summary: Facility Evaluation

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Narrative:
On 07/26/2022, an unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Melikian at 9:45AM. During the inspection, LPA met with Veronica Manzo, Administrator and Brian Land, Child Care Counselor II and inspected the facility inside and out. LPA reviewed five children's records and reviewed two staff personnel records for the facility at 10:00AM. LPA conducted a medication count at 10:45AM. LPA interviewed two staff at 11:30AM. LPA did not interview any children in the home as there are no dependents in placement at this time. No deficiencies to be cited at this time. LPA conducted exit interview with Veronica Manzo, Administrator at 12:30PM. LPA provided the summary report to Veronica Manzo, Administrator upon completion.

met_with: Veronica Manzo, Brian Land


state: CA

facility_name: DN ASSOCIATES- BLYTHE

summary: Facility Evaluation

raw_content:
Narrative:
On 08/24/22, Licensing Program Analyst (LPA) Lisa Slusher conducted an unannounced annual inspection following a pre-visit Covid Assessment. Met at the facility by Facility Manager Victor Lockett. 1. Facility Grounds were inspected and generally free from Hazard. 2. Outdoor space observed. Facility has a pool, which is locked and meets fencing requirements. 3. Chemicals were stored in locked closets/cabinets. 4. Locked and centrally stored medications were observed on this date 5. First aid kit complete with appropriate manual was present upon inspection. 6. Adequate storage space observed. 7. Individual beds in good repair observed. One mattress cover is being replaced due to a tear, but client is not present in the room. 8. The house has 5 bedrooms, double occupancy, all located on one single level. Bedrooms are accommodating of all required furnishings 9. Adequate food storage space observed. 2 days of perishable foods and 7 days of non-perishable foods observed 10. Weekly menu observed 11. Dining room observed. Table and benches provide seating for 6 youth. 12.Facility has two full restrooms, both for client use. Water temperature was within the regulatory range. 13. Licensee has a vehicle for use at the facility. insurance and registration are both current. Client files (5) were reviewed. Agency will forward LIC 308, 309, 500, Current Accreditation certification, current mental health certificate. Annual Inspection to be continued at a later date.

report_type: Facility Evaluation

visit_type: Annual

met_with: Victor Lockett, Veronica Manzo


summary: Facility Evaluation

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Narrative:
On the above date, LPA (Licensing Program Analyst) Lisa Slusher continued an annual inspection for the above facility. LPA reviewed personnel records, including training records. Prior to this inspection, LPA reviewed Personnel Report and Criminal Record Clearance Information for the above facilities. According to documentation reviewed, Facility is meeting regulatory staff/child ratios. All staff are fingerprint cleared or have current exemptions on file and are associated to the facility in which they work. Agency has current Mental Health Program Approval through Fresno County Department of Behavioral Health. MHPA is current through 1/27/23. Agency is accredited by CARF and accreditation is current and expires June 30 2025. LPA Reviewed 14 personnel records. All staff have current Emergency Intervention, First Aid/CPR and Water Safety Certificates.

visit_type: Case Management


summary: Facility Evaluation

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Narrative:
On the above date, LPA L Slusher conducted an announced case management with DN Associates-Blythe. LPA met with Veronica Manzo and Jennifer Preston via an online format. The purpose was to review the agency's incident report forms, for routine incidents and then incidents specific to the use of Manual restraints and those involving law enforcement contact. LPA Provided information on requirements for reports as well as Provider information notice 23-02 discussing the new LIC 624-LE specifying new information required for law enforcement incident reports. LPA also provided information regarding an upcoming Guardian Webinar


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Melikian on July 28, 2023 at 1:00PM. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPA met with Veronica Manzo, Administrator and inspected the facility inside and out. LPA reviewed 0 child's records and 2 staff personnel files on site at the facility. The facility did not have any dependents in placement at this time. LPA reviewed 0 child's psychotropic medications and medication records as the facility did not have any dependents in placement at this time. LPA interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPA interviewed 0 children on site. LPA provided a copy of the licensing report to Administrator, Veronica Manzo. No deficiencies are being cited at this time. LPA conducted exit interview with Veronica Manzo, Administrator.

met_with: Veronica Manzo; Jennifer Preston


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Melikian on June 14, 2024 at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPA met with Veronica Manzo, Administrator and inspected the facility inside and out. LPA reviewed 0 child's records and 2 staff personnel files on site at the facility. There were no dependents in placement at this time. LPA reviewed 0 child's psychotropic medications and medication records. LPA interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPA interviewed no children currently psychotropic medication as there are no dependents in placement at this time. LPA provided a copy of the licensing report to Administrator, Veronica Manzo. No deficiencies are being cited at this time. LPA conducted exit interview with Veronica Manzo, Administrator.

met_with: Veronica Manzo


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analysts (LPAS) Lisa Slusher and Danny Macias travelled to the facility listed above to conduct an Annual Inspection. Met at the facility at 8:30 am by Supervisor Victor Lockett. Two additional staff members and 6 clients present upon inspection. A physical plant inspection was conducted with Victor Lockett. The facility has current Mental Health Program Approval through Fresno County expiring in January 2025. The facility is accredited through CARF and their accreditation expires June 30, 2025. 1. Facility Grounds are clean and free of debris or observable hazard. Facility pool is appropriately fenced and maintained. 2. Adequate indoor and outdoor activity space and materials observed. 3. Chemicals appropriately locked. 4. Locked and centrally stored medications observed. Licensee has made provisions for contraceptives to be held in individually locked containers by clients. Observed medication logs and discussed procedures for psychotropic medications. 5. First aid kit complete with appropriate manual observed. 6. Adequate storage space observed. 7. Individual beds in good repair observed. 8. The house has 5 bedrooms, a mixture of single and double occupancy all located on one single level. Bedrooms are accommodating of all required furnishings. 9. Adequate food storage space observed. Supply of two days of perishable foods and a week of nonperishable foods observed upon inspection. 10. Weekly menu posted and accessible to clients. 11.Dining room equipped with large table and chairs accommodating of all clients. 12.Facility has two full restrooms in the house for client use, both are operable 13. Facility has no animals or firearms At 1: LPAs were met at the corporate office by Annette, office manager, to review Personnel files. Five personnel files were reviewed, and criminal record clearances were verified for all staff listed on the LIC 500 dated 7/15/2024. LPA requests the following updated forms/items: LIC 308, Designation of facility responsibility; LIC 309, Administrative Organization; LIC 400, Affadavit regarding client cash resources; LIC 500, personnel report; LIC 610, Emergency Disaster plan; LIC 9020, client roster; current lease agreement/control of property

met_with: Veronica Manzo, Victor Lockett, Annette Robles


facility_name: DN ASSOCIATES- POLK

summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13On 08/29/2022, Licensing Program Analyst (LPA) Tamara Melikian conducted a complaint inspection for DN Associates-Polk for the purpose of delivering the findings for the above complaint allegation. Met by Administrator Curtis Donovan. Based on confidential interviews and documents obtained, a restraint did occur that resulted in bruising, however it was not at inappropriate restraint. Therefore, the allegation is unsubstantiated. There are no deficiencies to be cited on this date. Exit interview conducted and a copy of the report was left with the Administrator. Computer malufunction during follow up inspection, unable to capture signature. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Tamara Melikian LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

report_type: Complaint Investigation

met_with: Curtis Donovan

complaint_status: unsubstantiated


summary: Facility Evaluation

raw_content:
Narrative:
On 10/25/2021, an unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Melikian at 9:00AM. During the inspection, LPA met with Veronica Manzo, Administrator and inspected the facility inside and out. LPA reviewed six children's records at 9:00AM and conducted a medication count. LPA reviewed two staff personnel files and training records and documentation at 10:30AM. A review of staff records on 10/25/2021 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. LPA interviewed two staff in the facility at 11:00AM. LPA interviewed one child in the home at 11:30AM. The remainder of the children were not dependents or were non-minor dependents. No deficiencies to be cited at this time. LPA conducted exit interview with Veronica Manzo, Administrator at 12:00PM. LPA provided the summary report to Veronica Manzo, Administrator upon completion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, LPA (Licensing Program Analyst) Lisa Slusher conducted an annual inspection for the above facility. LPA reviewed personnel records, including training records. Met with Curtis Donovan. Prior to this inspection, LPA reviewed Personnel Report and Criminal Record Clearance Information for the above facilities. According to documentation reviewed, Facility is meeting regulatory staff/child ratios. All staff are fingerprint cleared or have current exemptions on file and are associated to the facility in which they work. Agency has current Mental Health Program Approval through Fresno County Department of Behavioral Health. MHPA is current through 1/27/23 . Agency is accredited by CARF and accreditation is current and expires 6/30/ LPA Reviewed 14 personnel records. All staff have current Emergency Intervention, First Aid/CPR and Water Safety Certificates.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Melikian at on 10/26/2022 at 1:00PM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Melikian met with Veronica Manzo, Administrator and inspected the facility inside and out. LPA reviewed 1 child's records and 2 staff personnel files on site at the facility. LPA reviewed 1 child's psychotropic medications and medication records. LPA interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPA did not interview any children currently prescribed psychotropic medication as the child is a non minor dependent. LPA provided a copy of this licensing report to Veronica Manzo, Administrator. No deficiencies are being cited at this time. LPA conducted exit interview with Veronica Manzo, Administrator.


