raw_content:
Narrative:
assisted to brush their teeth on a daily basis due to not having a 1:1 staff to assist C1 with hygiene needs. Documents reviewed indicated that it was determined that C1 is to have a 1:1 staff. Confidential interviews also revealed that staff were reluctant to take C1 to the dentist due to aggressive behaviors, which was difficult for one staff to constrain. Based on confidential interviews and records reviewed, the preponderance of evidence standard has been met and the allegation that facility staff are not meeting minor's dental hygiene needs is substantiated. The Group Home facility is being cited for violation of Title 22, Division 6, Chapter 5, Continuing Requirements: 87072(d)(25) Personal Rights. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with XXX. A copy of this report, LIC 811, and appeal rights was provided to the Administrator. information received, no identifying information of the staff member or a specific date given when the alleged incident occurred, the allegation could not be confirmed, or denied. Based on confidential interviews, that staff was smoking in the facility. may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained. A copy of this report, LIC 811, and appeal rights was provided to the Administrator.

Investigation Findings:
13On February 28, 2025, at 1: PM, Licensing Program Analyst (LPA) Guadalupe Munoz arrived unannounced at the facility and met with Administrator, Corazon Paison, to discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 07/02/24 at 10: AM and no deficiencies were observed at this time. LPA Interviewed three Staff (S1-3) and Biological Parent. LPA interviewed one of three Clients (C2), LPA attempted to interview Client #1 (C1), however, C1 was unable to articulate words. During the investigation, the following documents were reviewed: staff schedule, special incident reports, medical and dental records and Needs and Services Plans for clients. On 06/26/2024, Community Care Licensing (CCL) received an allegation that facility staff are not meeting minor's dental hygiene needs. Specifically, it was reported "The child was observed having 'two very big cavities in the back and that the last dental appointment on record was on April 28, 2023. Confidential interviews confirmed that C1 had not attended a dentist appointment since 2023 and C1 has not been SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz 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 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: CYNCO CHILD CARE IIFACILITY NUMBER: VISIT DATE: 02/28/2025

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

met_with: Corazon Paison


state: CA

facility_name: CYNCO CHILD CARE II

summary: Facility Evaluation

raw_content:
Narrative:
On February 16, 2022, at 09: AM, Licensing Program Analyst (LPA), Val Wilson, conducted an unannounced SB Psychotropic Medication Inspection. LPA was met at the door by Corazon Pasion, Licensee. LPA inspected the inside and outside of facility with the Licensee. LPA reviewed four of four child's records on site at the facility at 10: AM . LPA reviewed three of three staff personnel files on site at the facility at 12: PM. LPA interviewed two of three staff on site at 12: PM. LPA interviewed three of four children currently taking psychotropic medication at 1: PM, 1: PM, and 1: PM. LPA provided the Summary Report and LIC 811 to Corazon Pasion, Licensee, upon completion. No deficiencies or concerns were noted or observed throughout the inspection and interviews.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Corazon Pasion, Licensee


summary: Facility Evaluation

raw_content:
Narrative:
On November 3, 2022 at 11:27am, Licensing Program Analyst (LPA) Adrian Mendez arrived unannounced at the facility to conduct an Annual/Random inspection of the facility. The facility was inspected inside and out with Administrator Corazon Pasion, Direct Support Professional Juana Aranda, and Direct Support Professional Carol Enriquez. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. The bathrooms were clean and in good repair. The hot water in one of the client bathrooms was measured at 116.0 degrees, which is within regulatory requirements. All hazardous items have been properly made inaccessible. The medications were stored and locked in a medication cabinet in the kitchen. Cleansers/chemicals are locked and stored in a locked cabinet in the garage. Sharp knives are inaccessible and stored in a lock box in the kitchen. The First Aid Kit is located in the medication cabinet and contained all required supplies. The facility's smoke/carbon monoxide detectors in the hallways and bedrooms were checked and were operable. There are no guns or weapons in the facility as stated by Direct Support Professional Carol Enriquez. The following required posted items were observed accessible to clients: Facility License, Grievance Procedures, Personal Rights, Visitation policies, Emergency Disaster Plan and current menu. The facility outside grounds was also inspected and it was observed to be clean and well maintained. There is a swimming pool located in the backyard of the facility which is made inaccessible with a fence. Emergency exits were free from obstruction. LPA discussed and reviewed the following inspection components; Emergency Disaster Preparedness. During the inspection, LPA reviewed 10 staff files and four client files. Cont. on 809-C A sample of four client files were reviewed during the inspection. All client files had the required documents per Title Regulations. LPA reviewed 10 staff files. All the staff have met the training and qualification requirements per regulation requirements. Per a review of the Community Care Licensing Information System (LIS), all staff met DOJ/FBI criminal record clearances and Child Abuse Index Check requirements. Due to time constraints and the need to complete client/staff interviews, this inspection will need to be continued at a later date. Based on the facility inspection, and files reviewed there are no deficiencies found at this time. An exit interview was conducted, and a copy of this report was explained to Direct Support Professional Carol Enriquez. Due to printer malfunction, this report will be emailed to Direct Support Professional Carol Enriquez and Administrator Corazon Pasion.

visit_type: Annual

met_with: Corazon Pasion


summary: Facility Evaluation

raw_content:
Narrative:
On December 8, 2022 at 3:22pm, Licensing Program Analyst (LPA) Adrian Mendez arrived unannounced at the facility to conduct an Annual Continuation inspection of the Annual/Random inspection that began on 11/03/2022. LPA met with Direct Support Professional (DSP) Carol Enriquez. During the inspection LPA conducted interviews with two facility staff, and two children. LPA discussed and reviewed the following inspection components; Operational Requirements, Emergency Intervention Plan, and Emergency Disaster Preparedness. Based on the facility inspection, interviews conducted, and files reviewed there are no deficiencies found at this time. An exit interview was conducted, and a copy of this report was explained to Direct Support Professional Carol Enriquez. Due to printer malfunction, this report will be emailed to Direct Support Professional Carol Enriquez.

met_with: Carol Enriquez


facility_name: CYNTHIA'S CHILDREN'S HOME

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
LPA requested the following documents for review: Annual required training logs, placement agreements/admission agreement, agency signed policies and procedures, and Client Information/Face Sheet, Needs and Services Plans/IPP, agency case notes regarding youth 1 (Y1), police reports, and LIC 500, employee staff schedule, and Staff 1 contact information. LPAs conducted an inspection of the agency. Confidential interviews were conducted with ten individuals, and attempted with 1 individual, during the period of October 23, 2024, to November 13, 2024. During the investigation of facility staff hit a minor and Facility staff scratched a minor, LPA Martinez and LPA Green toured the facility with William Riddle (house manager). On this inspection, LPA inspected the physical plant including but not limited to the kitchen, dining room, children bedrooms, children bathrooms, laundry room, activity room, and outside courtyards of the facility. LPA Martinez reviewed client 1's (C1) file, on October 23, 2024, and obtained documentation for the complaint investigation. Annual required training logs, placement agreements/admission agreement, agency signed policies and procedures, and Client Information/Face Sheet, Needs and Services Plans/IPP, agency case notes regarding youth 1 (Y1), police reports, and LIC 500, employee staff schedule, and Staff 1 contact information. LPA conducted interviews from October 23, 2024, to November 13, 2024. Five out of ten confidential interviewees reported they never witnessed staff 1 (S1) being aggressive towards the children or hitting them. The six out ten interviewees reported they had no concerns about S1 or the facility. One out of ten Interviewees reported an altercation did occur, and they were aggressive towards a staff and hit them. One out of ten interviewees reported they never fought with C1 and C1 did not hit them. One out of ten interviewees reported they were not able to corroborate C1's physical fight with a staff. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No title 22 regulations were cited during today's inspection. An exit interview was conducted, and a copy of this report was left with William Riddle/house manager.

