C2 were dropped off at school like normal. LPA was unable to gather additional interview due to client's refusal to be interviewed. Based on confidential interviews, the allegations that S3 member threatened C2 while in care, staff member handled C2 in a rough manner and staff left minor unsupervised may have occurred, however, there was not a preponderance of evidence to support or deny the allegations. Therefore, the above allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report along with the appeal right were reviewed and provided to facility representative.

Investigation Findings:
13On February 09, 2024, Licensing Program Analyst (LPA) Rafael Enriquez arrived at Creekside Short Term Residential Therapeutic Program (STRTP) and met with Program Supervisor Shanikka Fields to deliver the finding for the allegations stated above involving the STRTP staff and clients (C1, C2, C3, C C5 and C6) as listed on the Confidential Names List (LIC 811) dated February 09, 2024. On October 26, 2023, at 12: PM, LPA Enriquez initiated the investigation at the STRTP and obtained documents from the files, conducted a safety inspection, no immediate hazards observed. LPA Enriquez interviewed C2, staff (S1, S2) and attempted to conduct collateral interviews with C1, C3, C4, C5 and C6 but clients refused to be interviewed. On November 13, 2023, Community Care Licensing (CCL) received a complaint alleging that staff member threatened minor while in care, staff member handled minor in a rough manner and staff left minor unsupervised. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Rafael Enriquez 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 19-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, MAIN ST., SUITE FACILITY NAME: CREEKSIDE STRTPFACILITY NUMBER: VISIT DATE: 02/09/2024

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

met_with: Lead Facility Manager Shanikka Fields


raw_content:
Narrative:
Regarding the allegation that staff are emotionally abusing a youth while in care, it was specifically alleged that there was some emotional abuse going on in the home. During the investigation, confidential interviews denied that C1 was emotionally abused by staff. It was added that staff can be stern sometimes but only when clients do not comply to rules and violating others' personal rights. C5 and C6 refused to be interviewed. LPA was unable to gather additional interview due to client's refusal to be interviewed. In regard to the allegation that staff do not allow a foster youth to wear cosmetics while in care, it was specifically alleged that C1 mentioned staff do not allow C1 to wear makeup. During the investigation, confidential interviews stated that C1 was allowed to wear make-up. The confidential interview continued stating that C1 has to be supervised while putting on makeup, so C1 doesn't self-harm with the container. C5 and C6 refused to be interviewed. LPA was unable to gather additional interview due to client's refusal to be interviewed. Based on confidential interviews, the allegations that staff were emotionally abusing C1 while in care and staff do not allow C1 to wear cosmetics while in care may have occurred, however, there was not a preponderance of evidence to support or deny the allegations. Therefore, the above allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report along with the appeal right were reviewed and provided to facility representative.

Investigation Findings:
13On June 10, 2024, Licensing Program Analyst (LPA) Rafael Enriquez arrived at Creekside Short Term Residential Therapeutic Program (STRTP) and met with Program Supervisor Shanikka Fields to deliver the finding for the allegations stated above involving the STRTP staff and clients (C1, C2, C3, C C5 and C6) as listed on the Confidential Names List (LIC 811) dated June 10, 2024. On January 18, 2024, LPA Enriquez initiated the investigation at the STRTP and obtained pertinent documents. Additionally, LPA conducted a safety inspection of the STRTP, no immediate health and safety hazards were observed. During investigation, LPA interviewed staff 1 & 2 (S1, S2), C1, C2, C3. LPA attempted to interview C4, C5 and C6 on multiple occasions. On January 11, 2024, Community Care Licensing (CCL) received a complaint alleging that staff are emotionally abusing a youth while in care and staff do not allow a foster youth to wear cosmetics while in care. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Rafael Enriquez 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 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE N CRP RO, MAIN ST., SUITE FACILITY NAME: CREEKSIDE STRTPFACILITY NUMBER: VISIT DATE: 06/10/2024

met_with: Program Supervisor Shanikka Fields


raw_content:
Narrative:
Regarding the allegation that staff did not prevent minor from being physically assaulted by other minors, it was specifically alleged that C5 was refusing to go back to the facility due to having a fear of being "jumped" by other youth at the home. During the investigation, confidential interviews denied that C5 was physically assaulted by any of the minors in the home. The confidential interview disclosed that C5 was the one who almost assaulted C1 while using the bathroom. Additional confidential interviews reported that C5 had not expressed that C5 was afraid of being in the home. C4 and C6 refused to be interviewed. LPA was unable to gather additional interview due to client's refusal to be interviewed. In regard to the allegation that staff are providing alcohol/drugs to youth, it was specifically alleged that staff provide minors with alcohol and drugs. During the investigation, confidential interviews denied that staff provide alcohol and drugs to the minors in care. Confidential interviews indicated that staff treat the clients fairly like their own children and do not provide drugs to minors. C4 and C6 refused to be interviewed. LPA was unable to gather additional interview due to client's refusal to be interviewed. Based on confidential interviews, the allegations that staff did not prevent C5 from being physically assaulted by other minors and staff are providing alcohol/drugs to youth may have occurred, however, there was not a preponderance of evidence to support or deny the allegations. Therefore, the above allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report along with the appeal right were reviewed and provided to facility representative.