summary: Facility Evaluation

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Narrative:
On the above date, LPA conducted a case management inspection at the potential office space for DN Associates. LPA observed office space and discussed agency operations.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, LPA L Slusher conducted an announced case management with DN Associates- Polk. LPA met with Veronica Manzo and Jennifer Preston via an online format. The purpose was to review the agency's incident report forms, for routine incidents and then incidents specific to the use of Manual restraints and those involving law enforcement contact. LPA Provided information on requirements for reports as well as Provider information notice 23-02 discussing the new LIC 624-LE specifying new information required for law enforcement incident reports. LPA also provided information regarding an upcoming Guardian Webinar

met_with: Jennifer Preston, Veronica Manzo


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Melikian on October 19, 2023 at 11:00AM. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPA met with Veronica Manzo, Administrator and inspected the facility inside and out. LPA reviewed 1 child's records and 2 staff personnel files on site at the facility. LPA reviewed 1 child's psychotropic medications and medication records. LPA interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPA interviewed 1 child on site. LPA provided a copy of the licensing report to Administrator, Veronica Manzo. No deficiencies are being cited at this time. LPA conducted exit interview with Veronica Manzo, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analysts (LPAS) Lisa Slusher and Danny Macias conducted an Annual Inspection. Met at the facility by Supervisor Victor Lockett. Two additional staff members and 6 clients present upon inspection. . The facility has current Mental Health Program Approval through Fresno County expiring in January 2025. The facility is accredited through CARF and their accreditation expires June 30, 2025. Client (five) and Staff files reviewed on this date. At 1: LPAs were met at the corporate office by Annette, office manager, to review Personnel files. Five personnel files were reviewed, and criminal record clearances were verified for all staff listed on the LIC 500 dated 7/15/2024. A case management- Annual Continuation inspection will be required. No deficiencies noted in areas observed on this date. LPA requests the following updated forms/items: LIC 308, Designation of facility responsibility; LIC 309, Administrative Organization; LIC 400, Affadavit regarding client cash resources; LIC 500, personnel report; LIC 610, Emergency Disaster plan; LIC 9020, client roster; current lease agreement/control of property

met_with: Veronica Manzo, Annette Robles


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Melissa Renovato and Reyna Martinez on May 20, 2026 at 10 am. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPAs met with Veronica Manzo, Administrator and inspected the facility inside and out. LPAs reviewed 0 child's records and 2 staff personnel files on site at the facility. There were no dependents in placement at this time that meet review qualifications. LPAs reviewed 0 child's psychotropic medications and medication records. LPAs interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPAs interviewed no children currently psychotropic medication as there are no dependents in placement at this time that meet review qualifications. LPAs provided a copy of the licensing report to Administrator, Veronica Manzo. LPAs toured the facility for a health and safety inspection. No deficiencies are being cited at this time. LPAs conducted exit interview with Veronica Manzo, Administrator.


