summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Danielle Walker-Flores arrived at the agency to conduct a case management inspection to issue citation for failure to report. Foster child (FC1, see confidential names titled 10/29/21) was in an altercation with another client on 10/07/21. This altercation resulted in FC1 being taken to the emergency room the following day due to headaches and at the request of the placing agency. Community Care Licensing was not notified of the incident involving the altercation. This agency is being cited under Reporting Requirements Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. Exit interview conducted and appeal rights provided. Due to technical difficulties, this deficiency was finalized with David Smith - Supervisor on 12/10/21.


state: CA

facility_name: MOUNTAIN VALLEY CHILD & FAMILY LIMA/SHADY

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Danielle Walker-Flores arrived at the facility on today's date for a case management inspection. On 10/27/21 foster child (FC1, see confidential names list titled 07/16/21), was administered the wrong psychotropic medication. Staff was distracted during medication distribution and accidentally administered psychotropic medications to FC1. Staff then directed FC1 to vomit. Initially, client was asked to stick his fingers down his throat to induce vomiting which client either refused or failed to vomit. Client was then given water and milk to induce vomiting. Client vomited and was monitored for side effects. FC1's guardians were contacted immediately. FC1's evening medications were held for safety concerns and FC1 was monitored with no side effects observed. LPA interviewed FC1 and Staff. At this time, Interim Licensing Standards (ILS) Section 80075(b)(5)(B) Health Related Services and 87072(d)(11) Personal Rights are being cited. Civil penalty assessed for repeat medication violation. Exit interview conducted.

report_type: Facility Evaluation

visit_type: Case Management

met_with: David Smith - Ranch Support Supervisor


facility_name: MT. LASSEN TREATMENT CENTER

summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Regarding the allegation that staff inappropriately restrained a minor resulting in injuries and staff handled minor in a rough manner, LPA obtained photos of a minor who sustained bruising and fingernail mark injuries from staff after being in a restraint. No full serious incident report was submitted to the Department regarding the restraint to detail staff's involvement. The client indicated they were running away, which does not provide justification for use of physical restraint. Regarding a lack of supervision for the clients resulting in unsafe behaviors, there was an incident in which four clients were able to sneak out of their dorm rooms during the night unnoticed, to break into a principal's office. During the months of July-September 2024, 19 (24) hour serious incident reports were submitted to the Department without corresponding final reports being submitted. There were two reports involving the use of a restraint with no final report submitted to the Department. Staff interviewed were unable to explain to the LPA what the process is to report incidents. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. Four citations are being issued for violating Interim Licensing Standards (ILS) Section 87061(i)(7)(E ):Incident Reports, ILS Section 87072(c)(17), Title 22, Section 80028(a): Responsibility for Providing Care and Supervision, and Title Section 80061(b): Reporting Requirements. A signed copy of this LIC-9099 report, the LIC-9099C, and LIC-9099D were provided to the facility. An exit interview was conducted. Appeal rights were provided. Regarding allegations of staff not addressing minors' health care needs, interviews with staff and clients indicated the facility has a medic on site. However, some interviews denied medical care as being available for clients when asked. Staff and clients reported that clients had access to three meals and a snack daily, but statements differed regarding the quality and quantity of the snacks, and the process for how to address when a client misses a meal. One staff reported that if a client acts up, they are not given a meal. Regarding the allegation of staff hitting a minor with a vehicle resulting in injuries, interviews were inconsistent. One staff reported that one client was hit by a golf cart and appeared to be injured, but when asked about their injuries, the client denied it. When LPA conducted additional client and staff interviews, none had knowledge of the incident. No incident report was submitted to confirm any other client or staff involvement. Regarding the allegation of staff not intervening when a minor engaged in self-harm, interviews were inconsistent. An incident did occur in the stabilization room involving electrical wiring. Client and staff interviews provided inconsistent statements regarding whether the wiring was exposed or not, and accessible to clients. LPA reviewed a video of a client pulling the electrical wire and getting shocked; however, interviews were inconsistent regarding whether there were holes or cracks in the electrical casing. Based on LPA's observations, interviews which were conducted, and records reviewed, although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove the violations did, or did not, occur. Therefore, the allegations are UNSUBSTANTIATED. A signed copy of this LIC-9099 report, the LIC-9099C, and appeal rights were provided to the facility. An exit interview was conducted.

Investigation Findings:
13Licensing Program Analyst (LPA) Tina Thorn arrived unannounced at the facility on 12.19.24 for the purpose of delivering findings for the complaint investigation. LPA met with NAME, TITLE. LPA Thorn and LPA Lyta Vue conducted the complaint investigation. LPA opened the investigation with the facility on 10.11.24 and met with Paige Woodard, Program Director and conducted a Health and Safety Inspection. During the course of the investigation, LPA interviewed One Probation Officer, six staff, and three clients, LPA reviewed records including: Needs and Services Plan for three clients, Intake forms for three clients, LIC 500, Placing Agency Contacts, Staff Training Log, Incident Reports, a video, and photographs. It was alleged that staff made inappropriate comments toward the minors. Client and staff interviews corroborated that on occasion, staff speak inappropriately to the clients, or with a derogatory tone. Two staff spoke of this being an ongoing problem and staff need more training. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Hillary Hall LICENSING EVALUATOR NAME: Tina Thorn LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: MT. LASSEN TREATMENT CENTERFACILITY NUMBER: VISIT DATE: 12/19/2024

report_type: Complaint Investigation

met_with: Paige Woodard, Program Director

complaint_status: unsubstantiated


raw_content:
Narrative:
The SIR's that were sent and reviewed for the months of October-December reflect an understanding by staff of emergency intervention strategies. There was not enough information provided from interviews and records to demonstrate whether the facility contacted law enforcement when specifically directed by the placing agency, in accordance with their Emergency Intervention Plan. The facility did follow policies in their Program Statement indicating law enforcement is contacted as a last resort when all other de-escalation measures are ineffectual. Based on LPA's observations, interviews which were conducted, and records reviewed, although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove the violation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED. A signed copy of this LIC-9099 report, the LIC-9099C, and appeal rights were provided to the facility. An exit interview was conducted. During the months of October-December 2024, 25 incident reports were submitted to the department without corresponding final reports being submitted. There were no incident reports submitted with information about the youth escaping their room, the incident stated above. Program Director admitted to not being aware of reporting requirements. Interviews with the County Social worker and Probation indicated that incident reports are also not being sent consistently to their respective departments from the facility. Based on LPA's interviews which were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. Citations were issued previously for the same allegations on December 19, 2024. No repeat citation is issued as a Plan of Correction was completed by January 17, 2025. A signed copy of this LIC-9099 report, the LIC-9099C were provided to the facility. An exit interview was conducted. Appeal rights were provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tina Thorn arrived unannounced at the facility on 02.07.25 for the purpose of delivering findings for the complaint investigation. LPA met with Paige Woodard, Program Director.LPA Thorn and LPA Aleza Ruiz conducted the complaint investigation. LPA opened the investigation with the facility on 11.14.24 and met with Paige Woodard, Program Director. During the course of the investigation, LPA interviewed 4 staff, 6 clients, a Probation Officer, and a County Social Worker. LPA reviewed records from the facility including Placement Roster, Training logs, prior complaint history, staff schedule, client roster, placing agency contact information, and Serious Incident Reports. It was alleged that lack of supervision resulted in inappropriate interactions between youth. Staff and Client interviews corroborated that on one evening bed checks were not properly performed and that two youth were able to escape their dorm room and engage in inappropriate and destructive activities. Interviews were inconsistent regarding a lack of supervision as the cause of two youth being inappropriate in the showering room. Continued on 812C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Hillary Hall LICENSING EVALUATOR NAME: Tina Thorn LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE This is an official report of an unannounced visit/investigation of a complaint received in our office on 11/08/2024 and conducted by Evaluator Tina Thorn COMPLAINT CONTROL NUMBER: 23-CR- FACILITY NAME:MT. LASSEN TREATMENT CENTERFACILITY NUMBER: ADMINISTRATOR:BROWN, ALVINFACILITY TYPE: ADDRESS: FRICOT CITY ROAD UNIT MTELEPHONE: (209) 639- CITY:SAN ANDREASSTATE: CAZIP CODE: CAPACITY:16CENSUS: DATE: 02/07/ UNANNOUNCEDTIME BEGAN: 11: AM MET WITH:Paige Woodard, Program DirectorTIME COMPLETED:01: PM 9Facility did not follow emergency intervention plan INVESTIGATION FINDINGS: 13Licensing Program Analyst (LPA) Tina Thorn arrived unannounced at the facility on 02.07.25 for the purpose of delivering findings for the complaint investigation. LPA met with Paige Woodard, Program Director. LPA Thorn and LPA Aleza Ruiz conducted the complaint investigation. LPA opened the investigation with the facility on 11.14.24 and met with Paige Woodard, Program Director. During the course of the investigation, LPA interviewed 4 staff, 6 clients, a Probation Officer, and a County Social Worker. LPA reviewed records from the facility including Placement Roster, Training logs, prior complaint history, staff schedule, client roster, placing agency contact information, and Serious Incident Reports. Regarding the allegation that the facility did not follow the Emergency Intervention Plan, upon LPA's review of the facility's Program Statement, the staff interviewed named various emergency situations and were able to explain the emergency intervention plan. Due to all full serious incident reports not being submitted to the Department, evaluating whether staff always used emergency interventions was not possible. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Hillary Hall LICENSING EVALUATOR NAME: Tina Thorn LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 2 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: MT. LASSEN TREATMENT CENTERFACILITY NUMBER: VISIT DATE: 02/07/2025