Investigation Findings:
13Licensing Program Analysts (LPAs) Avelina Martinez and Maie Soliman conducted an unannounced inspection to the facility on December 06, 2024 at 12: PM to deliver complaint allegation findings. LPA Martinez met with William Riddle and discussed the above allegations. On October 23, 2024, at 1: PM, Licensing Program Analysts (LPA) Kayla Green and Avelina Martinez arrived unannounced at the agency for the purpose of initiating a complaint investigation related to the above allegations. LPAs met with William Riddle and Etiana Jackson and explained the purpose of the visit. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Avelina Martinez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: CYNTHIA'S CHILDREN'S HOMEFACILITY NUMBER: VISIT DATE: 12/06/2024

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

report_type: Complaint Investigation

met_with: William Riddle, House Manager

complaint_status: unsubstantiated


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst, Ignacia Villapudua-Soto arrived at the above Group Home to conduct an announced Pre Licensing inspection of the facility on February 10, 2022 at 11: AM. LPA met with Administrator, Desiree Clifton to conduct the inspection LPA and Administrator conducted a joint inspection of the interior and exterior areas of the facility's physical plant. The front and back yards were free of clutter; and the passage ways and egress were unobstructed. No potentially hazardous items or areas were observed. The group home is requesting to be licensed for a capacity of 4 ambulatory clients, ages 7 and 17 years old. The clients are developmentally disabled. The home is a two story home. LPA observed near the front door, a single occupancy bedroom that had a single bed, bedding including mattress cover, fitted sheet, top sheet and blanket, dresser, night stand, lamp, chair and closet area. LPA observed Carbon Monoxide detectors and a gaming area is near the front entrance of the facility and has a couple of small gaming chairs and television. First level bathroom was observed and is equipped with a shower and tub with glass sliding doors and a shower curtain for privacy. LPA observed an activity area in the main seating and kitchen area of the facility and this activity area was equipped with computer, books, remote control cars, coloring pages with crayons, colored pencils, markers and sketch pads, card games and charades for kids game, puzzles and an extra table in the middle of the room that can be removed for other activities not requiring a table. LPA observed that the dining area is off of the kitchen and the table is set up for placement of four clients, however, the kitchen counter has four chairs for clients. LPA observed that there is a fire extinguisher in the dining area and upstairs. LPA observed that the kitchen area is located off the dining and living room area of the facility and that the kitchen area had the stove, microwave built in, refrigerator, double oven and pantry with no lock on the door. Inside the pantry, LPA observed plenty of non-perishable food items and snacks. LPA also observed perishable food items in the refrigerator. LPA observed that sharps are to be kept in a drawer in the kitchen and this drawer is secured by a magnetic locking system. Chemicals are to be stored under the kitchen sink and this lock is also the magnetic locking system. The facility has a working land line and cell phone. Menus and activity schedules are posted. LPA observed that the medications are stored in the closet by the front door, under the stair case leading to the second story of the facility. This closet has the first aid kit and other first aid supplies as well as cubbies to hold client medications. LPA also observed a small refrigerator in this closet that will also house medications that need refrigeration for clients in care. LPA observed that this closet has a locking door and will not be accessible to clients in care. Second story of the facility ,LPA observed that there is a laundry room in the landing area of the upstairs that is locked. The laundry room is located next to the bathroom for the clients and bedrooms for the clients. LPA observed that the three client bedrooms located on the second floor that are all single occupancy rooms equipped with the single beds in each room, bedding including mattress covers, fitted sheet, top sheet and blanket, dresser in each room, night stand in each room, lamp in each room, chair in each room and closet areas in each room as required. The bedrooms have fire detectors in each room and the Carbon Monoxide is placed in the hallway wall. LPA observed that the bathroom is equipped with a dual sink vanity and that the bathroom on the second level has a tub and shower area, no glass doors and a shower curtain. LPA toured the master bedroom on the second floor that is equipped with a bathroom for staff use; it also has extra hygiene items and beddings and the confidential staff files are locked in a cabinet. Administrator did advise that this room will be utilized for staff only and that no clients will be given access to this area. The home has a Disaster plan, Facility Sketch and Personal Rights. The facility was clean, safe, sanitary and in good repair. The facility is prepared for licensure pending a final review of the file and Licensing Program Manager's Approval. Exit interview was conducted with Administrator.

visit_type: Prelicensing

met_with: Desiree Clifton, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 2/8/ Licensing Program Analyst (LPA) Jean Stidman met with Desiree Clifton Administrator for the purpose of a Case Management Inspection. The facility had an incident that occurred when the client was not in their care on 01/12/2023 that should have been reported by 01/13/2023 but was not reported until 01/18/2023. Technical Assistance was given to the Administrator as well as Title 22 regulation 80061 on Reporting Requirements. The Administrator will ensure all incidents are reported as per required in regulations. A copy of this report was left with Desiree Clifton Administrator.

met_with: Desiree Clifton Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Jean Stidman made an unannounced Annual inspection on 6/22/23 at 10am. During the inspection LPA met with Desiree Clifton, Administrator who assisted with the inspection. LPA conducted a walk-through of the facility inside and out. Facility staff-client ratio at the beginning of inspection was one staff and one client, then three other clients and the administrator arrived during the inspection. LPA observed the home is a two story home with four bedrooms, three bathrooms and one staff office. LPA interviewed four clients and three staff. LPA inspected and/or reviewed the following: Physical Plant Posting of license_X_ Personal Rights_X__ Menu present and posted_ X__ Working telephone X Hot Water between 105-120 degree F _X_is 114 degrees F. Client Records LPA observed four client records contain the Regional Center Admission Agreement, LPA observed four out of four client records contain the medical assessment, examination for tuberculosis and immunization records. Disaster Preparedness Quarterly Drills conducted and documented_X__ Disaster preparedness supplies verified _X__ Emergency Intervention Review of manual restraint log __X__ The following items were reviewed for compliance in the regional office prior to the facility inspection: · Annual fees, Administrator Certificate for: Desiree Clifton, LIC 500, Waivers and Exceptions Facility citation violation of California Code of Regulations, Title 22, Division 6, regulation 84065(1) Personnel Requirements due to the facility does not have any staff trained to apply the Reasonable and Prudent Parent Standard. An exit interview was conducted a copy of this report was left with Desiree Clifton, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Kayla Green made an unannounced Annual inspection on 4/4/24 at 10am. During the inspection LPA met with Desiree Clifton, Administrator who assisted with the inspection. LPA conducted a walk-through of the facility inside and out. Two staff and three clients arrived during the inspection. LPA observed the home is a two story home with four bedrooms, three bathrooms and one staff office. LPA interviewed two clients and two staff. LPA inspected and/or reviewed the following: Physical Plant Posting of license_X_ Personal Rights_X__ Menu present and posted_ X__ Working telephone X Hot Water between 105-120 degree F _X_is 113 degrees F. Client Records LPA observed four client records contain the Regional Center Admission Agreement, LPA observed four out of four client records contain the medical assessment, examination for tuberculosis and immunization records. LPA observed Six staff files and criminal records were verified, first aid certificates verified, and training verified. Disaster Preparedness Quarterly Drills conducted and documented_X__ Disaster preparedness supplies verified _X__ The following items were reviewed for compliance in the regional office prior to the facility inspection: Annual fees, Administrator Certificate for: Desiree Clifton, LIC 500, Waivers and Exceptions An exit interview was conducted a copy of this report was left with Desiree Clifton, Administrator.

met_with: Desiree Clifton


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 4/16/2025 at 09:52AM Licensing Program Analyst (LPA) Angelique Hill arrived unannounced for the purpose of an annual inspection. During the inspection LPA met with Desiree Clifton, Administrator who assisted with the inspection. LPA conducted a walk-through of the facility inside and out. Two staff and three clients arrived during the inspection. LPA observed the home is a two story home with five bedrooms, three bathrooms and one staff office. LPA interviewed four staff. LPA inspected and/or reviewed the following: Physical Plant Posting of license_X_ Personal Rights_X__ Menu present and posted_ X__ Working telephone X Hot Water between 105-120 degree F _X_is 113 degrees F. Client Records LPA observed four client records contain the Regional Center Admission Agreement, LPA observed four out of four client records contain the medical assessment, examination for tuberculosis and immunization records. LPA observed four staff files and criminal records were verified, first aid certificates verified, and training verified. Disaster Preparedness Quarterly Drills conducted and documented _X__ Disaster preparedness supplies verified _X__ The following items were reviewed for compliance in the regional office prior to the facility inspection: Annual fees, Administrator Certificate for: Desiree Clifton, LIC 500, Waivers and Exceptions An exit interview was conducted a copy of this report was left with Desiree Clifton, Administrator.

Deficiencies:
84068.3(a): Modifications to Needs and Services Plan

(a) The needs and services plan specified in Section 84068.2 shall be updated at least every six months to determine the following