facility_name: DOWNS & MARTIN CHILDREN'S SERVICES

summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
Licensing Program Analyst, Daniel Mena conducted a technical assistance meeting virtually via Teams with Downs and Martin Short Term Residential Therapeutic Program (STRTP) Executive Director, Emmett Downs and STRTP Consultant, Daniel Thorne. Present at the meeting were Licensing Program Manager, Jennifer Smith, System of Care Branch Analyst, Ansar Mohammed, System of Care Branch Supervisor, Marjana Jackson and Riverside County Representative Jenell Ross. The Purpose of the meeting was to discuss and review the following pending Plan of Operation (POO) and Program Statement (PS) revisions: Plan of Operation Section A, Purpose and Goals- Does Not Meet Standards • Typos Pgs. 8 & 9. Section B, Administrative Organization- Does Not Meet Standards • Pg. 29 # 10. "Transports youth to medical/dental appointments, for clothing, and directed activities as needed or required." Can volunteers do this? Section C, Facility Sketches- Does Not Meet Standards • Does not indicate dimensions of rooms. • Which room would be designated as the NMD room if necessary? • Indicate 2 clients per bedroom Section D, Staff Plan- Does Not Meet Standards 1.recommend creating a training matrix/table (see below) for the direct care staff initial 8 hours, 16 hours, annual training, and facility manager training ... 2. Please Describe the utilization, screening, and training of peer partners, volunteers. 87065.1 (a) 3.The 8-hour training shall include trauma-informed training as specified in Section 87078.2(a)(3). *Includes the types of traumata experienced by children and NMDs, the effects and impact of abuse, neglect and trauma, how trauma may manifest itself in daily functioning and behaviors, how to provide care and supervision that is trauma-informed, how to facilitate healing, and how to reduce the risk of re-traumatization 4. Please clearly identity which training will make up the 8 hours of training. recommend training matrix (see above) 5.Please ensure as part of the 8-hour training, a trauma informed training which includes the types of traumata experienced by children and NMDs, the effects and impact of abuse, neglect and trauma, how trauma may manifest itself in daily functioning and behaviors, how to provide care and supervision that is trauma-informed, how to facilitate healing, and how to reduce the risk of re-traumatization 6.Please ensure to clearly identify which training topics will be completed from job shadowing.87065.1(d)(1)(4) • Successful completion of job shadowing shall be verified by a statement completed by the experienced facility personnel being shadowed affirming: a) specific activity observed; b) dates and times of shadowing; and c) training topic. 7.please clearly identify which training topics will make up the 16 hours of training completed within 90 days, 87065.1(d)(3) 8. please ensure the training topics for direct care staff (16 hours, within 90 days) also includes 87065.1(d)(3). • Best practices for providing care and supervision to nonminor dependents. • Health issues in foster care.... *; • * *(AA) A child's right to receive gender affirming sexual and reproductive health care and information. • A child's right to have their health information kept confidential. • (CC) Guidance about how to engage and talk with children about healthy sexual development and reproductive and sexual health in a manner that is medically accurate, gender affirming, age or developmentally appropriate, and trauma informed. • Information about current contraception methods and how to select and provide appropriate referral resources and materials for information and service delivery. 9. Within *thirty* *(*30*)* days of completion of the 16-hour training, the administrator or administrator's designee shall assess if each newly hired direct care staff understands and can apply the training. 10. Recommend including a training matrix/table as discussed above. The 40 hours of ongoing (annual) training for newly hired and existing direct care staff 11.At minimum, Annual training topic must include the following training topics 87065.1( e): • Child and adolescent development, including sexual orientation, gender identity and gender expression. • (B) Core practice model. • (C) Permanence, well-being, and educational needs of children. • (D) Basic instruction on existing laws and procedures regarding the safety of foster .youth. *children* at school; and ensuring a harassment and violence free school environment. • (E) Best practices for providing care and supervision to nonminor dependents. • (F) Oversight and monitoring of psychotropic medications for children in foster care and related topics described in the training developed pursuant to Section 16501.4(d) of the Welfare and Institutions Code. • *(G) Trauma-informed interventions and practices.* 12. -Facility Manager Training plan for facility managers is hard to understand. 13.As a remind please ensure all training include course title, subject matter, learning objective and activities , # of hours and training evaluation. Recommend training matrix table. 14.Facility managers are required the following training topics 87065.1(b)(5): • (A)Interaction with the Department, including inspection authority. • (B) Licensee appeal rights. • (C) Interaction with placement agencies, neighbors, mental health agencies, law enforcement, medical/emergency personnel, children's family members and child and family teams. • (D) Laws and regulations governing short-term residential therapeutic programs. • (E) Emergency and disaster response. • (F) Implementation of the assessment by the Qualified Individual, as specified in section 87022.1(b)(8)(A), and information about the Qualified Individual's assessment process pursuant to Sections 4096 and 11462.01 of the Welfare and Institution's Code. • (G) Facilitation of participation of family members in child's treatment program and documentation of integration of family members into the treatment process, as specified in section 87022.1(b)(13)(A). • (H) Facilitation of outreach to family members and documentation of outreach, as specified in section 87022.1(b)(13)(A). • *(I) A child's right to receive gender affirming sexual and reproductive health care and information. • (J) A child's right to have their health information kept confidential. • (K) The duties and responsibilities of the assigned case management worker and the licensee to ensure that children can obtain sexual and reproductive health services and information. • (L) Guidance about how to engage and talk with children about healthy sexual development and reproductive and sexual health in a manner that is medically accurate, gender affirming, age or developmentally appropriate, and trauma informed. (M) Information about current contraception methods and how to select and provide appropriate referral resources and materials for information and service delivery.* 15. as a reminder Facility manager training is in addition to first aid and CPR training, and other training as required in Section 87095.65. 87065.1 (b)(8) 16.Please include how volunteers will be utilized. 17.Peer partners and Volunteers require the same training. 87065.1 (f) and (g) 18.As a reminder, all training plans shall include for each training session the following: (A) Course title and subject matter; (B) Learning objectives and activities: (C) Number of hours per training session; (D) Qualification of the trainer; and (E) Training evaluation.(Each session shall include an evaluation of the trainer and course content to determine if the training is meeting the needs of direct care staff.) (B) Recommend creating a training matrix/table for volunteers/peer partners (see below): 19. Please ensure prior to working with youth volunteers and peer partners receive 16 hours of training which include 87065.1(f) and (g): • the confidentiality of information and records relating to children in the short-term residential therapeutic program; • (B) Teamwork and interpersonal communication among facility personnel and children, children's family members and child and family team members; • (C) The children's personal rights as specified in Welfare and Institutions Code section 16001.9 and Section 87072, including, *but not limited to,* the right to have fair and equal access to all available services, placement, care, treatment, and benefits, and to not be subjected to discrimination or harassment on the basis of actual or perceived race, ethnic group identification, ancestry, national origin, color, religion, sex, sexual orientation, gender identity *and expression*, mental or physical disability, or HIV status; • (D) Physical and psychosocial needs of children, including behavior management, de-escalation techniques, and trauma-informed crisis management planning; including the use of emergency interventions*;* .... (E) Child and adolescent development, including sexual orientation, gender identity and gender expression. 20. Peer partners/volunteers are then required to take an additional 16 hours of training (within 90 days) which include • An overview of the child welfare and probation systems. • Permanence, well-being, and educational needs of children; • (C) Overview of the population served by the short-term residential therapeutic program; • (D) Physical and psychosocial needs of children, including behavior management, de-escalation techniques, and trauma-informed crisis management planning, including the use of emergency interventions; • (E) The effects of trauma, including grief and loss, and child abuse and neglect on child development and behavior and methods to behaviorally support children impacted by that trauma or child abuse and neglect; • (F) Awareness and identification of commercial sexual exploitation and best practices for providing care and supervision to commercially sexually exploited children.;.. *.* 21.Will this program require staff an emergency intervention training? If so , please describe in the training plan and please ensure to state it is "in addition to initial and annual training. Section E, Policies Regarding Child Abuse Reporting- Does Not Meet Standards • Did not specify that the facility will not sanction, punish or discipline any staff for making a report. Section F, Administrative Policies and Procedures- Meets Standards • Are the first four pages necessary? • Much is not required in this the section. Section G, Admission Determination Procedures- Does Not Meet Standards 1. This section shall be used to discuss the facilities procedures for determining admission only. This section appears to discuss some intake procedures that are best fit in section H. some examples include "a copy of admission agreement, county/private placement, Procedures between placing agency and the STRTP no later than seven (7) days after admission of a youth/NMD, Medical assessment and physical examination requirements, including TB results, Procedures for accepting emergency placements, Procedures for admission agreements for NMDs including modifying agreements. 2. When a child is referred for placement in a short-term residential therapeutic program, the licensee shall document the referral including 87068.05(b): • Documentation of referrals shall include but not be limited to the following: • The placing agency making the referral request. • The date and time that the referral was received. • The name, age, and gender identity of the child being referred. 3. Please specify the procedures by which a determination is made in response to a referral from a placing agency to include 87068.05 ©: a. Consideration of the child's needs and strengths, the likelihood that the child will benefit from the program, 4. Determination procedures shall include an explanation of how the program will evaluate the appropriateness of placement for referred children with any of the following behaviors or characteristics, including how the licensee defines these characteristics for the purposes of assessing appropriateness of fit. Appears to be somewhat discussed in section H. please move the content from section H. to G. 5. Please Include an explanation of how the program will evaluate the appropriateness of placement for referred children with any of the following behaviors or characteristics (see below), o Frequent runaways o Gang-related activity o Fire-starting o Sexually assaultive behaviors o History of Commercial Sexual Exploitation o Substance abuse 6. Please also include how the licensee defines these characteristics (above) for the purposes of assessing appropriateness of fit 87068.05 ©(3): • -as a reminder , the licensee shall not utilize the behaviors and characteristics (frequent runaways, gag activity, fire-starting, CSEC, substance abuse, etc.) as the sole basis to assess or determine placement appropriateness or deny admission.* 87087068.05 (e) 3. Please include a statement that recognizes interviews with youth are not used to assess or determine placement appropriateness or deny admission.* 87068.05 (d) 6. Determination procedures shall specify the following .* 87068.05 ©(4): 1. The facility shall establish timeframes for response to the county placing agency regarding referrals for placement. a. The established timeframes must include, but are not limited to, an initial response period in which the facility accepts, denies, or requires more information for the consideration of the referral for placement. The facility's initial response period shall not exceed 5 days following the receipt of referral for placement and , b. a final response period in which the facility accepts or denies the referral for placement. 7. Elevated review procedures appears somewhat discussed in section H, on page 183 as "Process for engaging and collaborating with inter-agency placement committee and Child and Family Team." • Upon the request of a placing agency director and the authorized representative of the county mental health plan, or their designees, the licensee shall engage in a good-faith effort, together with the placing agency director and the authorized representative of the county mental health plan, or their designees, to determine the appropriateness of the placement. 87068.05(f) • If the licensee determines that the program is not capable of meeting the child's needs without additional services and/or supports, the licensee shall request such assistance from the placing agency, Community Based Organization, or any other resource, and shall document this request. 87068.05 (g) • If the licensee determines that the program is not capable of meeting the child's needs, even with additional services and/or supports, or if the identified services and supports are not available, the licensee shall document this denial, including the reason for denial. 87068.05 (h) Section H, Intake Policies and Procedures- Does Not Meet Standards • In this section, I did not see a description of trauma-informed and evidence-based intervention and de-escalation techniques that will be used to promote the safety of all individuals in the facility, including but not limited to children or NMDs who have the propensity for behaviors that result in harm to self or others. 1. This section is to discuss procedures and policies after a youth has been accepted for admission. It appears to discuss many procedures for "admission determination". Please move that content to section G. Procedures for special services (i.e., CSEC, Special health care needs, Regional Center, Non-ambulatory), Process for engaging and collaborating with inter-agency placement committee and Child and Family Team, Process for coordination with placing and mental health plans, Process for assessing children to determine commonality of needs, Ineligibility for Placement, Specific process, Facility unable to meet specific needs, Comprehensive explanation of characteristics, procedure by which the facility determines characteristic, and why the facility is unable to meet specific needs, Criteria for evaluating and assessing children/non-minor dependent upon admission 2. The following information regarding the child shall be obtained and maintained in the child's record: *(1) The child's preferred pronouns*. *(2)* The name, address, and telephone number of all adults with whom the child was living immediately prior to the current placement *(3)* The name, address, and telephone number of the child's parent(s) or legal guardian, biological family members of the child, including siblings, and nonrelative extended family members, if known. *(4)* The name, address, and telephone number of the placement worker and placement agency. (5)* Educational records, if available, describing the child's present academic level, including their grade or performance level, and any previous school-related problems. .