Investigation Findings:
13On June 10, 2024, Licensing Program Analyst (LPA) Rafael Enriquez arrived at Creekside Short Term Residential Therapeutic Program (STRTP) and met with Program Supervisor Shanikka Fields to deliver the findings for the allegations stated above involving the STRTP staff and clients (C1, C2, C3, C C5 and C6) as listed on the Confidential Names List (LIC 811) dated June 10, 2024. On February 09, 2024, LPA Enriquez initiated the investigation at the STRTP and obtained pertinent documents. Additionally, LPA conducted a safety inspection of the STRTP, no immediate health and safety hazards were observed. During investigation, LPA interviewed staff 1 & 2 (S1, S2), C1, C2, C3. LPA attempted to interview C4, C5 and C6 on multiple occasions. On January 30, 2024, Community Care Licensing (CCL) received a complaint alleging that staff did not prevent minor from being physically assaulted by other minors and staff are providing alcohol/drugs to youth. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Rafael Enriquez 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 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE N CRP RO, MAIN ST., SUITE FACILITY NAME: CREEKSIDE STRTPFACILITY NUMBER: VISIT DATE: 06/10/2024


raw_content:
Narrative:
and would often leave the facility without permission together. Confidential interviews and record review revealed suspicions were confirmed in early April at which time staff made changes to room assignments. Confidential interviews and record review revealed conflicting statements regarding how often room check were done, what supervision in the facility consisted of and house rules regarding the doors to bedrooms being shut. Confidential interviews could not confirm or dispute the allegation. Based on record review and confidential interviews the allegations alleging lack of supervision resulted in inappropriate interactions between minors may have occurred, however they are not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of the report was provided along with appeal rights to Creekside STRTP Program Supervisor, Shanikka Fields.

Investigation Findings:
13On June 26, 2024 at 12:03pm Licensing Program Analyst (LPA), Nicole Strickland met with Creekside STRTP Program Supervisor, Shanikka Fields, to deliver the finding for the above stated allegation. A Health and safety inspection of the facility was conducted on April 18, 2024, and no immediate hazards were observed. The investigation included interviews with four foster children (C1, C2, C4, C5), C3 refused interview and LPA was unsuccessful in interviewing C6 after several attempts, LPA interviewed two staff (S1-S2), administrator (ADM), and one county social worker. In addition, county records, and facility records were reviewed. On April 10, 2024, Community Care Licensing (CCL) received an allegation alleging lack of supervision resulted in inappropriate interactions between minors. Confidential interviews reported that staff had suspicions of C1 and C6 being in an on again and off again relationship as C1 and C6 were roommates UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: LaCresha Cook LICENSING EVALUATOR NAME: Nicole Strickland 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 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE N CRP RO, MAIN ST., SUITE FACILITY NAME: CREEKSIDE STRTPFACILITY NUMBER: VISIT DATE: 06/26/2024

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

met_with: Program Supervisor, Shanikka Fields


raw_content:
Narrative:
review revealed during room checks staff heard a voice of someone staff did not recognize coming from one of the residents' rooms. Confidential interviews confirmed that staff questioned the resident at the time, who reported the voice came from the resident's electronic device. Confidential interviews and record review could not confirm staff took additional steps to verify where the unrecognized voice came from. Confidential interviews and record review could not confirm or dispute that after hearing the unrecognized voice, staff increased supervision and/or increased room checks. Based on record review and confidential interviews the allegation alleging lack of supervision resulted in unauthorized individual in the facility may have occurred, however it is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of the report was provided along with appeal rights to Creekside STRTP Program Supervisor, Shanikka Fields.

