raw_content:
Narrative:
There was no evidence that Facility staff member had a physical altercation with minor while in care. LPA collected several incident reports stating that Child #1 attacked several staff. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or disprove that a violation occurred; therefore, the above allegation is Unsubstantiated. There are no deficiencies being cited at this time.

Investigation Findings:
13On April 18, 2023 at 4pm Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for the purpose of delivering findings for the above complaint allegations. LPA was met by Facility Manager, Lupe Castro and allowed into the facility. During the course of investigating the allegations for facility staff member had a physical altercation with minor while in care. interviews were conducted, files were reviewed and documents were obtained. The interview did not produce corroborating evidence to support said allegations. Interviews revealed inconsistent statements and no witnesses to suggest allegations occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin 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 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: ROP HARBOR CITY HOMEFACILITY NUMBER: VISIT DATE: 04/18/2023

met_with: Lupe Castro-Facility Manager


state: CA

facility_name: ROP HARBOR CITY HOME

summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
There was no evidence that staff are not providing adequate supervision to minor in care. Staff followed elopement procedures and confiscated the packages sent to Child #1 before the client could get them in his possession. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred; therefore, the above allegation is Unsubstantiated. There are no deficiencies being cited at this time.

Investigation Findings:
13On September 6, 2024 at 12pm Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for the purpose of delivering findings for the above complaint allegations. LPA was met by Administrator, Faaputu Vaafuti and allowed into the facility. During the course of investigating the allegations for staff are not providing adequate supervision to minor in care, interviews were conducted and files were reviewed. The interview did not produce corroborating evidence to support said allegations. Interviews revealed inconsistent statements and no witnesses to suggest allegations occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin 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 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: ROP HARBOR CITY HOMEFACILITY NUMBER: VISIT DATE: 09/06/2024

report_type: Complaint Investigation

met_with: Faaputu Vaafuti-Program Manager

complaint_status: unsubstantiated


raw_content:
Narrative:
Regarding the allegations of the outings, client interviews did not state any complaints against the facility. Client interviews shared that the facility does provide outings on the weekends and does request client input, but that some clients don't participate in the outings because they either go home on the weekends or decline to attend. Staff interviews confirmed that outings are provided on the weekends with clients' input, but often clients decline to attend. LPA observed a copy of the facility activity schedule. LPA also observed a copy of an outing's idea form filled out and signed by clients. Regarding the allegation of the facility providing comfort, client interviews shared that the facility has a mixed placement of both DCFS and probation clients. The different placement agencies have different requirements and standards of care and supervision that the facility has to balance. Staff interviews confirmed the placement situation and explained how the facility has to balance both sets of rules and regulations, especially with the probation requirements being more strict as compared to the DCFS requirements. Staff shared, for example, that probation clients can not go into the community without supervision, which is new to DCFS clients. Client interviews shared that they understood the reasons and just needed time to adjust to the new environment. Finally, regarding the allegation that staff are inappropriately abusing staff funds, neither staff nor clients expressed any concerns or complaints regarding funds being stolen or misused. Staff shared that the budget is used appropriately only for reasons that benefit the clients and facility. Staff shared that they have never noticed anyone buying personal items from the facility's funds. LPA reviewed the expense reports for the 1/26 & 2/26, the the budget report, and observed receipts for expense purchases. LPA did not observe any discrepancies. Based on staff & client testimony evidence, records review, and lack of supporting evidence LPA determined that the facility is providing clients with adequate amounts of food, hygiene products, and outings. LPA also determined that the facility is providing comfort to the clients while maintaining their multi-placement regulations. Finally, LPA did not observe any evidence of facility funds being abused. Therefore, based on the available information LPA gathered from interviews and records reviews, the preponderance of the evidence standard has not been met; therefore, the allegation that "Staff are not providing minors with hygiene products, Staff are not providing adequate food service to the minors, Staff are not providing outings for the minors, Staff are not providing comfortable environment for minors, & Staff are inappropriately abusing facility funds." are found to be unsubstantiated. Exit Interview Conducted

Investigation Findings:
13On 4/22/26, Licensing Program Analyst (LPA) Reagan Cohen arrived at the above facility and met with Administrator Faaputu Vaafuti for the purpose of delivering complaint findings regarding the above allegation. During the course of the investigation, LPA interviewed involved staff and clients. Regarding the allegations of hygiene products and food services, clients did not share any complaints during their interviews. Staff testimonies also shared that the food and hygiene products are always adequately stocked, and the clients' input is requested and taken into consideration. LPA also observed the facility's food and hygiene products and saw an adequate supply of each in the facility. LPA observed the facility's weekly menu and a menu suggestions form left blank by the clients. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Reagan Cohen 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 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: ROP HARBOR CITY HOMEFACILITY NUMBER: VISIT DATE: 04/22/2026

met_with: Administrator Faaputu Vaafuti


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
Based on staff testimony and records review, LPA determined that S1, who is operating as the current Administrator, is unqualified due to missing the correct certificate and documentation. Therefore, based on the available information LPA gathered from interviews and records reviews, the preponderance of the evidence standard has been met; therefore, the allegation that "Unqualified administrator working in the facility" is found to be substantiated. LPA is citing the facility for violation of ILS 87064 (b). See LIC 809-D Exit Interview Conducted.

Investigation Findings:
13On 4/22/26, Licensing Program Analyst (LPA) Reagan Cohen arrived at the above facility and met with Administrator Faaputu Vaafuti for the purpose of delivering complaint findings regarding the above allegation. During the course of the investigation, LPA interviewed involved staff and clients. During staff interviews, S1 shared, "I am the pending administrator. I submitted all my paperwork to licensing But haven't received official confirmation yet. I believe I have all the qualifications according to the regulations and have turned them all in to my normal LPA as proof." When LPA examined the submitted documents, they observed a number of required forms to be missing. LPA informed S1, who then submitted some of the missing forms. LPA never received a copy of a current STRT P Administrator's certificate for S1. This is a required document and qualification to be an Administrator. S1 shared with LPA that they took the class and exam and passed, but never received the certificate. LPA observed a copy of the certificate showing completion of the training and an email confirming the passing of the exam, but with the requirement to apply for the certificate within 30 days. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Reagan Cohen 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 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: ROP HARBOR CITY HOMEFACILITY NUMBER: VISIT DATE: 04/22/2026

complaint_status: SUBSTANTIATED


facility_name: ROP LIVINGSTON HOUSE

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
On April 05, 2021, Community Care Licensing received an allegation that foster children are not treated with respect by S3, and staff (S2 and S3) ignore C1, S2 and S3 made inappropriate comments towards C1, and S2 and S3 encouraged other foster children to ignore C1. Confidential interviews revealed staff always treat foster children in care with respect. However, confidential interviews revealed staff can get agitated at foster children and they don't treat them respectfully. LPA received inconsistent information regarding the allegation. Confidential interviews revealed staff do not ignore foster children, however there may be times where a foster child is argumentative and verbal redirection does not work. Staff will then listen to the foster child but will not engage in further dialogue to avoid further conflict. Confidential interviews revealed staff did not make inappropriate comments towards C1, however confidential interviews revealed that a staff member did make an inappropriate comment towards C1. LPA received inconsistent information regarding the allegation. Confidential interviews revealed that staff at times do tell other foster children to ignore C1 when C1 is argumentative with staff. Confidential interviews revealed that C1 tends to try to create a hostile environment by bringing in other foster children into C1 arguments with staff. In order to deescalate an argument, staff discourage other foster children from partaking in C1's arguments with staff. Based on confidential interviews and record review, the allegations that foster children are not treated with respect by S3, and staff (S2 and S3) ignore C1, S2 and S3 made inappropriate comments towards C1, and staff (S2 and S3) encouraged other foster children to ignore C1 may have occurred; however, it is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this report along with appeal rights was provided to Dana Centanni.