(6)* Dental and medical history, if available, including immunization records and physician's orders for any medically necessary diet as specified in California Code of Regulations, Title 22, Section 80076(a)(6)... *(7)* The child's court status, if applicable, including a copy of any custody orders and agreements with parent(s) or person(s) having legal custody... *(8)* The placement agency's list of persons who should or should not be allowed to visit.(9)* The interagency placement committee's written determination and the qualified individual's assessment of the child, required to be completed and provided to the short-term residential therapeutic program pursuant to subdivisions (f) and (g) of Section 4096 of the Welfare and Institutions Code (10)Medical, psychiatric and psychological reports that identify special needs of children diagnosed as mentally disordered or developmentally disabled. .. *(11)* Medical and dental insurance coverage information, or information regarding the agency or person responsible for medical and dental costs (12) Consent forms, completed by the child's authorized representative(s), to permit the facility to authorize medical care. (13)copy of the current court order, or written authorization of the child's parent or guardian, for each psychotropic medication. 3. 87068.11 (f)Intake for NMD shall include Name, address, and telephone number of the nonminor dependent's: Placement worker and placement agency, Authorized representative, if any, and persons to be contacted in an emergency when the nonminor dependent's authorized representative cannot be contacted., Physician and dentist, and other medical and mental health providers, if any. Current employer, if applicable, with address of employment Medical and dental insurance coverage information, including the agency or person responsible for medical and dental costs, Names of all persons who are prohibited by court order from contacting or visiting the nonminor dependent, The Health and Education Passport, the assessment made by the Qualified Individual, The Transitional Independent Living Case Plan, The Transitional Independent Living plan , 4. 87068.11 (E)-Prior to, or within 30 calendar days of placement of a nonminor dependent, a licensee shall obtain a written medical assessment of the nonminor dependent, including ambulatory status, . • If the information above is .not completed.. */ provided* by a placement agency, the licensee shall make telephone and/or written requests for the information to the child's placement agency and/or authorized representative and shall record and retain the details of those requests. 87068.1 ©(1)-(2) and if the information is not received within 15 days of the requests specified in (A) above, the licensee shall obtain the information necessary to complete a standard appraisal form from other sources. • © When the information is received, social work staff shall complete a standard appraisal for the child on a form approved and/or furnished by the licensing agency. • The needs and services plan shall be completed. 5. An admission agreement shall be completed and signed *no later than seven (7) calendar days following admission .A copy of any court order authorizing psychotropic medications, if the child is currently taking psychotropic medication, shall be obtained. 6. if the child is currently taking psychotropic medications, A separate log for each psychotropic medication prescribed to a child documenting all of the following 87068.1 ©(8) and 87070 : o The name of the medication. o The date of the prescription. o The quantity of medication and number of refills initially prescribed. o When applicable, any additional refills prescribed. o The required dosage and directions for use as specified in writing by the physician prescribing the medication, including any changes directed by the physician. o The date and time of each dose taken by the child. o Documentation of each refusal. o Documentation shall include the name of the medication refused, • date and time of the refusal, the reason for the refusal, who was notified of the refusal, and any observed results of the refusal. 7. Please include evidence-based intervention and de-escalation techniques that will be used to promote the safety of all individuals in the facility, who have the propensity for behaviors that result in harm to self or others. 8. Procedures for child/youth emergency placement shall include: 1. Please ensure emergency Placement of the child in the facility shall not result in the facility exceeding its licensed capacity, 2. The admission agreement will be completed no later than seven days following the emergency placement And The administrator or their designee, and the child and/or their authorized representative(s), shall sign copies of*:* the removal and/or transfer policies and procedures specified in Section 87068.4(a); of the discipline policies and procedures specified in Section 87072.1(a); and of the complaint procedures specified in Section 87072.2(a), to verify the receipt of such information 3. If it is determined, following emergency placement of the child in the facility, that the facility cannot continue to provide necessary services, applicable transfer procedures specified in Sections 87068.4(b), (c) and (e); and 87070(d) through (d)(3) shall be followed. 4. If the child is continued in placement, the following requirements shall be met no later than 30 days following the emergency placement: intake documents shall be obtained, the needs and services plan specified in Section 87068.2, shall be reviewed by social work staff to determine whether the facility can continue to provide services necessary to meet the child's needs and The admission agreement shall be modified as specified in California Code of Regulations, Title 22, Section 80068(d), if necessary. 9. Procedures for NMD emergency placement shall include: Placement of the nonminor dependent in the facility may not result in the facility exceeding its licensed capacity, No later than 30 days following the emergency placement, the administrator or social work staff shall request and Obtain intake information (mentioned above), Complete the **...Needs and ..S.*services *..P..lan for the nonminor dependent and No later than 7 days after emergency placement of a nonminor dependent, the administrator or social work staff shall complete an admission agreement for the nonminor dependent.. 87068.11 (h)and (j) 10. Intake for NMD shall include: 1. intake documentation shall be obtained from the placement agency to include: (A) Name, address, and telephone number of the nonminor dependent's: 1. Placement worker and placement agency. 2. Authorized representative, if any, and persons to be contacted in an emergency when the nonminor dependent's authorized representative cannot be contacted. 3. Physician and dentist, and other medical and mental health providers, if any. 4. Current employer, if applicable, with address of employment. (B) Medical and dental insurance coverage information, including the agency or person responsible for medical and dental costs. (C) Names of all persons who are prohibited by court order from contacting or visiting the nonminor dependent. (2) The following intake information shall be requested from the placement agency: (A) The Health and Education Passport. 1. The placing agency is required to provide the health and education summary within 48 hours of a subsequent placement. Any *n*.Needs and *..services *p*.lan (C) The Transitional Independent Living Case Plan .(or case plan).. 1. The licensee shall document in the nonminor dependent's needs and services plan when the case plan is received from the county placing agency. 2. If the case plan is not received from the county placing agency, the licensee shall document the attempts made to obtain the case plan in the nonminor dependent's needs and services plan (D) The Transitional Independent Living Plan. (E) The assessment made by the Qualified Individual. 11. the administrator or social work staff shall complete an admission agreement for the nonminor dependent. 87068.11 (g) 12. The administrator or social work staff shall ensure that intake documents are signed as necessary( including needs and services, policies and procedures for removal or transfer, Expectations and consequences for living in the facility, The complaint procedures) 1. Prior to a nonemergency placement or no later than 7 days after an emergency placement, the admission agreement shall be signed and dated by a nonminor dependent, the nonminor dependent's authorized representative if applicable, and the administrator or social work staff. o Whenever circumstances covered in the admission agreement change, a licensee shall make modifications to the current agreement. Any modifications to the agreement shall be signed as specified in subsection. 13. 87068.11 (L) . NMD shall receive copies of the Admission agreement and any modifications to .this.. *The admission* agreement, Personal rights as specified in Section 87072. , Expectations and consequences for living in the facility as specified in Section 87072.1*1*. The *n*.Needs and *..services *p*.lan as specified in Section 87068.22, the Transitional Independent Living Plan, and any modifications to these plans. • (5) Removal or transfer policies and procedures for the facility as specified in Section 87068.4. • *(6) The complaint procedures as specified in Section 87072.2(a).* Section I, Admission Agreement- Does Not Meet Standards • Did not see a copy of admission agreement for NMDs, including procedures for modifying the agreements. Section J, Removal or Transfer Policies and Procedures - Does Not Meet Standards Section is somewhat hard to follow. 1. Please include a description of how the licensee will mitigate against potential impacts to a child as a result of removal or transfer, including but not limited to how licensee will assist in preventing delays or gaps in delivery of services, , and best practices for staff communication with the child during the transition. 87068.4 (a). recommend including this under "Planned Youth/NMD Transfer/Removal" on page 210. 2. Children and their authorized representative(s) shall receive copies of such policies and procedures and an explanation of such policies and procedures in an age and developmentally appropriate manner. 2. An unplanned foster care placement change shall not take place between 9 p.m. and 7 a.m. 3. Procedures when STRTP is concerned that it cannot meet a child/NMD's needs or when there is an indication that the placement may be disrupted, including: • Notify authorized representative(s) of the concern. • Communicate the concern to the county placing agency. • Request additional support services from the community if necessary. • Request a Child and Family Team (CFT) Meeting. • Make a reasonably good faith effort to engage in the development and implementation of placement preservation strategies in collaboration with the county placing agency and in consultation with the CFT. 4. Upon a concern that the facility cannot meet the needs of the child or when there is an indication that the placement may be disrupted, the licensee shall 87068.4 €(1): • Notify the authorized representative(s) of the concern. • Communicate the concern *in writing* to the county placing agency *, including identifying the specific needs of the child that the facility is not able to meet.* (C) Request additional support services from the community if necessary*.* ., and.. • Request a Child and Family Team meeting. • Make a reasonable and good faith effort to engage in the development and implementation of placement preservation strategies in collaboration with the county placing agency and in consultation with the Child and Family Team. (F) Participate and request technical assistance from the Department at a time jointly agreed upon by the licensee and the Department.* .If it is determined that the facility cannot meet the needs of the child the licensee shall notify the authorized representative(s) of the determination and request that the child be placed elsewhere. The Requests shall be submitted to the county placing agency and shall contain the following information87068.4 (e )(2): • Legal name, preferred name if different from legal name, and preferred gender pronouns. • Date the authorized representative was informed of the concern pursuant to Section 87068.4(e)(1)(A). • 3. Date the county placing agency was informed of the concern pursuant to Section 87068.4 (e)(1)(B). • 4. Date of request for additional support services and types of services received pursuant to Section 87068.4 (e)(1)(C). • 5. Date of request for Child and Family Team meeting and date the Child and Family Team meeting was held pursuant to Section 87068.4 (e)(1)(D). • 6. Efforts undertaken by the licensee to engage in placement preservation strategies pursuant to Section 87068.4(e)(1)(E). Requests shall be accompanied by a statement, signed by the facility's Mental Health Head of Service, providing an explanation of why the facility was unable to meet the needs of the child, including the following information 87068.4 (e )(2)(b): • A description of what specialty mental health services, trauma-informed interventions and treatment practices, and any other services or supports that were provided to the child. • 2. A description of which of these services were successful, which were unsuccessful, and why. • 3. A description of any Placement Preservation Strategies that were developed by the social worker or placing agency for the child, pursuant to Welfare and Institutions Code Section 16010.7(b). • 4. If applicable, an explanation of why the Placement Preservation Strategies did not resolve the facility's concern that they are unable to meet the needs of the child. 2. If a nonminor dependent transfers from the facility for other reasons, a licensee shall: (1) Provide written notice to the nonminor dependent that they will transfer from the facility. The written notice shall: (A) State the reason for the transfer of the nonminor dependent, including specific facts about any circumstance or event that resulted in the pending transfer of the nonminor dependent. (B) Request that the nonminor dependent be placed elsewhere and provide a copy of the written notice via e-mail, fax, or overnight mail to the placement agency on the same day the notice is provided. 5. At least once a month for the six-month period prior to a nonminor dependent's removal and/or transfer, the licensee shall meet with the county placing agency, the nonminor dependent, and other stakeholders such as the Department of Health Care Services, as needed, to develop a removal and/or transfer plan for the nonminor dependent. (1) The monthly meetings shall begin: (A) For a nonminor dependent who has not reached 19 years of age, six months before the nonminor dependent is scheduled to complete high school or the nonminor dependent will reach age 19, whichever is earlier. (B) For a nonminor dependent who has not reached 21 years of age as specified in subdivision (a) of the Welfare and Institutions Code 11403 and who is incapable of participating in educational or employment activities as specified in subdivision (b) of Welfare and Institutions Code section 11403 due to a document medical conditions, six months before the nonminor dependent's medical condition is expected to alleviate enough to allow the nonminor dependent to participate in education or employment activities, or six months before the nonminor dependent reaches age 21 if the medical conditions is not alleviated, whichever is earlier. (2) Documentation of the monthly meetings shall be maintained in the nonminor dependent's records.