summary: Facility Evaluation

raw_content:
Narrative:
On August 12, 2022, Licensing Program Analyst's (LPA) Cynthia Galindo and Briana Placencia returned to The Raft to continue and finalize annual inspection which began on August 9, 2022. On this day, LPAs reviewed nine staff files and interviewed 2 staff. LPA's met with Alfredo Ceja and reviewed outcome of annual inspection, discussed staff training, updating files, nursing services, and TSP referral. Alfredo said they would like TSP. Deficiencies are being cited on todays visit, see LIC809-D. A copy of this report was left at the facility at the conclusion of inspection


state: CA

facility_name: RAINBOW VALLEY GROUP HOME, INC.

summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
On July 19, 2021, Licensing Program Analyst (LPA) Rachel Bruce conducted an unannounced telephonic inspection. The purpose of the inspection was to deliver findings on the above allegation. On May 7, 2021 the above allegation was referred to Community Care Licensing for investigation. The investigation included review of documentation supplied by the STRTP, interviews with clients in care and staff members who worked with the AWOLing minors. Staff members indicated it was not due to lack of supervision as did 2 clients; however 1 client was not available to confirm or deny and 2 others would not provide a statement. Based on interviews, inspection and documents reviewed, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the allegations occurred. Therefore, the allegations are UNSUBSTANTIATED at this time. A copy of this report will be provided to the Facility Representative for signature and return. Appeal rights were also provided. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Rachel A Bruce LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2

report_type: Complaint Investigation

met_with: Deserie Ramos, Supervisor

complaint_status: unsubstantiated


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13On September 10, 2021, Licensing Program Analyst (LPA) Rachel Bruce conducted an unannounced inspection at the STRTP and spoke with Barbara Aramburu, Mental Health Professional. The purpose of the inspection was to deliver the findings for the above complaint allegation. On July 13, 2021, the above allegation was referred to Community Care Licensing for investigation. The investigation included review of documentation supplied by the STRTP, interviews with clients in care and staff members. Based on the information obtained during the course of the investigation, there is a preponderance of the evidence to prove the above allegation is SUBSTANTIATED. Deficiencies were cited. A copy of this report along with appeal rights were left with Barbara Aramburu. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Rachel A Bruce LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, E SHAW AVE FACILITY NAME: RAINBOW VALLEY GROUP HOME, INC.FACILITY NUMBER: 247202586

met_with: Barbara Aramburu

complaint_status: SUBSTANTIATED


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Rachel Bruce conducted an unannounced visit to the Rainbow Valley STRTP - JOERG in order to deliver the findings of the above allegation. LPA met with Barbara Aramburu, Mental Health Professional . On April 22, 2021, the above allegation was referred to Community Care Licensing for investigation. The investigation included interviews, facility inspection, and review of documentation. No staff or minors observed any inappropriate touching and the alleged victim denied any inappropriate interactions with any staff member. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation occurred. Therefore, the allegation that a staff member had inappropriate interactions with minors in the house is UNSUBSTANTIATED at this time. A copy of this report was discussed and provided to Barbara Aramburu along with appeal rights. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Rachel A Bruce LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2


raw_content:
Investigation Findings:
13Complaint Specialist C.K. Kinney(CS) traveled to the home of Board Member Roberta Ortiz to deliver the findings of the investigation. Investigator Barragan conducted investigation that included review of documentation, interviews of staff, clients and witnesses and due to inconsistencies in the information obtained a preponderance of the evidence could not be obtained. The allegations are deemed Unsubstantiated. Although the allegations may or may have not occurred or are or are not valid a preponderance of the evidence could not be met so allegations are deemed Unsubstantiated. Copy of this report left with Roberta Ortiz at conclusion of inspection. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Charles Kinney LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

met_with: Roberta Ortiz


summary: Facility Evaluation

raw_content:
Narrative:
On July 7, 2021, Licensing Program Analysts (LPA's) Rachel Bruce and Priscilla Zamudio met with Angela Martinez at the Joerg STRTP. The purpose of the visit was to inspect the fence that had been taken down due to a fire at the property adjacent to the STRTP on the south side. On July 4, 2021 the house next door had severe burn damage due to fireworks that had ignited the roof. Residents of the STRTP were not responsible for lighting the fireworks and no one at the STRTP received any injuries. As a result of the fire department needing to access the building, the fence between the properties came down. The landlord and director of the facility Jason Enger will work together to get the fence repaired as soon as possible. It is not posing an immediate risk to the safety and well being of the clients in care. LPA Bruce also took this oppurtunity to introduce the staff at JOERG to LPA Zamudio who will be their new assigned analyst. She was provided a brief tour of the facility to get acquainted with the layout. Due to printer and computer issues, this document was not prepared at the facility nor was it available to be signed.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Angela Martinez, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On October 1, 2021, Licensing Program Analyst (LPA) Rachel Bruce conducted an unannounced Case Management- Informal Conference for the purpose of discussing the number and severity of complaints against the facility. Specifically, on July 13, 2021 a complaint was opened regarding a client (FC1) accessing unlocked medication and overdosing. This complaint was found to be substantiated. Findings revealed that while staff was involved with another client who was causing substantial property damage, FC1 absconded out of her bedroom window unnoticed. She proceeded to climb through the unlocked bathroom window to the office. Once inside she accessed the unlocked medicine storage unit and overdosed on her own medication. Staff admitted that while the office was locked the medicine cabinet and the bathroom window were both unlocked and ultimately accessible to the client. A citation was issued for not securing medicine. For purposes of this meeting CCL is focusing on JOERG. CCL acknowledges and will honor the STRTP closure plan effective 10/4/21. As such, there will be no citations issued at this time. Acknowledging the planned closure does not negate legal action in the future or CCL's ability to consult with their legal division


summary: Facility Evaluation

raw_content:
Narrative:
On October 4, 2021, Licensing Program Analyst (LPA) Rachel Bruce conducted an announced visit to the facility to have the facility licence relinquished and signed over to CCL. LPA conducted a tour of the home and noted that there are no residents and no personal belongings or medication. Staff was on site cleaning and boxing up supplies. Angela Martinez signed the back of the license indicating that the facility would be closed effective today.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA) Rachel Bruce travelled to the facility listed above to conduct an announced annual required inspection. A general overview of their program and tour of the facility inside and out was provided on this date. The agency's current LIC500 accurately reflects current staffing. The STRTP is licensed to serve 6 ambulatory identifying female clients ages 12-17 years old. Current capacity is 6. LPA observed the following: 1. Facility Grounds have a few issues to be addressed. See Deficiency page attached. 2. Adequate indoor and outdoor activity space and materials observed. 3. Chemicals appropriately locked. 4. Locked and centrally stored medications observed. Observed medication logs and discussed procedures for psychotropic medications. Facility is in compliance. 5. First aid kit complete and accessible 6. Adequate storage space observed. 7. Individual beds in good repair observed with clean linens 8. The house has 3 bedrooms, double occupancy, all located on a single level. Bedrooms are accommodating of all required furnishings. 9. Adequate food storage space observed. Supply of two days of perishable foods and a week of nonperishable foods observed upon inspection. 10. Monthly menu and monthly activity schedule is posted and accessible to clients. 11. Dining room equipped with large table and chairs accommodating of all clients. 12. Facility has one and a half restrooms in the house for client use, both are operable. 13. Client's rights and other appropriate and required are forms posted in view of clients. 14. No firearms or weapons are allowed in the facility. 15. Fire extinguisher is properly charged and serviced. Continued Inspection of the client's files reflect appropriate and timely documentation. All JV220's were checked as well as Needs and Services and found to be in compliance with the regulations. Inspection of a sample of the staff files was completed. All were appropriately associated to the facility and received fingerprinting and child abuse index check clearances. Training is up to date and filed/documented and in compliance. Deficiencies cited during this inspection relate to Buildings and Grounds. See attached. A copy of this report along with appeal rights will be left with the facility.

