summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On April 2, 2026, at 12:05 pm, Licensing Program Analysts (LPAs) Charmaine Linley and Stefanie Mutialu arrived unannounced at the facility to continue the Post-Licensing Inspection, which was started on March 27, 2026. The facility is located on a cul-de-sac behind a large multi-story medical building. The facility was licensed on December 2, 2025. The group home serves clients between the ages of 12-17 years old, both female and male for a capacity of 60 clients. There are eleven clients at the facility. LPA's met with Program Director, Kendra Mejia and Chief Executive Officer, Jenny Morey. Client files are maintained using the KIPU system which is a portal to store client files and keep all information confidential. LPAs reviewed five out of eleven client files. LPA's conducted six of eleven client interviews during the inspection (see confidential names list, LIC 811, dated 04/02/2026). Employee files are stored electronically and LPAs reviewed five out of fifty five staff files (see confidential names list, LIC 811, dated 04/02/2026). LPA's conducted three of five staff interviews. All staff that work at the facility have Department of Justice, Federal Bureau of Investigation and Child Abuse Index Check clearances. Based on LPA observation and record review, the facility did not have a client roster that was made available to licensing that contains the information in Sections 80071(a)(1)(A)-(C). The facility is being cited for California Code of Regulations Section 80071(a)(1) Register of Clients (see LIC 809D). *** Based on records review, Client #2, Client #3 and Client #9 did not have needs and services plan within 30 days of admission that lists the information in California Code of Regulations Section 84068.2(b)(1)-(5) and 84068.2(c)1-3. The facility is being cited for California Code of Regulations Section 84268.2(a) Needs and Services Plan (see LIC 809D). Based on record review, Client #2, Client #3 and Client #4 did not have a separate log for each psychotropic medication prescribed to the child documenting....the date of the prescription and the number of refills initially prescribed. The facility is being cited for California Code of Regulations Section 84070(b)(16) Children's Records (see LIC 809D). Based on record review, Client #2, Client #3, Client #4, Client #6, Client #7, Client #8, Client #9, Client #10, Client #11 and Client #12 did not have a record of centrally stored prescription medications which includes the following: the name of the prescribing physician, the date filled, name of the issuing pharmacy, and number of refills for each medication. Based on LPA's observation of counting the medication and record review, Client #2, had two medication's total quantity that did not match what was documented on the medication administration record, Client #3 had one medication's total quantity that did not match what was documented on the medication administration record, Client #4 had four medications total quantity that did not match what was documented on the medication administration record and Client #10 had one medication's total quantity that did not match what was documented on the medication administration record. The facility is being cited for the California Code of Regulations Section 80075(k)(7) Health-Related Services (see LIC 809D). Based on record review, Client #2, Client #3 and Client #9 did not have a written medical assessment prior to or within 30 calendar days following their acceptance. The facility is cited for California Code of Regulations Section 80069(a) Client Medical Assessments (see LIC 809D). Based on observation, the facility has locked individual bathroom doors in all bedrooms and the bathroom in the milieu area per Administrator the clients must ask permission from a staff member to unlock the bathroom door before the clients can use a bathroom. The facility is cited for California Code of Regulations Section 84072(d)(18) Personal rights (see LIC 809D). The facility needs to update their Program Statement, send to LPA Linley for review and approval regarding the locked bathroom and bedroom doors. *** The facility was encouraged to use the Compliance and Regulatory Enforcement (CARE) Tools that are available on the CCL website at cdss.ca.gov for all facilities to use as quality assurance tools and to ensure the information requested in the following forms is made available to CCL at future inspections: LIC Client Roster, LIC Identification and Emergency Information and LIC 622b Psychotropic Medication Administration Record. The facility was asked to provide an updated LIC Personnel Report and updated LIC Designation of Facility Responsibility by April 17, 2026. The facility was reminded to submit an updated LIC Personnel Report at a minimum on a quarterly basis if there are personnel changes. An exit interview was conducted and a copy of this report, LIC 811 and appeal rights were provided to Kendra Mejia. A copy of this report will be placed in the facility file.

Deficiencies:
84268.2(a): the name of the prescribing physician, the date filled, name of the issuing pharmacy, and number of refills for each medication. Based on LPA's observation of counting the medication and record review, Client #2, had two medication's total quantity that did not match what was documented on the medication administration record, Client #3 had one medication's total quantity that did not match what was documented on the medication administration record, Client #4 had four medications total quantity that did not match what was documented on the medication administration record and Client #10 had one medication's total quantity that did not match what was documented on the medication administration record.

met_with: Kenra Mejia


state: CA

facility_name: CENTER FOR DISCOVERY -VISTA

summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Continuation of LIC 9099... Consistent confidential interviews confirmed that the facility has an outside cleaning and pest control service that is contracted to go out to the facility monthly. During the visit, LPA's observed the facility to be clean and sanitary, the food was labeled properly, and confidential interviews did not indicate that the facility is not kept clean. Confidential interviews confirmed that staff are in charge of labeling the food after the food is purchased and brought back to the facility. Confidential interviews also reported that clients also enjoy helping to label and put the food away and, at times, ask if they can rotate who the helper is with labeling food. Confidential interviews confirmed that insects or pests have not been seen inside the facility and pests have never been an issue in the home. During the inspection, LPA was able to retrieve the invoices for the pest control agency that provides the monthly upkeeping of the facility. Based on confidential interviews and observations, the allegations that staff do not ensure the facility was free from pests and staff are not labelling food properly are unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Shaianne Tamaleaa, Mental Health Tech III and a copy of this report and appeal rights were provided.

Investigation Findings:
13On June 18, 2025, Licensing Program Analysts (LPA) Lisa Bernabe and Lucero Jauregui, arrived unannounced to Center for Discovery- Vista and met with Shawana Dorsey, Facility Administrator. During the visit, an inspection of the facility was conducted, and no immediate deficiencies were observed. During the investigation, LPA Bernabe interviewed Staff (S1-S3) and Clients (C1- C6). On June 11, 2025, Community Care Licensing (CCL) received allegations that staff did not ensure facility was free from pests and staff are not labeling food properly. It was reported that the company does not follow food safety protocols, and the food is improperly labeled. It was alleged that the facility is not kept clean and free of pests. Continuation on LIC 9099-C.... UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Lisa Bernabe 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: CENTER FOR DISCOVERY -VISTAFACILITY NUMBER: VISIT DATE: 09/23/2025

report_type: Complaint Investigation

complaint_status: unsubstantiated


summary: Facility Evaluation

raw_content:
Narrative:
On June 03, 2022 at 10: AM, Licensing Program Analyst (LPA) Marisol Lopez conducted an unannounced inspection at the facility above. LPA met with Program Administrator (P1) Nicole Seibert. The purpose of the inspection is to conduct a required annual inspection. LPA inspected the facility inside and out with facility administrator. All six (C1-C6) ambulatory clients were present at time of inspection. LPA inspected the physical plant, operational requirements, disaster preparedness, emergency intervention plan and reviewed six of six client files (C1-C6) (see confidential name list, LIC811, dated 06/03/2022) and four of four staff files (S1-S4). LPA conducted two of two staff interviews (S1-S2) and three of three client interviews (C1-C3). The client and staff files are maintained online and readily available. Medication is kept inside a locked closet in a locked cabinet and centrally stored in the Administrator office. The hot water was measured 110.0 to be within the regulatory requirements. All hazardous items have been properly locked and made inaccessible to clients. The two story residence facility is set up as follows: The first floor consists of the milieu room, dining room, kitchen, four offices located downstairs used for the therapist, psychiatrist, program director, dieticians, and counselors. The second floor consists of bedrooms: Bedroom #1- is set up with two twin beds, adequate dresser, night stand and closet space for two clients with a full bath room attached. Bedroom #2- is set up with two full beds, adequate dresser, night stand and closet space for two clients with a full bath room attached. Bedroom #3- is set up with two twin beds, adequate dresser, night stand and closet space for two clients. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. The staff supervision station is located in the upstairs milieu for adequate supervision. Based on interviews and observations made during the inspection, no deficiencies were observed during today's visit. An exit interview was conducted, and this report was reviewed with Program Administrator Nicole Seibert and a copy of this report was provided.

