summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) T. Davis went to San Gabriel Children's Center/Homerest Home on October 06, 2025 at 12:30pm for the purposes of conducting an unannounced Random Annual inspection. The facility is licensed to serve six male clients ages 12-17 years old. LPA met with Stacia Mayonte, Lead Residential Counselor (LRC), and Bobby Patton, House Manager. LPA and LRC toured the facility together. The facility is a Short Term Residential Therapeutic Program (STRTP) and is located in a residential neighborhood. It is a single story home with three bedrooms, two bathrooms, kitchen, dining area ,staff office, kitchen, living room, and a backyard. Currently, there are six clients in placement at the facility. The backyard and front yards were observed to be free of debris and hazards. All three bedrooms contained two twin beds, dressers, and closet space. Smoke alarms were operable in each bedroom. LPA observed two bathrooms to be in good repair and working order. There is adequate seating in the living room and dining area. LPA observed a fully stocked refrigerator and a fully stocked linen closet at the facility. Sharp knives, cleaning supplies, and medications are kept locked in areas inaccessible to clients. There is adequate perishable and nonperishable food supply at the facility. The First Aid kit was fully stocked. There are no guns or weapons at the facility. All rules and regulations were posted at the facility. Files were reviewed and found to be in order. LPA spoke with two clients during the inspection. Both clients appeared neat and well groomed. LRC provided LPA an updated LIC500 (Personnel Report) as well a client roster. Licensee previously provided LPA a copy of the minutes of their most recent Board of Director's meeting that was held on 06/16/25. There is no swimming pool or other bodies of water on the premises. LPA found no Title 22 deficiencies on this date. Exit interview done.

met_with: Stacia Mayonte, Lead Residential Counselor and Bobby Patton, House Manager


state: CA

facility_name: SAN GABRIEL CHILDREN'S CENTER/HOMEREST HOME

summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Pamela Silva and Timika Martin on February 12, 2026 at 9: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs met with Administrator, Sylvester Johnson, and inspected the facility inside and out. There are no clients at this facility currently eligible for client file review and inspection. LPAs reviewed 0 child record and 3 of staff personnel files on site at the facility. LPAs reviewed 0 child psychotropic medications and medication records. LPAs interviewed 2 of staff on site to discuss the facility's policies and procedures of operation. LPAs provided a copy of this licensing report to Administrator, Sylvester Johnson. No deficiencies are being cited at this time. LPA conducted exit interview with Administrator, Sylvester Johnson.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Sylvester Johnson


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) T. Davis went to San Gabriel Children's Center/Homerest Home on March 25, 2026 at 12:20pm for the purposes of conducting an unannounced case management inspection. Community Care Licensing (CCL) has received some information as it relates to a visit conducted by the Department of Health Care Services. LPA met with Sylvester Johnson, Site Administrator, and discussed the matter. The information received by CCL indicated that the Department of Health Care Services observed some deficiencies during their file review inspection. Evidence gathered shows that the facility has submitted their Corrective Action Plan (CAP) to the Department of Health Care Services. The CAP was accepted and approved by the Department of Health Care Services. Based on a review of client files, LPA has determined that the files were in order and no issues or deficiencies were observed. The Department has concluded that all issues have been resolved and no further follow up is necessary. LPA found no Title 22/ILS deficiencies on this date. Exit interview conducted.

met_with: Sylvester Johnson, Site Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) T. Davis went to San Gabriel Children's Center/Homerest Home on April 17, 2026, at 3:52pm for the purposes of conducting an unannounced case management inspection to follow up on some information relating to a Contract Compliance review done by the Department of Children and Family Services Contract Compliance Division. LPA met Barbara Byrd, Residential Counselor, and discussed the purpose of today's visit. The Department of Children and Families Services Contract Compliance Division (DCFS) completed its Calendar Year 2025 review of the facility and observed several items/areas that needed improvement. The improvements were needed in the areas of General Contract Requirements, Personnel Files, and Facility and Environment. The facility was requested to submit a Corrective Action Plan (CAP) to DCFS for approval. Information gathered shows that a CAP was submitted to resolve the findings. The CAP was accepted and approved. LPA observed the corrections made by the facility. The hot water temperature was also tested and found to be within the 105-120 degree range. Based on observations, LPA found no Title 22 deficiencies on this date. Exit interview done

met_with: Barbara Byrd, Residential Counselor


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Regarding the allegation that staff did not prevent bullying among children resulting in an altercation; it was specifically reported that C2 and C3 were bullying C1 which ultimately led to an incident where C1 was chasing C2 and C3 with a large rock, and at one point, C2 tripped and fell sustaining a knee injury when trying to get away from C1. In addition, it was reported that C1 didn't make contact with either C2 or C3 with the rock, but law enforcement called in a violation of assault with a deadly weapon. During investigation, multiple confidential interviews disclosed that C1 and C2 were involved in a verbal altercation that escalated to a physical altercation outside, although staff attempted to prevent C1 from going outside. However, C1 was able to get outside by escaping the house through the back door. In addition, multiple confidential interviews corroborated that staff attempted to de-escalate the altercation, however, C1 exited the area and pursued C2 and C3 with a rock. During the pursuit, C2 tripped and sustained a knee injury. LPAs received conflicting information. Based on interviews, the allegation that staff did not prevent bullying among children resulting in an altercation may have occurred, however, there was not a preponderance of evidence to support the alleged violations, therefore, this allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Regional Director, Dana Centanni.

Investigation Findings:
13On 08/21/2025, at 1:00PM, Licensing Program Analyst (LPA) Maya Chavez met with Regional Director, Dana Centanni of San Pasqual Academy (SPA) to deliver the investigative finding for the allegation listed above involving staff and clients (C1-C3) as listed on the Confidential Names List (LIC811). On 04/22/2025, Community Care Licensing (CCL) received a complaint that staff did not prevent bullying among children resulting in an altercation. On 05/01/2025, LPA J. Salem initiated the complaint at the facility and completed health and safety inspection. During the inspection, LPAs interviewed clients (C2 and C3), staff (S1, S3, and S4), and C1's County Social Worker (CSW). LPAs were unable to interview client 1 (C1) and staff (S2). Pertinent records were obtained and reviewed. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Maya Chavez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: SAN PASQUAL TREATMENT CENTER - FEMALE PROGRAMFACILITY NUMBER: VISIT DATE: 08/21/2025

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

report_type: Complaint Investigation

met_with: Regional Director, Dana Centanni

complaint_status: unsubstantiated


facility_name: SAN PASQUAL TREATMENT CENTER - FEMALE PROGRAM

summary: Facility Evaluation

raw_content:
Narrative:
On February 10, 2025, at 2: PM, Licensing Program Analyst (LPA) Jacob Salem conducted an announced visit to the above facility and met with San Pasqual Treatment Center Frank Simmons Program Manager, Keary Mason Head of Service, Dana Centanni Regional Director for the purpose of conducting a pre-licensing inspection. Currently there are no clients placed in the home. The applicant is applying to serve six ambulatory clients ages 12 to 17 and Non-Minor Dependents. LPA conducted component III of the orientation process and reviewed with the applicants Licensing requirements. The home is a one-story building with three client bedrooms and two client bathrooms which are set up as follows: · Bedroom #1 (Client) has two twin beds and will sleep two clients. · Bedroom #2 (Client) has two twin beds and will sleep two clients. · Bedroom #3 (Client) has two twin bed and will sleep two client and attached bathroom · Kitchen, dining area, and family room area, locked storage and laundry room, hallway and storage closets, backyard/patio area, and attached two car garage for set up for visitation and mental health services. The Emergency Disaster Plan, Personal Rights, and complaint procedures are posted in the hallway of the home. The license will be posted as soon as it is issued. LPA and the applicants toured the facility inside and out and conducted a full inspection of the facilities physical plant, including building and grounds, food service, furniture fixtures and supplies, telephone service, health-related services, personal services, and activity space. The facility has demonstrated compliance with Title 22, Division 6 of the California Code of Regulations and Interim Lincensing Standards. An exit interview was conducted and a copy of this report was provided to Frank Simmons, Program Manager.