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Continued from The facility subsequently drug tested the youth which resulted in positive tests for marijuana. During interviews there was no mention of clients having access to marijuana before this incident took place. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. Citation is being issued for violating Interim Licensing standards Section Personal Rights: (c)(16) A signed copy of this LIC-9099 report, the LIC-9099C, and LIC-9099D were provided to the facility. An exit interview was conducted. Appeal rights were provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Aleza Ruiz arrived unannounced at the facility on this date for the purpose of delivering findings for the complaint investigation. LPA met with Paige Woodard, Program Director. LPA Aleza Ruiz and LPA Elena Gonzalez-Soto conducted the complaint investigation. LPA Gonzalez-Soto initiated the investigation with the facility on 12/30/2024 and met with Paige Woodard, Program Director. During the course of the investigation, LPA Ruiz interviewed three youth, one probation officer, and six staff members. LPA reviewed records including: Placement Roster, Training logs, prior complaint history, drug test findings, Serious Incident Reports, and video footage. Regarding the allegations listed, the facility submitted an incident report to the department alleging a staff member provided a marijuana pen to clients and participated in marijuana use with clients. Two youth present during the incident reported the staff did provide marijuana to the clients and participated in marijuana use with the clients. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Hillary Hall LICENSING EVALUATOR NAME: Aleza Ruiz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: MT. LASSEN TREATMENT CENTERFACILITY NUMBER: VISIT DATE: 03/13/2025

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

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
Continued from During interviews two individuals stated a marijuana pen was used, one denying nicotine was in the pen at all, one denying a pen was given to clients at all and one denying witnessing any other clients smoke and denying they smoked at all. Regarding the inappropriate comments made to clients, there were conflicting interviews stating this did or did not happen along with an incident report that staff refused to sign and hand-printed that they did not make the statements alleged on the incident report. Based on LPA's observations, interviews which were conducted, and records reviewed, although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove the violation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED. A signed copy of this LIC-9099 report, the LIC-9099C, and appeal rights were provided to the facility. An exit interview was conducted.

Investigation Findings:
13Licensing Program Analyst (LPA) Aleza Ruiz arrived unannounced at the facility on this date for the purpose of delivering findings for the complaint investigation. LPA met with Paige Woodard, Program Director. LPA Aleza Ruiz and LPA Elena Gonzalez-Soto conducted the complaint investigation. LPA Gonzalez-Soto initiated the investigation with the facility on 12/30/2024 and met with Paige Woodard, Program Director. During the course of the investigation, LPA Ruiz interviewed three youth, one probation officer and six staff members. LPA reviewed records including: Placement Roster, Training logs, prior complaint history, Serious Incident Reports, and video footage. The facility submitted an incident report to the department alleging staff provided a nicotine vape pen to clients and that staff made inappropriate comments to clients. While observing the video footage that was provided by the facility from the events that took place there is no clear visual of what type of 'pen' is handed to clients. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Hillary Hall LICENSING EVALUATOR NAME: Aleza Ruiz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: MT. LASSEN TREATMENT CENTERFACILITY NUMBER: VISIT DATE: 03/13/2025


raw_content:
Narrative:
It was alleged that one youth was sexually abused multiple times while in care, with the extent of the abuse being that one staff allegedly asked the youth to undress. Interviews with five staff and three youth provided inconsistent statements regarding these inappropriate interactions between the youth and the one staff member, with only one individual reporting these inappropriate interactions. No physical contact was reported between the staff and youth. Camera footage from one of the reported incidents, shows that the staff did not even enter the youth's room on the date and time of one of the alleged interactions. Interviews conducted with five staff were consistent that they have no knowledge of the youth being handled in a rough manner by any staff members. Three youth interviewed spoke of a staff member breaking up a physical altercation between the three youths. Two of the three youth stated that a staff member performed a restraint on one youth in order to separate this youth from the altercation. One youth was unsure if a restraint was used or whether the staff was holding the youth to break up the fight. An Incident Report received by the department explains that the youth were separated physically, but that no restraint was secured and that no injuries were sustained as a result of the staff member. Based on LPA's observations, interviews which were conducted, and records reviewed, although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove the violation did, or did not, occur. Therefore, the allegations are UNSUBSTANTIATED. A signed copy of this LIC-9099 report, the LIC-9099C, and appeal rights were provided to the facility. An exit interview was conducted

Investigation Findings:
13Licensing Program Analyst (LPA) Tina Thorn arrived unannounced at the facility on 07.25.25 for the purpose of delivering findings for the complaint investigation. LPA met with Paige Woodard, Program Director. LPA Thorn conducted the complaint investigation along with the Investigations Branch (IB's). LPA opened the investigation with the facility on 04.28.25 and met with Paige Woodard, Program Director and conducted a Health and Safety Inspection. During the course of the investigation, LPA was present during IB's interviews with 5 staff members and 3 youth. LPA reviewed records from the facility including: prior complaint history, Serious Incident Reports, CFT notes, Case plan for 1 youth, fingerprint clearance roster, LIC 500-personnel roster, Client roster, Youth intake face sheet, a Calaveras County Sheriff's report, and camera footage of one incident. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Hillary Hall LICENSING EVALUATOR NAME: Tina Thorn LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: MT. LASSEN TREATMENT CENTERFACILITY NUMBER: VISIT DATE: 07/25/2025


summary: Facility Evaluation

raw_content:
Narrative:
On 1/17/2024, Licensing Program Analyst (LPA) Tina Thorn and Licensing Program Manager (LPM) Hillary Hall arrived unannounced at the facility and met with Paige Woodard, Administrator for Yosemite Treatment Facility, which shares the campus. The purpose of the visit was to conduct a Required Annual Inspection of the facility. The facility was licensed on 12/22/2022 but has not opened and has not placed any clients since being licensed. The facility has no staff, aside from Corporate staff who are not on site. LPA and LPM utilized the CARE Tool to complete the Annual inspection. LPA and LPM conducted an inspection of the physical property, which is a large campus consisting of multiple buildings. The dormitory, which would be used for clients is mostly empty and currently locked and kept inaccessible due to no clients. The capacity of the facility is sixteen and there is a bedroom for each client. A separate dining hall is shared by Mt Lassen and Yosemite Treatment facility. In the dormitories, each client will have a closet and dresser. A fenced pool is shared by the two facilities. The campus property allows for clients to access a variety of sports equipment. LPA observed the proper postings including: facility license, complaint hot-line, client personal rights, and emergency disaster plan. As there are no clients, no client files were observed or reviewed. The facility has no outstanding fees. As there are no clients or staff, no interviews were conducted. No citations were given on this date. A signed copy of this LIC-809 and LIC-809C report was provided to Paige Woodard. An exit interview was conducted.