Investigation Findings:
13On June 26, 2024 at 12:22 pm Licensing Program Analyst (LPA), Nicole Strickland met with Creekside STRTP Program Supervisor, Shanikka Fields, to deliver the finding for the above stated allegation. A Health and safety inspection of the facility was conducted on April 18, 2024, and no immediate hazards were observed. The investigation included interviews with four foster children (C1 - C3, and C6), three staff (Administrator, S1 and S2), and one county social worker. One confidential witness was unable to be contacted and therefore was unable to be interviewed. In addition, county records, and facility records were reviewed. On April 17, 2024, Community Care Licensing (CCL) received an allegation alleging lack of supervision resulted in unauthorized individual in the facility. Specifically, it was reported an unnamed resident of the facility hid an unauthorized individual in the unnamed resident's room. Confidential interviews and record UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: LaCresha Cook LICENSING EVALUATOR NAME: Nicole Strickland 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 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE N CRP RO, MAIN ST., SUITE FACILITY NAME: CREEKSIDE STRTPFACILITY NUMBER: VISIT DATE: 06/26/2024

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


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Furthermore, an additional confidential witness informed LPA that they heard S1 making inappropriate comments toward clients. Based on confidential interviews the preponderance of evidence standard has been met and the Department has determined that staff made inappropriate comments towards a minor in care. Therefore, the allegation is substantiated. The facility is being cited for violation of the Interim Licensing Standards, Chapter 7. Short-Term Residential Therapeutic Program, Articles Through 10, Version 5 87072 (c)(1) Personal Rights. An exit interview was conducted, appeal rights explained, and a copy of this report and LIC 811 was provided to Shanikka Fields.

Investigation Findings:
13On August 22, 2025, at 2: PM Licensing Program Analyst (LPA) Michael Almaraz met with Creekside Short Term Residential Treatment Program (STRTP) Program Supervisor, Shanikka Fields, to issue the finding for the above allegation involving client 1 (C1) and staff 1 (S1) listed on the confidential names list (LIC 811) dated August 22, 2025. On May 7, 2025, at 12: PM LPA inspected the facility and conducted a health and safety inspection. During LPA inspection LPA reviewed clients' records and interviewed two staff (S2, S3). Additionally, LPA Almaraz conducted interviews with three county social workers and seven clients (C1, C2, C3, C4, C5, C6, C7). LPA attempted to interview S1 but was unsuccessful. On April 28, 2025, the Department received a complaint alleging that staff made inappropriate comments towards a minor in care. It was specifically reported that on April 19, 2025, S1 made inappropriate comments toward C1. Confidential witness informed LPA that on April 19, 2025, while on an outing with C1, S1 made sexually inappropriate comments. Additional confidential witnesses provided LPA with consistent statements that S1 made inappropriate comments toward clients. (continued on page 2...) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Michael Almaraz 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 61-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE N CRP RO, MAIN ST., SUITE FACILITY NAME: CREEKSIDE STRTPFACILITY NUMBER: VISIT DATE: 08/22/2025

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

met_with: Shanikka Fields

complaint_status: SUBSTANTIATED


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analysts (LPAs) Shanae Pharaoh and Babatunde Aborchie, and Licensing Program Manager Abdoulaye Traore met with Administrator Erin Franco and CEO Darryl Monteilh who granted access to the facility. The purpose of this visit was to conduct a pre-licensing inspection of the Short Term Residential Therapeutic Program (STRTP). Applicants are applying for a maximum capacity of six ambulatory clients age 12-17 including non-minor dependents. The facility was toured both inside and out. The facility is a one story residence with 4 bedrooms and 2 and a half bathrooms. The half bathroom will be used for staff. Bedroom #1: the room was furnished with two twin-size beds - Vacant Bedroom #2: the room was furnished with one twin-size bed - Vacant Bedroom #3, the room was furnished with two twin-size bed - Vacant. Bedroom #4, the room was furnished with one twin-size bed - Vacant There was one group meeting/therapy/ activity area There was a common area There was a dining room area with a table that fit 6 client Bedrooms were arranged so that no more than two clients share a room, and there was one client per bed. There was adequate shelves and closet space for clients' belongings. There were additional linens located in the hallway closets and client towels were stored in a bathroom cabinet. The bathrooms were clean and in good repair. The hot water in the client bathroom was measured to be 110.8 degrees. All hazardous items have been properly made inaccessible to areas where clients will have access. The medications will be stored and locked in a cabinet in the staff office. Cleansers/chemicals were locked and stored in the garage storage closet. Sharp knives were inaccessible and stored in a locked storage pantry in the kitchen. The First Aid Kit was located in the staff office and contained all required supplies. The facility's smoke detectors in the rooms and hallways were checked and they were operable. The carbon monoxide detectors located in common area outside the kitchen were also operable. There were two fireplaces located in common areas and they were properly screened. Toys were observed to be safe, clean and age appropriate for the age group of children to be cared. There were no guns or weapons in the facility as stated by the Administrator. LPA observed a minimum 7-day non-perishable and a 2-day perishable supply of food. Proper storage of all food was noted. Food will be stored in kitchen cabinets and accessible to clients. Additional food storage will be stored in a locked pantry in the kitchen. An operable fire extinguishers was located in the kitchen and another fire extinguisher was in the garage. There was an additional refrigerator and freezer in the garage. The laundry was located in the garage. Client files will be stored in a locked cabinet in the staff office. The following required posted items were observed accessible to clients: Grievance Procedures, Personal Rights, visitation policies, menu, Emergency Disaster Plan and facility sketch. The facility outside ground was also inspected and it was observed to be clean and maintained. Emergency exits were free from obstruction. There is a swimming pool located in the backyard of the facility, which was unlocked and inaccessible to clients. The pool was surrounded by a wrought iron fence measured to be 5 feet tall with a gate that self-latches and opens outward. Administrator's First Aid and CPR cards expire on June 2023. Based on this inspection of the STRTP, the facility will need the following corrections: Lock box for clients personal items and contraceptives Lock box for refrigerated medications After corrections are completed, the applicant will send verification of corrections to LPA.. Also, the applicant has been scheduled for a Component III on August 24, 2021. An exit interview was conducted and a copy of this report was discussed and provided to applicant on this date.