Investigation Findings:
13On August 20, 2021, at 11: AM, Licensing Program Analyst (LPA) Jesus Cervantes made an unannounced visit at the facility. LPA met with Dana Centanni, to issue the investigative findings of the allegations listed above. On April 14, 2021, Licensing Program Analyst (LPA), Jesus Cervantes, conducted an unannounced tele-inspection of the facility, and no deficiencies were noted. LPA Cervantes conducted interviews with three of three (S1, S2, and S3) staff members, two of six (C2, and C3) foster children, and Orange County Senior Social Worker (SSW). Four of six (C1, C4, C5, and C6) foster children declined to be interviewed. During the investigation, LPA reviewed facility records and obtained copies of the following documents: Needs and Service plan for C1 and Case Notes. 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: ROP LIVINGSTON HOUSEFACILITY NUMBER: VISIT DATE: 08/20/2021

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

met_with: Dana Centanni


raw_content:
Narrative:
Confidential interviews reported that C1 might have been drinking alcohol the night before. Confidential interviews reported that C1 was taken to the hospital from school. Confidential interviews reported that C1's toxicology screening showed an alcohol level of 0.001. Confidential interviews reported that C1 has a history of running away from their facility. Confidential interviews reported that sometimes it was suspected that C1 was under the influence of alcohol upon return from AWOL. Confidential interviews reported that C1 did not obtain alcohol at the facility, nor was their alcohol available at the facility or provided by staff. Confidential interviews reported that C1 may have received alcohol while AWOL from the facility but could not prove it. Confidential interviews reported that alcoholic beverages or alcoholic containers were not found in C1's room or the facility premises. Community Care Licensing also received an allegation that medication is accessible to a minor (C1). Confidential interviews reported that a minor in care (C1) admitted to taking Percocet before attending school on 04/19/2022. Confidential interviews reported that C1 was not prescribed Percocet while at the facility. Confidential interviews reported that facility staff locked and secured all psychotropic medication within the facility. During the health and safety inspection, LPA observed that the psychotropic medication was locked and inaccessible to clients. Confidential interviews reported that it was unknown where C1 obtained the Percocet. Confidential interviews reported that C1 may have received Percocet while C1 was absent without permission from the facility. Confidential interviews reported that facility staff did not find any Percocet in C1's or any other client's bedroom. Based on inconsistent confidential interviews, the allegations that the minor (C1) has access to alcohol and medication accessible to minor (C1), may have occurred, however, is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted. A copy of this report and appeal rights were explained and provided to Senior Coach Counselor Angelica Littlefield.

Investigation Findings:
13On 01/24/2023, at 01:40PM, Licensing Program Analyst (LPA) Joon Choi conducted an unannounced visit to Rite of Passage (ROP) Livingston Short Term Residential Treatment Facility (STRTP) to deliver the investigative findings for the allegations listed above. On 04/28/2022, LPA Leslie Covarrubias conducted an initial health and safety inspection at the facility, and no immediate health and safety hazards were observed. On 12/30/2022, LPA Choi conducted a follow-up health and safety inspection of the facility, and no immediate health and safety hazards were observed. The investigation included interviews with clients (C1, C2, and C3) and staff (S1, S2, and S3). LPA obtained pertinent documentation during this investigation, such as the Special Incident Report relating to this complaint and the Orange County Child Protective Services Cross Report Documents. On 04/20/2022, Community Care Licensing received an allegation that a minor (C1) in care, has access to alcohol. Confidential interviews reported that C1 was observed to be sleeping at school on 04/19/2022. CONTINUED ON THE NEXT PAGE UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Joon R Choi 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, FACILITY NAME: ROP LIVINGSTON HOUSEFACILITY NUMBER: VISIT DATE: 01/24/2023

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

met_with: Angelica Littlefield, Senior Coach Counselor


raw_content:
Narrative:
reviewed indicated C1 was not given medication #1 on November 29, 2023, medication #2 was not given to C1 from December 23-27, 30-31 in 2023, medication #3 was not given to C1 on December 23-26, 28-31 in 2023, and medication #4 was not given to C1 on December 23-24 (in the evening) and December 27 (in the morning) in 2023. Based on confidential interviews and record review the allegation that C1's medication log is incomplete is substantiated. The preponderance of evidence standard has been met. The facility is cited for violation of the California Code of Regulations, Title Division Six, regulation 80075(b) Health Related Services. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Kayla Dembek. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights will be emailed to the Administrator. A copy of this report will be placed in the facility file. Confidential interviews revealed conflicting statements. Due to not being able to interview all individuals, although multiple attempted contacts were made, confidential interviews did not corroborate the allegations with a preponderance of evidence. Based on confidential interviews and records reviewed the allegations that S9 yells at C1 in care, S4 engaged in a verbal altercation with C1, and S5 speaks inappropriately about minors in care, which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights were reviewed with Kayla Dembek Due to printer malfunction, a copy of this report and the LIC 811 will be emailed to the Facility Administrator. A signed copy of this report will be kept in the Facility file.

Investigation Findings:
13On July 18, 2024, at 10:05 am, Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced complaint inspection at the above facility. LPA Linley met with Kayla Dembek, Facility Administrator. The purpose of the inspection was to deliver the findings of the complaint investigation. LPA Linley conducted an inspection of the facility on May 6, 2024, and no deficiencies were observed. LPA interviewed two clients (C1-2), one County Social Worker (CSW), eight staff (S1-8), and LPA was unable to interview one staff (S9) despite multiple attempts to contact them. During the investigation, the following documents were reviewed: Staff Schedule, C Medication Administration Records, C1's Standing Order for medication, C1's Child-Family-Team Meeting Notes, C1's Needs and Services Plan, C1's Behavior Contract, and the facility's visitor log. On April 30, 2024, Community Care Licensing (CCL) received an allegation that C1's medication log is incomplete. Confidential interviews indicated staff forgot to give C1 their prescribed medication. Records 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: ROP LIVINGSTON HOUSEFACILITY NUMBER: VISIT DATE: 07/18/2024