report_type: Facility Evaluation

visit_type: Annual

met_with: Nicole Seibert


summary: Facility Evaluation

raw_content:
Narrative:
On May 19, 2023 at 8: AM, Licensing Program Analyst (LPA) Lucero Jauregui conducted an unannounced inspection of the facility. LPA met wit Administrator Nicole Seibert. LPA inspected the facility inside and out with facility administrator. All five (C1-C5) ambulatory clients were present at time of inspection. The facility is a three bedroom four bathroom (for client use) in this two story home. The first floor consists of the milieu room, dining room, kitchen, four staff offices, and a two car garage. Offices are used for the therapist, psychiatrist, program director, dieticians, and counselors. The second floor consists of bedrooms: Bedroom #1- is set up with two twin beds, adequate dresser, night stand and closet space for two clients with a full bathroom attached. Bedroom #2- is set up with two full beds, adequate dresser, night stand and closet space for two clients with a full bathroom attached. Bedroom #3- is set up with two twin beds, adequate dresser, night stand and closet space for two clients. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. All beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The staff supervision station is in the upstairs milieu for adequate supervision. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; five fire extinguisher are properly charged and serviced. The hot water was measured 110.0 to be within the regulatory requirements. All hazardous items have been properly locked and made inaccessible to clients. Continued... Facility has a pool which is appropriately fenced and secured with a mesh fence. The enclosure was measured to be 5 feet with a self-latching gate that swings outward. Per facility staff, no firearms or weapons are allowed in the facility. LPA observed the following items posted Personal Rights, Grievance Procedures, Visitation Policy, Facility sketch, Activity Schedule, Menu, Staff Schedule and Emergency Plan. LPA reviewed operational requirements, disaster preparedness, emergency intervention plan and reviewed five of five client files (C1-C5) (see confidential name list, LIC811, dated 05/19/2023) and three of three staff files (S1-S3).The client and staff files are maintained online and readily available. LPA conducted two of two staff interviews (S1-S2) and two of two client interviews (C1,C4). A exit interview was conducted. A copy of the report was discussed and provided along with appeal rights to Nicole Seibert, Administrator.

met_with: Nicole Seibert, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On April 19, 2024 at 8: AM, Licensing Program Analyst (LPA) Lucero Jauregui conducted an unannounced inspection of the facility. LPA met with Julia Franco, Mental Health Technician and Shawana Dorsey, Facility Manager. LPA inspected the facility inside and out with Mental Health Technician. All six (C1-C6) ambulatory clients were present at time of inspection. The facility is a three bedroom four bathroom (for client use) in this two story home. The first floor consists of the milieu room, dining room, kitchen, four staff offices, and a two car garage. Offices are used for the therapist, psychiatrist, program director, dieticians, and counselors. The second floor consists of bedrooms: Bedroom #1- is set up with two twin beds, adequate dresser, night stand and closet space for two clients with a full bathroom attached. Bedroom #2- is set up with two full beds, adequate dresser, night stand and closet space for two clients with a full bathroom attached. Bedroom #3- is set up with two twin beds, adequate dresser, night stand and closet space for two clients. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. All beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The staff supervision station is in the upstairs milieu for adequate supervision. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; five fire extinguisher are properly charged and serviced. The hot water was measured 114.2 to be within the regulatory requirements. All hazardous items have been properly locked and made inaccessible to clients. Continued... Facility has a pool that is fenced and secured with a mesh fence. The enclosure was measured to be 5 feet with a self-latching gate that swings outward. LPA issued a Technical Violation for pool fence not being stable around the back corner of the pool (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. Per facility staff, no firearms or weapons are allowed in the facility. LPA observed the following items posted Personal Rights, Grievance Procedures, Visitation Policy, Facility sketch, Activity Schedule, Menu, Staff Schedule and Emergency Plan. LPA reviewed operational requirements, disaster preparedness, emergency intervention plan and reviewed six of six client files (C1-C6) (see confidential name list, LIC811, dated 4/19/2023) and five of five staff files (S1-S5).The client and staff files are maintained online and readily available. LPA conducted two of two staff interviews and two of two client interviews. An exit interview was conducted. A copy of the report was discussed and provided to Shawana Dorsey, Facility Manager

met_with: Shawana Dorsey, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On March 19, 2025 at 9: AM, Licensing Program Analysts (LPA's) Lucero Jauregui and Lisa Bernabe conducted an unannounced inspection of the facility. LPA's met with Julia Franco, Mental Health Technician and Shawana Dorsey, Administrator. LPA's inspected the facility inside and out with Mental Health Technician. All six (C1-C6) ambulatory clients were present at time of inspection. The facility is a three bedroom four bathroom (for client use) in this two story home. The first floor consists of the milieu room, dining room, kitchen, four staff offices, and a two car garage. Offices are used for the therapist, psychiatrist, program director, dieticians, and counselors. The second floor consists of bedrooms: Bedroom #1- is set up with two twin beds, adequate dresser, night stand and closet space for two clients with a full bathroom attached. Bedroom #2- is set up with two full beds, adequate dresser, night stand and closet space for two clients with a full bathroom attached. Bedroom #3- is set up with two twin beds, adequate dresser, night stand and closet space for two clients. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. All beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The staff supervision station is in the upstairs milieu for adequate supervision. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; five fire extinguisher are properly charged and serviced. The hot water was measured in bedroom #1 to be at 129.3, and warning sign posted on bathroom sink All hazardous items have been properly locked and made inaccessible to clients. Continued... Facility has a pool that is fenced and secured with a mesh fence. The enclosure was measured to be 5 feet and LPA's observed a deficiency with the self-latching gate. The facility will be cited for Buildings and Grounds 80087(e)(1) [SEE LIC809D]. Additionally, LPA's issued a Technical Violation for Buildings and Grounds 80087(a). [See Lic9102]. Per facility staff, no firearms or weapons are allowed in the facility. LPA observed the following items posted Personal Rights, Grievance Procedures, Visitation Policy, Facility sketch, Activity Schedule, Menu,and Emergency Plan. LPA's reviewed operational requirements, disaster preparedness, emergency intervention plan and reviewed six of six client files (C1-C6) (see confidential name list, LIC811, dated 3/19/25) and five of five staff files (S1-S5). The client and staff files are maintained online and readily available. LPA's observed a deficiency with client records. The facility will be cited for Client Medical Assessments 80069(c1)(1) [SEE LIC 809D]. LPA's conducted two of two staff interviews and two of two client interviews. An exit interview was conducted, plan of corrections with developed with Shawana Dorsey, Administrator. A copy of the report was discussed and appeal rights were provided to Shawana Dorsey, Administrator.

met_with: Shawana Dorsey, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On May 7, 2025, at 11: AM. Licensing Program Analyst (LPA) Lucero Jauregui conducted an unannounced Plan of Correction visit at the facility. LPA Jauregui met with Shawana Dorsey, Administrator. The purpose of the visit is to issue an LIC 421FC Civil Penalty Assessment for a deficiency that was cited on April 2, 2025. Wet signatures were obtained during today's visit. A hard copy of the signed LIC 421FC will be accessible in the facility file in the San Diego Regional Office. An exit interview was conducted. A copy of this report, along with copies of the LIC421FC and appeal rights were provided to Shawana Dorsey, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On May 28, 2025 at 11: AM Licensing Program Analyst (LPA) Lucero Jauregui conducted an unannounced visit to the facility. The purpose of the f the visit is to follow-up on a Plan of Correction (POC). LPA Jauregui met with Shawana Dorsey, Administrator. LPA conducted a safety inspection of the facility and no deficiencies were observed. LPA observed POC to be completed. An exit interview was conducted and a copy of this signed report was provided to Shawana Dorsey, Administrator.


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Confidential interviews were conducted with seven individuals, C1, C2, C3, M1, P1, S1, S5 during the period of 07/28/2025 to 09/23/2025. An investigation was conducted regarding the allegation: Staff did not treat minor in care with dignity and respect. Six out of seven confidential interviews conducted were consistent that staff do treat minors in care with dignity and respect. C1, C2, C3, M1, P1, and S1 did not express any concerns related to minors being mistreated or dis-respected by staff. Additionally, documentation reviewed, including mealtime rules, Employee code of conduct, chores list and Needs and Services plans does not report children conducting bathroom chores, mistreating or disrespectful behavior between minors and staff. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegation(s) are found to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur. No title 22 regulations were cited during today's inspection. Exit interview conducted and a copy of this report was left with Lisa Molbert, Program Director.