visit_type: Annual

met_with: Paige Woodard, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 12.19.24, Licensing Program Analyst (LPA) Tina Thorn arrived unannounced at the facility and met with Paige Woodard, Administrator. The purpose of the visit was to conduct a Required, Two-year Annual Inspection of the facility. The inspection was completed on 12.20.24. The facility was licensed on 12.23.22. LPA utilized the CARE Tool to complete the inspection. LPA conducted an inspection of the physical plant and checked for all necessary requirements. The facility was clean and organized and maintained an acceptable room temperature. The facility is on a large campus with many buildings. There are no more than 2 clients sharing a bedroom in a dorm like setting. The facility has 3 client bathrooms. All bathrooms were observed to be clean and fully functioning. The dining hall is separate from the dorms. Each client had a closet and dresser in good repair. Mattresses and bedding were observed to be clean. Clients were able to decorate their rooms with their personal belongings. The facility has a properly fenced pool, and opportunities for clients to access sports equipment. LPA observed the proper postings including facility license, complaint hotline, client personal rights, and emergency disaster plan. Smoke alarms, fire extinguishers and a first aid kit were observed to be current and within regulations. LPA observed the kitchen to have 3 restaurant sized refrigerators and freezers with at least 2 days of perishable food and 7 days of non-perishable food on hand. LPA observed client medications were stored in a locked file cabinet in the locked medical office. Client files are primarily electronic with paper files for clients locked in the Head of Service's office. The facility has no outstanding fees. The facility currently has 13 clients, with a licensed maximum capacity of 16. Staff to client ratio is 1 to 4. LPA reviewed 3 staff files. Staff files had completed criminal record clearances, and all required initial and annual training. All first Aide and CPR certifications were up to date for staff. Continued C LPA reviewed 3 client files. All clients had signed Admission Agreements on file. Client files had completed initial Needs and Services Treatment Plans, signed by clients and staff, and updated Needs and Service plans every 30 days. Needs and Service Plans detailed adequate supportive services the facility offers to the clients. Clients were current on physical and dental exams. Six were taking court ordered psychotropic medications and had current JV-220's on file. LPA interviewed 3 clients and 3 staff. No citations were given on this date. A signed copy of this LIC-809 and LIC 809C report was provided to Administrator An exit interview was conducted.

met_with: Paige Woodard, Program Direcdtor


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Aleza Ruiz arrived unannounced at the facility for the purpose of a case management following an incident report received by the department regarding an incident that took place on 2/25/2025 that required follow up. This incident involved a staff member pushing a client away from them "instead of placing [them] in a Safe Crisis Management." LPA conducted two staff interviews and one client interview. No citations given at this time. Further follow up is needed. Exit interview was conducted and a copy of this report was left with the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On 05.15. Licensing Program Analyst (LPA) Tina Thorn received an incident report regarding a verbal altercation between staff and youth preceding a physical restraint given by staff. On 05.27. LPA followed up with Paige Woodard, Program Director who agreed to email details about the incident. On 05.29. LPA received an email from Program Director explaining the incident in more detail. The email stated that the staff was placed on administrative leave while an investigation was being completed. On 06.04. Program Director called LPA to report that the staff had been terminated from his position due to inappropriate conduct. On 06.12. LPA spoke in person with Program Director as a follow-up and to request that written confirmation of staff's termination be sent to LPA. On June 24, LPA received an email from Program Director with written confirmation that the staff involved had been terminated on 06.04.25.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tina Thorn arrived unannounced at the facility for the purpose of a case management following a record review of drug tests conducted on youth at the facility. Licensing Program Manager (LPM) Hillary Hall conducted the record review. LPM reviewed Incident reports, and records from the facility indicating 6 youth were drug tested 10 times during the time period of 8/24/24-12/27/24. Drug testing results provided to the Department did not include reported testing of 3 youth, referenced in an Incident report occurring 12/21/24. Of the 10 drug tests documented, three were done for reasons listed as return from home pass or day pass. All documented tests were negative for illegal substances. LPM reviewed the Program Statement for the facility and found no policies and procedures regarding drug testing youth. LPA Elena Soto-Gonzalez interviewed facility Head of Service on 12/30/24, who indicated the facility does drug testing when they have a concern the youth may have used illegal substances. LPM spoke with Program Director (PD) Paige Woodard on 2/4/2025 who indicated there were no known written or internal policies on drug testing the youth and the staff are not trained on drug testing. LPM spoke with representatives from five different Probation Departments. Two of these departments were unaware their youth had been drug tested at the facility, with one department specifically not authorizing the tests. Two departments had given verbal permission for the facility to drug test the youth, but were unaware policies or procedures were not outlined in the facility program statement regarding testing, with one of these counties choosing to no longer authorize testing by the facility. The fifth department contacted indicated they have not placed youth at the facility recently, but have detained multiple youth from the facility who had been drug tested following a return from home or a visit. One citation is being issued per Title Division 6, Section 80022(k): Plan of Operation: (k) The facility shall operate in accordance with the terms specified in the Plan of Operation and may be cited for not doing so. A signed copy of this 809 and 809D was provided to the facility.


raw_content:
Narrative:
It was alleged that one staff spoke inappropriately to a youth in care. Six of six interviews with staff indicate that this staff member would consistently make inappropriate and antagonistic comments to the youth. The youth who were interviewed corroborated that this staff would often engage argumentatively and use derogatory language with them. Records reviewed included documentation of previous disciplinary action taken against this staff for inappropriate conduct and this staff member has been terminated. Based on LPA's interviews which were conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. Citation is being issued for violating Interim Licensing standards Section # 87072 (c) (16) A signed copy of this LIC-9099 report, the LIC-9099C, and LIC-9099D were provided to the facility. An exit interview was conducted. Appeal rights were provided. There was an allegation that one staff member inappropriately touched a youth in care while engaging in a group activity. Another staff member that was present at this group activity did not witness any physical contact but had suggested the game be modified to ensure that no physical contact was likely. Youth who were interviewed denied ever being inappropriately touched by this staff member. It was alleged that one staff slept while on duty and that this staff exposed their body to youth in care. Two youth interviewed agreed that this staff fell asleep on a couch. Both denied observing, at any time, this staff member's body parts being exposed. One staff member indicated that the other staff member did slouch down and may have fallen asleep but clarified that this staff was not on duty at the time and did not expose body parts. None of the other staff members interviewed had knowledge of this incident. Based on LPA's interviews which were conducted and records reviewed, although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove the violations did, or did not, occur. Therefore, the allegations are UNSUBSTANTIATED. A signed copy of this LIC-9099 report, the LIC-9099C, and appeal rights were provided to the facility. An exit interview was conducted.

Investigation Findings:
13Licensing Program Analyst (LPA) Tina Thorn arrived unannounced at the facility on 04.02.26 for the purpose of delivering findings for the complaint investigation. LPA met with Paige Woodard, Program Director. LPA Thorn conducted the complaint investigation. LPA opened the investigation with the facility on 01.29.26 and met with Paige Woodard, Program Director and Columbus Bender, Compliance Manager and conducted a Health and Safety Inspection. During the course of the investigation, LPA interviewed two youths, one county social worker, six facility staff members and one other confidential interview. LPA reviewed records including Placement Roster, prior complaint history, Serious Incident Reports, Child and Family Team Notes, Needs and Service Plans for one foster youth, emails between staff, a youth grievance form, placing agency documentation and a staff incident statement. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Hillary Hall LICENSING EVALUATOR NAME: Tina Thorn LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: MT. LASSEN TREATMENT CENTERFACILITY NUMBER: VISIT DATE: 04/02/2026