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
Licensing Program Analyst (LPA) Jean Stidman made an unannounced Post Licensing inspection on 6/16/23 at 12:45pm. During the inspection LPA met with Anne Cheryl Abenes, House Manager who assisted with the inspection. LPA conducted a walk-through of the facility inside and out. Facility staff-client ratio at the beginning of inspection was two staff, one client and one infant. LPA observed the home is a two story home with four bedrooms, three bathrooms and one staff office. LPA inspected and/or reviewed the following: I. Physical Plant Posting of license_Not posted in a prominent place_ Personal Rights_X__ Disinfectants/Cleaning solutions inaccessible_X_ Refrigerator Temperature at or below 45 degrees F X Freezer Temperature at or below 0 degrees X_ Nonperishable Foods one week and fresh perishable foods two days minimum_ X Menu present and posted_ X__ Working telephone X Carbon monoxide detectors _ X_Smoke Detector X First Aid Kit fully stocked_No _ Common Room available X Dining area (enough seating, furniture good condition, not broke or damaged) _ X Medication centrally stored, locked/inaccessible X Office (locked and privacy) _ X_ Hot Water between 105-120 degree F (Properly labeled if over 125 degree F_No hot water is 130 degrees_ Fire Extinguishers were inspected April Toilets wash basin, bath and shower fixtures in good repair/no leaks _ X Soap and Paper towels _ X_ Laundry Facilities(available) X_ Bedrooms-required linen and furnishings X_ Motor Vehicle properly maintained, lights, tires, registration/insurance and working seat belts X Facility free of vermin X Locked Facilities (open locked storage area/building/sheds) _No the front door was unlocked and open from approximately 12:45pm-1:45pm while three clients were being dropped off from school. Bedroom (required bedding/furniture, furniture in good repair) _ X_ IV. Emergency Intervention LPA reviewed three staff files contain current MABPro restraint training V.Staffing/Volunteers Number of Staff files reviewed _three_Criminal record clearances verified _X_ First Aid Certificate_ X Certified Administrators certificate valid and current__ administrator has applied to renew their administrator's certificate that expired in April 2023. Job title/qualification verified _X_ VI. Client Records Number of Clients files reviewed four Needs and Services Plan X_ LPA observed four client records contain the Regional Center Admission Agreement, LPA observed one out four client records were missing the medical assessment, two out four client records were missing Ambulatory status, examination for tuberculosis and immunization records. LPA observed the facility license is not posted in a prominent place, the first aid kit is not fully stocked, the hot water temperature was 130 degrees Fahrenheit, the facility front door was left open from approximately 12:45pm-1:45pm with one client and two staff present while three other clients were being dropped off from school. LPA observed the Administrator has applied to renew their administrator's certificated that expired in April 2023. LPA observed one out four client records were missing the medical assessment, two out four client records were missing Ambulatory status, examination for tuberculosis and immunization records. Facility citation violation of California Code of Regulations, Title 22, Division 6, regulations 80088(e)(1) Fixtures, Furniture Equipment and Supplies, Client Medical Assessment and 80022(k) Plan of Operation. LPA was unable to complete this inspection and will return at a later date to complete the inspection. An exit interview was conducted and a copy of this report was left with Anne Cheryl Abenes, House Manager.

Deficiencies:
80069: 1
2
3
4
5
6
7

met_with: Anne Cheryl Abenes, House Manager

title:
1
2
3
4
5
6
780069 Client Medical Assessment. 80069(a) Client Medical Assessment. The licensee shall obtain a written medical assessment of the client prior to or within 30 calendar days following the acceptance of a client and 80069(c)(1) Client medical assessments shall include results of...tuberculosis..... This requirement is not met as evidenced by

description:
1
2
3
4
5
6
7


facility_name: DANROSE HOME

summary: Facility Evaluation

raw_content:
Narrative:
On 11/17/25, Licensing Program Analyst (LPA) Mariah Hawkins met with Applicant Danrose Corporation on for the scheduled Component II face-to-face meeting. Representing the Applicant were CEO Vener Joshua Gano, Administrator Vincent Gano, Secretary/Director Jane Gano, Treasurer Venerando Gano. During the meeting, the following topics were discussed. Application Process Overview Goal/Purpose of the Facility Basic Services and Planned Activities Needs and Services Plans Care and Supervision Policies Emergency Intervention Policies Emergency Disaster Procedures Reporting Requirements Background Clearance/Guardian Process LPA and Applicant also discussed the pending application items, including the updated LIC 200, LIC 500, and revised program statement. The Applicant discussed potentially changing the served population to be all ambulatory and agreed to update LPA when that decision is finalized with Regional Center. The Component III was scheduled for 12/18/25 from 1PM-5PM. LPA thanked the Applicant representatives for attending the meeting. A copy of this report was provided to the Applicant representatives.

met_with: CEO Vener Joshua Gano; Administrator Vincent Gano; Secretary/Director Jane Gano; Treasurer/Director Venerando Gano


summary: Facility Evaluation

raw_content:
Narrative:
On Wednesday, March 25th 2026, Licensing Program Analyst (LPA) Mariah Hawkins conducted an announced prelicensing inspection that was scheduled in advance with the applicant. LPA met with Chief Executive Officer and Assistant Administrator Vener Joshua Gano, Vice President and Administrator Vincent Gano, Directors Venerando Gano, Jane Gano, Vito Jason Gano, and Facility Manager Leoraine Carandang. During the inspection, LPA toured the facility site and reviewed licensing procedures. LPA observed the facility to be a single-story house in a residential neighborhood. The facility and grounds were maintained in safe condition. The kitchen and bathrooms were sanitary. There are two refrigerators on site and kitchen cabinetry and backup pantry storage which contained cooking and eating utensils and a large supply of fresh foods and dry foods. Bedrooms, bathrooms, and living spaces were decorated and organized. There are four single-occupancy bedrooms with individual beds, individual linens including mattress pads, closets and drawers. Lights were observed to be functioning in all rooms. The outdoor space is free of obstructions. Activity supplies have been obtained and were stored neatly in the living room. Sharps were stored in a locked drawer. Chemicals were stored in a locked cabinet. Medications will be stored in a locked cabinet. A facility sketch, emergency disaster procedures, personal rights, disability rights, licensing agency complaint line, and facility grievance procedures were posted prominently in the living room. Continued -- See Lic 809-c Using the CARE inspection tool, LPA identified a few items to correct. LPA provided the regulatory language for applicant's reference. A) Obtain first aid scissors for the first aid kit. [80075(g)(1)(E)] B) Lower hot water to within permitted range of F to F. [80088(e)(1)-(2)] C) Include summary of emergency intervention procedures (intervention descriptions, time limits) provided in the CPI training within the emergency intervention plan (EIP) in the program statement (PS). [84322] D) Include discussion of monthly manual restraint log in the EIP in the PS. [84361(f)] LPA discussed the next steps in the application process and the anticipated timeline. The application is in Pending status and is pending completion of the items above and licensing management review and approval. An exit interview was conducted, and a copy of this report was provided to applicant representatives.

met_with: Vener Joshua Gano, Vincent Gano, Venerando Gano, Jane Gano, Vito Jason Gano, Leoraine Carandang


facility_name: DAYLEE JOY RESIDENTIAL

summary: Facility Evaluation

raw_content:
Narrative:
On July 23, 2024, at 9: AM, Component II of the application process for Daylee Joy Residential Group Home located Hobart Blvd. Los Angeles, Ca. 90047 was held at the El Segundo Children's Residential Regional Office in El Segundo. Attending Component II were the following individuals: Licensing Program Analyst (LPA), Charmetha White, and Administrator, Leah Hawkins. The purposes of this Component II meeting were to review the incomplete application and Program Statement and to resolve any outstanding concerns that may have existed. The following incomplete application forms were discussed at the meeting: Financial Information Release and Verification (LIC 404), Personnel Report (LIC 500), Group Home Orientation Certificate, CPR certificates, staff facility association and Group Home Hour Administrator certificate. Program Statement: Sections 1-29 was reviewed and discussed. Pre-Licensing Inspection will be conducted on July 26, 2024, at 9: AM. A copy of this report was issued to the Administrator, Leah Hawkins.

met_with: Administrator - Leah Hawkins


summary: Facility Evaluation

raw_content:
Narrative:
On July 26, 2024, at 9: AM, Licensing Program Analyst (LPA) C. White made an announced visit to the above location, for the purpose of conducting a Pre-Licensing Inspection for the pending licensure of Daylee Joy Residential Group Home. LPA met with Administrator, Leah Hawkins, who granted access to the home, and provided a tour of the interior and exterior physical plant. This home is seeking a license to provide care and supervision for five (5) developmentally disable children ages, 12-17 years old, ambulatory only, and non-minor dependents. Currently the census is zero (0). There is no pool or bodies of water on the premises. The Administrator confirmed that there are no firearms or dangerous weapons on the premises. LPA observed the following during the inspection: The facility is a three (3) bedroom, two (2) bathroom single family dwelling located in a residential neighborhood. The front porch is completely enclosed with a black iron gate and the home is set up as follows: Living room, Dining room, Kitchen, Office area, Laundry area, Backyard, detached garage, and detached office. Living room: has two (2) couches, a chair, a mounted TV, and a glass enclosed non-operational fireplace. Dining room: has table and four (4) chairs. Kitchen: has double door refrigerator/freezer, five (5) burner gas stove/oven (all burners were operational at time of this inspection), a microwave, dishwasher, ample plates, cups, and eating utensils. There is also a kitchen nook containing a small table with two (2) chairs, and a locked filed cabinet, which will be used to store medication. Laundry area: is located off the kitchen and has a stackable washer and dryer, there is also an exit door leading to the side of the home. Backyard: has ample space. LPA observed lose stones and a hole in walkway. Report continued on LIC 809C. (Page 1 of 3) Detached garage: Administrator informed LPA the garage is used for storage by property owner. LPA will return to view garage as administrator did not have access at the time of this inspection. Detached Office: LPA observed office is under construction; the outer exterior has unfinished walls, interior will be used as an office, and at the time of this inspection it is being used for storage. Bedrooms: Bedroom #1 and #3: have two (2) twin beds; Bedroom #2 has one (1) twin bed. Each room has closet space. There were no dressers in the bedrooms. All bedrooms have a mounted TV, a ceiling fan/working light, and security bars. The security bar emergency latches were not operational at the time of this inspection. Bathrooms: Bathroom #1 is located along the hallway, adjacent to bedroom #1 and has a toilet, tub, shower, and sink. Bathroom #2 is located off the kitchen near the laundry area and has a toilet and sink. Hot water was tested and measured within 105 - 120 degrees Fahrenheit. LPA observed the home to have a three (3) fully charged fire extinguisher. The smoke detectors were tested and found to be in working order. All posting requirements were met. The temperature of the facility is regulated by window mounted air conditioners throughout and electric floor heaters. LPA observe the facility to have a camera system that monitors the exterior of the home (front yard, both sides of the home, porch, and driveway) only. LPA reminded Administrator to ensure the following when children are in placement: Children are accorded personal rights. Children are to be supported and encouraged to participate in extracurricular activities. Children are allowed and encouraged to contact the licensing agency, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. During the visit, LPA reiterated the importance of submitting Special Incident Reports, Law Enforcement contacts, and to report all changes within the home to Community Care Licensing and any other appropriate agency. Administrator acknowledges abuse reporting requirements. Report continued on LIC 809C (Page 2 of 3). Vehicle: Currently the facility does not have a vehicle to transport the clients. The administrator will provide information about the company vehicle later to be inspected. The following items need to be in the home prior to licensure: Perishable and Nonperishable food supply in the quantity per the regulations Drawers for clients' rooms Operational Security bar releases Carbon monoxide deter Extra linens Hygiene products for clients Cleaning/laundry supplies Locked storage for poisons/cleaning supplies First Aid kit complete with scissors, thermometer, tweezers Working facility telephone Locked storage cabinet for client & staff files An exit interview was conducted. A copy of this report was left with the Administrator. Application review will continue when the above items and all items discussed during the Component II (face-to-face office meeting) have been completed. (Page 3 of 3).


