summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Jean Stidman and Misty Valencia on 2/24/23 at 8am. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9(a)(2). During the inspection, LPs met with Diane McGill Administrator and inspected the facility inside and out. LPAs reviewed one child's record and three staff personnel files on site at the facility. LPAs reviewed one child's psychotropic medications and medication record. LPAs interviewed three staff on site to discuss the facilities policies and procedures of operation. LPAs interviewed one child currently prescribed psychotropic medication. During the inspection the LPAs observed deficiencies (see attached 809D), plan of corrections were discussed and appeal rights were provided. LPA provided a copy of this licensing report to Diane McGill Administrator. LPAs observed one child file was missing past or current JV220 forms and the Medication Administration Records (MAR) were missing prescription quantity and number of refills for current psychotropic medications being taken. LPAs observed 2 of 3 staff files missing training on psychotropic medication. LPAs reviewed two client files and observed the parental consent form to administer psychotropic medications are missing written authorization of the child's parent or guardian, for each psychotropic medication. Facility citation violation of California Code of Regulations, Title 22, Division 6, Chapter 5, Article 06 regulation 84070(b)(12) and 84070(b)(13) Children's Records and 84065(j)(O) Personnel Requirements See attached 809D, plan of correction was discussed, appeal rights were provided and LPA provided a copy of this report to Diane McGill Administrator.


state: CA

facility_name: PEOPLE'S CARE SHAWMUTT

summary: Facility Evaluation

raw_content:
Narrative:
On 03/07/2023, at 4: PM, Licensing Program Analyst (LPA) Connie Goldie made an unannounced case management visit to deliver the findings from visits conducted on 01/26/2023 and 03/01/2023 regarding observations identified during Annual inspection on 11/18/2022. LPA Goldie met with Program Administrator (PA) McGil and conducted a walk through of the facility both inside and out. During walk through of the facility, LPA observed a 4 bedroom, 3 1/2 bath single story home, living room, family room, kitchen, laundry room and pantry with perishables for 2 days and non-perishables for 5 days. LPA also observed outside to be clear of debris. LPA observed a stained mattress in bedroom 2 which requires replacement. No other deficiencies were observed during walk through. The purpose of the visit is to deliver findings of deficiencies observed during interviews in the course of a case management investigation. LPA Goldie conducted case management on observed vehicle damage to front bumper and right side of van. The observation of damaged van was investigated. During the investigation, LPA Goldie identified during interviews with S1, S2, and S3 that the van sustained damage early last year (date unknown) and was reported to Program Administrator. Through observation of incident reports and based on interviews, LPA identified the incident was not reported as required by regulation. On this date the facility is being cited for the following violations of Title 22, Division 6, Chapter 5. One deficiency was found during case management interviews on 01/26/2023, and 03/01/ Reporting Requirements 80061 (a)(1) (E) and the second one was observed during today's inspection. Personal Rights 80072 (2). Exit interview conducted with Diane McGil, Program Administrator. A copy of the report along with appeal rights were discussed and left at the facility.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Diane McGil Program Administrator


summary: Facility Evaluation - 2 deficiencies

raw_content:
Narrative:
On 03/21/2023,at 10: AM, Licensing Program Analyst, (LPA), Connie Goldie made an unannounced case management inspection to deliver findings from Annual follow up visit conducted on 03/17/2023 regarding observations made. LPA Goldie met with Lead Staff, Alecia Loyd, to discuss the findings. During investigation on 03/17/2023, LPA Connie Goldie observed schedule posted which included additional staff not on LIC500 and determined one staff on the schedule for 03/04/2023 was not associated. This is a repeat violation within 12 months as a citation was issued on 11/22/2022. LPA Goldie viewed Board Minutes from previous meeting held in December 2022. It was observed that the Annual held 11/18/2022- 11/22/2022 was not discussed during the meeting. Additionally, 5 crisis events were notated on the Minutes agenda and zero incident reports were received by licensing. Regional Director, Abe Avila, checked for notation regarding crisis events and was unable to locate any information. This indicates that incidents were not reported as required. LPA reviewed medication MAR sheets and observed that controlled medications are still not separated to a PMAR sheet. Program Administrator McGil provided status update for completion as a plan of correction (POC) is due by 03/24/2023. PA stated the controlled medications will be placed on PMAR's as required on 03/21/2023 by facility nurse prior to POC due date. Review of clients facility files indicate LIC601's have been put into files stating who can and cannot have visitation with client. LPA verified 3 of 4 clients do not have a dentist. PA stated she was actively searching for a dentist who would take special needs kids. During review of Personals & Incidentals- (P & I's), LPA identified allowance was not provided to 4/4 clients in January 2023 and February 2023. This is a repeat violation. RD stated that the allowance issue is now clear and going forward this will not be an issue. Restraint Log was observed to be implemented and updated as required. Continued on LIC809C The facility is being cited for the following California Code of Regulations (CCR) Title Division Chapter 1 regulations 80019 (e) (2) Criminal Record Clearance and 80070 (b) (7) Client Records, and Division Chapter 5 80061 (a) (1)(E) Reporting requirements, and 84077 (a)(2) Personal Services. Two Civil Penalties are being assessed for repeat violations one of which is an immediate civil penalty for Criminal Record Clearance. LPA Goldie spoke with Program Administrator, Diane McGil by phone at (916) 430-6149 to determine plan of corrections. See attached 809D, plan of correction was discussed, appeal rights were provided and LPA provided a copy of this report to Alecia Loyd, Lead Staff.

Deficiencies:
80070: (7) Name, address and telephone number of physician and dentist, and other medical and mental health providers, if any.
84077: (2)	Provision of an allowance to all children no less frequently than once per month...

met_with: Alecia Loyd Lead Staff

title:
(b) (7) Client Records
(b) Each record must contain information including, but not limited to, the following

title:
Personal Services
(a)	The licensee shall ensure the following


summary: Facility Evaluation

raw_content:
Narrative:
On 08/16/2023, at 10: AM, Licensing Program Analyst, (LPA) Connie Goldie made an unannounced case management inspection to discuss new hire orientation/ on boarding for new staff members. LPA Goldie was greeted by Bridgette Harton upon arrival. Program Administrator, Diane McGill, called LPA Goldie at 10: AM and stated Lead Alecia Loyd was on her way to facility and would assist with the inspection. LPA conducted walk through of facility and observed a single story four bedroom, four bathroom home. LPA observed 3 occupied bedrooms with adequate furniture for youth and one unoccupied room with bed, dresser and closet space. The smoke/carbon-monoxide detectors were tested and functioning. Outside was clear of debris and pool secured. No deficiencies were observed. LPA conducted two interviews and did a record review of program statement, schedules 08/06/2023 -08/19/2023 and New Hire Orientation paperwork for S1, S2, S3 and S4. LPA observed that S4 did work in home prior to completing new hire orientation. Program Administrator acknowledged this was the case. This was in violation of facility's Program Statement pertaining to training requirements for staff. The Program Statement states, "All new employees will receive a 16 hour orientation within the first 40 hours of working in the home. " S4 worked more than 40 hours prior to completing orientation portion of her training as only Day 1 was completed. The facility is being cited for the following California Code of Regulations (CCR) Title Division Chapter 5 regulations 84065 (h) (1) Personnel Requirements. LPA Goldie spoke with Program Administrator, Diane McGil by phone at (916) 430-6149 to determine plan of corrections. See attached 809D. Plan of correction was discussed, appeal rights were provided and LPA provided a copy of this report to Alecia Loyd, Lead Staff.

met_with: Alecia Loyd DSP Lead


summary: Facility Evaluation

raw_content:
Narrative:
On 03/29/2024, at 10: AM, Licensing Program Analyst, (LPA), Connie Goldie made an unannounced case management Quarter Non-Compliance plan, (NCCP) inspection. LPA Goldie was greeted by DSP Lixie Ceballos (S1) who granted LPA Goldie access. S1 stated three clients are present and four staff are present. LPA Goldie met with Program Administrator, Diane McGill, who assisted with the inspection. LPA conducted a walk through of home inside and out during case management. LPA observed two fence posts on the ground next to fence due to storm. One fence post is on the exterior side behind pool fencing and is inaccessible to clients. The second fence post is on the right hand side of backyard fence. The Administrator called in a work order during inspection to have them repaired. LPA interviewed 5 staff and 1 client during inspection. 2 clients were observed as they are non-verbal. LPA reviewed LIC500 to verify staff clearances. All staff are background cleared as required. LPA audited Medication Administration Records (MARs) and (PMARs) with LVN Alex Pulido. LPA Goldie observed 2 of MARs with missing refill numbers on Medication Administration Record as required. The agency is being cited for the following Title 22, Division 6, Chapter 5, Article 6, 84070 (b)(13)(C) Children's Records during this inspection. Exit interview was conducted with Administrator McGill. A copy of the report along with appeal rights was discussed and provided.

met_with: Program Administrator Diane McGill


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Corroborating statements from staff confirmed that multiple doses of a client's medication were misplaced and ultimately never found-the exact number remains unknown as Centrally Stored Medication logs were found to be incomplete. Facility management confirmed that this unusual and reportable circumstance was never made known to Community Care Licensing (CCL) nor the Regional Center. Based on LPA's interviews which were conducted and records reviewed, the preponderance of evidence standard has been met; therefore, the allegations are found to be SUBSTANTIATED. The facility is cited on the attached LIC 9099D under the California Code of Regulations Title 22, Division 6, Chapter 5, Article 06, Section 84075(b) "The licensee shall ensure that all prescribed medications are centrally stored..." and Chapter 1, Article 06, Section 80061(b)(1)(E) "Any unusual incident...which threatens the physical...health or safety of any client." Exit interview conducted and a copy of this report and a copy of the appeal rights were provided to the facility.