Investigation Findings:
13Licensing Program Analyst (LPA) Angelique Hill conducted an unannounced complaint inspection with the above facility on 10/20/2025 at 10:00AM and met with Lisa Molbert, Program Director. The purpose of the inspection was to deliver complaint findings for the allegation of: Staff did not treat minor in care with dignity and respect. On 07/28/2025 at 10:30AM Licensing Program Analyst (LPA), Angelique Hill, arrived unannounced at the facility for the purpose of initiating a complaint investigation related to the above allegations. LPA met with Cassandra Linger, House Manager. LPA conducted an inspection of the facility. During the course of the investigation, the following documents were gathered and reviewed: Client Roster for May - July 2025, Staff Roster from May - July 2025, and work schedule for May - July 2025, Needs and Services Plan for all clients, Safety Plans, House rules, Employee rules and incident Reports for all youth between May - July 2025. No serious concerns noted. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Angelique Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: CENTER FOR DISCOVERY MOOD&ANXIETY PROGRAM, SAC MHFACILITY NUMBER: VISIT DATE: 10/20/2025

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

met_with: Lisa Molbert, Program Director


facility_name: CENTER FOR DISCOVERY MOOD&ANXIETY PROGRAM, SAC MH

summary: Facility Evaluation

raw_content:
Narrative:
On June 24, 2022, Licensing Program Analysts (LPAs) Jessica Caplinger and Yuvi Diaz conducted an unannounced inspection to the facility for the purpose of the required 2 year inspection. LPAs met with Rob Thomas, Regional Director, and Armando Orneles, Facility Manager (FM). Walk through was conducted with FM. Administrator (AD), Britney Gay arrived and conducted the remainder of the inspection with LPAs. During the course of this inspection, LPAs observed the facility to be clean, safe and sanitary. Six staff and six clients were present during inspection. Two staff took five clients on an outing shortly after LPAs arrived to facility and returned later in the inspection. Postings observed in the entryway included the facility license, personal rights and accreditations. The facility is equipped with 4 bedrooms for client use and 3.5 bathrooms. Bedroom #1 is a single set up while bedrooms #2-4 are doubles. The home has a large family room inside the entry way to be utilized for visitation, relaxation and phone conversations, and a large dining room on the other side of the entry. The home has a large kitchen which opens to the main family room/group space. Kitchen was observed with a stocked fridge and freezer with adequate food supply and perishables. Menu was observed posted. On the back of the family room is a small separate space that has been designed to be an art therapy studio. Both the family room and art room open up to a large covered patio with outdoor bbq, ping pong table and several sitting areas. Over the counter medications, first aid supplies and a refrigerator for medication that may need cold storage are all locked . There are several cupboards in the bathrooms and hall with an abundance of linens, towels and cleaning supplies. The attached two car garage has an extra refrigerator and storage space. Report continues on LIC 809-C There is a second separate building with a garage and an apartment suite on the second floor that is being utilized for the therapy offices. There are no fire arms or bodies of water. All dangerous objects and chemicals are locked. Facility is well maintained and clean through out, the facility is comfortable and set up to support clients. Fire extinguishers are up to date, carbon monoxide was tested and in working condition, water temperature was on average at 110 degrees throughout the facility, and the first aid kit was stocked. Medication is stored correctly and locked. Sharps are kept locked in the locked office. Staff and client files are kept secured. A review of licensing information system was done on 5/31/22 indicating that all staff associated to the facility had DOJ, FBI and Child Abuse Index Check clearances. The facility currently has six clients, two full time clinicians, six full time staff and two part time staff. LPAs interviewed three clients and two staff. LPAs reviewed three staff and three client files. Review of staff files indicate that staff have current training in CPR, FA, AED, disaster preparedness and meet the educational and medical health requirements. Client files contained copies of personal rights, needs and services plans, medical history and consent form. CARE Tools completed. The following domains were completed: Physical Plant, Operations, Emergency Intervention, Disaster Preparedness, Client Files, and Staffing. No deficiencies were noted at this inspection. Exit interview was conducted with Britney Gay, administrator, and a final copy of this report will be emailed to the facility.

met_with: Britney Gay, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 9/8/22, Licensing Program Analyst (LPA) Jessica Caplinger, conducted an unannounced inspection for the purpose of conducting a case management regarding an incident that occurred on 7/24/22. LPA met with Taylor Artley, Therapist, to discuss the incident and obtained documentation of treatment plan and treatment team notes for one youth. LPA conducted a walk through to observe the facility inside and outside. LPA met with Sarah Dunning, Education Liaison, to review the incident and review this report. No deficiencies were noted during this inspection. Exit interview was conducted with Sarah Dunning, Education Liaison, and a final copy of this report was left at the facility.

visit_type: Case Management

met_with: Sarah Dunning; Education Liaison


summary: Facility Evaluation

raw_content:
Narrative:
On August 16, 2023 at 11: AM Licensing Program Analyst (LPA), Stephannie Verna, arrived unannounced at the facility for the purpose of gathering information related to an incident that was reported to the Department. LPA met with Sarah Dunning, Milieu Manager, (S1) who assisted LPA with the inspection of the facility. LPA Verna gathered information regarding client(s) involved in an incident, and S1 informed LPA that they are not residents at the facility based on a review of the facility's client roster. LPA Verna gathered information regarding their placement location, and confirmed FC1 is not residing the residential facility (C1). LPA conducted an inspection of the facility. No deficiencies were observed during today's inspection. A copy of this report was issued to the facility and an exit interview was conducted with Sarah Dunning, Milieu Manager.

met_with: Sarah Dunning, Milieu Manager


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Jean Stidman and Janie Davis made an unannounced Annual inspection on 11/3/23 10am During the inspection LPAs met with Diana MacNeill Program Director who assisted with the inspection.LPAs conducted a walk-through of the facility inside and out. Facility staff-client ratio at time of inspection three staff and six clients were present. Number of staff interviewed two Number of clients interviewed two. LPA observed # 4 bedrooms, # 3 bathrooms LPAs inspected and/or reviewed the following: I. Physical Plant Posting of license_X_ Personal Rights__X___ Disinfectants/Cleaning solutions inaccessible__X___ Refrigerator Temperature at or below 45 degrees F 41 degrees Freezer Temperature at or below 0 degrees_-2 degrees F Nonperishable Foods one week and fresh perishable foods two days minimum__X___ Menu present and posted__X__ Working telephone __X_ Carbon monoxide detectors __X_Smoke Detector _X__ First Aid Kit fully stocked_X__ Common Room available__X__ Dining area (enough seating, furniture good condition, not broke or damaged) __X_ Medication centrally stored, locked/inaccessible _X_ Office (locked and privacy) _X_ Hot Water between 105-120 degree F (Properly labeled if over 125 degree F__122.5 degrees_. LPA observed facility staff have hot water warning signs posted; Fire Extinguishers inspected Jan/Feb 2023. Toilets wash basin, bath and shower fixtures in good repair/no leaks/hot water temperature _x Soap and Paper towels __X_ Laundry Facilities(available) __X___ Bedrooms-required linen and furnishings __X___ Motor Vehicle properly maintained, lights, tires, registration/insurance and working seat belts_X__ Facility free of vermin _X__ Bedroom (required bedding/furniture, furniture in good repair) __X___ II. Operations Complaint Procedures For Youth Posted _X__ Board Minutes Reviewed __X__ III.Disaster Preparedness Disaster and mass casualty plan updated and available__X_ Quarterly Drills conducted and documented__X_____ Disaster preparedness supplies verified __X__ IV.Emergency Intervention Review of manual restraint log __N/A_ Staff training _X___ V.Staffing/Volunteers Number of Staff files reviewed _five Criminal record clearances verified _five_ First Aid Certificate__five__ Certified Administrators certificate valid and current__X_ VI.Client Records Number of Clients files reviewed five Needs and Services Plan five Centrally Stored Medication and log reviewed five Psychotropic Medication and log reviewed five__Cash Resources__N/A__ Facility citation violation of California Code of Regulations, Title 22, Division 6, regulation 80069(c)(1) and 80069(c)(4) Client Medical Assessments due to three out of five clients records were missing documentation of the client's ambulatory status and two out of five clients records are missing documentation of the client's examination for communicable tuberculosis and other contagious/infectious diseases. The following items were reviewed for compliance: · Annual fees · Administrator Certificate for: Diana MacNeill Program Director · Emergency Disaster Plan (per H&S Code 1565) · Personnel Roster, Facility Sketch, LIC500 and LIC610C. An exit interview was conducted with Diana MacNeill Program Director and a copy of this report was left with Diana MacNeill Program Director.

met_with: Diana MacNeill Program Director


summary: Facility Evaluation

raw_content:
Narrative:
On March 21, 2024, Licensing Program Analysts (LPAs) Jean Stidman and Angelique Hill, met with Sara Dunning, Millieu Manager, for the purpose of a case management inspection regarding an incident that occurred on 03/08/2024. LPA's inspected the facility inside and out. A new client arrived during the inspection. LPA's observed five clients on site and four staff. No violations were sited. Exit interview conducted and a copy of the report left with Sara Dunning, Millieu Manager.

met_with: Sara Dunning, Millieu Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 10/17/24 at 9:40AM Licensing Program Analyst (LPA), Angelique Hill, made an unannounced inspection for the purpose of a case management. LPA met with Diana MacNeill, Program Director, to discuss one child's medication intake. LPA conducted an inspection inside and outside of the facility. LPA requested the following documents for review: Staff Roster, Client Roster, Staff Work Schedule, Medication procedures, training logs for three staff. For one youth, LPA requested: Needs and Services plan, Client Information/Face sheet, medication logs, Identification and Emergency Information, Vital sign history and emails from psychiatrist dated from 10/03/24 and 10/15/24. No citations were issued related to the case management inspection. Further Investigation is needed. A copy of this report was left with Diana MacNeill, Program Director.