visit_type: Annual


facility_name: RAINBOW VALLEY MERCED

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Rachel Bruce conducted an unannounced visit to the STRTP Cavalaire Court for the purpose of delivering the findings on the above allegations and met with Roberta Ortiz, Board Member. On May 6, 2021, the above allegations were referred to Community Care Licensing for investigation. The investigation included an inspection of the facility, interviews with the staff, foster children and a review of client's records. The complaint alleged that a minor in care had her personal rights violated. (see the six specific allegations above). The foster child in question and other clients interviewed provided conflicting information regarding the issues and staff interviewed denied the allegations. Although the allegations may have happened or may be valid, there is not a preponderance of evidence to prove the Personal Right violations occurred. Therefore, the allegations are UNSUBSTANTIATED at this time. A copy of this report was discussed and provided to Roberta Ortiz along with appeal rights. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Rachel A Bruce LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2

met_with: Roberta Ortiz, Board Member


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13On October 1, 2021, Licensing Program Analysts (LPA) Rachel Bruce conducted a follow up complaint inspection to the STRTP and met with Roberta Ortiz, Board Member. The purpose of the inspection was to deliver the findings for the above complaint allegation. Based on interviews of Foster Children, Social Workers, Staff and review of records, it was determined that the staff failed to provide medical attention until hours later to a client that was involved in a serious physical altercation. Based on the information obtained, there is a preponderance of the evidence to prove the above allegation is substantiated. Deficiencies were cited. A copy of the report was provided to the FFA. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Rachel A Bruce LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, E SHAW AVE FACILITY NAME: RAINBOW VALLEY MERCEDFACILITY NUMBER: 247203971

met_with: Roberta Ortiz, Boardmember


summary: Facility Evaluation

narrative: On October 4, 2021, Licensing Program Analyst (LPA) Rachel Bruce conducted an announced visit to the facility to have the facility licence relinquished and signed over to CCL. LPA conducted a tour of the home and noted that there are no residents and no personal belongings or medication. Staff was on site cleaning and boxing up supplies. Angela Martinez signed the back of the license indicating that the facility would be closed effective today.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA) Rachel Bruce travelled to the facility listed above to conduct an announced annual required inspection. A general overview of their program and tour of the facility inside and out was provided on this date. The agency's current LIC500 accurately reflects current staffing. The STRTP is licensed to serve 6 ambulatory identifying female clients ages 12-17 years old. Current capacity is 6. LPA observed the following: 1. Facility Grounds have a few issues to be addressed. See Deficiency page attached. 2. Adequate indoor and outdoor activity space and materials observed. 3. Chemicals appropriately locked. 4. Locked and centrally stored medications observed. Observed medication logs and discussed procedures for psychotropic medications. Facility is in compliance. 5. First aid kit complete and accessible 6. Adequate storage space observed. 7. Individual beds in good repair observed with clean linens 8. The house has 3 bedrooms for clients, double occupancy, all located on the upstairs level. Bedrooms are accommodating of all required furnishings. 9. Adequate food storage space observed. Supply of two days of perishable foods and a week of nonperishable foods observed upon inspection. 10. Monthly menu and monthly activity schedule is posted and accessible to clients. 11. Dining room equipped with large table and chairs accommodating of all clients. 12. Facility has one and a half restrooms in the house for client use, both are operable. 13. Client's rights and other appropriate and required are forms posted in view of clients. 14. No firearms or weapons are allowed in the facility. 15. Fire extinguisher is properly charged and serviced. Continued Inspection of the client's files reflect appropriate and timely documentation. All JV220's were checked as well as Needs and Services and found to be in compliance with the regulations. Inspection of a sample of the staff files was completed. All were appropriately associated to the facility and received fingerprinting and child abuse index check clearances. Training is up to date and filed/documented and in compliance. Deficiencies cited during this inspection relate to Buildings and Grounds. See attached. A copy of this report along with appeal rights will be left with the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On September 24, 2021, Licensing Program Analyst (LPA) Rachel Bruce conducted an unannounced case management inspection at the Rainbow Valley STRTP- Cavalaire Court. LPA Bruce conducted a case management inspection with Angela Martinez for the purpose of discussing the following concerns: 1. The requirement and necessity to report any unusual incident relating to the safety and well being of clients in care. On September 16, 2021, the foster children in the home accessed paint and did considerable damage to the property by painting obscenities on the wall and spreading paint across the walls. This incident was not reported timely or through the appropriate channels. A citation for missing this requirement will be issued at today's visit. 2. Access to dangerous items. On September 16, 2021, a foster child in the home accessed paint that was not securely stored. As a result there was considerable damage to the property. The paint was accessible because the children were in the middle of an art project when one of the children chose to vandalize the property. Although staff were available the foster child did not respond to direction or de-escalation. No citation will be issued at this time.


facility_name: RAISED BY LOVE HOME #1

summary: Facility Evaluation

raw_content:
Narrative:
On November 25, 2025, Licensing Program Analyst (LPA) Cynthia Urena and Licensing Program Manager (LPM), Cheraki Davis met with Raised by Love # Short Term Residential Therapeutic Program (STRTP) Applicant, Portia Love, and Compliance Officer, Akila Crane to complete Component II, face-to-face interview, for the STRTP application process. The purpose of today's meeting was to address any questions or concerns and to review the application packet and process, ensuring that the applicant, and all relevant parties understand and can provide the services outlined in the Plan of Operations/ Program Statement that align with Community Care Licensing regulations. LPA reviewed the application documents, addressing and correcting discrepancies on the LIC Application for Community Care Facility, LIC Criminal Record Statement, LIC 610C Emergency Disaster Plan, and LIC Board of Directors Statement. In addition, missing documents for the named Administrator were addressed with the applicant and persons in attendance. During this meeting the facility staff plan was discussed to ensure compliance. The applicant does not yet have direct care staff but stated that a temporary staffing plan is in place. LPA reminded the applicant of the required staff-to-client ratios and reviewed the relevant regulations outlined in STRTP Interim Licensing Standards (ILS) 87065.5. Additionally, LPA discussed the need for supportive financial documents, which must be submitted prior to provisional licensure. In addition, the applicant has been made aware of the concerns observed on their Plan of Operation/Program Statement (POO/PS). Revisions will be provided in writing prior to the pre-technical assistance meeting, which will be scheduled at a later date in collaboration with State personnel, applicant, and the applicant's administrative board members. LPA concluded this meeting by informing the applicant of the next steps in the application process.An exit interview was conducted, and a copy of this report was provided to the applicant.

met_with: Applicant, Portia Love


summary: Facility Evaluation

raw_content:
Narrative:
On December 18, 2025, at 1: PM a Teams meeting was held with Licensing Program Analyst (LPA), Cynthia Urena, Licensing Program Manager (LPM), Cheraki Davis, Regional Manager (RM), Natasha Dunlap, Systems of Care (SOC) Branch Analyst, Ansar Muhammad, Systems of Care (SOC) Branch Manager, Marjana Jackson, and Applicant Portia Love to discuss questions or concerns that the applicant may have regarding Raised by Love # Short-Term Residential Therapeutic Program (STRTP) Plan of Operations/Program Statement POO/PS Revisions. During the meeting, the applicant stated that they did not have any questions regarding the requested revisions. The applicant has stated that they will submit their revisions to Community Care Licensing Division by Monday December 22, 2025. In addition, the applicant was reminded that the population to be served must be clearly stated, and consistent throughout the POO/PS. As the applicant stated they will not be serving parenting youth, the revisions should be updated to remove any language implying that parenting youth will be served at the program. The applicant confirmed the intent to serve female youth between the ages of six (6) and seventeen (17) years old, and non-minor dependents (NMDs). Therefore, POO/PS should consistently reflect the identified targeted population throughout all sections. As the Short-Term Residential Therapeutic Program intends to serve a large age group, the POO/PS should be tailored to meet the needs of the identified targeted population in accordance with all applicable state regulations. A copy of this report was emailed to the applicant for their records. The applicant will sign and return the report to LPA Urena via email.


summary: Facility Evaluation

raw_content:
Narrative:
On February 10, 2026, at 2: PM, a Teams meeting was held with Licensing Program Analyst (LPA), Cynthia Urena, Licensing Program Manager (LPM), Cheraki Davis, Regional Manager (RM), Natasha Dunlap, Systems of Care (SOC) Analyst, Ansar Muhammad, SOC Manager, Marjana Jackson, Applicant Portia Love, and Board Member, Akila Crane. The purpose of this meeting was to discuss questions or concerns that the applicant may have regarding Raised by Love # Short-Term Residential Therapeutic Program (STRTP) Plan of Operations/Program Statement POO/PS 1st Revisions. The following information was addressed with the applicant: Population inconsistencies: The applicant was advised that the POO/PS must remain consistent with the intended population to be served (ages 6-17) and Non-Minor Dependents. If the applicant changes the targeted population from what was previously listed, they must ensure that this change is reflected consistently throughout the entire POO/PS. The applicant was further advised that the POO/PS should be tailored to meet the needs of the targeted population, with close attention to the younger age group ages (6-11). If the intent is to serve this younger age group ages (6-11), the Applicant must revise sections such as planned activities and other relevant areas to ensure information is age appropriate and specific to this population. Section 16: Personal Rights The applicant was informed that this section contains a discrepancy where LPA indicated that standard was not met along an advisory note which further indicated to "See Best Practice Note", however, this section does meet standards, and no additional information is required on behalf of the applicant. (**Continued on the next page**) This error will be corrected to reflect the accurate information. LPA also provided the Applicant and their Board Member clarification about "Best Practice Notes. LPA explained to the Applicant and Board Member that best practice notes are recommendations applicable to the operations of an STRTP and should be considered in the POO/PS and overall revisions. Section 26: Emergency Intervention Plan (EIP) (Runway Plan) The applicant was advised that, although this section provides thorough detail regarding restraints, reporting requirements, and incidents resulting in law enforcement involvement, the POO/PS should also clearly demonstrate a runaway plan appropriate for the targeted population. LPA referenced items listed in Section 26, including LPA's revision notes, which further described the information required for this section, including but is not limited to: Staff, response before, during, and after runaway incidences, law enforcement notification, authorized representative notification, licensing notification, documentation, and approved transportation protocols. LPA further advised the Applicant that the EIP should clearly describe protocols, procedures, and staff responsibilities for ensuring a client's safe return to care, including transportation arrangements and transportation pickups, while maintaining the safety of both clients and staff. The Emergency Intervention Plan must be specific for the targeted population. More importantly, the EIP should also include a thorough detail EIP runaway protocol and procedures for children ages six to eleven years old. The applicant reported that they anticipate submitting their 2nd revisions to their Plan of Operation and Program Statement later today February 10, 2026. This concludes the information that was discussed during this meeting. A copy of this report was emailed to the applicant for their records. The applicant will sign and return the report to LPA Urena via email. The signed copies will be placed in the facility file.