facility_name: MUNCIE HOUSE

summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13On April 28, 2021, Licensing Program Analyst (LPA) Eduardo Barragan conducted a complaint inspection at Muncie Home by phone and spoke with Shayla Taylor, Residential Director. The purpose of the call was to deliver the findings for the above complaint allegations. During the investigation, LPA Barragan, reviewed documents, interviewed staff and Clients. The administrator stated they did discharge C1 from their facility without his belongings. Interviews with Staff and a Client also confirmed this information. Based off interviews and record review the facility did not follow the proper discharge procedures as directed by Short Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS). The Licensee stated that they did not inform C1 that he was being removed from the facility, and they tricked C1 into thinking they were taking him out on an outing. "Based on LPA's observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.") Due to the deficiency's listed above two deficiency's are being cited on todays visit. An exit interview was conducted with Shayla Taylor, Residential Director. A copy of the report and appeal rights were emails to Shayla Taylor, Residential Director, in order to obtain a signature. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Eduardo Barragan 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 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, E SHAW AVE FACILITY NAME: MUNCIE HOUSEFACILITY NUMBER: 107202348

met_with: Shayla Taylor, Residential Director


raw_content:
Investigation Findings:
13On April 28, 2021, Licensing Program Analyst (LPA) Eduardo Barragan conducted a complaint inspection at Muncie House and spoke with Shayla Taylor, Residential Director. The purpose of the inspection was to deliver the findings for the above complaint allegation. The Department has investigated the complaint alleging a "client was not provided mental health services " LPA Barragan spoke with Staff, Clients, Social Workers and reviewed predominant documents. Based on documents reviewed and conversations with the Staff, Clients, and Social Workers, all the information that was gathered was contradicting. "Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED." An exit interview was conducted with Shayla Taylor, Residential Director. A copy of the report and appeal rights were emailed to Shayla Taylor, Residential Director, in order to obtain a signature. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Eduardo Barragan 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 2


raw_content:
Investigation Findings:
13On this date, Licensing Program Analyst (LPA) Jessica Rodriguez conducted a follow up complaint inspection for the Muncie Group Home and met with Administrator, Dekeydra Mothershed. The purpose of the inspection was to deliver the findings for the above complaint allegations. During the investigating, LPA conducted interviews with residents and staff. The statements provided to LPA by both residents and staff were inconsistent. Due to the conflicting information revealed in the interview process, the agency has deemed the allegations to be unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to provide the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted and a copy of the report was left with the agency. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Jessica Rodriguez 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 2

met_with: Dekeydra Mothershed


raw_content:
Investigation Findings:
13On this date, Licensing Program Analyst (LPA) Jessica Rodriguez conducted a follow up complaint inspection for the Muncie Group Home and met with Administrator, Dekeydra Mothershed. The purpose of the inspection was to deliver the findings for the above complaint allegation. During the investigating, LPA conducted interviews with residents and staff and reviewed incident reports. Due to the conflicting information revealed in the interview process, the agency has deemed the allegation to be unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted and a copy of the report was left with the agency. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Jessica Rodriguez 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 2


summary: Facility Evaluation

raw_content:
Narrative:
On October 22, 2021, Licensing Program Analyst (LPA) Jessica Rodriguez conducted an unannounced case management at the corporate offices of KYJO, two discuss two deficiencies for the above facility. LPA was met with Administrator, Virginia Hernandez. After reviewing incident reports, and interviews conducted by LPA Barragan with staff and clients, LPA Rodriguez noted a lack of supervision. LPA Rodriguez noted several incident/ encounters were C1 hit and bullied C2, yet staff continuously seemed unaware. During those incidents C1 and C2 were the only two residents at the facility at that time therefore, there was no reason for the clients to not be supervised. Interviews conducted by LPA Barragan with staff confirmed that both staff were in the office together during many of these occasions, yet staff was aware that C1 was hitting and bullying C2. LPA also discussed a second deficiency regarding the inappropriate discharge for C2. C2 was not discharged from the program in a trauma informed way. As these requirements were not met, the facility is receiving two deficiencies. A copy of the deficiency log with appeal rights was provided to the Agency See attached LIC Confidential Names List.

met_with: Virginia Hernandez


facility_name: NABEA FAMILY YOUTH SERVICES INC

summary: Facility Evaluation

raw_content:
Narrative:
On Frebruary 5. 2026, Licensing Program Analyst (LPA) Babatunde Aborchie and Licensing Program Manager (LPM) Abdoulaye Traore met with applicant Tiara Johnson and Tiyon Johnson for component II. LPA and LPM went over revisions needed for the application prior to licensure. Applicant is applying for STRTP license. LPA and LPM gave a copy of the LIC 184, Notice of Incomplete Application, and additional correspondence to assist with the revisions needed to the application. Copy of this report was provided to applicant.

met_with: Licensee


summary: Facility Evaluation

raw_content:
Narrative:
On February 12, 2026, Licensing Program Analyst (LPA) Babatunde Aborchie began a pre-licensing inspection for a Short Term Residential Therapeutic Program (STRTP) license. LPA met with administrator, Tiara Johnson at the facility. The facility was toured both inside and out with the applicant. The applicant is applying to serve six minor and nonminor dependent (NMD) children. The residence is a six-bedroom two story-house with three and half bathrooms. The downstairs area consists of a living room, a kitchen, dining area, laundry room, storage down the stairs, one and a half bathrooms, the garage, and the backyard. There were two rooms downstairs. Bedroom #1 was fully furnished with office furniture, a desk, chair, office cabinets and used as an office. Bedroom #2 was fully furnished; it consists of one Cal-King-sized bed; it will sleep one client. In addition to the downstairs, medication will be locked in the office cabinet. Upstairs consist of four bedrooms and two bathrooms. Bedroom #3 was furnished with a full-sized bunked bed; it will sleep two clients. It was vacant. Bedroom #4 was furnished with one twin-sized bunk bed, it will sleep two clients. Bedroom#5 was furnished with two twin-sized beds; it will sleep two clients. It was vacant. Bedroom #6 was furnished with a king-sized bed, fully furnished; Licensee stated it will be used as a lounge for clients to use. Bedrooms were arranged so that no more than two clients share a room, and there was one child per bed. No room commonly used for other purposes was used as a bedroom, and no bedroom serves as a passageway to another room. There were adequate drawers and closet space for children's belongings. Towels and linens were stored in a cabinet by the clients' bedrooms. Two smoke and carbon monoxides detectors were checked and were working properly. All hazardous items have been properly made inaccessible to areas where clients would have access. Sharp objects/knives were locked and stored in the kitchen cabinet. Cleansers/chemicals were locked and stored in the closet upstairs. The first aid kit was in the laundry room area, accessible and contained all required items. There were no guns or weapons as stated by the administrator at this time. The hot water temperature was tested and noted to be 118 degrees. There was adequate food storage supply of two days of perishable foods and a week of non-perishable food. Proper storage of all food was discussed. Trash cans for storage of solid waste have tight fitting lids. The Facility Sketch, Emergency Disaster Plan, visitation policy and Personal Rights were posted. There were no pool or other body of water and the backyard where clients would have access to play was completely fenced and free of hazards. There was a total of four cameras, all located indoors which met the title 22 camera policy. LPA conducted a component III during the visit. The facility is appropriate for a capacity of six ambulatory clients, ages ten to seventeen and non-minor dependents. All requirements were met at this time. Licensing Program Manager will complete a final review prior to issuing a provisional license. A copy of this report was reviewed and provided to the administrator.

visit_type: Prelicensing

met_with: Administrator


facility_name: NEW ALTERNATIVES, INC #5

raw_content:
Narrative:
(SIR) to Orange County Social Services (OCSSA) and the Department via OCSSA's FYI Reporting System. Confidential interviews revealed C1's authorized representative is not included in that system. Confidential interviews and documents obtained revealed that SIR's involving C1 included the use of manual restraints. Confidential interviews revealed that C1's authorized representative was not notified in writing or by telephone when the use of a manual restraint was used on C1. Confidential interviews revealed that C1's authorized representative had requested SIR's and other documents related to C1 and the facility did not provide the requested documents. Based on confidential interviews, the preponderance of evidence standard has been met regarding the allegation that that the facility is failing to notify the authorized representative of incidents involving C1. This poses a potential Health, Safety or Personal Rights risk to the children in care. The facility will be cited for violating Short-Term Residential Therapeutic Program Interim Licensing Standards, Version 3.1, Section 87061(b)(3) Reporting Requirements - The licensee shall ensure that the child's authorized representative is notified no later than the next business day if the following circumstances have occurred without the authorized representative's participation: Each time the child has been placed in a manual restraint, to be reported as required in Section 87095.61. Exit interview was conducted and a copy of this report, along with a Confidential Names List (LIC 811 dated 07/09/2021), and the appeal rights were explained and provided to Program Director Meaghan Critchlow.