met_with: Diana MacNeill, Program Director


summary: Facility Evaluation

raw_content:
Narrative:
On 10/01/2025 at 09:00AM Licensing Program Analyst (LPA) Angelique Hill arrived unannounced for the purpose of an annual inspection. During the inspection LPA met with Lashiqua Davis, Mental Health Technician III who assisted with the walk-through of the facility. LPA conducted a walk-through of the facility inside and out. Two staff and five youth were present during the inspection. LPA reviewed five staff files and interviewed two staff and two youth clients. LPA inspected and reviewed the following: I. Physical Plant Personal Rights__X___ Disinfectants/Cleaning solutions inaccessible __X___ Refrigerator Nonperishable Foods and fresh perishable foods __X___ Menu present and posted__X__ Working telephone __X_ Carbon monoxide detectors __X_ Smoke Detector _X__ First Aid Kit fully stocked_X__ Common Room available__X__ Dining area (enough seating, furniture good condition, not broke or damaged) __X_ Medication centrally stored, locked/inaccessible _X_ Office (locked and privacy) _X_.Toilets wash basin, bath and shower fixtures in good repair/no leaks/hot water temperature _x Laundry Facilities __X___ Bedrooms-required linen and furnishings __X___ Bedroom (required bedding/furniture, furniture in good repair) __X___ No citations were issued related to the annual inspection. Continuation of annual inspection is needed. A copy of this report was left with Lisa Molbert, Program Director (P1).


summary: Facility Evaluation - 3 deficiencies

raw_content:
Narrative:
On 10/09/2025 at 9:48AM Licensing Program Analyst (LPA), Angelique Hill arrived unannounced at the facility for the purpose of an annual continuation. LPA met with Lisa Molbert, Program Director. Three staff and five client were present during inspection. LPA observed a one story home with four bedrooms, three bathrooms. LPA interviewed three staff and five clients. LPA inspected and/or reviewed the following: Posting of license_X_ Hot Water between 105-120 degree F _X_is 113 degrees F. LPA reviewed four client records and five staff files, criminal records were verified, four out of five first aid certificates verified, and training verified. Disaster Preparedness Quarterly Drills conducted and documented _X__ Disaster preparedness supplies verified _X__ The following items were reviewed for compliance in the regional office prior to the facility inspection: Annual fees, Administrator certificate: Kendra Mejia, LIC 500, and Waivers and Exceptions. An exit interview was conducted and a copy of this report was left with Lisa Molbert, Program Director.

Deficiencies:
84078(d): Deficient Practice Statement
1
2
3
4Based on LPA's record review, the licensee did not comply with the section cited above in four out of four youth client files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2025
Plan of Correction
1
2
3
4
84068.2(b): Needs and Services Plan

(b) The needs and services plan shall identify the child's needs in the following areas
84087(e): Deficient Practice Statement
1
2
3
4Based on LPA's record review, the licensee did not comply with the section cited above in four out of four which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2025
Plan of Correction
1
2
3
4

title:
Responsibility for Providing Care and Supervision

(d) The licensee shall ensure each child's attendance at an educational program in accordance with state law.

This requirement is not met as evidenced by

title:
Buildings and Grounds

(e) In every situation where children share a bedroom, the licensee shall document that the bedroom sharing arrangement ensures the health and safety of each child and that the children are compatible. When considering compatibility, a Licensee shall consult with children in their care, in an age and developmentally appropriate manner, regarding the child's sexual orientation and gender identity and what information the child wishes to disclose and to whom. A licensee shall not disclose information about the child's sexual orientation and/or gender and gender expression against the child's wishes, unless disclosure is required to protect the child's health and safety or compelled to do so by law or court order. This documentation shall be maintained in the child's record.

This requirement is not met as evidenced by


summary: Facility Evaluation

raw_content:
Narrative:
On 11/17/2025 at 09:55AM Licensing Program Analyst (LPA), Angelique Hill, met with Alexandra Weltz and Cassandra Linger, Milieu Manager, for the purpose of a 10-day Plan of Correction inspection (POC). During the inspection, LPA informed Cassandra the facility is late on submitting their POC's for deficiencies that were cited 10/09/2025. LPA cleared one out four POC's that were due 11/09/2025. LPA, Cassandra Linger, and Marissa Jones, Vice President of Program Operations discussed a plan to change the plan of corrections for the following deficiencies: 84065(i)(1)(C)(4) Job Shadowing, 84068.2(b) Needs and Services Plan, and 84070(c)(1) Children's Records. The facility agreed to email LPA the new plan of action and expected date of correction for the remaining deficiencies. No deficiencies were cited during this inspection. Exit interview conducted and a copy of this report is left with Cassandra Linger, Milieu Manager.

met_with: Cassandra Linger, Milieu Manager


raw_content:
Narrative:
Current client Roster, Staff Roster and Schedule, Needs and Services Plan, Therapy Notes, staff shift notes September to October 2025, Incident Reports for seven youth, Telephone policy, youth personal rights, Parent contact list, text messages and call logs from August - October. Text messages revealed staff were following phone policy procedures from the Dept. of Health Care Services. Confidential interviews were conducted with RP, S2, S3, M1, C2, C3, C4, C6 and attempted with C1 during the period of 10/27/2025 to 10/28/2025. An investigation was conducted regarding the allegation: Staff restricted minors' access to confidential communication. Six out of nine confidential interviews conducted were consistent that staff restricted minor's access to confidential phone calls. RP, S2, C3, S3, C2, and M1 admitted to occupying the same room as minor's in the attempt to monitor phone calls regardless of clinical approval. In addition, records reviewed including text messages revealed staff were given instruction from management to abide regulations that do not reflect CCL requirements. Based on LPA documentation reviewed, and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Chapter 5, Division 6, Group Homes, Article 6. Continuing Requirements, 84072(d)(13) Personal Rights are being cited on the attached LIC 9099D. An exit interview was conducted with and a copy of this report and appeal rights were provided to Sydney Harkruiz, Program Director. Current client Roster, Staff Roster and Schedule, Needs and Services Plan, Therapy Notes, staff shift notes September to October 2025, Incident Reports for seven youth, Telephone policy, youth personal rights, Parent contact list, text messages and call logs from August - October. Confidential interviews were conducted with RP, S2, S3, M1, C2, C3, C4, C6 and attempted with C1 during the period of 10/27/2025 to 10/28/2025. An investigation was conducted regarding the allegation: Staff caused emotional distress to minors. Five out of nine confidential interviews conducted were inconsistent that staff caused emotional distressed to minors. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegation is found to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Exit interview conducted and a copy of this report was left with Sydney Harkruiz, Program Director.

Investigation Findings:
13Licensing Program Analyst (LPA) Angelique Hill conducted an unannounced complaint inspection with the above facility on 12/23/2025 at 12:25PM and met with Sydney Harkruiz, Program Director. The purpose of the inspection was to deliver complaint findings for the allegation of: Staff restricted minors' access to confidential communication. On 10/28/2025 at 12:30PM Licensing Program Analysts (LPA), Angelique Hill, arrived unannounced at the agency for the purpose of initiating a complaint inspection related to the above allegation. LPA met with Cassandra Linger, Milieu Manager. LPA conducted an inspection of the facility. During the course of the investigation, the following documents were gathered and reviewed: SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Angelique Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: CENTER FOR DISCOVERY MOOD&ANXIETY PROGRAM, SAC MHFACILITY NUMBER: VISIT DATE: 12/23/2025

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: Sydney Harkruiz, Program Director


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 10/01/2025 at 09:00AM Licensing Program Analyst (LPA), Angelique Hill, met with Lisa Molbert, Program Director (P1), for the purpose of a case management inspection. During an inspection, it was discovered the facility did not notify Community Care Licensing (CCL) for having a change in administrator. The facility is cited violation of Title 22, Division 6, Chapter Group Homes, Article 1. General Requirements and Definitions, 84061(e) Reporting Requirements on the attached LIC809D. Exit interview conducted and a copy of this report is left with Lisa Molbert, Program Director (P1).