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:

report_type: Complaint Investigation

met_with: Arneatha Simon, District Manager

complaint_status: SUBSTANTIATED


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Four confidential interviews corroborated that even more personal items would go missing throughout the client's placement in the facility; no updated Personal Property & Valuables log was kept for the client. The facility had no process in place to secure the personal property of clients in care to safeguard their personal items. Based on LPA's interviews which were conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation is found to be Substantiated. Citation is being issued for violating Title 22, Division 6, Chapter 1, Article 3, Section 80026(b) A signed copy of this LIC-9099 report, the LIC-9099C, and LIC-9099D were provided to the facility. An exit interview was conducted. Appeal rights were provided. As for the client acquiring an infection, all interviewees corroborated that a client did get an infection which, in and of itself is not sufficient evidence that the infection was due to the level of care provided by the facility. Based on LPA's observations, interviews which were conducted, and records reviewed, although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove the violationa did, or did not, occur; therefore, the allegations are UNSUBSTANTIATED. A signed copy of this LIC-9099 report, the LIC-9099C, and appeal rights were provided to the facility. An exit interview was conducted.

Investigation Findings:
13Licensing Program Analyst (LPA) Chad Cabigon arrived unannounced at the facility on this date for the purpose of delivering findings for the complaint investigation; LPA met with Arneatha Simon, District Manager. LPA Cabigon conducted the complaint investigation and initiated it with the facility on 12/05/2025, during which time LPA met with then-interim administrator Emilio Saucedo; LPA also conducted a physical plant inspection on that day. During the course of the investigation, LPA interviewed nine People's Care staff, three Regional Center personnel, two clients, and clients' family. LPA reviewed records including: Medication Administration Records (MARs), body check logs (Consumer Mark and Bruise Documentation Sheets), Physician's Reports, Appraisal/Needs & Services Plans, and relevant incident reports. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Chad Cabigon 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: PEOPLE'S CARE SHAWMUTTFACILITY NUMBER: VISIT DATE: 02/27/2026

complaint_status: unsubstantiated


facility_name: PEOPLE'S CARE TALLY HO

summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
Facility staff did not follow residents IPP Confidential interviews and documentation obtained reported that the facility did not follow the client's IPP plan in providing the necessary care and ensuring the client's safety. Facility staff is not adequate to meet resident's needs. Confidential interviews and documentation obtained reported that staff was not at the client's side while eating a peanut butter sandwich, resulting in the client choking and being taken to the hospital. Based on all of the interviews conducted, the Department has concluded the above allegation of a Neglect/ Lack of Supervision violation to be Substantiated, meaning that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code Regulation, Title 22, Division 6, Chapters 5, General Licensing Regulations, the following deficiency has been cited. (See LIC9099-D). Exit interview was conducted and a copy of this report will be emailed to FM, due to technical difficulties with the printer

Investigation Findings:
13On January 25, 2022 10:40am Licensing Program Analyst (LPA) Enrique Hernandez arrived at the facility to deliver the findings of a complaint investigation. LPA Hernandez met with Guadalupe Ramirez Facility Administrator (FA) and discussed the investigative findings. On October 7, 2020, the Department received a complaint alleging Facility staff was not properly supervising resident, Facility staff did not follow residents IPP, and Facility staff is not adequate to meet resident's needs. Confidential interviews were conducted during the investigation process. The following information was obtained during the course of the investigation: Facility staff was not properly supervising resident. Confidential interviews indicated that staff who was supposed to be sitting next to the client to assist while the client ate a peanut butter sandwich was not sitting next to the client leaving the client unattended. During that time, the client began to choke while chewing on the sandwich and another staff member who was present ran to the client and began performing abdominal thrusts (Heimlich maneuver). SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Enrique M Hernandez 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, FACILITY NAME: PEOPLE'S CARE TALLY HOFACILITY NUMBER: VISIT DATE: 01/25/2022

met_with: Facility Administrator


raw_content:
Narrative:
continued from LIC The investigation revealed that at time of inspections, blinds and/or padding were in good repair in the client's rooms. Confidential interviews revealed that a request for a bathroom remodel and carpet to be replaced in the activity room was first made in October 2021, however the remodel of the hallway bathroom wasn't until May 2022. The carpet was cleaned in late April following a plan of correction, and subsequently removed and new flooring was added. Staff do receive certification training in medication handling and passing of meds at initial hire during orientation and job-shadowing for five days. Most recently staff had in-service Medication Administration Training in June 2022 and a test. This home doesn't require an LVN or a trained technician to be on staff to manage medications. The facility provides in-house training as well as additional training from the local pharmacy as needed. The facility currently doesn't have an LMFT on staff, however there is a Behavioralist that comes weekly to the home as well as a Psychiatrist once a month to meet resident's mental health needs. The facility has an Amazon account where $100 of supplies can be ordered (linens, supplies, etc.) monthly, a Grocery Card in the amount of $300 for food ($75 per resident) weekly, and petty cash available for activities with approval from Facility Administrator and District Manager. A monthly activity calendar is posted with in-house activities as well as activities outside of the house in the dining area. AGPA Woodard has determined the preponderance of evidence standard has not been met due to conflicting statements. Therefore, the allegation is found to be unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted, and a copy of this report was left at the facility.

Investigation Findings:
13On July 1, 2022, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted a follow-up inspection at the facility for the purpose of delivering findings on the above allegations. Upon arrival, AGPA Woodard was greeted by House Lead, Crystal Sierra. On February 22, 2022, Community Care Licensing Division (CCLD) received a phone call regarding concerns at People's Care Tally Ho facility. It was reported that there were several "safety concerns" in the group home, such as physical plant, personal rights, and qualifications. Licensing Program Analyst (LPA) Enrique Hernandez and Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted the investigation into allegations. LPA Hernandez conducted the initial 10-day complaint inspection on February 24, 2022 and a subsequent inspection on March 11, 2022; both days confidential interviews were conducted. AGPA Woodard conducted subsequent inspections on April 10, 2022 and June 25, 2022 where a total of two confidential interviews with staff were conducted. AGPA Woodard also conducted two phone interviews with a past and present staff. continue on LIC 9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard 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: PEOPLE'S CARE TALLY HOFACILITY NUMBER: VISIT DATE: 07/01/2022

met_with: Crystal Sierra


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
People's Care Tally Ho Continuation Pg Based on observation and the interviews with staff, there are always three (3) restrooms at the facility available for use. Some clients are incontinent and need assistance using the restroom and bathing. Therefore, there is not enough evidence to corroborate the allegation, minors do not have access to facility bathroom(s) while in care. Based on review and analyzing all evidence, the LPA has found the above allegations to be Unsubstantiated, meaning the allegations may have happened or are valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. There are no deficiencies to be cited at the time of this inspection. A copy of this report and appeal rights were provided to Crystal Sierra at the facility.