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:

met_with: Kayla Dembek


summary: Facility Evaluation

raw_content:
Narrative:
On September 20, 2021, at 1: PM Licensing Program Analyst (LPA) Jesus Cervantes conducted an unannounced annual inspection. The facility converted from a Group Home to a STRTP (Short Term Therapeutic Program) on August 24, 2018. LPA was met at the facility by Senior Coach, Kammy Delp. There are currently six residents in placement. LPA toured the facility inside and out at 1: PM. The facility consists of a common area, kitchen, pantry, laundry room, three client bedrooms, one client bathroom, one staff bathroom, and one staff office. The client bedrooms are set up so there are two clients to a bedroom and one client per bed. There is adequate closet and drawer space for client's belongings. A client's mattress and box spring in bedroom #2 did not have good springs and was in disrepair. The bathroom was clean and in good repair. The hot water was tested in client bathroom #1 at 3: PM and registered at 109.4 degrees Fahrenheit which is within the appropriate range of 105 degrees to 120 degrees Fahrenheit. Cleaning solutions and hazardous items were observed to be stored in a locked cabinet in the laundry room. Sharp knives were observed to be inaccessible and stored in a locked closet. Medications are stored in a locked filing cabinet inside the entry closet. The facility's smoke and carbon monoxide detectors are electrically hard wired and observed to be operable. The fire extinguishers are properly charged and serviced. There are no guns or weapons in the facility as stated by Senior Coach, Kammy Delp. LPA observed facility posted items in the living room that included: Disaster Plan, Personal Rights, Grievance Procedures, and Foster Care Ombudsman poster. LPA observed a minimum 7-day non-perishable and a 2-day perishable supply of food. There is one camera at the facility located on the wall in the hallway. The facility outside grounds was also inspected and it was observed to be clean and well maintained. There are no bodies of water located on the premises. Emergency exits were free from obstruction. LPA interviewed two clients in care. Due to the need to complete staff/client interviews, staff/client file reviews, and complete the inspection, this annual will continue on a later date. A copy of this report was provided to House Parent Lisa Ramirez.

report_type: Facility Evaluation

visit_type: Annual

met_with: Kammy Delp


summary: Facility Evaluation

raw_content:
Narrative:
On September 21, 2021, at 9: AM, Licensing Program Analysts (LPA), Jesus Cervantes continued the unannounced annual inspection, which was started on September 20, 2021. LPA met with Senior Coach, Kamy Delp. Licensee obtained their Mental Health (MH) Certification on March 14, 2021 and it expires on March 24, 2022. Licensee obtained National Accreditation through CARF and the accreditation is valid through August 31, 2022. Licensee has received a Medi-Cal approval through March 24, 2022. Licensing fee payments are current. LPA discussed the following with Senior Coach, Kamy Delp: operational requirements, disaster preparedness, and core/therapeutic services. All the client files are stored and locked in the file cabinet in the staff office. At 10: AM, LPA began to review a sample of six clients files during the time of inspection. Due to the need to conduct client/staff interviews, and continue client/staff file reviews, this inspection will need to be continued at later date. An exit interview was conducted, and a copy of this report was provided to Senior Coach, Kamy Delp.

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
On September 22, 2021, at 9: AM, Licensing Program Analysts (LPA), Jesus Cervantes continued the unannounced annual inspection, which was started on September 20, 2021. LPA met with Senior Coach, Kamy Delp. At 9: AM, LPA began to review a sample of six clients files during the time of inspection. All files contained the required documentation per Title Regulations. Three facility staff were interviewed during the inspection. Personnel files are located at ROP Corporate Office located at N. Tustin Ave. Suit #120. Santa Ana, CA 92705. At 2: PM, LPA met with Director, Dana Centanni. LPA reviewed sample of ten of ten staff files. Per a review of the Community Care Licensing Information System (LIS), all staff met DOJ/FBI criminal record clearances and Child Abuse Index Check requirements. All staff have proof in file of acknowledging the child abuse reporting requirements. Due to the need to conduct additional client/staff interviews, and continue staff training file reviews, this inspection will need to be continued at later date. An exit interview was conducted, and a copy of this report was provided to Director, Dana Centanni.


summary: Facility Evaluation

raw_content:
Narrative:
On September 23, 2021, at 9: AM, Licensing Program Analysts (LPA), Jesus Cervantes continued the unannounced annual inspection, which was started on September 20, 2021. LPA met with Compliance Manager, Crystal Maxwell. Personnel and training files are located at ROP Corporate Office located at N. Tustin Ave. Suit #120. Santa Ana, CA 92705. At 9: PM, LPA reviewed sample of ten of ten staff training files. All files contained the required documentation and training per Title Regulations. At 2: PM, LPA returned to the facility and met with Child Care Worker, Yesennia Villa. LPA completed three staff interviews. Four clients refused to be interviewed. Based on the facility inspection completed and files reviewed, the facility is not in compliance. The facility is cited for Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS), Chapter 7.5, Version 3.1, Section 87088(c)(1), Furniture, Fixtures, Equipment, Supplies. (c) The licensee shall provide and make readily available to each child the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene: (1) An individual bed maintained in good repair; equipped with good springs and a clean mattress; and supplied with pillow(s) which are clean and in good repair. Based on the observation, the licensee did not comply with the section cited above in one out of six beds which posed a potential health, safety or personal rights risk to persons in care. An exit interview was conducted, and a copy of this report, LIC 811, and LIC 809D was provided to Senior Coach, Leo Trammell

met_with: Crystal Maxwell


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Veronica Whitaker conducted a case management inspection May 24, 2022, at 11: AM, based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During the inspection, 9 out of Direct Care Staff and 6 out of 6 youth files were reviewed. 4 out of Direct Care Staff and 2 out of 6 youth were interviewed. (See the Confidential Names List, LIC 811, dated May 24, 2022). The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, youth case plans, quarterly assessments, and crisis intervention plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Veronica Whitaker observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Sylvia Arballo,Compliance Manager, Dana Centanni, Program Director, Rabah Mahmoud..

met_with: Sylvia Arballo, Compliance Manager, Dana Centanni, Director, Rabah Mahmoud, Administrator


facility_name: ROP PARAGON HOUSE

raw_content:
Narrative:
Confidential interviews revealed that whenever the staff are made aware that a client may be in possession of drugs or under the influence of drugs the staff performs a room search, and the incident is reported to Community Care Licensing (CCL). Confidential interviews revealed that there was a wax pen given to staff that was reported to belong to C1. Staff completed a search of C1's room and did not find any other drug paraphernalia. Additional confidential interviews stated that C2 advised C1 how to sneak drug paraphernalia into the facility. It is unclear how the drug paraphernalia was brought to the facility. Based on confidential interviews and record review, the allegation that Minor in possession of drug paraphernalia may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. A copy of this report and Appeals Rights were provided and explained to Sylvia Arballo, Compliance Manager.

Investigation Findings:
13On March 23, 2022 at 10:05 a.m., Licensing Program Analyst (LPA) Sarah Smith met with ROP Paragon House Short Term Residential Therapeutic Program (STRTP) Compliance Manager, Sylvia Arballo to deliver the findings of the complaint investigation for the above allegation. LPA Cervantes conducted a health and safety inspection of the facility on 10/12/2021 at 3:15 p.m. and no immediate deficiencies were observed. During the course of investigating the allegation, LPA Smith conducted confidential interviews with three staff, three clients, and the County Social Workers (CSW1 and CSW2). LPA reviewed reports and records for the facility and clients (C1, C2, and C3). On October 06, 2021, a complaint was received that Minor in possession of drug paraphernalia. During confidential interviews it was revealed that C1 would return to the facility with drug paraphernalia and offer it to the other clients in care. Information obtained from confidential interviews disclosed that staff became aware of C1 being in possession of the drug paraphernalia and performed a search of C1's possessions. -----Continued on the next page----- UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Sarah Smith 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: ROP PARAGON HOUSEFACILITY NUMBER: VISIT DATE: 03/23/2022

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

met_with: Sylvia Arballo, Compliance Manager


raw_content:
Narrative:
denied the allegations that there was a lack of supervision. Confidential information received revealed that the facility was in ratio and had no staffing issues at the time of the allegation. According to confidential interviews, once staff became aware of the allegation, the staff put a plan in place to monitor and inspect food deliveries. Other confidential information received by Licensing Office stated that these allegations had occurred, and that C1 had engaged in inappropriate relationship and had access to contraband due to a lack of staff supervision. LPA received inconsistent information regarding staff providing a lack of supervision at the facility. Based on confidential information obtained during the course of this investigation, the allegations that staff failed to prevent minor from engaging in inappropriate behavior with an adult, as well as did not prevent minor from obtaining illegal paraphernalia, more specifically that Child # 1 (C1) had been communicating with and had sent nude pictures to an adult male via telephone, and that this adult male had also placed contraband such as "wax pens" inside food delivery, may have occurred, however is not supported or proven by evidence. Therefore, the above allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report was provided.