* Section L. Handling Money, Personal Property, and/or Valuables- Does Not Meet standards • Pg 141 "The allowances are portioned out according to the Daily Data Collection Sheets and Weekly Behavioral Charts as compiled by the Facility In-House Therapist." Explain this, is this a form of "punishment" if it depends on behavior?? Is it still a form of punishment? • Pg. 142 "Packing residents Belongings When a resident runs away from placement, is hospitalized, is detained or the bed is closed, the youth/NMDs belongings are packed ....." Where specifically, who specifically has access to these belongings? Section N. Trauma-Informed Intervention and De-Escalation Techniques- Meets Standards 1.Are there any specific interventions used by the facility for children who have a propensity for behaviors that result in self-harm? Section Q, Continuous Quality Improvement (CQI)- Does Not Meet Standards 1. Please include as part of the CQI process how the facility will ensure frequent review, documentation, and, if necessary, adjustment of the child's needs and services plan and treatment plan 87078.1 ©(1)• Please ensure the frequency of review, documentation, and adjustment to the child's needs and services plan or treatment plan shall be conducted on a monthly basis or as frequently as possible.*2. Please include a description of how outcome measures will inform Dignity of its program being trauma-informed and culturally relevant. ILS v4 87081(c)(1) 3. Please detail specific qualitative and quantitative data that the facilities collect related to outcomes, indicators , practice standards. • Please consider including collecting data (qualitative and quantitative) about staff: training, workload and performance, and peer review with a short-term residential therapeutic program that serves a similar population or a panel. 87081(c)(2)(A) through (c) • Please consider collecting data from Feedback from children, nonminor dependents, families, and staff at all levels which can include. 4. How the facility will review, analyze, and interpret the data that is quantitative in nature. ILS § 87081(c)(4) 5. Please collect and review data on the numbers and types of complaints received and, if applicable, the resolution of each complaint.* 87081(c)(7) 6. Please describe how facility's CQI procedures are culturally relevant, trauma-informed, and age and developmentally appropriate Program Statement Section 1, Population Served- Does Not Meet Standards • A description of programs or services to be provided consistent with assisting an NMD in preparing for the transition to independent living. Not covered sufficiently. 1. recommend including the facilities plans/policy for accepting female Youth who identify as male 2. The program statement shall include a description of how the facility programs have the ability to support: The individual needs of children, NMDs, and their families, with short-term, specialized, trauma-informed, and intensive treatment, including, but not limited to, treatment that implements child-specific short-and long-term needs and goals identified by the qualified individual's assessment of the child- Section 4, Core Services and Supports- Does Not Meet Standards • Did not see any attached agreements. None? 1. What practices are used to ensure that core services are trauma-informed, culturally relevant, and age and developmentally appropriate- meet standards? 2. There may be instances where agreement with other agencies may be necessary on an individualized basis ( to provide additional core services and supports,). In the event where the facility may have to contract with other agencies, please describe how the facility ensures all core services secured through any agency are trauma informed and culturally relevant. 3. Please include a statement that the facility will document and maintain any agreements with any agency. Section 5, Culturally Relevant Interventions, Practices, Services, and Supports - Does Not Meet Standards • Typo pg. 51 1. Please describe any culturally specific services/supports the STRTP offers for youth of different backgrounds (example: Latino, African American, and native American youth, etc.) including mentoring, educational enrichment, college and career prep, arts, recreation, cultural and ethnic studies, cultural healing practices, permanency services, self-awareness • Does the STRTP link youth to any outside resources/CBO's that may aid in providing services specific to youth of diverse backgrounds. Such as local pow wows, cultural centers, LGBT youth groups, mentoring groups for Latino/African American/native American youth, etc.? Section 6, Trauma Informed Interventions and Treatment Practices - Does Not Meet Standards 1. Please detail trauma-informed interventions, practices, services, and supports that recognize and adequately demonstrate how the program addresses. 87022.1(a)(2) • A child or NMD's need to feel safe, be respected, informed, connected, and hopeful regarding their own experience with trauma. • The interrelationship between trauma and the impacts of trauma including, but not limited to, neuro-cognitive problems, neuro-psychological issues such as depression and anxiety, and behaviors. • The need to work in a collaborative way with a child or NMD, their family and friends, and human services agencies in a manner that will empower the child or NMD. 2. Please include the evidence-based or informed screening or assessment tools the facility uses to identify trauma history and trauma-related symptoms or problems. 3. The trauma-informed prevention services, interventions, practices, services and supports must demonstrate the following: • How observable behaviors will be identified and evaluated to assess the need for services. Recommend detailing how the facility will evaluate behaviors and access the need for services. • What individualized strategies for trauma-specific interventions address trauma's consequences and facilitate healing and can be implemented in components including, but not limited to, the Needs and Services Plan and Treatment Plan; 4. Please include the results from assessment tool will be included in the NSP within 30 days of admission. 5. What are the facilities policies and procedures that ensures consistent provisions of care and services that are trauma informed. Please detail the procedures Section 7, Development, Implementation, and Modification of Needs and Services Plan - Does Not Meet Standards 1. Describe the procedures for the development, implementation, and periodic updating of needs and services plan for children and NMDs, that are trauma-informed, culturally relevant, and age and developmentally appropriate, and procedures for collaborating with the CFT that include a description of the following: • The services to be provided or arranged to meet the short-and long-term needs and goals of the child or NMD as assessed by the qualified individual under WIC sections 4096 and 11462.01 - • -Processes to ensure treatment is consistent with the short-and long-term needs and goals for the child, including as specified in the child's permanency plan- meet standards • -Please detail Processes to ensure that consistent progress is made toward the timeframe and plan for transitioning the child or NMD to a less restrictive family environment- • -The procedure to ensure the child or NMD's needs and services plan is consistent with the case plans including the needs as identified by the qualified individual, as developed by the county placing agency and recommendations by the CFT . please ensure it is also consistent with the needs identified by the Qualified Individual Section 8, Planned Activities- Does Not Meet Standards • Where are some of these places located? Give names of hiking trails & specific parks in the area. • Any on site vocational trainings provided in the facility? If so, hours per day/days per week, and funding? 1. Indoor and outdoor activities appear to be missing the following. • Pre-vocational or vocational counseling. • *Access to computer technology and the internet, consistent with the child's age, maturity, developmental level, court order, and child and family team decision need 2. please include policies which include providing A schedule of the planned activities posted on at least a weekly basis in a central facility location readily accessible to children, relatives, and representatives of placement 87079 (e) 3. Please include for youth 16 and over the facility will provide vocational and postsecondary educational options 87079 (g ) 4. A child who is capable shall be given the opportunity to participate in the planning, preparation, *selection,* conduct, cleanup, and critique of planned activities. 87079 (c ) recommend allowing feedback from youth/NMD on planning of activities. Some programs have meeting to include youth voice. 5. Please include a statement if program will have/not have on site vocational training? If so, please including skills taught, goals of the training, hands-on experience received, materials provided, number of hours per day/days per week, and funding Section 9, Services During Placement and After Discharge - Does Not Meet Standards 1. Please include all names, locations, and services that will be provided by an agency or agencies that the applicant or licensee has partnered with, either formally or informally, to provide additional supports and services to families and children including NMDs during care and post-permanency. • Recommend also including a statement that references section "M" as there appears to have agencies listed there. Section 10, Plan for Participation in Child and Family Team ("CFT")- Does Not Meet Standards 1. Please describe when the provider will request a CFT meeting if needed? What is the process? How is the CFTM initiated? What staff members are responsible for scheduling CFTM? 2. Please also include a CFTM will be held on an as needed basis as well. 3. Describe plan that shall demonstrate that the facility will participate in CFT meetings in a manner that is trauma-informed, culturally relevant, and age and developmentally appropriate. Please see ILS § 87022.1(a); ILS 87022.1(b)(11); ILS § 87078.2(a). • Recommend more detail on how facility will ensure trauma informed participation in CFT. what does this look like. Recommend including Examples including adding translation services, use language that is easily understood by youth/NMDs and their families, ensuring that complex concepts are broken down into simpler terms. Section 11, Identification of Home-Based Settings, Development of Individualized Aftercare Support Plan, & Documentation of Process to Implement Treatment and Services-87022.1(b)(12)(A)- Does Not Meet Standards • Did not see services, and treatment to be provided for at least six months postdischarge as a child moves from the STRTP to homebased family care setting or to a permanent living situation through reunification, adoption, or guardianship, or to a transitional housing program. 1. Please include how the facility will assist in the Development of an individualized family-based aftercare support plan that identifies necessary supports, services, and treatment to be provided for at least six months post discharge as a child moves from the STRTP to homebased family care setting or to a permanent living situation through reunification, adoption, or guardianship, or to a transitional housing program. This plan shall be developed, pursuant to WIC section 4096.6, in collaboration with the county placing agency, the CFT, and other necessary agencies or individuals for at least six months post discharge. 2. Please describe aftercare services and who may provide them (a STRTP, county placing agency, child welfare agency, probation department, mental health plan, or other agencies) 3. Please describe how the facility Documents the process by which the STRTP will implement treatment and services to support the short- and long-term, child-specific mental health goals identified by a qualified individual pursuant to WIC section 4096(g). Section 12, Participation of Family Members in Treatment & Outreach to Family- Does Not Meet Standards 1.Please also ensure to include family participation in the plan for aftercare services. 2.Please include documentation of family members integrated in post discharge and how sibling connections are maintained. Section 13, Complaints and Grievances - Does Not Meet Standards • Should note that, complaint procedure postings must be visible and posted in a location that is easily seen and not obstructed. Section 14, Participation and Assistance in Initiatives to Improve the Child Welfare System - Meets Standards · Recommend more detail on DMCS policy for participation in QIP/QPI initiatives: are all staff members at DMCS encourage to attend QIP/QPI committee meetings, advocacy groups, · Is the administrative or designee required to attend these meetings? Section 15, Family Visitation - Does Not Meet Standards • Should have a process by which staff speak to child to "debrief" and ensure that all went well and clients are not victimized during unsupervised visits or visitations. Section 16, Children and Nonminor Dependents Personal Rights - Does Not Meet Standards • How does facility ensure that staff is aware of client's personal rights. Additional trainings after hire? Mention that staff also sign personal rights form. 1. Please ensure to provide the following (87072(b)(1)): • DMCS policy does "address personal rights verbally at intake (pg. 242)", but please ensure it is provided in an age or developmentally appropriate way that includes an explanation of the rights of the child, as specified in subsection (c) below and in Welfare and Institutions Code section 16001.9, and addresses the child's questions and concerns • Contact . *information *for* .regarding.. * the agencies * .entities to. . *the child may* contact .regarding.. *concerning* violations of *these * rights *and other complaints should also * include the address, email address, and telephone number of the California Department of Social Services Community Care Licensing • Copies of any law related to the filing of complaints including, but not limited to, the confidentiality of complaints.* 2. Please ensure each school age.Child, and their authorized representative are provided the information in comment above (#1) • .Upon placement in a facility • At the request of a child; and • Each time a new right has been added to this Section or Welfare and Institutions Code section 16001.9. 87072(b)(1) Section 17, House Rules for Children/Nonminor Dependants - Does Not Meet Standards 1. Recommend removing language stating " Wi-Fi is shut down or not allowing cellphone" to avoid any personal rights violations 2. As a reminder, youth/NMD shall have "Access to computer technology and the internet, consistent with the child's age, maturity, developmental level, court order, and child and family team decision.