Investigation Findings:
13On August 24, 2022, at 2: Pm., Licensing Program Analyst (LPA), Kuliema Calloway, made an unannounced visit to the above facility for the purpose of concluding complaint findings. LPA met with Crystal Sierra, Facility Manager at People's Care Tally Ho who granted access and toured the facility. During the tour, there was one (1) client observed in care, which was C4 and one staff member S1. During the investigation, LPA conducted interviews with clients and staff. Based on observations and the interviews, the evidence revealed that meals are being provided three times a day, along with snacks. Liquids such as cranberry, apple, or make your own juice, and water are provided at any time the client's request. There is food and drink monitoring for the clients that have choking behaviors. Therefore, there is not enough evidence to corroborate the allegations, minors are being denied access to food while in care, and minors are being denied access to liquids while in care. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Kuliema Calloway 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, FACILITY NAME: PEOPLE'S CARE TALLY HOFACILITY NUMBER: VISIT DATE: 08/24/2022

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

met_with: Crystal Sierra, Facility Manager


raw_content:
Investigation Findings:
13On January 18, 2023, at 1:30pm, Licensing Program Analyst (LPA) Nancy O'Connell made an unannounced inspection to the above facility for the purpose of concluding the investigation on the above allegations and deliver the finding. LPA spoke with Crystal Sierra and together, discussed the investigative finding. During the investigative process by Licensing program Analyst (LPA), Nancy O'Connell, all relevant parties have been accounted for. Supporting evidence includes conflicting statements with house resident and staff that do not support evidence that a resident sustained injuries while under the supervision of facility staff. Evidence reflects that the resident presents with aggressive behaviors and there is documented history of self-injurious behaviors associated with C1's presentation. Further, there is no evidence to support that injuries were perpetrated by staff, clients, or were sustained as a result of a lack of supervision. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. If evidence is obtained in the future to substantiate allegation, findings to this allegation may be changed. No deficiencies are being cited at this time. Exit Interview conducted, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Nancy O'Connell 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

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


raw_content:
Investigation Findings:
13On February 15, 2023, at 10:00am, Licensing Program Analyst Enrique Hernandez made an unannounced inspection to the above facility to conclude the investigation on the above allegations and deliver the findings. LPA spoke with Crystal Sierra and, together, discussed the investigative findings. All relevant parties were accounted for during Licensing Program Analyst (LPA) Enrique Hernandez's investigation process. Supporting evidence includes conflicting statements by residents and facility staff and does not support allegations that facility staff spoke inappropriately to a resident and that facility staff hit a resident. The evidence reflects that the resident presents aggressive behaviors toward the facility staff. In addition, the resident stated feeling safe living in the facility. Furthermore, during the interview with the resident, LPA Hernandez did not observe marks or bruises on the resident's body. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations is unsubstantiated. If evidence is obtained in the future to substantiate allegation, findings to this allegation may be changed. No deficiencies are being cited at this time. Exit interview was conducted and a copy of this report will be emailed to the facility administrator UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Enrique M Hernandez 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

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


raw_content:
Investigation Findings:
13On February 16, 2023, at 10:00am, Licensing Program Analyst Enrique Hernandez made an unannounced inspection to the above facility to conclude the investigation on the above allegations and deliver the findings. LPA spoke with Crystal Sierra and, together, discussed the investigative findings. All relevant parties were accounted for during Licensing Program Analyst (LPA) Enrique Hernandez's investigation process. Statements obtained during the investigation demonstrate inconsistent reports, and a single narrative could not be corroborated during the statements from the facility staff and the residents. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove that the alleged violations occurred. The Department has decided that the allegations of Staff cut a minor's nails short while in care, Staff cut a minor's hair without proper authorization and Staff used other clothing for a minor while in care 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 per the California Code of Regulations, Title Regulations, Division 6, chapters 5, Exit interview was conducted, and a copy of this report will be emailed to the facility administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Enrique M Hernandez 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

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


raw_content:
Investigation Findings:
13On 10/11/23 at 12:00pm, Licensing Program Analyst (LPA) Nancy O'Connell and LPA Jhane Haynes made unannounced inspection to the above-listed facility for the purpose of concluding the investigation on the above allegation and deliver the finding. LPA O'Connell met with S1 and discussed the investigative finding. During the investigative process, LPA O'Connell conducted confidential interviews with all relevant parties and collected information on the above allegation. After reviewing all the statements and the information obtained, the above allegation is supported, as the confidential interviews confirmed that C2's personal belongings were not safegaurrded according to facility policies, resulting in a technical device not being provided to C2 upon their move to a new facility. Further, record reviews reflect that inventory lists were not kept updated and did not accurately reflect client belongings. Lastly, during the initial inspection, LPA O'Connell observed the FM produce the personal belonging (specified in complaint) from the kitchen drawer in the facility, proving that the belonging was not properly safeguarded and provided to C2 upon her move to a new facility. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with appeal rights were emailed to the administrator. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Nancy O'Connell 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 WOODLAND HILLS S.Ro, Ventura Blvd., STE. WOODLAND HILLS, CA FACILITY NAME: PEOPLE'S CARE TALLY HOFACILITY NUMBER: 405802268

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


raw_content:
Investigation Findings:
13On 10/11/23, at 12pm, Licensing Program Analyst (LPA) Nancy O'Connell and LPA Jhane Haynes made an unannounced inspection to the above facility for the purpose of concluding the investigation on the above allegations and deliver the findings. LPA spoke with S1 and together, discussed the investigative finding. During the investigative process by Licensing program Analyst (LPA), Nancy O'Connell, all relevant parties have been accounted for. Supporting evidence includes: conflicting interview attesting to the occurance of allegations. Further, statements taken from both staff and clients do not present evidence to prove that staff scratched, pulled clients hair, engaged in a verbal altercation, and are not meeting client's grooming needs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated. No deficiencies are being cited at this time. Exit Interview conducted, and a copy of this report was emailed to the administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Nancy O'Connell 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

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


raw_content:
Investigation Findings:
13On March 21, 2024 at 12:20 pm, Licensing Program Analyst (LPA) Christine Wilson made an unannounced visit to the above listed facility, in order to conclude a complaint investigation on the above allegations. LPA Wilson was met by the Facility Administrator, who was previously, the Assistant Administrator, and who provided LPA with entry into the home.. During the course of the complaint investigation LPA conducted interviews, and review of records. There was not enough corroborating evidence to support the above allegations, therefore the fIndings are unsubstantiated, meaning the allegations may have happened, but there is not a preponderance of the evidence to prove that the alleged violation occurred. There are no other deficiencies cited at this time. An exit interview was conducted and reviewed with the licensee. A copy of this report will be emailed to the licensee (AA) whose signature on this form confirm receipt of these documents. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Christine Wilson 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:

met_with: Facility Administrator (FA)


raw_content:
Investigation Findings:
13Licensing Program Analyst Connie Jones-Steward met with the administrator to investigate the allegations that he is mishandling funds and that Staff 1 is getting paid but not working, LPA viewed the food supply and found food in adequate supply to meet the Title 22 requirements. LPA verified that all clients had adequate personal hygiene supplies.. Administrator explained that the allowances for clients are controlled by their respective parents. LPA was not able to interview clients due to their non-verbal status. LPA reviewed time cards for Staff 1 for the months of November and December 2024. Time cards show that Staff 1 clocked in almost everyday during those two months. LPA also reviewed the P & I folders for each client. Each log showed a lump sum payment from the corporate office for the month of December 2024. Based on the a interviews with the administrator, Staff 1 and Staff 2 and on personal observance by this LPA, the allegations are resolved as inconclusive meaning that although an allegation is true or is valid there is not enough evidence to prove that it did happen. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Connie Jones-Steward LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Moshe Davis, Administrator


raw_content:
Narrative:
There was no documentary evidence to support that C1 choked C2 or pulled C2 pants down. Documentary evidence indicated that incidents and clients' behaviors are logged in Therap APP and crossed reported to appropriate parties. Due to lack of evidence obtained during the investigation, LPA Gray determines that the allegation is Unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that a violation occurred. There are no deficiencies cited at this time. An exit interview was conducted, and a copy of this report was emailed to the Program Administrator.

Investigation Findings:
13On April 23, 2025, at 8: AM, Licensing Program Analyst (LPA), Nestor Gomez made an unannounced visit to conclude the investigation conducted by LPA Rosslyn Gray. Prior to entering the facility LPA Gomez conducted a health and safety risk assessment. During the investigation, LPA Gray interviewed all available relevant parties and gathered pertinent information in reference to the allegation. The Licensee denied the allegation. Based on confidential interviews and review of documentary evidence, there is no evidence or witnesses to support that the staff did not provide proper supervision to prevent client in care from harassing another client in care. Records indicated that staff were in ratio to monitor clients in care. Confidential interviews were consistent that the staff utilized crisis communication protocol and provided redirection in attempt to prevent Child 2 (C2) from harassing and calling Child 1 (C1) inappropriate names. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Nestor Gomez 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 WOODLAND HILLS S.Ro, Ventura Blvd., STE. WOODLAND HILLS, CA FACILITY NAME: PEOPLE'S CARE TALLY HOFACILITY NUMBER: VISIT DATE: 04/23/2025

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

met_with: Moche Davis - Facility Administrator


raw_content:
Narrative:
continued from A The complaint was originally investigated by Enrique Hernandez, Licensing Program Analyst (LPA). LPA Hernandez conducted interview withs Reporting Party, two staff, and Tri-Counties Quality Assurance. On April 5th, 2022, AGPA Woodard was reassigned the complaint. AGPA conducted the investigation into the above allegation by conducting an interview with staff and a tour of the facility. On April 10th, AGPA observed a pile of feces on the carpet as well as stains, and resident's clothing with soiled diapers. AGPA Woodard has determined the preponderance of evidence standard has been met. Therefore, the allegation is found to be substantiated. Deficiencies were cited to the facility for physical plant. An exit interview was conducted, appeal rights discussed and a copy of this report was left at the facility.