Deficiencies:
84061(e): (e) Effective January 1, 2000, the licensee shall notify the Department
in writing, within ten (10) days of any change in the facility administrator.

title:
1
2
3
4
5
6
784061 Reporting Requirements


summary: Facility Evaluation

raw_content:
Narrative:
On 11/17/2025 at 9:55AM Licensing Program Analyst (LPA), Angelique Hill, met with Alexandra Weltz, Education Liaison and Cassandra Linger, Milieu Manager for the purpose of a case management inspection. During an inspection, it was discovered that a staff member yelled at the children in care. The facility is cited violation of California Code and Regulations, Title 22, Division 6, Chapter Group Homes, Subchapter 1, Community Treatment Facilities, Article 5. Enforcement Provisions, 84172(b)(5)(1) Personal Rights on the attached LIC809D. Exit interview conducted and a copy of this report is left with Cassandra Linger, Milieu Manager.

met_with: Alexandra Weltz, Education Liaison


summary: Facility Evaluation

raw_content:
Narrative:
On January 21, 2026 at 1:00PM the Department met with Licensee for the purpose of an Informal Office Meeting to discuss areas of facility compliance. Attendees were Licensing Program Analyst (LPA), Angelique Hill, Licensing Program Manager (LPM), Dara Campos, Regional Director, Jessica Harris, Program Director, Sydney Harkruiz, Director of Regulatory Affairs, Jeff Marshall, and Group Home Administrator, Carolyn Williams. Areas of Concern: The purpose of the meeting was to discuss the trends of the facility, including complaint allegations and case management visits, ways the Department can support the facility, and to discuss a plan to mitigate those trends. Compliance History (12 months): Complaints Received: 5 complaints with 10 allegations , not reporting change in administrator, not reporting incidents, 6 allegations are open, 3 unsubstantiated, 1 substantiated for personal rights CM with citation for personal rights, CM for not reporting Annual 7 citations for records Reporting Requirements: Licensee was reminded of Reporting Requirements as it relates to LIC 500 and notification of new administrator. Support & Resources: CCL will send TSP referral. Facility will Submit LIC 500 by the fifth of every month w/ exception of any administrator change. Submit an LIC 308 for designated staff by 02-04-2026. Submit an updated GHA certificate for Carolyn Williams by 02-04-2026. The facility was not issued citations at this meeting. Exit interview was conducted and a copy of this report was provided to Regional Director, Jessica Harris and Program Director, Sydney Harkruiz.

met_with: Jessica Harris, Sydeny Harkruiz, Jeff Marshall, Carolyn Williams


raw_content:
Narrative:
Confidential interviews were conducted with RP, M1, T1, T2, E1, and S2 during the period of 11/03/2025 to 01/06/2026. An investigation was conducted regarding the allegation: Licensee does not ensure that all staff are fingerprint cleared and associated prior to working at the facility. Five out of six confidential interviews conducted were consistent that T1 was working at the facility since June 2025 without a background clearance. Additionally, documentation reviewed, including a letter of clearance for T1 stated the clearance was granted October 29, 2025. Based on LPA documentation reviewed, and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Chapter 5, Division 6, Group Homes, Article 6. Continuing Requirements, 84072() are being cited on the attached LIC 9099D and issued a civil penalty. An exit interview was conducted with and a copy of this report and appeal rights were provided to Sydney Harkruiz, Program Director. During the course of the investigation, the following documents were gathered and reviewed: background clearances for all associated adults for 2025, Job duties and job descriptions for therapists, and lead mental health technicians, Therapist roster June - October 2025 and Staff training logs for June -October 2025. No serious concerns noted. Confidential interviews were conducted with RP, M1, T1, T2, E1, and S2 during the period of 11/03/2025 to 01/06/2026. An investigation was conducted regarding the allegation: Staff do not follow the children's treatment plans. Six out of six confidential interviews conducted were consistent that staff follow treatment plans. RP, M1, T1, T2, E1 and S2 stated they are aware and follow treatment plans and expressed no concerns. Additionally, documentation reviewed, including eight treatment plans were being updated, notes were in each treatment plan regarding each client, and documented as needed. An investigation was conducted regarding the allegation: Staff are not adequately trained. Four out of six confidential interviews conducted were inconsistent that staff are not adequately trained. RP, M1, S2, and T2 stated the lack of training caused staff to quit due to working with children without on-the-job training. Additionally, documentation reviewed, including training logs for six staff revealed that online training was conducted and on the job training was verified and signed off by a previous program director. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegation(s) are found to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur. No title 22 regulations were cited during today's inspection. Exit interview conducted and a copy of this report was left with Sydney Harkruiz, Program Director.

Investigation Findings:
13Licensing Program Analyst (LPA) Angelique Hill conducted an unannounced complaint inspection with the above facility on 01/29/2026 at 9:45AM and met with Sydney Harkruiz, Program Director. The purpose of the inspection was to deliver complaint findings for the allegation of: Licensee does not ensure that all staff are fingerprint cleared. On 11/03/2025 at 11:00AM Licensing Program Analyst (LPA), Angelique Hill, arrived unannounced at the agency for the purpose of initiating a complaint inspection related to the above allegation. LPA met with Jennifer Ross, Mental Health Technician III. LPA conducted an inspection of the facility. During the course of the investigation, the following documents were gathered and reviewed: background clearances for all associated adults for 2025, Job duties and job descriptions for therapists, and lead mental health technicians, Therapist roster June - October 2025 and Staff training logs for June - October 2025. No serious concerns noted. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Angelique Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: CENTER FOR DISCOVERY MOOD&ANXIETY PROGRAM, SAC MHFACILITY NUMBER: VISIT DATE: 01/29/2026

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:


raw_content:
Narrative:
Confidential interviews were conducted with S2, M1, E1, C1, C2, C3, R1. B1, and B2 during the period of 12/10/2025 to 02/23/2026. An investigation was conducted regarding the allegation: Staff did not ensure they had an administrator. Seven out of nine confidential interviews conducted were inconsistent on whether the facility had an administrator or not. C1, C2, and C3 stated they were unsure who the administrator was. Additionally, documentation reviewed, including history of administrator, administrator certification list and email correspondence confirmed there was an assigned administrator at the facility. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegation is found to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Exit interview conducted and a copy of this report was left with Alexandra Weltz, Education Liaison.

Investigation Findings:
13Licensing Program Analyst (LPA) Angelique Hill conducted an unannounced complaint inspection with the above facility on 03/10/2026 at 09:05AM and met with Alexandra Weltz, Education Liasion. The purpose of the inspection was to deliver complaint findings for the allegation of: Staff did not ensure they had an administrator. On 12/10/2025 at 10:10AM Licensing Program Analyst (LPA), Angelique Hill, arrived unannounced at the agency for the purpose of initiating a complaint inspection related to the above allegations. LPA met with Cassandra Linger, Milieu Manager. LPA conducted an inspection of the facility. During the course of the investigation, the following documents were gathered and reviewed: Client Roster for October to December 2025, job duties/description for Education Liaison, Client face sheet for current clients, Staff Roster, staff schedule for October to December 2025, training log for one staff and Incident reports for October to December 2025. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Angelique Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: CENTER FOR DISCOVERY MOOD&ANXIETY PROGRAM, SAC MHFACILITY NUMBER: VISIT DATE: 03/10/2026

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


facility_name: CENTER FOR DISCOVERY, BRENTWOOD II

summary: Complaint Investigation - Unsubstantiated - 1 deficiency

raw_content:
Narrative:
... oral sex, "fingering" (or digital sex) in the living room while night staff was not looking, and kissing and sexual acts in the laundry room during the day. The preponderance of evidence standard has been met, and therefore the above allegation is found to be Substantiated. LPA is issuing a citation of California Code of Regulations, Title 22, Section Responsibility for Providing Care and Supervision. See attached LIC 9099-D. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Program Director Virginia Parish, whose signature on this form confirms receipt. ... the full movie was shown or that residents have felt traumatized/re-traumatized by media at the facility. Additionally, a book on the Wicca faith was read by R1 while in care, but it could not be determined how the youth obtained the book, and staff named as the one who brought it in and approved it denied doing so, stating, as supported by the plan of operation and staff statements, that they are not the one responsible for approving books and would not have done so. The facility removed the book upon authorized representative's request. The facility policy is to have the therapist and/or facility manager approve media (books, movies) available to clients while in care. However, the facility does not keep a list of already approved books or movies nor of movies or media shown to residents. LPA advises, as best practice, that the facility consider maintaining a list of approved films and books and/or maintain a log of films shown on movie nights. Based on the report, the allegation "Facility not meeting minor's educational needs" pertains to resident R1 not completing homework while in treatment. Based on interviews and record review, R1 was not completing all homework assignments, but was completing treatment goals. R1 was allowed to schedule therapy sessions during homework blocks, but 20 hours are provided a week for homework completion. In the remainder of that time, R1 did not complete all homework assignments. Staff statements indicate that, as a short-term treatment program, the program prioritizes patients'/residents' well-being and treatment goals. The program plan of operation provides that completing homework is a house rule, but staff statements indicate that staff cannot force patients to complete homework. Based on the report, the allegation "Facility not following admission agreement" pertains to R1 not receiving 24/7 supervision, as stated in the parent welcome packet provided at admission. Based on interviews and record review, R1 was to receive 24/7 care and be checked at least every 15 minutes. The parent welcome packet provides for four phases with different supervision requirements and privileges. R1 achieved a higher phase and was dropped according to behaviors. Following R1's suicide attempt, supervision was enhanced. Additionally, shift notes indicate staff were attentive to R1, and R1's statements indicate that R1's incidents occurred in part specifically in brief moments when staff turned around and that R1 felt comfortable talking to staff about their treatment goals. The investigation found that there was a lack of supervision resulting in residents engaging in sexual behaviors at the facility, but it could not be determined that a lack of supervision resulted in other violations. Although the allegations may have happened or are valid, based on LPA's observations and interviews with residents, staff, and witnesses, there is not a preponderance of the evidence to prove the alleged violation(s) did or did not occur. Therefore, the allegations are Unsubstantiated. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Program Director Virginia Parish, whose signature on this form confirms receipt.