* 8707287072 3. Recommend reviewing some of the language used to describe house rules. Some rules appear harsh/ not trauma informed Example: if a child refuses to not go to school , "they are bound to their room the entire day" , "nobody wants to be around a funky body", Point systems, allowance and outing being determined by points 4. AS a reminder, point systems aren't allowed as they aren't trauma informed. Please remove point systems Section 18, Positive Discipline Policies - Does Not Meet Standards 1. Please ensure discipline policies are also age and developmentally appropriate 87072.1 (a)(2) 2. Please ensure authorized representative receives a copy of discipline policies as well. 87072.1 (a)(3) 3. Please ensure Signed copies of such policies and procedures are maintained in the child's record, 87072.1 (a)(4) 4. Please ensure When a child is subject to positive discipline,* a licensee shall do all of the following 987072.1(e) : • Inform the child that it is necessary for the licensee to impose a ..consequence.. *discipline* on the child *and explain why the behavior or action is not acceptable*. • Discuss the reason and need for the licensee to impose a ..consequence.. *discipline* on the child and provide the child with the opportunity to participate in choosing the appropriate ..consequence.. *form of discipline*. • Develop a plan, including time limit, with the child ..for the nonminor dependent.. to be subject to and comply with the chosen ..consequence.. *form of discipline that is trauma-informed, culturally relevant, and age and developmentally appropriate.* • Document the decision to subject the *child* to the chosen ..consequence.. *form of discipline* and the steps taken in subjecting the child to the ..consequence.. *form of discipline.* Section 19, Storage of Medications- Meets Standards • What is PRN Acronym? Section 20, Documentation of Accreditation- Meets Standards 1. Please include a statement that "If a corrective action is required by the accrediting entity in response to the final accreditation summary report, or at any other time following accreditation, an STRTP shall provide a copy of their corrected action to the licensing agency within 30 days of its completion date. CARF Accredited. Expires 3/31/ Section 21, Mental Health Program Approval - Does Not Meet Standards 1. Please describe how the facility shall Ensure continuity of care, services, and treatment as a child moves to home-based family care or to a permanent living situation, in accordance with the child's case plan or treatment plan. 2. Please describe how the facility shall Document the child's ability to access mental health services identified in the needs and services plan, or efforts made by the STRTP to ensure access to identified mental health services, including utilization of any existing grievance processes for accessing services. 3. Please include a statement that the facility will ensure access to mental health services, including specialty mental health services and mental health supports that meet short and long term mental and behavioral health goals and treatment as identified by the qualified individual, and as appropriate to the needs of the child or NMD in its care, 4. Please ensure children diagnosed by a physician, psychologist, or licensed clinical social worker as mentally disordered shall make provision for at least monthly consultation from a psychiatrist, or clinical psychologist, or licensed clinical social worker 87089.1 (g) 5. Please ensure to maintain on file copies of reports signed by any such consultation, noting the types and hours of services provided. 87089.1 (g)(1) Section 23, FOOD AND NUTRITIONAL PLAN/SAMPLE MENUS/SCHEDULE - Does Not Meet Standards • Procedures on how all staff will be made aware of any special dietary needs due to allergies, medical conditions, religion etc. • Clothing and incidentals in this section ? Pgs 292-298 24. Emergency Intervention Plan (Runaway Plan)- Does Not Meet Standards • Intervention plan procedure if multiple children AWOLing? • Did not see how runaway plan must be trauma informed. 1. A written Emergency Intervention Plan that includes a Runaway Plan 87095.24© which includes • Time frames for determining when a child is absent without permission. • Recommend giving a timeframe to do an initial search, after the initial search each child's grace period to be determined absent may be determined by individualized treatment plan as it may be unsafe for youth to be absent for any length of time , but for others a longer "grace period" may be appropriate based on the youth individual risk factors • Actions for staff to take to locate the child. • please describe (in depth) what action DMCS staff will take to locate a child who is absent. Recommend calling cell phones, representative, checking last known locations, etc. • Please include Procedures for notifying the child's authorized representative • Please include Procedure for notifying staff that a child is absent without permission at the change of shift. • Procedure for complying with Reporting Requirements specified in Section 87061(i). need see below. • Procedures for management review of incident reports, policies, and practices to determine the cause of, and to develop strategies to address, runaway children, both on an individual and facility-wide level. Procedures must include regular management reviews to be conducted at least once a year. 2. Incident Reports documenting a runaway situation of a ..minor dependent.. *child* must include the following: • When, how and by whom was the child's absence first noted. • (B) The child's last known activities. • (C) What were the circumstances surrounding the child's absence. • (D) What action did the facility personnel take to discourage the child from leaving and what interventions were utilized. • (E) What action was taken by facility personnel to locate the child.If a manual restraint was used, and if it is determined by the post incident review, as required in Section 87095.68, that facility personnel did not attempt to prevent the manual restraint, a description of what action should have been taken by facility personnel to prevent the manual restraint incident. • (F) *Describe the* ..What.. corrective action *that* will be taken or *will* not *be* taken *against the facility personnel* and why. • (G) If law enforcement was involved in the incident, a detailed description of the *events involving the law enforcement contact, including a police report number if available.* ..incident... • (H) Documentation that the child's authorized representative has been notified of the incident. 3. 87095.22 (e) ):The runaway plan described in Section 87095.24(a), must be provided to, and discussed with, each child and their authorized representative*, if any,* at the time of admission. o If, during the discussion, it is determined that the child has a history of running away from placement or is identified as having been commercially sexually exploited ..child.., then the following must occur:  The facility social work personnel and the child's authorized representative*, if any,* must develop an individualized plan for that particular child, taking into consideration any recommendations provided by the child and family team.  The individualized plan must be included in the child's needs and services plan, taking into consideration the any recommendations provided by the child and family team.  The individualized plan must include a plan to prevent and discourage children from running away. 5. Please Specify that contacting law enforcement shall only be used as a last resort once all other de-escalation and intervention techniques have been exhausted, and only upon approval of a staff supervisor. 6. Please Identify and describe collaborative relationships with community-based service organizations that provide culturally relevant and trauma-informed services to youth served by the facility to prevent, or as an alternative to, arrest, detention, and incarceration for system-impacted youth. 7. The emergency intervention plan must include the requirements specified in ILS Sections 87095.22(d) through (h). 8. For each type of emergency intervention, the plan must include the following: • A description of each emergency intervention technique, including manual restraints, to be used and in what types of situations they will be used- pg. 319 recommend giving a description under each intervention what type of situation it will be used. For example, What type of situation would occur in order for staff to complete a seated restraint. • Maximum time limits for each emergency intervention technique, not to exceed maximum time limits as specified in Section 87095.22(f). please review and ensure a maximum time limit is include for each emergency intervention technique. • Expected outcome, benefits to the child. For each technique used, please include expected outcome. 9. Please include A statement specifying what emergency interventions will never be used. 10. A description of how the assessments for each child, required in Section*s* 87068.1(c) *and 87068.11(f), which includes the needs and services plan per Sections 87068.2 and 87068.22*, will be used to inform the licensee's emergency intervention plan. 11. Procedures for using emergency interventions if more than one child requires the use of emergency intervention at the same time. ok, recommend calling additional staff members. 12. Procedures for ensuring that care and supervision are maintained in the facility when all available staff are required for the use of emergency interventions. Please detail. 13. Procedures for re-integrating the child back into the facility routine after an emergency intervention technique has been used. Please detail. 14. Criteria for assessing when an emergency intervention plan needs to be modified or terminated, along with the procedures for terminating the plan or making any necessary modifications. Please detail. 15. Manual Restraint Plan, if applicable, as specified in ILS Section 87095.22(f). 1. Please include Procedures for ensuring a child's safety when a manual restraint is being used including, but not limited to, the titles of staff responsible for checking the child's breathing and circulation and the job titles or names of the administrator's designee(s) who will be authorized to extend the restraint time. 2. After written approval of continued use of manual restraint passed 15 minutes, please ensure the following 87095.22(F)(a): a. The individual who approves the continuation of the restraint must be a person other than the individual who restrained the child. b. 2. The individual who visually checks the child after 15 minutes to ensure the child is not injured and that the child's personal needs, such as access to toilet facilities, are being met, must be a person other than the individual restraining the child. c. After the initial 15 minutes, the individual who approves the continuation of the manual restraint shall observe the child's behavior while the child is being restrained to determine whether continued use of the manual restraint is justified. d. 4. Written approval to continue a manual restraint beyond 15 consecutive minutes must be documented in the child's record. 3. If a child is still presenting dangerous behavior or escalated emotions after 30 mins, what are the facilities plan? 16. In addition to the requirements in California Code of Regulations, Title 22, Section 80068, the admission agreement must include a written statement regarding the type(s) of emergency interventions the licensee has been approved to use. 87095.22(I) o The facility's policy regarding the use of emergency intervention must be reviewed with the child and the*ir * authorized representative*, if any,* at the time of admission.  The licensee shall provide a copy of the approved emergency intervention plan to *the child and* their authorized representative, if any, upon request. 17. Procedure for documenting and maintaining a monthly log of each use of manual restraints (87095.61) o Each use of manual restraints must be reported to the Department and the child's authorized representative by telephone no later than the next working day following the incident. A written incident report must be submitted to the Department within seven (7) days, as required by California Code of Regulations, Title 22, Section 80061. o If a child is restrained more than once in a 24-hour period, each use of manual restraints must be reported. • *(2) Incident reports must follow the requirements set forth in Section 87061(i)(6)(A)-(K).* • (b) Any report of the use of manual restraints must be reviewed, for accuracy and completeness, and signed by the administrator or administrator's designee following the incident. • (c) A copy of the written incident report must be maintained in the child's record. • *(d) Incident reports must be shared with the placing agency and must maintain the confidentiality of the child's identity.* • .(d). *(e)* The information required in Section 87095.61(a) must be documented immediately following the use of manual restraints or no later than the end of the working shift of the staff member(s) who participated in the manual restraint. • .(e). *(f)* The child's record must be available for review by the Department, as required in California Code of Regulations, Title 22, Section 80070. 18. Procedures for documenting each use of manual restraints in the child/NMDs records Please include the procedures for documenting manual restraint in the child record. Incident reports for manual restrain use must include (87061): Date and time of other manual restraints involving the same child in the past 24 hours. (B) A description of the child's behavior that required the use of manual restraints, and description of the precipitating factors which led to the intervention. (C) Description of what manual restraints were used, and how long the child was restrained. (D) Description of what non-physical interventions *, trauma-informed practices, or de-escalation techniques* were utilized prior to the restraint *and an* .; explanation of why more restrictive interventions was necessary. (E).... Description of any injuries sustained by the child or facility personnel *, including w* ...I. Hat type of medical treatment was sought and where .was. *the* child *was* taken. Provide an explanation if medical treatment was not sought for injuries. (F) Name(s) of facility personnel who conducted the manual restraint. (G) Name(s) of facility personnel who witnessed the child's behavior and the restraint. (H) The child's verbal response and physical appearance, including a description of any injuries at the completion of the restraint. (I) If it is determined by the post incident review, as required in Section 87095.68, that facility personnel did not attempt to prevent the manual restraint, *provide* a description of what action should have been taken by facility personnel to prevent the manual restraint incident. *Describe the* .What. corrective action *that* will be taken or *will* not *be* taken *against the facility personnel* and why. (J) If law enforcement was involved, a detailed description of the *events involving the law enforcement contact, including a police report number if available* .incident... (K) Documentation that the child's authorized representative has been notified of the incident 19. Procedures for review of manual restraint use Please review 87095.68 for additional requirements when debriefing/reviewing Manu restraints. At minimum, the discussion regarding the use of the manual restraint shall include, (A) Exploring if there is anything the staff could have done differently to redirect the child and deescalate the situation; (B) Assisting the staff in understanding the circumstances, including any triggering situation or incident, surrounding the child's behavior that preceded the staff's use of manual restraint; (C) Assisting the staff in identifying and developing alternative methods of responding to the child's behaviors; and (D) Determining whether the child's personal rights were violated and the steps that will be taken to address the violation.* 20. Procedures for medical examinations, if necessary 87095.69 1. Please ensure medical examination will also be completed "upon the request of the child." 2. Please ensure the administrator or the social work supervisor must see and talk with the child before a determination can be made. A copy of this report was provided. Executive Director, Emmett Downs stated that corrections would be submitted for review to Licensing Office by February 26, 2024. Corrections made will be highlighted.