Investigation Findings:
13On April 10, 2022 at 11:50AM, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted a follow-up complaint inspection to deliver findings on the above allegation. Upon arrival, AGPA was greeted by Crystal Sierra, House Lead. On February 22, 2022, CCL received a complaint allegation concerning "safety concerns" in the group home. The Reporting Party (R/P) states that the rug in the activity room smells of urine and should be removed. On March 10, 2022, a co-complainant addressed similar concerns and reported the activity room smells of urine and feces. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard 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 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: PEOPLE'S CARE TALLY HOFACILITY NUMBER: VISIT DATE: 04/10/2022

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


raw_content:
Narrative:
continued from 9099-A The complaint was originally investigated by Enrique Hernandez, Licensing Program Analyst (LPA). LPA Hernandez conducted interview with Reporting Party, two staff, and Tri-Counties Quality Assurance. On April 5th, 2022, AGPA Woodard was reassigned the complaint. AGPA conducted the investigation into the above allegation by conducting an interview with staff and a tour of the facility. On April 10th, AGPA observed linens and sheets, and additional blankets. Staff provided a copy of an order from Amazon.com where a total of 8 sets of linens were ordered on February 24, 2022 and received on February 25, 2022. AGPA Woodard has determined the preponderance of evidence standard has not been met. Therefore, the allegation is found to be unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of this report was left at the facility.

Investigation Findings:
13On April 10, 2022 at 11:50AM, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted a follow-up complaint inspection to deliver findings on the above allegation. Upon arrival, AGPA was greeted by Crystal Sierra, House Lead. On February 22, 2022, CCL received a complaint allegation concerning "safety concerns" in the group home. The Reporting Party (R/P) states that residents are not provided sufficient bed linens and the sheets and blankets are old and worn. There are not enough blankets or sheets to rotate and the bed covers are too small to fit the resident's beds. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard 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: 5 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: PEOPLE'S CARE TALLY HOFACILITY NUMBER: VISIT DATE: 04/10/2022

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


summary: Facility Evaluation

raw_content:
Narrative:
On 10/11/2021, at 11:00 am Licensing Program Analyst (LPA) Enrique Hernandez conducted an unannounced annual required inspection at the People's Care Tally Ho group home. LPA met with the facility administrator Charlotte Acosta who granted access to the home and together toured the house inside and out. People Care's program is designed to accept children with developmental disabilities from the Tri-Counties Regional Center. LPA informed the facility Administrator that annual fee is due. Administrator stated that she approved the payment on 10/7/2021. LPA observed the following: Bedroom #1 is occupied by Client #1. It has one (1) queen size bed, adequate closet space and four (4) drawer space. LPA observed no bed frame in the room. Facility administrator will send the IPP tomorrow 10/12/2021 to LPA the reasons for not having a bedframe. Bedroom #2 is occupied by Client # It has one (1) full size bed, adequate closet space and four (4) drawer space. Bedroom #3 is occupied by Client # It has one (1) full size bed, adequate closet space and four (4) drawer space. Bedroom #4 is occupied by Client # It has one (1) full size bed, adequate closet space and four (4) drawer space. This bedroom has private bathroom. LPA Hernandez toured the detached guest house that has been converted to an activity room that meets regulations. LPA observed non-perishable foods for one week and perishable food for two days. Nutritious snacks are available in the facility. Facility is clean, safe, sanitary, and in good repair. Passageways, stairways, inclines, ramps, and open porches are unobstructed. LPA Hernandez observed that the knives were in the kitchen cabinet and the lock was not in place. Where the knives were there were other things like scissors, phone charger, and can opener. Continue on LIC809-C LPA observed that the current menu is not posted in the kitchen. Hazardous and cleaning solutions, disinfectants, poisons, medication are inaccessible to the clients. Meds are locked and accessible only to employees supervising stored medications. LPA heard that one of the smog detectors was running out of battery and beeped throughout the inspection time. The other smog detectors in the facility were tested and worked properly. The administrator gave LPA a copy of the email that was sent to the maintenance guy on October 5, 2021 and is scheduled for repair today 10/11/2021. The battery was changed before the LPA left the premises. There is one carbon monoxide in the home. Client Bedrooms were inspected and found to be in compliance. Bathrooms were toured and found to have regulation temperature hot water. There is no bodies of water on the premises. There are no weapons or guns on the premises. A Review of the Facility's Personnel Summary on 10/11/ Reveals That Staff Have Doj/fbi Criminal Record Clearances and a Child Abuse Background Clearance. LPA Hernandez due to time constraints, LPA shall return to continue annual required inspection review personnel and clients files to ensure it meets regulatory requirements. Client and staff interviews will be conducted at a later date. PER California Code Regulation, TITLE 22, DIVISION 5, CHAPTERS 1, General Licensing Regulations, the following deficiency was cited at the time of the inspection. See D Exit interview was conducted with the facility Administrator. A copy of this report was left with the facility administrator whose signature on this form confirm receipt of this document.

visit_type: Annual

met_with: Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On December 16, 2021 at 8:05 am Licensing Program Analyst (LPA) Enrique Hernandez made an unannounced visit at the above facility for the purpose of conducting a case management Annual Continuation inspection. LPA met with the Facility Administrator Guadalupe Ramirez who granted access into the facility LPA Hernandez review the following sections with the facility administrator: Operations Disaster preparedness and Emer intervention Due to time constraints, LPA shall return to complete the Annual inspection. LPA will return to review personnel and clients files to ensure it meets regulatory requirements and interviews with Client and staff . PER California Code Regulation, TITLE 22, DIVISION 5, CHAPTERS 1, General Licensing Regulations, no deficiencies cited at this time. Advisory notes were issued. Exit interview was conducted with the facility Administrator. A copy of this report was left with the facility administrator whose signature on this form confirm receipt of this document.


summary: Facility Evaluation

raw_content:
Narrative:
On 10/11/2023, at 9:00 am Licensing Program Analysts (LPA) Nancy O'Connell and Jhane Haynes conducted an unannounced annual required inspection at the People's Care Tally Ho group home. LPAs met with staff who granted access to the home and together toured the house inside and out. People's Care- Tally Ho program is designed to accept children with developmental disabilities from the Tri-Counties Regional Center. LPA observed the following: Bedroom #1 is empty and not occupied at this time. It has one (1) queen size bed, adequate closet and drawer space. Bedroom #2 is occupied by Client # It has one (1) full size bed, adequate closet and drawer space. Bedroom #3 is occupied by Client # It has one (1) full size bed, adequate closet and drawer space. Bedroom #4 is occupied by Client # It has one (1) full size bed, adequate closet and drawer space. This bedroom has private bathroom. In the kitchen, LPA observed non-perishable foods for one week and perishable food for two days. Snacks are available in the facility. Menu is posted. LPA observed sharps to be secured within a locked box, stored in separate cabinet. Keys were kept in drawer above within the kitchen. There is enough tableware and utensils to accommodate all residents. Continued on LIC809-C Hazardous and cleaning solutions, disinfectants, poisons, medication are inaccessible to the clients. Meds are locked and accessible only to employees supervising stored medications. Bathrooms were toured and found to have regulation temperature hot water. LPAs observed mold in tub and toilet areas, LS reported that tub is scheduled to be replaced. There is no bodies of water on the premises. There are no weapons or guns on the premises. LPAs toured the detached guest house that has been converted to an activity room and observed debris on the ground, cobwebs visualized throughout and old furniture. Old activity equipment observed adjacent to activity building. LS communicated furniture will be removed, and staff will be instructed to clean. LPAs observed required postings(license, fire clearance, LIC610c, personal rights, grievance procedures). LPAs inspected facility vehicle and found it to be functional and confirmed current registration and insurance. LPAs observed facility temperature within required range. LPAs tested smoke alarms and observed to be functional. LPAs observed client and staff files centrally stored and locked in staff office. Due to time constraints, LPAs will return to continue the annual required inspection and review personnel/ client files to ensure they meet regulatory requirements. Client and staff interviews will be conducted at a later time. Per California Code of Regulations, Title 22 there is one deficiency to be cited at this time. Exit interview was conducted with staff and a copy of this report was emailed to the staff.

