raw_content:
Narrative:
Continued... During the investigation, LPA Saeteurn interviewed clients (C2-C6), Staff (S1-S2), one witness (W1), and reviewed facility pertinent records. Confidential interviews revealed an incident in which C1 became upset with S1. Confidential interviews indicated that while C1 and other clients were being transported to school, S1 requested C1 to fill in open seats in the back of the facility van after C1 sat between two clients in the middle row, leaving minimal space between them. A confidential interview indicated that although there are no rules regarding client seating, C1 was asked to leave space after both clients sitting next to C1 complained about there not being enough room and to prevent clients from touching each other due to the lack of space. Confidential interviews revealed that C1 became upset and began to yell at S1. Confidential interviews revealed S1 asked C1 multiple times to stop their behavior due to C1 yelling. Confidential interviews revealed that S1 did not yell at C1 and was not disrespectful while addressing C1. Confidential interviews did not reveal any additional information on how S1 interacts with C1 or other clients in care, and due to C1 refusing an interview, LPA was unable to receive additional information regarding the way S1 treats C1. During the investigation a confidential interview revealed that C1 later expressed not wanting their video games taken away. Confidential interviews revealed that the facility wi-fi is disconnected from clients' personal devices as a form of consequence. Additionally, confidential interviews revealed that the disconnection from Wi-Fi prevents clients from playing games online. Confidential interviews revealed that all clients, including C1, are aware of this consequence. Additionally, confidential interviews revealed there was no specific time frame of how long these consequences can last however, confidential interviews revealed the length depends on the severity of the clients' actions. Confidential interviews did, however, reveal that in situations in which clients need to utilize the internet to complete homework or other important needs, facility staff will provide internet connection. A review of the facility's Program Statement revealed that when consequences are given to clients their privileges are limited. The program statement includes that appropriate forms of limiting privileges include, limiting radio, TV, and outings, however, there is no information on the disconnection of Wi-Fi. Continued... Continued... Based on interviews conducted and record review, the allegations that staff did not treat minor with dignity and staff used inappropriate forms of punishment are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove the alleged violations occurred. An exit interview was conducted with Robyn Reyes, Residential Director. A copy of this report and appeal rights were provided and reviewed with Robyn Reyes, Residential Director, whose signature on this report confirms receipt of these documents.

Investigation Findings:
13On December 5, 2024 at 9: AM. Licensing Program Analyst (LPA) Abby Saeteurn made an unannounced visit to First Step Treatment Home and met with Robyn Reyes, Residential Director to deliver the findings for the above-stated allegations. LPA Saeteurn initiated a complaint inspection at the facility on September 25, 2024, at 1: PM and no immediate deficiencies were observed. On September 19, 2024, Community Care Licensing (CCL) received a complaint alleging that staff did not treat a minor in care with dignity and staff used inappropriate forms of punishment. It was reported that S1 treats C1 unfairly and C1 is the only client that gets in trouble when bringing up concerns about other clients in care to S1. It was reported that S1 threatens to take away C1's games and Wi-fi as a form of punishment. It was also reported that S1 raises their voice and is rude and does not treat C1 with respect and C1 believes it us due to their race. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Abby Saeteurn 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. # San Diego, CA Facility Name: First Step Treatment Homefacility Number: Visit Date: 12/05/ 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 32continued... During the investigation, LPA Saeteurn interviewed clients (C2-C6), Staff (S1-S2), one witness (W1), and reviewed facility pertinent records. Confidential interviews revealed an incident in which C1 became upset with S1. Confidential interviews indicated that while C1 and other clients were being transported to school, S1 requested C1 to fill in open seats in the back of the facility van after C1 sat between two clients in the middle row, leaving minimal space between them. A confidential interview indicated that although there are no rules regarding client seating, C1 was asked to leave space after both clients sitting next to C1 complained about there not being enough room and to prevent clients from touching each other due to the lack of space. Confidential interviews revealed that C1 became upset and began to yell at S1. Confidential interviews revealed S1 asked C1 multiple times to stop their behavior due to C1 yelling. Confidential interviews revealed that S1 did not yell at C1 and was not disrespectful while addressing C1. Confidential interviews did not reveal any additional information on how S1 interacts with C1 or other clients in care, and due to C1 refusing an interview, LPA was unable to receive additional information regarding the way S1 treats C1. During the investigation a confidential interview revealed that C1 later expressed not wanting their video games taken away. Confidential interviews revealed that the facility wi-fi is disconnected from clients' personal devices as a form of consequence. Additionally, confidential interviews revealed that the disconnection from Wi-Fi prevents clients from playing games online. Confidential interviews revealed that all clients, including C1, are aware of this consequence. Additionally, confidential interviews revealed there was no specific time frame of how long these consequences can last however, confidential interviews revealed the length depends on the severity of the clients' actions. Confidential interviews did, however, reveal that in situations in which clients need to utilize the internet to complete homework or other important needs, facility staff will provide internet connection. A review of the facility's Program Statement revealed that when consequences are given to clients their privileges are limited. The program statement includes that appropriate forms of limiting privileges include, limiting radio, TV, and outings, however, there is no information on the disconnection of Wi-Fi. SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Abby Saeteurn LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 3 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. # San Diego, CA Facility Name: First Step Treatment Homefacility Number: Visit Date: 12/05/ 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 32continued... Based on interviews conducted and record review, the allegations that staff did not treat minor with dignity and staff used inappropriate forms of punishment are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove the alleged violations occurred. An exit interview was conducted with Robyn Reyes, Residential Director. A copy of this report and appeal rights were provided and reviewed with Robyn Reyes, Residential Director, whose signature on this report confirms receipt of these documents. SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Abby Saeteurn LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 2 of 3

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0

met_with: Robyn Reyes, Residential Director


state: CA

facility_name: FIRST STEP TREATMENT HOME

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
It was reported C1 and the other client were throwing sand at each other when S1 called C1 over to a table. It was reported C1 tried to explain the situation to S1 when S1 used profanity while responding to C1, causing C1 to feel uncomfortable. Confidential interviews and a review of pertinent facility records confirmed that on September 28, 2024, the facility hosted an outing to Mission Beach. Confidential interviews revealed all clients attended the outing which was supervised by S1 and S2. In addition, confidential interviews revealed that W1 also attended the event. A confidential interview and review of pertinent facility records revealed that during the outing, C1 and C2 engaged in an inappropriate conversation which led to C1 throwing sand at C2. A confidential interview and review of records confirmed that staff prompted both clients to stop, resulting in C1 becoming upset and punching C2. Confidential interviews and a review of pertinent facility records revealed that staff intervened by putting separation between clients and prompting both clients to stop, however, C1 proceeded to hit C2 a second time and C2 defended their self. Confidential interviews revealed that C1 was upset at staff intervening and was reported to be defiant in their behavior by arguing with staff. A confidential interview indicated that S1 used profanity when addressing C1, and one confidential interview confirmed that S1 used a profane word while in the proximity of C1. The confidential interview revealed that the word was said under S1's breath and was not directed at C1 or any other client. The confidential interview revealed that C1 mistakenly thought S1 told C1 to shut up and S1 clarified they did not. An attempt to complete an interview with S2 who was reported to be present during this interaction was unsuccessful. Based on conflicting interviews and records review, the allegation that staff spoke to minor in an inappropriate manner is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation occurred. An exit interview was conducted with Antonio "Shawn" Tucker, Facility Manager. A copy of this report and appeal rights were provided and reviewed with Antonio "Shawn" Tucker, whose signature on this report confirms receipt of these documents.