Deficiencies:
87068.05: a.	Consideration of  the child's needs and strengths, the likelihood that the child will benefit from the program,
4.	Determination procedures shall include an explanation of how the program will evaluate the appropriateness of placement for referred children with any of the following behaviors or characteristics, including how the licensee defines these characteristics for the purposes of assessing appropriateness of fit. Appears to be somewhat discussed in section H. please move the content from section H. to G.
5.	Please Include an explanation of how the program will evaluate the appropriateness of placement for referred children with any of the following behaviors or characteristics (see below),
o	Frequent runaways
o	Gang-related activity
o	Fire-starting
o	Sexually assaultive behaviors
o	History of Commercial Sexual Exploitation
o	Substance abuse
6.	Please also include how the licensee defines these characteristics (above) for the purposes of assessing appropriateness of fit 87068.05 ©(3):
•	-as a reminder , the licensee shall not utilize the behaviors and characteristics (frequent runaways, gag activity, fire-starting, CSEC, substance abuse, etc.) as the sole basis to assess or determine placement appropriateness or deny admission.* 87087068.05 (e)
3. Please include a statement that recognizes interviews with youth are not used to assess or determine placement appropriateness or deny admission.*  87068.05 (d)
6. Determination procedures shall specify the following .*  87068.05 ©(4):
1.