summary: Facility Evaluation

raw_content:
Narrative:
On April 1, 2026, at 9: AM, Licensing Program Analysts (LPA), Cynthia Urena arrived announced at Raised by Love # Short Term Residential Therapeutic Program for the purpose of conducting Pre-licensing inspection at the facility. LPA was met by Licensee/Chief Executive Officer (CEO), Portia Love, and Chief Operating Officer, Akila Crane. The Licensee/CEO submitted a Short Term Residential Therapeutic Program (STRTP) application. There are no clients in care at the proposed new location. The STRTP has an approved capacity of six and has obtained the fire clearance. The age range for the clients are 10-17 including Non-Minor Dependents. Upon arrival to the facility LPA observed that the facility is located in a residential community with accessible entry to the front door. The facility is a two-story residential dwelling equipped with five bedrooms and three bathrooms, and an attached two car garage. LPA observed a camera facing the driveway. The pre-licensing facility physical inspection was conducted with Licensee/CEO, Portia Love. Indoor Physical Plant Observations: During the walk-through of the first floor of the facility, it was observed that the first floor is equipped with a mental health room, living room, kitchen, dining room, and full bathroom. LPA observed age-appropriate games, and puzzle for clients. Knives, and cleaning supplies, are kept locked in a storage room in the hallway and they are inaccessible to clients. The Applicants has sufficient dishes, cups and silverware for client use and the gas stove is in working order. The bathroom down stairs was observed clean and in sanitary condition, with slip mats in place. (**Continued on the next page**) LPA tested the water, and it measured within 105 degrees Fahrenheit and 120 degrees Fahrenheit. A pantry with an ample amount of non-perishable foods was also observed and labeled with their expiration dates. The garage will be used for storage purposes and made inaccessible to clients. This is evident by a deadbolt observed on the door. The second floor of the facility consists of a loft, study area, three bedrooms, one master bedroom, two bathrooms (1 bathroom in master bedroom), and laundry room. The bedrooms are arranged so that no more than two clients are in a room, and there will be one client per bed. All bedrooms will be utilized for client use and they have two beds per room. All bedding was found to be clean, and in ready to use condition. The master bedroom is utilized as a staff office. The staff office was observed with multiple cabinets for confidential files. The Licensee was advised that client files must be kept locked and accessible only to authorized personnel. Client files will be stored in a locked room located in the staff office. A staff desk, a working telephone, and an ample amount of office supplies for staff use was also observed. Medication will be centrally stored in locked boxes located in the staff office. Medications requiring refrigeration will be stored in a refrigerator to ensure proper temperature control. This refrigerator, and medication boxes were observed in the staff office and inaccessible to clients in care. The bathroom in the staff office is only for staff usage per Licensee/CEO and it was observed to be clean and in sanitary condition. The client bathroom was observed to be clean and in sanitary condition, with slip mats in place. LPA tested the water, and it measured within 105 degrees Fahrenheit and 120 degrees Fahrenheit. The facility has a storage room located in the staff office that provides an ample amount of storage for client toiletries. The door is kept locked however, toiletries will be provided with staff assistance and made available upon request and or as needed. The laundry room was observed to be in ready to use, operating condition. A laundry service signs was visible and posted on the door. Detergent and cleaning supplies were observed secured in a locked cabinet in the laundry room. The loft is set up with couches, a television, and games for client usage. (**Continued on the next page**) A study area was also observed, that included a desk area, printer, tablets, and office supplies. All required Community Care Licensing postings were observed in a common areas of the facility and are accessible and visible to clients. Since the Licensee/CEO intends to serve female youth, LPA observed that contraceptive boxes are kept secured with a key, and a spare key. These boxes will be made available to clients upon their placement. The Licensee/CEO has two working fire extinguishers one located by the kitchen and the second located in the second floor (laundry room) of the facility. Carbon monoxides and smoke detectors were observed in the first and second floor of the facility. There is a landline telephone that is in working order that will be available to clients. There were no observable hazards or obstructions by the walkways and entries/exits of the facility. There is one sliding door exit in the kitchen area leading to the backyard. Outdoor Physical Plant Observations: During a walk-through of the backyard, the following was observed: There are no pools or bodies of water present. The backyard has a cemented covered patio with patio furniture. The central air conditioner unit is in the backyard located on the left side of the home. LPA observed two cameras one of the two cameras are pointed at the right side of the home, and the second camera is pointing at the open space of the backyard. Deficiency observed: The window screen located in the left side of the home in the backyard was not in good repair. This was visible by an obstruction observed on the upper right side. The Licensee/CEO reported that the plan of correction of deficiency will be corrected by April 1, 2026 end of day. After the above deficiencies is/are corrected the facility will be submitted for licensure. Component III On April 1, 2026, at 11: AM, Licensing Program Analysts (LPA), Cynthia completed and discussed Component III with Chief Executive Officer (CEO) Portia Love. The Licensee/CEO was advised that all special incidents reports will be sent via email to: cclpaccr@dss.ca.gov. In addition, all manual restraints conducted will be submitted via the Manual Restraint Incident Reporting System (MRIRS). LPA discussed PIN 26-02 with the CEO. Reporting requirements were reviewed.LPA also explained that once the license is approved, all employees must have an approved criminal record clearance and be associated with the facility. A copy of PIN 26-02 was emailed to the Licensee for further reference. (****) The Pre-Licensing inspection was completed, and a copy of this report was given to the Licensee/CEO, Portia Love.

visit_type: Prelicensing

met_with: Licensee/Chief Executive Officer, Portia Love


facility_name: RANCHO SAN ANTONIO BOYS HOME, INC

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
There was no evidence that staff speaks inappropriate to minors. Client involved refused to speak with LPA. There was no evidence that Staff did not ensure that hazardous item is inaccessible to minor. It was documented that client picked up said item during off campus schooling. 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 January 16, 2023 at 8:45am Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for the purpose of delivering findings for the above compliant investigation. LPA met with Troy McNair, Residential Director and was allowed into the facility. During the course of investigation the allegation for facility Facility does not meet minor's nutritional needs, Staff speaks inappropriately in the presence of minors and Staff did not ensure that hazardous item is inaccessible to minor, interviews were conducted and documents obtained. The interviews did not produce corroborating evidence to support said allegations. Interviews revealed inconsistent statements and no witnesses to suggest allegations occurred. There was no evidence that facility does not meet minor's nutritional needs. Facility had a weekly menu posted and enough perishable and non perishable food for the clients. 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: RANCHO SAN ANTONIO BOYS HOME, INCFACILITY NUMBER: VISIT DATE: 01/17/2023

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

met_with: Troy McNair-Residential Director


raw_content:
Narrative:
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 March 17, 2023 at 10am Licensing Program Analyst (LPA) Donald Martin arrived at the above facility. LPA met with Residential Director, Troy Mcnair and was allowed into the facility. The purpose of this visit is to deliver findings for the above complaint investigation. During the course of investigation the allegation Staff did not prevent the minors from causing harm to another minor while in care, interviews were conducted and documents obtained. The interviews did not produce corroborating evidence to support said allegations. Interviews revealed inconsistent statements and no witnesses to suggest allegations occurred. There was no evidence that Staff did not prevent the minors from causing harm to another minor while in care. Client recanted his statement according to given statements. Client refused to speak with LPA. 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: RANCHO SAN ANTONIO - BROTHER JOHN'S HOUSEFACILITY NUMBER: VISIT DATE: 03/15/2023

met_with: Troy Mcnair-Residential Director


summary: Facility Evaluation

raw_content:
Narrative:
On August 19, 2021, at 1pm Licensing Program Analyst, LPA Donald Martin made an inspection visit to Rancho San Antonio for the purpose of conducting a Case Management Investigation. LPA met with Judy Brevaire, Clinical Director (CD). The department received several SIR's regarding clients overdosing while in care of the facility. As a result some of the clients were detained and some remain at the facility. The clients that have returned from the Emergency Room back to the facility have been put on Relapse Prevention Plans that include a written safety plan, individual therapy, drug treatment therapist, and a child family Specialist for skill building. The facility has created supervision planning and training to increase staff awareness with the clients, documentation, and the location of the Naloxone in case of an emergency. They have increased room searches, CFT's were conducted immediately for all youth on campus regarding Fentanyl and CFT's are conducted every 30 days to get ahead of an issue with the client. A drug prevention committee was formed that includes CD, the residential director and several therapists to discuss daily the progress with the new program and the clients. According to CD the idea is to become more proactive than reactive. No clients were interviewed during this visit due to them being in school. Nothing further to report at this time.