Investigation Findings:
13On January 10, 2025 at 11: AM. Licensing Program Analyst (LPA) Abby Saeteurn made an unannounced visit to First Step Treatment Home and met with Antonio "Shawn" Tucker, Facility Manager to deliver findings to for the above stated allegation. LPA Saeteurn initiated a complaint inspection at the facility on October 11, 2024, at 12: PM and no immediate deficiencies were observed. During the investigation, LPA Saeteurn interviewed clients (C1-C6), staff (S1 and S3), witnesses (W1-W2), and reviewed pertinent facility records. On October 4, 2024, Community Care Licensing (CCL) received a complaint alleging that staff spoke to a minor in an inappropriate manner. It was reported that while at the beach on an outing, C1 and another client were involved in an altercation. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Abby Saeteurn 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: FIRST STEP TREATMENT HOMEFACILITY NUMBER: VISIT DATE: 01/10/2025

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

report_type: Complaint Investigation

complaint_status: unsubstantiated


raw_content:
Narrative:
Continuation of LIC9099. Confidential interview indicated that C2 walked into C1's room to wake C1 up and told C1 to follow them to the restroom where C2 got on their knees, pulled C1's pants down, and touched C1's private area. Conflicting confidential interview indicated that C1 went into C2's room, asked C2 if C2 wanted to go AWOL, C1 told C2 to pack a bag, and C1 and C2 left the home through a door in C1's bedroom. Confidential interviews confirmed that C1 and C2 went AWOL together after the alleged incident took place. Confidential interview indicated that upon returning to the facility, C1 reported the incident to S1. Confidential interviews revealed that it was reported to facility staff and managers hours after the alleged inappropriate touching between C1 and C2 occurred. Confidential interviews revealed that C1's story was constantly changing when talking to staff and manager about the alleged incident. Confidential interviews reported that staff were supervising the common area and did not hear or notice that any clients were awake. Based on conflicting confidential interviews, the allegation that due to lack of supervision, minor touched another minor inappropriately while in care wasn't corroborated and is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of this report and appeal rights were given to Antonio "Shawn" Tucker, Facility Manager.

Investigation Findings:
13On November 6,2025, at 9:15AM Licensing Program Analyst (LPA) Lisa Bernabe made an unannounced visit to First Step Treatment Home and met with Antonio "Shawn" Tucker, Facility Manager, to deliver findings for the above stated allegation. LPA Bernabe initiated a complaint investigation at the facility on July 18, 2025, at 11: AM. An inspection was conducted, and no immediate deficiencies were observed. During the investigation, LPA Bernabe interviewed clients (C1, C2, C3, C4, and C5), staff (S1, S2, S3, and S4), and reviewed pertinent facility records. On July 15, 2025, Community Care Licensing (CCL) received a complaint alleging that due to lack of supervision, minor touched another minor inappropriately. It was reported that C1 was in the bathroom with C2 when C2 pulled down C1's pants and grabbed C1's private part. It was reported that C1 pulled up their pants and said, "No stop." Continuation on LIC9099-C. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Lisa Bernabe LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: FIRST STEP TREATMENT HOMEFACILITY NUMBER: VISIT DATE: 11/06/2025

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


summary: Facility Evaluation

raw_content:
Narrative:
On 6/07/2021 at 12: PM, Licensing Program Analyst (LPA) M. Lopez conducted an announced required annual inspection of the facility. LPA met with Program Director (PD) Deanna Mellos and inspected the facility inside and out. The facility is a one story residence with four bedrooms, two bathrooms, dining room, living room, kitchen, laundry room, and staff room. The facility has been operating with the capacity of six male from ages 13 years old to 17 years old and non-minor dependents. There were five male clients residing at this facility. The bedrooms are set up as follows: Bedroom #1 is occupied by two clients; two twin beds, all required linen, mattress in good condition. Bedroom #2 is occupied by two clients; two twin beds, all required linen, mattress in good condition and share a bathroom. Bedroom #3 is occupied by one client; one twin bed, all required linen, mattress in good condition. Bedroom #4 is occupied by one client; one twin bed, all required linen, mattress is good condition. Bedroom #1, Bedroom #3 and Bedroom #4 share a bathroom. All bedrooms contained adequate shelf and closet space for resident's belongings. The bathrooms were clean and in good repair. The closet in the living room is locked and contains office supplies, knives, medication, medication logs, first aid kit and clients' files. The medication is locked in a locked box inside a cabinet in the lock closet. All hazardous items were made inaccessible to areas where residents do not have access. Cleansers/chemicals were stored in a locked cabinet above the washer in the laundry room. The facility's smoke detectors in the hallways and bedrooms were checked and were operable. The carbon monoxide detector are located in the hallway across from Bedroom #1 and across bedroom # 2; and was tested and in operable condition. The following required posted items were observed and accessible to children: Ombudsman and Foster Youth Bill of Rights, Grievance Procedures, the updated Personal Rights, Visitation policies, house rules, current menu and neighborhood complaint. LPA observed a sufficient supply of 7-day non-perishable food for six residents and a sufficient supply of 2-day perishable food in the kitchen. LPA observed the kitchen to be clean, sanitary and in good repair. The facility outside grounds were inspected. LPA observed the outside ground to be clean and maintenance. There was an ample amount of recreational and leisure supplies such as books, games and television available for client use. Emergency exits were free from obstruction. Licensee has National Accreditation through CARF and is valid until August 31, 2022. LPA discussed the following with the Administrator: Incident reporting, including incidents related to Assembly Bill 388 law enforcement contacts as well as incidents involving emergency interventions. Personnel Files are maintained off-site and transported to LPA within reasonable time. All staff who work at the facility have Department of Justice and Child Abuse Clearance index check clearances. A review of client records was also completed on this date including the Medication Administration Record (See Confidential Name List- LIC 811 dated on June 07, 2021). Personnel files were reviewed to ensure they contained all required documentation. Children and staff records are organized. Staff's CPR and First Aid card were current. Child's records contain original needs and services plan signed by the child and their authorized rep. Child's records contain authorization for emergency medical care signed by each child's authorized rep. Licensee has a current needs and services plan for each resident on file. Facility personnel meet staff training requirements. Based on observations made during the inspection, no deficiencies observed or cited. An exit interview was conducted and this report was reviewed with Program Director (PD) Deanna Mellos and a copy of this report was provided.

report_type: Facility Evaluation

visit_type: Annual

met_with: Deanna Mellos


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Latricia Rogers conducted a case management inspection on May 9. 2023 @ 10:43 am, based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 4 out of Child Care Workers and 5 out of 5 youth files were reviewed. 3 out of Child Care Workers and 2 out of 5 youth were interviewed. (See the Confidential Names List, LIC 811, dated May 9, 2023). The Plan of Operation including policies and procedures were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, youth case plans, and crisis intervention plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Latricia Rogers observed documentation of completed training records indicating staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Antonio Tucker, Administrator.