visit_type: Prelicensing

met_with: Administration - Erin Franco


summary: Facility Evaluation

raw_content:
Narrative:
On August 26, Licensing Program Analyst (LPA), Shanae Pharaoh and Licensing Program Manager (LPM), Abdoulaye Traore, met with applicants Erin Franco and Darryl Monteilh for the purpose of conducting a Component III Orientation. LPM and LPA reviewed and discussed reporting requirement, AB 388, SIRs, accreditation requirements, mental health program approval and other licensing rules and regulations for Short-Term Residential Therapeutic Program. Recommendation for licensure will be sent to LPM to approve provisional llicense. Applicants were informed that the provisional license will be mailed to Applicants.

met_with: Erin Franco and Darryl Montehl


summary: Facility Evaluation

raw_content:
Narrative:
On November 1, 2021 at 1: PM, Licensing Program Analyst (LPA), Cindy Hamilton conducted a collateral visit at this facility to interview Client #1 (C1), (see Confidential Names List LIC 811, dated 11/01/2021), regarding allegations from a prior placement. The allegations are not related to this facility. Exit interview conducted and a copy of this report was provided to the Erin Franco, Program Director/Administrator.


summary: Facility Evaluation - 1 deficiency

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Narrative:
On November 18, 2021, Licensing Program Analyst (LPA) Shanae Pharaoh conducted a post-licensing inspection of the facility. At 9:49AM LPA met with Administrator, Erin Franco. The facility was toured inside and out at 10: AM. There are currently three clients in placement (See Confidential Names List (LIC 811) dated November 18, 2021. The facility was toured both inside and out. The facility is a one story residence with 4 bedrooms and 2 and a half bathrooms. The half bathroom is used for staff. Bedroom #1: the room was furnished with two twin-size beds - Sleeps C Bedroom #2: the room was furnished with two twin-size bed - Vacant Bedroom #3, the room was furnished with one twin-size bed - Sleeps C Bedroom #4, the room was furnished with one twin-size bed - Sleeps C There was one group meeting/therapy/ activity area There was a common area There was a dining room area with a table that fit 6 client A physical plant inspection was completed and included the following checks: Facility grounds are clean; free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for client's recreation time. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster. Medications are locked and centrally stored in the staff office. A complete First Aid Kit was locked and stored in the staff office as well. The facility has 4 bedrooms and are arranged so that no more than two clients share a room and there is one client per bed. There is adequate shelf and closet space for client's belongings. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The facility has two bathrooms for clients' use. The bathrooms were in working order. The hot water in the client bathroom sink was measured and deemed to be safe. LPA observed an empty trash can in the bathroom that was missing a lid. Licensee immediately replaced the trash can with one that had a lid. Facility has a pool which is appropriately fenced and secured with a wrought iron exterior. The enclosure was measured to be 5 feet tall, with a self-latching gate that swings outward. During the facility inspection. Per Administrator, there are no firearms or weapons in the facility. Facility appears to be meeting the terms and conditions of their license. Administrator, Erin Franco is present at the facility a minimum of 20 hours a week, as verified by staff schedule and interviews. Appropriate staff/client ratios were verified during this inspection. The facility employs Facility Manager and Therapuetic Counselor/ Direct Care Staff. Licensee is in the process of obtaining Mental Health Certification and COA Accreditation LPA reviewed 3 clients files. Client files were complete. Five staff files were reviewed. One of five staff were missing education and experience. One of five personnel who require caregiver background checks did not have criminal record and child abuse index check clearances or exemptions. An immediate $500 civil penalty was assessed. LPA discussed the following with Administrator: Incident reporting, including incidents related to Assembly Bill 388 law enforcement contacts, as well as incidents involving emergency interventions. LPA discussed procedures for Child and Family Team (CFT) meetings, including an overview of required Core Services and Supports. Based upon the inspection of client records and interviews with staff, the Licensee appears to be meeting CFT and Core Services/Supports requirements. Exit interview conducted and copy of this report will be provided to the facility.