met_with: Crystal Sierra Lead Staff (LS)


summary: Facility Evaluation

raw_content:
Narrative:
On December 4, 2023 at 12:10pm Licensing Program Analyst (LPA) Christine Wilson made an unannounced visit to the above listed facility to conduct a case management inspection. LPA met with the Assistant Administrator (AA) who provided entrance into the facility. During the time of the inspection LPA conducted confidential interviews with (S2 and AA). [See Confidential Names form (LIC811), dated 12/4/23, for names]. During the inspection, the LIC500 was not updated to reflect new staff. The Assistant Administrator (AA) updated the LIC500 and LPA Wilson obtained a copy, signed and dated. LPA Wilson also obtained copies of Client Roster and Administrative Leave Notifications (S4, S6,and S7) , emails, After Visit Summary, and text messages. No other deficiencies were observed. An exit interview was conducted. A copy of the report was provided to the facility

met_with: Administrative Assistant


summary: Facility Evaluation

raw_content:
Narrative:
On December 4, 2023 at 12:10pm Licensing Program Analyst (LPA) Christine Wilson made an unannounced visit to the above listed facility to conduct a case management inspection LPA met with the Assistant Administrator (AA) who provided entrance into the facility. During the time of the inspection LPA conducted confidential interviews with (S2 and AA). [See Confidential Names form (LIC811), dated 12/4/23, for names]. During the inspection, the LIC500 was not updated to reflect new staff. The Assistant Administrator (AA) updated the LIC500 and LPA Wilson obtained a copy, signed and dated. LPA Wilson also obtained copies of Client Roster and Administrative Leave Notifications (S4, S6,and S7) , emails, After Visit Summary, and text messages. No other deficiencies were observed. An exit interview was conducted. A copy of the report was provided to the facility

met_with: Assistant Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On March 21, 2024 at 12:17 pm, Licensing Program Analyst (LPA) Christine Wilson made an unannounced visit to the above listed facility, in order to conduct a case management deficiency.LPA Wilson was met by the Facility Administrator, who was previously, the Assistant Administrator, and who provided LPA with entry into the home. During the course of the case management related to SIR dated 11/05/23, LPA conducted interviews, and review of records. Findings are unsubstantiated, that staff (S6) pushed client (C2), meaning the allegations may have happened, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the finding is unsubstantiated. There are no other deficiencies cited at this time. An exit interview was conducted and reviewed with the licensee. A copy of this report will be emailed to the licensee (AA) whose signature on this form confirm receipt of these documents.


summary: Facility Evaluation

raw_content:
Narrative:
On Sept. 18, Licensing Program Analyst Connie Jones-Steward conducted the annual/required inspection. The following was observed. This is a 4 bedroom, three bathroom single family home located in a residential area of the City of Arroyo Grande, CA. People's Care- Tally Ho program is designed to accept four children with developmental disabilities from the Tri-Counties Regional Center. Today's census is four. Fire Clearance: There are no security bars on windows. There are no fireplaces. There are smoke detectors in each bedroom. However a carbon monoxide detector was not in place at the beginning of the inspection. One was added prior to conclusion if inspection. LPA counted two fully charged fire extinguishers. Kitchen area: There are food supplies to meet Title 22 regulations. Stove and refrigerator are in good working order. All household cleaners and knives are securely stored. Bathroom area: All bathrooms are clean with equipment in good working order. Hot water temperature does not exceed 120 degrees. There were no hazardous items found. Bedrooms: All bedrooms have single beds in good condition with good linens. There is the required storage space. There are no security bars on windows. All windows are operational. Yard Space The backyard is free of hazards. There is a recreation room with equipment in good condition. There are no swimming pools or other bodies of water. Children's Records: Client records were reviewed and found to missing the required parental consent forms for psychotropic medication. Postings: LPA Jones-Steward observed that the license, floor plan, menu, employee schedule and notice of personal rights were posted as required. Operations/Disaster Plan The facility has a complete first aid kit. The last disaster drill was conducted on 09/13/24. The board of directors meets monthly. There were two clients that exceed the allowable age. LPA Jones-Steward will view employee files and conduct employee interviews at a future date. The only available client is non-verbal. The facility was cited under Title 22 84087(d), 80010(a) and 84070(b)(12)

met_with: Moshe Davis


summary: Facility Evaluation

raw_content:
Narrative:
On September 19, 2024, Licensing Program Analyst Connie Jones-Steward conducted the annual continuation inspection. LPA Jones-Steward reviewed the employee files for the administrator, the house lead (facility manager) and three direct service providers. LPA Jones-Steward also reviewed the job descriptions section of the program statement. Staff interviews were conducted with the administrator and the house lead. All staff files that were reviewed contained documentation of the required clearances, trainings, etc. There were no staff record citations issued.


summary: Facility Evaluation

raw_content:
Narrative:
On March 21, 2024 at 11:34 am, Licensing Program Analyst (LPA) Christine Wilson made an unannounced visit to the above listed facility, in order to conduct a case management deficiency.LPA Wilson was met by the Facility Administrator, who was previously, the Assistant Administrator, and who gave LPA entry into the home. During the course of the case management related to SIR dated 11/06/23, it was discovered that the youth (C2) was verbally mistreated and physically humiliated by inflicting injury on his side abdomen area by staff (C4) who was placed on Administrative leave.Based on information from record review and confidential interviews, the preponderance of the evidence standard has been met. The Department has determined substantiated finding for violation of client's personal rights; thus, posing an immediate health, safety and personal rights risk of harm to children placed in care. A (1) deficiency Type A has been determined at this time. The following deficiency has been cited. (See LIC 809D) An exit interview was conducted and Plans of Correction was developed and reviewed with the licensee. A copy of this report and appeals rights were discussed and left with licensee. (AA) whose signature on this form confirm receipt of these documents. .


facility_name: PHOENIX RISING YOUTH HOME

summary: Facility Evaluation

raw_content:
Narrative:
On 11/20/24 at 10:30AM, Licensing Program Analyst (LPA) Mariah Hawkins met with Administrator Helen Ayala for the scheduled Component II face-to-face meeting. The licensee submitted a Board Resolution letter designating Helen the responsibility of representing the licensee. Helen will also serve as the facility's administrator. 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 - Care and Supervision Policies - Staff Training - Emergency Intervention Policies - Reporting Requirements - Admission Procedures - Needs and Services Plans - Basic Services and Planned Activities - Visitation Policies - Background Clearance/Guardian Process Helen demonstrated understanding of the program policies and procedures. An exit interview was conducted, and a copy of this report was provided to Administrator Helen Ayala.

met_with: Administrator Helen Ayala


summary: Facility Evaluation

raw_content:
Narrative:
On 11/20/24 at 11:30AM, Licensing Program Analyst (LPA) Mariah Hawkins conducted the announced Prelicensing Inspection. LPA met with Administrator Helen Ayala. LPA toured the facility site and observed the facility to be clean and in sanitary condition. The facility is a 2-story building, and there is one kitchen, three bedrooms, and two client bathrooms on each story. There is a common space on each floor that can be used for visitation and lounging. There is no outdoor activity space. The program plan includes utilization of local youth activity centers and/or parks. Hot water measured within required range, and bedrooms offer two beds each as well as personal storage space. The facility will have a maximum capacity of 11 clients and will serve children ages 13 to 17 and 18 if in high school. 18-year-old cilents will not share a bedroom with minors unless the licensing agency approves an exception. The facility has submitted a complete application packet and plan of operation with program statement. All requested revisions were made. The financial institution has submitted the financial verification. Administrator Helen Ayala holds a current and valid administrator certificate and first aid certificate and has demonstrated understanding of the program's plan of operation. See Lic 809-c Page PAGE Items to complete prior to licensure/placement: - The licensing agency is awaiting receipt of the fire clearance from the fire department. - New beds, a dining table, sofa, and dressers have been purchased and will be moved in prior to placement of any clients. - There are unsused motion detectors in each bedroom, which licensee intends to remove. - The licensee will be installing a landline phone for each floor and providing the phone number to LPA. - There are patched sections of the common space room that will be painted over, which the licensee plans to complete prior to placing any clients. Licensee will provide a written plan with time frame to LPA. This facility will be ready for licensure once the above is completed and Licensing Program Manager Isabel Diego has reviewed and approved the application. An exit interview was conducted, and a copy of this report was provided to Administrator Helen Ayala.

visit_type: Prelicensing


summary: Facility Evaluation

raw_content:
Narrative:
On 11/20/24 at 3PM, Licensing Program Analyst (LPA) Mariah Hawkins met with Administrator Helen Ayala for the scheduled Component III orientation. The licensee submitted a Board Resolution letter designating Helen the responsibility of representing the licensee. Helen will also serve as the facility's administrator. LPA provided a slide show orientation of regulations and requirements applicable to the facility type. Administrator demonstrated familiarity with licensing regulations and licensing forms. The following items were discussed: - Title 22 regulations and applicable licensing requirements - Reporting requirements, mandated reporting, incident reporting procedures - The facility's licensed age range and age exceptions, waivers and other exception requests - Plan of operation revision notification and procedures - Safeguarding cash resources and personal property - Accountability, availability of board meeting minutes - Basic services, hygiene supplies, activity planning, food services, and transportation - Personnel files, job duties, qualifications, training, first aid, and emergency intervention - Client files, medical assessments, register of clients, needs and services plans - Buildings and grounds, care and supervision, utilization of surveillance cameras - Inspection authority, inspection types and expectations - Deficiencies, plans of correction, and civil penalties - Provider Information Notices, navigating the CCLD website An exit interview was conducted, and a copy of this report was provided to Administrator Helen Ayala.