visit_type: Case Management

met_with: Antonio Tucker- Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On October 6, 2023, at 8:25 am, Licensing Program Analyst (LPA) Jacob Salem arrived at the above facility for the purpose of conducted an unannounced annual inspection. LPA met with administrator Antonio "Sean" Tucker and explained the purpose of the visit. LPA began the inspection by conducting two client interviews and two staff interviews. LPA inspected the facility's physical plant. The facility is a one-story residence with a circular driveway and separate office in the back yard. Inside the main facility there are four bedrooms, two bathrooms, kitchen, staff room, living room, and laundry room. There are currently five clients residing at this facility with no more than two clients sharing a bedroom. All four bedrooms had mattresses and pillows in good condition, clean sheets and blankets, and closet or dresser space with clothing. LPA observed extra linens and towels in the closet, which were clean and in good condition. Both bathrooms were clean and sanitary with a working shower, sink, and toilet. Additionally, the sink in each bathroom fell within the regulations for water temperature: 118.4- and 109.8-degrees Fahrenheit. LPA observed the kitchen to be clean and sanitary with fresh fruit available on the counter. LPA observed the refrigerator, pantry, and chest freezer to be fully stocked, exceeding the requirement for food supplies. Finally, LPA observed a menu for the week posted on the refrigerator door consisting of three meals and snacks. Adjacent to the kitchen area, the staff room prominently displays the facility license, grievance procedures, foster child bill of rights, facility sketch, and emergency disaster plan. LPA observed the living room to be clean and contain a large couch, two TV's, video games, and board games. Continued... ...CONTINUED The closet in the living room is locked and contains sharps, medication, medication logs, and first aid kits. The facility contains multiple carbon monoxide and smoke detectors, all of which were tested to be operable. The laundry rooms consist of a washer and dryer machine, and all detergents, disinfectants, and cleaning solutions are made inaccessible and locked in cabinets above the washer and dryer. The backyard consists of several patios, a basketball hoop, and exercise area. LPA observed no safety hazards in the backyard. Finally, LPA tested the seatbelts and blinkers in the car used to transport clients, all of which were operable. Client files were provided to LPA for review, and of which contained the required paperwork, including signed admission agreement, signed needs and services plans, and records of cash resources and personal property. Additionally, one staff file was reviewed, and no deficiencies were observed. Due to time constraints, the annual is being extended to conduct an inspection of the remaining staff files. Based on observations made during the inspection, there were no deficiencies cited at this time. An exit interview was conducted with Administrator Tucker. A copy of the report was emailed for signatures and the signed documents will be kept in the facility file.

met_with: Antonio Tucker, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On October 12, 2023 at 9: AM, Licensing Program Analyst (LPA) Lucero Jauregui arrived to the facility's corporate office and met with Deanna Mellos, Director. The purpose of this Case Management inspection is to conduct an annual continuation from 10/6/2023. LPA Jauregui reviewed three staff files (S1-S3). The staff files have the acknowledgement of child abuse reporting requirements, criminal record clearances, staff qualifications, job duties, and training requirements. LPA reviewed Board Meeting notes to be filed and conducted quarterly. Based on observations made during the inspection and file reviews no deficiencies were observed during today's inspection. An exit interview was conducted, and a copy of this report was given to Deanna Mellos, Director.

met_with: Deanna Mellos, Director


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Joon Choi on April 18, 2024 at 9: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Choi met with Residential Director, Robyn Reyes and conducted an inspection of the facility. LPA reviewed two of child's records and three of staff personnel files on site at the facility. LPA reviewed two of child's psychotropic medications and medication records. LPA interviewed two staff on site to discuss the facilities policies and procedures of operation. LPA will interview two clients that are prescribed psychotropic medication, at a later time and/or date. . During the inspection LPA observed no deficiencies. LPA provided a copy of this licensing report to Residential Director Robyn Reyes.

met_with: Robyn Reyes, Residential Direcgtor


summary: Facility Evaluation

raw_content:
Narrative:
On September 5, 2025 at 12: PM, Licensing Program Analyst (LPA) Jacob Salem conducted an announced visit to the above facility and met with Robyn Reyes, Residential Director for the purpose of conducting an annual inspection. 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 residential building with four client bedrooms and two client bathrooms which are set up as follows: Bedroom #1 has two twin beds and currently sleeps two clients, bedroom #2 has one twin bed and currently sleeps one client, bedroom #3 has one twin bed and currently sleeps one client, and bedroom #4 has two twin beds and currently sleeps two clients,. There is a kitchen, two living rooms, laundry room, locked storage closets, separate therapy office, and backyard/patio. LPA reviewed five client files (C1-C5), which are kept locked in the staff closet. The client files reviewed contained the required information and records, including pre-placement screenings, personal rights and facility policy acknowledgements, and medication logs. LPA conducted two staff and two client interviews. Due to time constraints, the annual is being extended to conduct a review of staff files. An exit interview was conducted and a signed copy of this report was provided to Robyn Reyes, Residential Director.


summary: Facility Evaluation

raw_content:
Narrative:
On September 10, 2025 at 9: AM, Licensing Program Analyst (LPA) Jacob Salem conducted an announced visit to the above facility and met with Robyn Reyes, Residential Director. The purpose of this Case Management inspection is to conduct an annual continuation from 9/05/2025. LPA reviewed six staff files (S1-S6), at the facility's corporate office. The staff files reviewed contained the required clearances and health screenings, hiring paperwork and qualifications, and on-boarding trainings. During the review, LPA observed that S5 and S6 did not meet the annual 40-hour training requirement in 2024, with S5 receiving 28 hours and S6 receiving 36 hours. 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 Robyn Reyes, Residential Director and a signed copy of this report, LIC 811, and appeal rights was provided.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Jose Gonzalez and Joon Choi on October 28, 2025, 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 Antonio "Shawn" Tucker, Facility Manager, and conducted an inspection of the facility. LPAs reviewed one of child's records and two staff personnel files on site at the facility. LPAs reviewed one of child psychotropic medications and medication records. LPAs interviewed two staff on site to discuss the facilities policies and procedures of operation. LPAs interviewed one client that is prescribed psychotropic medication. During the inspection LPAs observed no deficiencies. LPAs provided a copy of this licensing report to Antonio "Shawn" Tucker, Facility Manager.


summary: Facility Evaluation

raw_content:
Narrative:
On December 9, 2025, at 9: AM, Licensing Program Analyst (LPA) Lisa Bernabe conducted an unannounced inspection at the facility and met with Derrick Neal, Manager. The purpose of the visit is to issue a case management deficiency. On July 15, 2025, Community Care Licensing (CCL) received a complaint alleging that due to a lack of supervision, a minor touched another minor inappropriately. It was reported that Client 1 (C1) was in the bathroom with Client 2 (C2) when C2 pulled down C1's pants and grabbed C1's private part. During the investigation, it was discovered that facility staff did not follow the policy of conducting safety checks every fifteen minutes. Confidential interviews revealed that when conducting overnight safety checks, a safety check was conducted at 4: AM, followed by another at 5: AM. According to the facility's plan of operation, staff are responsible for checking on youth every 15 minutes while they are asleep. Based on the information gathered, this posed a potential Health, Safety, or Personal Rights risk to youth in care. The facility will be cited for violation of Title 22, Division 6, Chapter 1, Article 06. Continuing Requirements 87022(f) Plan of Operation. An exit interview was conducted with Derrick Neal, Manager.

met_with: Derrick Neal, Manager


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On June 27, 2023, at 9: AM Licensing Program Analyst (LPA) Lucero Jauregui arrived unannounced to First Step Treatment Home and met with Amber Carter, Shift Supervisor. The purpose of this visit was to address a deficiency that was noted. On March 20, 2023, the Department received information regarding an incident that took place at the facility. On June 19, 2023, LPA Jauregui was conducting confidential interviews which revealed S1 placed C1 in a bear hug during a physical altercation, falling to the floor, and continuing bear hug. Based on interviews, the Licensee did not follow their plan of operations in utilizing physical restraint on C1; plan of operation indicates there will be no use of physical restraints. An exit interview was conducted, and plan of correction was developed and discussed with Amber Carter, Shift Supervisor. A copy of this report and appeal rights were provided to Amber Carter, Shift Supervisor.