Investigation Findings:
13On July 09, 2021, at 9: AM, Licensing Program Analyst (LPA) Jesus Cervantes made an unannounced visit at the facility. LPA met with Program Director Meaghan Critchlow, to issue the investigative findings of the allegations listed above. On June 07, 2021, Licensing Program Analyst (LPA), Jesus Cervantes, inspected the facility, and no deficiencies were noted. LPA Cervantes conducted interviews with Staff 1 (S1) and the County Social Worker (CSW). During the investigation, LPA reviewed facility records and obtained copies of the following documents: Special Incident Reports (SIR's) associated with Foster Child #1 (C1). On June 02, 2021, Community Care Licensing received an allegation that the facility is failing to notify the authorized representative of incidents involving C1. Confidential interviews revealed the authorized representative of C1 has not been receiving incidents reports involving C1. However, confidential interviews and documents obtained revealed the facility has been submitting Special Incident Reports ... SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Jesus Cervantes LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: NEW ALTERNATIVES, INC #5FACILITY NUMBER: VISIT DATE: 07/09/2021

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

met_with: Meaghan Critchlow


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
S2 intervened and began to attempt to redirect C1's behavior verbally. C1 refused to listen to S2 and began to verbally and physically assault S2. Confidential interviews revealed that in the process of C1 attacking S2, C1 fell on C1's back and began to scoot on C1's back towards S2 to kick S2. S2 would move around to avoid being kicked by C1, and C1 continued to try to kick S2, C1 obtained rug burns in the process. However, other confidential interviews revealed that C1 was dragged by S2 to C1's bedroom and received rug burns while being dragged. Based on confidential interviews and records reviewed, the allegations that C1 sustained injuries while in care, and S2 handled C1 in a rough manner may have occurred; however, it is 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 along with appeal rights was provided to Administrator Meaghan Critchlow.

Investigation Findings:
13On December 09, 2021, at 1: PM, Licensing Program Analyst (LPA) Jesus Cervantes made an unannounced visit at the facility. LPA met with Administrator Meaghan Critchlow, to issue the investigative findings of the allegations listed above. On May 21, 2021, Licensing Program Analyst (LPA), Jesus Cervantes, conducted an inspection of the facility, and no deficiencies were noted. LPA Cervantes conducted interviews with a Confidential Witness, three staff members (S1, S2, and S3), and Foster Child #1 (C1). During the investigation, LPA reviewed facility records and obtained copies of the following documents: facility case notes, special incident reports, photographs of injuries, and foster child files. On May 11, 2021, Community Care Licensing received the allegation that C1 sustained injuries while in care, and S2 handled C1 in a rough manner. Confidential interviews revealed C1 was refusing to get ready for bedtime and began to physically assault S3. SEE PAGE TWO UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Jesus Cervantes LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: NEW ALTERNATIVES, INC #5FACILITY NUMBER: VISIT DATE: 12/09/2021

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


raw_content:
Narrative:
Confidential interviews revealed C1 may have been inappropriately touched by C2 which led to C1 enduring physical and emotional pain. However, confidential interviews revealed no staff witnessed C1 being inappropriately touched or physically and emotionally hurt by C2. There were no witnesses to the alleged incidents. Based on confidential interviews, the allegations that C1 was physically hurt while in care and C1 was emotionally hurt while in care may have occurred; however, it is 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 along with appeal rights was provided to Administrator Meaghan Critchlow.

Investigation Findings:
13On December 16, 2021, at 10: AM, Licensing Program Analyst (LPA) Jesus Cervantes and Sarah Alvizo made an unannounced inspection at the facility. LPA met with Administrator Meaghan Critchlow, to issue the investigative finding of the allegations listed above. On September 27, 2021, Licensing Program Analyst (LPA), Jesus Cervantes, conducted an inspection of the facility, and no deficiencies were noted. LPA Cervantes conducted interviews with a Confidential Witness, four staff members (S1, S2, S3, and S4), and two of two foster children (C1 and C2). During the investigation, LPA reviewed facility records and obtained copies of the following documents: facility case notes, special incident reports, and foster children files. On September 22, 2021, Community Care Licensing received the allegation that C1 was physically hurt while in care and C1 was emotionally hurt while in care. Confidential interviews revealed conflicting information regarding C1 being physically and emotionally hurt while in care. SEE PAGE TWO UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Jesus Cervantes LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: NEW ALTERNATIVES, INC #5FACILITY NUMBER: VISIT DATE: 12/16/2021

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


raw_content:
Narrative:
Confidential witnesses also revealed that S1 had made threats of recording client's inappropriate behavior to share it with clients' families. In addition, the confidential witnesses stated that S1 yelled at clients. CSW reiterated that he was informed that S1 threatened C1 and used inappropriate comments toward C1. CSW stated that he was also informed that S1 had yelled at C1. During LPA's review of S1's employment records, it was observed that on February 2, 2022, S1 had been given an employee warning report for poor work quality. Moreover, S1 resigned from the facility without notice and left during shift on February 7, 2022. Based on confidential interviews and record review, the preponderance of evidence standard has been met and the Department has determined that S1 had spoken inappropriately to C1, S1 threatened C1 and yelled at clients while in care. Therefore, these allegations are substantiated. The facility is being cited for violation of the Interim Licensing Standards, Chapter 7. Short Term Residential Therapeutic Program, Articles 1 through 10, Version Personal Rights 87072(c)(11) An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Breanna Tucker.

Investigation Findings:
13On May 5, 2022, at 12: PM Licensing Program Analyst (LPA) Michael Almaraz arrived at the facility and met with facility program administrative director, Breanna Tucker, to issue the finding for the above stated allegations involving the facility and the clients (C1, C2, C3...C8) listed on the Confidential Names List (LIC 811) dated on 05/05/2022. On February 16, 2022, at 10: AM LPA Almaraz conducted a safety inspection at the facility. During the inspection, LPA reviewed one client's records, reviewed one staff's employment records, and conducted interviews with two staff. Additionally, LPA conducted interviews with five of eight clients, an additional staff and a county social worker (CSW). Three clients were unavailable for interviews. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore 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 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: NEW ALTERNATIVES, INC #5FACILITY NUMBER: VISIT DATE: 05/05/2022

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

met_with: Breanna Tucker


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

raw_content:
Narrative:
Documents reviewed confirmed that S6 was terminated for sleeping during the night shift. Based on confidential interviews and documents reviewed, the preponderance of evidence standard has been met and the allegations that Staff are sleeping during the evening hours is substantiated. The facility is being cited for violation of Interim Licensing Standards (ILS), version 5, article Continuing Requirements, section 87065.5 (a)(2) Direct Care Staff/Child Ratios. An exit interview was conducted, and a copy of this report along with appeal rights was provided to Michael Armas. Based on confidential interviews and records reviewed Staff do not provide adequate care and supervision to the minors, which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this report along with appeal rights was provided to Michael Armas.

Investigation Findings:
13On August 07, 2024, at 10: AM, Licensing Program Analyst (LPA) Jacqueline Garcia conducted an unannounced visit to New Alternatives INC #5 and met with Program Director, Michael Armas, to deliver the investigative findings for the allegation listed above. On 03/25/24, LPA conducted a health and safety inspection at the facility, and no immediate health and safety hazards were observed. During the investigation, LPA reviewed C1 facility file and staff files. LPA interviewed three clients (C2-C4), five staff (S1-S5) and attempted to interview one client (C1), however was not able to reach. LPA Also attempted to interview S6 however, they no longer worked at the facility. On 03/19/24, Community Care Licensing (CCL) received allegation that staff are sleeping during the evening hours. It was specifically reported that C1 got up in the middle of the night and two staff were sleeping. Confidential interviews indicated that a staff (unknown) was seen sitting in the hallway with their head back in the middle of the night. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Jacqueline Garcia LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: NEW ALTERNATIVES, INC #5FACILITY NUMBER: VISIT DATE: 08/07/2024

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

Deficiencies:
87065.5: In a facility with a licensed capacity of six or fewer children, there shall be coverage by direct care staff as follows: During the hours of 10 pm to 7 am, there shall be one awake and on duty direct care staff for every six children, or fraction thereof, present, at a minimum.

met_with: Michael Armas-Program Director

title: (a)(2) Direct Care Staff/Child Ratios


raw_content:
Narrative:
interviews denied staff checked on C1 and C2 in their bedroom and C1 was able to walk to C2's bedroom and walk back to their bedroom and did not observe staff in the hallway. Based on confidential interviews the allegation that lack of supervision resulting in minors engaging in inappropriate activity is substantiated. The preponderance of evidence standard has been met. The facility is cited for violation of the Interim Licensing Standards STRTP 87065.2(b)(1) Personnel Duties. An exit interview was conducted, and appeal rights reviewed. A copy of this report and appeal rights were provided to Susan Shannon. A copy of this report will be placed in the facility file.

Investigation Findings:
13On March 6, 2025, at 11:45 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility and met with Susan Shannon, Senior Manager, to discuss the investigative finding for the allegation noted above. LPA Jacqueline Garcia conducted an inspection of the facility on September 11, 2024, at 3:15 pm. No deficiencies were observed. LPA Linley interviewed three out of eight Clients (C1-3), and four Staff (S1-4), LPA was unable to interview four Staff (S4-8), despite multiple attempts to contact them. LPA reviewed facility documents during the investigation. On September 10, 2024, Community Care Licensing (CCL) received an allegation that lack of supervision resulting in minors engaging in inappropriate activity. It was reported that C1 and C2 had sexual intercourse in C2's bedroom and staff was unaware that C1 was in C2's bedroom. Confidential interviews indicated C1 walked to C2's bedroom and C1 and C2 had sexual intercourse in C2's bedroom. Confidential interviews indicated C3 saw C1 and C2 in C2's bedroom without their clothes and C1 got on top of C2. Confidential SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: NEW ALTERNATIVES, INC #5FACILITY NUMBER: VISIT DATE: 03/06/2025

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

met_with: Susan Shannon


raw_content:
Narrative:
and C2's bedrooms each night and did not observe C2 go into C1's bedroom. Other interviews indicated C2's bedroom screen was removed at times by C2; however, interviews could not recall C1's screen being removed. LPA was unable to interview all individuals, although multiple attempts were made, thus, confidential interviews could not confirm or deny the allegations. Confidential interviews did not corroborate the allegation with a preponderance of evidence. Based on confidential interviews and records reviewed the allegation that staff did not provide adequate supervision resulting in minors engaging in inappropriate sexual behavior, which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report, LIC 811, and appeal rights were provided to Skylar Boulton. A copy of this report will be placed in the facility file.

Investigation Findings:
13On May 5, 2025, at 11:30 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Skylar Boulton, Facility Coordinator, to discuss the investigative finding for the allegation noted above. LPA Jacqueline Garcia conducted an inspection of the facility on December 11, 2024, at 9:00 am and no deficiencies were observed. LPA interviewed one Client (C2) and six Staff (S1-6), and LPA was unable to interview two Clients (C1, C3), despite multiple attempts to contact them. LPA reviewed the facility documents during the investigation. On December 9, 2024, Community Care Licensing (CCL) received an allegation that staff did not provide adequate supervision resulting in minors engaging in inappropriate sexual behavior. It was reported that C2 climbed through C1's window and touched C1 and started having sex with C1 while C1 was laying in their bed. Confidential interviews revealed conflicting statements. Some interviews indicated staff sat outside of C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: NEW ALTERNATIVES, INC #5FACILITY NUMBER: VISIT DATE: 05/05/2025

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

met_with: Skylar Boulton


raw_content:
Narrative:
****PAGE CONTINUED: However, clients C1 and C2 were unable to be interviewed to confirm that Facility staff did not prevent inappropriate interaction between minors. Thus, confidential interviews and records reviewed did not corroborate the allegation with a preponderance of evidence. Based on confidential interviews and records reviewed the allegation Facility staff did not prevent inappropriate interaction between minors, which may have occurred, however, are not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this report, LIC 811 and appeal rights was provided to Clinical Director, Porsha Draper.

Investigation Findings:
13On September 25, 2025 at 01: PM, Licensing Program Analyst (LPA) Jacqueline Garcia arrived unannounced at the facility and met with Clinical Director, Porsha Draper, to discuss the investigative findings for the allegation noted above. On 04/17/ LPA Linley conducted an inspection of the facility, and no deficiencies were noted. LPA Garcia attempted to interview two clients (C1, C2), and after several attempts LPA Garcia was not able to reach C1 and C2 for an interview. LPA Garcia interviewed two Staff (S1, S3) and attempted to interview one staff (S2), however after several attempts S2 did not respond and no longer works at the Facility. During the investigation, LPA Garcia reviewed two client files (C1, C2). On 04/15/25, Community Care Licensing (CCL) received an allegation that facility staff did not prevent inappropriate interaction between minors. During the investigation, there was no corroborating evidence to support the above allegation. Confidential interviews and documents reviewed revealed conflicting statements to the allegation, as to if facility staff did not prevent inappropriate interaction between minors C1 and C2.************R- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: NEW ALTERNATIVES, INC #5FACILITY NUMBER: VISIT DATE: 09/25/2025

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

met_with: Porsha Draper-Clinical Director


summary: Complaint Investigation - Unsubstantiated - 3 allegations

raw_content:
Narrative:
Based on confidential interviews the allegation that facility staff caused C1 bruising may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. LPA conducted an exit interview and provided a copy of this report along with appeal rights to Taylor Rehak, Assistant Clinical Director and Daisy Madera, Assistant Program Director.

Investigation Findings:
13On November 14, 2022, at 9: AM, Licensing Program Analyst (LPA) Eduardo Barragan conducted a complaint inspection at New Alternatives Inc #5 and met with Taylor Rehak, Clinical Director and Daisy Madera, Assistant Program Director. The purpose of the inspection was to deliver the findings for the above complaint allegation. LPA Eduardo Barragan conducted an inspection of the facility on September 08, 2022, and no deficiencies were noted. LPA Barragan interviewed two of two clients (C1 - C2), three of three staff (S1 - S3), reviewed needs and service reports, staff schedules and incident reports. The Department has investigated the complaints alleging facility staff caused C1 bruising. Confidential interviews stated that facility staff did cause C1 bruising, while other interviews revealed that facility staff did not cause C1 bruising. All statements led to a conflicting finding. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Eduardo Barragan LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 2 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SO. Region Ac/res., 770 the City Dr., SUITE FACILITY NAME: NEW ALTERNATIVES, INC #5FACILITY NUMBER: VISIT DATE: 11/14/2022

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


summary: Complaint Investigation - Substantiated - 3 allegations

raw_content:
Narrative:
Which resulted in C2 assaulting and injuring C3. All interviews confirmed this information as well. There are corroborating statements regarding the allegations. Based on LPA's observations, confidential interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. Interim Licensing Standards Section 87078(b) Responsibility for Providing Care and Supervision LPA conducted an exit interview and provided a copy of this report along with appeal rights to Taylor Rehak, Clinical Director and Daisy Madera, Assistant Program Director.

Investigation Findings:
13On November 14, 2022, at 9: AM, Licensing Program Analyst (LPA) Eduardo Barragan conducted a complaint inspection at New Alternatives Inc #5 and met with Taylor Rehak, assistant Clinical Director and Daisy Madera, Assistant Program Director. The purpose of the inspection was to deliver the findings for the above complaint allegation. LPA Eduardo Barragan conducted an inspection of the facility on September 08, 2022, and no deficiencies were noted. LPA Barragan interviewed three of three clients (C1 - C3), four of four staff (S1 - S4), reviewed needs and service reports, staff schedules and incident reports. The Department has investigated the complaint alleging C3 was injured by C2 while in care. Interviews confirmed that C3 was injured by C2 while in care, which resulted in C3 having to get five staples on his head. The facility knew that C2 had a trend of hurting clients and had escalating behaviors, yet C2's supervision was not increased nor did the facility provide extra supervision to the other clients to keep them safe. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Eduardo Barragan LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 2 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SO. Region Ac/res., 770 the City Dr., SUITE FACILITY NAME: NEW ALTERNATIVES, INC #5FACILITY NUMBER: 300603549

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


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Nicole Strickland arrived unannounced to the facility to conduct interviews with Child #1 (C1) and Child #2 (C2) regarding former placement of C1 and C2 and not relating to this facility.


summary: Facility Evaluation

raw_content:
Narrative:
On November 8, 2021 at 9: AM, Licensing Program Analysts (LPAs), Jesus Cervantes, Sarah Alvizo, and Adrian Mendez, arrived at New Alternatives #5 to conduct an unannounced annual inspection. LPAs met with Administrator, Meaghan Critchlow, who led a tour of the facility. LPAs toured the facility inside and out at 9: AM. The facility is a one-story residence with ten bedrooms and eight bathrooms for the clients. There are currently nine clients in placement. The facility consists of a front house and back house. The front house is designated for the clinic, therapy room, visitation room, and staff offices. The back house consists of a common area, kitchen, pantry, laundry room, ten client bedrooms, eight client bathrooms, medication room, and one staff office. The client bedrooms are set up so there are two clients to a bedroom and one client per bed. Cleaning solutions and hazardous items were not observed to be stored in a locked room inside of the kitchen. At 10: AM LPA observed two 90 oz bottles of dish soap under the kitchen sink which was not locked and secured. This poses an immediate health, safety, or personal rights risk to the residents in care, the facility will be cited. The facility immediately secured the dish soap and secured them in a locked cabinet. At 10: AM, LPA observed expired food and spoiled vegetables in the facility client refrigerator. This poses an immediate health, safety or personal rights risk to persons in care. Facility immediately disposed of the spoiled and expired food. The client's bathrooms were observed to be clean. At 11: AM, the hot water in the client's bathroom was measured to be 108.1 degrees Fahrenheit which is within the appropriate range of 105 degrees to 120 degrees Fahrenheit. Sharp knives were stored in a locked kitchen drawer. Medications are stored inside of a locked cabinet in the medication room. The facility's smoke and carbon monoxide detectors were observed to be operable. The fire extinguishers are properly charged and serviced. There are no guns or weapons in the facility as stated by the administrator. The Personal Rights form and Foster Care Ombudsman poster were posted in the facility. See Page Two LPAs observed a minimum 7-day non-perishable and a 2-day perishable supply of food. The exterior of facility was also inspected and observed to be clean and the landscape well maintained. Emergency exits were free from obstruction. There is no swimming pool or other body of water located on the facility premises. Administrator, Meaghan Critchlow is present at the facility a minimum of 20 hours a week. Licensee has obtained Mental Health Certification and is valid through March 13, 2022. Licensee has obtained accreditation through CARF International and is valid through September 30, 2023. Personnel files are maintained on site. At 9: AM, LPA's reviewed ten of ten staff files. All files contained all required documentation per Title Regulations and Interim Licensing Standards (ILS). All appropriate personnel who require caregiver background checks did have criminal record and child abuse index check clearances. At 1: PM, LPAs reviewed nine client files for nine of nine clients and all files did have the necessary documents required per STRTP regulations. Based on this inspection, the facility is not in compliance. The facility is being cited for Title 22, Division Six, Regulation 80087(g), Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This poses an immediate health, safety, or personal rights risk to the residents in care. The facility is being cited for Title 22, Division Six, Regulation 80076(a)(7), (a) In facilities providing meals to clients, the following shall apply: (7) ...All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption. Food in damaged containers shall not be accepted, used or retained. Due to time constraints, LPA will return to the facility to conduct a continuation of staff and client interviews. Exit interview was conducted and a copy of this report, along with Appeal Rights was provided to Administrator, Meaghan Critchlow.


summary: Facility Evaluation

raw_content:
Narrative:
On November 9, 2021 at 12: PM, Licensing Program Analysts (LPA) Jesus Cervantes and Sarah Alvizo arrived unannounced at the facility to conduct an Annual Continuation inspection for the annual that began on November 8, 2021. LPA met with Administrator, Meaghan Critchlow. At 12: PM, LPA's discussed Plan of Operations, Disaster Preparedness, Emergency Intervention, and Core Therapeutic Services with Administrator, Meaghan Critchlow. During the inspection, five of ten staff members were interviewed. Due to the need to complete staff and client interviews, this inspection will need to be continued at later date. Based on the facility inspection, there are no deficiencies found at this time. An exit interview was conducted, and a copy of this report was explained to Administrator, Meaghan Critchlow.


summary: Facility Evaluation

raw_content:
Narrative:
On November 10, 2021 at 10: AM, Licensing Program Analysts (LPA) Jesus Cervantes and Sarah Alvizo arrived unannounced at the facility to conduct an Annual Continuation inspection for the annual that began on November 8, 2021. LPA met with Administrator, Meaghan Critchlow. During the inspection, five staff of ten members were interviewed for a total of 10 staff members interviewed during this inspection. Five of nine clients were interviewed. Due to the need to complete client interviews, this inspection will need to be continued at later date. Based on the facility inspection, there are no deficiencies found at this time. An exit interview was conducted, and a copy of this report was explained to Administrator, Meaghan Critchlow.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPA) Shanae Pharaoh on June 2, 2022 at 1:30PM. During the inspection, LPA met with Administrator Breanna Tucker and inspected the facility inside and out. LPA reviewed four of four client records C1, C2, C3 and C4 on site at the facility at 1: PM. During the records review. LPA did not observe a current JV223 for C2 and C4. LPA did observe JV220 with the date of submission by the physician prior to expiration. LPA interviewed two of two staff, S1 and S2 3:00 and 3: PM. LPA reviewed two of two staff S1 and S2 personnel files on site at the facility at 3: PM. LPA interviewed two of four children currently taking psychotropic medication at 3: PM. The other 1 client was not available to be interviewed due to prior appointments and one was not feeling well enough to interview. LPA conducted exit interview with Administrator at 4: PM. LPA issued technical violation for Interim Licensing Standards Section 87070(b)(11), Children Records. LPA provided the Summary Report to the Administrator, Breanna Tucker upon completion.

met_with: Administrator - Breanna Tucker


summary: Facility Evaluation

raw_content:
Narrative:
On October 4, 2022 at 1: PM, Licensing Program Analyst (LPA) Eduardo Barragan conducted an announced pre-licensing inspection at New Alternatives In #5. LPA met with Breanna Tucker, Administrator. A physical plant inspection was completed at a temporary housing placement and included the following checks: Facility grounds are clean but still needed some organizing. Bedrooms are arranged so that no more than two client resided in each room. There is adequate shelving and closet space for client's belongings. The bathrooms were clean; however, the shower still need to be repaired. The hot water in the client bathroom's and in the kitchen was measured to be 112 degrees, which is in range (105 degrees and 120 degrees). All hazardous items have been properly made inaccessible to areas where clients will have access. The medications were stored and double locked in a lock box in the kitchen. Cleansers/chemicals are double locked and inaccessible to client and were located in a closet. The First Aid Kit is located in the staff office. The facility's smoke detectors in the hallways/bedrooms were operable. They were just in just installed. The carbon monoxide detector located in hallways/bedrooms were operable. There are no guns or weapons in the facility as stated by Breanna Tucker, Administrator. The following required posted items were observed accessible to clients: Grievance Procedures, Personal Rights, and Visitation policies. The postings were located near the front door of the facility. Fire extinguisher is properly charged and serviced. There was actually no sharps nor knifes at the facility currently. LPA notified the agency that they will need the ombudsmen poster posted and new menu prior to moving in as well. Additionally, the facility needed an update and up to code fire clearance prior to officially moving in. At this moment the facility is still not up to code therefore, the facility is going to continue to reside in the hotel. An exit interview was conducted, and a copy of this report was provided to Breanna Tucker, Administrator.