Investigation Findings:
13Licensing Program Analyst (LPA), Daniel Mena met with Senior Coach, Shanice Green to discuss the investigative findings for the above stated allegations. Licensing Program Analysts (LPAs), Jesus Cervantes and Daniel Mena conducted an inspection to the Short Term Residential Therapeutic Program (STRTP) on September 02, 2021 at 3:15pm and on May 12, 2022 at 1:58pm. No immediate hazards observed. LPAs Cervantes and Mena interviewed three staff (S1, S2 & S3), three foster children (C1, C2 & C3), as well as reviewed client and facility records. Community Care Licensing received information on September 01, 2021 alleging that staff did not prevent minor from engaging in inappropriate behavior with an adult, as well as did not prevent minor from obtaining illegal paraphernalia, more specifically that Child # 1 (C1) had been communicating with and had sent nude pictures to an adult male via telephone, and that this adult male had also placed contraband such as "wax pens" inside McDonald's food delivery. Information obtained in confidential interviews did not corroborate the allegations with a preponderance of evidence. Information obtained from confidential interviews disclosed that the allegations occurred while other confidential UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Daniel Mena 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, FACILITY NAME: ROP PARAGON HOUSEFACILITY NUMBER: VISIT DATE: 05/27/2022

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

met_with: Shanice Green


raw_content:
Narrative:
interviews also stated that staff took immediate action and reported incident to all required agencies once they had been made aware of these allegations. According to confidential interviews, staff provide proper supervision and will conduct random checks to all bedrooms throughout the day and night every 15 to 30 minutes. While other confidential information received by Licensing Office stated that these allegations had occurred. There were no other known witnesses to this allegation. Based on confidential information obtained during the course of this investigation, the allegation of a lack of supervision resulting in minors engaging in inappropriate sexual behavior, may have occurred, however is not supported or proven by evidence. Therefore, the above allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report was provided

Investigation Findings:
13Licensing Program Analyst (LPA), Daniel Mena met with Program Manager, Rabah Mahmoud to discuss the investigative findings for the above stated allegation. Licensing Program Analyst, Nicole Strickland conducted an inspection to the facility on January 21, 2022 at 9:16am. Special Investigator (SI), Nikki Vo interviewed four staff (S1, S2, S3, S4 & S5), three foster children (C1, C2 & C3), County Social Worker (CSW), as well as reviewed client and facility records. Community Care Licensing received information on January 13, 2022 alleging a lack of supervision resulting in minors engaging in inappropriate sexual behavior. Information obtained in confidential interviews did not corroborate the allegation with a preponderance of evidence. Confidential interviews denied that Child # 1 (C1) had ever been sexually inappropriate or had touched Child # 2 (C2) on or near their private parts. Confidential interviews also denied that either C1 and C2 had taken sexually explicit photos of one another, as well as masturbated together in their bedroom. Confidential UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Daniel Mena 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, FACILITY NAME: ROP PARAGON HOUSEFACILITY NUMBER: VISIT DATE: 07/08/2022

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

met_with: Rabah Mahmoud


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
out the UIR and the report was not sent to the Probation Officer and CCL within the allotted time frame. On all the above dates, the facility failed to make the required notices within the allotted time frame. Based on confidential interviews and record review, the preponderance of evidence standard has been met regarding the allegation that the Facility did not report Unusual Incident Reports, therefore the allegation is substantiated. This poses an immediate Health, Safety or Personal Rights risk to the children in care. The facility will be cited for violating California Code of Regulations, Title 22, 80061(b)(E) Reporting Requirements. An exit interview and appeal rights were reviewed with Reyna Salas. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights will be emailed to the Facility Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On April 18, 2023, at 2:30 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Reyna Salas of ROP/Paragon to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 01/23/2023 at 10:45 am. No deficiencies were observed. LPA interviewed one out of one staff (S1). LPA reviewed the following documents: Special Incident Reports, Placentia Police Department Incident Reports/CAD calls, and Special Incident Reports sent to C1's Probation Officer. On 01/20/2023, Community Care Licensing (CCL) received an allegation that the Facility did not report Unusual Incident Reports (URI). Confidential interviews and record review indicated that the facility did not report reportable incidents on 01/05/2023, 01/10/2023, and 01/11/2023 involving C1. Regarding the incident on 01/05/2023, confidential interviews revealed there was a miscommunication regarding who was to send 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 CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: ROP PARAGON HOUSEFACILITY NUMBER: VISIT DATE: 04/18/2023

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

met_with: Reyna Salas


raw_content:
Narrative:
Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Cedric Jones. A copy of this report, LIC 811, and appeal rights were provided to the Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On November 14, 2023, at 11: AM, Licensing Program Analyst (LPA) Guadalupe Munoz arrived unannounced at the facility and met with ROP/Paragon Administrator to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 8/22/2023 at 1:00 pm. No deficiencies were observed at that time. LPA interviewed four staff (S1-S4) and three clients (C1-C3). LPA reviewed the following documents: Special Incident Reports and Needs and Services Plan for C1 and C2. On 08/15/2023, Community Care Licensing (CCL) received an allegation that the staff at the facility did not intervene in minor on minor assault. Confidential interviews did not corroborate the allegation with a preponderance of evidence. Based on confidential interviews and records reviewed regarding the allegation that, staff did not intervene in minor on minor assault. it may have occurred, however, it is not supported or proven by the evidence. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz 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: ROP PARAGON HOUSEFACILITY NUMBER: VISIT DATE: 11/14/2023

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

met_with: Cedric Jones


raw_content:
Narrative:
the clients and called C1 weird. Confidential interviews indicated that S2 asked C5 to go to their bedroom so they could check their backpack for inappropriate items and C5 did not listen, so S2 told C5, "I don't give a fuck, you are going to stay in your bedroom." Confidential interviews indicated that S2 lost their temper and later apologized to the clients. It was also reported that S2 called C1 weird. Confidential interviews and an audio recording confirmed that S2 told C1, "your mama is weird...you are a square...you a sucker." Based on confidential interviews and audio recording, the allegations that staff spoke inappropriately to minors in care and that staff's behavior poses a risk to minors in care is substantiated. The preponderance of evidence standard has been met. The facility is cited for violation of the California Code of Regulations, Title Division Six, regulation 87072(c)(15) Personal Rights. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Sylvia Arballo. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights will be emailed to the Administrator. A copy of this report will be placed in the facility file. facility. Confidential interviews revealed conflicting statements. Some interviews indicated that staff contacted Law Enforcement after C1 ran away from the facility. While other interviews indicated that staff did not contact Law Enforcement to report C1 ran away, however, an exact date could not be provided. Thus, 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 follow proper reporting requirements, which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Sylvia Arballo. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights will be emailed to the Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On January 5, 2024, at 2:55 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility and met with Julia West, Senior Coach Counselor, while Sylvia Arballo, Compliance Manager, was on the phone to discuss the investigative finding for the allegations noted above. LPA conducted an inspection of the facility on 09/11/2023 at 2:00 pm and no deficiencies were observed. LPA interviewed two staff (S1, S2), and one County Social Worker (CSW), LPA interviewed three clients (C1, C2, C4), and LPA was unable to interview one client (C3), despite multiple attempts to contact them. LPA reviewed the following documents: Client Roster, Personnel Record, Overnight room check forms, staff schedule, staff communication log, C1's Needs and Services Plan, C1's Special Incident Reports, and a cell phone audio recording of C1 and S2. On 09/01/2023, Community Care Licensing (CCL) received allegations that staff spoke inappropriately to minors in care and that staff's behavior poses a risk to minors in care. It was reported that staff yelled at 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: ROP PARAGON HOUSEFACILITY NUMBER: VISIT DATE: 01/05/2024

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:

met_with: Julia West


raw_content:
Narrative:
interviews indicated C1 refused to complete their chores and S1 yelled at them and called them "lazy." Other interviews denied S1 yelled at C1 and denied S1 called C1 "lazy." While other interviews, denied staff yelled at the clients. Confidential interviews indicated S1 was joking around with another staff and made a gesture to choke them. Some interviews denied S1 made any comments that they were going to choke C1. Other interviews indicated S1 and C1 were laughing and made a joke about being choked. Due to being unable to interview all individuals, confidential interviews did not corroborate the allegations with a preponderance of evidence. Based on confidential interviews and records reviewed the allegations that staff speak inappropriately to minors in care and staff yell at minors, which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Kayla Dembek. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights were emailed to the Facility Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On April 8, 2024, at 10:20 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Kayla Dembek, Facility Administrator, to discuss the investigative finding for the allegations noted above. LPA conducted an inspection of the facility on January 18, 2024, at 9:45 am and no deficiencies were observed. LPA Linley interviewed three clients (C1, C2, C3), one client declined to interview (C4), five staff (S1-5), and was unable to interview one staff (S6), despite multiple attempts to contact them. LPA reviewed the following documents during the investigation: C Needs and Services Plan, Client Roster, Staff Schedule, Special Incident Reports, Police Department Incident Report. On January 8, 2024, Community Care Licensing (CCL) received allegations that staff speak inappropriately to minors in care and staff yell at minors. It was reported that S1 yelled at C1, other staff yell at the clients, and S1 said they were going to choke C1. Confidential interviews revealed conflicting statements. Some 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: ROP PARAGON HOUSEFACILITY NUMBER: VISIT DATE: 04/08/2024

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


raw_content:
Narrative:
Based on confidential interviews and records reviewed the allegation that staff did not provide adequate supervision resulting in minor engaging in inappropriate behavior with another minor in care, which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Kayla Dembek. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights were emailed to the Facility Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On April 8, 2024, at 10:00 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Kayla Dembek, Facility Administrator, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on February 1, 2024, at 4:15 pm and no deficiencies were observed. LPA Linley interviewed two clients (C1-2) and two staff (S1-2) and one client declined to interview (C3). LPA reviewed the following documents during the investigation: C1 and C Needs and Services Plan, Client Roster, Staff Schedule, and Special Incident Reports. On January 29, 2024, Community Care Licensing (CCL) received an allegation that staff did not provide adequate supervision resulting in minor engaging in inappropriate behavior with another minor in care. It was reported that C1 pulled down their pants and exposed themselves to C3. Disclosures during the interviews were inconsistent with the allegation and due to being unable to interview all individuals, confidential interviews did not corroborate the allegation with a preponderance of evidence. 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: ROP PARAGON HOUSEFACILITY NUMBER: VISIT DATE: 04/08/2024

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


summary: Facility Evaluation

raw_content:
Narrative:
On May 4, 2026, at 10:50 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with House Parent, Yeraldina Polanco. LPA conducted a walk-through of the facility with Ms. Polanco and observed the ingredients for dinner tonight were not in the facility in the quantity necessary to meet the needs of the clients. LPA also observed there was not enough food to make the next day's menu items as indicated by the menu. LPA observed that the menu did not indicate the date, times for meals and/or snacks and the meals did not indicate the quantities necessary to meet the needs of the clients. Ms. Polanco stated the facility was grocery shopping later today. Based on LPA's observation, the facility is cited for one deficiency (refer to LIC 809D) from Title Division Chapter Article 06, 80076(a)(1) Food Service. An exit interview and appeal rights were discussed with Yeraldina Polanco. A copy of this report, LIC 811, and appeal rights were provided to the facility. A signed copy of the report will be placed in the facility file.

met_with: Yeraldino Polanco


facility_name: ROP QUALIFYING HOUSE FREEL

summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
As a result of the information obtained and interviews conducted, the complaint is SUBSTANTIATED at this time meaning that the allegation is valid because the preponderance of the evidence standard has been met. The facility was cited for violation of California Code of Regulations, Title Division Six, regulation 80087(a): Buildings and Grounds. Interview conducted demonstrated that staff knew about the trash but did not clean it up for approximately two hours. Exit interview was conducted and documents provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection at the facility on 8/17/21 at 10: AM but nobody was home. LPA then went to the administrative/nonpublic school location in Minden, Nevada and met with the administrator, Tracy Edwards. Interview with S1 (see LIC811 dated 8/17/21) on 8/17/21 demonstrates that S2 was aware of a bear leaving the property about 6: AM after having accessed the trash bins and caused the trash to be strung out in front of the facility and across the street. S1 states they received a text from S2 stating C1 (who is no longer residing in the facility) had taken out the trash the night prior as part of their chore and had not secured the trash bin as required to prevent wildlife from accessing the trash bin. S2 told S1 that C1 needed to clean up the trash themselves as they were at fault for it being left accessible to the bear. S2, being the newer staff, did not clean up the mess left behind by the bear until C1 woke up and was taken outside to clean up the mess, two hours later. Administrator arrived to the facility at approximately 9: AM to find S1 and C1 outside cleaning up the mess left by the bear, including the trash that was taken across the street. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: ROP QUALIFYING HOUSE FREELFACILITY NUMBER: 027202889

met_with: Tracy Edwards, Administrator


raw_content:
Narrative:
The allegation that staff did not prohibit youth from smoking on the grounds is related to an incident that took place on June 15, 2022, where an Alpine County Sheriff responded to the facility due to a youth in care running away from the facility. Upon arrival, Sheriff located S1 who informed Sheriff that the other youth from the facility were in the rear of the facility smoking. While S1 was present and supervising youth, Sheriff indicated that S1 made no attempts to direct the youth to stop smoking or extinguish their cigarettes. Sheriff indicated that they told youth to stop smoking and youth complied, but that S1 never told the youth that smoking was prohibited on the grounds of the facility nor did S1 indicate to youth the dangers of smoking for the youth's health or the dangers of fires to the community. LPA Hill made three attempts to contact the overnight awake staff on duty, (S1), on the date of the incident and was unable to interview S1 due to S1's work/sleep hours. LPA Hill interviewed other staff that are familiar with S1 and learned that S1 is not assertive with the youth in care and is not confrontational with youth. Staff stated that S1 would rather take daily points from youth for these types of behaviors/choices rather than confront the youth and counsel them to make better choices. LPA Hill also interviewed youth present and smoking and youth denied S1 telling them that they could not smoke or to put the cigarettes out. Youth further stated that S1 never told them about the dangers in the community, including wildfires. Youth stated that they knew that they were not to smoke but that information came from other staff and not S1. As a result of the information obtained and interviews conducted, the allegation that staff did not prohibit youth from smoking on the grounds is SUBSTANTIATED at this time meaning that the The "preponderance of the evidence" standard has been met. The facility was cited for 87087(c) Buildings and Grounds as the licensee shall prohibit smoking in the facility and on the grounds of the facility. Exit interview was conducted with Mr. Edwards and documents were provided via email.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 10/7/22 at 10: AM and met with Tracy Edwards, Administrator for the purposes of delivering findings for the allegation as stated. LPA Hill informed Mr. Woods that the complaint investigation included an initial inspeciton on July 5, 2022 and a subsequent inspeciton on September 1, 2022, where files were reviewed, documents obtained, and interviews were conducted with clients and staff. LPA Hill conducted additional interviews with staff on September 20, 2022 and made three attempts to contact S1 that sleeps during the daytime due to their work hours. LPA Hill was not successful in contacting S1 for this complaint investigation. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: ROP QUALIFYING HOUSE FREELFACILITY NUMBER: 027202889

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


raw_content:
Narrative:
coerced to take medications, even if prescribed by the doctor or psychiatrist. As a result of the confidential interviews conducted, the allegation that youth were pressured to take medications prescribed or authorized is UNSUBSTANTIATED meaning the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. The allegation regarding a lack of supervision is related to an incident during an outing which lead to a youth being harassed by other youth. During confidential interviews with staff and youth, seven out of eight youth stated that they were "rough-housing" with all of the youth during the outing and staff denied any youth indicating that they felt scared or threatened during the outing or after the outing. LPA Hill attempted contact with two youth identified as being possible witnesses but one is absent from care and their whereabouts are unknown and the other has not responded to requests for interview. During interviews with staff, all staff indicated that there were never reports made and they were not informed that any of the youth felt threatened or were harmed during this outing. As a result of the confidential interviews conducted, the allegation that a lack of supervision lead to youth feeling threatened during an outing is UNSUBSTANTIATED meaning the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. The allegation that staff did not provide a safe environment is related to the staff not being able to provide for youth's safety due to being new or inexperienced. During confidential interviews, youth confirmed that the majority of staff are new and/or lack experience in this field and may be immature. Youth confirmed however they trust the supervision that staff provide and fairness they demonstrate to youth. Confidential interviews indicated youth felt that staff are not perfect but are doing a good job protecting youth during incidents that happen in the facility, redirecting youth prior to physical incidents, supporting youths' mental health goals, trying to get to know youth, and supporting youth's transition goals. Confidential interviews indicated that staff did not always know when youth were going to "go off" thus leading to them not always being prepared. Staff indicated that there have been times when physical interventions have not been utilized when they should have been due to prior staff injuries which has lead to escalated behaviors with youth. As a result of the confidential interviews conducted, the allegation that staff did not provide a safe environment is UNSUBSTANTIATED meaning the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred Exit interview was conducted and documents, along with appeal rights were provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 1/26/24 at 1: PM and met with Alina Scott, Head of Service to discuss the complaint findings for the allegations. LPA Hill informed Ms. Scott that the complaint investigation included an initial inspection at the facility on 9/8/23, subsequent inspection on 11/17/23 and interviews of eight youth and six staff from 11/16/23 to 12/21/23. LPA Hill attempted to interview two past clients but was not able to secure those interviews. The allegation that staff pressure youth to take medications is related to over the counter medications that are authorized by youths' doctors to aid in youths' sleep. It was alleged that staff were forcing and/or enticing youth to take medications so that they sleep through the night and not wake or that youth were being given more than the authorized dosage of these sleep medications. In addition, it was alleged that medications were administered and not documented when given to youth. During confidential interviews with staff and youth in care, all staff and seven out of eight youth denied being given more medications than what was authorized. Seven out of eight youth and six out of six staff interviewed denied being forced, bullied, or UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE FREELFACILITY NUMBER: VISIT DATE: 01/26/2024

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

met_with: Alina Scott, Head of Service


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Narrative:
During confidential interviews, LPA Hill learned that there was "tension in the house" between C1 and C2. Staff in the facility decided to take youth on an outing to give the youth space due to this tension. C2 was on outing restriction due to behaviors but C1 chose not to go on the outing so the on-call staff made the decision to allow C2 to attend to create space for the day. When youth returned from the outing, C2 attacked C1 while C1 was in the den speaking with C3. C4 was present when the fighting started and, knowing that S1 could not intervene, C4 stepped in to assist in separating the youth and protect C1. C2 has a history of assaulting staff and youth since being placed with the agency. The agency's policy on restraints requires two staff to engage in physical restraints. Knowing that S1 could not engage in physical restraints as necessary and knowing C2's assaultive history, the agency did not provide an additional staff on 12/9/23, knowing that there was tension between the youth in the facility. As a result of the investigation and confidential interviews conducted, the allegation that staff did not provide adequate supervision resulting in C1 being assaulted by other youth at the facility is SUBSTANTIATED at this time meaning that the "preponderance of the evidence" standard has been met. The facility was cited for violation of Title Regulation Responsibility for Providing Care and Supervision as the facility has a responsibility to provide care and supervision to meet the clients' needs and the facility did not protect C1's safety while at the facility, despite knowing of the tension between the youth and knowing that staff was unable to engage as necessary in their emergency intervention plan to protect C1 as required. Exit interview conducted and documentation, along with appeal rights were provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill conducted an unannounced complaint inspection on 1/26/24 at 1: PM and met with Alina Scott, Head of Service to discuss the findings of the complaint allegations. LPA Hill informed Ms. Hill that the investigation included an initial inspection to the facility on 12/21/23. This investigation is related to an incident that happened at the facility on 12/9/23. LPA Hill conducted interviews of three staff and two youth on 12/21/23 while at the administrative office. LPA Hill also reviewed the camera footage of the incident while at the administrative offices on12/21/23. LPA Hill conducted a collateral inspection to the facility's administrative office on 1/17/24 where additional interviews were conducted. The allegation that staff did not provide adequate supervision is related to the incident on 12/9/23 where C1 (see LIC811 dated 1/26/24) was assaulted by C2 and C3. While there were two staff present in the facility supervising four youth, S1 was unable to assist in emergency interventions due to a medical condition. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE FREELFACILITY NUMBER: VISIT DATE: 01/26/2024

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


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Narrative:
housing or rough play with youth in care. The specific incidents included smearing mayonnaise on C1 in the facility (date unknown), pulling youth off a the facility sofa by their legs (date unknown), pulling on C1's seat belt during transport, S1 placing their lanyard over C1's head/neck during transport, forcibly removing C1's shoe(s) from their feet, and/or S1 placing their foot near C1's face during transport, S1 telling youth in the facility that staff can do what they want because they are staff but that youth cannot do the same things. During an interview with S1, S1 did admit to some of the reported incidents but stated that they were done in fun and not meant maliciously. S1 stated that C1 did get upset sometimes when playing around and when C1 got upset, S1 stopped horse playing. Regarding telling the youth that they can do anything they want, S1 stated that all the staff say this and is not just S1 themselves. S1 stated that they are aware of the grievance filed against them and since this, none of the horse play has happened between S1 and C1. As a result of the information obtained and interviews conducted, the allegation that Staff violated youths personal rights is SUBSTANTIATED at this time meaning the "preponderance of the evidence" standard has been met. The facility was cited under Short Term Residential Therapeutic Program, Interim Licensing Standards, Personal Rights, Section 87072(c)(1) as the licensee has a responsibility to ensure youth are accorded personal rights specified in Welfare and Institutions Code Section 16001.9 including the right to live in a safe, healthy, and comfortable home where they are treated with respect and this did not happen for C1 and other youth that were witness to these incident(s). Documentation was provided to Ms. Edwards along with appeal rights and exit interview was conducted. Licensing within the agency's next working day, during normal business hours as required, but the written report containing all of the required information was received within seven days following the receipt of the grievance, as required by regulation. Confidential interviews with the agency revealed that the agency was not handling the grievance as an incident initially but were investigating as a grievance until it was realized that it was a reportable incident. As a result of the information obtained and interviews conducted, the allegation that the facility failed to report a serious incident to the Department is UNSUBSTANTIATED at this time meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Facility was issued a Technical Advisory regarding the 24 hour reporting requirement. Exit interview conducted and documentation was provided to Ms Edwards.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 2/29/24 at 12: PM and met with Tracy Edwards, Program Director to discuss the complaint allegation as stated. LPA Hill informed Ms. Edwards that the complaint investigation included an initial inspection at the facility on 12/7/23 where one staff was interviewed. Subsequent collateral inspections were conducted from 12/20/23 to 1/17/24 where five staff and two youth were interviewed. In addition, LPA Hill obtained documentation related to C1, C2, S1 and S2 (see LIC811 dated 2/29/24). LPA Hill also received documentation related to a grievance filed related to the allegation(s) and incident(s). LPA Hill informed Ms. Edwards that the allegation that staff violated youths' personal rights is related to a series of incidents in the facility and facility transport vehicle between C1 and S1 which included rough SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE FREELFACILITY NUMBER: VISIT DATE: 02/29/2024

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:

met_with: Tracy Edwards, Program Director


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youth in care are left vulnerable to physical attacks by youth and the agency not proactively addressing these issues for the safety of the other youth in care and staff working at the facility. LPA Hill informed Ms. Edwards that the investigation and confidential interviews show that when youth are accepted and have a history of violence, whether against adults or other youth, the facility is not staffing to the need of the youth by having additional staff in the facility until they are better familiar with the youth or ensuring that staff that are properly trained and/or without restrictions or limitations on mobility are present to work with the newly admitted youth. This was evidenced by one incident on 12/9/23 where a youth was attacked in the facility by another youth and one of the two staff present was unable to engage in physical restraints due to a medical restriction. Another incident happened on 11/5/23 where a youth attacked two staff present at the facility, resulting in at least one staff being hurt. There were two additional incidents where the same youth allegedly attacked staff at the nonpublic school site, 12/7/23 and 12/12/23. Confidential interviews revealed that while staff was within ratio at the time of the incident(s), most staff expressed not feeling appropriately trained or comfortable in the emergency intervention training, confronting youth, or preventing incidents from happening. Review of the documentation received related to C1 in particular (see LIC811 dated 2/29/24) indicates that the agency knew or should have known that youth was a risk to the health and safety of the other youth in care and staff as the youth had a history of verbal aggression and physical aggression resulting in violence. In addition, following the initial attack at the facility on 11/5/23, the licensee did not increase staffing at the facility when the agency suspected that situations were escalated, as seen in the 12/9/23 incident. As a result of the information obtained, documentation received, confidential interviews conducted, the allegation that staff do not prevent the minors from engaging in physical altercations is SUBSTANTIATED as the "preponderance of the evidence" standard has been met. The facility was cited under Short Term Residential Therapeutic Program, Interim Licensing Standards, Personnel Requirements, Section 87065(g) as the licensee shall employ the number of direct care staff necessary to meet the needs of children and provide adequate care and supervision, including staff needing to be able to administer discipline and setting of limits for behavior, consistent with trauma-informed standards. Documentation was provided to NAME and exit interview conducted.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 2/29/24 at 12: PM and met with Tracy Edwards, Program Director to discuss the findings of the complaint allegation. LPA Hill informed Ms. Edwards that the investigation included initial complaint inspections to the administrative office and facility on 11/16/3. Subsequent insections were conducted 11/17/23, 12/7/23, 12/21,23, 1/7/24, and 2/15/24 where eight youth and five staff were interviewed, including the Head of Service and administrator. In addition, documentation was obtained and reviewed related to incident reports of assaults, law enforcement calls, and how youth are assessed when being considered for acceptance. The allegation that staff do not prevent minors from engaging in physical altercations is related to youth not being assessed properly assessed prior to acceptance into the program and subsequently staff and other SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE FREELFACILITY NUMBER: VISIT DATE: 02/29/2024

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


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Narrative:
C1 was accepted in July 2023, during the time the agency was in the process of changing psychiatrists. The facility did not have a psychiatrist for the months of September 2023 and October 2023. Prior to this transition, C1 did see the psychiatrist 8/3/23 and 8/17/23. While the agency was unable to provide monthly consultation records from a psychiatrist as required for the months of September and October 2023, they were able to provide the Department with proof of active efforts in getting the selected doctor approved from July 2023 through October 2023. The new psychiatrist started in November 2023. C1 was receiving all other mental health services offered by the agency, including individual, family, and group therapy, as well as other mental health services despite not seeing a psychiatrist during the months of September and October. Investigation also showed that C2 was accepted despite knowing C2 had a history of violence. During the six weeks C2 was in placement, from October 2023 to December 2023, there were five incidents of violence, including attacks on staff and other clients in care. Subsequent to each of these incidents, Child and Family Team meetings were called to discuss the issues and how to resolve them. The facility continued to work with the placing agency on C2's placement until December 2023 when C2 was removed from this agency. Confidential interviews conducted with the HOS and Administrator revealed that when youth are referred for placement, most of them have some kind of violence in their history and as a result, it is not an automatic denial. Administrator states that youth with violent pasts are accepted if they agree to the program and are willing to abide by the program's expectations and rules. While the facility was within ratio of one staff to three clients during these episodes, staff knew, or should have known, there was a potential for violence and the agency should have augmented staffing in the facility, but this did not happen. During one specific incident on 12/9/23, staff knew that tensions were high between youth in care but one of the staff working was on light duty and unable to restrain or assist in a manual restraint as needed. When an incident did happen between youth in care, staff was unable to physically assist to break the youth up, resulting in another youth in care getting involved and assisting staff to break up the assault. (The facility was cited for this incident and lack of appropriate supervision on 1/26/24). As a result of the investigation, interviews conducted and documentation reviewed, the allegation that the facility did not follow their preplacement procedures when assessing youth for placement is SUBSTANTIATED meaning that the "preponderance of evidence" standard has been met. The licensee has a responsibility to augment staffing levels in the facility based on identified needs, behaviors or other factors but this did not happen. The facility was cited per STRTP Interim Licensing Standards, Section 87065.5(g) Direct Care Staff/Child Ratios as the facility shall increase the number of on-duty direct care staff if a child requires special care and supervision because of age, behavior or other factors. Exit interview was conducted with Ms. Edwards and documentation provided including appeal rights. Confidential interviews conducted demonstrated that the agency was given a 60-day notice in June 2023 that their current psychiatrist was terminating their contracted psychiatry services as of August 2023. In July 2023, the agency found and began the process of on-boarding a new psychiatrist, but the process was lengthy, and the agency did not have the new psychiatrist on board until November 2023, meaning the youth did not have the required monthly psychiatry appointments for the months of September 2023 and October 2023. The agency was able to provide documentation including emails and correspondence between the agency's HOS, Placer County, the new contracted provider, Health Link Now, and the psychiatrist from July 2023 through November 2023, indicating that the agency was actively trying to get the new psychiatrist through the contract and on-boarding process to provide services to youth in care. In addition, in anticipation of not having the psychiatrist in time, HOS did reach out to Barton Psychiatry in South Lake Tahoe on 8/5/23 but were informed that the wait time would be until January 2024, and Washoe County (Nevada) Behavioral Health but were informed they could not provide services to the agency's youth. HOS presumed it due to the youth being California youth and not from Nevada. The new psychiatrist was providing psychiatry services to youth in care as of November 14, 2023. LPA Hill learned that during the time without psychiatry services, the agency had prepared in advanced and did have prescription refills for all youths' medications and no youth went without medications or had lapses in medications during the months of September or October. As a result of the investigation, interviews conducted, and documentation received, the allegation that the facility did not provide clients in care with consultation from a psychiatrist as required for the months of September and October 2023, is UNSUBSTANTIATED as facility did employ active efforts in locating and on-boarding a replacement psychiatrist during the months of September and October 2023. This means that the allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. The allegation that the facility did not ensure client's medical and/or mental health needs were met is related to the same allegation as stated regarding the youth having the required psychiatry consultations prescribed in regulation. When interviewing C1's social worker, it was indicated that all medical and mental health services were provided except for the psychiatry consultations as described. Social worker states that the facility did ensure that youth had consultations with doctor, dentist, and optometry as needed while at the facility and that the agency did ensure that therapy, and other mental health services were being provided during this time. As a result of this information, the allegation that the facility did not ensure medical and/or mental health needs were met is UNSUBSTANTIATED at this time as the facility did employ active efforts in locating and on-boarding the new psychiatrist. This means that the allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. Exit interview was conducted with Ms. Edwards and documentation was provided along with appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 3/13/24 at 10: AM and met with Tracy Edwards, Program Director to discuss the complaint findings as stated. LPA Hill informed Ms. Edwards that the complaint investigation included an initial inspection to the agency on 10/27/23 where LPA Hill interviewed Head of Services (HOS) and Administrator and obtained documentation related to the allegations and LPA Hill obtained the agency's approved mental health program plan as approved by the Department of Health Services. Subsequent inspections were conducted on 11/17/23, 12/7/23, 12/20/23, 12/21/23, 1/10/24, and 2/15/24 to interview youth and staff related to the allegations. LPA Hill also interviewed a social workers and public health nurse related to the allegations. The allegation that the facility is not following their preplacement procedures when assessing youth to be accepted is related to the agency's process of assessing youths' compatibility for the facility. The original allegation is related to the accepting of youth knowing that the facility cannot meet the needs of the youths' mental health needs and specifically the psychiatry needs when admitted. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE FREELFACILITY NUMBER: VISIT DATE: 03/13/2024

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:


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Plan or treatment plan to C1's placing agency, but they were unable to provide proof that this happened. LPA Hill then questioned the agency about implementation of the Needs and Services Plan as the regulations require that a signature be obtained as evidence that the placement agency agrees prior to implementation and the administrator and Head of Service both indicated that the needs of C1 and treatment for C1 was discussed on multiple occasions as C1 had high needs. The facility/agency did acknowledge that C1's soothing plan was provided to the placing agency. As a result of the interviews conducted and documentation obtained and reviewed, the allegation that staff did not follow youth's treatment plan is SUBSTANTIATED meaning the "preponderance of the evidence" standard has been met. The facility was cited per STRTP Interim Licensing Standards Section 87068.2(g) Needs and Services Plan as the licensee shall obtain written approval from the child...and the child's authorized representative prior to implementing the child's needs and services plan. The allegation that staff speak inappropriately to youth in care is related to staff not using Trauma-Informed language when speaking with youth in the facility. Confidential interviews with staff and clients indicated that some staff would say things in a demanding tone, were rude, and argued with clients or would tell youth that they were staff, they could get away with speaking to youth in this manner or in other ways penalize youth in care for speaking up for themselves. As a result of the investigation and confidential interviews conducted, the allegation that staff speak inappropriately to youth in care is SUBSTANTIATED meaning the "preponderance of the evidence" standard has been met. The facility was cited per STRTP Interim Licensing Standards Section 80072(c)(1) Personal Rights as the licensee shall ensure that each child...is accorded the personal rights specified in Welfare and Institutions Code Section 16001.9 including the right to live in a safe, healthy, and comfortable home where they are treated with respect. Continued on LIC9099C. The allegation that youth are unable to make private phone calls is related to the youth not being able to make calls to whomever they choose, staff listening to calls, and youth overall not having privacy during calls. During confidential interviews with youth and staff in care, it was noted that youth are not allowed to have confidential calls in that all calls must be done in the facility den, with the door open, and some staff sit at the doorway and listen to the calls, regardless of who youth is speaking to on the phone. At the conclusion of the interviews with staff and clients on 11/17/23, LPA Hill informed the agency that this practice shall cease immediately and informed the staff and agency that youth have the right to call who they want unless there is a court order restricting their calls. In addition, LPA Hill advised the agency that staff cannot monitor the calls, listen to the calls, be in the room with youth while making calls, log their phone calls, write down the phone numbers of calls made or in any way question youth about who they were calling during the designated call time allotted to youth. LPA Hill did confirm during follow up inspections and interviews that the staff are no longer monitoring youths' calls and that the phone policy is changed so that youth are afforded privacy during calls. While the alleged violation has been remedied, it was true at the time that the initial complaint investigation was filed. As a result of the investigation and interviews conducted, the allegation that youth are unable to make private phone calls is SUBSTANTIATED at this time meaning the "preponderance of the evidence" standard has been met. The facility was cited per STRTP Interim Licensing Standards Section 80072(c)(1) Personal Rights as the licensee shall ensure that each child...is accorded the personal rights specified in Welfare and Institutions Code Section 16001.9 including the right to To make, send, and receive confidential telephone calls...unless prohibited by court order. While this allegation was remedied immediately, it still was a violation at the time the complaint was filed. Exit interview was conducted with Ms. Edwards and documentation including appeal rights were provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 3/13/24 at 10: AM and met with Tracy Edwards, Program Director to discuss the complaint findings as stated. LPA Hill informed Ms. Edwards that the complaint investigation included an initial inspection to the agency on 11/16/23 where LPA Hill obtained documentation. Subsequent inspections were conducted 11/17/23, and 2/15/24. Seven youth were interviewed and five staff, including Head of Services (HOS) and Administrator from 11/17/23 to 2/15/24. In addition, outside parties related to C1 (see LIC811 dated 3/13/24) were interviewed 2/28/24 and 2/29/24 as pertinent to the investigation. This allegation is related to the agency not providing C1's Needs and Services Plan and/or treatment plan to the placing agency to verify that the agency, facility, and staff are following it or updating it as necessary for C1. The placing agency states that they only received C1's Regulation and Soothing Plan and that it was not being followed either. LPA Hill requested proof that the facility/agency had provided C1's Needs and Services SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE FREELFACILITY NUMBER: VISIT DATE: 03/13/2024

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