Deficiencies:
80022: (f) (4) A description of how the facility will manage residents' lack of hazard awareness and impulse control behavior, which shall emphasize positive behavioral supports and techniques that are alternatives to physical, chemical, or mechanical restraints, or seclusion.

met_with: Amber Carter, Shift Supervisor

title: Plan of Operation Health and Safety Code section 1531.15 provides in pertinent part


summary: Facility Evaluation

raw_content:
Narrative:
On January 23, 2023 at 8: AM, Licensing Program Analyst (LPA) Jacob Salem arrived unannounced to the facility and met with First Step Treatment Home (FS) Antonio "Shawn" Tucker, Administrator to discuss a case management inspection. Community Care Licensing (CCL) received information that the Facility did not report to CCL multiple incidents that occurred in the home which involved Client #1 (C1) prior to discharge. Confidential interviews reveal that C1 absconded from FS for several days after stealing $140.00 from staff, often appeared under the influence of "something stronger than marijuana," and attempted to break into the medicine and knife cabinet. Record review reveals that CCL did not receive incident reports for any of these occurrences. The facility is being cited for violating California Code of Regulations Title 22, Division 6, Chapter 1, Article 6, regulation 80061(b)(1)(E) Reporting Requirements. An exit interview was conducted with Antonio "Shawn" Tucker, and a signed copy of this report and appeal rights were provided.

met_with: Antonio "Shawn" Tucker


raw_content:
Narrative:
Continuation of LIC 9099. Confidential interviews revealed the incident happened so fast staff were not expecting a physical altercation to break out between clients. Confidential interviews revealed that C1, C3 and C4 were all in the living room watching television (TV) but C1 and C3 were being obnoxious and were told to turn off the TV and go to their rooms. Confidential interviews revealed that C1 and C3 did not make it to their rooms but stayed in the second living room and were wrestling on the couch when C4 entered the room and walked over to punch C1, got on top of C1, and continued to hit C1 in the face. Confidential interviews revealed that S4 and S5 heard the chaos and approached the clients and were verbally instructing clients to stop in an attempt to deescalate the situation. Confidential interviews revealed that S5 got in between the clients because C4 had a cast on their arm when they were hitting C1. When S5 was able to get C4 to stop hitting C1, C4 jumped over to the couch and started attacking C3 who was sitting on the couch. Confidential interviews revealed that staff were redirecting C4 to stop and C4 walked away and went into their room. Based on interviews and review of records, the allegation that staff did not prevent minors from engaging in physical altercation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation occurred. An exit interview was conducted with Robyn Reyes, Residental Director. A copy of this report and appeal rights were provided and reviewed with Robyn Reyes whose signature on this report confirms receipt of these documents.

Investigation Findings:
13On February 5, 2026, at 11: AM, Licensing Program Analyst (LPA) Lisa Bernabe made an unannounced visit to First Step Treatment Home and met with Robyn Reyes, Residental Director, to deliver findings for the above stated allegation. LPA Bernabe initiated a complaint investigation at the facility on January 14, 2026, at 1: PM. An inspection was conducted, and no immediate deficiencies were observed. During the investigation, LPA Bernabe interviewed clients (C1, C2, C3), staff (S1, S2, S3, S4, and S5), and reviewed pertinent facility records. LPA was not able to interview Client 4 (C4) because C4 has been absent without leave from the facility. On January 13, 2026, Community Care Licensing (CCL) received a complaint alleging that staff did not prevent minors from engaging in a physical altercation. It was reported that C1 and C3 were punched in the face multiple times by C4. During the investigation, confidential interviews and a review of records revealed there have been prior incidents where C4 has targeted C1 while in care. Continuation on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Lisa Bernabe LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: FIRST STEP TREATMENT HOMEFACILITY NUMBER: VISIT DATE: 02/05/2026

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

met_with: Robyn Reyes, Residental Director


raw_content:
Narrative:
Continuation of LIC 9099. It was also reported that C5 got into a physical altercation with another client in the facility because C5 wanted the client not to touch them, and the client didn't leave C5 alone which resulted in a physical altercation between C5 and the client. Police were contacted and took C5 to the Emergency Screening Unit (ESU) as a danger to others. Confidential interviews revealed that staff were present during the altercation between C3 and C5, staff were utilizing verbal de-escalation techniques and S2 got in between C3 and C5. Additional interviews revealed that multiple altercations occurred between the same clients and facility staff were present and utilized de-escalation techniques to prevent clients from hurting each other. Confidential interviews revealed that staff stood in between clients to prevent the clients from hitting each other. According to confidential interviews, after the altercation, C5 was transported to ESU. Confidential interviews revealed that when the facility received a call from ESU stating C5 was being discharged, S6 took the call and stated they were not able to pick C5 up because staff were in ratio and the call was ended. According to confidential interview, immediately after, S6 called the hospital back to provide the hospital S3's contact information, so S3 could properly arrange pick up for C5. S3 arranged C5's pickup with their social worker. Confidential interviews revealed that C5 was not returned to the home after being discharged from ESU for the safety of clients in care. Based on confidential interviews, the allegations that staff unlawfully evicted a minor and staff did not prevent the minors from engaging in a physical altercation are unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted, and a copy of this report and appeal rights were given to Antonio "Shawn" Tucker, Facility Manager.

Investigation Findings:
13On February 24, 2026 at 2: PM, Licensing Program Analyst (LPA) Lisa Bernabe made an unannounced visit to First Step Treatment Home and met with Antonio "Shawn" Tucker, Facility Manager, to deliver findings for the above stated allegation. LPA Bernabe initiated a complaint investigation at the facility on August 20, 2025, at 2: PM. An inspection was conducted, and no immediate deficiencies were observed. During the investigation, LPA Bernabe interviewed clients (C1, C2, C3, and C4), staff (S1, S2, S3, S4, and S5), social worker and reviewed pertinent facility records. C5 was not interviewed due to client not wanting to be interviewed. On August 18, 2025, Community Care Licensing (CCL) received a complaint alleging that staff unlawfully evicted a minor and staff did not prevent minors from engaging in a physical altercation. It was reported that C5 was abandoned by their group home because facility staff refused to pick C5 up after C5 was discharged from the hospital. continuation on LIC 9099-C. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Lisa Bernabe LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: FIRST STEP TREATMENT HOMEFACILITY NUMBER: VISIT DATE: 02/24/2026

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


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Continuation of LIC Confidential interview indicated that S1 is the only staff to have authorization to clear client's self passes once their social worker provides a list of authorized adults that can take the clients out of the facility. Confidential interviews confirmed that S1 did not get approval from C3's social worker for this specific outing. Confidential interviews revealed that S1 gives instructions to staff and informs staff which clients will be on pass and when they will be back. Confidential interviews revealed that S1 confirmed it was a mistake on their end to not get this pass approved by social workers and grant this pass for client to attend a church event. Based on confidential interviews, the allegation that staff allowed minors to have unauthorized/unapproved passes with an adult is substantiated because the preponderance of evidence standard has been met. This posed a potential health, safety, or personal rights risk to child in care. The facility will be cited for violating, California Code of Regulations Title 22, Division 6, Section 80078(a) Responsibility for Providing Care and Supervision. An exit interview was conducted, and a copy of this report and appeal rights were given to Antonio "Shawn" Tucker, Facility Manager.