summary: Facility Evaluation

raw_content:
Narrative:
Control #: 2238-FN On October 1, 2025 at 10:20AM Licensing Program Analyst (LPA) Omar Sawyer and LPA Hanako Primer made an unannounced Case Management inspection at the above facility for an Incident Report Follow-up. LPA Sawyer and LPA Primer met with, Care Advocate, Derrick Wright. There are 4 clients in care, but none were present at the time of the inspection. The purpose of the visit was to obtain more information from the Group Home regarding an incident report that was submitted to Community Care Licensing (CCL) by the Group Home on 09/29/25. LPA Sawyer requested the Client files, Needs and Services Plan for current clients, and current Staff Roster/schedule. LPA Sawyer will issue a Technical Violation per Title 22, Division 6, Health Related Services. 80075(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. LPA Sawyer will return at a later date to complete the inspection. An exit interview was conducted with Derrick Wright, Care Advocate. A copy of this signed report was printed and left with Mr. Wright, whose signature confirms receipt.

met_with: Derrick White, Care Advocate


summary: Facility Evaluation

raw_content:
Narrative:
On October 23, 2025 at 09:45AM Licensing Program Analyst (LPA) Omar Sawyer and LPA Mariah Hawkins made an unannounced Case Management inspection at the above facility for a Continuation of an Incident Report Follow-up. LPA Sawyer and LPA Hawkins met with, Youth Advocate, Darrick Wright. There are 5 clients in care, four are present at the time of the inspection. One Client is at school. Administrator, Valeria Morales, arrived shortly after LPA's arrived. LPA Sawyer and LPA Hawkins conducted a facility walk through with Administrator, Valeria Morales. LPA Sawyer and LPA Hawkins reviewed the Medication Log, reviewed Client Files, LPA Sawyer reviewed Full Time Staff Training files, and Requested Staff Files that were emailed to LPA Sawyer by Megan Lantz, Director of Human Resources, for Restorative Pathways- Phoenix Rising Youth Home. An exit interview was conducted with Valeria Morales, Administrator/Facility Manager. A copy of this signed report was printed and left with Ms. Morales, whose signature confirms receipt.

met_with: Darrick White, Youth Advocate


summary: Facility Evaluation

raw_content:
Narrative:
On December, 17 2025, at 10: AM Licensing Program Analyst (LPA) Omar Sawyer and LPA, Mona Lam conducted an unannounced inspection of the above facility for the purpose of conducting an Annual/Required inspection. LPA Sawyer and LPA Lam met with Kyley Mettier, Youth Advocate, and Administrator, Valeria Morales, of Phoenix Rising Youth Home and toured the facility, inside and grounds. The Group Home is licensed to serve eleven clients, ages 13-17 years (18 if they are completing high school) Ambulatory Only. Currently in placement are two clients. No clients were present during this inspection. LPA Sawyer observed at the time of this inspection, the facility to be clean and in safe condition. All fire alarms, and carbon monoxide detectors were in good working condition, and the fire extinguisher is current and was serviced on November 6, 2025. LPA's inspected Staff files and Client files. LPA Sawyer will be issuing Technical Violations for 84065(i)(3)(Y) and also 80069(c). LPA will follow up with facility on completing LIC 602. LPA conducted one confidential Staff Interview. The following documents are posted in the facility: facility license, emergency disaster plan, menu, activity calendar and personal rights. The thermostat is set at 72 degrees. The hot water temperature was at (Kitchen Sink - 114, Hall Bathroom 110, and Downstairs kitchen sink 111 degrees Fahrenheit). Based on LPA observations there are no bodies of water at the facility. No deficiencies were cited at this time. An exit interview was conducted and a copy of the report was provided to Administrator, Valeria Morales, whose signature confirms receipt.

met_with: Valeria Morales, Administrator and Kyley Mettier


facility_name: PIERCE HOUSE

summary: Facility Evaluation

raw_content:
Narrative:
On August 30, 2022 at 11:30AM, Licensing Program Analyst (LPA) Carol Anderson made an unannounced inspection to the facility for a required 2yr. LPA met Heather Fulkerson, Residential Facility Administrator. The facility serves four ambulatory male ages from 12-17 yrs. Clients were at school during today's visit. LPA interviewed one staff. LPA toured the exterior and interior of facility. The facility is one story home. The facility is set up as follows: Bedroom #1 with one bed and adequate dresser and closet space for one client. Bedroom #2 with one bed and adequate dresser and closet space for one client. Bedroom #3 with one bed and adequate dresser and closet space for one client. Bedroom #4 with one bed and adequate dresser and closet space for one client. Each client has their own room and bed. There are two bathrooms for the clients to share. The hot water temperature was measured at 107 degrees F. There is a seven day of non-perishable and three days of perishable foods and snacks available. There is adequate supply of sheets, blankets, bedspreads, bath towels, mattress pads and washcloths. The smoke detectors and carbon monoxide are in working order. LPA reviewed four client files. LPA reviewed 10 staff files. The staff and clients' files in order and complete. The medication is locked in cabinet in kitchen area. Sharp knives are inaccessible and stored in a locked cabinet in the kitchen area. The cleaning products and all chemical are stored in locked laundry room. The first aid kit is stored in a cabinet in the dining area. The following required posted items were observed accessible to clients. Grievance Procedures, Personal Rights, "If You SEE Something, SAY Something" Visitation policies, and current menu. Based on the facility inspection and file reviews this date, there is no deficiencies found at this time. . Exit Interview was conducted, and a copy of this report was given to Residential Facility Administrator, Heather Fulkerson.

met_with: Heather Fulkerson


summary: Facility Evaluation

raw_content:
Narrative:
On July 24, 2024, at 10:00AM, Licensing Program Analyst (LPA) Carol Anderson made an unannounced annual/required inspection to the facility. LPA met Heather Fulkerson, Program Administrator (PA). The facility serves six ambulatory male ages from 12-year-old to 17-year-old. There were three clients present at the time of annual/required inspection. LPA interviewed one of two clients. LPA was unsuccessful in interview two clients.LPA interviewed two staff. LPA and PA toured the exterior and interior of facility. The facility is one story home. The facility is set up as follows: Bedroom #1 with one bed and adequate dresser and closet space for one client. Bedroom #2 with one bed and adequate dresser and closet space for one client. Bedroom #3 with one bed and adequate dresser and closet space for one client. Bedroom #4,with one bed and adequate dresser and closet space for one client Each client has their own room and bed. There are two bathrooms for the clients to share. The bedrooms and bathrooms were clean, sanitary, and good repair. The hot water temperature was measured at 112 degrees F. There is a seven day of non-perishable and three days of perishable foods and snacks available. There is adequate supply of sheets, blankets, bedspreads, bath towels, mattress pads and washcloths. The smoke detectors and carbon monoxide are in working order. The staff and clients' files are stored in a locked cabinet in the kitchen. LPA reviewed three client files and five staff files. All the necessary forms were in file. The medication is locked in cabinet in kitchen area. Sharp knives are inaccessible and stored in a locked cabinet in the kitchen area.The cleaning products and all chemicals are stored in locked laundry room. The first aid kit is stored in a cabinet in the dining area. ...Continue on next page The following required posted items were observed accessible to clients. Grievance Procedures, Personal Rights, Ombudsman Poster, Visitation policies, and current menu. LPA reviewed the fire drill log and board of directors' minutes meetings are updated. A review of Guardian on July 24, 2024, indicates that all facility staff associated to the facility had DOJ, FBI, and Child Abuse index check clearances. Based on observations made during the inspection, no deficiencies observed during today's visit. An exit interview was conducted, a copy of this report was given to PA Fulkerson.

met_with: Heather Fulkerson,Group Home Administrator


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst Latricia Rogers conducted a case management inspection October 1, 2024, based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection,9 out of Direct Care Staff and 2 out of 2 youth files were reviewed. 2 out of Direct Care Staff and 0 out of 2 youth were interviewed. (See the Confidential Names List, LIC 811, dated October 1, 2024). The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the Individual Service Plans, and quarterly assessments, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Latricia Rogers observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Heather Fulkerson- Administrator.

met_with: Heather Fulkerson- Administrator


summary: Facility Evaluation

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Narrative:
On August 26, 2025, at 9:42AM, Licensing Program Analyst (LPA) Lisa Bernabe made an unannounced annual/required inspection to the facility. The facility was toured inside and out with Heather Fulkerson, Program Administrator (PA). The facility serves four ambulatory clients ages from 12-year-old to 17-year-old. LPA and PA toured the exterior and interior of facility. The facility is one story home and the facility is set up as follows: Bedroom #1 with one bed and adequate dresser and closet space for one client. Bedroom #2 with one bed and adequate dresser and closet space for one client. Bedroom #3 with one bed and adequate dresser and closet space for one client. Bedroom #4, with one bed and adequate dresser and closet space for one client Each client has their own room and bed. There are two bathrooms for the clients to share. All beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. There is adequate shelf and closet space for the client's belongings. The bathrooms were clean and in good repair. The hot water in the client bathroom was measured and was 116 degrees F. All hazardous items are stored where inaccessible to clients in care. Cleansers/chemicals are locked and stored in cabinet in the laundry room. Sharp knives are inaccessible and stored in a locked cabinet in the kitchen. The First Aid Kit is fully stocked and stored in the kitchen cabinet. The facility's smoke detectors in the kitchen was checked and was operable. The carbon monoxide detector located in entry way was operable. There are no guns or weapons in the facility as stated by Heather Fulkerson, Administrator. The following items were observed accessible to clients: Grievance Procedures, Personal Rights, Ombudsman Poster, Visitation policies, and current menu. See LIC 809-C for continuation). (Continuation of LIC 809) LPA observed a minimum 7-day non-perishable and a 2-day perishable supply of food. There was a variety of snacks available for clients as well. Clients' medications were observed to be inaccessible and stored in the kitchen cabinet. The medication logs are kept updated and the dispensing records had no discrepancies. During the inspection LPA Bernabe interviewed the only staff present during the inspection, there were no clients present during the inspection due to clients being in school. LPA reviewed four client files (C1-C4) and six staff files (S1-S6). Based on today's inspection no deficiencies were observed. An exit interview was conducted, and a copy of this report was given to Heather Fulkerson, Administrator.