Deficiencies:
80019(e): Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility

met_with: Administrator - Erin Franco


summary: Facility Evaluation - 4 deficiencies

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Narrative:
On August 10, 2022 at 9: AM, Licensing Program Analysts (LPAs) Rafael Enriquez, Cynthia Urena and Licensing Program Manager (LPM) Abdoulaye Traore conducted a required annual inspection at Creekside Short-Term Residential Therapeutic Program (STRTP). The facility was issued a provisional license for STRTP on September 03, 2021. LPAs and LPM were met at the facility by Program Supervisor Elizabeth Pryer. At 9: AM, LPAs and LPM began the facility tour inside and out with the Program Supervisor. Facility grounds were clean and free of debris and observable hazards. There was adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors were in appropriate working order. Licensee maintains an adequate supply of perishable and non-perishable foods and appeared to be following the posted menu. All required forms were posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster. Medications were locked and centrally stored in locked cabinet in the staff office. Licensee did not have provisions for contraceptives to be held in individually locked containers by clients. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The hot water in the client's bathroom was measured to be 108 degrees. The facility outside ground was also inspected and it was observed to be clean and maintained. Emergency exits were free from obstruction. There is a swimming pool located in the backyard of the facility, which was unlocked and inaccessible to clients. The pool was surrounded by a wrought iron fence measured to be 5 feet tall with a gate that self-latches and opens outward. A Review of staff fingerprint clearance showed that S1 didn't have a fingerprint clearance. Facility is being cited for a violation of California Code of Regulations Section 80019(e)(2). An immediate civil penalty of $500 is assessed for the day of 08/10/2022. A review of client records was also completed on this date and deficiencies were observed. All six clients (C1, C2, C3, C C5 and C6) (see Confidential Names List, LIC 811 dated August 10, 2022) did not have Needs and Services Plan; Client Mental Health assessment; C1, C2 and C5 were missing signed copies of policy and procedures; C5 was missing immunization and all clients were missing initial crisis management assessments in their files which poses a potential health and safety risk to clients in care. In addition, the facility was unable to provide copies of the Board of Director's meeting minutes. Other deficiencies were observed: technical violations and deficiencies will be assessed. Facility Administrator/ Chief Executive Officer (CEO) authorized Program Supervisor to sign and receive licensing reports. Exit interview was conducted and deficiencies were advised. A copy of this report along with the Appeal Rights were given to the Supervisor. A continuation annual inspection will be conducted at a later date.

Deficiencies:
80019(d): Deficient Practice Statement
1
2
3
4Based on records review the licensee did not comply with the section cited above. S1 did not have a fingerprint clearances which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2022
Plan of Correction
1
2
3
4Effective immediatelty, Staff to be removed from the facility.
80070(d): Client Records

(d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements
87068.2(b): Needs and Services Plan

(b) The needs and services plan shall be trauma informed, culturally relevant, and age and developmentally appropriate and shall identify the child's needs in the following areas
87068.3(a): Modifications to The Needs And Services Plan

(a) The needs and services plan specified in Section 87068.2 shall be updated at least every 30 days to determine the following

visit_type: Annual

met_with: Program Supervisor - Elizabeth Pryer

title:
Criminal Record Clearance

(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury.

This requirement is not met as evidenced by


summary: Facility Evaluation - 4 deficiencies

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Narrative:
On August 12, 2022, Licensing Program Analysts (LPAs) Rafael Enriquez, Cynthia Urena and Licensing Program Manager (LPM) Abdoulaye Traore continued the annual inspection. The purpose of the continuance was to review the facility's staff and client files and conduct staff and client interviews. LPAs and LPM was met at the facility by Program Supervisor Elizabeth Pryer. Personnel files were reviewed to ensure they contained all required documentation per Title 22 and Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) regulations. Per record review, personnel files were missing the following information: All staff required orientation for new staff; 8 hours and 16 hours trainings; facility manager additional training; competency assessments; required training documentation; trauma informed care; emergency disaster trainings; staff evaluations; emergency intervention trainings; all required ILS training topics; Administrator designating a person responsible for activities; medication trainings and core therapeutic services. Client and staff interviews were conducted and revealed concerns regarding trauma informed care. Licensee has not obtained a Mental Health contract with San Bernardino County or Riverside County. Licensee has not obtained National Accreditation. Based on records review and interviews, the facility is being cited for violation of Title 22 and Interim Licensing Standards: ILS Section Personnel requirement; ILS Section 87065. Training Requirements; Title Section 80070, Client records; ILS Sections 87068. Needs and Services Plans, ILS Section 87078. Core Services and Support and ILS Section 87089. Mental Health. Citation details on LIC 809D pages. LPA contacted Administrator/ CEO to authorize program supervisor to sign and receive licensing reports including plan of correction. An exit interview was conducted and a copy of this report and appeal rights was explained and provided to Program Supervisor