Investigation Findings:
13On March 30, 2026 at 12: PM Licensing Program Analyst (LPA) Lisa Bernabe accompanied by LPA Stephanie Arreola made an unannounced visit to First Step Treatment Home and met with Antonio "Shawn" Tucker, Facility Manager, to deliver findings for the above stated allegation. LPA Bernabe initiated a complaint investigation at the facility on October 13, at 1: PM. An inspection was conducted, and no immediate deficiencies were observed. During the investigation, LPA Bernabe interviewed clients (C1, C2, C3, and C4), staff (S1, S2, and S3), Social worker and reviewed pertinent facility records. On October 7, 2025, Community Care Licensing (CCL) received a complaint alleging staff allowed minor to have unauthorized/unapproved passes with an adult. It was reported that C3 was given permission to go on pass with an unapproved adult for 3 hours. Confidential interview indicated that S1 approved a self-pass for C3 to leave the facility and attend church. Continuation on LIC 9099C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Lisa Bernabe LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: FIRST STEP TREATMENT HOMEFACILITY NUMBER: VISIT DATE: 03/30/2026

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

complaint_status: SUBSTANTIATED


facility_name: FIVE ACRES

summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13On 05/12/2021, Licensing Program Analysts (LPA) Meghan McGee contacted Five Acres via telephone for the purpose of concluding the investigation on the above allegation and to deliver the findings. LPA McGee spoke with Claudia Rice, Division Manager and together discussed the investigation details. Based on the interview information obtained and review of facility documentation, the allegation(s) are concluded as unsubstantiated meaning that although the allegation(s) may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Interviews conducted confirmed there was not enough evidence to prove that a child was hit while in care. CSW stated that when she asked C1 about what happened she admitted that she was upset and lied about the whole thing. C1 stated that C2 hit her, staff allowed it, and C1 did not defended her self. C2 stated that C1 had put her hands on S1 and C2 fought C1. S1 pulled C2 off of C1. Exit interview was conducted, Appeal Rights were issued, and a copy of this report was emailed to Claudia Rice Division Director for signature due to COVID- Public Health Crisis. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Alan Henry LICENSING EVALUATOR NAME: Meghan McGee LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Claudia Rice, Division Director


raw_content:
Investigation Findings:
13Licesning Program Analyst Connie Jones-Steward investigated the above allegation. LPA spoke to staff and Child #1. LPA also reviewed the records of Child #1. There was no DCFS investigation to review. Based on the available information, the allegation is resolved as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Alan Henry LICENSING EVALUATOR NAME: Connie Jones-Steward LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Jalisa McFee


raw_content:
Investigation Findings:
13On 06/02/2021, Licensing Program Analysts (LPA) Meghan McGee contacted Five Acres via telephone for the purpose of concluding the investigation on the above allegation and to deliver the findings. LPA McGee spoke with Claudia Rice, Division Manager and together discussed the investigation details. Based on the interview information obtained and review of facility documentation, the allegation(s) are concluded as unsubstantiated meaning that although the allegation(s) may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Interviews conducted and video footage confirmed there was not enough evidence to prove that a child was hit while in care or inappropriately restrained. C1 and C2 were out of the facility. S1 had ran after C1 and put her in a wall restraint as S2 came to assist with the restraint. While trying to walk C1 to the CIS office, C1 was put back in a wall restraint a few times due to her dragging her feet or not complying with the walking restraint. Exit interview was conducted, Appeal Rights were issued, and a copy of this report was emailed to Claudia Rice Division Director for signature due to COVID- Public Health Crisis. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Alan Henry LICENSING EVALUATOR NAME: Meghan McGee LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


raw_content:
Investigation Findings:
13On August 12, 2021 at 2: PM Licensing Program Analyst (LPA) Meghan McGee made an unannounced visit to Five Acres for the purpose of concluding the investigation on the above allegation and to deliver the findings. LPA McGee spoke with Claudia Rice Division Director and together discussed the investigation details. An investigation was completed on 08/31/2020, control number 34-CR-20200413120730, referencing the same allegation. From the referenced complaint, based on the interview information obtained and review of facility documentation, the allegation(s) are concluded as unsubstantiated meaning that although the allegation(s) may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Due to the complaint already being investigated, no more interviews needed to be conducted; therefore, this complaint will be closed out due to a prior investigation being completed. Exit interview was conducted, Appeal Rights were issued, and a copy of this report was emailed to Claudia Rice Division Director due to COVID- Public Health Crisis. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Meghan McGee LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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


raw_content:
Investigation Findings:
13This an amended report from the original date of 5/26/2021. On January 6, 2022 at 11:40am, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Five Acres and spoke with Administrator, Claudia Rice. The purpose of this visit was to deliver the findings for the above complaint allegations. During the course of the investigation, a total of four (4) clients and two (2) staff were interviewed. Interviews conducted confirmed there was not enough evidence to prove that a child was threatened by a staff member or staff member had another resident beat up child. Child 1 (C1) is known to be aggressive and has fought staff and clients when C1 was a resident at the facility. Staff 1 (S1) denied the allegations. S1 stated that C1 had fought a staff member and when a client saw, the client started to fight C1. S1 stated that C1 thought S1 had the client do so and apologized when realized it did not happen. County Social Worker (CSW) stated that C1 can be impulsive. Based on the interview information obtained and review of facility documentation, the allegation(s) are concluded as unsubstantiated meaning that although the allegation(s) may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were observed or cited at the time of this investigation. Exit interview was conducted, and a copy of this report will be emailed to the Administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Daphne Edison LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2

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

met_with: Claudia Rice -Division Director


raw_content:
Narrative:
Based on the interviews conducted, the information gathered did not produce corroborating evidence to support the above said allegations. Due to inconsistent statements and documentary evidence obtained, LPA Edison was not able to determine if the above said allegations occurred, therefore the allegations are determined to be unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. No deficiencies were observed or cited at the time of this investigation. Exit interview was conducted, and a copy of this report will be emailed to the Division Director.

Investigation Findings:
13On January 6, 2022 at 12:11pm, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Five Acres and spoke with Division Director, Claudia Rice. The purpose of this visit was to deliver the findings for the above complaint allegations. During the course of the investigation, a total of three (3) clients and four (4) staff were interviewed. Interviews conducted confirmed there was not enough evidence to prove that the facility is not adhering to staffing ratios, facility is preventing minors from participating in extracurricular activities, and minors do not have access to their funds. Documentary evidence as well as confidential interviews confirm that the ratio of staff to clients meet licensing regulations as required. LPA obtained copies of the LIC 500 to confirm staffing ratios. LPA also obtained copies of the activity schedule and allowance logs for the clients in care. Continued on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Daphne Edison LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: FIVE ACRESFACILITY NUMBER: VISIT DATE: 01/06/2022

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

met_with: Claudia Rice - Division Director


raw_content:
Investigation Findings:
13On January 18, 2022 at 1:25pm, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Five Acres and spoke with Claudia Rice, Division Director. The purpose of this visit was to deliver the findings for the above complaint allegations. During the investigation, LPA interviewed a total of three (3) staff and one (1) witness. LPA was unable to interview Client #1 (C1) who refused to participate in the interview process to discuss the allegations. Interviews conducted confirmed there was not enough evidence to prove that staff stepped on youth's hand, staff locked youth in a room, staff denied youth access to a restroom, and staff spoke inappropriately to youth. Video evidence reviewed by the LPA, confidential interviews conducted, and C1's refusal to discuss the allegations provided conflicting information that staff locked youth in a room. LPA observed the video footage which revealed that the door of the room in which C1 was located in does not have a lock and therefore allowing C1 to exit the room if necessary. Based on the interviews conducted, the video footage reviewed, and the information gathered, the allegation has been determined to be unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. No deficiencies were observed or cited at the time of this investigation. Exit interview was conducted, and a copy of this report will be emailed to the Division Director. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Daphne Edison LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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


raw_content:
Narrative:
The matter was brought to the attention of Facility Administration and upon facility internal investigation, it was discovered that S1 was communicating with C1 via text message and Instagram. It was also discovered that S1 had purchased gifts for C1. When confronted by facility Administration, S1 denied buying gifts or texting C1; however, facility obtained proof to support the claims that S1 was communicating with C1 and had purchased gifts for C1. On May 26, 2021, S1 was terminated from employment for reasons including, but not limited to, having inappropriate unauthorized communication and purchasing various gifts for C1. The Department has investigated the complaint and found that the allegation is Unsubstantiated at this time meaning, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove sexual abuse by S1 on C1. There were no deficiencies cited at this time. The text messages contained messages alluding to inappropriate content by S1. It was further revealed that S1 had purchased various gifts for C1 that were against facility gift policy. An interview with S1 by CCL Investigator Seng revealed admission by S1 of sending text messages to C1 and purchasing various gifts for C1. Based on information obtained from interviews and documentary facts, the preponderance of the evidence standard has been met. The Department has determined former staff member S1 engaged in inappropriate conduct with C1 while in care. The allegation is deemed substantiated at this time and thus poses potential Health, Safety or Personal Rights risk to children in care. The following citation is issued in accordance with the Health and Safety Code 1550(c) Conduct Inimical. An exit interview was conducted, and appeal rights were discussed. A copy of this report, Confidential Names List and appeal rights emailed to Facility Administrator Claudia Rice. (Continued on page LIC9099-D)

Investigation Findings:
13On January 28, 2022 at 1: PM, Licensing Program Analyst Regina Martin conducted a subsequent complaint inspection to conclude and deliver findings concerning the allegation as mentioned above. LPA Martin met with Oscar Menendez, Crisis Intervention Specialist and advised that the Complaint Investigation investigated by Community Care Licensing Division (CCLD) Investigations Bureau, Investigator Dennis Seng has been completed. On June 10, 2021, CCLD received a complaint referral alleging sexual abuse on Child #1 (C1) as C1 reportedly sustained explicit relations/contacts with former Staff Member #1 (S1) [see LIC811, dated January 28, 2022]. It was further reported that S1 continued having inappropriate interaction with C1 after being terminated from the facility. The investigation including interviews and review of related reports from the Department of Children and Family Services and the County of Los Angeles Sheriff's Department Incident Report revealed a lack of evidence to support alleged sexual abuse by S1 on C1. (Continued on page LIC9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Regina Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: FIVE ACRESFACILITY NUMBER: VISIT DATE: 01/28/2022

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

visit_type: Complaint Investigation


raw_content:
Narrative:
No deficiencies were observed or cited at the time of this investigation. Exit interview was conducted, and a copy of this report will be emailed to the Division Director.

Investigation Findings:
13On February 4, 2022 at 11:46am, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Five Acres and spoke with Julian White, Crisis Intervention Specialist (CIS). The purpose of this visit was to deliver the findings for the above complaint allegations. During the investigation, LPA interviewed a total of three (3) staff and four (4) clients. Confidential Interviews conducted did not substantiate the allegations. Confidential interviews and documentary evidence revealed that clients are provided with personal hygiene products for each client and that staff assist clients with hygiene care if needed. Confidential interviews and documentary evidence also revealed that each client is responsible for their own laundry with assistance by staff if needed. Confidential interviews did not reveal that staff pinched client in care. LPA Edison was not able to determine if the above said allegations occurred. Based on the interviews conducted, the documentary evidence reviewed, and the information gathered, the allegations have been determined to be unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. Continued on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Daphne Edison LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: FIVE ACRESFACILITY NUMBER: VISIT DATE: 02/04/2022

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


raw_content:
Narrative:
No deficiencies were observed or cited at the time of this investigation. Exit interview was conducted, and a copy of this report will be emailed to the Division Director.

Investigation Findings:
13On February 4, 2022 at 11:55am, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Five Acres and spoke with Julian White, Crisis Intervention Specialist (CIS). The purpose of this visit was to deliver the findings for the above complaint allegations. During the investigation, LPA interviewed a total of four (4) staff and three (3) clients. Confidential Interviews conducted confirmed there was not enough evidence to substantiate that the cottage is dirty, cottage has an odor, cottage has bed bugs, cottage furniture broken, cottage bedding is stained, and cottage bedding is dirty. Confidential interviews and facility inspection revealed that the cottage is clean, without odor and with furniture in good repair. Facility inspection of the cottage also revealed that all bathrooms are clean and sanitary. Confidential interviews and bed inspections revealed there were no bed bugs on any of the mattresses in the cottage and that all beds in the cottage were new with new mattresses and new bedding. Based on the interviews conducted, inspection of the cottage, and the information gathered, the allegations have been determined to be unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. Continued on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Daphne Edison LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: FIVE ACRESFACILITY NUMBER: VISIT DATE: 02/04/2022

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

met_with: Julian White-Crisis Intervention Specialist


raw_content:
Narrative:
Based on the interviews conducted, documentary evidence, and LPA video review, the preponderance of standard has been met, therefore the above allegation is found to be substantiated. Facility cited on the attached LIC 9099D for violation of California Code of Regulations, Title 22, Division 6, regulation 80078(a) Responsibility for Providing Care and Supervision. Facility did not provide adequate supervision of residents in care which allowed minors to engage in inappropriate interactions. Exit interview was conducted, and a copy of this report will be emailed to the Division Director.