met_with: Emett Downs


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst, Daniel Mena conducted a technical assistance meeting virtually via Teams with Downs and Martin Short Term Residential Therapeutic Program (STRTP) Executive Director, Emmett Downs. Present at the meeting was System of Care Branch Analyst, Ansar Mohammed. The Purpose of the meeting was to discuss and review the following pending Plan of Operation (POO) and Program Statement (PS) revisions: Plan of Operation Section D, Staff Plan 1. Please ensure Within *thirty* *(*30*)* days of completion of the 16-hour training, the administrator or administrator's designee shall assess if each newly hired direct care staff understands and can apply the training. 2. At minimum, Annual training topic must include the training topics below 87065.1( e): please review the training table on page 73.: • Child and adolescent development, including sexual orientation, gender identity and gender expression. • (B) Core practice model. • (C) Permanence, well-being, and educational needs of children. • (D) Basic instruction on existing laws and procedures regarding the safety of foster .youth. *children* at school; and ensuring a harassment and violence free school environment. • (E) Best practices for providing care and supervision to nonminor dependents. • (F) Oversight and monitoring of psychotropic medications for children in foster care and related topics described in the training developed pursuant to Section 16501.4(d) of the Welfare and Institutions Code. • *(G) Trauma-informed interventions and practices.* 3. Peer partners/volunteers are then required to take an additional 16 hours of training (within 90 days) which include • An overview of the child welfare and probation systems. • Permanence, well-being, and educational needs of children; • (C) Overview of the population served by the short-term residential therapeutic program; • (D) Physical and psychosocial needs of children, including behavior management, de-escalation techniques, and trauma-informed crisis management planning, including the use of emergency interventions; • (E) The effects of trauma, including grief and loss, and child abuse and neglect on child development and behavior and methods to behaviorally support children impacted by that trauma or child abuse and neglect; • (F) Awareness and identification of commercial sexual exploitation and best practices for providing care and supervision to commercially sexually exploited children.;.. *.* Section G, Admission Determination Procedures- 1. Determination procedures should consider if the child's needs are in common with children currently placed in the facility.. 87068.05 ©(2). Page 103. · of the characteristic (CSEC, gang youth, etc), how does the facility define commonality of need and ensure they aren't accepting placement that may cause traumatization or unsafe environments. For example, accepting youth from different rival gangs may create an unsafe environment. Accepting CSEC youth and youth with sexually assaultive behavior may create unsafe environments and traumatization. 2. Determination procedures shall specify the following .* 87068.05 ©(4): · please determine the first initial response to a referral for placement rather to accept, deny or request more information and a final response period in which the facility will deny or accept referral for placement. 3. Elevated review procedures : · Please ensure If the licensee determines that the program is not capable of meeting the child's needs without additional services and/or supports, the licensee shall request such assistance from the placing agency, Community Based Organization, or any other resource, and shall document this request. 87068.05 (g). Section H, Intake Policies and Procedures- 1. The licensee shall document in the nonminor dependent's needs and services plan when the case plan is received from the county placing agency. If the case plan is not received from the county placing agency, the licensee shall document the attempts made to obtain the case plan in the nonminor dependent's needs and services plan 2. Please ensure NMD signs and receives a copy of any modification of the following documents The admission* agreement, Personal rights. , Expectations and consequences The NSP, the Transitional Independent Living Plan, and any modifications to these plans. Removal or transfer policies. The complaint procedures as specified in Section 87072.2(a). Section J, Removal or Transfer Policies and Procedures - 1. Please ensure the letter explain on page 138, the Requests for a youth/NMD to be placed somewhere else shall be accompanied by a statement, signed by the facility's Mental Health Head of Service, providing an explanation of why the facility was unable to meet the needs of the child, including the following information 87068.4 (e )(2)(b) 2. Please ensure , At least once a month for the six-month period prior to a nonminor dependent's removal and/or transfer, the licensee shall meet with the county placing agency, the nonminor dependent, and other stakeholders such as the Department of Health Care Services, as needed, to develop a removal and/or transfer plan for the nonminor dependent. And Please ensure monthly meetings for NMD are documented and maintained in the nonminor dependent's records Section Q, Continuous Quality Improvement (CQI)- Under - Review, Analyze, & Interpret Data. · Did not understand how "Executive Director will gather information from other local STRTPs and foster family agencies about their issues with these populations." How is that information Gathered/process? 1. Please ensure the frequency of review, documentation, and adjustment to the child's needs and services plan or treatment plan shall be conducted on a monthly basis or as frequently as possible. 3. on page 160, Please consider including collecting data (qualitative and quantitative) about staff: training, workload and performance, and peer review with a short-term residential therapeutic program that serves a similar population or a panel. 87081(c)(2)(A) through (c). 5. Please collect and review data on the numbers and types of complaints received and, if applicable, the resolution of each complaint.* 87081(c)(7) Program Statement Section 1, Population Served- 1. what are the facilities plans/policy for accepting female Youth who identify as male (did not see this addressed) Section 6, Trauma Informed Interventions and Treatment Practices - · detail trauma-informed interventions, practices, services, and supports that recognize The need to work in a collaborative way with a child or NMD, their family and friends, and human services agencies in a manner that will empower the child or NMD. · detail trauma-informed interventions, practices, services, and supports that recognize The interrelationship between trauma and the impacts of trauma including, but not limited to, neuro-cognitive problems, neuro-psychological issues such as depression and anxiety, and behaviors. · What are the facilities policies and procedures that ensures consistent provisions of care and services that are trauma informed. Please detail the procedures • The need to work in a collaborative way with a child or NMD, their family and friends, and human services agencies in a manner that will empower the child or NMD. (did not see this addressed) Section 8, Planned Activities- · Please include for youth 16 and over the facility will provide vocational and postsecondary educational options 87079 (g ) Section 10, Plan for Participation in Child and Family Team ("CFT")- 1. Please describe when the provider will request a CFT meeting if needed? What is the process? How is the CFTM initiated? What staff members are responsible for scheduling CFTM? Section 11, Identification of Home-Based Settings, Development of Individualized Aftercare Support Plan, & Documentation of Process to Implement Treatment and Services-87022.1(b)(12)(A)- · Did not see services, and treatment to be provided for at least six months post discharge as a child moves from the STRTP to homebased family care setting or to a permanent living situation through reunification, adoption, or guardianship, or to a transitional housing program. Describe the specific services. Section 12, Participation of Family Members in Treatment & Outreach to Family- · Please include how downs and martin documents the integration of family members in post discharge and how sibling connections are maintained. Section 16, Children and Nonminor Dependents Personal Rights - · Please ensure each school age Child, and their authorized representative are provided personal rights. • How does facility ensure that staff is aware of client's personal rights. Additional trainings after hire? Mention that staff also sign personal rights form. · Please ensure each school age.Child, and their authorized representative are provided the information (did not see AR addressed specifically) Section 17, House Rules for Children/Nonminor Dependents - · The following contracts/house rules seem to have been removed from the last revision. are these rules no longer applicable (DMCS general rules, electronic contract, cell phone contract, chore)?. If the rules/contracts still apply, please attach copies in this section: Section 19, Storage of Medications- • What is PRN Acronym? Did not see this. Section 20, Documentation of Accreditation- · Please include a statement that "If a corrective action is required by the accrediting entity in response to the final accreditation summary report, or at any other time following accreditation, an STRTP shall provide a copy of their corrected action to the licensing agency within 30 days of its completion date. (did not see this addressed) Section 21, Mental Health Program Approval - · Please describe how the facility shall Document the child's ability to access mental health services identified in the needs and services plan, or efforts made by the STRTP to ensure access to identified mental health services, including utilization of any existing grievance processes for accessing services. · Please ensure to maintain on file copies of reports signed by any such consultation (for children diagnosed by a physician, psychologist, or licensed clinical social worker as mentally disordered,) noting the types and hours of services provided. 87089.1 (g)(1) 24. Emergency Intervention Plan (Runaway Plan)- 1. Intervention plan procedure if multiple children AWOLing? 2. A written Emergency Intervention Plan that includes a Runaway Plan 87095.24© which includes · Time frames for determining when a child is absent without permission. Recommend giving a timeframe to do an initial search, after the initial search each child's grace period to be determined absent may be determined by individualized treatment plan as it may be unsafe for youth to be absent for any length of time , but for others a longer "grace period" may be appropriate based on the youth individual risk factors · Actions for staff to take to locate the child. · please describe (in depth) what action DMCS staff will take to locate a child who is absent. Recommend calling cell phones, representative, checking last known locations, etc. · Please include Procedures for notifying the child's authorized representative · Please include Procedure for notifying staff that a child is absent without permission at the change of shift. 3.Incident Reports documenting a runaway situation must include the following: · (A)When, how and by whom was the child's absence first noted. (B) The child's last known activities. (C) What were the circumstances surrounding the child's absence. (D) What action did the facility personnel take to discourage the child from leaving and what interventions were utilized. (E) What action was taken by facility personnel to locate the child. If a manual restraint was used, and if it is determined by the post incident review, as required in Section 87095.68, that facility personnel did not attempt to prevent the manual restraint, a description of what action should have been taken by facility personnel to prevent the manual restraint incident.(F) *Describe what corrective action that will be taken or *will* not *be* taken *against the facility personnel* and why. (G) If law enforcement was involved in the incident, a detailed description of the *events involving the law enforcement contact, including a police report number if available incident...(H) Documentation that the child's authorized representative has been notified of the incident. 3. Procedures for documenting each use of manual restraints in the child/NMDs records When documenting each manual restraint (page 79) Incident reports must include (87061): (A)Date and time of other manual restraints involving the same child in the past 24 hours. (B) A description of the child's behavior that required the use of manual restraints, and description of the precipitating factors which led to the intervention. (C) Description of what manual restraints were used, and how long the child was restrained. (D) Description of what non-physical interventions *, trauma-informed practices, or de-escalation techniques* were utilized prior to the restraint *and an* .; explanation of why more restrictive interventions was necessary. (E).... Description of any injuries sustained by the child or facility personnel *, including w* ...I. Hat type of medical treatment was sought and where .was. *the* child *was* taken. Provide an explanation if medical treatment was not sought for injuries. (F) Name(s) of facility personnel who conducted the manual restraint. (G) Name(s) of facility personnel who witnessed the child's behavior and the restraint. (H) The child's verbal response and physical appearance, including a description of any injuries at the completion of the restraint. (I) If it is determined by the post incident review, as required in Section 87095.68, that facility personnel did not attempt to prevent the manual restraint, *provide* a description of what action should have been taken by facility personnel to prevent the manual restraint incident. *Describe the* .What. corrective action *that* will be taken or *will* not *be* taken *against the facility personnel* and why. (J) If law enforcement was involved, a detailed description of the *events involving the law enforcement contact, including a police report number if available* .incident... (K) Documentation that the child's authorized representative has been notified of the incident Please ensure Any report of the use of manual restraints must be reviewed, for accuracy and completeness, and signed by the administrator or administrator's designee following the incident. A copy of this report was provided. Executive Director, Emmett Downs stated that corrections would be submitted for review to Licensing Office by May 8, 2024. Corrections made will be highlighted.

met_with: Emmett Downs