met_with: Breanna Tucker, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On December 16, 2022 at 11: AM, Licensing Program Analyst (LPA) Eduardo Barragan conducted an announced Annual inspection at New Alternatives Inc #5. LPA met with Breanna Tucker, Administrator. A physical plant inspection was completed at a temporary housing placement and included the following checks: Facility grounds are clean. Bedrooms are arranged so that no more than two client resided in each room. There is adequate shelving and closet space for client's belongings. The bathrooms were clean. The hot water in the client bathroom's and in the kitchen was measured to be 112 degrees, which is in range (105 degrees and 120 degrees). All hazardous items have been properly made inaccessible to areas where clients will have access. The medications were stored and double locked in a lock box in the kitchen. Cleansers/chemicals are double locked and inaccessible to client and were located in a closet. The First Aid Kit is located in the staff office. The facility's smoke detectors in the hallways/bedrooms were operable. They were just in just installed. The carbon monoxide detector located in hallways/bedrooms were operable. There are no guns or weapons in the facility as stated by Breanna Tucker, Administrator. LPA Barragan also conducted a walk through of the facility's actual home which is currently under repair. The facility's home is projected to be ready by December 20, 2022. LPA Barragan noted that new flooring was installed, the facility was painted in the interior and new shower and bath tubes were placed as well. LPA Barragan noted that a relatively new kitchen was installed as well. LPA Barragan will come at a later date and time to inspect the facility home to ensure everything was in compliance. Continued... The following required posted items were observed accessible to clients: Grievance Procedures, Personal Rights, and Visitation policies. The postings were located near the front door of the facility. Fire extinguisher is properly charged and serviced. There was actually no sharps nor knifes at the facility currently. Prior to inspection LPA Barragan reviewed a personnel files to ensure they contained all required documentation per Title Regulations. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. All licensing fees have been paid and are current at this time. LPA Barragan conducted a client file review as well. All files were neatly organized. Based on the facility inspection and file reviews this date there were no deficiencies found at this time. A exit interview was conducted. A copy of the report was discussed and provided along with appeal rights to Breanna Tucker, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On December 20, 2022 at 3: PM, Licensing Program Analyst (LPA) Eduardo Barragan conducted an announced Post Licensing inspection at New Alternatives In #5. LPA met with Breanna Tucker, Administrator. A physical plant inspection was completed of the facility due to recent reservations and included the following checks: Facility grounds are clean. Bedrooms are arranged so that no more than two clients resided in each room. There is adequate shelving and closet space for client's belongings. The bathrooms were clean. The hot water in the client bathroom's and in the kitchen was measured to be 112 degrees, which is in range (105 degrees and 120 degrees). All hazardous items have been properly made inaccessible to areas where clients will have access. The medications were stored in the medication room and were double locked. Cleansers/chemicals were locked and inaccessible to client and were located in the kitchen. The First Aid Kit is located in the medication room, the kitchen and one in the staff office. The facility's smoke detectors in the hallways/bedrooms were operable. The carbon monoxide detector located in hallways/bedrooms were operable. There are no guns or weapons in the facility as stated by Breanna Tucker, Administrator. LPA Barragan noted that new flooring was installed, the facility was painted in the interior and new shower and bath tubes were placed as well. LPA Barragan noted that a relatively new kitchen was installed as well. Continued... The following required posted items were observed/ accessible to clients: Grievance Procedures, Personal Rights, and ombudsman postings were all posted. Fire extinguisher is properly charged and serviced. The sharps and knifes were kept in a locked cabinet in the kitchen. Prior to inspection LPA Barragan reviewed a personnel files to ensure they contained all required documentation per Title Regulations. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. All licensing fees have been paid and are current at this time. LPA Barragan conducted a client file review as well. All files were neatly organized. Based on the facility inspection and file reviews this date there were no deficiencies found at this time. A exit interview was conducted. A copy of the report was discussed and provided along with appeal rights to Breanna Tucker, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On August 2, 2022 at 11:25 am, Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced visit at the facility. The purpose of the visit was to interview one client regarding an incident at a prior placement. No other information needed at this time. The Administrator change information is requested to be resubmitted to LPA, Jacqueline Garcia by end of business day today. No deficiencies were cited. Exit interview was conducted and a copy of this report was explained to Assistant Program Directory, Daisy Madera. Due to printer malfunction, this report will be emailed to Assistant Program Directory, Daisy Madera and the Facility Administrator.

met_with: Daisy Madera


summary: Facility Evaluation

raw_content:
Narrative:
On November 2, 2023, at 3:15pm, Licensing Program Analyst (LPA) Jacqueline Garcia arrived unannounced at New Alternatives Inc #5 facility and met with Michael Armas, STRTP Administrator. The purpose of the case management inspection is to follow up on information received on 10/25/2023 regarding a change of administrator. It was reported that Michael Armas replaced Administrator Breanna Tucker on 10/06/2023 and Community Care License has not received notification of change of the Administrator. LPA spoke with Michael, who confirmed that their Administrator Breanna Tucker resigned on 10/6/2023. LPA requested documentation of Community Care License department being notified of the change. LPA reviewed the Administrator's employee file. After review, no deficiency were noted. Exit interview was conducted and a copy of this report was explained and given to Administrator Michael Armas.

met_with: Michael Armas-Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On January 26, 2024, at 10:30AM, Licensing Program Analyst (LPA) Jacqueline Garcia arrived unannounced at New Alternatives Inc #5 facility and met with Clinical Director-Taylor Rehak. The purpose of the case management inspection is to follow up on Special Incident Report that occurred on 01/09/2024. LPA reviewed one staff file and one client file. LPA conducted an inspection of the facility, and no immediate health or safety concerns were observed. LPA was not able to interview C1 due to being at school. Further review and information will be needed. Upon completion of the review, the outcome and/or recommendations will be provided to the licensee. Exit interview was conducted and a copy of this report along with LIC 811 dated (01/26/24) was explained and given to Clinical Director-Taylor Rehak.

met_with: Taylor Rehak-Clinical Director


summary: Facility Evaluation

raw_content:
Narrative:
On February 8, 2024 at 1: PM, Licensing Program Analyst (LPA) Guadalupe Munoz made an unannounced collateral visit to interview one youth that recently moved to this facility. LPA met with Program Director, Michael J. Armas. LPA interviewed one youth at today's visit. LPA did not observe any deficiencies during the visit. Exit interview was conducted with Program Director and a copy of this report will be provided via email.

met_with: Michael Justin Armas


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Leslie Covarrubias on April 25, 2024 at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Covarrubias met with Administrator, Michael Armas and inspected the facility inside and out. LPA reviewed three of child's records and three of staff personnel files on site at the facility. LPA reviewed three of child's psychotropic medications and medication records. LPA interviewed three of staff on site to discuss the facilities policies and procedures of operation. LPA interviewed one of children currently prescribed psychotropic medication. LPA provided a copy of this licensing report to Administrator, Michael Armas No deficiencies are being cited at this time. LPA conducted exit interview with Administrator, Michael Armas.

met_with: Administraor, Michael Armas


summary: Facility Evaluation

raw_content:
Narrative:
On August 13, 2024, at 12: PM, Licensing Program Analyst (LPA) Jacqueline Garcia conducted an unannounced case management inspection at the facility and met with New Alternatives Inc. # Short-Term Residential Treatment Program (STRTP), Administrator, Michael Armas. The purpose of the case management inspection is to follow up on a Special Incident Report that occurred on 08/06/24 involving C1 see Confidential Names form (LIC 811) dated August 13, 2024. LPA conducted interviews with one client (C1) and two staff (S1-S2). LPA reviewed C1's facility file and obtained records for C1.LPA reviewed staff files and obtained records. LPA conducted an investigation to see if all proper protocol was taken during the incident to ensure C1's safety. Due to further review the investigation is being extended. An exit interview was conducted with Michael Armas, Program Director. A copy of this report and LIC 811 were provided to Michael Armas, Program Director.

met_with: Michael Armas