Investigation Findings:
13On March 30, 2022 at 9:37am, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Five Acres and spoke with Claudia Rice, Division Director. The purpose of this visit was to deliver the findings for the above complaint allegation. During the investigation, a total of three (3) clients and five (5) staff were interviewed. Confidential interviews, documentary evidence of Special Incident Report (SIR) # 797310, and LPA review of video footage of the incident revealed adequate supervision was not provided by staff, thus the minors engaged in inappropriate interactions while in care. Minors were out of the supervised view of staff. Continued on LIC 9099-C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Daphne Edison LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: FIVE ACRESFACILITY NUMBER: VISIT DATE: 03/30/2022

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

met_with: Claudia Rice-Division Director


raw_content:
Narrative:
Based on the observations made during today's inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. Exit interview was conducted, and a copy of this report will be emailed to the Division Director.

Investigation Findings:
13On March 30, 2022 at 11:07am, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Five Acres and spoke with Claudia Rice, Division Director. The purpose of this visit was to deliver the findings for the above complaint allegation. During the investigation, a total of three (3) clients, two (2) staff, and two (2) witnesses were interviewed. Confidential interviews and documentary evidence provided did not substantiate the allegation of Staff are not ensuring child has necessary supplies for school. Based on the interviews conducted, the information gathered did not produce corroborating evidence to support the above said allegation. LPA Edison was not able to determine if the above said allegation occurred, therefore the allegation is determined to be unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. Continued on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Daphne Edison LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: FIVE ACRESFACILITY NUMBER: VISIT DATE: 03/30/2022

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


raw_content:
Narrative:
Confidential interviews conducted revealed that C1 was not getting proper sleep due to prescribed medication. Confidential interviews revealed that the dosage for the morning medication for C1 has been reduced and that C1 is now receiving proper sleep. Based on the interviews conducted and documentary evidence, the information gathered did not produce corroborating evidence to support the above said allegations. LPA Edison was not able to determine if the above said allegations occurred, therefore the allegations are determined to be unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. Based on the observations made during today's inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. Exit interview was conducted, and a copy of this report will be emailed to the Division Director.

Investigation Findings:
13On March 30, 2022 at 11:24am, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Five Acres and spoke with Claudia Rice, Division Director. The purpose of this visit was to deliver the findings for the above complaint allegations. During the investigation, a total of three (3) clients, three (3) staff and three (3) witnesses were interviewed. Confidential interviews and documentary evidence provided did not substantiate the allegation of Staff are not providing basic laundry services for minor. LPA obtained copies of monthly clothing inventory, monthly clothing allowance logs and weekly laundry schedule for Client #1 (C1). Confidential interviews and documentary evidence provided does not substantiate the allegation that Staff are not providing adequate food service for minor. LPA obtained copies of the weekly café menu for C1. Continued on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Daphne Edison LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: FIVE ACRESFACILITY NUMBER: VISIT DATE: 03/30/2022

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


raw_content:
Narrative:
Based on the interviews conducted and documentary evidence, the information gathered did not produce corroborating evidence to support the above said allegations. LPA Edison was not able to determine if the above said allegations occurred, therefore the allegations are determined to be unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. Based on the observations made during today's inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. Exit interview was conducted, and a copy of this report will be emailed to the Division Director.

Investigation Findings:
13On March 30, 2022 at 1:31pm, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Five Acres and spoke with Claudia Rice, Division Director. The purpose of this visit was to deliver the findings for the above complaint allegations. During the investigation, a total of three (3) clients and four (4) staff were interviewed. Confidential interviews and documentary evidence revealed Covid-19 safety protocols were being followed. LPA obtained copies of COVID-19 protocol and procedures and janitorial cleaning schedule for cottages. Confidential interviews did not substantiate that minors are smoking marijuana in the facility and not enough staff to meet the needs of the minors in care. Confidential interviews revealed Client #1 (C1) would often AWOL from school and did not substantiate that minor is not prevented from AWOLing. Confidential interviews and documentary evidence revealed Client #1 (C1) was attending school while in care. LPA obtained copies of C1's school attendance summary. Continued on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Daphne Edison LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: FIVE ACRESFACILITY NUMBER: VISIT DATE: 03/30/2022

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


raw_content:
Narrative:
Based on the observations made during today's inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. Exit interview was conducted, and a copy of this report will be emailed to the Division Director.

Investigation Findings:
13On April 19, 2022 at 1:02pm, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Five Acres and spoke with Angie Wilbur, Residential Supervisor. The purpose of this visit was to deliver the findings for the above complaint allegation. During the investigation, a total of three (3) clients and three (3) staff were interviewed. Confidential interviews did not reveal staff caused injury to Client #1 (C1). Based on the interviews conducted, the information gathered did not produce corroborating evidence to support the above said allegation. LPA Edison was not able to determine if the above said allegation occurred, therefore the allegation is determined to be unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. Continued on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Daphne Edison LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: FIVE ACRESFACILITY NUMBER: VISIT DATE: 04/19/2022

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

met_with: Angie Wilbur-Residential Supervisor


raw_content:
Narrative:
Based on the interviews conducted, documentary evidence, and LPA video review, the information gathered did not produce corroborating evidence to support the above said allegations. LPA Edison was not able to determine if the above said allegations occurred, therefore the allegations are determined to be unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. Based on the observations made during today's inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. Exit interview was conducted, and a copy of this report will be emailed to the Division Director.

Investigation Findings:
13On April 19, 2022 at 1:51pm, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Five Acres and spoke with Angie Wilbur, Residential Supervisor. The purpose of this visit was to deliver the findings for the above complaint allegations. During the investigation, a total of six (6) clients, three (3) staff, and one (1) witness were interviewed. Confidential interviews, documentary evidence, and LPA review of video footage did not reveal minor sustained injuries while in care, staff failed to prevent minor from harm while in care, staff failed to notify minor's authorized representative of incidents, staff failed to safeguard minor's personal belongings, and staff failed to meet minor's needs. Continued on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Daphne Edison LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: FIVE ACRESFACILITY NUMBER: VISIT DATE: 04/19/2022

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


raw_content:
Narrative:
LPA review of video footage did not reveal injuries consistent with C1 receiving such injuries while in care. LPA was unable to substantiate the allegation that staff failed to prevent minor from harm while in care. Confidential interviews revealed that residents are supervised at all times but sometimes they may fall or hurt themselves while playing which is not always preventable. Confidential interviews also revealed that Client #1 (C1) did have a few scratches due to being "hyper" and also "bumped" their chin during play which could not be prevented. LPA review of video footage determined that C1 appears to be "hyper" and unable to control movements which could possibly result in injuries if not careful. LPA was unable to substantiate the allegation that staff failed to notify minor's authorized representative of incidents. Confidential interviews revealed that incidents are cross reported to all reporting agencies including C1's authorized representative. LPA was unable to substantiate the allegation that staff failed to safeguard minor's personal belongings. Although documentary evidence shows an inventory of C1's missing clothing items when C1 returned home from Five Acres, it did not reveal that staff failed to safeguard C1's personal belongings as it only reveals that clothing items can be lost, missing, or mixed up with other client belongings. It was also revealed that C1 would run out of the cottage with one shoe on which would result in a missing shoe. Confidential interviews did not reveal that staff did not meet C1's needs. Confidential interviews revealed that there was a misunderstanding by the parents of C1 of services being provided for C1. The parents of C1 were under the impression that staff would be providing a one-on-one for C1 and became upset with Five Acres with not being in agreement with what C1's diagnosis should be necessitating the need for C1 to have a one-on-one. Based on the interviews conducted, documentary evidence, and LPA video review, the information gathered did not produce corroborating evidence to support the above said allegations. LPA Edison was not able to determine if the above said allegations occurred, therefore the allegations are determined to be unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. Based on the observations made during today's inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. Exit interview was conducted, and a copy of this report will be emailed to the Division Director.