visit_type: Prelicensing

met_with: Frank Simmons, Program Manager


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On February 24, 2025, at 11: AM, Licensing Program Analyst (LPA) Jacob Salem and Licensing Program Manager (LPM) Dawn Segura conducted a technical assistance meeting virtually, via Teams, with San Pasqual Treatment Center (STRTP) Executive Director (ED) Lawrence Howell, Regional Director (RD) Dana Centanni, and Business Manager (BM) Jennifer Stoops. Also present at the meeting were System of Care Branch Analyst, Ansar Mohammed, System of Care Branch Manager, Marjana Jackson, and San Diego County Representatives Eileen Marshall, Jimabeth Ramsey, and Christina Bradley. The Purpose of the meeting was to discuss and review the following pending Licensing forms, Plan of Operation (POO), and Program Statement (PS) revisions: Application and Supporting Documentation (LIC 281E) 1. Application for a Community Care Facility (LIC 200) - Meets Standards 2. Orientation Certificate (Reference CCR § 80018(b) - Proof of attendance on file/Meets Standards 3. County Letter of Recommendation (Reference HSC § 1562.01(f) ILS § 87018(c)(6)) - Pending 4. Applicant information (LIC 215) - Does Not Meet Standards 1. Photocopied signature was provided. Please provide the original wet signature or new forms with electronic signature (using Adobe). 4. Designation of Facility Responsibility (LIC 308) (Reference CCR § 80064) - Meets Standards 5. Affidavit Regarding Client Cash Resources (LIC 400) (Reference HSC § CCR § 80018) - Does Not Meet Standards 1. Wrong bond amount listed on the form. Based on the amount stated the facility will hold at one time, a surety bond of $5000 is required. Please correct. 2. Photocopied signature was provided. Please provide the original wet signature or new form with electronic signature (using Adobe). 6. Surety Bond (LIC 402) (Reference CCR § 80018(d)) - Pending CONTINUED... ...Continued 2 7. Monthly Operating Statement (LIC 401) (Reference HSC § 1520(c) CCR § 80018 - Does Not Meet Standards 1. Wrong number of clients listed under program revenue section at top of form. 2. Salary and wages is too low given the number of employees listed on the LIC Personnel Report. Please correct or provide break down of employee salary/wages. 3. Photocopied signature was provided. Please provide the original wet signature or new forms with electronic signature (using Adobe). 8. Supplemental Financial Information (LIC 401A) (Reference HSC § 1520(c) CCR § 80018) - Does Not Meet Standards 1. Please complete Part II of the form. 2. Photocopied signature was provided. Please provide the original wet signature or new forms with electronic signature (using Adobe). 9. Balance Sheet (LIC 403) (Reference HSC § 1520(c), CCR § 80018) - Does Not Meet Standards 1. Numbers not transferred over correctly from LIC 403a forms, specifically lines 8 & 13. Please correct or provide explanation of discrepancy. 2. Photocopied signature was provided. Please provide the original wet signature or new forms with electronic signature (Adobe). 10. Balance Sheet supplemental Schedule (LIC 403A) (Reference HSC § 1520(c), CCR § 80018) - Does Not Meet Standards 1. Numbers not transferred over correctly to LIC 403 forms, specifically lines 23 & 29. Please correct or provide explanation of discrepancy. 2. Photocopied signature was provided. Please provide the original wet signature or new forms with electronic signature (using Adobe). 11. Financial Information Release and Verification (LIC 404) (Reference HSC § 1520(c), CCR § 80018) - Pending 12. Personnel Report (LIC 500) (Reference HSC § 1522, CCR § 80018) - Does not Meet Standards 1. Staff are currently scheduled to work at the same time in both facilities. Please correct. 13. Health Screening Personnel (LIC 503) (Reference CCR § 80018(d)) - Meets Standards 14. Emergency Disaster Plan (LIC 610C) (Reference CCR § 80023) - Does not Meet Standards 1. Form is not signed by administrator. Please ensure wet or electronic signature is provided. Continued... ...Continued 3 2. Letters of approval from relocation sites are missing. Please include. 15. Fire Inspection Authority (LIC 9054) (Reference CCR § 80018(d)), CCR § 87018(d)) - Meets Standards 16. Board of Directors Statement (LIC 9165) contained in PUB 326) (Reference CCR § 87018(d)) - Meets Standards 17. Control of Property (Reference CCR § 80018(c) - Meets Standards 18. Bacterial Analysis of Water (Reference CCR § 80021) - Meets Standards 19. Application or Documentation of Accreditation (Reference ILS § 87089) - Does not Meet Standards 1. See below notes for Section 20 of Program Statement Plan of Operation Section A, Purpose and Goals - Meets Standards Section B, Administrative Organization - Does Not Meet Standards 1. Organizational chart on page 220 is outdated. Please update. 2. Administrator certificate pending. Section C, Facility Sketch - Meets Standards Section D, Staff Plan - Does Not Meet Standards 1. At a minimum, the following course should be included in the 16 minimum training plans: Health issues in foster care-missing (87065.1 (d)(3)(Z)). 2. Facility Manager training missing the following training: - 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 Institutions Code. - 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). - Facilitation of outreach to family members and documentation of outreach, as specified in section 87022.1(b)(13)(A). - 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. - 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. Continued... ...CONTINUED 4 - 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. 3. Please ensure required training below has been included in their training: - Prior to working with children, a peer partner shall be certified in cardiopulmonary resuscitation (CPR) and first aid and are required 16 of training prior to working with children and those training are required at minimum to include (87065.1(g)(1) and 87065.1 (f)(1)). i. The confidentiality of information and records relating to children in the short term residential therapeutic program. ii. Teamwork and interpersonal communication among facility personnel and children, children's family members, and the child and family team members. iii. 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. iv. Physical and psychosocial needs of children, including behavior management, de-escalation techniques, and trauma-informed crisis management planning, including the use of emergency interventions. v. Child and adolescent development, including sexual orientation, gender identity and gender expression. Section E, Policies Regarding Child Abuse Reporting - Meets Standards Section F, Administrative Policies and Procedures - Meets Standards Section G, Admission Determination Procedures - Does Not Meet Standards 1. Please also include how the licensee defines these characteristics (CSEC, fire starting) for the purposes of assessing appropriateness of fit (87068.05 (C)(3)). 2. Please clearly detail the timeframes for initial and final response to the county placing agency regarding referrals for placement. 87068.05(c)(4)(A). Continued... ...CONTINUED 5 - 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-meets standards. - A final response period in which the facility accepts or denies the referral for placement. 3. Elevated review procedures: 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) please ensure to document this request. Recommend adding this on page 284, after "the Head of Service will make the support request." Section H, Intake Policies and Procedures - Does Not Meet Standards 1. Please mention that a needs and services plan will be completed within 30 days of intake. Page 289 mentions Needs and Services Plans for Non-minor dependents, but a Needs and Services Plan should be completed for all youth. 2. Please update procedures for child/youth emergency placement to include 87068.1(e): No later than 7 days after emergency placement, the administrator or social work staff shall review the intake documents to determine whether the facility can continue to provide the services necessary to meet the needs of the nonminor dependent. Section I, Admission Agreement - Meets Standards Section J, Removal or Transfer Policies and Procedures - Does Not Meet Standards 1. Please detail policies and procedures for removal or transfer of children and nonminor dependents during the following times (87022 (c)): After program goals have been reached. 2. 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 87068.4 (a): - how licensee will assist in preventing delays or gaps in delivery of services(please describe on page 302). - The program statement states "Maintain contact and provide aftercare support to the child after transfer (if applicable and not the responsibility of another STRTP)." Please describe the types of trauma-informed support and transition services to be provided. Continued... ...CONTINUED 6 - The program statement states, "San Pasqual Treatment Center will incorporate best practices for staff communication with the child and family prior to their transition." Please explain these best practices. As a reminder, the facility shall provide trauma-informed support and transition services to children/foster youth as part of a planned or unplanned removal or transfer, as specified in Subdivision (l) of Section 1562.01 of the Health and Safety Code (87068.4 (c)(1)). 3. 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 information: 87068.4 (e)(2) - on page 304, please ensure the letter is submitted to the county placing agency and includes a request for the child to be placed somewhere else. Please ensure the following as well: - Date the county placing agency was informed of the concern pursuant to Section 87068.4 (e)(1)(B). - date the Child and Family Team meeting was held pursuant to Section 87068.4 (e)(1)(D). - Please ensure requests that the child 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: 4. Please include the procedures for an NMD to transfer from an STRTP in accordance 87068.4 (h): - Written notice to the NMD and placement agency; - Transfer shall state the reason for the transfer and request the NMD be placed elsewhere; and - Procedures for appropriately distributing the NMD's records. Section K, Rate Setting and Refunds - Meets Standards Section L, Handling Money, Personal Property, and or Valuables - Meets Standards Section M, Consultants and Community Resources to be Utilized - Meets Standards Section N, Trauma-informed Intervention and De-Escalation Techniques - Meets Standards Section O, Plan or Use of Delayed Egress Devices - Meets Standards Section P, Conflict of Interest Mitigation Plan - Meets Standards Section Q, Continuous Quality Improvement (CQI) - Does Not Meet Standards 1. Please detail how the CQI plan is developed based on the mission, vision, and values. (87081) 2. Please describe how direct input is used to inform program development and improvement. (87081 (b)(1)) CONTINUED... ...Continued 7 3. Please include a description of how outcome measures will inform Dignity of its program being trauma-informed and culturally relevant. 87081(c)(2) 4. Include collecting data on the numbers and types of complaints received and, if applicable, the resolution of each complaint. 87081(c)(7) 5. How the facility will take the data to inform and improve policies, practices, and programs. 6. After the facility has analyzed and interpreted the data, how does the facility use that data to improve polices, practices and programs? 