summary: Facility Evaluation

raw_content:
Narrative:
On September 19, 2024, at 9: AM, Licensing Program Analysts (LPA's) C. White and J. Armstrong made an announced visit to the above location, for the purpose of conducting a second Pre-Licensing Inspection for the pending licensure of Daylee Joy Residential Group Home. LPA's met with Administrator, Leah Hawkins, who granted access to the home, and provided a tour of the interior and exterior physical plant. This home is seeking a license to provide care and supervision for five (5) developmentally disable children ages, 12-17 years old, ambulatory only, and non-minor dependents. Currently the census is zero (0). LPA's observed the following during the inspection: The facility is a three (3) bedroom, two (2) bathroom single family dwelling located in a residential neighborhood. The front porch is enclosed with a black iron gate and the home is set up as follows: Living room, Dining room, Kitchen, Office area, Laundry area, Backyard, detached garage, and detached office. Living room: has two (2) couches, a chair, a mounted TV, a glass enclosed non-operational fireplace. LPA's observe the facility to have a camera system that monitors the exterior of the home (front yard, both sides of the home, porch, and driveway) only. Dining room: has a wooden table and six (6) chairs. Kitchen: has double door refrigerator/freezer, five (5) burner gas stove/oven (all burners were operational at time of this inspection), two (2) microwaves, a dishwasher, ample plates, cups, and eating utensils. There is also a kitchen nook containing a small table with two (2) chairs, and a locked filed cabinet, which will be used to store medication. Laundry area: located off the kitchen, has a stackable washer and dryer, an exit door leading to the side of the home, and a staff bathroom. Backyard: has ample space, with turf grass. Report continued on LIC 809C (page 1 of 3) Detached garage: LPA's observed the garage being used to store clothing, it also contains a small sink and a non-operational stove. Administrator informed LPA's items in the garage belong to the property owner. Detached Office: LPA's observed to office being used as storage. Bedrooms: Bedroom #1 and #3: have two (2) twin beds; Bedroom #2 has one (1) twin bed. Each room has ample closet space, two (2) drawers for each client, and working combination light/ceiling fans. All bedrooms have a mounted TV. LPA's observed partial security bars on bedroom windows which allow for emergency exiting. Bathrooms: Bathroom #1 is located along the hallway, adjacent to bedroom #1 and has a toilet, tub, and separate shower, and sink. Bathroom #2 is located off the kitchen near the laundry area and has a toilet and sink. Hot water was tested and measured within 105 - 120 degrees Fahrenheit. LPA's observed the home to have a three (3) fully charged fire extinguisher, one (1) in the kitchen, one (1) in the living room, and one (1) along the hallway. The smoke alarms and carbon monoxide detectors were tested and found to be in working order. All posting requirements were met. Temperature in the facility is regulated by window mounted air conditioners throughout and electric floor heaters. There is no pool or bodies of water on the premises. The Administrator confirmed that there are no firearms or dangerous weapons on the premises. LPA's observed the facility to be clean, safe, and sanitary. Passageways, stairways, inclines, ramps and open porches are unobstructed. The front and backyard were clean and free of debris. Vehicle: Facility will use a Dodge Caravan to transport the clients. LPA's inspected the interior and exterior of the vehicle. LPA's observed all seatbelts, the front lights, brake lights, back up lights, blinkers, and horn to be in working order. Vehicle registration is current through June 2025. Report continued on LIC C (page 2 of 3). LPA's reminded Administrator to ensure the following when children are in placement: Children are accorded personal rights and to ensure the corresponding form are placed in their file. Children are supported and encouraged to participate in extracurricular activities. Children are allowed and encouraged to contact the licensing agency, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. Administrator acknowledges abuse reporting requirements. During the inspection, LPA's reiterated the importance of submitting Special Incident Reports, Law Enforcement contacts, and to report all changes within the facility to Community Care Licensing and any other appropriate agency. LPA's informed Administrator that a Component III Tele-orientation will be scheduled per Community Care Licensing procedures. An exit interview was conducted. A copy of this report was left with the Administrator. (Page 3 of 3).


summary: Facility Evaluation

raw_content:
Narrative:
On March 28, at 9: AM, Licensing Program Analysts J. Armstrong and License Program Manager E. Hernandez made an announced visit to the above location, for the purpose of conducting a Post Licensing Inspection. LPA and LPM met with Administrator, Leah Hawkins, who granted access to the home, and provided a tour of the interior and exterior physical plant. This home is licensed to provide care and supervision for five (5) developmentally disable children ages, 12-17 years old, ambulatory only, and non-minor dependents. Currently the census is zero (0). LPA and LPM observed the following during the inspection: The facility is a three (3) bedroom, two (2) bathroom single family home located in a residential neighborhood. The front porch is enclosed with a black iron gate and the home is set up as follows: Living room, Dining room, Kitchen, Office area, Laundry area, Backyard, detached garage, and detached office. Living room: has two (2) couches, a chair, a mounted TV, a glass enclosed non-operational fireplace. LPA and LPM observe the facility to have a camera system that monitors the front yard. Dining room: has a wooden table and six (6) chairs. With the posting of Personal Rights, Facility Map, Emergency Contact list, and House Values/Expectations. Kitchen: has double door refrigerator/freezer, five (5) burner gas stove/oven (all burners were operational at time of this inspection), two (2) microwaves, a dishwasher, ample plates, cups, and eating utensils. There is also small office space in the kitchen containing a small table with two (2) chairs, and a locked filed cabinet, which will be used to store medication. Laundry area: located off the kitchen, has a stackable washer and dryer, an exit door leading to the side of the home, locked cabinets for storage and a staff bathroom. Report continued on LIC 809C (page 1 of 3) Backyard: has ample space, with turf grass. Detached garage: LPA and LPM was not able to see the garage due to Licensee not having the key, Licensee will get a copy of the key from the property owner. Licensee stated the garage is used for storage for the property owner. Detached Office: LPA's observed to office being used as storage. Bedrooms: Bedroom #1 and #3: have two (2) twin beds; Bedroom #2 has one (1) twin bed. Each room has ample closet space, two (2) drawers for each client, and working combination light/ceiling fans. All bedrooms have a mounted TV. LPA and LPM observed partial security bars on bedroom windows which allow for emergency exiting. Bathrooms: Bathroom #1 is located along the hallway, adjacent to bedroom #1 and has a toilet, tub, and separate shower, and sink. Bathroom #2 is located off the kitchen near the laundry area and has a toilet and sink. Hot water was tested and measured within 105 - 120 degrees Fahrenheit. LPA's observed the home to have a three (3) fully charged fire extinguisher, one (1) in the kitchen, one (1) in the living room, and one (1) along the hallway. The smoke alarms and carbon monoxide detectors were tested and found to be in working. All posting requirements were met. Temperature in the facility is regulated by window mounted air conditioners throughout and electric floor heaters. There is no pool or bodies of water on the premises. The Administrator confirmed that there are no firearms or dangerous weapons on the premises. LPA's observed the facility to be clean, safe, and sanitary. Passageways, stairways, inclines, ramps and open porches are unobstructed. The front and backyard were clean and free of debris. Vehicle: Facility will use a Dodge Caravan to transport the clients. LPA inspected the interior and exterior of the vehicle. LPA observed all seatbelts, the front lights, brake lights, back up lights, blinkers, and horn to be in working order. Vehicle registration is current through June 2025. Report continued on LIC C (page 2 of 3). LPA's reminded Administrator to ensure the following when children are in Place: To make sure to have non- perishable and perishable foods that is not expired, to clean the backyard to be free of debris, to retrieve a copy of the garage key from the property owner. During the inspection, LPA reiterated the importance of submitting Special Incident Reports, Law Enforcement contacts, and to report all changes within the facility to Community Care Licensing and any other appropriate agency. An exit interview was conducted. A copy of this report was left with the Administrator. (Page 3 of 3).