Investigation Findings:
13This an amended report from the original date of April 19, 2022. On May 19, 2022 at 11:24am, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Five Acres and spoke with Claudia Rice, Division Director. The purpose of this visit was to deliver the findings for the above complaint allegations. During the investigation, a total of six (6) clients, three (3) staff, and one (1) witness were interviewed. LPA was unable to substantiate the allegation that minor sustained injuries while in care. Although documentary evidence shows minor sustained injuries, the evidence did not reveal that those injuries were sustained while minor was in care at Five Acres. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Daphne Edison LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: FIVE ACRESFACILITY NUMBER: VISIT DATE: 05/19/2022

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


raw_content:
Narrative:
Additional confidential interviews did not reveal that staff hit or pinched C1 while in care. Confidential interviews with Witness #1 (W1) and W2 revealed that C1 did not want to return to placement at Five Acres and deny that the allegations are true. Confidential interviews with C1 revealed C1 denied staff hit or pinched them. Based on the interviews conducted, documentary evidence, the information gathered did not produce corroborating evidence to support the above said allegations. LPA Edison was unable to determine if the above said allegations occurred, therefore the allegations are determined to be unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. Based on the observations made during today's inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. Exit interview was conducted, and a copy of this report will be emailed to the Division Director.

Investigation Findings:
13On July 19, 2022 at 9:46am, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Five Acres and spoke with Claudia Rice, Division Director. The purpose of this visit was to deliver the findings for the above complaint allegations. During the investigation, a total of four (4) staff, three (3) clients, and two (2) witnesses were interviewed. Confidential interviews did not reveal staff hit minor while in care and staff pinched minor while in care. Confidential interviews with Witness #2 (W2) revealed Client #1 (C1) was unable to provide W2 with information on when the incidents regarding the allegations occurred and was unable to provide a name of what staff hit and pinched them when C1 was previously placed at Five Acres. W2 revealed C1 never reported any staff hitting or pinching them during C1's placement at Five Acres. Continued on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Daphne Edison LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: FIVE ACRESFACILITY NUMBER: VISIT DATE: 07/19/2022

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


raw_content:
Narrative:
Based on the interviews conducted, documentary evidence, the information gathered did not produce corroborating evidence to support the above said allegations. LPA Edison was unable to determine if the above said allegations occurred, therefore the allegations are determined to be unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. Based on the observations made during today's inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. Exit interview was conducted, and a copy of this report will be emailed to the Division Director.

Investigation Findings:
13On July 19, 2022 at 11:42am, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Five Acres and spoke with Claudia Rice, Division Director. The purpose of this visit was to deliver the findings for the above complaint allegations. During the investigation, a total of three (3) staff and three (3) clients were interviewed. Confidential interviews did not substantiate the allegation that Facility does not ensure that minor's hygiene needs are being met. Confidential interviews with Client #1 (C1) revealed that they have been provided with personal hygiene products such as soap and shampoo and that they maintain good hygiene. Confidential interviews with staff and documentary evidence provided did not substantiate the allegation of Facility does not ensure that minor's laundry needs are being met. C1 revealed that they do their own laundry weekly. LPA obtained copies of monthly clothing inventory, monthly clothing allowance logs and weekly laundry schedule for C1. Confidential interviews and documentary evidence provided does not substantiate the allegation that Facility does not ensure that minor is being adequately fed at the facility. LPA obtained copies of the weekly café menu for C1. Continued on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Daphne Edison LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: FIVE ACRESFACILITY NUMBER: VISIT DATE: 07/19/2022

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


raw_content:
Narrative:
This an amended report from the original date of 7/28/2022. Documentary evidence revealed that Staff #1 (S1) caused an injury to Client #1 (C1) in the form of a red handprint on C1's back which is consistent with statements that S1 "slapped" C1 on the back. LPA obtained photos of the injury to C1's back which clearly show the red imprint of a hand on C1's back. LPA obtained a copy of the Health Services Illness/Injury Report completed by the nurse who treated C1 for the injury. Information provided in the report revealed "there was a visible imprint of a hand" on C1's mid back area which was red but not yet bruised. Based on the interviews conducted and documentary evidence, the preponderance of standard has been met, therefore the above allegation is found to be substantiated. Facility cited on the attached LIC 9099-D for violation of California Code of Regulations, Title 22, Division 6, regulation 87072(c)(11) Personal Rights. Staff caused an injury to Client #1 by slapping C1 on the back leaving a red handprint on C1's back. Appeal rights were discussed with Crisis Intervention Specialist. Exit interview was conducted, and a copy of this report will be emailed to the Division Director.

Investigation Findings:
13On July 28, 2022 at 10:35am, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Five Acres and spoke with Julian White, Crisis Intervention Specialist (CIS). The purpose of this visit was to deliver the findings for the above complaint allegation. During the investigation, a total of three (3) clients and (4) staff were interviewed. Confidential interviews with staff, clients, and documentary evidence revealed inconsistent statements as to the validity of the allegation, Staff caused injury to minor. Documentary evidence provided inconsistent reports regarding the allegation. LPA obtained copies of Special Incident Report # 745252 which did not reveal that Staff #1 (S1) slapped Client #1 (C1) on the back leaving a red handprint and Special Incident Report # 745222 which revealed the injury of a red handprint on C1's back. Confidential interviews with C1 revealed that it was S1 which caused the injury. Continued on LIC 9099-C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Daphne Edison LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: FIVE ACRESFACILITY NUMBER: VISIT DATE: 07/28/2022

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


raw_content:
Narrative:
Witness statements revealed that the improvement in C1's sleeping habits may have stemmed from a change in medication that was prescribed for C1. Confidential interviews and documentary evidence provided did not substantiate the allegation of Staff are not ensuring child has necessary supplies for school. Witness statements revealed that there was no concern of C1 not having school supplies but the lack of communication between staff at C1's school and Five Acres facility staff addressing concerns regarding C1. Based on the interviews conducted, the information gathered did not produce corroborating evidence to support the above said allegation. LPA Edison was not able to determine if the above said allegation occurred, therefore the allegation is determined to be unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. Based on the observations made during today's inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. Exit interview was conducted, and a copy of this report will be emailed to the Division Director.

Investigation Findings:
13This an amended report from the original date of 3/30/2022. On March 30, 2022 at 11:07am, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Five Acres and spoke with Claudia Rice, Division Director. The purpose of this visit was to deliver the findings for the above complaint allegation. During the investigation, a total of three (3) clients, two (2) staff, and two (2) witnesses were interviewed. Confidential interviews revealed that although Client #1 was coming to school regularly with dirty clothes and shoes and lack of sleep. It was revealed that communication with Five Acres addressing concerns for C1's hygiene and lack of sleep activated improvements in C1's clothing and hygiene. Additional interviews also revealed that C1 began coming to school alert and was no longer sleeping in class. Continued on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Daphne Edison LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: FIVE ACRESFACILITY NUMBER: VISIT DATE: 09/22/2022

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