met_with: Judy Brevaire-Clinical Director


summary: Facility Evaluation

raw_content:
Narrative:
On May 5, 2022 at 11am Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for the purpose of conducting a Case Management investigation. LPA met with Program Director, Judy Brevaire and discussed the incident. Client stated that he was injured (whiplash) in an accident on 3/16/2022, while out in the facility vehicle. LPA conducted interviews. Special Incident Report dated 4/29/2022 indicated C1 reported whiplash over 30 days after being involved in a car accident in the facility vehicle. There was no evidence to support claim and no evidence to support facility staff did not provide medical attention. There were no deficiencies cited at the time of the visit. A copy of this report was left at the facility. Nothing further to report at this time.

met_with: Judy Brevaire-Program Director


summary: Facility Evaluation

raw_content:
Narrative:
On August 2, 2022 at 12:30pm Licensing Program Analyst (LPA) Donald Martin, Licensing Program Manager (LPM) JoAunne Griffin and Regional Manager (RM) Kellee Coleman arrive at the above facility for the purpose of conducting a population reduction Case Management inspection. The purpose of this inspection is to reduce the STRTP capacity from 106 clients to 54 clients. LPA met with Troy McNair, Residential Director and Zeena Burse, Contracts and Compliance Director who escorted us through the inspection. Inspection is as follows: Frisco: There are Four bedrooms. Each room contains two beds and two stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There are two large windows in front of each bed that have large pull down window covers. The bathroom was equip with a shower, sink and toilet all in good condition. Rafael: There are Four bedrooms. Each room contains two beds and two stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There are two large windows in front of each bed that have large pull down window covers. The bathroom was equip with a shower, sink and toilet all in good condition. Flippo: There are Four bedrooms. Each room contains two beds and two stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There are two large windows in front of each bed that have large pull down window covers. The bathroom was equip with a shower, sink and toilet all in good condition. Fernando: There are Four bedrooms. Each room contains two beds and two stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There are two large windows in front of each bed that have large pull down window covers. The bathroom was equip with a shower, sink and toilet all in good condition. Cont. 9099-C Santa Cruz: Two very large bedrooms which contain two beds, two dressers, and two utility cabinets for hang up clothing storage and also converts to a desk area in each room. Each room also had two bathrooms per room. The bathrooms contained a sink, toilet and shower all in good working condition. Note: None of the rooms had entrance doors on them. LPA advised Troy McNair to have an enclosure attached to each room for client privacy. There is a day room with couches and a table with enough seating to accommodate staff and clients and a kitchen area with a refrigerator and a microwave. San Juan: Two very large bedrooms which contain two beds, two dressers, and two utility cabinets for hang up clothing storage and also converts to a desk area in each room. Each room also had two bathrooms per room. The bathrooms contained a sink, toilet and shower all in good working condition. Note: None of the rooms had entrance doors on them. LPA advised Troy McNair to have an enclosure attached to each room for client privacy. There is a day room with couches and a table with enough seating to accommodate staff and clients and a kitchen area with a refrigerator and a microwave. St Anthony: The cottage has 7 individual bedrooms all equip with two beds, two stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There are two large windows in front of each bed that have large pull down window covers. Each room has its own bathroom that contains a sink, toilet and shower all in good working condition. There is a day room with couches and a table with enough seating to accommodate staff and clients and a kitchen area with a refrigerator and a microwave. There is a large TV attached to the wall and computers, computer tables and books for the clients use. Note: Ensure all closets are covered, All rooms must have doors/enclosure to allow privacy. Ensure there is no obstruction blocking the windows. Replace break in blinds (San Juan). Replace face on drawer in bedroom (St Anthony). Ensure all windows have curtains to allow privacy. Although citations were not issued due to relocation of bedrooms, corrections are needed to complete this inspection. Nothing further to report at this time.


summary: Facility Evaluation

raw_content:
Narrative:
On September 8, 2022 at 9:45am Licensing Program Analyst (LPA) Donald Martin, arrive at the above facility for the purpose of conducting a population reduction Case Management inspection. The purpose of this inspection is to reduce the STRTP capacity from 106 clients to 54 clients. LPA met with Troy McNair, Residential Director who escorted me through the inspection. Inspection is as follows: Frisco: There are Four bedrooms. Each room contains two beds and two stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There are two large windows in front of each bed that have large pull down window covers. The bathroom was equip with a shower, sink and toilet all in good condition. Rafael: There are Four bedrooms. Each room contains two beds and two stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There are two large windows in front of each bed that have large pull down window covers. The bathroom was equip with a shower, sink and toilet all in good condition. Flippo: There are Four bedrooms. Each room contains two beds and two stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There are two large windows in front of each bed that have large pull down window covers. The bathroom was equip with a shower, sink and toilet all in good condition. Fernando: There are Four bedrooms. Each room contains two beds and two stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There are two large windows in front of each bed that have large pull down window covers. The bathroom was equip with a shower, sink and toilet all in good condition. Cont. 9099-C Santa Cruz: Two very large bedrooms which contain two beds, two dressers, and now have 4 utility cabinets for hang up clothing storage and also converts to a desk area in each room. Each room also had two bathrooms per room. The bathrooms contained a sink, toilet and shower all in good working condition. Note: Curtains have been installed as an enclosure attached to the bedroom doorways for client privacy. LPA requested that a sign be posted as caution for stairs in the entry way of the bedroom. There is a day room with couches and a table with enough seating to accommodate staff and clients and a kitchen area with a refrigerator and a microwave. San Juan: Two very large bedrooms which contain two beds, two dressers, and now have 4 utility cabinets for hang up clothing storage and also converts to a desk area in each room. Each room also had two bathrooms per room. The bathrooms contained a sink, toilet and shower all in good working condition. Note: Curtains have been installed as an enclosure attached to the bedroom doorways for client privacy. There is a day room with couches and a table with enough seating to accommodate staff and clients and a kitchen area with a refrigerator and a microwave. St Anthony: The cottage has 7 individual bedrooms all equip with two beds, two stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There are two large windows in front of each bed that have large pull down window covers. Each room has its own bathroom that contains a sink, toilet and shower all in good working condition. There is a day room with couches and a table with enough seating to accommodate staff and clients and a kitchen area with a refrigerator and a microwave. There is a large TV attached to the wall and computers, computer tables and books for the clients use. Note: Open closets have been replaced with an additional cabinet for clothing storage. Blinds were replaced an new desks were added to the dorms. Corrections from previous inspection were made. Nothing further to report at this time.


summary: Facility Evaluation

raw_content:
Narrative:
On December 15, 2022 at 11am Licensing Program Analyst (LPA) Donald Martin, arrive at the above facility for the purpose of conducting a Capacity Reduction Case Management inspection. The purpose of this inspection is to reduce the STRTP capacity from 54 clients to 16 clients. LPA met with Troy McNair, The name of the entire STRTP will be The Brother Johns House. LPA will use the existing names for a reference. LPA met with Troy McNair, Residential Director who escorted me through the inspection. Inspection is as follows: Frisco: There are Four bedrooms. Each room contains 1 bed and 2 stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There is an additional large desk located against the wall as well. There are two large windows that have large pull down window covers. Rafael: There are Four bedrooms. Each room contains 1 bed and 2 stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There is an additional large desk located against the wall as well. There are two large windows that have large pull down window covers. Flippo: There are Four bedrooms. Each room contains 1 bed and 2 stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There is an additional large desk located against the wall as well. There are two large windows that have large pull down window covers. Fernando: There are Four bedrooms. Each room contains 1 bed and 2 stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There is an additional large desk located against the wall as well. There are two large windows that have large pull down window covers. Cont. 9099-C Note: None of the rooms have doors/closures on them. Residential Director, Troy McNair provided LPA a receipt showing the purchase of the closures, but the parts wont be delivered until December 28, 2022. Bathroom: There are two large bathrooms with 4 sinks and 4 toilets and a large shower. There are more than one shower heads in the shower area, however clients are instructed to shower one at a time. Living Room: The Living Room has a large couch area with a TV. There is a bookshelf and a small kitchen area equip with a microwave, refrigerator, and sink. Snacks for clients are also kept in that area. There are no deficiencies cited at the time of the visit.