met_with: Leah Hawkins


summary: Facility Evaluation

raw_content:
Narrative:
On 12/30/2025, Licensing Program Analyst, C. White arrived at Daylee Joy Residential for the purpose of conducting an Annual/Required Inspection. LPA met with Facility Manager, Jason Watson who granted access to the facility and together toured the interior and exterior of the facility. The facility is licensed to provide care and supervision to five (5) children, ages 13-17 years old, ambulatory only. The current census is zero (0). The facility is a three (3) bedroom, two (2) bathroom single family home located in a residential neighborhood. The front porch is enclosed with a black iron gate, and the home is set up as follows: Living room, Dining room, Kitchen, Office area, Laundry area, Backyard, Detached Garage, and Detached Office. Living room: has one (1) couch, one (1) ottoman, a mounted TV, and a glass enclosed non-operational fireplace. Dining room: has a wooden table and eight (8) chairs. With the posting of Personal Rights, Facility Map, Emergency Contact list, and House Values/Expectations. Kitchen: a kitchen nook, double door refrigerator/freezer, five (5) burner gas stove/oven (all burners were operational at time of this inspection), two (2) microwaves, a dishwasher, ample plates, cups, and eating utensils, and a covered trash can. Office Area: is located in the kitchen nook. It contains a small table with two (2) chairs, and a locked filed cabinet, which will be used to store medication. Laundry area: located off the kitchen, has a stackable washer and dryer, an exit door leading to the side of the home, and a staff bathroom. Report continued on LIC 809C (Page 1 of 3) Backyard: has ample space, turf grass covers a portion of the area, and there is an additional cemented area. Detached garage: LPA was unable to view the interior due to Licensee not having the key. Facility Manager stated the garage is used for storage for the property owner. Detached Office: LPA observed to office being used for storage. Bedrooms: Bedroom #1 and #3: have two (2) twin beds; Bedroom #2 has one (1) twin bed. Each room has ample closet space, two (2) drawers for each client, and working combination light/ceiling fans. All bedrooms have a mounted TV. LPA observed partial security bars on bedroom windows which allow for emergency exiting. Bathrooms: Bathroom #1 is located along the hallway, adjacent to bedroom #1 and has a toilet, tub, and separate shower, and sink. Bathroom #2 is located off the kitchen near the laundry area and has a toilet and sink. Hot water was tested and measured within 105 - 120 degrees Fahrenheit. LPA observed the home to have a three (3) fully charged fire extinguisher. The carbon monoxide detector and smoke alarms were tested and found to be in working order. All posting requirements were met. Temperature in the facility is regulated by window mounted air conditioners throughout and space heaters. The Facility Manager confirmed that there are no firearms or dangerous weapons on the premises. LPA observed the facility to be clean, safe, and sanitary. Passageways, stairways, inclines, ramps and open porches are unobstructed. The front and backyard were clean and free of debris. LPA reminded Facility Manager to ensure the following when children are in placement: Children are accorded personal rights and to ensure the corresponding form are placed in their file. Children are supported and encouraged to participate in extracurricular activities. Children are allowed and encouraged to contact the licensing agency, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. Facility Manager acknowledges abuse reporting requirements. Report continued on LIC 809C (Page 2 of 3) During the inspection, LPA reiterated the importance of submitting Special Incident Reports, Law Enforcement contacts, and to report all changes within the facility to Community Care Licensing and any other appropriate agency. LPA did not review client or staff files as there are no clients in placement at this time. LPA informed Facility Manager, Jason Watson, that the facility would be cited. The following deficiency is being cited for violating of California Code of Regulations Title 22, Division Regulation Section 80023(a) Disaster and Mass Casualty Plan and Regulation Section 84087.2(a) Outdoor Activity Space. (see page D). An exit interview was conducted. A copy of this report was left with the Facility Manager. (Page 3 of 3).

met_with: Jason Watson - Facility Manager


facility_name: DELTA RESIDENTIAL - RIDGE CREST

summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
inappropriate sexual incidents among residents, particularly during times when residents are still awake. While residents were upstairs to fall asleep, supervision should not lapse during night time, particularly at a time where it could be reasonably believed that not all residents are yet asleep, as was the case with this incident. Night staff should be present in the facility at a location where supervision can be provided to all residents and all activity can be clearly seen and heard to ensure appropriate intervention can be provided as needed. The preponderance of evidence standard has been met, and therefore the above allegation is found to be Substantiated. LPA is issuing a citation of California Code of Regulations, Title 22, Section 84065. Staff/Child Ratios. LPA also recommends that moving forward, the facility consider the history of and/or tendency for, within the served population, inappropriate sexual incidents and ensure that all residents have appropriate supervision when at the facility together, including those who do not have a specific requirement in their program plan for 24/7 supervision. An exit interview was conducted, appeal rights provided, and a copy of this report left with Facility Manager Liza Tagpis, whose signature on this form confirms receipt.

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

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

met_with: Facility Manager Liza Tagpis

complaint_status: SUBSTANTIATED


summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13On 11/03/22, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility, which has transitioned to an adult facility, to deliver findings for the invesitgation of the above allegation. LPA met with Facility Manager Liza Tagpis and informed of the purpose of the visit. Based on confidential interviews and record review, the allegation pertains to an incident in which a staff member sent inappropriate messages to a then former resident. Based on interviews, it is not clear that any inappropriate messages or interactions occurred or were sent while the resident was in care at this facility. The staff member was immediately removed from the schedule and no longer works for the licensee, and based on interviews, no repeat or similar incident has occurred. Although the allegation may have happened or is valid, based on LPA's observations and interviews, there is not a preponderance of the evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. An exit interview was conducted, appeal rights provided, and a copy of this report was provided to Facility Manager Liza Tagpis, whose signature on this form confirms receipt. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Mendoza LICENSING EVALUATOR NAME: Mariah Hawkins LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3


summary: Facility Evaluation

raw_content:
Narrative:
On 4/7/22 at 1PM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility regarding the group home facility closure. LPA met with Supervisor Edwin Isip and Administrator Ryan Busalacchi informed of the purpose of the visit. Safety precautions were taken, including mask-wearing, entry screening, and pre-visit screening call. The facility has received an Adult Residential Facility (ARF) license on 12/14/21 and will be closing the group home facility. Closure letter, closure plan, and forfeited license have not yet been sent to Licensing. LPA requested these items when notified of the transition to ARF and surrender of group home license on 3/2/22. Today, LPA received the formal closure notice and closure plan from Administrator Ryan Busalacchi, as well as the ARF license, and LPA collected the forfeited group home license at visit. LPA issued a citation of Health and Safety Code, Section 1524. See attached LIC 809-D. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Supervisor Edwin Isip and Administrator Ryan Busalacchi, whose signature on this form confirms receipt.

met_with: Supervisor Edwin Isip, Administrator Ryan Busalacchi


summary: Facility Evaluation

raw_content:
Narrative:
On 11/03/22, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility, which has transitioned to an adult facility, to deliver a deficiency citation regarding an investigation at the facility. LPA met with Facility Manager Liza Tagpis and informed of the purpose of the visit. During an investigation at the facility, it was learned that an incident occurred involving a facility staff member sending inappropriate online messages to a former resident shortly after their move to a new placement. While the resident was no longer in care, their online information and/or identifying information to locate them online was secured due to the resident having been in care while the staff member was employed at the facility. The staff member did not ensure the resident was accorded dignity and respect. LPA is issuing a citation of California Code of Regulations, Title 22, Section 84072(d)(1). See attached LIC 809-D. An exit interview was conducted, appeal rights provided, and a copy of this report was provided to Facility Manager, whose signature on this form confirms receipt.


facility_name: DELTA RESIDENTIAL - STONY HILL

summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
... at the facility at between 6-6:30AM, the Facility Manager checked on the resident and then called 911. The resident was assessed by a doctor on the same day of the seizure, and a follow-up evaluation by a neurologist was scheduled. Due to the fact that the resident did not have seizures in their care plan, there was no seizure plan in place, so when the signs of a seizure were recognized, 911 should have been called immediately. The preponderance of evidence standard has been met, and therefore the above allegation is found to be substantiated. LPA is issuing a citation of California Code of Regulations, Title 22, Division 6, Chapter 1, Article 6, Section Health Related Services. See attached LIC 9099-D. An exit interview was conducted, appeal rights provided, and a copy of this report left with Supervisor Edwin Isip and Administrator Ryan Busalacchi, whose signature on this form confirms receipt.