met_with: Heather Fulkerson, Administrator


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Narrative:
Continuation of LIC 9099. Confidential interviews indicated that C1 was secured by a harness while being transported on the school bus. Confidential interviews revealed that when C1 was being returned to the facility from school, once C1's harness was released to S2, C1 lunged from the second step of the bus in an attempt to reach the bus driver who was standing outside the school bus. Confidential interviews revealed that C1 fell on top of S2, and S2 was able to get into a stance position while C1 was on the ground, but S2 did not have their knee on C1's back. Confidential interviews revealed C1was aggravated because they were trying to go after the bus driver, but S2 was able to calm C1 down and get C1 to go into the group home calmly. Confidential interviews did not yield evidence to conclude that staff restrained C1 during the incident. Based on confidential interviews, the allegation staff inappropriately restrained minor is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of this report and appeal rights were given to Hannah Woodill, Residential Faculter.

Investigation Findings:
13On December 5, 2025 at 8:48AM, Licensing Program Analyst (LPA) Lisa Bernabe conducted an unannounced visit to Pierce House and met with Hannah Woodill, Residential Faculter, to deliver the investigative finding for the allegation listed above. On August 28, 2025, Community Care Licensing received allegation that staff inappropriately restrained a minor. On September 3, 2025, LPA Bernabe initiated the complaint at the facility and conducted a health and safety inspection of the facility. No immediate safety hazards were observed. In addition, LPA Bernabe obtained documents pertinent to the investigation and conducted three client interviews (C2, C3 and C4) and three staff interviews (S1, S2 and S3). It was reported that C1 became agitated while on the bus and was aggressive towards paraprofessionals on the bus. It was reported that C1 was met by a male group home staff member who restrained C1 by holding C1 by their restraints, pushing C1 against the floor, and placing their knee on C1's back. Continuation on LIC 9099-C. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Lisa Bernabe LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: PIERCE HOUSEFACILITY NUMBER: VISIT DATE: 12/05/2025

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

met_with: Hannah Woodill, Residential Faculter


facility_name: POLARIS TEEN CENTER II

summary: Facility Evaluation

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Narrative:
On Thursday, October 28, 2021 at 9:15am Licensing Program Analyst (LPA) Bernice Karnsrithong arrived at the above facility, for the purpose of conducting an annual inspection. LPA met with Ari Brown, Administrator who provided accessed to the facility. The facility is licensed to care for up to six (6) children ages 12-17 years, ambulatory only. LPA Bernice Karnsrithong had observed the following: This facility is a two (2) story home. There is a long driveway from the street to a giant electric fence. The home opens into a grand foyer and a circular staircase with marble flooring throughout with carpet in the bedrooms. The closet under the circular staircase is being used to store emergency supplies and sports equipment. There are no firearms or dangerous weapons in the home. Medicines are inaccessible to children and are stored in a locked cabinet in an office room. All smoke detectors were tested and are operating properly in the home at the time of visit. Carbon Monoxide alarms were observed and functional in the home at the time of the visit. There are three (3) operable fire extinguishers in the facility. Two first aid kits were checked (one on each floor) and complete with scissors, tweezers, thermometer, gauzes, antiseptic and First Aid Manual. Licensing postings (i.e. Facility License, Fire Clearance, Personal Rights, Emergency Disaster Plan) are located downstairs next to the staircase. Cleaning supplies and chemicals are stored in locked storage downstairs and some in the laundry room. There is a fenced in pool located in front of the staff office which is accessible from the driveway of the home and from inside the home. When pool is in use by children, the Licensee ensures that staff supervising children in the pool area is Water Safety trained. The facility's water heater is locked in a basement room that is inaccessible to clients. Utility shut off valves are clearly marked in the emergency floor plan sketches posted around the facility. Staff were aware were the electrical and gas utility shut off valves are located. There are two (2) common rooms, one is located downstairs which has a large sectional seating area and a coffee table. The upstairs common room has seating area, books, television, and video game console to be used by clients. The downstairs has a nook counter area which has a coffee maker and a small refrigerator that staff can used. The backyard has a seating area, and a fountain that is non-functional. All crawlspaces are locked. There are two (2) covered fireplaces upstairs that are locked and non-operable. The entire facility perimeter is fenced in. Therapy Room: Is located downstairs and includes one walk-in closet, two (2) desks, a sitting area, and a bathroom that can be used by staff or clients. Staff Office: Is currently used for admissions, that includes two (2) desks, a table with four (4) chairs. Program Aide Office: This office is used to store facility logs (Day/Swing/Overnight Facility Checklist, Medication Logs) and medications; including refrigerated medication for clients. Medication logs are reviewed by the facility health care staff. First Aid Kit Supplies, Defibrillator, and hygiene and toiletries are also stored in this room. Kitchen: This area includes a large built-in refrigerator, a functional six (6) burner stove, microwave, and toaster. LPA observed a menu posted for three (3) meals. There are enough supplies of staple perishable and nonperishable food for clients. Dining Room: It is located next to the kitchen area and has two (2) bench seats and a large table that can sit up to eight (8) people. The dining room has a sliding door that leads to the upstairs outdoor area. The upstairs outdoor area has patio seating, rocking chairs, table, and a Ping-Pong table to be used by clients. There is stairwell in the upstairs outdoor area that leads to side of the house and to the pool area. There is door that leads to the pool area from the side of the home. Garage: This area is locked, finished, and converted into an office space. It has a long table with eight (8) chairs, and four (4) desks. It is used as a conference room. There are cabinets to be used for storing extra food and hygiene supplies. This area is used for intake purposes. Laundry Area: This area is locked, and equipped with a washer and dryer, a cabinet space to store laundry and cleaning supplies and linens. Pantry: This area is locked which stores non-perishable food items for clients. Bathrooms: There are two (2) bathrooms downstairs. Bathroom#1 downstairs is a 3/4 bath with shower for only staff and guests. Clients will not be allowed in this bathroom because it can be locked from the inside and has access to the front yard. Bathroom #2 downstairs is located in the therapy room and can be used by staff or clients who are currently in the therapy room. There is one (1) common full bathroom used by clients located upstairs. Each bedroom also has their own bathroom. Bedrooms: 3 bedrooms each have its own bathroom and observed with sufficient lighting, drawer and closet space, desk, chair, comfortable mattresses, clean linens, blankets and pillows. • Master bedroom- is equipped with three (3) full sized beds, and two (2) walk-in closets, a full bath and lock and key on doors that access to a balcony overlooking the driveway. (These doors are kept locked at all times) • Blue Room- is equipped with two (2) full sized beds and a 3/4 bath • Yellow Room - is equipped with one (1) full sized bed, a 3/4 bath and lock and key on doors that access a balcony overlooking the front yard swimming pool (These doors are kept locked at all times) LPA reviewed four (4) staff files and conducted two (2) staff interviews. Staff records are stored in an online portal but can be accessed during inspection. There are no clients at the time of the inspection. There are no deficiencies observed or cited at the time of this inspection. Exit interview conducted, and a copy of this report will be emailed to the facility.