summary: Facility Evaluation

raw_content:
Narrative:
On April 4, 2023 at 09:30am Licensing Program Analyst (LPA) Donald Martin, arrive at the above facility for the purpose of conducting an Annual/Random inspection. LPA met with Troy McNair and together, conducted an inspection of the The Brother John's House. The Brother John's House consists of one building with two sides: Frisco/Rafael & Flippo/Fernando. There are 4 hallways in total. 4 beds in each hallway with a total of 16 beds. The Brother John's House services 12- Minors and Non-Minor Dependents. The Inspection went as follows: Frisco: There are Four bedrooms. Each room contains 1 bed and 2 stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There is an additional large desk located against the wall as well. There are two large windows that have large pull down window covers. Rafael: There are Four bedrooms. Each room contains 1 bed and 2 stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There is an additional large desk located against the wall as well. There are two large windows that have large pull down window covers. Flippo: There are Four bedrooms. Each room contains 1 bed and 2 stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There is an additional large desk located against the wall as well. There are two large windows that have large pull down window covers. Fernando: There are Four bedrooms. Each room contains 1 bed and 2 stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There is an additional large desk located against the wall as well. There are two large windows that have large pull down window covers. Cont. 9099-C The common area in Frisco/Rafael and Flippo/Fernanado contain a sectional, two large book cases, a TV on the wall and a computer desk area. There are Therapists offices against the wall. The kitchen area has a sink, microwave and a room with a refrigerator in it. This area is for clients snacks and to heat up leftover food. Note: clients eat their meals in the cafeteria. No foods are prepared in the unit kitchens. The facility uses a cleaning service for the linen. The supply is kept in another building. Staff has access to them at anytime of the day and night. Dividing the hallways is a desk where staff sits. Behind that desk is a staff office where supplies for cleaning and snacks are kept locked up as well. The bathrooms contains 4 sinks, four urinals, four stalls that contain toilets, a water faucet and a large shower area with 4 shower head areas with dividers. Behind the bathroom area is the Laundry Room. The laundry room has two large machines for the clients clothing and towels. The overall facility was in good condition, Note: LPA discussed the importance of unit cleanliness with Residential Director, Troy McNair. The Flippo/Fernando side of the facility rooms and common areas were in disarray. LPA considered the fact that all 8 clients were home on spring break and the unit was actively being used. Staff and Clients were interviewed. Client and staff files are on the computer system and up to date. There were no citations given at the time of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On October 20, 2022 at 10am Licensing Program Analyst (LPA) Donald Martin arrived at the above facility. The purpose of this visit is to complete a Pre-Licensing Inspection. LPA met with Troy McNair, Residential Director and Zeena Burse, Contracts and Compliance Director who escorted LPA through the inspection. Saint Anthony's Separation Unit/ Youth Support Annex: This unit will be used as a separation unit in conjunction with the Saint Anthony's dorm. The ratio of the dorm and Separation unit will stay at the capacity of no more than 16 clients. This unit will be used for Complex Care which will provide a more one on one assistance to clients in care. The unit consists of two very large bedrooms which contain one bed each, two dressers, and two utility cabinets for hang up clothing storage and also converts to a desk area in each room. Each room also has two bathrooms per room. The bathrooms contained a sink, toilet and shower all in good working condition. There is a day room with couches and a table with enough seating to accommodate staff and clients and a kitchen area with a refrigerator and a microwave. St Anthony: The cottage has 8 individual bedrooms all equip with two beds, two stand up closets that contain a clothes hanging area, two dresser drawers and a pull out desk. There are two large windows in front of each bed that have large pull down window covers. Each room has its own bathroom that contains a sink, toilet and shower all in good working condition. There is a day room with couches and a table with enough seating to accommodate staff and clients and a kitchen area with a refrigerator and a microwave. There is a large TV attached to the wall and computers, computer tables and books for the clients use. There were no deficiencies cited at the time of the visit.


summary: Facility Evaluation

raw_content:
Narrative:
On March 17, 2023 at 9am Licensing Program Analyst (LPA) Donald Martin and Deputy Director (DD) Kevin Gaines arrived at the above facility. The purpose of this visit is to complete a Post-Licensing Inspection. LPA met with Troy McNair, Residential Director who escorted us through the inspection. Saint Anthony's Youth Support annex: This unit has the capacity of no more than 16 clients ambulatory Minor and Non-Minor dependents ages 12-17yrs old. St Anthony: The cottage has 8 individual bedrooms all equip with two beds, two stand up closets that contain a clothes hanging area, two dresser drawers and two large desks. There are two large windows in front of each bed that have large pull down window covers. Each room has its own bathroom that contains a sink, toilet and shower all in good working condition. The day room is equip with couches and a dining table with enough seating to accommodate staff and clients. Adjacent to the day room is a kitchen area with a refrigerator, stove, toaster oven and a microwave. The kitchen is only used for snacks or heating up meals. Clients eat their meals in the dining hall located on the campus. There was perishable fruit accessible to clients and there were other snacks available on request. The TV room has a large mounted TV attached to the wall and a computer area that houses 3 computers for the clients use. There are two large bookshelves containing books for the clients use. The office is at the front of the hallway. Clients files, sharps, snacks and other items are kept in there. Clients on medication has it administered by nurses. The medication is kept in the infirmary. Note: The Pool is in a large locked building on the campus away from the dorm Cont 809-C The Laundry Room contains 2 washers and 2 dryers in good working condition. Inside the laundry room is a cabinet that has a lock on it where cleaning supplies are kept. The laundry room has a lock on the door. Clients must be allowed access to enter the laundry room. LPA advised Residential Director, Troy McNair the following things: Keep the cleaning supply cabinet locked at all times. Discard can goods (not expired, but no plans of use) that were kept stored in the kitchen cabinet. Place the word "Grievance" on the Suggestion box and check it daily. An Administrator or Facility Manager should be the only ones checking the box. Staff and clients interviewed. Staff and client files inspected. No deficiencies cited at the time of the inspection.

met_with: Troy McNair-Resident Director


summary: Facility Evaluation

raw_content:
Narrative:
On December 15, 2023 at 11am Licensing Program Analyst (LPA) Donald Martin, arrived at the above facility. The purpose of this inspection is to conduct an Annual/Random inspection and remove the facility from provisional to permanent status. LPA met with Troy McNair and together, conducted an inspection of St. Anthony's House. This unit has 8 rooms and a total of 16 beds. The St. Anthony's House services 12- Minors and Non-Minor Dependents. The Inspection went as follows: Saint Anthony's Youth Support annex: This unit has the capacity of no more than 16 clients ambulatory Minor and Non-Minor dependents ages 12-17yrs old. St Anthony: The cottage has 8 individual bedrooms all equip with two beds, two stand up closets that contain a clothes hanging area, two dresser drawers and two large desks. There are two large windows in front of each bed that have large pull down window covers. Each room has its own bathroom that contains a sink, toilet and shower all in good working condition. The day room is equip with 4 large couches. The dining room area has a dining table with 8 chairs. Adjacent to the day room is a kitchen area. The kitchen area has two refrigerators one for Clients and one for Staff. There is also a stove, toaster oven, coffee maker and a microwave. There is a large TV on the wall above the door. The kitchen is only used for snacks or heating up meals. Clients eat their meals in the dining hall located on the campus. There was perishable fruit accessible to clients and there were other snacks available on request. The office is at the front of the hallway. Clients files, sharps, snacks and other items are kept in there. Clients on medication has it administered by nurses. The medication is kept in the infirmary. Note: The Pool is in a large locked building on the campus away from the dorm Cont 809-C The Laundry Room contains 2 washers and 2 dryers in good working condition. Inside the laundry room is a cabinet that has a lock on it where cleaning supplies are kept. The laundry room has a lock on the door. Clients must be allowed access to enter the laundry room. Advisory Note: The overall unit was in good condition, however the trash cans in several of the clients rooms were full. Staff needs to create a system to have the trash cans emptied and the rooms clean on a consistent basis. Waiting on the clients to return to the unit to take out the trash is unacceptable and is citable. LPA will return to review the medication log/Infirmary and interview Staff and Clients within Days. No deficiencies cited at the time of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On January 19, 2024 at 10am Licensing Program Analyst (LPA) Donald Martin, arrived at the above facility. The purpose of this inspection is to conduct an Annual/Random inspection continuation. LPA met with Troy McNair and was allowed into the facility offices. LPA will complete the annual inspection. The St. Anthony's House services 12- Minors and Non-Minor Dependents. The Inspection went as follows: Saint Anthony's Youth Support annex: This unit has the capacity of no more than 16 clients ambulatory Minor and Non-Minor dependents ages 12-17yrs old. LPA reviewed files for S1, S2 and S3. LPA reviewed files for C1, C2, C3 and C4. LPA completed staff and client interviews. LPA reviewed the medication log, allowance "Canteen" log and training log. All files were complete and in order . LPA has concluded this annual inspection. There were no deficiencies sited at the time of the visit.