Deficiencies:
87095.65(b): Emergency Intervention Staff Training

(b) The emergency intervention training curriculum must address the following areas
87065.1(a): (6) A record of each work performance evaluation and any correspondence with the employee.
87065.1(d): Supervision, Evaluation And Training Requirements

(d) Notwithstanding California Code of Regulations, Title 22, Section 80065(f)(1) through (6), new direct 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
87078.1(a): Core Services and Supports

(a) A short-term residential therapeutic program shall provide core services and supports to children and nonminor dependents as appropriate or necessary that are trauma informed, culturally relevant, age and developmentally appropriate, and include the following

title:
through (d) inclusive to CCL by POC date.

Type BSection CitedILS87066(b)(6)

Personnel Records

(b) The licensee shall maintain the following personnel records


summary: Facility Evaluation

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Narrative:
On August 17, 2022 at 4: PM, Associate Governmental Program Analyst (AGPA) Kim Robinson met with the Short Term Residential Therapeutic Program (STRTP) Licensee, Darryl Monteilh, to assess an Enhanced Civil Penalty (ECP). On July 20, 2022, the Department concluded a complaint investigation alleging that child care staff neglected to provide comfortable and safe environment to minors, resulting with a fifteen-year-old child #5 (C5) sustaining serious bodily injuries. (See the Confidential Names List, LIC 811, dated August 17, 2022). The allegations were substantiated and the STRTP was cited under the Interim Licensing Standards, Section 87072(c) Personal Rights with a $500.00 immediate civil penalty assessment. The investigative evidence gathered shows two minors assaulted C5, without staff supervising to ensure the health and safety of all minors placed in care. Based on the analysis of the police and medical reports, including interviews, the Department has determined that an enhanced civil penalty is warranted for STRTP staff neglecting to provide a safe and comfortable home for the wellbeing of all minors in care as required in the Interim Licensing Standards. Section 11165.2 of the Penal Code defines severe neglect as negligent treatment or maltreatment of a child when a person responsible for the child's welfare permits any child to suffer unjustifiable physical pain. This section describes a number of more or less direct and (always) willful acts that constitute physical abuse. Pursuant to the Enhanced Civil Penalty law, Health and Safety (H&S) code section 1548 (f)(1)(A), the Department will be issuing an immediate civil penalty of $2,000.00. An exit interview was completed, and appeal rights discussed. A copy of this report, the Confidential Names List, Appeal Rights, and a Civil Penalty Assessment - Serious Bodily Injury/Physical Abuse (Form 421-D) were provided to the licensee. **Due to technical difficulties this is an electronic copy of a written report that was issued on 8/17/22. Original signatures on the written report are maintained in the facility file.