summary: Facility Evaluation

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Narrative:
On 10/19/2023 at 09:00AM Licensing Program Analyst (LPA) Nancy O'Connell arrived at the above facility, for the purpose of conducting an Annual/ Required inspection. LPA O'Connell met with Ari Brown, Facility Administrator, Michelle Butle COO, Lisa Rodriguez, Administrative Coordinator, Stephanie Guttierez Assistant Program Director, and Jessica Meyer, Program Director. FA granted access into the home, and provided a tour of the entire physical plant inside and out. The facility is licensed to care for a capacity of six (6) ambulatory only children. This program is designed to accept private placements and there are currently no clients in placement at the time of the visit. General overview: There is a long driveway from the street to a giant electric fence. The home opens up into a foyer and a circular staircase with marble flooring throughout and carpet in the bedrooms. The closet under the circular staircase is used to store exercise/recreational equipment. There are no security bars on the windows. There are no firearms or dangerous weapons in the home. Medicine office is located on the first floor and is locked, ensuring medications are inaccessible to children when they are in care. All smoke detectors were tested and are operating properly in the home at the time of visit. Carbon Monoxide alarms were observed and functional in the home at the time of the visit. There are operable fire extinguishers available throughout. Outdoor activity space was clean, and free of obstructions. First aid kit is located within the medication office and was checked and complete with scissors, tweezers, thermometer, gauzes, antiseptic and 1st Aid Manual. All posting requirements were observed and Emergency Plan was observed and posted on first floor. There are covered fireplaces in the home that will not be used. The Exterior consists of the following: POOL: Located in the front yard, which is accessible from the driveway of the home and from inside the home. There is a fenced and gated pool on the premises that meets regulations. Licensees have installed a pool fence that meets standards. The pool gate has a lock on it, ensuring that the body of water is inaccessible to clients when they are in care. Pool area also has space for lounging and access to a BBQ that is not currently in use. (Continued on page LIC809-C) 1st Floor: The first level of the home includes the following: Garage: locked, finished, and converted garage with cabinets, a long table with chairs, and staff desks to be used as a conference/training room. No clients will be allowed in this garage. Pantry: also locked with a dumbwaiter which can store non-perishable foods. Another Pantry: also locked, and stores extra supplies Storage Closets: is unlocked with nothing in it at this time originally a kitchen. Has one small refrigerator. Living Room: with plenty of seating for clients, and with locked doors that open up to the front yard. Bathroom#1: 3/4 bath with shower for only staff and guests. (Clients will not be allowed in this bathroom because it can be locked from the inside, and has access to the front yard). Laundry Area: locked, and equipped with a washer and dryer, and cabinet space to store detergent, and cleaning solutions. Therapy Room: used for clinical work that includes one walk-in closet, desks, and a sitting area. Staff Office: used for admissions, that includes 2 desks, printer, and office supplies. Bathroom#2: full bath located in the Staff Office. Back Staircase: located next to the Staff Office. 2nd Floor: The second level of the home includes the following: Living Room: with plenty of seating, television, locked doors that open up to the balcony overlooking the front yard, and a covered fireplace. Kitchen: includes a large built-in refrigerator, a functional 6-burner Viking stove on the island, and plenty of cabinet space. Knives / Sharp objects were not present in the facility due to no clients being in care and FA reports that the staff cook retains knives in their possession. Chemicals are kept in one of the locked storage closets downstairs in the laundry room, when not in use. Dining Room: next to the kitchen that has a dining area, 2 bench seats, 2 chairs, that seats up to 8 people. 3 bedrooms that each have its own bathroom, and observed with sufficient lighting, drawer and closet space, comfortable mattresses, and clean lines, blankets, and pillows. · Bedroom # 1- (Master bedroom) equipped with 3 queen beds, 2 walk-in closets, a full bath (Bathroom#3), and lock and key on doors that access to a balcony overlooking the driveway. · Bedroom # 2 - equipped with 2 full beds, a 3/4 bath (Bathroom#4). · Bedroom # 3 - equipped with 2 full beds, a 3/4 bath (Bathroom#5), and lock and key on doors that access a balcony overlooking the front yard swimming pool. (Continued on page LIC809-C) LPA observed locks on all bathrooms in bedrooms for the purpose of supervising all clients, including but not limited to those with eating disorders. All clients reportedly require permission before using the bathroom, so staff are aware of each use. Bathrooms located in the main hallway are available for use at any time. LPA reviewed staff record for FA (admin cert/renewal, TB screening, and CPR recert). LPA reviewed resources related to CARE Tool, required documents. LPA reviewed the Disaster Plan, Operations, and Emergency Intervention Plan. The home is clean, safe & in good repair. Per California Code Regulations, TITLE 22, DIVISION 6, CHAPTERS 1 & 5, there are no deficiencies observed or cited at the time of this inspection. Exit interview conducted, and a copy of this report was sent to the FA.

met_with: Ari Brown, Facility Administrator (FA)


facility_name: POLARIS TEEN CENTER III

summary: Facility Evaluation

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Narrative:
On June 24, 2021 @ 9AM Licensing Program Analyst (LPA) Kathy Landry made an unannounced site inspection to facility above for the purpose of conducting a Required Annual evaluation. LPA Kathy Landry met with CEO, Facility Administrator and Program Director. Facility was toured @ 9:20AM inside and out. There were 5 clients residing in the home. Home is set up as follows: Downstairs has 1 conference room, 3 clinical offices, group room, family room, art room, kitchen, dining room, and 2.5 bathrooms. Upstairs consists of 3 bedrooms, clinical office, program aid-nurse office (where medications are stored) and 3 bathrooms. Facility excepts children ages 12-17, Private Placement. Master bedroom has 3 full size beds. The other upstairs bedrooms each have two full size beds. Home has no fire arms. There is an inground swimming pool/spa with 5' mesh fence and a self latching gate with latch at the top. Gateway opens outward. Children are supervised all the times and treated with dignity. Facility is clean, safe and in good repair. No passage ways, inclines, stairways, ramps or open porches are obstructed. Disinfectants/poisons are inaccessible. There is an adequate food supply (2 day perishable and at least 7 day non-perishable). Nutritious snacks are served between meals. Medication is locked except to supervising employees. Personal Rights is posted, upheld and staff instructed to report violations. Children are not restricted to telephone use except by court order and can contact Foster Care Ombudsman without threats or punishment. Children have extracurricular activities, attend school and have enrichment studies. Childrens records were reviewed for Cash Resources, Emergency Consent & Appraisal Needs & Services. Facility operates within its licensed conditions & limitations, including capacity. There are no excluded persons on premises. LPA requested Administrator to submit an updated LIC Personnel form for LPA Landry to review All Criminal Record Clearances. Facility has a current Plan of Operation. Disaster Plan is on file and posted at facility along with Indoor/Outdoor Sketch Administrator meets qualifications. Licensee/Admin have been instructed to report changes in the plan of operation which affects clients. Facility Rep has been reminded to report client injuries requiring medical treatment and other special incidents. Both Administrator, Program Director and clients records were reviewed. Covid signs were posted. First Aid Kit is complete with all required items. Smoke detectors/Carbon Monoxide equipment was tested Fire Extinguishers are up to date and have been serviced. Facility is within Title Regulations at this time. There were no violations observed and no citations issued. Exit interview conducted. Copy of Report given

met_with: CEO, Ari Brown, Admn Michelle Butler & Program Director Jessica Meyer


summary: Facility Evaluation

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Narrative:
On June 24, 2021 @ 9AM Licensing Program Analyst (LPA) Kathy Landry made an unannounced site inspection to facility above for the purpose of conducting a Post Licensing Evaluation. LPA Kathy Landry met with CEO, Facility Administrator and Program Director. Facility was toured @ 9:20AM inside and out. There were 5 clients residing in the home. Home is set up as follows: Downstairs has 1 conference room, 3 clinical offices, group room, family room, art room, kitchen, dining room, and 2.5 bathrooms. Upstairs consists of 3 bedrooms, clinical office, program aid-nurse office (where medications are stored) and 3 bathrooms. Facility excepts children ages 12-17, Private Placement. Master bedroom has 3 full size beds. The other upstairs bedrooms each have two full size beds. Home has no fire arms. There is an inground swimming pool/spa with 5' mesh fence and a self latching gate with latch at the top. Gateway opens outward. Children are supervised all the times and treated with dignity. Facility is clean, safe and in good repair. No passage ways, inclines, stairways, ramps or open porches are obstructed. Disinfectants/poisons are inaccessible. There is an adequate food supply (2 day perishable and at least 7 day non-perishable). Nutritious snacks are served between meals. Medication is locked except to supervising employees. Personal Rights is posted, upheld and staff instructed to report violations. Children are not restricted to telephone use except by court order and can contact Foster Care Ombudsman without threats or punishment. Children have extracurricular activities, attend school and have enrichment studies. Childrens records were reviewed for Cash Resources, Emergency Consent & Appraisal Needs & Services. Facility operates within its licensed conditions & limitations, including capacity. There are no excluded persons on premises. LPA requested Administrator to submit an updated LIC Personnel form for LPA Landry to review All Criminal Record Clearances. Facility has a current Plan of Operation. Disaster Plan is on file and posted at facility along with Indoor/Outdoor Sketch Administrator meets qualifications. Licensee/Admin have been instructed to report changes in the plan of operation which affects clients. Facility Rep has been reminded to report client injuries requiring medical treatment and other special incidents. Both Administrator, Program Director and clients records were reviewed. Covid signs were posted. First Aid Kit is complete with all required items. Smoke detectors/Carbon Monoxide equipment was tested Fire Extinguishers are up to date and have been serviced. Facility is within Title Regulations at this time. There were no violations observed and no citations issued. Exit interview conducted. Copy of Report given

met_with: CEO Ari Brown, Admn Michelle Butler & Program Director Jessica Meyer