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


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

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

met_with: Edwin Isip, Facility Supervisor


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

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

met_with: Edwin Isip, Facility Manager


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

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


met_with: Edwin Isip, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 3/7/22 at 10:04AM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility for a required annual inspection. LPA met with Supervisor Edwin Isip and House Manager Maria Tan and informed of the purpose of the visit. A screening call was conducted with Supervisor Edwin and Administrator Ryan Busalacchi prior to visit. Safety precautions taken including mask-wearing and social distancing. The CARES Inspection Tool was used to conduct this inspection. At 10:15AM, LPA toured the facility site. At 11AM, LPA inspected the facility and personnel records. At 2:55PM, LPA had completed the review of facility and personnel records but determined that a follow-up visit would be needed in order to complete the inspection of the resident records and to complete the visit report. LPA communicated the pending items that needed to be addressed and that the full report would be available during the follow-up visit. Supervisor and House Manager stated they agreed and understood. An exit interview was conducted, and a copy of this report was left with Supervisor Edwin Isip, whose signature on this form confirms receipt.

met_with: Supervisor Edwin Isip, House Manager Maria Tan


summary: Facility Evaluation

raw_content:
Narrative:
On 3/11/22 at 11:17AM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility for a case management - annual continuation. LPA met with Supervisor Edwin Isip and House Manager Maria Tan and informed of the purpose of the visit. Safety precautions were taken, including mask-wearing, entry screening, and pre-visit screening call. During the initial inspection on 3/07/22, LPA inspected the facility and grounds and facility and personnel files using the CARES Inspection Tool. LPA continued with the tool to complete the inspection of resident records. At visit, LPA re-toured the facility and reviewed the resident records. At 4:30PM, LPA had completed the review of all records but determined that a follow-up visit would be needed in order to complete the visit report and supplemental pages. LPA communicated the deficiencies with Supervisor and House Manager and that the full report would be available during a follow-up visit. Supervisor and House Manager stated they agreed and understood. An exit interview was conducted, and a copy of this report was left with Supervisor Edwin Isip, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Alyssa Ng on 3/14/22 at 10:45AM. During the inspection, LPA Ng met with Maria Tan (Facility Manager) and inspected the facility inside and out. LPA reviewed 2 of child's records on site at the facility at 11: PM. At 12:30, LPA asked facility manager for staff files regarding training. The facility was given two technical violations during an annual inspection on 3/11/2022 for: CCR 84068.3(a): The needs and services plan specified in Section 84068.2 shall be updated at least every six months to determine the following. CCR 84066(b)(6): The licensee shall maintain the following personnel records: (6) A record of each work performance evaluation and any correspondence with the employee. Both plan of correction dates are on April 4th 2022. LPA reviewed 2 of child's psychotropic medications and records at 1: PM. Due to not having staff files ready for review and needs and service plans available, LPA was unable to review staff files but reviewed C1 and C2's 2020- ISP. LPA interviewed 2 of staff on site at 2: PM. ------ Cont. On Lic809-c------ LPA interviewed 0 clients currently taking psychotropic medication at 2: PM. C1 said waved Hi but was unable to answer questions. C1 seemed to be in good spirits. When counting one of the medications for C1, there was 18 pills extra. Facility Manager advised that C1 went to the hospital for those days and did not know if the hospital gave the medication to C1. LPA Ng advised to put it on a destruction log and properly dispose of the extra medication. LPA conducted exit interview with Maria Tan, Facility Manager at 3: PM. LPA provided the Summary Report to Maria Tan, Facility Manager upon completion. No deficiencies were cited today. LPA conducted exit interview with Maria Tan, Facility Manager at 3: PM.

met_with: Maria Tan


summary: Facility Evaluation

raw_content:
Narrative:
On 05/13/26 at 12:04PM, Licensing Program Analyst (LPA) Kaitlyn Wong conducted a quarterly case management inspection in accordance with the terms agreed upon during the April Noncompliance Conference (NCC). LPA met with Ryan Bussalacchi, Licensee, and Edwin Isip, Administrator, and explained the purpose of the visit. LPA requested a tour of the facility and found it to be in good repair. There were two days of perishable foods and seven days non-perishable foods. LPA observed facility license, personal rights, facility sketch, meal menu, and other forms posted on the walls throughout the facility. No deficiencies were found at this time. The facility has a census of 3. Facility is currently licensed to serve a capacity of six clients, up to two non-ambulatory, and ages 6-17. Licensee explains the application to transition into an Adult Residential Facility has completed review and were awaiting the fire clearance to be received. As outlined in the NCC terms, several requirements were reviewed. The administrator is working the required 16 hours per week at the facility. The facility has a compatibility review to be used for new client intake. LPA reviewed 3 resident files and found them to be up to date and containing all required documents. LPA reviewed 4 random staff files to have Mandated Reporter certificates and Title Reporting Requirement Training certificates. LPA observed that the facility reviewed licensing reporting requirements during a weekly meeting for all facility managers on April 6, 2026. LPA also reviewed an in-house training on Title 22 reporting requirements, and all staff were last trained on April 7, 2025 and scheduled to be retrained August 2026. Facility Administrator stated that the three mandated reporter postings were temporarily removed for review. LPA observed that the posters were still located on-site and re-posted where visible to all personnel. No deficiencies were found. An exit interview was conducted and a copy of this report was left with Ryan Bussalacchi, Licensee whose signature confirms receipt.

met_with: Ryan Bussalacchi, Licensee


facility_name: DELTA SERENITY HOME

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

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

met_with: Jamila Wilson-Smith, Facility Manager


met_with: Jamila Wilson, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 12/19/24 at 11AM, Licensing Program Analyst (LPA) Mariah Hawkins met with Chief Executive Officer Ron Dhillon, Chief Financial Officer Mandave Sandhu, Administrator Nick Moriana, and Consultant Amy Fox for the scheduled Component II face-to-face meeting. The meeting was held over Microsoft Teams. The purpose of this meeting was to discuss the facility's Plan of Operation and Program Statement. The following items were discussed: - Goal/Purpose of the Group Home - Admission Criteria - Basic Services and Planned Activities - Needs and Services Plans - Care and Supervision Policies - Staff Training - Emergency Intervention Policies - Reporting Requirements - Visitation Policies - Background Clearance/Guardian Process LPA provided clarification on the next steps in the application process. An exit interview was conducted, and a copy of this report was provided to Chief Executive Officer Ron Dhillon via email.

met_with: Director Ron Dhillon


summary: Facility Evaluation

raw_content:
Narrative:
On 2/6/25 at 12PM, Licensing Program Analyst (LPA) Mariah Hawkins met with Executive Director Ron Dhillon, Administrator Nick Moriana, and Board Member Mandave Sandhu for a schedule prelicensing inspection. Using the CARE Inspection Tool, LPA toured the facility site and grounds and discussed the facility's application. The facility is a single-story house in a residential neighborhood. The house is set up with three double-occupancy bedrooms, one and a half bathrooms, and a master suite bedroom currently set up as a staff office with locked storage for medications and emergency supplies. There are three living areas, one dining area, a laundry room, and a two-car garage. There are multiple closets and cabinets throughout the facility for storage of linens and other facility supplies. Hot water initially measured above the permitted range, but the water heater setting was lowered, and hot water measured within range by the end of the visit. The facility has a thermometer and the Applicant plans to monitor hot water temperatures. The facility has a video camera set up beside the garage that is not in use. However, Appilcant expressed interest in putting up cameras, and LPA suggested Applicant refer to PIN 24-09-CRP. Additionally, there are unsecured paint cans in the garage that Applicant agreed to remove upon completion of planned painting touch-ups and notify LPA once that is complete. LPA discussed the forms still needed for the application and the pending program statement updates. Most forms were obtained at visit. LPA informed Applicant to expect a summary of all pending items by 2/11/25. Based on this inspection, upon completion of the items discussed above, the facility will be ready for licensure. A copy of this report was provided to Executive Director Ron Dhillon.

met_with: Director Ron Dhillon, Administrator Nick Moriana, Board Member Mandave Sandhu


summary: Facility Evaluation

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Narrative:
On 06/17/25 at 10:50am, Licensing Program Analyst (LPA) Kristin Pierotti and LPA Simran Nayar conducted a post-licensing inspection. LPAs met with Nick Moriana, Facility Administrator and informed of the purpose of the visit. LPAs used the CARE Inspection Tool and conducted a tour of the facility site, review of 5 personnel records and 2 resident records, and confidential interviews with 1 staff member and 1 resident. LPAs observed the facility to be in good condition, clean and well organized. Kitchen and bathrooms are sanitary. The facility currently has 2 residents and each resident has their own bedroom with individual beds and plenty of storage for personal items. The rooms and common spaces are nicely decorated and furnished. Medications, sharps, and chemicals are stored where inaccessible to the residents. LPAs observed personnel and resident records to be complete and had all necessary documents. Staff have full background clearances, and first aid training certifications. All staff are actively completing the initial training requirements. Residents' records contain current emergency contact information, complete care plans, accurate medication records and cash records. Based on interviews, LPAs observed staff to be knowledgeable of facility policies, mandated reporting, and intervention procedures. LPAs observed residents to each be provided 1:1 supervision, to be dressed in well-fitting, appropriate, and clean clothes, and to appear comfortable in care, showing no hesitation around staff or in responding to staff guidance. Continue on LIC812C No deficiencies were observed. An exit interview was conducted and a copy of this report, was left with Facility Administrator whose signature confirms receipt.