summary: Facility Evaluation

raw_content:
Narrative:
REPORT AMENDED ON 06/14/ TO CHANGE LANGUAGE On 06/14/2024, at 9: AM, Licensing Program Analyst (LPA), Donald Martin made an unannounced visit to the above facility for the purpose of concluding a Case Management - Incident Inspection. LPA spoke with Residential Director, Troy McNair. A health and safety assessment were conducted. On 02/03/2024, the department received an Incident Report, dated 02/02/2024, indicating that Child 1 (C1) was told by Staff 1 (S1) that he was unable to use the telephone to call a nonapproved telephone number. C1 escalated, walked out the office, and caused damage to cork board due to punching with right hand. Incident Report further indicates that C1 will be charged for property damage. LPA spoke with Troy McNair and obtained copy of Program Statement. Program Statement indicates that restitution shall be imposed on a child or non-minor dependent in a manner that is consistent with trauma-informed practices. RSA shall impose fines for acts of vandalism, damage of property and to replace stolen property only after review with Probation, DCFS, and/or a Child and Family Team (CFT) meeting. There was no evidence that restitution has been imposed without further review with placing agency. There was no evidence that C1 was not allowed to make a phone call. Evidence indicated that C1 was not allowed to make a call to a non-approved telephone number indicated in his intake documents. Children in care can make phone calls unless prohibited by information gathered in the initial CFT meeting. Facility representative was advised to amend Program Statement and outline written policies ensuring that cash resources are not taken from children in care in the form of fines/restitution. Revisions should be submitted by 06/28/2024, for review. Based on the information obtained, no further investigation is needed. An exit interview was conducted, and a copy of this report was left with Troy McNair, Residential Director.There were no deficiencies cited at time.


summary: Facility Evaluation

raw_content:
Narrative:
REPORT AMENDED ON 06/14/ TO CHANGE LANGUAGE On 06/14/2024, at 9: AM, Licensing Program Analyst (LPA), Donald Martin made an unannounced visit to the above facility for the purpose of concluding a Case Management - Incident Inspection. LPA spoke with Residential Director, Troy McNair. A health and safety assessment were conducted. On 01/26/2024, the department received an Incident Report dated 01/25/2024, indicating that Child 1 (C1) was told by Staff 1 (S1) that he was unable to use the telephone to call an ex-girlfriend as calls had not been approved by . C1 escalated, punched a hole into the wall adjacent to the STRTP staff office. Incident Report further indicates that C1 will be charged for property damage. LPA spoke with Troy McNair and obtained copy of Program Statement. Program Statement indicates that restitution shall be imposed on a child or non-minor dependent in a manner that is consistent with trauma-informed practices. RSA shall impose fines for acts of vandalism, damage of property and to replace stolen property only after review with Probation, DCFS, and/or a Child and Family Team (CFT) meeting. There was no evidence that restitution has been imposed without further review with placing agency. There was no evidence that C1 was not allowed to make a phone call. Evidence indicated that C1 was not allowed to make a call to a non-approved telephone number indicated in his intake documents. Children in care can make phone calls unless prohibited by court order. Facility representative was advised to amend Program Statement and outline written policies ensuring that cash resources are not taken from children in care in the form of fines/restitution. Revisions should be submitted by 06/28/2024, for review. Based on the information obtained, no further investigation is needed. An exit interview was conducted, and a copy of this report was left with Troy McNair, Residential Director. There were no deficiencies cited at time.


summary: Facility Evaluation

raw_content:
Narrative:
On December 30, 2024 at 11:30am Licensing Program Analyst (LPA) Donald Martin, arrived at the above facility. The purpose of this inspection is to conduct an Annual/Random inspection. LPA met with Troy McNair and together, conducted an inspection of St. Anthony's House. This unit has 8 rooms and a total of 16 beds. The St. Anthony's House services 12- Minors and Non-Minor Dependents. The Inspection went as follows: Saint Anthony's Youth Support annex: This unit has the capacity of no more than 16 clients ambulatory Minor and Non-Minor dependents ages 12-17yrs old. St Anthony: The cottage has 8 individual bedrooms all equip with two beds, two stand up closets that contain a clothes hanging area, two dresser drawers and two large desks. There are two large windows in front of each bed that have large pull down window covers. Each room has its own bathroom that contains a sink, toilet and shower all in good working condition. The day room is equip with 4 large couches. The dining room area has a dining table with 8 chairs. Adjacent to the day room is a kitchen area. The kitchen area has two refrigerators one for Clients and one for Staff. There is also a stove, toaster oven, coffee maker and a microwave. There is a large TV on the wall above the door. The kitchen is only used for snacks or heating up meals. Clients eat their meals in the dining hall located on the campus. There was perishable fruit accessible to clients and there were other snacks available on request. The office is at the front of the hallway. Clients files, snacks and other items are kept in there. Clients on medication has it administered by nurses. The medication is kept in the infirmary. Note: The Pool is in a large locked building on the campus away from the dorm Cont 809-C The Laundry Room contains 2 washers and 2 dryers in good working condition. Inside the laundry room is a cabinet that has a lock on it where cleaning supplies are kept. The laundry room has a lock on the door. Clients must be allowed access to enter the laundry room. The facility vans are kept in good working condition. The van inspected is registered and is insured through 2025. LPA reviewed 3 staff and 3 client files. LPA interviewed 3 staff and 3 residents during the visit. Clients were preparing to depart on a facility outing. No deficiencies cited at the time of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On February 13, 2026 at 11am Licensing Program Analyst (LPA) Donald Martin, arrived at the above facility. The purpose of this inspection is to conduct an Annual/Random inspection. LPA met with Residential Director, Troy McNair and together, conducted an inspection of St. Anthony's House/Support Annex. This unit has 8 rooms and a total of 16 beds. The St. Anthony's House services 12- Minors and Non-Minor Dependents. The Inspection went as follows: St Anthony: The cottage has 8 individual bedrooms all equip with two beds, two stand up closets that contain a clothes hanging area, two dresser drawers and two large desks. There are two large windows in front of each bed that have large pull down window covers. Each room has its own bathroom that contains a sink, toilet and shower all in good working condition. The day room is equip with 4 large couches. The dining room area has a dining table with 8 chairs. Adjacent to the day room is a kitchen area. The kitchen area has two refrigerators one for Clients and one for Staff. There is also a stove, toaster oven, coffee maker and a microwave. There is a large TV on the wall above the door. The kitchen is only used for snacks or heating up meals. Clients eat their meals in the dining hall located on the campus. There was perishable fruit accessible to clients and there were other snacks available on request. The office is at the front of the hallway. Clients files, snacks and other items are kept in there. Clients on medication has it administered by nurses. The medication is kept in the infirmary. Note: The Pool is in a large locked building on the campus away from the dorm Cont 809-C The Laundry Room contains 2 washers and 2 dryers in good working condition. Inside the laundry room is a cabinet that has a lock on it where cleaning supplies are kept. The laundry room has a lock on the door. Clients must be allowed access to enter the laundry room. There is a dispenser on the wall that disperses no toxic cleaning liquid for the clients use. The facility vans are kept in good working condition. The van inspected is registered and is insured through 2026. LPA reviewed 3 staff and LPA interviewed 3 staff residents during the visit. LPA will return to review client files and conduct client interviews. No deficiencies cited at the time of the inspection. A copy of this report will be mailed to Campus Supervisor, Ronald Mc Cloud


summary: Facility Evaluation

raw_content:
Narrative:
On 5/7/26 at 3:15pm, Licensing Program Analyst (LPA) Nancy O'Connell made an unannounced Case Management inspection to the above-listed facility, and met with John Wallace, STRTP Program Manager. The purpose of this inspection is to conduct an initial case-management incident inspection regarding a recent incident involving a minor in care. On 4-17-26, The Department received a Serious Incident Report (SIR), communicating that on 4-16-26, S1 transported C1 to a scheduled medical appointment. During the time of the reported incident, it was alleged that S1 did not follow supervision policies according to facility procedures. It was reported that S1 left the medical office multiple times, resulting in a lack of supervision for C1. During the time of the inspection LPA O'Connell conducted confidential interviews with PS, and C1 [See Confidential Names form (LIC811), dated 5-7-26, for names]. LPA O'Connell requested copies of the client roster, LIC500, facility supervision policies and personnel records for S1. Further investigation is required in order to resolve this case management incident. PER California Code Regulation, there are no deficiencies to be cited at this time. Exit Interview conducted, and a copy of this report was sent to the facility staff via email.

met_with: John Wallace, STRTP Program Manager


summary: Facility Evaluation

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Narrative:
On 5/13/2026, at 11;30AM, Licensing Program Analyst (LPA) Nancy O'Connell conducted an announced follow-up Case Management inspection at the above-listed facility from the initial inspection conducted on 5/7/2026. LPA met with John Wallace, STRTP Program Manager, who granted access into the facility. During the course of the investigation, the Department reviewed the Serious Incident Report (SIR) submitted by the facility regarding an incident that occurred on 4/16/2026 involving lack of supervision during a medical appointment. The SIR documented that S1 left the medical office multiple times while supervising C1, resulting in lack of supervision. Afterreviewing records and information obtained during the investigation, it was confirmed that S1 left C1 unattended multiple times during the medical appointment. The facility confirmed S1 acknowledged the incident and corrective action was taken, including suspension and issuance of a formal warning. Per California Code Regulation, STRTP Interim Licensing Standards (ILS), a deficiency has been cited. See LIC809-D for details. Exit interview was conducted and a copy of this report and LIC809-D was sent to the facility staff via email.

met_with: John Wallace, STRTP Program Supervisor


facility_name: REACH TO WIN YOUTH HOME FACILITY 1

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

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: Gina Chriselle, Mental Health Rehab Specialist


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

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

met_with: Tyisha Jefferson, Senior Facilty Manager


summary: Complaint Investigation - Substantiated - 1 allegation

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Narrative:
LPA is issuing citations of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87074 (e) Transportation, 87022 (f) Plan of Operation, and 87072 (c)(16) Personal Rights. (See LIC9099-D). An exit interview was conducted, appeal rights provided, and a copy of this report was left with the facility.

Investigation Findings:
SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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

met_with: Facility Manager, Tyisha Jefferson


met_with: Administrator, Alicia Culbertson

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

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


summary: Facility Evaluation

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Narrative:
On January 26, 2023 at 1:45pm, Licensing Program Analyst (LPA) Monica Pavia conducted an announced pre-licensing inspection of the facility. LPA met and toured the facility with Licensee/applicant, Alicia Culbertson. This Short-Term Residential Therapeutic Program is a one story house located in a residential area. The facility consists of 3 client bedrooms, living and dining areas, kitchen and laundry area. The facility is clean, safe, sanitary, and in good repair. All passageways are unobstructed and all doors open freely. There is a hot tub on the facility premises, and meets safety standards. Fire arms are not allowed on the facility premises. At the time of visit, the following was observed: Fire extinguishers are throughout the house. Smoke detectors are throughout the house and operational. Carbon monoxide detectors are located in the hallway, outside of the client bedrooms. Each bedroom has a bed, clean linens, and adequate drawer/cabinet space. Facility has a fire clearance. First aid kit was observed. Hot water temperature measured at 108 degrees Fahrenheit. Staff and client files will be kept in a locked filing cabinet. Medications will be centrally stored and locked in the pantry. Disinfectants and other toxic materials will be locked in a cabinet, in the garage. Extra bedding and towels are kept in the hallway closet. Knives and sharps will be kept locked in the pantry. Head of Services (HOS) for this location will be hired. Personal Rights and client grievance forms will be posted in a community area. LPA Pavia will notify licensee, once POO/PS is approved and facility is licensed. Component II: LPA Pavia discussed with the following, with Licensee: - Administrator on site required hours - facility core services and support - facility emergency intervention plan

met_with: Alicia Culbertson


summary: Facility Evaluation

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Narrative:
On 2/23/24, Licensing Program Analyst (LPA) Mariah Hawkins and Health Program Specialist (HPS) Shamika Payne conducted a required annual inspection. LPA and HPS met with Administrator Alicia Culbertson and informed of the purpose of the visit. During the inspection, the CARE Inspection Tool was used. A tour of the inside and outside of the facility as well as a review of facility records were conducted. LPA and HPS discussed facility procedures and provided feedback on program implementation. The facility was observed to be in safe condition, with clean double-occupancy bedrooms ready for residents' use, sanitary kitchen and bathrooms, and clean activity spaces. There is ample storage for residents' personal belongings as well as locked storage for medications, chemicals, and dangerous household items, such as kitchen knives. Administrator agreed to obtain and post the foster care ombudspersons office personal rights poster. Additionally, Administrator agrees to submit a written waiver request for the cameras around the facility. Some areas in which technical support will be beneficial were documented on the LIC 9102s provided with this report. No deficiency citations were issued. An exit interview was conducted, appeal rights were discussed, and a copy of this report was left with Administrator Alicia Culbertson, whose signature on this form confirms receipt.

met_with: Administrator Alicia Culbertson


summary: Facility Evaluation

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Narrative:
On 03/11/2025 at 10:00am, Licensing Program Analyst (LPA) Kristin Pierotti and LPA Simran Nayyar conducted a required annual inspection. LPAs met with Facility Manager, Tyisha Jefferson and informed of the purpose of the visit. LPAs used the CARE Inspection Tool and conducted a tour of the facility site, review of 5 personnel records and 2 resident records, and confidential interviews with 1 staff member and 0 residents. Residents declined an interview. LPAs observed the facility to be in good condition, clean and well organized. Kitchen and bathrooms are sanitary. The facility currently has 2 residents and each resident has their own bedroom with individual beds and plenty of storage for personal items. The rooms and common spaces are nicely decorated and furnished. Medications, sharps, and chemicals are stored where inaccessible to the residents. Cameras are posted in public spaces, and the licensee recently submitted program statement revisions with surveillance camera procedures, as requested. LPAs observed personnel and resident records to be complete and had all necessary documents. Staff have full background clearances, valid intervention and first aid training certifications, and have completed their annual training hours. Residents' records contain current emergency contact information, complete care plans, and accurate medication and cash records. Based on interviews, LPAs observed staff to be knowledgeable of facility policies, mandated reporting, and intervention procedures. LPAs observed residents to each be provided 1:1 supervision, to be dressed in well-fitting, appropriate, and clean clothes, and to appear comfortable in care, showing no hesitation around staff or in responding to staff guidance.Continue on LIC809-C No deficiencies were observed. An exit interview was conducted, and a copy of this report was left with Facility Administrator, Alicia Culbertson whose signature confirms receipt.

met_with: Tyisha Jefferson, Facility Manager


summary: Facility Evaluation

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Narrative:
On 7/23/25, Licensing Program Analyst (LPA) Celeste Aparicio conducted a case management visit to the facility for the purpose of discussing initial staff training plans. LPA met with Tyisha Jefferson, Facility Manager and informed them of the purpose of the visit. During a virtual review of the a staff members personnel file, LPA was unable to view the the subject matter, learning objectives, number of hours per training session, qualifications of the trainer, or training evaluation for the initial 8 hour trainings for the involved staff member. During the inspection the facility was able to provide the required training documentation for the staff member and confirm the staff members date of employment. LPA identified an area in which a technical assistance maybe beneficial. LPA provided a technical assistance for Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87065.1 (b)(2)(A-E) Supervision, Evaluation and Training Requirements No deficiencies were observed or cited. An exit interview was conducted, and a copy of the report was given to the facility.


summary: Facility Evaluation

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Narrative:
On May 13, 2026, at 10:40am, Licensing Program Analyst (LPA) Celeste Aparicio conducted a case management visit to the facility to follow up on an incident reported to the Department that occurred on April 1, 2026. At the time of the inspection, there were one (1) client and one (1) staff present at the facility. The Department received a report indicating that on April 1, 2026, facility staff conducted a search of a resident's bedroom while the youth was away at school and not present at the facility. During the search, staff discovered paraphernalia inside a drawer located in the youth's bedroom. The item was removed and secured in the facility contraband safe. The incident was flagged for follow-up to determine whether the youth's right to be free from unreasonable searches of personal belongings had been violated. During the follow up of this incident report, LPA Aparicio reviewed the resident's Needs and Services Plan and observed documentation authorizing searches of the client's personal belongings based on the client's behavioral history and in accordance with the facility's safety protocols/ House rules. LPA also reviewed the facility Program Statement, Section 17: House Rules for Children/Non-Minor Dependents. The approved search policy states: "Searches of a youth's room are only conducted when there is reasonable suspicion that the youth may possess contraband, stolen items, or belongings that violate House Rules. Youths will be informed of the reason for the search and may be present during the search." [Report Continued on LIC809-C] Based on confidential interviews and record reviews, LPA determined that the search did not violate the youth's right to be free from unreasonable searches of personal belongings. The search was supported by reasonable suspicion related to the client's documented behaviors and was conducted in accordance with the facility's approved search policy. LPA further advised the facility that blanket search policies are not permitted; however, case-specific search provisions authorized by the appropriate representative and documented within the client's Needs and Services Plan may be reviewed and approved by the licensing agency. No deficiencies were observed or cited during today's inspection. No further follow-up is required. An exit interview was conducted and a copy of this report was left at the facility.

met_with: Facility Manager, Laquitta Cazares


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Narrative:
Interviews conducted by LPAs were inconsistent that facility staff are not providing minor with adequate transportation to school. Facility Staff interviewed reported that they did everything they could to provide transportation to and from school for one minor, but on multiple occasions, the minor had behaviors which made it unsafe to transport the minor. LPA reviewed multiple SIRs that documented the minor became aggressive during the 2-hour transport from the minor's school of origin. It was documented that the minor was throwing items and attacking staff during transportation. On one occasion, the minor became so aggressive, they broke the car windows and door, and tore out the center console. For a period of possibly 5 days, or up to 2 weeks, based on interviews, the facility did not transport the minor, while researching and trying out other transportation options. There were some days, the minor refused being transported. The transportation concerns were discussed, and a behavioral plan was created at a CFT meeting. The youth is currently complying with transportation without unsafe behaviors. Based on LPA's interviews which were conducted, and records reviewed, although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove the violation did, or did not occur. Therefore, the allegation is UNSUBSTANTIATED. A signed copy of this LIC-9099 report, the LIC-9099C, and appeal rights were provided to the facility. An exit interview was conducted.

Investigation Findings:
13Licensing Program Analyst (LPA) Lyta Vue arrived unannounced at the facility on this date for the purpose of delivering findings for the complaint investigation. LPA met with Progam Manager, Amanda Shelton. LPAs Misty Valencia, Lyta Vue, and Kellie McKinley conducted the complaint investigation. LPA McKinley initiated the investigation with the facility on 12/10/2024 and met with Program Manager, Amanda Sheltonl and conducted a Health and Safety Inspection. During the course of the investigation, interviews were conducted with four facility staff members, one County Social Worker (CSW) and the Reporting Party. LPAs reviewed records including staff and client roster from September, October and November 2024, Needs and Services, CFT notes, Case notes, Serious Incident reports (SIR)'s for one client between September, October, and November 2024, IEP meetings, and a School Attendance Records from October to January. Report continued on 9099c UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Hillary Hall LICENSING EVALUATOR NAME: Lyta Vue 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 25-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CHICO - RESIDENTIAL, COHASSET RD., STE. FACILITY NAME: REDWOOD COMMUNITY SERVICES, INC - SEQUOIA HOUSEFACILITY NUMBER: VISIT DATE: 03/12/2025

met_with: Progam Manager, Amanda Shelton


summary: Complaint Investigation - Substantiated - 1 deficiency

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Narrative:
During the complaint investigation of the allegation: Staff do not ensure that the facility is free of pests, interviews were consistent that staff saw rats and rat droppings after the last client exited on 09/19/25. On the same day, Support Services Manager (SSM) and Program Supervisor (PS) took immediate action, and a maintenance request was made. Staff reported that pest control was contacted and scheduled, but it was later cancelled because the facility planned for maintenance staff to set out traps and rat boxes first. SSM and PS reported that the next step if the traps failed, would be to reach out to pest control. While conducting the facility inspection on 10/15/25, LPA and two staff observed rat droppings in the new client's bedroom and in a closet that was used for the client's belongings. Rat droppings were also observed in the client's bathroom and hallway, which poses a risk to client's health. LPA also observed a flap in the wall in the closet which was easily opened to the ground under the facility, from which rodents could enter the home . Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. One citation is being issued for violating Title 22, Division 6, Section 80087(a) Buildings and Grounds documented on subsequent LIC-9099D. A signed copy of this LIC-9099 report, the LIC-9099C, and LIC-9099D were provided to the facility. An exit interview was conducted. Appeal rights were provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Lyta Vue arrived unannounced at the facility on this date for the purpose of delivering findings for the complaint investigation. LPA met with Chris Jeffrey, Program Supervisor (PS). LPA Vue conducted the complaint investigation. LPA initiated the investigation with the facility on 10/15/25 and met with Chris Jeffrey, Program Supervisor (PS) and conducted a Health and Safety Inspection. During the course of the investigation, LPA interviewed nine (9) additional facility staff, and one (1) confidential interview. LPA reviewed records including Staff Personnel Report-LIC500, Staff Schedule, Client Roster/Register, Maintenance and Repair Log, Time Clock log requesting services, emails and text messages. Report continued on 9099c SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Hillary Hall LICENSING EVALUATOR NAME: Lyta Vue 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 25-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CHICO - RESIDENTIAL, COHASSET RD., STE. FACILITY NAME: REDWOOD COMMUNITY SERVICES, INC - SEQUOIA HOUSEFACILITY NUMBER: VISIT DATE: 11/03/2025

Deficiencies:
80087(a): (a)

met_with: Chris Jeffrey, Program Supervisor (PS)

title: Buildings and Grounds

description: (a)


facility_name: REDWOOD COMMUNITY SERVICES, INC - SEQUOIA HOUSE

summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Lyta Vue conducted an announced Pre-licensing inspection on 10/23/23 at 12: PM at the above location, as required for the Short Term Residential Therapeutic Program (STRTP) licensure. LPA met with Lorraine Montano, Administrator. During the pre-licensing visit, LPA conducted a Health and Safety inspection using the CARE tool. LPA observed the facility was clean inside and safe. The outside of the facility is fenced in the backyard, and spacious, clean and well maintained for outdoor activities. LPA observed that there are two floors to the facility. LPA observed three client bedrooms, equipped with appropriate furniture, bedding, and supplies for clients. Sufficient storage space for client's personal belongings was observed in each room. The facility is requesting to be licensed for 3 clients. (10 staff are hired but staff will work according to ratio, and additional staff will be on-call). LPA observed a medication cabinet in the medication room with a medication fridge which was empty, but locked, and accessible only to designated staff. The kitchen area was equipped with an adequate number of utensils, dining supplies, and cups for clients. No food was observed as there are no clients, and no pending placement at this time. Facility will verify required food on hand at time of client placement. LPA observed a staff office space that is locked and inaccessible to clients, where client records will be locked in file cabinets in a lock closet. Facility has a garage used for maintenance supplies and is locked and made inaccessible for clients. The laundry room does not have a door, but all cleaning supplies are locked up high in cabinets. The smoke detectors were tested and found to be functional during the inspection and there were functioning carbon monoxide detectors on each floor of the facility. Four fire extinguishers were present with a recent inspection date of 9/30/23. A fully equipped first aid kit was in the kitchen area. Pre-licensing report continued on 809c The Foster Youth Bill of Rights was posted in a conspicuous location. There are two bathrooms in the facility that are accessible to client use. The water temperature was tested and found to be DEGREES. The facility is ready for licensure as a STRTP and LPA recommends that the facility be licensed. A signed copy of this report was provided to Lorraine Montano, Administrator. End of report.

met_with: Lorraine Montano, Administrator


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Lyta Vue conducted an unannounced Post-licensing inspection on 2/28/24 at 12: PM at the above location, as required for the Short Term Residential Therapeutic Program (STRTP) licensure. LPA met with Michelle Gibbons, Program Supervisor (PS). During the post-licensing visit, LPA conducted a Health and Safety inspection using the CARE tool. LPA observed the facility was clean inside and safe. The outside of the facility is fenced in the backyard, and spacious, clean and well maintained for outdoor activities. LPA observed that there are two floors to the facility. LPA observed two client bedrooms, equipped with appropriate furniture, bedding, and supplies for clients. Sufficient storage space for client's personal belongings was observed in each room. The facility is licensed for 2 clients and 2 clients are currently in placement. An LIC 500 was received, and the facility has 9 staff. Staff to client ratio is 1:1, and the ratio for staff to client at 10: PM to 7: AM is a 1:2. LPA observed the medications to be stored and locked in the staff office in the cabinet. The kitchen area was equipped with an adequate number of utensils, dining supplies, and cups for clients. LPA observed 3 days of perishable food and 7 days of non-perishable food on site. LPA observed a staff office space that is locked and inaccessible to clients, where client records are locked in file cabinets in a locked closet. The facility has a garage used for maintenance supplies and is locked and made inaccessible to clients. The laundry room does not have a door, but all cleaning supplies are locked up high in cabinets. The smoke detectors were tested and found to be functional during the inspection and there were functioning carbon monoxide detectors on each floor of the facility. Five fire extinguishers were present with a recent inspection date of 9/30/23 and will expire on 9/2024. A fully equipped first aid kit was in the kitchen area. Report continued on 809c LPA observed the following items posted: - Personal Rights - Emergency Disaster - Exit signs - Foster Care Bill of Rights - Facility Sketch with emergency exit routes identified There are three bathrooms in the facility and one is made accessible for client use. The water temperature was tested and found to be within regulatory temperature. Post-Licensing is not completed, will be completed on a later day.


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Lyta Vue returned to the facility to finish conducting an unannounced Post-licensing inspection on 2/29/24 at 9: AM at the above location, as required for the Short Term Residential Therapeutic Program (STRTP) licensure. LPA met with Michelle Gibbons, Program Supervisor (PS). During today's post-licensing visit, LPA finished conducting a Health and Safety inspection using the CARE tool. LPA conducted 3 staff interviews and 0 of clients interviews (Clients left facility Unauthorized Absences- no clients on site). LPA reviewed 5 staff files and 2 client files. This facility meets Interim Licensing Standards mandates and is clean safe, sanitary and in good repair. LPA recommends the facility obtains permanent license with management approval. A signed copy of this report was provided to Michelle Gibbons, Program Supervisor (PS) . End of report.