887071(c)(5) 7. Describe how CQI program will be culturally relevant, trauma-informed, and age and developmentally appropriate. For example, input is received from all levels of staff, children and CQI objectives and plan is directly tied to trauma informed principles of safety, permanency, and trauma informed services/supports. Program Statement Section 1, Population Served - Does Not Meet Standards 1. Please describe the treatment modalities aimed at addressing the needs of youth in the population served by your facility (probation youth/ survivors of commercial sexual exploitation/various diversities/LGBTQ/probation/substance abuse). ILS 87022.1 (b)(2)(A) - page 349 "all interventions will be evidence based and trauma informed", integrated core practice. 2. Can you describe programs and services specific to assisting an NMD in preparing for the transition to independent living? 3. Does the facility plan to serve youth with special heath care needs? Section 2, Emergency Disaster Response Procedures - Meets Standards Section 3, Transportation Arrangements - Meets Standards Section 4, Core Services and Supports - Does Not Meet Standards 1. Please describe the core services and supports offered to youth at the facility to include the following 87078.1 (a)(1-5): Services to achieve permanency, including supporting efforts to reunify or achieve adoption or guardianship and efforts to maintain or establish relationships with parents, siblings, extended family members, tribes, or others important to the child or nonminor dependent, as appropriate. Please describe in depth what the services/supports to achieve permanency look like, for example family therapy sessions, transportation to visits. Continued... ...Continued 8 2. Does the facility plan to contract (or hold any current contracts) with any community-based providers/agencies/organizations to provide core services and supports? If so, please attach the agreements and ensure documentation of agreements with other agencies shall be maintained by a short-term residential therapeutic program and be available upon request by the licensing agency. 87078.1(b)(2) 3. Please provide the names of any existing relationships with community and county-based providers and describe the core services secured through agreements (87078.1(b)(2)). This may include local parks and recreation to support extracurricular activities, LGBTQ centers to support clients, colleges for NMD support in academic continuation, linkages to TAY programs, American Indian centers/programs, regional centers. Section 5, Culturally Relevant Interventions, Practices, Services, and Supports - Meets Standards 1. Recommend describing any specific services for CSEC, African American, Latino. Does the facility work with any specific culturally relevant community-based organizations or agencies? In addition to discussion of services and supports pg. 390, recommend describing how these services are implemented. Section 6, Trauma Informed Interventions and Treatment Practices - Does Not Meet Standards 1. The trauma-informed prevention services, interventions, practices, services and supports must demonstrate the following: maximization of physical and psychological safety for the child or nonminor dependent; recommend describing examples. 2. Please provide the procedures for how the provider will access and make referrals for evidence-based and/or promising services and practices that are trauma informed. 3. Please provide the procedures for maintaining consistency with TILPS (when applicable). Section 7, Development, Implementation, and Modification of Needs and Services Plan - Meets Standards Section 8, Planned Activities - Meets Standards 1. Please include a written plan for indoor and outdoor activities including, but not limited to, the following: - Activities which meet the training, money management, and personal care, grooming needs, and any other independent living skills identified in the children's needs and services plans, as specified in Section 87068.2(b)(3) through (5) and Section 87068.22(c)(1); recommend describing the money management planned activities: credit recovery, how to open a bank account, etc. Fake monopoly is a great way to help learn financial management, but since you already have classes to teach these things, could it be more age appropriate to allow the "younger" youth access to the classes instead? Continued... ...CONTINUED 9 - As a reminder, a schedule of the planned activities shall be posted on at least a weekly basis in a central facility location readily accessible to children, relatives, and representatives of placement. 87079(e) Section 9, Services During Placement and After Discharge - Does Not Meet Standards 1. Please use this section to list any agencies or community-based organizations that the facility has identified or commonly uses to provide additional services during care and after care. Please add the name, location, and the services. You can also include a statement that references another section where this information can be found. Section 10, Plan of Participation in the Child and Family Team - Does Not Meet Standards 1. How often will CFTM be held after the initial CFTM? Please see ILS § 87022.1(b)(11); ILS § 87001(c)(4). 2. Repetitive language. Recommend condensing. Section 11, Identification of Home-Based Care - Meets Standards Section 12, Participation of Family Members in Treatment & Outreach to Family - Meets Standards Section 13, Complaints and Grievances - Meets Standards Section 14, Participation and Assistance in Initiatives to Improve the Child Welfare System - Meets Standards Section 15, Family Visitation - Meets Standards Section 16, Children and Non-minor Dependents Personal Rights - Meets Standards Section 17, House Rules for Children and Non-minor Dependents - Does Not Meet Standards 1. What is the actual curfew time? 2. Please detail house rules on alcohol, drugs, weapons, smoking, room search/search of personal belongings. Section 18, Positive Discipline Policies - Does Not Meet Standards 1. Please include a copy of the code of conduct. 2. Please include a description on how discipline policies are trauma informed and include a description on how discipline policies account for specialized populations (CSEC youth). 3. Please ensure Staff, children, and authorized representatives shall sign and receive copies of discipline policies and procedures and the Signed copies shall be maintained in the child's record 87072.1(a)(3-4) Section 19, Storage of Medication - Meets Standards Section 20, Documentation of Accreditation - Does Not Meet Standards CONTINUED... ...Continued 10 1. The facility has included a copy of an accreditation. Please demonstrate that this is the accreditation for this specific facility's location. 2. New applicants should submit a declaration of accreditation status including what accrediting entity was chosen and a description of steps the applicant has taken to acquire accreditation. 87089 (c)(1). The applicant shall submit documentation of accreditation/a copy of its application for accreditation (87089(c)). 3. Please include a statement that the facility will provide documentation to the Department reporting its accreditation status at 12 months and 18 months after the date of provisional licensure (87089 (d)). 4. Please include a statement that the facility will provide a copy of final accreditation summary report to the licensing agency within 30 days of its release date (87089 (f)) 5. 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, a short-term residential therapeutic program shall provide documentation of its corrective action to the ..licensing agency Department within 30 days of its completion date (87089(g)) Section 21, Mental Health Program Approval - Meets Standards 1. Please update section if Mental Health approval has been received since submitting application. Section 22, Nursing Services - Does Not Meet Standards 1. Page 547 states "The ROP Nurse oversees multiple STRTP homes and is not based solely at one home." Is this nurse employed/hired by ROP or contracted? If so, please detail and include any MOU/contracts. Section 23, Food and Nutritional Plan/Sample Menus/Schedule - Meets Standards Section 24, Emergency Intervention Plan - Does Not Meet Standards 1. Please include the following in runaway plan: - Procedure for complying with Reporting Requirements specified in Section 87061(i). - 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.*n - How staff respond to runaway child(ren) and child(ren) outside of the facility property without permission, but who are within view of the staff. Continued... ...CONTINUED 11 i. The section stated "If a client is outside the facility without permission in view of staff, they will be immediately informed they must ask to return to the facility," is this what was intended to have been said? When reporting incidents, please ensure all report requirements specified in Section 87061(I) are also maintained 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 thefacility 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. (H) Documentation that the child's authorized representative has been notified of the incident. 2. Please specify whether the youth are being supervised during the 15 min cool down. 3. Please describe the procedures for determining and using age and size appropriate emergency intervention techniques. 4. Please include 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. 5. The section stated, "Manual restraints shall not be longer than 15 minutes." Please describe in-depth what the facilities' intervention process is after 15 minutes. If the youth is unable to remain calm, what are the facilities' policies? If the facility will use restraints longer than 15 mins, please describe the procedures. Recommend detailing these procedures if the facility plans to use restraints past 15 mins. 6. The following required detail in the descriptions of the monthly restraint log was left out: result of licensee review. Please include. 7. Please include if facility will use separation rooms. Continued... ...Continued 12 8. Please state that the admissions agreement will include a written statement regarding the types of emergency interventions the licensee has been approved to use and must be reviewed with the child/NMD and authorized representative at the time of admission, and that a copy of the interventions used will be provided to the authorized rep upon request. (87095.22(i)(1)(A)) 9. Please state that the facility will follow the reporting requirements for each use of manual restraints of a child/NMD (87061(i)(7), which are: - Date and time of other manual restraints involving the same child in the past 24 hours. - 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. - Description of what manual restraints were used and how long the child was restrained. - 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 were necessary. - Description of any injuries sustained by the child or facility personnel, including what type of medical treatment was sought and where the child was taken. Provide an explanation if medical treatment was not sought for injuries. - Name(s) of facility personnel who conducted the manual restraint. - Name(s) of facility personnel who witnessed the child's behavior and the restraint. - The child's verbal response and physical appearance, including a description of any injuries at the completion of the restraint. - 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 corrective action that will be taken or will not be taken against the facility personnel and why. - If law enforcement was involved, a detailed description of the events involving the law enforcement contact, including a police report number if available. - Documentation that the child's authorized representative has been notified of the incident. General Notes: -Correction of "The Southern California Treatment Programs" used on page 564. A copy of this report was sent to Lawrence Howell, Executive Director for signature. The original signed copy will be maintained in the facility file in the San Diego Regional Office.

Deficiencies:
90087: 02/24/2025 Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32...Continued 10 1.

met_with: Lawrence Howell, Executive Director

title: Visit Date


summary: Facility Evaluation

raw_content:
Narrative:
On May 6, 2025 at 3: PM, Licensing Program Analyst (LPA) Jacob Salem conducted an unannounced visit to the above facility for the purpose of conducting a post-licensing inspection and met with Frank Simmons, Administrator. LPA conducted two staff interviews (S1 and S2) and one client interview (C1). LPA initiated an inspection the facility's physical plant. Due to time constraints, the annual is being extended to complete the physical inspection, as well as conduct files reviews and client interview. An exit interview was conducted and a signed copy of this report was provided to Frank Simmons, Administrator.

met_with: Frank Simmons, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On May 15, 2025 at 10: AM, Licensing Program Analyst (LPA) Jacob Salem conducted an announced visit to the above facility and met with Frank Simmons, Administrator. The purpose of this Case Management inspection is to conduct an annual continuation from 5/06/2025. LPA inspected the facility's physical plant, including personal rights postings, health-related services, buildings and grounds, food services, telephones, indoor and outdoor activity space, and furniture, fixtures, equipment and supplies. The home is clean, in good repair, and free from observable risks to clients' health, safety, and personal rights. The home is a one story building with three client bedrooms and two client bathrooms which are set up as follows: Bedroom #1 has two twin beds and sleeps two clients, bedroom #2 has two twin beds and sleeps two clients, and bedroom #3 has two twin beds and sleeps two clients. There is a kitchen and living room, separate office garage for client visitation and therapy, laundry room and locked storage closets, and backyard/patio area. LPA reviewed two client files (C1 and C2), which are on kept locked in the staff office garage. The client files reviewed contain required information and records, including demographic information, needs and services plans, personal rights and facility policy acknowledgements, and medication logs. LPA reviewed staff files (S1-S5), which are kept in the human resource building on campus. The files reviewed contain the required background clearance and demographic information, educational and professional background information, and job description and duties. The annual is being extended to conduct a review of staff training records and conduct one client interview. An exit interview was conducted and a signed copy of this report was provided to Frank Simmons, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On May 21, 2025 at 10: AM, Licensing Program Analyst (LPA) Jacob Salem conducted an unannounced visit to the above facility and met with Frank Simmons. The purpose of this Case Management inspection is to conduct an annual continuation from 3/15/2025. LPA reviewed staff (S1-S5) training records, which are kept in a separate human resource building on campus. LPA observed initial and ongoing training to be documented in staff files, including training on personal rights, reporting requirements, emergency intervention plan, disaster preparedness plan, and trauma informed care. LPA conducted one client interview. Based on observations made during the inspection, there were no deficiencies cited at this time. An exit interview was conducted with Frank Simmons, Administrator and a signed copy of this report was provided.


raw_content:
Narrative:
conflicting statements. Some interviews indicated that C1 was not allowed use a cell phone and was required to have their phone calls supervised by staff. Some interviews indicated that staff supervised C1 closely and checked on C1 while C1 was in their bedroom every fifteen minutes up to every hour. Some interviews indicated that C1 asked to use C3 and C5's cell phones and C5 allowed C1 to use their phone. Some interviews indicated that when staff checked on C1 in their bedroom, C1 hid the phone from staff. Other interviews indicated that staff observed C1 hiding under a blanket using the cell phone and C1 was told not to use the cell phone and staff observed C1 at the Hospital with C5's cell phone in their possession. Regarding the allegation that staff slapped minor, it was also reported that C1 was arguing with the other clients at the facility and then the clients walked out of the facility and S2 walked into the facility and told C1 to "shut up," and S2 hit C1 on the mouth with the back of their hand. Some confidential interviews denied that S2 hit C1 or told C1 to "shut up." Records reviewed indicated that C1 stated they lied about the incident in which S2 allegedly told them to "shut up," and hit C1. Conflicting interviews indicated C1 was persuaded to admit they lied about the allegations to remain placed at the facility. LPA was unable to interview all individuals, although multiple attempts were made, thus, confidential interviews could not confirm or deny the allegations. Based on confidential interviews and records reviewed the allegations that staff are not providing adequate supervision to minors engaging in inappropriate activities and staff slapped a minor, which may have occurred, however, they are not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report and appeal rights were provided to Frank Simmons. A copy of this report will be placed in the facility file.

Investigation Findings:
13On December 22, 2025, at 11:10 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Frank Simmons, Program Director, to discuss the investigative finding for the allegations noted above. LPA Jacob Salem conducted an inspection of the facility on September 2, 2025, at 1:30 pm and no deficiencies were observed. LPA Salem interviewed two Clients (C1, C6) and two Staff (S1, S5) and one County Social Worker (CSW). LPA Linley interviewed one Client (C5), and four Staff (S2, S7-S9). LPA was unable to interview three Clients (C2-4) and four Staff (S3, S4, S6, S10), despite multiple attempts to contact them. LPA reviewed the facility documents during the investigation. On August 29, 2025, Community Care Licensing received allegations that staff are not providing adequate supervision to minors engaging in inappropriate activities and staff slapped a minor. It was reported that C1 sent partially nude images of themselves via Snapchat to unknown adults. Confidential interviews revealed UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: SAN PASQUAL TREATMENT CENTER - FEMALE PROGRAMFACILITY NUMBER: VISIT DATE: 12/22/2025

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

met_with: Frank Simmons


raw_content:
Narrative:
arguing with the other clients at the facility and then the clients walked out of the facility and S2 walked into the facility and told C1 to "shut up," and S2 hit C1 on the mouth with the back of their hand. Some confidential interviews denied that S2 hit C1 or told C1 to shut up. Conflicting interviews indicated that S2 told C1 to "shut up," and hit C1 on their face. Records reviewed indicated that C1 later denied that S2 told them to "shut up," or that S2 hit C1. Conflicting interviews indicated C1 was persuaded to admit they lied about the allegations to remain placed at the facility. There were no witnesses to this allegation. It was also reported that staff used unapproved restraint technique on client in care. Confidential interviews indicated that staff could not recall the specific restraint they used, however confidential interviews indicated S5 restrained C1 for a short period of time after C1 attempted to break the front door handle and S2 and S5 restrained C1 by C1's arms under one minute and then walked C1 to another area to get away from the broken glass and rock. Lastly, regarding the allegation staff did not prevent client from physically attacking another client in care it was reported that C1 was trying to break a window because C1 wanted to go to the bathroom and staff held C1 back so they would not break the window and clients came into the room and hit C1. Confidential interviews indicated conflicting statements. LPA was unable to interview all individuals, although multiple attempts were made, thus, confidential interviews could not confirm or deny the allegations. Based on confidential interviews and records reviewed the allegations that S2 spoke to C1 in an inappropriate manner, S2 hit C1 in care, staff used unapproved restraint technique on C2 in care, and staff did not prevent client from physically attacking C1 while in care, which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report and appeal rights were provided to Frank Simmons. A copy of this report will be placed in the facility file.

Investigation Findings:
13On December 22, 2025, at 11:30 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Frank Simmons, Program Director, to discuss the investigative finding for the allegations noted above. LPA Jacob Salem conducted an inspection of the facility on August 26, 2025, at 3:45 pm and no deficiencies were observed. LPA Salem interviewed two Clients (C1, C6) and two Staff (S1, S5) and one County Social Worker (CSW). LPA Linley interviewed one Client (C5), and four Staff (S2, S7-S9). LPA was unable to interview three Clients (C2-4) and four Staff (S3, S4, S6, S10), despite multiple attempts to contact them. LPA reviewed the facility documents during the investigation. On August 21, 2025, Community Care Licensing (CCL) received allegations that staff spoke to client in an inappropriate manner, staff hit client in care, staff used unapproved restraint technique on client in care, and staff did not prevent client from physically attacking another client in care. It was reported that C1 was UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: SAN PASQUAL TREATMENT CENTER - FEMALE PROGRAMFACILITY NUMBER: VISIT DATE: 12/22/2025

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


raw_content:
Narrative:
Confidential interview stated C1 was set up to meet an unknown male off campus. Confidential interview disclosed that C1 met the male by the bus stop and was gone for 30-45 minutes. Confidential interview declared that C1 was assaulted by the male and taken back to the facility. Confidential interview revealed that C1 told staff about what occurred, and they were coached to not say anything about what occurred. Confidential interview communicated that a few days later, C1 informed staff that they had lied about being assaulted. Another confidential Interview disclosed that they were unaware of any incident that had occurred to C1. Confidential interview revealed that an incident report was created upon client's absconding and returning, as to follow protocol. Confidential interview communicated that, upon client's return to the facility, client was asked if they needed medical attention and client denied that they needed any. Confidential interview explained that had they known about the alleged incident they would have contacted the authorities immediately. Confidential interview communicated that client used other people's cellphones to log into their Snapchat and meet males. Confidential interview expressed that client often lied. Confidential interview disclosed that when client returned from absconding on the date in question, they were bragging about being sexually assaulted and laughing about it. Another confidential interview declared that client did not say anything about being assaulted when they returned from absconding. Confidential interview disclosed that client stated they had been followed back to the house after getting chips from the store. Additional confidential interview proclaimed that client was followed to the bus stop and noticed a vehicle pulled up and left with client. Confidential interview disclosed that after around 30 minutes the client arrived back at the facility with chips and unfastened pants. Confidential interview recounted that they contacted facility security, but they could not locate the vehicle. Confidential interview revealed that they contacted authority non-emergency line to report that the client had returned. Confidential interview proclaimed that client later reported that they had previously made up a story of being assaulted; however, staff was not aware of the alleged incident. Based on conflicting confidential interviews, the allegation that staff did not ensure reporting requirements were followed may have occurred or is valid, however, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated. A copy of this report and appeal rights were discussed and provided to San Pasqual Treatment Center - Female Program, Frank Simmons, Program Manager.

Investigation Findings:
13On December 18, 2025, at 10: AM, Licensing Program Analyst (LPA) Cynthia Velasquez met with San Pasqual Treatment Center - Female Program, Frank Simmons, Program Manager, to deliver the findings for the above complaint allegation. On 09/24/2025, an inspection of the facility was conducted; no immediate health and safety hazards were observed. The investigation included interviews with Staff (S1-S3) and Clients (C1-C2). Pertinent documents and rosters were gathered. On September 16, 2025, the Department received an allegation that staff did not ensure reporting requirements were followed. It was reported that a client told the staff (name unknown) about an incident that occurred, and the staff did not report it to police. It was reported that client was very emotional when explaining what occurred to them while absconding from the facility for a few hours. Reportedly, once client returned to the dorm and told staff (name unknown), who is a mandated reporter, they did not report it to the authorities. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Cynthia Ann Velasquez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: SAN PASQUAL TREATMENT CENTER - FEMALE PROGRAMFACILITY NUMBER: VISIT DATE: 12/18/2025

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


summary: Facility Evaluation

raw_content:
Narrative:
On October 10, 2025, at 2: PM, Licensing Program Analyst (LPA) Jacob Salem made an unannounced visit to the facility and met with Frank Simmons, Administrator. The purpose of the visit was a case management inspection. LPA reviewed psychotropic medication administration records (PMARs) and observed that several days in October 2025 had not been initialed by staff on multiple of client's (C1) PMARs. Based on records reviewed, the facility is being cited for violation of Interim Licensing Standards 87070(b)(14) Children's Records. An exit interview was conducted and a copy of this report, LIC 809D, LIC 811, and appeal rights were provided to Frank Simmons Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On February 2, 2026, at 4: PM, Licensing Program Analyst (LPA) Jacob Salem conducted an unannounced inspection at the facility and met with Alysia Martinez, Senior Coach Counselor for the purpose of following up on a Serious Incident Report (SIR) that was submitted to Community Care Licensing (CCL) on 1/14/2026. CCL was made aware of incidents that occurred on 1/13/26 and 1/14/2026 wherein a client (C1) was not administered their prescribed psychotropic medication on two consecutive days due to staff not ordering refills of the medication in time. Following the error, the licensee disclosed the missed dosages to CCL as per State reporting requirements. Based on records reviewed, the facility is being cited for violating Interim Licensing Standards for Short Term Residential Treatment Programs, Article 6, section 87075(c) Health Related Services. An exit interview was conducted and a copy of this report along with appeal rights and LIC Confidential Names List were provided to Alysia Martinez, Senior Coach Counselor.

met_with: Alysia Martinez, Senior Coach Counselor


summary: Facility Evaluation

raw_content:
Narrative:
On February 10, 2026, at 11: AM, Licensing Program Analyst (LPA) Jacob Salem conducted an unannounced visit to the above facility for the purpose of conducting an annual inspection and met with Alysia Martinez, Senior Coach Counselor. LPA initiated an inspection of the facility's physical plant and a review of staff files. Due to time constraints, the annual is being extended to review client files and conduct interviews. An exit interview was conducted and a signed copy of this report was provided to Alysia Martinez, Senior Coach Counselor.

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
On February 13, 2026 at 10: AM, Licensing Program Analyst (LPA) Jacob Salem conducted an announced visit to the above facility and met with Frank Simmons, Administrator. The purpose of this Case Management inspection is to conduct an annual continuation from 2/10/2026. LPA conducted two client interviews and two staff interviews. LPA inspected the facility's physical plant, including personal rights postings, health related services, buildings and grounds, food services, indoor and outdoor activity space, and furniture, fixtures, equipment and supplies. The home is clean, in good repair, and free from observable risks to clients' health, safety, and personal rights. The home is a one story building with three client bedrooms and two client bathrooms which are set up as follows: Bedroom #1 has two twin beds and currently sleeps one client, bedroom #2 has two twin beds and currently sleeps one client, and bedroom #3 has two twin beds and currently sleeps two clients. There is a kitchen and living room, storage closets, and back and front patio and separate garage used as a therapy office or for visitation. LPA reviewed five staff files (S1-S5), which are kept locked in a separate HR building next door. The staff files reviewed contained the required demographic and hiring information, criminal background clearances, and health screenings. During the review, LPA observed that S5's file did not contain documentation of the required training to occur within 90 days of hire. LPA reviewed four client files (C1-C4), which are kept locked in the administrator's garage office. Continued... ...CONTINUED The client files contained the required pre-placement screenings, personal rights acknowledgements, and medication logs. During the review, LPA observed written authorization and court orders for each psychotropic medication to be missing or outdated for clients (C2-C4). Based on observations during staff and client file review, the facility is being issued citations (see LIC 809D) for violating Interim Licensing Standards Version 5 section 87065.1(d)(5) Supervision, Evaluation, and Training Requirements and section 87070(b)(13) Children's Records. An exit interview was conducted with Frank Simmons, Administrator and a signed copy of this report, LIC 811, LIC 809D and appeal rights was provided.


facility_name: SAN PASQUAL TREATMENT CENTER - MALE PROGRAM

summary: Facility Evaluation

raw_content:
Narrative:
On February 10, 2025, at 1: PM, Licensing Program Analyst (LPA) Jacob Salem conducted an announced visit to the above facility and met with San Pasqual Treatment Center Frank Simmons Program Manager, Keary Mason Head of Service, Dana Centanni Regional Director for the purpose of conducting a pre-licensing inspection. Currently there are no clients placed in the home. The applicant is applying to serve six ambulatory clients ages 12 to 17 and Non-Minor Dependents. LPA conducted component III of the orientation process and reviewed with the applicants Licensing requirements. The home is a one-story building with three client bedrooms and two client bathrooms which are set up as follows: · Bedroom #1 (Client) has two twin beds and will sleep two clients. · Bedroom #2 (Client) has two twin beds and will sleep two clients. · Bedroom #3 (Client) has two twin bed and will sleep two client and attached bathroom. · Kitchen, dining area, and family room area, locked storage and laundry room, hallway and storage closets, backyard/patio area, and attached two car garage which is set up for visitation and mental health services. The Emergency Disaster Plan, Personal Rights, and complaint procedures are posted in the hallway of the home. The license will be posted as soon as it is issued. LPA and the applicants toured the facility inside and out and conducted a full inspection of the facilities physical plant, including building and grounds, food service, furniture fixtures and supplies, telephone service, health-related services, personal services, and activity space. The facility has demonstrated compliance with Title 22, Division 6 of the California Code of Regulations and Interim Lincensing Standards. An exit interview was conducted and a copy of this report was provided to Frank Simmons, Program Manager.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On February 24, 2025, at 11: AM, Licensing Program Analyst (LPA) Jacob Salem and Licensing Program Manager (LPM) Dawn Segura conducted a technical assistance meeting virtually, via Teams, with San Pasqual Treatment Center (STRTP) Executive Director (ED) Lawrence Howell, Regional Director (RD) Dana Centanni, and Business Manager (BM) Jennifer Stoops. Also present at the meeting were System of Care Branch Analyst, Ansar Mohammed, System of Care Branch Manager, Marjana Jackson, and San Diego County Representatives Eileen Marshall, Jimabeth Ramsey, and Christina Bradley. The Purpose of the meeting was to discuss and review the following pending Licensing forms, Plan of Operation (POO), and Program Statement (PS) revisions: Application and Supporting Documentation (LIC 281E) 1. Application for a Community Care Facility (LIC 200) - Meets Standards 2. Orientation Certificate (Reference CCR § 80018(b) - Proof of attendance on file/Meets Standards 3. County Letter of Recommendation (Reference HSC § 1562.01(f) ILS § 87018(c)(6)) - Pending 4. Applicant information (LIC 215) - Does Not Meet Standards 1. Photocopied signature was provided. Please provide the original wet signature or new forms with electronic signature (using Adobe). 4. Designation of Facility Responsibility (LIC 308) (Reference CCR § 80064) - Meets Standards 5. Affidavit Regarding Client Cash Resources (LIC 400) (Reference HSC § CCR § 80018) - Does Not Meet Standards 1. Wrong bond amount listed on the form. Based on the amount stated the facility will hold at one time, a surety bond of $5000 is required. Please correct. 2. Photocopied signature was provided. Please provide the original wet signature or new form with electronic signature (using Adobe). 6. Surety Bond (LIC 402) (Reference CCR § 80018(d)) - Pending CONTINUED... ...Continued 2 7. Monthly Operating Statement (LIC 401) (Reference HSC § 1520(c) CCR § 80018 - Does Not Meet Standards 1. Wrong number of clients listed under program revenue section at top of form. 2. Salary and wages is too low given the number of employees listed on the LIC Personnel Report. Please correct or provide break down of employee salary/wages. 3. Photocopied signature was provided. Please provide the original wet signature or new forms with electronic signature (using Adobe). 8. Supplemental Financial Information (LIC 401A) (Reference HSC § 1520(c) CCR § 80018) - Does Not Meet Standards 1. Please complete Part II of the form. 2. Photocopied signature was provided. Please provide the original wet signature or new forms with electronic signature (using Adobe). 9. Balance Sheet (LIC 403) (Reference HSC § 1520(c), CCR § 80018) - Does Not Meet Standards 1. Numbers not transferred over correctly from LIC 403a forms, specifically lines 8 & 13. Please correct or provide explanation of discrepancy. 2. Photocopied signature was provided. Please provide the original wet signature or new forms with electronic signature (Adobe). 10. Balance Sheet supplemental Schedule (LIC 403A) (Reference HSC § 1520(c), CCR § 80018) - Does Not Meet Standards 1. Numbers not transferred over correctly to LIC 403 forms, specifically lines 23 & 29. Please correct or provide explanation of discrepancy. 2. Photocopied signature was provided. Please provide the original wet signature or new forms with electronic signature (using Adobe). 11. Financial Information Release and Verification (LIC 404) (Reference HSC § 1520(c), CCR § 80018) - Pending 12. Personnel Report (LIC 500) (Reference HSC § 1522, CCR § 80018) - Does not Meet Standards 1. Staff are currently scheduled to work at the same time in both facilities. Please correct. 13. Health Screening Personnel (LIC 503) (Reference CCR § 80018(d)) - Meets Standards 14. Emergency Disaster Plan (LIC 610C) (Reference CCR § 80023) - Does not Meet Standards 1. Form is not signed by administrator. Please ensure wet or electronic signature is provided. Continued... ...Continued 3 2. Letters of approval from relocation sites are missing. Please include. 15. Fire Inspection Authority (LIC 9054) (Reference CCR § 80018(d)), CCR § 87018(d)) - Meets Standards 16. Board of Directors Statement (LIC 9165) contained in PUB 326) (Reference CCR § 87018(d)) - Meets Standards 17. Control of Property (Reference CCR § 80018(c) - Meets Standards 18. Bacterial Analysis of Water (Reference CCR § 80021) - Meets Standards 19. Application or Documentation of Accreditation (Reference ILS § 87089) - Does not Meet Standards 1. See below notes for Section 20 of Program Statement Plan of Operation Section A, Purpose and Goals - Meets Standards Section B, Administrative Organization - Does Not Meet Standards 1. Organizational chart on page 220 is outdated. Please update. 2. Administrator certificate pending. Section C, Facility Sketch - Meets Standards Section D, Staff Plan - Does Not Meet Standards 1. At a minimum, the following course should be included in the 16 minimum training plans: Health issues in foster care-missing (87065.1 (d)(3)(Z)). 2. Facility Manager training missing the following training: - 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 Institutions Code. - 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). - Facilitation of outreach to family members and documentation of outreach, as specified in section 87022.1(b)(13)(A). - 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. - 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. Continued... ...CONTINUED 4 - 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. 3. Please ensure required training below has been included in their training: - Prior to working with children, a peer partner shall be certified in cardiopulmonary resuscitation (CPR) and first aid and are required 16 of training prior to working with children and those training are required at minimum to include (87065.1(g)(1) and 87065.1 (f)(1)). i. The confidentiality of information and records relating to children in the short term residential therapeutic program. ii. Teamwork and interpersonal communication among facility personnel and children, children's family members, and the child and family team members. iii. 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. iv. Physical and psychosocial needs of children, including behavior management, de-escalation techniques, and trauma-informed crisis management planning, including the use of emergency interventions. v. Child and adolescent development, including sexual orientation, gender identity and gender expression. Section E, Policies Regarding Child Abuse Reporting - Meets Standards Section F, Administrative Policies and Procedures - Meets Standards Section G, Admission Determination Procedures - Does Not Meet Standards 1. Please also include how the licensee defines these characteristics (CSEC, fire starting) for the purposes of assessing appropriateness of fit (87068.05 (C)(3)). 2. Please clearly detail the timeframes for initial and final response to the county placing agency regarding referrals for placement. 87068.05(c)(4)(A). Continued... ...CONTINUED 5 - 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-meets standards. - A final response period in which the facility accepts or denies the referral for placement. 3. Elevated review procedures: 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) please ensure to document this request. Recommend adding this on page 284, after "the Head of Service will make the support request." Section H, Intake Policies and Procedures - Does Not Meet Standards 1. Please mention that a needs and services plan will be completed within 30 days of intake. Page 289 mentions Needs and Services Plans for Non-minor dependents, but a Needs and Services Plan should be completed for all youth. 2. Please update procedures for child/youth emergency placement to include 87068.1(e): No later than 7 days after emergency placement, the administrator or social work staff shall review the intake documents to determine whether the facility can continue to provide the services necessary to meet the needs of the nonminor dependent. Section I, Admission Agreement - Meets Standards Section J, Removal or Transfer Policies and Procedures - Does Not Meet Standards 1. Please detail policies and procedures for removal or transfer of children and nonminor dependents during the following times (87022 (c)): After program goals have been reached. 2. 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 87068.4 (a): - how licensee will assist in preventing delays or gaps in delivery of services(please describe on page 302). - The program statement states "Maintain contact and provide aftercare support to the child after transfer (if applicable and not the responsibility of another STRTP)." Please describe the types of trauma-informed support and transition services to be provided. Continued... ...CONTINUED 6 - The program statement states, "San Pasqual Treatment Center will incorporate best practices for staff communication with the child and family prior to their transition." Please explain these best practices. As a reminder, the facility shall provide trauma-informed support and transition services to children/foster youth as part of a planned or unplanned removal or transfer, as specified in Subdivision (l) of Section 1562.01 of the Health and Safety Code (87068.4 (c)(1)). 3. 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 information: 87068.4 (e)(2) - on page 304, please ensure the letter is submitted to the county placing agency and includes a request for the child to be placed somewhere else. Please ensure the following as well: - Date the county placing agency was informed of the concern pursuant to Section 87068.4 (e)(1)(B). - date the Child and Family Team meeting was held pursuant to Section 87068.4 (e)(1)(D). - Please ensure requests that the child 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: 4. Please include the procedures for an NMD to transfer from an STRTP in accordance 87068.4 (h): - Written notice to the NMD and placement agency; - Transfer shall state the reason for the transfer and request the NMD be placed elsewhere; and - Procedures for appropriately distributing the NMD's records. Section K, Rate Setting and Refunds - Meets Standards Section L, Handling Money, Personal Property, and or Valuables - Meets Standards Section M, Consultants and Community Resources to be Utilized - Meets Standards Section N, Trauma-informed Intervention and De-Escalation Techniques - Meets Standards Section O, Plan or Use of Delayed Egress Devices - Meets Standards Section P, Conflict of Interest Mitigation Plan - Meets Standards Section Q, Continuous Quality Improvement (CQI) - Does Not Meet Standards 1. Please detail how the CQI plan is developed based on the mission, vision, and values. (87081) 2. Please describe how direct input is used to inform program development and improvement. (87081 (b)(1)) CONTINUED... ...Continued 7 3. Please include a description of how outcome measures will inform Dignity of its program being trauma-informed and culturally relevant. 87081(c)(2) 4. Include collecting data on the numbers and types of complaints received and, if applicable, the resolution of each complaint. 87081(c)(7) 5. How the facility will take the data to inform and improve policies, practices, and programs. 6. After the facility has analyzed and interpreted the data, how does the facility use that data to improve polices, practices and programs? 887071(c)(5) 7. Describe how CQI program will be culturally relevant, trauma-informed, and age and developmentally appropriate. For example, input is received from all levels of staff, children and CQI objectives and plan is directly tied to trauma informed principles of safety, permanency, and trauma informed services/supports. Program Statement Section 1, Population Served - Does Not Meet Standards 1. Please describe the treatment modalities aimed at addressing the needs of youth in the population served by your facility (probation youth/ survivors of commercial sexual exploitation/various diversities/LGBTQ/probation/substance abuse). ILS 87022.1 (b)(2)(A) - page 349 "all interventions will be evidence based and trauma informed", integrated core practice. 2. Can you describe programs and services specific to assisting an NMD in preparing for the transition to independent living? 3. Does the facility plan to serve youth with special heath care needs? Section 2, Emergency Disaster Response Procedures - Meets Standards Section 3, Transportation Arrangements - Meets Standards Section 4, Core Services and Supports - Does Not Meet Standards 1. Please describe the core services and supports offered to youth at the facility to include the following 87078.1 (a)(1-5): Services to achieve permanency, including supporting efforts to reunify or achieve adoption or guardianship and efforts to maintain or establish relationships with parents, siblings, extended family members, tribes, or others important to the child or nonminor dependent, as appropriate. Please describe in depth what the services/supports to achieve permanency look like, for example family therapy sessions, transportation to visits. Continued... ...Continued 8 2. Does the facility plan to contract (or hold any current contracts) with any community-based providers/agencies/organizations to provide core services and supports? If so, please attach the agreements and ensure documentation of agreements with other agencies shall be maintained by a short-term residential therapeutic program and be available upon request by the licensing agency. 87078.1(b)(2) 3. Please provide the names of any existing relationships with community and county-based providers and describe the core services secured through agreements (87078.1(b)(2)). This may include local parks and recreation to support extracurricular activities, LGBTQ centers to support clients, colleges for NMD support in academic continuation, linkages to TAY programs, American Indian centers/programs, regional centers. Section 5, Culturally Relevant Interventions, Practices, Services, and Supports - Meets Standards 1. Recommend describing any specific services for CSEC, African American, Latino. Does the facility work with any specific culturally relevant community-based organizations or agencies? In addition to discussion of services and supports pg. 390, recommend describing how these services are implemented. Section 6, Trauma Informed Interventions and Treatment Practices - Does Not Meet Standards 1. The trauma-informed prevention services, interventions, practices, services and supports must demonstrate the following: maximization of physical and psychological safety for the child or nonminor dependent; recommend describing examples. 2. Please provide the procedures for how the provider will access and make referrals for evidence-based and/or promising services and practices that are trauma informed. 3. Please provide the procedures for maintaining consistency with TILPS (when applicable). Section 7, Development, Implementation, and Modification of Needs and Services Plan - Meets Standards Section 8, Planned Activities - Meets Standards 1. Please include a written plan for indoor and outdoor activities including, but not limited to, the following: - Activities which meet the training, money management, and personal care, grooming needs, and any other independent living skills identified in the children's needs and services plans, as specified in Section 87068.2(b)(3) through (5) and Section 87068.22(c)(1); recommend describing the money management planned activities: credit recovery, how to open a bank account, etc. Fake monopoly is a great way to help learn financial management, but since you already have classes to teach these things, could it be more age appropriate to allow the "younger" youth access to the classes instead? Continued... ...CONTINUED 9 - As a reminder, a schedule of the planned activities shall be posted on at least a weekly basis in a central facility location readily accessible to children, relatives, and representatives of placement. 87079(e) Section 9, Services During Placement and After Discharge - Does Not Meet Standards 1. Please use this section to list any agencies or community-based organizations that the facility has identified or commonly uses to provide additional services during care and after care. Please add the name, location, and the services. You can also include a statement that references another section where this information can be found. Section 10, Plan of Participation in the Child and Family Team - Does Not Meet Standards 1. How often will CFTM be held after the initial CFTM? Please see ILS § 87022.1(b)(11); ILS § 87001(c)(4). 2. Repetitive language. Recommend condensing. Section 11, Identification of Home-Based Care - Meets Standards Section 12, Participation of Family Members in Treatment & Outreach to Family - Meets Standards Section 13, Complaints and Grievances - Meets Standards Section 14, Participation and Assistance in Initiatives to Improve the Child Welfare System - Meets Standards Section 15, Family Visitation - Meets Standards Section 16, Children and Non-minor Dependents Personal Rights - Meets Standards Section 17, House Rules for Children and Non-minor Dependents - Does Not Meet Standards 1. What is the actual curfew time? 2. Please detail house rules on alcohol, drugs, weapons, smoking, room search/search of personal belongings. Section 18, Positive Discipline Policies - Does Not Meet Standards 1. Please include a copy of the code of conduct. 2. Please include a description on how discipline policies are trauma informed and include a description on how discipline policies account for specialized populations (CSEC youth). 3. Please ensure Staff, children, and authorized representatives shall sign and receive copies of discipline policies and procedures and the Signed copies shall be maintained in the child's record 87072.1(a)(3-4) Section 19, Storage of Medication - Meets Standards Section 20, Documentation of Accreditation - Does Not Meet Standards CONTINUED... ...Continued 10 1. The facility has included a copy of an accreditation. Please demonstrate that this is the accreditation for this specific facility's location. 2. New applicants should submit a declaration of accreditation status including what accrediting entity was chosen and a description of steps the applicant has taken to acquire accreditation. 87089 (c)(1). The applicant shall submit documentation of accreditation/a copy of its application for accreditation (87089(c)). 3. Please include a statement that the facility will provide documentation to the Department reporting its accreditation status at 12 months and 18 months after the date of provisional licensure (87089 (d)). 4. Please include a statement that the facility will provide a copy of final accreditation summary report to the licensing agency within 30 days of its release date (87089 (f)) 5. 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, a short-term residential therapeutic program shall provide documentation of its corrective action to the ..licensing agency Department within 30 days of its completion date (87089(g)) Section 21, Mental Health Program Approval - Meets Standards 1. Please update section if Mental Health approval has been received since submitting application. Section 22, Nursing Services - Does Not Meet Standards 1. Page 547 states "The ROP Nurse oversees multiple STRTP homes and is not based solely at one home." Is this nurse employed/hired by ROP or contracted? If so, please detail and include any MOU/contracts. Section 23, Food and Nutritional Plan/Sample Menus/Schedule - Meets Standards Section 24, Emergency Intervention Plan - Does Not Meet Standards 1. Please include the following in runaway plan: - Procedure for complying with Reporting Requirements specified in Section 87061(i). - 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.*n - How staff respond to runaway child(ren) and child(ren) outside of the facility property without permission, but who are within view of the staff. Continued... ...CONTINUED 11 i. The section stated "If a client is outside the facility without permission in view of staff, they will be immediately informed they must ask to return to the facility," is this what was intended to have been said? When reporting incidents, please ensure all report requirements specified in Section 87061(I) are also maintained 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 thefacility 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. (H) Documentation that the child's authorized representative has been notified of the incident. 2. Please specify whether the youth are being supervised during the 15 min cool down. 3. Please describe the procedures for determining and using age and size appropriate emergency intervention techniques. 4. Please include 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. 5. The section stated, "Manual restraints shall not be longer than 15 minutes." Please describe in-depth what the facilities' intervention process is after 15 minutes. If the youth is unable to remain calm, what are the facilities' policies? If the facility will use restraints longer than 15 mins, please describe the procedures. Recommend detailing these procedures if the facility plans to use restraints past 15 mins. 6. The following required detail in the descriptions of the monthly restraint log was left out: result of licensee review. Please include. 7. Please include if facility will use separation rooms. Continued... ...Continued 12 8. Please state that the admissions agreement will include a written statement regarding the types of emergency interventions the licensee has been approved to use and must be reviewed with the child/NMD and authorized representative at the time of admission, and that a copy of the interventions used will be provided to the authorized rep upon request. (87095.22(i)(1)(A)) 9. Please state that the facility will follow the reporting requirements for each use of manual restraints of a child/NMD (87061(i)(7), which are: - Date and time of other manual restraints involving the same child in the past 24 hours. - 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. - Description of what manual restraints were used and how long the child was restrained. - 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 were necessary. - Description of any injuries sustained by the child or facility personnel, including what type of medical treatment was sought and where the child was taken. Provide an explanation if medical treatment was not sought for injuries. - Name(s) of facility personnel who conducted the manual restraint. - Name(s) of facility personnel who witnessed the child's behavior and the restraint. - The child's verbal response and physical appearance, including a description of any injuries at the completion of the restraint. - 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 corrective action that will be taken or will not be taken against the facility personnel and why. - If law enforcement was involved, a detailed description of the events involving the law enforcement contact, including a police report number if available. - Documentation that the child's authorized representative has been notified of the incident. General Notes: -Correction of "The Southern California Treatment Programs" used on page 564. A copy of this report was sent to Lawrence Howell, Executive Director for signature. The original signed copy will be maintained in the facility file in the San Diego Regional Office.

Deficiencies:
90086: 02/24/2025 Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32...Continued 10 1.

title: Visit Date


summary: Facility Evaluation

raw_content:
Narrative:
On October 9, 2025 at 1: PM, Licensing Program Analyst (LPA) Jacob Salem conducted an unannounced visit to the above facility for the purpose of conducting a post-licensing inspection and met with Frank Simmons, Administrator. LPA inspected the facility's physical plant, including personal rights postings, health-related services, buildings and grounds, food services, telephones, indoor and outdoor activity space, and furniture, fixtures, equipment and supplies. Their are currently no clients in care. The home is a one story building with three client bedrooms and two client bathrooms which are set up as follows: Bedroom #1 has two twin beds and can sleep two clients, bedroom #2 has two twin beds and can sleep two clients, and bedroom #3 has two twin beds and can sleep two clients. There is a kitchen and living room, separate office garage for client visitation and therapy, laundry room and locked storage closets, and backyard/patio area. Due to time constraints, the annual is being extended to complete file reviews and interviews. An exit interview was conducted and a signed copy of this report was provided to Frank Simmons, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On October 10, 2025 at 10: AM, Licensing Program Analyst (LPA) Jacob Salem conducted an unannounced visit to the above facility and met with Monica Gastelum, Designee. The purpose of this Case Management inspection is to conduct an annual continuation from 10/09/2025. LPA conducted two staff interviews. LPA reviewed five staff files (S1-S5), which contained the required demographic information, background clearances, and qualifications. Based on observations made during the inspection, there were no deficiencies cited at this time. An exit interview was conducted with Monica Gastelum, Designee and a signed copy of this report was provided.

met_with: Monica Gastelum, Designee


summary: Facility Evaluation

raw_content:
Narrative:
On October 10, 2025, at 2: PM, Licensing Program Analyst (LPA) Jacob Salem made an unannounced visit to the facility and met with Frank Simmons, Administrator. The purpose of the visit was to discuss a case management inspection. During an inspection of the facility on 10/09/25, LPA reviewed psychotropic medication administration records for former client (C1) and observed that two days in July 2025 had not been initialed by staff while C1 was away from the facility. Based on records reviewed, the facility is being cited for violation of Interim Licensing Standards 87070(b)(14) Children's Records. An exit interview was conducted and a copy of this report, LIC 809D, LIC 811, and appeal rights were provided to Frank Simmons Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On February 23, 2026, at 11: AM, Licensing Program Analyst (LPA) Jacob Salem conducted an unannounced visit to the above facility for the purpose of conducting an annual inspection and met with Frank Simmons, Administrator. LPA initiated an inspection of the facility's physical plant and a review of clients files. LPA conducted two staff and two client interviews. Due to time constraints, the annual is being extended to review client and staff files. An exit interview was conducted and a signed copy of this report was provided to Frank Simmons, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On February 24, 2026 at 10: AM, Licensing Program Analysts (LPAs) Jacob Salem and Stephanie Arreola conducted an announced visit to the above facility and met with Frank Simmons, Administrator. The purpose of this Case Management inspection is to conduct an annual continuation from 2/23/2026. LPA Salem inspected the facility's physical plant, including personal rights postings, health related services, buildings and grounds, food services, indoor and outdoor activity space, and furniture, fixtures, equipment and supplies. The home is clean, in good repair, and free from observable risks to clients' health, safety, and personal rights. The home is a one story building with three client bedrooms and two client bathrooms which are set up as follows: Bedroom #1 has two twin beds and currently sleeps one client, bedroom #2 has two twin beds and currently sleeps two clients, and bedroom #3 has two twin beds and currently sleeps no clients. There is a kitchen and living room, storage closets, and back and front patio and separate garage used as an administrative office or for visitation. LPAs Salem and Arreola reviewed five staff files (S1-S5), which are kept locked in a separate HR building next door. The staff files reviewed contained the required demographic and hiring information, criminal background clearances, and health screenings. During the review, LPAs observed that S3's file did not contain documentation of the required annual training. LPAs reviewed three client files (C1-C3), which are kept locked in the administrator's garage office. Continued... ...CONTINUED The client files contained the required demographic information, physical health assessments, and medication logs and court authorizations. Based on observations during staff file review, the facility is being issued a citation (see LIC 809D) for violating Interim Licensing Standards Version 5 section 87065.1(e)(1) Supervision, Evaluation, and Training Requirements. An exit interview was conducted with Frank Simmons, Administrator and a signed copy of this report, LIC 811, LIC 809D and appeal rights was provided.


summary: Facility Evaluation

raw_content:
Narrative:
On April 9, 2026, at 11: AM, Licensing Program Analyst (LPA) Jacob Salem made an unannounced visit to the facility and met with Frank Simmons, Administrator. The purpose of the visit was to assess a civil penalty for failure to correct a deficiency cited on 2/24/26. An exit interview was conducted and a copy of this report, LIC 421FC, and appeal rights were provided to Frank Simmons Administrator.