met_with: Nick Moriana, Facility Administrator


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Investigation Findings:
13On 11/18/2025 at 11:00am, Licensing Program Analyst (LPA) Jonathan Medina conducted a visit at the facility regarding the above complaint allegation. During visit LPA amended and corrected previous licensing visit reports for this complaint. LPA met with Jamila Wilson, Facility Manager and informed them of the purpose of the visit. Based on confidential interviews the preponderance of evidence standard has been met. Therefore, the allegation "Licensee encourages youth to depart from the facility for long periods of time" is SUBSTANTIATED. Facility is being cited for violation of California Code of Regulations (CCR), Title 22, Division 6, Chapter 1, Section 80022(k). See attached LIC9099-D. An exit interview was conducted, appeal rights discussed and a copy of this report was left with Jamila Wilson, Facility Manager whose signature on this form confirms receipt. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Jonathan Medina LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., SUITE FACILITY NAME: DELTA SERENITY HOMEFACILITY NUMBER: 075650180

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

met_with: Jamila Wilson-Smith (Facility Manager)


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Investigation Findings:
13On December 11, 2025, at 12:00 p.m., Licensing Program Analyst (LPA) Jonathan Medina conducted a complaint inspection at the facility and spoke with Facility Manager Jamila Wilson-Smith. The purpose of the visit was to deliver findings for the above listed complaint allegation. Through interviews with staff and clients, and a review of facility records, the preponderance of evidence standard has been met. The allegation that facility staff are not providing a safe environment to clients in care is SUBSTANTIATED. According to the facility's Program Statement, staff are required to be certified in Pro-Act training within 90 days of being hired. This requirement was not met. Pro-Act is a training program designed to help staff respond to and de-escalate challenging behaviors safely. Because this training was not completed as required and there were several incidents of clients experiencing escalated behaviors, the facility is being cited for violating California Code of Regulations (CCR), Title 22, Division 6, Section 80022(k) - Plan of Operation. Please refer to the attached LIC9099-D for more details. An exit interview was conducted, appeals rights discussed, and a copy of this report was provided to Facility Manager Jamila Wilson-Smith. Her signature confirms receipt of the report. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Jonathan Medina LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., SUITE This is an official report of an unannounced visit/investigation of a complaint received in our office on 10/30/2025 and conducted by Evaluator Jonathan Medina COMPLAINT CONTROL NUMBER: 14-CR- FACILITY NAME:DELTA SERENITY HOMEFACILITY NUMBER: ADMINISTRATOR:CRYSTAL LANDAFACILITY TYPE: ADDRESS: INCLINE CTTELEPHONE: (925) 300- CITY:ANTIOCHSTATE: CAZIP CODE: CAPACITY:6CENSUS: 4DATE: 12/11/ UNANNOUNCEDTIME BEGAN: 12: PM MET WITH:Jamila Wilson-Smith, Facility ManagerTIME COMPLETED:01: PM 9Lack of supervision - staff allowing inappropriate interaction between youth. INVESTIGATION FINDINGS: 13On December 11, 2024, at 12:00 p.m., Licensing Program Analyst (LPA) Jonathan Medina conducted a complaint investigation visit to deliver the findings. LPA met with Facility Manager Jamila Wilson-Smith and explained the purpose of the visit. Based on confidential interviews and record review, although the above allegation may have happened or is valid, there is not a preponderance of evidence to prove that the above-listed allegation did or did not occur. Therefore, the above allegation is UNSUBSTANTIATED. Due to conflicting statements and review of video footage, there is insufficient evidence to confirm that staff are allowing inappropriate interactions. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to Facility Manager, Jamila Wilson-Smith. Her signature on this form confirms receipt. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Jonathan Medina LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 2 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., SUITE FACILITY NAME: DELTA SERENITY HOMEFACILITY NUMBER: 075650180

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


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Narrative:
POC was cleared immediately due to facility management putting staff member on 30 day leave to investigate then provided staff with additional training on boundaries and good practice for youth service providers through Seneca trainings. An exit interview was conducted, appeals rights discussed, and a copy of this report was provided to Administrator, Carolyn Williams. Her signature confirms receipt of the report.

Investigation Findings:
13On April 14, 2026, at 12:00 p.m., Licensing Program Analyst (LPA) Jonathan Medina conducted a complaint inspection at the facility and spoke with Adminitrator, Carolyn Williams. The purpose of the visit was to deliver findings for the above listed complaint allegation. Facility Manager, Mandave Sandhu was also present during the visit. Through confidential interviews and a review of facility records, the preponderance of evidence standard has been met. The allegation that facility staff showed an inappropriate photo to a minor in care is SUBSTANTIATED. The investigation determined that during a conversation between a client and a staff member about Ozempic, the staff member showed the client progress photos of body improvements. Although the staff member cropped out private areas, they were nude in the photos, which made the client feel uncomfortable. The facility is being cited under California Code of Regulations (CCR), Title 22, Division 6, Section 84072(d)(1) Personal Rights. Please refer to the attached LIC9099-D for more details. Continues on LIC9099-C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Jonathan Medina LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., SUITE FACILITY NAME: DELTA SERENITY HOMEFACILITY NUMBER: 075650180

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

met_with: Carolyn Williams - Administrator


facility_name: DIAMONDS IN THE ROUGH GROUP HOME

summary: Facility Evaluation

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Narrative:
On 08/23/21 at 9: AM, Licensing Program Analyst's (LPAs), Pamela Silva and Juliet Robles, conducted an unannounced Post Licensing inspection at the facility and met with Dr Dwon Phillips, Administrator. This is a 24-hour facility which offers services and supervision to ambulatory clients with developmental disabilities. The facility is licensed for a capacity of four (4) clients, male or female ages 8 to 17 years old. There are currently three (3) clients in placement. The LPAs requested the following items and information: Personnel Report LIC 500, client roster, Plan of Operation/Program Statement (POO/PS), Board of Directors Meeting Minutes, and client and staff files. At 9: AM, LPAs and the Administrator did a walkthrough of the entire facility. The facility is clean, safe and in good repair. All exits and hallways were observed to be free and clear of hazards and obstruction. There are no bodies of water in the premises. There are no weapons or firearms in the facility. Facility has all required posters throughout the facility. Smoke detectors and carbon monoxide alarms were tested and are operable at the time of the inspection. Hot water temperatures are maintained between 105 and 120 degrees (F). Temperature in clients' rooms are maintained between 68 and 85 degrees (F). All sinks, showers and toilets were clean and in working order. First aid kit was readily available and complete. Medications were observed to be centrally locked and are accessible only to staff responsible for stored medications. Medication Administration Records (MAR) versus medication logs were checked. The facility has perishable food supplies for at least 2 days and non-perishable food supplies for two weeks. The facility provides nutritious snacks between meals. Food Menu is posted. Knives and other sharps were observed to be locked in the kitchen cabinet. Disinfectants, cleaning solutions and toxins are locked and inaccessible to clients. Children live in a safe, healthy and comfortable home. Bedrooms are accommodating of all required furnishings. Individual beds are in good repair, equipped with good springs, clean mattresses and pillows observed. Adequate supply of additional bedding and linens observed. All children attend school when school is in session. The facility's Emergency Disaster Plan needs to be updated per Provider Information Notice (PIN) 21-03-CRP 2020. At 10: AM, LPAs reviewed three (3) client and five (5) staff files. All facility staff or other individuals who require caregiver background checks have received DOJ/FBI criminal record and child abuse index check clearances or exemptions. At the conclusion of the inspection, LPAs discussed the findings with the facility administrator. LPAs issued five (5) Technical Advisories on the following: CCR 84365(d)(1)(A) and 84365((d)(1)(C) Emergency Intervention Plan, CCR 84065(i)(3) Staffing Records, CCR 84070(b)(12) and CCR 84070(b)(13) Client Records. LPAs agreed to work with facility administrator to collaborate with guidance to get the facility in compliance with CCR Regulations. The administrator was provided information on where to locate Provider Information Notices (PINs), guidance of the new CARE Tools Inspection Process and Guardian. Exit interview was conducted and a copy of this report, LIC9102TAs and the confidential names list were provided to the Administrator.