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:

Deficiencies:
32804: Center for Discovery, Brentwood Iifacility Number: 075650142 Visit Date: 05/05/2022 Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32... the full movie was shown or that residents have felt traumatized/re-traumatized by media at the facility.   Additionally, a book on the Wicca faith was read by R1 while in care, but it could not be determined how the youth obtained the book, and staff named as the one who brought it in and approved it denied doing so, stating, as supported by the plan of operation and staff statements, that they are not the one responsible for approving books and would not have done so.

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

title:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., Suite 360 San Bruno, CA 94066 Facility Name


summary: Complaint Investigation - Substantiated

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

met_with: Administrator Sara Stokes; Lead Tech Carolyn Williams

complaint_status: SUBSTANTIATED


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

met_with: Interim Administrator - Carolyn Williams


summary: Complaint Investigation - Substantiated

investigation_findings: SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:


raw_content:
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: Carolyn Williams - Administrator


raw_content:
Narrative:
However, the facility is being cited for the second allegation in regards to clients cleaning hazardous material as a violation of California Code of Regulations (CCR), Title 22, Division 6, Chapter 5, Section 84072(d)(1) - Personal Rights. Please refer to LIC9909-D for details. At this time, one deficiency has been issued. An exit interview was conducted, appeal rights were provided and discussed, and a copy of this report was given to Lewis Farias, Milieu Manager.

Investigation Findings:
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:

met_with: Lewis Farias - Milieu Manager


raw_content:
Investigation Findings:
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:


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Investigation Findings:
13On 6/20/25 at 11: AM, Licensing Program Analyst (LPA) Jonathan Medina conducted a complaint inspection at Center for Discovery and spoke with Carolyn Williams, Administrator. The purpose of the inspection was to deliver the findings for the above complaint allegation. Based on LPA's interviews with staff and clients, as well as a review of records, the preponderance of evidence standard has been met. Therefore, the allegation-Staff spoke inappropriately to minor in care-is SUBSTANTIATED. This is a violation of California Code of Regulations (CCR), Title 22, Division 6, Chapter 5, Section 84072(d)(19) - Personal Rights. Please refer to LIC9909-D for details. Since the staff member in the allegation was terminated the Plan of Correction (POC) was cleared immediately. LPA substantiated the same allegation for another complaint on todays date due to there being two different incidents on seperate days. At this time, one deficiency has been issued. An exit interview was conducted, appeal rights were provided and discussed, and a copy of this report was given to Carolyn Williams, Administrator. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Jonathan Medina LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., SUITE FACILITY NAME: CENTER FOR DISCOVERY, BRENTWOOD IIFACILITY NUMBER: 075650142

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


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:


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:


raw_content:
Investigation Findings:
13On 7/11/25, Licensing Program Analyst (LPA) Jonathan Medina conducted a visit to the facility to deliver the findings of a complaint investigation. LPA met with Administrator Carolyn Williams and explained the purpose of the visit. Based on a review of confidential records and interviews, although the allegations may have occurred or are valid, there is not a preponderance of evidence to support that the allegation did or did not occur. Therefore, the allegation is deemed unsubstantiated. The incident reportedly occurred three years ago, and several pertinent documents-such as shift notes, internal incident reports, staff interviews, staff schedules, and staff files (including documentation of supervision training)-were not available for review due to the amount of time that has passed. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to Administrator Carolyn Williams. Her signature on this form acknowledges receipt. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Jonathan Medina LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


summary: Facility Evaluation

raw_content:
Narrative:
At 11:23AM, Licensing Program Analyst (LPA) Madeleine Fremont traveled to the home above for the purpose of conducting an unannounced Required - Year Inspection. LPA met with Program Director Virginia Parish, who helped facilitate this inspection. Currently in care are 3 ambulatory clients. During this visit, LPA toured the home inside and out. The home has 4 client bedrooms, 5 bathrooms, and 3 therapists offices. No bodies of water. All walkways are unobstructed. The home is well lit and equipped with comfortable furnishings. LPA observed 3 fire extinguishers, all of which were inspected on 03/28/2022. Carbon monoxide and smoke detectors are located throughout the house. Smoke detectors were tested and are functional. The thermostat was set to 70 degrees upon arrival. In the kitchen, LPA observed at least 2 days of perishable food and at least 7 days of nonperishable food. The kitchen was clean and free from hazards. Sharps are kept locked away from client access. LPA toured the backyard and front yard on the property. The front yard has an enclosed courtyard which has a table and chairs for client leisure. There is a non-operational fire place in the courtyard that is closed by a glass cover. One non-operational fireplace in the living room as well. The backyard surrounds the home on 2 sides, and is enclosed by a wooden fence on all sides. LPA observed 3-4 boards which had come loose in a recent wind storm, and the facility will be submitting a work order to their handyman today 04/27/2022. Facility will send proof of this fix to LPA once it is completed. During this visit, LPA inspected 3 client files. All files were in order with required documentation. One client's admission agreement is missing authorized representative signature, but it is noted this form was sent for signature and has not been returned. LPA Mariah Hawkins will return on another day to inspect staff files, med count, and conduct interviews with staff and clients. At this time, no deficiencies were observed or cited. An exit interview was conducted, and a copy of this report was emailed to the facility for their records.

met_with: Program Director Virginia Parish


summary: Facility Evaluation

raw_content:
Narrative:
On 4/26/23, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility for a required annual inspection. LPA met with Administrator Sara Stokes and informed of the purpose of the visit. The CARE inspection tool was used to complete this inspection. During visit, LPA conducted interviews with two staff and two residents and toured the facility site. LPA verified that everyone on the staff schedule has a background clearance reflected on Guardian. LPA observed that the facility was clean, organized, and pathways free of obstructions or hazards. There are no bodies of water. The kitchen was fully stocked with a varied supply of food within date. Bathrooms were sanitary. Bedrooms have clean linens and ample storage space. Hot water temperature measured within permitted range. LPA observed that there are seven beds, three double-occupancy bedrooms and one single-occupancy bedroom. Administrator stated the extra bed is to better accommodate youth with different needs or different gender identities and that the facility has not used the bed to exceed the capacity. LPA advised that the facility cannot have more beds than the licensed capacity and advised either removing the bed in the single-occupancy room or removing the second bed in the room next to it, as these are the two smaller rooms and share a bathroom. A continuation visit will be required to complete the personnel file review. The LIC 311B was provided for the future to allow the licensee to consider different methods for ensuring these forms, which the licensee maintains but which are not all easily accessible during licensing visits, are available for future visits. For the continuation visit, LPA requested the following be consolidated in a printed or electronic format that is ready for review by LPA for staff S1, S2, S3, S4, and S5 (See LIC Confidential Names): LIC 501 or resume; LIC 503 or health screening and TB test results; LIC 508 criminal record statement; LIC 9108 mandated reporter statement; LIC 9052 employee rights; initial training documentation; annual/continued training, including intervention/de-escalation training, with verification of hours received and training certificates, for no less... ... than the last 12 months; CPI certificate; and first aid certificate. An exit interview was conducted, appeal rights discussed, and a copy of this report was left with Administrator Sara Stokes, whose signature on this form confirms receipt.

met_with: Administrator Sara Stokes


summary: Facility Evaluation

raw_content:
Narrative:
On 4/26/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit as a follow-up to the January 2023 noncompliance conference (NCC). LPA met with Administrator Sara Stokes and informed of the purpose of the visit. Per the NCC terms, the following was to be completed: (2) to ensure staff were fully trained, per applicable regulations, at hire and additionally on no less than a quarterly basis; (3) to designate two overnight staff each night with at least one being a facility manager, meeting this requirement by March 13, 2023; (4) to designate an administrator to oversee only one facility, meeting this requirement by March 13, 2023; (5) to revise the plan of operation / program statement (POO/PS) and/or develop an addendum to include discussion of the use and purpose of motion sensors in the facility, meeting this requirement by March 13, 2023; (6) to provide notification of desire to utilize technical support program (TSP) services by January 25, 2023; and (7), if desired, submitting a central administrative facility waiver by January 25, 2023. See the notes by the corresponding number below. (2) During the visit, LPA reviewed staff training and interviewed staff. Interviews and training records reflect that trainings are conducted at monthly staff meetings and include the topics of supervision, de-escalation, and reporting requirements. Staff interviewed were knowledgeable of facility procedures, and resident reports support appropriate staff supervision. (3) LPA obtained a current LIC 500. The facility has designated two staff for each night. There is at least one facility manager on each night shift. The facility is conducting 15-minute bed check rounds during the night, and staff log and sign off on each check for each resident. The logs were available for LPA's review, and LPA observed checks each night. LPA advises that staff sign/initial at each check rather than drawing a line down the page to indicate no change, as better verification of separate checks. [] (4) The facility had a candidate for the administrator role who ended up leaving the organization. Another candidate has been hired but still needs to complete administrator training. (5) LPA has not received a POO/PS addendum or revision. LPA is granting one extension. The revision/addendum to meet the requirement as stated above and in the NCC report provided to the licensee is requested to be submitted no later than May 1, 2023. (6) The licensee was referred for TSP services. (7) The licensee has decided to not request a central administrative facility waiver at this time. An exit interview was conducted, appeal rights discussed, and a copy of this report was left with Administrator Sara Stokes, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 7/28/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a visit to the facility for the annual continuation. LPA met with Administrator Sara Stokes and informed of the purpose of the visit. An agreement was made to have Administrator send copies of personnel records to LPA for review. LPA reviewed files for 5 staff, including four direct care staff / lead staff (facility managers) and one therapist. LPA observed records to be complete. During today's tour, LPA observed that there were 7 beds, three double-occupancy bedrooms and one single-occupancy bedroom. LPA previously advised on 4/26/23, that per applicable regulations, the facility shall not have more beds for childrens' use than required for the maximum capacity, which for this facility is 6. Administrator stated the room is being used as an isolation room. LPA agreed to review program statement for a section on the isolation room, and Administrator agreed to request approval of an addendum should LPA find that such a section is not yet included in the program statement. An exit interview was conducted, appeal rights discussed, and a copy of this report was left with Administrator Sara Stokes, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 7/28/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit as a follow-up to the January 2023 noncompliance conference (NCC), per the first NCC term. LPA met with Administrator Sara Stokes and informed of the purpose of the visit. During visit, LPA conducted interviews with 2 residents. Per the NCC terms and previous inspections, the following was required and reviewed: (2) Ensure staff were fully trained, per applicable regulations, at hire and additionally on no less than a quarterly basis. | The annual inspection was completed on 7/28/23, and based on review of personnel files, training was complete. (3) Designate two overnight staff each night with at least one being a facility manager. | The facility had some overnight staff leave the agency, but the facility is hiring and has an on-call for overnight. The facility is continuing to work toward maintaining two overnight staff and has reduced their census to 3. (4) Designate an administrator to oversee only one facility. | The licensee had two candidates who did not remain in the role. The licensee has a third candidate who has been enrolled in the administrator training. (5) Revise the plan of operation / program statement (POO/PS) and/or develop an addendum to include discussion of the use and purpose of motion sensors in the facility. | An extension was granted. Administrator confirmed it was in progress, and the draft document was shown to LPA during visit. LPA is requesting submission no later than 8/31/23, allowing time for internal approvals. An exit interview was conducted and a copy of this report was left with Administrator Sara Stokes, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 1/22/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a quarterly case management inspection, per the agreed upon terms of the January 2023 noncompliance conference (NCC). LPA met with Administrator Sara Stokes and informed of the purpose of the visit. Per the NCC terms and previous inspection(s), the following was required and reviewed: -- Ensure staff were fully trained, per applicable regulations, at hire and additionally on no less than a quarterly basis. | LPA reviewed staff training records since November 2023 and observed training to include personal rights, mandated reporting, supervision requirements, and mental health awareness. LPA obtained copies of recent monthly staff trainings. Additional trainings are provided through the an electronic training site for staff to complete individually. -- Designate two overnight staff each night with at least one being a facility manager. | The facility has continued to maintain two overnight staff, and staff conduct 15 minute rounds during the overnight shift and document them on paper and electronically. LPA reviewed the 'as worked' staff schedules and rounds documentation. The facility previously conducted rounds from 10PM to 7AM and is now in the process of switching to 8PM to 8AM. -- Designate an administrator to oversee only one facility. | The licensee has closed one of their children's programs, and now the administrator is designated to only one facility. LPA identified one area in which technical assistance may be beneficial. See LIC 9102 dated 1/22/24. An exit interview was conducted, appeal rights were discussed, and a copy of this report was left with Administrator Sara Stokes, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 4/22/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a required annual inspection. LPA met with Administrator Sara Stokes and informed of the purpose of the visit. Using the CARE Inspection Tool, LPA toured the facility site and grounds, reviewed facility records, and conducted confidential interviews with two staff and two residents. Personnel records reflect staff have completed required training and are on track to complete the required hours of training this year. Additionally, all staff whose files were reviewed have a background clearance and eligibility to work on site. Resident records were complete, and emergency contact information is contained within their records. Each resident has an individual care plan. Medications are locked away. Chemicals are stored where inaccessible to residents. No hazards were observed on the premises, all bedrooms offer individual beds and ample storage, and all kitchen and bathroom spaces are maintained in sanitary condition. Based on LPA's observations and the CARE Inspection Tool, no deficiency citations were issued. LPA observed one area where technical support may be beneficial. See LIC 9102 dated 4/22/24. An exit interview was conducted, appeal rights discussed, and a copy of this report was left with Administrator Sara Stokes.


summary: Facility Evaluation

raw_content:
Narrative:
On 4/22/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a quarterly case management inspection, per the agreed upon terms of the January 2023 noncompliance conference (NCC). LPA met with Administrator Sara Stokes and informed of the purpose of the visit. Per the NCC terms and previous inspection(s), the following was required and reviewed: -- Ensure staff were fully trained, per applicable regulations, at hire and additionally on no less than a quarterly basis. | LPA reviewed 2024 staff training records and observed training to include mandated reporting, trauma-informed care, rounds training, and management training. 5 individual staff training records were reviewed, and it was observed that all 5 were on track to complete the required annual training hours. -- Designate two overnight staff each night with at least one being a facility manager. | The facility has continued to maintain two overnight staff. Overnight staff conduct bedroom rounds every 15 minutes. Paper documentation is maintained for these rounds. LPA reviewed the documentation from 2/1/24 to 4/21/24 and observed consistent and accurate records that reflect there are at least two overnight staff providing supervision and conducting rounds. -- Designate an administrator to oversee only one facility. | The licensee has closed one of their children's programs, and now the administrator is designated to only one facility. Additionally, a lead facility manager has been designated to support the day to day management of the facility. Additionally, LPA discussed incident reporting and staffing with Administrator. No deficiencies were observed at this inspection. An exit interview was conducted, and a copy of this report was left with Administrator Sara Stokes, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 7/31/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a quarterly case management inspection, per the agreed upon terms of the January 2023 noncompliance conference (NCC). LPA met with Administrator Sara Stokes and informed of the purpose of the visit. Per the NCC terms and previous inspection(s), the following was required and reviewed: -- Ensure staff were fully trained, per applicable regulations, at hire and additionally on no less than a quarterly basis. | LPA reviewed May through July 2024 staff training records, which LPA observed to cover crisis interventions, licensing requirements, program guidelines, mandatory staff trainings, and reviewing clients' background information and care plans. LPA requested a copy of the current LIC 500 and the last 12 months training logs for S1, S2, S3, S4, and S5. See LIC Confidential Names. Please submit by (8/8/24 11AM). -- Designate two overnight staff each night with at least one being a facility manager. | The facility has continued to maintain two overnight staff. Overnight rounds consist of bedroom checks every 15 minutes, and each check is documented on a separate log for each resident in care. Both paper logs and electronic logs are maintained. LPA reviewed the documentation from the past quarter and observed complete and consistent overnight logs. -- Designate an administrator to oversee only one facility. | The facility has maintained an administrator who is designated to only one facility as well as a lead facility manager to support the day to day management of the facility. The facility has also designated a lead staff member to enroll in administrator training. Additionally, LPA discussed incident reporting and staffing with Administrator. The facility has not received any deficiencies or complaints in the past quarter. No deficiencies were observed at today's inspection. An exit interview was conducted, and a copy of this report was provided to Administrator Sara Stokes.


summary: Facility Evaluation

raw_content:
Narrative:
On 10/11/24, Licensing Program Analysts (LPAs) Mariah Hawkins and Jonathan Medina conducted a quarterly case management inspection, per the agreed upon terms of the January 2023 noncompliance conference (NCC). LPA met with Interim Administrator Carolyn Williams and informed of the purpose of the visit. Per the NCC terms and previous inspections, the following was required and reviewed: -- Ensure staff were fully trained, per applicable regulations, at hire and additionally on no less than a quarterly basis. | The previous submission of training records reflected complete training. Interim Administrator agreed to submit a current LIC 500 as well as the following items for Staff S1, S2, S3, S4, and S5 (See LIC 811) by 10/18/24: LIC 501, First Aid training, CPI training, current training record for the last 12 months. -- Designate two overnight staff each night with at least one being a facility manager. | The facility has maintained two staff on each overnight shift. Bed check logs were complete and organized. Some disrepancies were observed and clarified by Interim Administrator, who aslo explained the prompt corrective action taken. -- Designate an administrator to oversee only one facility. | The facility's former administrator has promoted to a higher position, and the former lead facility manager has promoted to the administrator position. Interim Administrator has completed the initial group home administrator training program and will be completing the examination soon. The facility has also designated a new lead facility manager. Additionally, LPAs discussed the facility's overall compliance over the past quarter. The facility has not submitted any reports of incidents requiring follow-up. During the visit, it was learned that some reportable incidents occurred in the past few months. Based on the discussion, the incidents were not high-priority incidents that would have required follow-up. LPAs advised on reporting requirements. See LIC 9102. In the past quarter, the facility has not received any complaints nor deficiencies. No deficiency citations were issued at today's inspection. An exit interview was conducted, and a copy of this report was left with Interim Administrator.

met_with: Interim Administrator Carolyn Williams


summary: Facility Evaluation

raw_content:
Narrative:
Control Number - 0001526-FN On March 11, 2025, at 10: AM, Licensing Program Analysts (LPAs) Jonathan Medina and Cole Oliver conducted an unannounced case management inspection at the above-referenced facility to follow up on a submitted Incident Report (IR). LPAs met with Carolyn Williams, Program Administrator. An IR was submitted regarding an event that occurred on February 23, 2025. According to the IR, a CPI restraint was conducted to bring client back into the facility. Administrator was able to provide further details about the clients elevated state that made the CPI restraint possible to protect the client from being a danger to themselves. Administrator noted that the client admitted to having suicidal ideations. Administrator explained that the client is now stable and a safety plan was created to improve the clients care outlining preventative measures. During the visit LPAs were able to confirm all involved staff are CPI certified. LPA's interviewed 3 staff and 4 clients. No violations of the California Code of Regulations, Title 22, Division 6 were cited during this inspection. An exit interview was conducted, and a copy of this report was provided to Carolyn Williams, Program Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On 04/30/2025, Licensing Program Analyst (LPA) Jonathan Medina conducted a visit to the facility for a required annual inspection. LPA met with Administrator Carolyn Williams and informed her of the purpose of the visit. The CARE Inspection Tool was used to complete this inspection. During the visit, LPA verified that all staff listed on the staff schedule have background clearances as reflected in Guardian. At approximately 1: PM, LPA began the Client Records Checklist section of the CARE Tool. The facility maintains all client documents in an online system called Kipu EMR. LPA Medina used the LIC858 checklist to document observations. Upon review, some client records were missing Needs and Services Plans, and one client was missing both a TB test and immunization records. Please refer to the LIC809-D for further information. At approximately 3: PM, LPA began reviewing the Staffing section of the CARE Tool. The facility maintains staff records across multiple platforms, including the internal Dayforce website, Navex One training program, and Dayforce training program. Additional missing documents were emailed by HR during the visit. LPA recommended that, for future licensing visits, all training and personnel documents be organized into a centralized folder for each staff member to facilitate future audits. Please refer to LIC9102 for further details. Continues on LIC809-C At approximately 5: PM although there was not sufficient time to conduct a thorough physical plant inspection, LPA conducted a general walk through of the home and found it to be clean and in good repair. A continuation visit will be required to complete the annual inspection. During today's visit, LPA completed the review of client and staff records. The LIC311B was provided to the licensee for future reference to assist in organizing documentation. It is recommended that the licensee consider methods to ensure that required forms, although maintained, are accessible and readily available during licensing visits. As a result of this inspection, three deficiencies are being cited in accordance with California Code of Regulations, Title 22, Sections 84070(c)(3), 80069(c)(1), and 84068.2(a). Please refer to the LIC809-D pages for additional information. An exit interview was conducted, and a copy of this report was provided to Carolyn Williams, Administrator, whose signature on this form confirms receipt.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On May 14, 2025, at approximately 2: PM, Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced annual/random inspection (continuation) at the above-mentioned facility. Upon arrival, LPA met with Program Administrator Carolyn Williams. The facility is licensed to serve up to six (6) clients. At the time of the inspection, there were four (4) clients and five (5) staff members present. At approximately 2: PM, LPA Medina began the physical plant inspection using the CARES Inspection Tool. The facility was observed to be clean, organized, and free of obstructions or hazards. No bodies of water were present. The kitchen was adequately stocked with a variety of food items, all within expiration dates. Bathrooms were found to be sanitary. There are a total of six (6) beds, arranged in three (3) double-occupancy bedrooms. All bedrooms had clean linens and sufficient storage space. The hot water temperature measured within the required range: 118.9°F at the shower faucet and 102.3°F at the bathroom sink. No deficiencies were observed in this section. At approximately 3: PM, LPA began reviewing the operational requirements of the CARES Inspection Tool. During the review, the program statement was initially misplaced but was located toward the end of the visit. Upon review, it was noted that the board of directors listed in the document was not recognized by the Administrator. Additionally, no records of board of directors meetings were available for review at the time of the visit (refer to LIC 809-D). Records of prior Licensing visits from the past three (3) years were also not immediately available but were located later during the inspection. LPA advised the Administrator to store all essential documents in a centralized location to ensure accessibility during future Licensing inspections. Continues on LIC809-C. The annual inspection is not yet complete. LPA Medina will return to complete the remaining components of the inspection, including staff and client interviews, at a later date. As a result of this inspection, one deficiency is being cited in accordance with California Code of Regulations, Title 22, Section 84063(a) - Accountability. An exit interview was conducted, and a copy of this report along with the Appeal Rights was provided to Administrator Carolyn Williams.

Deficiencies:
84063(a): Accountability

(a) The board of directors shall be active in ensuring accountability, and shall perform, at a minimum, the following duties


summary: Facility Evaluation

raw_content:
Narrative:
On May 15, 2025, at approximately 3: PM, Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced annual/random inspection (continuation) at the above-mentioned facility. Upon arrival, LPA met with Program Administrator Carolyn Williams. The facility is licensed to serve up to six (6) clients. At the time of the inspection, there were four (4) clients and five (5) staff members present. At approximately 3: PM, LPA began reviewing the Disaster Preparedness section of the CARE Inspection Tool with the Administrator. The facility maintains a backpack stocked and ready at all times in case of an emergency, which contains essential documents for each client, including medication lists, Needs and Services Plans, contact information, and insurance information. No deficiencies were observed in this section of the CARE Inspection Tool. At approximately 3: PM, LPA began reviewing the Emergency Intervention Plan section of the CARE Inspection Tool. Staff at the facility are trained in CPI (Crisis Prevention Institute) intervention techniques. LPA verified staff training by randomly reviewing staff files, which confirmed completion of the required training. At 4: PM, LPA reviewed the Special Health Care Needs section of the CARE Inspection Tool. There are currently no clients with special health care needs residing at the facility. Continues on LIC809-C At 4: PM, LPA began conducting interviews. Two (2) staff members and two (2) clients were interviewed, in accordance with regulations. During the course of the interviews, LPA discovered that the facility has been operating outside of its approved Plan of Operation regarding the number of therapy sessions provided to clients. Currently, the facility conducts only one (1) individual therapy session and one (1) family therapy session per week. However, the approved Plan of Operation states that the facility will provide 2-3 individual therapy sessions and two (2) family therapy sessions per week. Please refer to LIC-809D for details. As a result of this inspection, one deficiency is being cited in accordance with California Code of Regulations, Title 22, Section 80022(k) - Plan of Operation. An exit interview was conducted, and a copy of this report, along with the Appeal Rights, was provided to Administrator Carolyn Williams.


summary: Facility Evaluation

raw_content:
Narrative:
On 5/15/2025, Licensing Program Analyst (LPA) Jonathan Medina made a visit to the home regarding outstanding Plans of Correction (POCs). Upon entering the home, LPA met with Carolyn Williams, Facility Administrator, and informed her of the reason for the visit. During LPA's initial annual inspection on 4/30/2025, three POCs were assessed for deficiencies observed during the inspection. For the deficiency cited under Title 22, Section 84068.2(a), regarding clients' Needs and Services Plans not being completed, the Administrator provided completed Needs and Services Plans for five clients. LPA reminded the facility that Needs and Services Plans must be developed upon each client's admission to the facility. For the deficiency cited under Title 22, Section 84070(c)(3), regarding a client's vaccination history, the required documentation was submitted by the client's parent. The Administrator presented the document to LPA, and it was confirmed to be accurate. For the deficiency cited under Title 22, Section 80069(c)(1), regarding a client not having a completed TB test, the test remains incomplete. The facility attempted to have the test administered on 5/2/2025 at 3: PM, but the clinic did not proceed due to the absence of a doctor's order. As a result, a civil penalty of $1,000 was assessed for failure to correct the deficiency. An exit interview was conducted, and a copy of this report, along with the Appeal Rights, was provided to Administrator Carolyn Williams.