met_with: Licensee


summary: Facility Evaluation

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Narrative:
On September 8, 2022, at 9:30 am a virtual informal office conference was held via Microsoft Teams with the Creekside Short-Term Residential Therapeutic Program (STRTP). The following people were in attendance: Community Care Licensing (CCL) Regional Manager (RM) LaCresha Cook, Licensing Program Manager (LPM) Abdoulaye Traore, Licensing Program Analysts (LPAs) Cynthia Urena and Anne Visaya, San Bernardino Behavioral Health Representative Diane Wolkenhauer, Social Services Practitioner (SSP) San Bernardino County Children Family Services (CFS) Amy Guisa, Andria Innerbichler, Sr DPO Riverside County Probation Juan Bretado, Riverside University Health Service- Behavioral Health (RUHS-BH) Deputy Director Janine Moore, CCL Provider Policy Implementation Unit Manager Policy and Technical Assistance Bureau, System of Care Branch Alicia Bernstein, LPM Law Enforcement Contact Review Unit (LECRU) Statewide CCLD Angela King, California Department of Social Services (CDSS) Child Trafficking Program Support Units Leeland Turner and Darrin Holt, Social Service Practitioner (SSP) Susan Maday, STRTP Coordinator SB County CFS Evelyn Martinez, CFS, SSP II Ivette Barcena, Creekside Consultant Tony Walker, Supervisor CFS San Bernadino County Hannah Gutierrez, Out of Home Investigations Supervisor Riverside County Karin Atkins, Deputy Director SB County CFS Nancy Satterwhite, Department of Behavioral Health Melissa Graham, RUHS-BH Children's Administrator Miranda DeShields, Manager CFT SB County Tracy Raymond, Creekside Consultant Courage Ekhaguere, Alain Dominique Riverside Department of Public Social Services (DPSS) Placement Monitor, Administrative Analyst Riverside County (DPSS) Jenell Ross, STRTP Representative Dr. Samita Kapoo, STRTP Representative Monica R. Williams, and CEO Creekside Daryl Monteilh The following information was discussed: · Lack of oversight of the facility by management. · Lack of trauma informed milieu · Emergency Intervention Plan (Needs to be trauma informed) · Harm Reduction [Continued on page 2] The facility was given until 09/16/2022 to submit a plan of correction to Community Care Licensing for approval. The licensee agrees to the following: · The licensee will submit a plan on how the Board of Directors will provide additional oversight to ensure a trauma informed care milieu is implemented including individualized trauma informed activities for each client in care. · The licensee will submit an updated training plan regarding what Trauma Informed trainings facility staff will received. · The licensee will submit a plan regarding how the Board of Directors will ensure facility staff comprehend the concepts of trauma informed care. · The licensee will submit proof of daily administrative rounds completed by Administrator or administrative staff. Overnight rounds should be included between the hours of 9pm and 6am to check on the well-being of clients and staff. The visits shall be at various hours, a minimum of 15 minutes, and shall be documented in the daily logbook and/or an administrative rounds sheet. The visiting Administrator or administrative staff and the facility staff member on shift shall sign the administrative rounds sheet, logbook, state the time and date of arrival, time and date of departure, and any unusual observations. · The licensee will submit a plan on how incident reports are reviewed by administration, including the facility's plan of action/correction and how the facility will ensure the appropriate agencies are receiving the incident reports. · The licensee shall submit the activity calendar of 2022 of the enrichment planned activities from January through December 31, 2022. The calendar needs to be specific for the facility to include the dates, times, and location of each activity, the names of clients who participated in each activity, and to include the names of clients who did not participate and the reasons why. · The licensee shall submit a plan on how individual specialty mental health services are being provided to clients in care. The plan shall include current information regarding therapeutic services provided at the STRTP weekly. Hold Children and Family Team meetings and discuss what is working and what is not. It was discussed that this cannot be done alone every key player must be involved. The following links were shared:ACIN I-59-18 (September 14, 2018) Introduction to the Harm Reduction Strategies Series, ACIN I-28-19 (July 22, 2019) Harm Reduction Series - Social Work, ACIN I-50-19 (July 29, 2019) Harm Reduction Series - Probation Officer, ACIN I-36-21 (June 22, 2021) Harm Reduction Series - Law Enforcement, ACIN I-31-22 (April 8, 2022) Harm Reduction Series - Caregiver, ACIN 1-14-19 -Recommended Practices for Serving Commercially Sexually Exploited Children (CSEC) Missing from Care, ACIN 1-21-21 -Recommended Practices Regarding Youth Who Have Experienced Commercial Sexual Exploitation and Their Usage of Cell Phones Regarding Mental Health Program Approval, San Bernardino Behavioral Health Representative Diane Wolkenhauer, stated that Creekside failed to complete the procedures for application submission and respond to emails regarding the procurement process for receiving a mental health ChrRis contract with San Bernardino County. Dianne stated that Creekside was sent various of emails and Creekside missed the ChrRis Program deadline. Currently Creekside does not have a Mental Health (MH) Contract with San Bernardino or Riverside Counties. Riverside County is not accepting out of county MH applications. Darryl Monteilh reported the STRTP has not completed the accreditation process but has hired a consultant to assist with the process. RM Cook reminded the licensee that prior to expiration of their provisional license the facility must meet the requirements of accreditation, receive a county MH contract, acquire Med-Cal certification, and receive Mental Health Program approval from the Department of Health Care Services.The facility was given until 09/16/2022 to submit a plan of correction to Community Care Licensing for approval. The licensee agrees to the following: · The licensee will submit a plan on how the Board of Directors will provide additional oversight to ensure a trauma informed care milieu is implemented including individualized trauma informed activities for each client in care. · The licensee will submit an updated training plan regarding what Trauma Informed trainings facility staff will received. · The licensee will submit a plan regarding how the Board of Directors will ensure facility staff comprehend the concepts of trauma informed care. [Continued on page 4] ·Law Enforcement Contact Unit update (AB388) · Mental Health Program Approval update · Administrator duties and Qualifications · Reporting Requirement (Deficiencies) · Lack of Required Staff Training · Serious Complaints Allegations ( Substantiated allegations and Enhanced Civil Penalty) · Maintaining Staff/Clients Records · Client Services · Technical Support Program referral The meeting included a discussion regarding the above concerns. At the beginning of the discussion, Regional Manager (RM) Cook and Licensing Program Manager (LPM) Traore explained the reason for the meeting and explained that the meeting would be a collaborative meeting which included the participation and input of all departments listed above that provide services to the Creekside STRTP. During the discussion, LPM King shared data regarding the facility law enforcement contacts and Special Incident Reports. LPM King discussed the importance of reporting accurate information and contacting law enforcement as a last resource unless there is imminent risk of danger. LPM Traore will provide LPM King's contact information for the STRTP to reach out to LPM King for additional information and virtual training. RM Cook and LPM discussed CCL's concerns regarding the above-mentioned issues and requested input from the various oversight agencies participating in the meeting discussion. Alicia Bernstein discussed trauma informed milieu. ILS Standards 87078. Trauma Informed Interventions and Treatment practices. Alicia specified the importance of providing trauma informed care for the population served. Specific resources, assessments and intake should come from a trauma informed perspective. The STRTP should provide individualized care that specializes on the individual needs of each client. Links to the following resources were provided regarding information on trauma informed care and treatment practices: NTCTSN (nctsn.org), Traumatic Stress Institute, and Dr Nadine Burke Harris. Leeland Turner and Darrin Holt, CDSS CTR, CDSS, Child Trafficking Program Support Unit provide information regarding Harm Reduction, focusing on treating behaviors overtime and ensuring it is client specific. Not every client shares the same needs. Documentation in the client's needs and service plan is important. When a client's plan is not working, provider should ensure communication with all entities is occurring and involve CCL, and the county social workers and other providers who are involved in the case. [Continued on page 3] ·The licensee will submit proof of daily administrative rounds completed by Administrator or administrative staff. Overnight rounds should be included between the hours of 9pm and 6am to check on the well-being of clients and staff. The visits shall be at various hours, a minimum of 15 minutes, and shall be documented in the daily logbook and/or an administrative rounds sheet. The visiting Administrator or administrative staff and the facility staff member on shift shall sign the administrative rounds sheet, logbook, state the time and date of arrival, time and date of departure, and any unusual observations. · The licensee will submit a plan on how incident reports are reviewed by administration, including the facility's plan of action/correction and how the facility will ensure the appropriate agencies are receiving the incident reports. ·The licensee shall submit the activity calendar of 2022 of the enrichment planned activities from January through December 31, 2022. The calendar needs to be specific for the facility to include the dates, times, and location of each activity, the names of clients who participated in each activity, and to include the names of clients who did not participate and the reasons why. · The licensee shall submit a plan on how individual specialty mental health services are being provided to clients in care. The plan shall include current information regarding therapeutic services provided at the STRTP weekly. · The licensee shall submit a plan on how bedroom sharing agreements are being assessed, reviewed, and updated by the administration. This plan will include the facility's plan of how the facility will ensure the clients are compatible. This form will be updated when a new client is placed into an existing client's bedroom. · The licensee shall submit a plan on how the Board of Directors will implement Harm Reduction into their Program. [Continued page 6] ·The licensee shall update the Emergency Intervention Plan to include additional trauma informed care techniques by 10/3/2022. · Licensee shall update Program Statement to include re-integrating policy-How clients are safely re-integrated when returning from AWOLs, trauma specific intervention plan, bullying policy and trauma informed de-escalation process. · The licensee shall submit a plan on how the Board of Directors will achieve Mental Health Program approval with the Department Healthcare Services and acquire Accreditation from COA. After completion of the conference LPM Traore and RM Cook thanked the facility representatives and all attendees. A copy of this report was emailed to CEO Daryl Monteilh for signature. Original signed reports will be placed in the facility file.

met_with: Darryl Monteilh


summary: Facility Evaluation

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Narrative:
On July 31th, 2023 at 3: PM Licensing Program Analyst (LPA), Emina Preciado, conducted a collateral visit at Creekside Short Term Residential Therapeutic Program (STRTP). LPA met with Shanikka Fields, Residential Treatment Counselor. The purpose of the visit was to conduct an interview with a resident client regarding allegations from a prior placement. The allegations are not related to this facility. No other information is needed at this time. Exit interview conducted and a copy of this report was given to facility representative.


summary: Facility Evaluation

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Narrative:
On August 4th, 2023 at 10: AM Licensing Program Analyst (LPA), Jessica Peete, conducted a collateral visit at Creekside Short Term Residential Therapeutic Program (STRTP). LPA met with Elizabeth Pryer, Program Supervisor The purpose of the visit was to conduct an interview with a resident client regarding allegations from a prior placement. The allegations are not related to this facility. No other information is needed at this time. Exit interview conducted and a copy of this report was given to the Program Supervisor.

met_with: Elizabeth Pryer, Program Supervisor