met_with: Dr, Dwon Phillips


summary: Facility Evaluation

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Narrative:
On 09/24/21, at 1:30 pm Licensing Program Analyst (LPA) Belinda Gilmer made an unannounced case management visit to the above facility. The purpose of the visit was to verify information Community Care Licensing received regarding the facility staff contacting the client's placement agency requesting the removal of the children because they were closing in fourteen (14) days. When LPA arrived at the home no one answered the door, the ring doorbell wasn't working, but the home doorbell worked. LPA rang the doorbell, knocked on the security door, walked around the home with no answer, and left a business card on the door. LPA Gilmer knocked on the neighbors at 15313 doors a young lady answered said she hadn't seen anyone at 15312 and that her mother has the telephone number of the licensee. LPA left a card and asked if she would have her mother call LPA with the telephone number. LPA also knocked on 15318 and 15319 doors no one answered. LPA later learned that the Licensee/Owner of the group home Dwon Phillip Hill passed away on 09/23/21. No further information has been provided.


facility_name: DISCOVERY ADOLESCENT PROGRAM II

summary: Facility Evaluation

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Narrative:
On August 24, 2022 at 9: AM, Licensing Program Analyst (LPA) Charmetha White arrived at the above facility, for the purpose of conducting a Required 2-Year Inspection. LPA met with Blaise Eversole, Milieu Manager who granted access to the location. LPA met with Maribel Eck, On Call Program Director and together a tour of the entire facility was conducted both inside and out. The facility is a private pay substance abuse & mental health facility licensed to provide care and supervision services for six (6) children ages 11-17 years old, ambulatory only. The census at the time of the inspection was six (6). The facility is a two story 3-bedroom, 2 ½ bathroom house which includes a Living room, Dining room, Kitchen, Laundry area, a Classroom area, Staffing offices, a Den/Group room, a Wrap-around Patio, a Gurage, and a Backyard. The home is set up as follows: Living room: Is equipped with two sofas. Dining room: Is equipped with a table with seating for 8 people. Kitchen: Is equipped with is 5 burner gas operated stove/oven (4 out of 5 were operational), a double door refrigerator/freezer, a dishwasher, and a microwave. The home was observed to have one-week supply of non-perishable and two days of perishable foods, including nutritious snacks, and the weekly menu is posted. The trash can is equipped with tight fitting lid. Laundry area: Is located in the locked staffing area. It is equipped with a washer/dryer, found to be in working order, and a locked storage cabinet containing all disinfectants, and cleaning solutions. Den: Is located on the second floor at the top of the stairs is used for group therapy sessions. It is furnished with equipped 3 sofas, a table with 8 chairs, and a mounted TV. This room has two separate doors leading to the outside wrap-around patio. Wrap-Around Patio: is covered, it has two (2) small locked storage bins, observed to store tools, two (2) seating areas, and a grill. Classroom: is equipped with tables, chairs, two (2) computers, school supplies, storage area for each client, and a sink for hand washing. Report continued on LIC 809C Gurage: is equipped with a pool table, a ping pong table, a locked deep freezer and refrigerator which stores extra food, and two locked storage cabinets which store the facilities emergency disaster equipment. Staffing Offices: are located on the first floor and remain locked. Backyard: has a basketball court. Bedroom #1- upstairs- two twin Beds, closet Space, dresser, window, working light, and an attached bathroom. Bedroom #2 - upstairs - two twin Beds, closet Space, dresser, window, and working light. Bedroom #3 - upstairs - two twin Beds, closet Space, dresser, window, and working light. Each room is occupied by two clients. Bathrooms: All bathrooms were checked and found to be in good repair and working order. The hot water temperature was tested and found to be between 105-120 degrees (F). The home was inspected, and the following was observed: The smoke and carbon monoxide detectors were tested and found to be in working order. The first aid kit was checked and found to be complete. The home has 3 regulation fire extinguishers. There is a working telephone readily accessible. Medications are locked in staffing office and made inaccessible to clients in care. Temperatures in client's room are maintained between 68-85 degrees (F). Sharp knives are locked in a toolbox stored in a locked pantry located at the front of the house. Overall LPA observed the home to be clean, safe, and sanitary. The front and backyard were clean and free of debris. Passageways, stairways, inclines, ramps and open porches are unobstructed. There are no firearms or dangerous weapons in the facility. There was no swimming pool or bodies of water located at the facility. The facility operates within license conditions and limitations including capacity limitations. LPA discussed and advised the Licensee to ensure the following: Children are supported and encouraged to participate in extracurricular activities. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. LPA reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. All posting requirements for Group Home Licensure and Emergency Plan were met. The Program has a total of fourteen Staff. LPA received copy of the LIC 500. LPA will return on a later date to review staff and client records and complete staff and client interviews. There were no deficiencies noted on this date. Exit interview was completed and a copy of this report was left at the facility.

met_with: Milieu Manager - Blaise Eversole & Maribel Eck - On Call Program Director


summary: Facility Evaluation

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Narrative:
On September 8, 2022 at 9: AM, Licensing Program Analyst (LPA) Charmetha White arrived at the above location for the purpose of reviewing staff and client records to complete the Required 2-Year Inspection which began on 08/24/2022. LPA met with the Program Director, Shelby Thirkill and Milieu Manager, Blaise Eversole who granted access to location and provided the files. The Program has a total of twelve staff. LPA reviewed six staff files, and interviewed five Staff. LPA observed all Staff records included annual personnel performance evaluations, all staff have met the education and experience requirements, and have completed the required training's. All staff that work directly with clients have current First Aid/CPR cards in their files. The Program currently has a total of twelve staff and six clients. LPA reviewed a total of six staff files and interviewed a total of five staff. LPA reviewed six client files and interviewed all six clients. There were no deficiencies noted on this date. An exit interview was conducted and a copy of this report was signed and left with the Program Director.

met_with: Milieu Manager - Blaise Eversole & Shelby Thirkill - Program Director


facility_name: DISCOVERY ADOLESCENT PROGRAM IV

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Narrative:
There was no evidence to support C1's limitations on phone calls and family visits due to their non-participation in the program. Documentary evidence revealed C1's attendance and participation in some program group activities. There is no evidence or witnesses to support that "Facility staff did not seek minor appropriate medical attention". Based on the interviews conducted, the information gathered did not produce corroborating evidence to support the above said allegation. LPA Edison was unable 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. If any additional information is received, this complaint can be amended, and the finding can be changed. Based on the observations made during today's visit, 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 Program Director.

Investigation Findings:
13This an amended report from the original date of 12/12/2022. On December 12, 2022 at 2:29pm, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Discovery Adolescent Program IV and spoke with Evan Sahn, Program Director. The purpose of this visit was to deliver the findings for the above complaint allegation. During the investigation LPA Edison interviewed and accounted for all available relevant parties; and gathered pertinent information regarding the allegation. Based on the interviews and statements obtained during the investigation process, the allegation could not be corroborated. Confidential interviews with staff, client, and witnesses revealed facility staff transported client to urgent care on multiple occasions to have eye infection treated. Inconsistent statements did not corroborate staff denied Client #1 (C1) participation in the program at Discovery Adolescent Program IV, however, it was stated that as a result of the temporary vision problems and eye pain C1 suffered, C1 was unable to participate in program at the facility. 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: DISCOVERY ADOLESCENT PROGRAM IVFACILITY NUMBER: VISIT DATE: 12/12/2022

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

met_with: Evan Sahn-Program Director


summary: Complaint Investigation - Unsubstantiated - 3 allegations

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Investigation Findings:
13On 1/30/2025 at 1:00pm Licensing Program Analyst (LPA) Justine Armstrong conducted an unannounced visit to Discovery Adolescent Program IV to conclude the investigation of the above allegations and deliver the findings. LPA met with Blaise Eversole, who granted access to the facility, and together, they discussed the investigation details. During the investigation process, all relevant parties have been accounted for. It was reported that Facility staff did not prevent inappropriate behaviors between youths in care. After conducting confidential interviews and reviewing documents, there was insufficient evidence or testimony to substantiate the allegations. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. LPA determines that the allegation of Neglect/Lack of Supervision is Unsubstantiated There were no deficiencies cited. An exit interview was completed, and a copy of this report was provided to the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Enrique M Hernandez LICENSING EVALUATOR NAME: Justine Armstrong 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: 60

met_with: Blaise Eversole


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Investigation Findings:
13On July 25, 2025, at 3:00PM , Licensing Program Analyst, (LPA), Justine Armstrong, conducted an unannounced visit to DISCOVERY ADOLESCENT PROGRAM IV facility for the purpose of delivering findings for a complaint investigation alleging that staff did not adequately supervise minor resulting in minor leaving the facility This complaint was received by the Department on May 21, 2024. Upon arrival, LPA was granted access to the facility by the Facility Manager Blaise Eversole. During the investigation process, all relevant parties have been accounted for. After conducting confidential interviews and reviewing documentary evidence, there was insufficient evidence or testimony to substantiate the allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. The Department has decided that the allegation are Unsubstantiated, but if any additional information is received, this complaint can be amended and the finding can be changed. There were no deficiencies cited. An exit interview was completed, and a copy of this report was provided to the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Enrique M Hernandez LICENSING EVALUATOR NAME: Justine Armstrong 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: