summary: Facility Evaluation

raw_content:
Narrative:
On November 29th, 2022 at 8: AM, Licensing Program Analyst (LPA) Jessica Peete, conducted an unannounced annual inspection at Born for Nia Maternity Home Short Term Residential Therapeutic Program ( (STRTP).LPA was met at the facility by Facility Manager Shiooan Shannon. LPA Peete visited the facility on 11/028/2022 to complete inspection of the Physical Plant, Disaster Preparedness, Operational Requirements, and Emergency Interventions. At 9: AM LPA began the review of four client files and (C1-C4) and Core Therapeutic Services. All the documentation pertaining to this area of the inspection was provided, and no deficiencies were noted. At 11: AM LPA began review of five staff files (S1-S5) Assisted by the Facility Manager and Human Resource Coordinator Vanessa Maddox. At 1: PM LPA observed S1 and S4 did not have the required health screening, placing the licensee out of compliance with following California Code of Regulations (CCR): CCR 80066(a)(10) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g). CCR 80065(g)(2) A health screening report signed by the person performing such screening shall be made on each person specified above, and shall indicate the following: CCR 80065(g)(2)(A) A health screening report signed by the person performing such screening shall be made on each person specified above, and shall indicate the following: (A) The person's physical qualifications to perform the duties to be assigned. (Continued on LIC C) CCR 80065(g)(2)(B) A health screening report signed by the person performing such screening shall be made on each person specified above, and shall indicate the following: (B) The presence of any health condition that would create a hazard to the person, clients or other staff members. At 2: PM LPA observed S1 did not have the required Tuberculosis test; placing the licensee out of compliance with the following California Code of Regulations (CCR): CCR 80066(a)(11) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g). CCR 80065(g)(1) good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure. At 3: PM LPA observed the S2 and S3 did not have the required 40 hours annual training. S2 completed 12.25 hours and S3 completed 30.75 hours. The licensee is not in compliance with Interim Licensing Standards (ILS) 87065.1(e)(1) .. all direct care staff shall complete a minimum of 40 hours of annual training... Based on observations made during the inspection, deficiencies are being cited see LIC D. An exit interview was conducted, and a copy of this report and appeal rights was provided to Facility Manager Shionna Shannon via email.


state: CA

facility_name: BORN FOR NIA MATERNITY HOME

summary: Facility Evaluation

raw_content:
Narrative:
On January 12, Licensing Program Analyst (LPA's) Leslie Covarrubias and Jessica Peete arrived at Born for Nia Maternity Home STRTP and met with Facility Manager, Sionna Shannon for the purpose of delivering an amended report.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Facility Manager, Sionna Shannon


summary: Facility Evaluation

raw_content:
Narrative:
**This is an amended report from the original to rectify errors found in the original report** On September 10, 2024, at 10: AM Licensing Program Analyst (LPA) Cynthia Urena, conducted an unannounced visit at Born for Nia Maternity Home Short Term Residential Therapeutic Program (STRTP). LPA was met by Facility Manager, Sionna Shannon. The purpose for this visit is to Amend an Annual inspection dated 08/27/24 where citations were issued by LPA that are not applicable to the facility's program. Below is a summary of the information observed during LPA's initial visit to the facility dated 08/27/24. LPA's observations: At 9: AM, LPA began a physical plant inspection with the assistance of the Administrator, DeVonda Blackmon. The inspection included the following observations: Entry area, kitchen, dining room, refrigerator/freezers, food storage areas, living room, sitting room, two client bathrooms, one staff office, one therapy office that is located in the backyard, four client bedrooms, and a garage. The bedrooms are arranged so that there is one parent and infant per room. Three of four client rooms observed have the appropriate linens, pillows, comforters, mattresses, and cribs. A crib located in bedroom #3 was not observed with fitted crib linen. This linen was also observed with stains, and with dirt debris. LPA was informed that clients in care are encouraged to maintain rooms clean including the cribs and bedding that belong to their infants who are not considered placements at the program. LPA observed that the sheets were removed and replaced with fitted and clean sheets by staff prior to LPA leaving the facility. All client bedrooms and furnishings were observed to be in good repair. The facility has extra linens that are stored in the hall closet. Furthermore, adequate drawer and closet space for each client's belongings was observed. The hot water in each client bathroom measured within 105-120 degrees Fahrenheit. (****) The facility grounds are clean and free of debris and observable hazards. Cleansers, chemicals, and cooking knives are inaccessible to clients. Cleaners and chemicals are locked in the garage cabinet and knives are locked inside the staff office. The Licensee maintains an adequate supply of perishable and non-perishable foods. LPA observed the following postings: Facility license, grievance procedures, personal rights, Ombudsman poster, visitation policies, and current menu. Age-appropriate toys, games and books were observed for client's recreation time. The facility has an operable smoke and carbon monoxide detector located in the hallway area. Fire extinguishers are properly charged, serviced, and located in the kitchen and staff office. The first aid kit is complete and kept in the staff office. The washer and dryer are located in the garage. Per Facility Manager statement clients are assisted while they do their own laundry and detergents are kept locked in the garage cabinet. The facility's outside grounds (front yard, backyard) were also inspected and were found to be clean, well maintained, and free of observable hazards. There is adequate indoor and outdoor activity space; all exits and walkways were free from obstruction. Per Facility Manager there are no guns or weapons on facility grounds. The facility has a total of two vehicles; that are used to transport clients to appointments and recreational activities. Both vehicles were operable and in good repair. At 10: AM, LPA began review of Disaster Preparedness, Operational Requirements, and Emergency Interventions assisted by the Facility Manager. All the documentation pertaining to this area of the inspection was provided, and no deficiencies were noted. At 11: AM LPA began the review of three client files and (C1-C2, C3) and Core Therapeutic Services. All the documentation pertaining to this area of the inspection was provided, and no deficiencies were noted. (****) At 12: PM, LPA began review of five staff files (S1, S3, S3, S4, S5). All personnel records reviewed have the verification of Department of Justice, Federal Bureau of Investigations, and Child Abuse Index Check clearances. All staff have proof in file of acknowledging confidentiality and mandated child abuse reporting requirements. All personnel records reviewed met the required education and experience requirement. All personnel records reviewed had a completed physical exam on file. Based on observation and record review, there are no deficiencies noted. An exit interview was conducted, a copy of this report along with the appeal rights was provided Facility Manager, Sionna Shannon.

visit_type: Annual

met_with: Administrator, DeVonda Blackmon


summary: Facility Evaluation

raw_content:
Narrative:
On September 20, Licensing Program Analyst (LPA) Linda Haynes met with Direct Care Staff Qunisha Miller to amend LIC 9099 dated 9/13/2024.

met_with: Qunisha Miller


summary: Facility Evaluation

raw_content:
Narrative:
On October 14. 2024, at 12: PM, Licensing Program Analyst (LPA) Val Wilson conducted an unannounced case management visit to Born for Nia Maternity Home, Short Term Therapeutic Program (STRTP) and met with Lead Facility Manager, Sionna Shannon, for the purpose of gathering signatures.

met_with: Sionna Shannon


summary: Facility Evaluation

raw_content:
Narrative:
On June 12, 2025, at 3: PM, Licensing Program Analyst (LPA), Val Wilson arrived and met with Lead Facility Manager (LFM), Sionna Shannon to conducted an unannounced case management visit to Born for Nia Maternity Home, Short Term Therapeutic Program (STRTP) regarding and incident that occurred at the facility on or around, June 3, 2025. LPA requested pertinent documents from LFM. Executive Assistant (EA), Vanessa Maddox called during the case management and LPA notified of the case management inspection. EA shared that the information will be emailed to LPA since LFM was unable to locate the requested information. A copy of the report, appeal rights, LIC809G, were reviewed, discussed and provided to Lead Facility Manager.


summary: Facility Evaluation

raw_content:
Narrative:
On July 2, 2025, at 1: PM, Licensing Program Analyst (LPA), Val Wilson arrived and met with Lead Facility Manager (LFM), Sionna Shannon to conduct an unannounced case management visit to Born for Nia Maternity Home, Short Term Residential Therapeutic Program (STRTP) regarding an incident that occurred at the facility on or around, June 3, 2025. LPA conducted one interviewed and received pertinent documents from LFM. A copy of the report, appeal rights, LIC809G, were reviewed, discussed, and provided to Lead Facility Manager.


summary: Facility Evaluation

raw_content:
Narrative:
On July 16, 2025, at 9: AM, Licensing Program Analyst (LPA), Val Wilson arrived and met with Lead Facility Manager (LFM), Sionna Shannon to conduct an unannounced case management visit to Born for Nia Maternity Home, Short Term Residential Therapeutic Program (STRTP) regarding an incident that occurred at the facility on or around, June 3, 2025. LPA conducted two interviews and received pertinent documents from LFM. A copy of the report, appeal rights, LIC809G, were reviewed, discussed, and provided to Qunisha Miller, parent mentor (PM). LPA verified the LIC308 for PM with the LFM.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On May 13, 2025, at 2: PM, Licensing Program Analyst (LPA) Val Wilson met with Born for Nia Maternity Home, Short Term Therapeutic Program (STRTP) Lead Facility Manager, Sionna Shannon, to deliver a case management deficiencies report. According to information obtained by Community Care Licensing (CCL), on or around April 2, 2025, at approximately 3: PM, a dependent and non-minor dependent [client 1 (C1) and client 2 (C2)] had a physical altercation resulting in an arrest made by law enforcement. Children and Family Services (CFS) was notified of the incident on April 2, 2025; However, the facility did not make an initial report to the CCL the next business day following the incident. Additionally, the facility did not ensure a written report was submitted to the CCL within seven days following the occurrence of such event. Based on interviews, review of documents, and county reports, the facility is being cited for violation of Interim Licensing Standards (ILS) 87061(j) Reporting Requirements. A copy of the report was discussed and provided along with appeal rights, LIC 809D, LIC 809G, and LIC 811 to the facility representative.

Deficiencies:
87061(j): 1
2
3
4
5
6
7

title:
1
2
3
4
5
6
787061 Reporting Requirements
(j) The licensee shall submit reports to the Department... regarding any incident that involves law enforcement contact with a child in the facility. (1) The licensee shall make an initial report to the Department no later than the next business day following each incident... (6) For the purposes of this subsection, "contact with law enforcement" means contact with police officers, sheriffs and others as defined in Section 87001(l)(1)...

This requirement is not met as evidenced by

description:
1
2
3
4
5
6
7


summary: Facility Evaluation

raw_content:
Narrative:
On June 12, 2025, at 3: PM, Licensing Program Analyst (LPA), Val Wilson arrived and met with Parent Mentor, Monique Bolding to deliver a case management deficiencies report. Lead Facility Manager, Sionna Shannon arrived and made Administrator, Dr. Dretona Maddox aware LPA was there to delver the deficiencies reports. Executive Assistant (EA), Vanessa Maddox called during the case management and LPA informed EA of the deficiencies. Information obtained by Community Care Licensing (CCL) revealed a concern regarding the administration of Born for Nia Short Term Residential Therapeutic Program (STRTP). LPA conducted an investigation regarding the concern which included a review of facility documents and confidential interviews. Record review and confidential interviews revealed Administrator, Dretona Maddox, holds several roles at the STRTP in addition to STRTP Administrator including Head of Services and Executive Director. In addition, record review and confidential interviews revealed that the Administrator is also an Administrator for another STRTP. Additionally, confidential interviews and record review revealed the Administrator was not present at the facility, and the Personnel Report (LIC 500) did not document the minimum of 20 hours per week the Administrator shall be on the premises. Based on file review and interviews, the facility is being cited for violation of Interim Licensing Standards (ILS) 87064(b)(5)(B). Administrator Qualifications and Duties. (b)(5)(B) a certified administrator who is also a facility's mental health head of service may not serve as a mental health head of service or an administrator of more than one short-term residential therapeutic program. The facility is also being cited for violation of ILS 87064(b)(1). Administrator Qualifications and Duties (b)(1) the administrator shall be on the premises for a minimum of 20 hours per week to manage and administer the short-term residential therapeutic program in compliance with applicable law and regulation. A copy of the report, appeal rights, LIC809G, LIC809D, and LIC811 was discussed and provided to Lead Facility Manager.

met_with: Sionna Sannon


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On December 6, 2022, at 12: PM, Licensing Program Analyst (LPA) Leslie Covarrubias met with Born For Nia (STRTP) Facility Manager (FM) Sionna Shannon to discuss incident reporting requirements and transportation violations discovered during recent record review and confidential interviews conducted in the facility. LPA Covarrubias reviewed and confirmed with Executive Assistant Vanessa Maddox that all six incident reports that Community Care Licensing (CCL) received for 2022 were the only incidents that occurred in the facility. During a file review on November 10, 2022, LPA Covarrubias observed the facility using an in-house incident report form to report incidents not reported to Community Care Licensing. LPA observed numerous incident reports, including 12/14/2021, 12/15/2021, 12/27/2021, 12/28/2021, 12/30/2021, 01/30/2022, and 02/1/2022, which none of these incident's reports were submitted to CCL. Therefore, the facility is being cited for violating the California Code Regulations Title 22, Chapter 1, Article 6, Division 6, Section 80061(E) Reporting Requirements. LPA Covarrubias received information during confidential interviews regarding the facility not providing clients transportation to school and medical appointments due to a lack of staff ratio. It was reported that because there is only one staff on the grounds, if not all, clients accompany the staff to transport the client needing transportation, then the client is not provided transportation and is told to "get an uber." The facilities Plan of Operation (Section 3. Transportation Arrangements) states: "Providing transportation for minor/nonminor dependent parents is a regular part of the daily responsibilities of staff on duty at Born for Nia Maternity Home. Minor/nonminor dependent parents are provided transportation by staff to and from school, medical/dental appointments..." Therefore, the facility is being cited for violating the Interim Licensing Standards, Article 6, Chapter 7.5, Version 4, Short Term Residential Therapeutic Program, Section 87074(c)(1) Transportation and Section 87022(b) Plan Of Operation. (Continue on next page...) A copy of the report LIC 809 and the Appeal Rights were discussed and provided to FM Sionna Shannon.

Deficiencies:
87074: (1) Health-related services.

met_with: Facility Manager (FM) Sionna Shannon

title:
1
2
3
4
5
6
7(c) Unless other arrangements are specified in the Needs and Services Plan...for a child or nonminor dependent, a licensee shall ensure transportation is provided to the following

description: (1) Health-related services.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs), Rachel Vanegas and Val Wilson, conducted an unannounced inspection on May 31, 2024. During the inspection, LPA met with lead facility manager, Sionna Shannon. The purpose of the inspection was to address information obtained during LPA's visit to the facility. During LPA's visit to the facility, LPAs found that the facility did not have a facility manager on site at 9: AM, when children were present. LPAs observed the lead facility manager arrive at 10: AM. The facility is being cited for violation of the Interim Licensing Standards, Short-Term Residential Therapeutic Program, Articles 6, Version 5, 87065(f) Personnel Requirements. An exit interview was conducted, a copy of this report along with LIC 809D, LIC 811, and appeal rights were provided to Sionna Shannon.


facility_name: BOULEVARD GROUP HOME

summary: Facility Evaluation

raw_content:
Narrative:
On 7/9/ Licensing Program Analyst (LPA) Reagan Cohen conducted the Component II - Face to Face Interview with Applicant Sheila Hatcher. Application and program statement was reviewed and discussed with Applicant. The applicant will oversee Boulevard Group Home (STRTP). The following documents were received and verified by LPA: 1. LPA verified and signed the orientation certificate for Component II. 2. LPA made a copy of Applicants ID for the records. 3. LPA observed that the criminal record clearance has not been approved yet for Applicant. LPA informed Applicant that LIC 200 needs to be resubmitted with a new name that does not include Group Home because it is an STRTP facility, and also the age group of the facility. Applicant will also resubmit LIC 401, LIC 500, LIC 999. Applicant will also add verbiage that the facility will not with hold client cash/allowances as punishment. Applicant will add a Table of Contents. Applicant will revise and resubmit application and Program Design by 7/16/25. LPA scheduled a Pre-Licensing visit for Boulevard for 7/24/25 at PM. A copy of this report was given to the applicants. Exit interview completed.

met_with: Sheila Hatcher


summary: Facility Evaluation

raw_content:
Narrative:
On 7/24/25, Licensing Program Analyst (LPA) Reagan Cohen arrived at the above facility, for the purpose of conducting a Pre- licensing inspection for an STRTP. LPA met with applicant Sheila Hatcher, who granted access into the home. The applicant and LPA toured the facility both inside and out. Applicant is requesting to be licensed for 4 clients ages 16-21 ambulatory only. The home was inspected and the following was observed This is a one-story house, with a front yard, backyard, and drive way. There are working duel smoke/carbon monoxide detector in every bedroom. They are synched throughout the house. Living Room: There is adequate lighting and air conditioning. There is a TV. There are 2 sofas that provide adequate seating. There is a coffee table. There is a landline in the living room. The living room leads to the kitchen/dinning area. Dinning Room/Kitchen: There is a dinning table with 4 chairs. There is a mini fridge that will hold snacks. There is a water cooler for clients to use. There are shelves along the wall for snack storage. There is a fridge/freezer with adequate storage space for food. There is a stove with 5 burners and an oven. There is a microwave and air fryer. There is adequate storage space for food, cooking supplies, and utensils. LPA observed an adequate amount of non perishable food, utensils, plates, cups, bowls, cooking tools, pots, & pans. The first aid kit is stored in the kitchen, it is complete with scissors, tweezers,gauzes, bandages, and antiseptic solution. There is also a first aid manual. This room leads to the office, bedroom #1, and to the hallway. There are no knives or cleaning solutions stored in the kitchen. Office: There is an office room for staff only. It must be made inaccessible to clients. There is a computer and printer. There is a closet that is storing all cleaning solutions and hygiene products. There is a cabinet for storage for staff and client files. There is a freezer for medication storage. There is a TV. There is a door that leads to the backyard. The office will not be used as a passageway to the back yard. Bedroom #1: For clients. The room has 2 beds, lights, AC, a closet, 2 dressers, extra linens and towels. There is one window with adequate screen covers and which opens for emergencies. After this room starts the hallway to the bathroom and bedroom #2. Bathroom #1: The bathroom is equipped with a toilet, shower, and sink. The sink temp was measured to be 120 degrees F. There are working lights and a fan. There are no cleaning solutions in the bathroom. Hallway: The hall way has a fully charged fire extinguisher. There is a wall heater in the hallway that is non operational/decommissioned. Bedroom #2: The bedroom is for clients. The room has 2 beds, lights, AC, a closet, 2 dressers, extra linens and towels. There are 2 windows with adequate screen covers and 1 which opens for emergencies. Front Yard: There is a front porch with 4 chairs. There is a front yard with adequate space for clients to hang out. There is a camera in the front yard. Driveway: There is a driveway along the side of the house that leads to the backyard. There is a gate that will be made accessible to the backyard. Backyard: There is a washer dryer set accessible to clients in the backyard. There are desks in the back yard for clients to use. There is adequate space for clients to run around and hangout. There are two cameras in the backyard. The backyard is free of debris. LPA will return to ensure that: Personal rights are posted in a public area Sample activity schedule and menu are posted in a public area Emergency/disaster plan is posted in a public place The office can lock and be made inaccessible to clients A trash can with a fitted lid is added A thermometer is added to the first aid kit A personal lock box is available for clients that will store their personal items that they have access to Complaint procedures are set up including a instructions, grievance forms, and a lock box to submit forms Laundry baskets and hygiene basket is available to clients An adequate amount of books, board games, and card games are available to clients Facility vehicle is in working order with insurance LPA will email applicant a copy of the facility cameras PIN Applicant and LPA agreed that LPA will return on 8/7/25 to ensure changes were made. Exit interview was conducted and a copy of this report was given to the applicants.

visit_type: Prelicensing

met_with: Sheila Hatcher Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 8/7/25, Licensing Program Analyst (LPA) Reagan Cohen arrived at the above facility, for the purpose of conducting a Pre- licensing inspection continuation for an STRTP. LPA met with applicant Sheila Hatcher, and continued the inspection by completing the CARE Tools and ensuring that all the previous observed missing items were added and fixed. LPA toured the facility that facility with the applicant. LPA observed the personal rights posted in a public space. LPA observed the the sample menu and activity schedule posted. A observed the emergency plan posted in a public place. observed the office being able to lock and can be made inaccessible to clients. LPA observed a trash can in the kitchen, and a thermometer with the first aid kit. LPA observed personal lock boxes for each client. LPA observed a grievance procedures lock box for clients to submit into. LPA observed a laundry and hygiene basket filled with toiletries for each client. LPA observed the facility to be filled with books and games/activities for clients. LPA observed the insurance and registration for the facility vehicle and LPS observed the vehicle to be in working order. LPA talked with applicant about the next steps and reviewed the CARE tools requirements for running the facility with the applicant. No deficiencies observed. LPA scheduled a component 3 meeting with the applicant for 8/14/25. Exit interview was conducted and a copy of this report was given to the applicant.

met_with: Sheila Hatcher Applicant


summary: Facility Evaluation

raw_content:
Narrative:
On 10/21/25 at PM LPA Reagan Cohen and LPM Lakescia Smith met with Applicant Sheila Hatcher and Ebony Streets at the El Segundo Regional Office for the purpose of a technical Assistance Meeting. System of Care representatives Cynthia Galindo and Marjana Jackson were present via zoom. The purpose of the meeting was for CCL and SOC to discuss the revision regarding the Facilities proposed Plan of Operation and Program Statement (POO/PS). The following items were discussed: Redoing the binder numbering to match the POO/PS Section D - Staff Plan G. Admission Determination Procedures H. Intake Policies and Procedures Section I Admission Agreement: Section J Removal and/or Transfer Policies and Procedure M. Consultants and Community Resources Utilized Plan of Opration 1. Population to be Served 4. Core Services and Supports 5. Trauma Informed Interventions and Treatment Practices 7. Development, Implementation, and Modification of Needs and Services Plan 8. Planned Activities 9. Services During Placement and After Discharge 7. Describe how the program will support caregiver staff in identifying and accessing services and supports to heal from trauma, including, for example, how they will address secondary trauma experienced by staff · Need to show specific training hours; training hours don't match · Need training assessment · Stated that there will be outside training, be specific, who will lead training & what topics will be covered? · Info on engaging and working with child's family and community · More cultural sensitivity G. Admission Determination Procedures 1. Determination procedures do not include a detailed explanation of how the program will evaluate the appropriateness of placement for referred children with any of the following behaviors or characteristics, including how the licensee defines these characteristics for the purposes of assessing appropriateness of fit: · Frequent runaways · Gang-related activity · Firestarting · Sexually assaultive behaviors · History of Commercial Sexual Exploitation · Substance abuse 2. Need to include a statement that the list of behaviors or characteristics (above list) shall not be utilized as the sole basis to determine the appropriateness of placement and/or deny admission. If the STRTP intends to deny admission, there needs to be an explanation of why the referral was denied. For example, STRTP cannot simply state, "if a referral indicates they will burn the property if admitted, they will not be admitted". STRTP MUST engage in a good-faith effort to determine the appropriateness of the placement. 3. This section mentions a 24-hour window to share the admission decision. However, need to include specific timeframes to respond to referrals for placement, as set forth in ILS Section 87068.05(c)(4): · The established timeframes must include, but are not limited to, an initial response period in which the facility accepts, denies, or requires more information for the consideration of the referral for placement and; · A final response period in which the facility accepts or denies the referral for placement. 11. Identification of Home-Based Settings and Family-Based Aftercare Support Plan and Aftercare Service12. Family and Sibling Participation 16. Personal Rights 17. House Rules for Child(ren)/NMDs 24. Mental Health Program Approval 26. Emergency Intervention Plan (Runaway Plan) LPA gave applicant a copy of the detailed notes regarding the revisions for each section. Applicant agreed to turn in the revisions by 11/4/ Applicant informed LPA that Ebony Streets would be the administrator for the facility. LPA informed applicant that Ebony would need to turn in their proof of qualifications, LIC 501, proof of completing component orientation 1,2,&3, and get transfer clearance to the facility. LPA and Applicant discussed the outstanding fire clearance. LPA will reach out to the local fire authorities to request a fire clearance. Exit Interview Conducted. A copy of this report was given to the applicant. N. Trauma-Informed Intervention and De-Escalation Techniques Q. Continuous Quality Improvement (CQI) Program Statement 1. Population to be Served 1. Specify if the facility intends to serve children or NMDs with special health care needs. 2. Does not include a description of how the facility programs have the ability to support: I. The individual needs of children, NMDs, and their families, with short-term, specialized, trauma-informed, and intensive treatment, including, but not limited to, treatment that implements child-specific short-and long-term needs and goals identified by the qualified individual's assessment of the child II. Children, NMDs, and their families from different backgrounds or experiences, including race, ethnicity, sexual orientation, gender identity, or a child/NMD who is gender non-conforming. 4. Core Services and Supports 1. Attach agreement(s), if any, with other agencies that provide core services and supports, and provide information on how the STRTP will ensure that the core services secured through agreements with other agencies are trauma informed and culturally relevant. 5. Trauma Informed Interventions and Treatment Practices 1. Demonstrate how the program addresses each of the following: · A child or NMD's needs to feel safe, respected, informed, connected, and hopeful regarding their own experience with trauma. · The interrelationship between trauma and the impacts of trauma includes, but is not limited to, neuro-cognitive problems, neuro-psychological issues such as depression and anxiety, and behaviors. · The need to work in a collaborative way with a child or NMD, their family and friends, and human services agencies in a manner that will empower the child or NMD. · Interventions, techniques, and practices that are trauma-informed, culturally relevant, age and developmentally appropriate as provided by direct care staff to a child or NMD consistent with a child's or NMD's needs and services plan and treatment plan. 2. Describe how the STRTP will meet ILS requirements for a comprehensive trauma-informed treatment model designed to address the individualized needs of children as specified in Sections 87022.1 and 87078.2, and include a description of the trauma-informed interventions and/or treatment practices that will be used by the program to serve children, NMDs, and families, as specified in Sections 87022.1(b)(7) and 87078.2, including, but not limited to, the evidence-based or informed screening or assessment tools to identify trauma history and trauma-related symptoms or problems. 3. Explain how the interventions, practices, services support the following: · Recognition and understanding of the trauma that children have experienced and how trauma impacts children · How observable behaviors will be identified and evaluated to assess the need for services · Maximization of physical and psychological safety for the child or NMD · How emergency interventions, including early interventions and de-escalation procedures, are trauma-informed 4. What screening or assessment tools will be used to identify trauma history and trauma-related symptoms or problems, and how that history is included in the child's Needs and Services case plan or Treatment plan within 30 days of admission. 5. Provide the procedures for how the provider will access and make referrals for evidence-based and/or promising services and practices that are trauma-informed · Missing whole sections 6. Licensed Nursing Staff 7. Development, Implementation, and Modification of Needs and Services Plan 1. Missing crisis management plan as an identified need. 2. There is duplicate information in this section. Recommend revising for clarity. 3. This section does not refer to a qualified individual. Please explain how the services will meet the short and long-term needs and goals of the youth. 4. Specify how the discussion with the youth will be age and developmentally appropriate and documented in the youth's NSP. 5. Missing requirement listed in section 87068.2(d)-(g). 6. Specify procedures for when the STRTP does not receive the case plan from the county placing agency. 7. Please note that section 87068.2 does not apply to NMD, therefore, please refer to section 87068.22 and specify how the STRTP will meet the requirements of that section. 8. The procedures for modifying the NSPs are not clear. It mentions that STRTP will analyze incident reports that occurred within the 30-days, but it's not clear what the purpose of this analysis is, nor its frequency. 9. Missing requirement listed in section 87068.3(b)(1)-(2). 10. Incident report analysis is missing requirements listed in section 87068.3(c)(1)(A)(1)-(6). · Add Reasonable & Prudent Parenting Standards (RPPS) 8. Planned Activities 1. Planned activities do not address access to computer technology and the internet, consistent with the youth's age, maturity, developmental level, court order, and CFT decision. 2. Does not include the development of community support systems for youth to maximize utilization of non-mental health community services and other resources. 3. The STRTP intends to serve young parents, but there are no planned activities that apply to that population. 4. The planned activities meet the needs of minor and NMD parents and their children. · Add vocational counseling activities · Add Community support activities 9. Services During Placement and After Discharge 1. Please note that the STRTP cannot provide mental health services until approved to do so. Please explain how the STRTP will ensure that youth receive mental health services. 2. Please specify how the STRTP will provide the services mentioned on the first page of this section. 3. Missing the name, location, and services provided by an agency or agencies that the applicant or licensee has partnered with, either formally or informally, to provide additional support and services to families and children including NMDs during care and post-permanency 10. Plan for Participation in Child and Family Team ("CFT") 11. Identification of Home-Based Settings and Family-Based Aftercare Support Plan and Aftercare Services 1. Explain how the facility, in accordance with the child's case plan and the CFT recommendations, will provide for, arrange for the provision of, or assist in, all of the following: ·Development of an individualized family-based aftercare support plan that identifies necessary supports, services, and treatment to be provided for at least six months postdischarge as a child moves from the STRTP to homebased family care setting or to a permanent living situation through reunification, adoption, or guardianship, or to a transitional housing program. This plan shall be developed, pursuant to WIC section 4096.6, in collaboration with the county placing agency, the CFT, and other necessary agencies or individuals for at least six months postdischarge. · Aftercare services may be provided by the following including, but not limited to: a STRTP, county placing agency, child welfare agency, probation department, mental health plan, or other agencies or individuals pursuant to WIC section 4096.6. Documentation of the process by which the STRTP will implement treatment and services to support the short- and long-term, child-specific mental health goals identified by a qualified individual pursuant to WIC section 4096(g). 12. Family and Sibling Participation 1. There is no mention of consulting with the youth regarding the preferred family members they would like to interact with per section 87022.1(b)(13)(A). 2. Document how family members will be integrated into the treatment process for the child, including postdischarge, and how sibling connections are maintained. · Need to work with child's family, friends, and community. 14. Participation and Assistance in Initiatives to Improve the Child Welfare System 16. Personal Rights 1. Describe the measures in place to ensure that youth are informed of how to contact appropriate agencies regarding potential violations of their rights before such violations occur. 2. Explain how personal rights competency & identifying personal rights violations competency are evaluated for each youth? 3. How will the STRTP ensure that youth rights are explained in an age and developmentally appropriate way per 87072(b)(2)? 4. Missing. Ensure that copies of all laws related to the filing of complaints at admission, at the child's request, and each time a new right has been added to the Section or Welfare and Institutions Code section 16001.9., per 87072(b)(2) 5. Provide PROCEDURES that demonstrate compliance with personal rights. 6. Include or reference the personal rights form. · Sample Personal rights · List rights · Staff training on personal rights 17. House Rules for Child(ren)/NMDs 1. What happens to the chores if the youth refuses to complete them? 2. This section mentions a level system. Explain how the level system is trauma-informed and meets the requirement of providing individualized care. 3. Specify the curfew for minors and NMDs. 4. This section states that no new piercings are allowed. Does that same rule apply to NMDs? 18. Positive Discipline Policies and Procedures- This section is missing. 1. Cover Sheet with number/letter and name of section 2. Provide a description of positive discipline policies and procedures describing type(s) of discipline permitted and rationale, conditions under which each type of discipline will be used, types of discipline not permitted, and provisions for informing the child's or NMD's authorized representative(s) of discipline policies, as specified in Section 87072.1. The description must include how the types of discipline are trauma informed. 3. Provide a description of how trauma-informed practices are embedded in the provider's discipline procedures, as well as how discipline policies account for the particular nature of youths' trauma (including specialized populations) 4. Expectations and consequences, including policies and procedures for NMDs. Specify: · Discipline policies and procedures not applicable to NMDs · Consequences for NMD when they do not comply with reasonable expectations 19. Expectations and Consequences for NMDs- This section is missing. 22. Child(ren)'s Direct Input 23. Documentation of Accreditation 24. Mental Health Program Approval 1. It is not clear how the facility will ensure access to mental health services, including specialty mental health services and mental health supports that meet short and long term mental and behavioral health goals and treatment as identified by the qualified individual, as appropriate to the needs of the child or NMD in its care, as set forth in Section 87089.1(d), that shall include all of the following: I.Ensuring continuity of care, services, and treatment as a child moves to home-based family care or to a permanent living situation, in accordance with the child's case plan or treatment plan II. Documenting the child's ability to access mental health services identified in the needs and services plan, or efforts made by the STRTP to ensure access to identified mental health services, including utilization of any existing grievance processes for accessing services. 2. Specify the community providers and external providers who will assist with providing services to youth. 3. An STRTP providing care and supervision to children diagnosed by a physician, psychologist, or licensed clinical social worker as mentally disordered shall make provision for at least monthly consultation from a psychiatrist, or clinical psychologist, or licensed clinical social worker regarding the program of services, or more often as appropriate to the needs of the child or NMD. · Intensive Day Treatment Services = Intensive Home-Based Services? · Missing Day Rehabilitation Services · Missing Therapeutic Behavioral Services 26. Emergency Intervention Plan (Runaway Plan) 1. Missing procedures for notifying staff that a youth is absent at the change of shift. 2. This section mentions that manual restraints will be used if a youth is a danger to themselves. This is a violation of section 87095.01. Recommend rephrasing or changing this sentence. 3. Specify time frames for reporting unauthorized absence. 4. What will happen if there isn't enough coverage by other staff to supervise residents if a youth is trying to leave the home? 5. Specify the Emergency Intervention techniques that will be used to prevent runaways. 6. Missing requirement listed in section 87095.24(c)(9). 7. Missing requirements listed in section 87095.68.

met_with: Applicant Sheila Hatcher


facility_name: BOURNE INC. - HILL

summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13On July 16, 2024, Licensing Program Analyst (LPA) C. White arrived Bourne Inc. - Hill for the purpose of delivering findings for a complaint investigation. LPA met with Facility Manager, Nick Walker. During the course of this investigation, LPA conducted confidential interviews and reviewed records. Confidential interviews and documentary evidence did not produce corroborating proof to support the allegations. Based on information obtained during the investigation, the allegations are found to be unsubstantiated, meaning although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a has violation did or did not occur. There are no deficiencies cited at this time. An exit interview was completed, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Bernice Karnsrithong LICENSING EVALUATOR NAME: Charmetha White 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

report_type: Complaint Investigation

met_with: Nick Walker - Facility Manager

complaint_status: unsubstantiated


raw_content:
Investigation Findings:
13Licensing Program Analyst Connie Jones-Steward investigated the above allegations. LPA interviewed staff, , DCFS social workers, and the mother of C1. LPA was not able to contact C1, LPA also reviewed related incident reports and the Needs and Services Plan for C1. Per the NSP and staff interviews, only the father of C1, his sister or his social worker were to be notified of incidents. However his social worker nad his mother refute this information and state that the facility was notified to contact the mother as well. Based on conflicting information and evidence, thie allegation that staff did not notify minor's authoriized representatives of incidents is resolved as unsubstantiated. Unsubtantiated means that even though an allegation may have happened or is true, 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: Lauren Bennett, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On October 18, 2021 at 10am Licensing Program Analyst (LPA) Donald Martin arrived at the main office of Bourne Inc. for the purpose of conducting an Annual Inspection. LPA was met by Administrator, Barbara Waffer and allowed into the Office located at N. Lake Ave Altadena, CA. 91001. LPA began with the review of the Staff files. LPA reviewed 3 staff files. All files contained all documentation necessary to be employed at the facility. All employee files were in outstanding order. LPA will continue the facility inspection, client files and interviews at N. Hill Ave. Pasadena, Ca. 91104. There were no deficiencies to cite at the time of this visit.

met_with: Barbara Waffer-Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 10/20/2021 at 12:30pm, Licensing Program Analysts (LPA), Donald Martin arrived at the above facility for the purpose of conducting an Annual Inspection Continuation. LPA was met by Dino Wilburn, Facility Manager who conducted the tour of the facility. The facility is licensed to care for six clients, ages 12 -17 years, ambulatory only. The facility also provides services to Non-Minor Dependents pursuant to W&I CODE 16501.1(C)(1). The facility was set as follow: This is a single story home located in a residential area. The home has 3 bedrooms, 2 bathrooms, living room, dining area, kitchen, therapy room, laundry room and detached garage. No bodies of water on the premises. Living Room: Has a fireplace with required security screen. Kitchen: Kitchen was equipped with refrigerator, 4 burner gas stove (operable at the time of inspection), oven, and microwave. Bedroom #1 is equipped with two twin size beds, dresser space, has adequate lighting and closet space. Bedroom #2 is equipped with two twin size beds, dresser space, has adequate lighting and closet space. Bedroom # 3 is equipped with two twin size beds, dresser space, has adequate lighting and closet space. Has bathroom inside of room and sliding door access to the porch on the rear of the home. Dining Area: has adequate space for required seating for clients. Bathroom: All 3 were clean and in good repair and toilets were operable, sinks and shower all had with running water Laundry Room: is located in the office/therapay room. It has a washer and dryer, has door which leads to the backyard. Outdoor Activity space: front and backyard was free from obstruction and debris. Detached Garage:in the backyard at the end of the driveway. (Continued on LIC 809-C) Detached Garage: the garage is used for extra storage space and contains a freezer for additional food, bikes, and household supplies. The garage remains locked at all time. All detergents and disinfectants are kept in the garage as well. LPA observed the following: Sharp knives and medications are kept in locked cabinets, inside a locked closet located in the staffing office. Extra linen is located in the Linen closet is located along the hallway. First aid kit was complete. The facility has one functioning carbon monoxide and several smoke detectors, all tested audible and were in proper working order. The facility has two (2) fully charged regulation fire extinguishers, one located in the hallway and the second located in the kitchen. There were no guns or weapons are in the home. There are no swimming pools or bodies of water on the premises. Central air and heating unit in the backyard. All window had screens, in good repair, and there are no security bars on the windows. The facility has one (1) vehicle to transport clients: a Honda Odessy 2010. The vehicle was inspected and found to be clean, in good repair, and has current automobile insurance is with Non-Profit Insurance. The following was discussed with the Facility Manager: Children will be accorded personal rights. Children in care will be supported, encouraged to participate in extracurricular activities. Children in care will be able to contact the licensing agency. Children in care will not be restricted in telephone use except by program choice. A working telephone line must be available for clients to use at all times. Hot water must be maintained between 105 and 120 degrees (F). Adequate supervision and protection must be provided for children in care. Staff will ensure three nutritious meals and snacks. Food supply must be ample in the home. The beds must have comfortable mattresses, clean linens, blankets, and pillows, to be maintained in good repair. The facility is currently operating within capacity and limitations of license. All posting requirements were met. Exit interview was conducted and a copy of this report was left with Facility Manager, Dino Wilburn.

met_with: Dino Wilburn-Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On October 4, 2022 at 10:31am, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Bourne Inc (Hill) for the purpose of conducting a Case Management (Other). LPA met with Kashmeir Tucker, Administrator. The purpose of this visit is to discuss concerns regarding increased number of law enforcement service calls regarding AWOL of residents and missing persons reports for the facility. The census on the day of this visit is four (4). During this visit, LPA discussed the area of concern regarding the increased number of Missing Person's reports filed with Pasadena Police Department in 2022 as well as provisions of the Program Statement for Bourne Inc.(Hill) regarding their policy on AWOLS and how they will be addressed. LPA and Administrator discussed possible solutions to reduce the number of Missing Person reports filed with law enforcement such as ensuring Child and Family Team meetings are conducted to address AWOL concerns and ensuring Needs and Services plans reflect what issues such as chronic AWOL'ing are addressed. Administrator stated will follow-up with staff and Executive Director to address the concerns regarding clients AWOL'ing and the increased number of Missing Persons filed with local law enforcement. LPA requested a copy of the current LIC 500 for the facility. LPA reviewed the LIC 500 (Personnel Report) and CCL Personnel Summary which revealed discrepancies. LPA will review discrepancies and will research Criminal Record Clearances for Staff #1 - 10. LPA will follow-up with provider on a later date regarding Criminal Record Clearances for staff. LPA informed Administrator to ensure all staff are associated to the facility through the Guardian process. No deficiencies cited during today's visit. Exit interview was conducted, and a copy of this report will be emailed to the Administrator.

met_with: Kashmeir Tucker-Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On January 24, 2022 at 10:38am, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Bourne Inc. (Hill) for the purpose of conducting a Case Management visit. LPA arrived at the facility to conduct an interview with Client #1 (C1) due to an incident which occurred at a previous placement. LPA met with Randi Lee, Direct Care Staff. LPA was informed that Administrator is at the agency's main office. LPA requested and was provided with a LIC 500. LPA provided facility with a new Foster Youth Bill of Rights poster. Based on the observations made during today's visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. Exit interview was conducted, and a copy of this report will be emailed to the Administrator.

met_with: Randi Lee-Direct Care Staff


summary: Facility Evaluation

raw_content:
Narrative:
On September 26, 2023 at 9:02 am, Licensing Program Analyst (LPA) Christine Wilson and Licensing Program Analyst (LPA) Jhane Haynes, made an unannounced visit to the above listed facility, in order to conduct a case management deficiency. LPAs were met by the Facility Manager (FM) who provided access to the facility. LPAs conducted a walk through of the facility. LPAs obtained copies of LIC 500, Client Roster, SIR dated 9/14/23, Shift notes, Intake packet for (C1). LPAs were unable to determine if there were any deficiencies at this time. A copy of this report was emailed to the licensee staff (FM), whose signature on this form confirm receipt of these documents.

met_with: Facility Manager (FM)


summary: Facility Evaluation

raw_content:
Narrative:
On November 20, 2023 at 1:00, Licensing Program Analyst (LPA) Deborah Lee and Licensing Program Manager (LPM) Lakescia Smith made an unannounced visit to Bourne Inc Hill for the purpose of conducting a Annual Random Inspection. LPA met with Nick Walker, House Manager who granted access to the facility. Thereafter Barbara Waffer, Administrator arrived to assist with inspection. The facility is licensed to care for six clients, ages 12 -17 years, ambulatory only. The facility also provides services to Non-Minor Dependents. Overview of facility: The Short Term Therapeutic Residential Program (STRTP) is a 3 bedroom, 2 bathroom home located in a residential area. living room has a sectional sofa, mounted TV, a non-operational covered fire place, 2 end tables, 2 chairs. There is a table designated for visitor sign-in. Dinning room has a 6 seated dinning table and a table with TV for gaming. There is a water dispenser located against the wall under a bulletin board that contains facility sketches and facility license. There is another bulletin board that contains client information. Kitchen has a stove in working order, two counter top air fryers, microwave oven, fully charged fire extinguisher, a dishwasher, covered waste basket. There is food supply meets title 22 regulations Washer and dryer is operable and located in room adjacent to staff office . Continued on 809C Bedrooms Bedroom1 is occupied by 2 clients, there are two twin bed that are in good repair with adequate linens, adequate drawer and closet space. LPA observed the two windows did not have window screens Bedroom 2 is occupied by 2 clients, there are two twin bed that are in good repair with adequate linens, adequate drawer and closet space. LPA observed that one window did not have window screens. Bedroom 3 is occupied by 2 clients, there are two twin bed that are in good repair with adequate linens, adequate drawer and closet space. LPA observed two windows did not have window screens. bathroom 1 was clean, sanitary and in good repair. Water temperature tested and within required range of 105-120 degree F Bathroom 2 was clean, sanitary and in good repair. Smoke detectors in each bedroom was tested and operable LPA observed linen closet to have adequate supply of clean linens. LPA reviewed LIC 500 and found 4 staff missing from Guardian association roster. LPA to follow up on individual clearance status of the 4 staff. LPA to return to facility to complete inspection: staff files, client files, staff and client interviews. Exit is completed and copy of report email to administrator

met_with: Barbara Waffer


summary: Facility Evaluation

raw_content:
Narrative:
On December 14, 2023 at 9:00am, Licensing Program Analyst (LPA) Deborah Lee and Licensing Program Manager (LPM) Lakescia Smith made an unannounced visit to Bourne Inc Hill for the purpose of conducting a Case Management-Annual Continuation Inspection. LPA met with Nick Walker who granted access to the facility. Thereafter Martin Gonzalez, Facility Manager arrived to assist with inspection. The facility is licensed to care for six clients, ages 12 -17 years, ambulatory only. The facility also provides services to Non-Minor Dependents. During the inspection LPA's conducted the following: Client file review: LPA reviewed (3) client files. Per review of files, 1 out of 3 files met current licensing requirements. Staff Interviews: LPA's conducted confidential interview with ( 2 ) on duty staff. LPA to return on different day to complete staff files and interview clients. There were no deficiencies cited at this time. An exit interview was conducted, and a copy of this report will be sent to Facility Administrator via email.

met_with: Nicholas Walker


summary: Facility Evaluation

raw_content:
Narrative:
On December 28, 2023 at 10:00am, Licensing Program Analyst (LPA) Deborah Lee made an unannounced visit to Bourne Inc Hill for the purpose of conducting a Case Management-Annual Continuation Inspection. LPA met with Barbara Waffer Administrator who granted access to the facility. The facility is licensed to care for six clients, ages 12 -17 years, ambulatory only. The facility also provides services to Non-Minor Dependents. Facility has Mental Health Program Approval April 13 2023 through April 13 2024. During the inspection LPA's conducted the following: Staff file review: LPA reviewed (4) staff files. Per review of files, 4 out of 4 files met current licensing requirements. LPA's conducted confidential interview with (1) available client on site (other available client declined to interview) There were no deficiencies cited at this time. LPA concluded the Case Management-Annual Continuation Inspection, an exit interview was conducted, and a copy of this report will be sent to Facility Administrator via email.


summary: Facility Evaluation

raw_content:
Narrative:
On July 16, 2025, Licensing Program Analyst (LPA) C. White arrived at the above location for the purpose of conducting a case management visit to close a complaint received on Bourne Inc. - La Corona, Facility #198207575, located at La Corona Ave Altadena, CA. 91001. LPA met with Administrator, Barbara Waffer. LPA was informed by the Administrator, that Bourne Inc. - La Corona was closed in February 2025 as the facility burned down due to the Eaton Fire. An exit interview was conducted, and a copy of this report was left with the Administrator.

met_with: Barbara Waffer - Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 01/05/2024 at 1:55pm, Licensing Program Analyst (LPA), Christine Wilson arrived at the above listed facility to conduct a case management deficiency visit, and met with (S1) Direct Care Staff, who granted entry into the home. LPA Wilson disclosed the purpose of the case management deficiency inspection. There were (3) clients and (2) staff present during the inspection. At 2:19pm (FA) Facility Administrator arrived and met with LPA Wilson. During the course of the case management investigation visit on 09/26/23, LPA Wilson conducted witness interviews, record reviews, and made observations. A violation of the following deficiencies are being cited based on LPA interviews conducted and records review. Facility has protocol in place to search client's belongings when leaving and returning from school. Staff confiscated client's phone and did not return it. Facility Staff did not notify child's authorized representative before bed closure, Two (2) deficiencies Type A have been determined at this time (see LIC809D). An exit interview conducted, plans of corrections reviewed with the licensee, and a copy of this report and appeal rights was left at the facility.

met_with: Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On March 27, 2026, Licensing Program Analyst (LPA) Justine Armstrong conducted a case management visit at the facility mentioned above. LPA Armstrong met with Lauren Bennett, the Facility Manager, to discuss a Special Incident Report (SIR) received by Community Care Licensing (CCL) on March 9, 2026. This report pertained to a physical altercation that was filmed between clients at the facility on March 8, 2026. Lauren Bennett, referred to as FM, provided LPA Armstrong with copies of the LIC 500, the Client Roster, and the Room Check Log. The Internal Incident Report indicated that staff and client interviews were conducted regarding the SIR. It also mentioned that retraining on safety protocols, supervision protocols, and incident reporting was conducted, and that clients were discharged due to the incident. FM showed LPA the physical assault video that was posted via TikTok, LPA received a copy of the video. LPA requested copies of the internal investigation, training agenda, sign-in sheet, and the discharge paperwork for the clients that were discharge due to the physical assault. FM will send the additional requested documents to LPA by April 3, 2026, via email. At this time, the case management requires further investigation to determine whether any violations occurred.Exit Interview conducted, and a copy of this report was provided to the Facility Administrator (FA).

met_with: Lauren Bennett


summary: Facility Evaluation

raw_content:
Narrative:
On April 15, 2026, Licensing Program Analyst (LPA) Justine Armstrong visited the facility to conduct a follow up Case Management on a Special Incident Report (SIR) received on March 9, 2026, regarding a physical altercation between clients that occurred on March 8, 2026. LPA Armstrong conducted confidential interviews and reviewed documentary evidence. Evidence confirmed that staff did not adhered to the facility's policies and procedures regarding client supervision to prevent or de-escalate an physical altercation that occurred in a client's bedroom while the client bedroom door was closed. According to California Code of Regulations, Title 22, Division Six, Interim Licensing Standards STRTP, 87065.2(b)(1) PERSONNEL DUTIES, the following deficiency has been cited (Continued on LIC 809-D). An exit interview was conducted, and a copy of this report was provided.


facility_name: BOURNE INC. - LA CORONA

summary: Complaint Investigation - Unsubstantiated - 2 allegations

raw_content:
Investigation Findings:
13On 01/05/2024 at 12:55pm, Licensing Program Analyst (LPA), Christine Wilson met with Facility Manager (FM), and concluded the investigation of the above allegatiosn. During the course of this investigation, LPA Wilson conducted witness interviews, record reviews, and made observations. The investigation included confidential interviews with clients, facility and administrative staff. Based on all interviews conducted, and documents obtained, the Department has found the above allegations to be substantiated, meaning that, the preponderance of the evidence has been met. Supporting evidence includes witness accounts direct statements, facility reports, and medical reports of documentary validation. There are (1) deficiencies to be cited at this time (see LIC9099D). An exit interview conducted, plans of corrections reviewed with the licensee, and a copy of this report and appeal rights was left at the facility. SubstantiatedEstimated 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 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: Bourne INC. - LA CORONAFACILITY NUMBER: 198207575

Allegations:
- SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion: Based on all interviews conducted, and documents obtained, the licensee did not provide adequate care and supervision to minor in care, minor had access to an unknown drug substance, minor had access to cough medicine and minor was physically assaulted by other minors in care, which poses an immediate danger to the health safety and personal rights risk to persons in care.
- UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:

met_with: Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 09/28/2021 9:30AM Licensing Program Analyst (LPA) Rosslyn Gray and LPA Bernice Karnsrithong made an unannounced to BOURNE INC. - LA CORONA for the purpose to conduct the Annual/Required licensing Inspection. LPA met with the Program Administrator, who granted access into the home, and who provided a tour of the entire physical plant inside and out. The facility is licensed to care for 6 clients, female only, ages 12 -17 years, ambulatory only. The facility also provides services to non-minor dependents. The facility acquired The National Accreditation through Commission on Accreditation of Rehabilitation Facilities (CARF) valid 05/11/2020 through 05/10/2022. There are no bodies on water on the premises. Staff confirmed that there are no firearms or dangerous weapons in the facility. There are no guns/weapons in the home. STRTP Overview: This is a one (1) story home, located in a residential area. This is a one (1) story, three (3) bedroom (STRP) Short Term Residential Therapeutic Program. There are three (3) bathrooms, living room, dining room, kitchen area. The garage is a detached from the main facility. 1 car garage has been converted into a laundry room used for storage. A portion of the garage is under construction for a therapy room. The administrator confirmed that the changes to facility will reported. Living Room: There is adequate furniture which appears to be in good condition. There is a television and fireplace that is non-operable. Dining Area: One table with six chairs. There is a book shelf that contains books and games for children to use. There is a staff sign-in area next to the dining area. Temperature and health checks are conducted in the sign-in area. Common Area: There is adequate furniture, television, and a coffee table. Kitchen: There is a gas stove/oven with four (4) burners, all operating. There is a microwave and refrigerator/freezer. There is a toaster oven and an air fryer in the kitchen. LPA's observed adequate perishable/nonperishable food supplies. Sharp knives, disinfectants/cleaning solutions, and medicines are made inaccessible to the children. (page 1 of 3) Water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. Bedroom # 1: Occupied by two (2) clients, has two (2) twin sized beds and comfortable mattresses, linen, blankets and pillows; adequate drawer and closet space. There is one (1) walk in closet. There is adequate lighting and the windows have vertical and horizontal slide locked with vertical shades observed to be in good condition. Bedroom # 2: Occupied by two (2) clients, has two (2) twin sized beds and comfortable mattresses, linen, blankets and pillows; adequate drawer and closet space. There is one (1) walk in closet. There is adequate lighting and the windows have vertical and horizontal slide locked with vertical shades observed to be in good condition. Bedroom # 3: Occupied by two (2) clients, has two (2) twin sized beds and comfortable mattresses, linen, blankets and pillows; adequate drawer and closet space. There is one (1) walk in closet. There is adequate lighting and the windows have vertical and horizontal slide locked with vertical shades observed to be in good condition. All Bathrooms: have toilets, sinks and tub/showers. All are in clean and operating properly. Water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. The Facility was inspected, and the following was observed: The home is clean, safe, sanitary, and in good repair. Carbon monoxide and smoke detectors are working properly. All fire extinguisher was fully charged. Smoke and carbon monoxide detectors were working properly in the facility. First Aid kit was complete with all required supplies. LPA observed a First Aid kit complete with scissors, tweezers, thermometer, gauzes, antiseptic and 1st Aid Manual. LPA observed carbon Monoxide alarms, located on each floor were observed and functional in the home. LPA observed five (3) fully charged fire extinguishers located throughout the facility. All posting requirements were met. Outdoor activity space is free of hazard materials and debris. LPAs observed that the perimeter screens of the house were in good condition. LPAs observed that there is a hot water heater that is enclosed and locked. LPAs confirm that staff were aware of the utility shut-off valves. Children will be accorded personal rights. The facility current License, Mental Health Certification; Ombudsperson Grievances and Personal Rights; are posted on the wall. Children are not restricted to make phones calls based on the court and or authorized representative. The staff room is available for the clients to make phones calls and the Phone Call Log is kept in the clients file.(page 2 of 3) LPA observed the child's Needs and Services plans kept in the client's chart; (filed electronic medical records). Some outside extracurricular activities and social events that take persons into public or crowded places have been restricted. Alternate activities have been implemented based the compliance of the client. Children are taken into the park, go hiking, and biking or have games within the facility. There were no deficiencies cited at this time. LPAs will return to the facility later to complete the inspection tool (Staff Records Reviews, Staff and Client interviews). LPA-Gray concluded the inspection and a copy of this report was left at the facility with the Program Administrator on 09/28/2021. (page 3 of 3)

met_with: ADMINISTRATOR


summary: Facility Evaluation

raw_content:
Narrative:
On 09/30/2021 at 10: AM Licensing Program Analyst (LPA) Rosslyn Gray, made an announced visit to BOURNE INC. - La Corona. LPA conducted a Case Management Annual Continuation Inspection. LPA met with the Program Director, identified as Staff #1(S1), who granted access to the facility and provided the requested information. LPA reviewed following during the inspection: Staff Records Review: LPA reviewed six (6) staff records stored in individual personnel file/binders provided by S1. LPA ensured to thoroughly review the records of the primary active staff (i.e The Program Administrator, Primary Therapist, Clinical Director, Residential Director, Facility Manager; and Five (5) Direct Care Staff. LPA reviewed the Personnel Report (LIC 500) and confirmed that Direct Care Staff Ratio present for the six (6) clients in placement. In review of the staff's records LPA confirmed that All staff have required criminal record clearance. DOJ, FBI and Child Abuse Response. LPA conducted a confidential interview with four (5) on duty staff. LPA randomly conducted a confidential interviews with staff as they arrived according to their work shift. On this day 09/30/ LPA randomly conducted a confidential interviews with client based on the time children transitioned from school. LPA interviewed two (2) of the five (5); two (2) clients were interviewed on 09/28/2021. There were no deficiencies cited at this time. LPA concluded the Annual/Required Inspection. An exit interview was conducted, and a copy of this report was left at the facility with the Program Administrator.


summary: Facility Evaluation

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Narrative:
On May 17, 2023 at 9: AM. Licensing Program Analysts (LPAs) Rosslyn Gray and Zena Phillips made an announced visit at BOURNE INC.- LA CORONA STRTP to conduct the Psychotropic Case Medication Inspection. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs Gray and Phillips met with Barbara Waffer/Administrator and inspected the facility inside and out. LPAs reviewed #4 of child's records and #3 of staff personnel files on site at the facility. LPAs reviewed #4 of child's psychotropic medications and medication records. LPAs interviewed #3 of staff on site to discuss the facilities policies and procedures of operation. LPAs did not interview the children currently prescribed psychotropic medication, due being offsite attending school. Child #1 was Exempt from Inspection due to residing in placement Less than Days. LPAs provided a copy of this licensing reports to the Administrator Barbara Waffer. No deficiency were cited per Interim Licensing Standards for STRTP Version 4. An exit interview was conducted, and a copy of this report was left with Barbara Waffer/Administrator


summary: Facility Evaluation

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Narrative:
On July 12, 2023 at 1:13pm, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Bourne Inc. (LA Corona) for the purpose of conducting a Case Management for SIR # 873449. LPA met with Lauren Bennett, Facility Manager and discussed the incident. LPA was informed Administrator is on vacation. During this visit, confidential interviews were conducted. Additional interviews will be conducted on a later date. LPA requested and received a copy of the current LIC 500. LPA also requested copies of hospital documentation for Client #1 (C1) and Client #2 (C2), medication log for C1, internal investigation report of incident, and CFT meeting notes for C1 and C2. Facility Manager stated that requested documents will be emailed to LPA by Administrator. This Case Management needs further investigation. Based on the observations made during today's visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. Exit interview was conducted, and a copy of this report will be emailed to the Administrator.

met_with: Lauren Bennett-Facility Manager


summary: Facility Evaluation

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Narrative:
On December 27, 2023 9:30AM Licensing Program Analyst (LPA) Deborah Lee made an unannounced visit to BOURNE INC. - LA CORONA for the purpose of conducting an Annual/Random licensing Inspection. LPA met with Leslie Allen, who granted access into the home, and who provided a tour of the entire physical plant inside and out. The facility Administrator Barbara Waffer arrived thereafter to assist with inspection. The facility is licensed to care for 6 clients, female only, ages 12 -17 years, ambulatory only. The facility also provides services to non-minor dependents. The facility acquired There are no bodies on water on the premises. Staff confirmed that there are no firearms or dangerous weapons in the facility. There are no guns/weapons in the home. Facility Overview: This is a one (1) story home, located in a residential area. There are three (3) bathrooms, living room, dining room, kitchen area. The garage is detached from the main facility. 1 car garage has been converted into a laundry room used for storage. A portion of the garage is used for a therapy room. Living Room: There is adequate furniture which appears to be in good condition. There is a television and fireplace that is non-operable. There is a visitor sign-in table approximately 3 feet from front entry way. It is situated between the living room and the dinning areas. Dining Area: One table with six chairs. There is a book shelf that contains books and games for children to use. There is a staff sign-in/out area next to the dining area. Common Area: There is adequate furniture, television, and a coffee table. Continued on 809C page 1 of Kitchen: There is a gas stove/oven with four (4) burners, all operating. There is a microwave and refrigerator/freezer. There is a toaster oven and an air fryer in the kitchen. LPA's observed that there is 7 day supply of perishables and 2 day supply of nonperishable food on hand. Sharp knives, disinfectants/cleaning solutions, and medicines are made inaccessible to the children. Bedroom # 1: Occupied by two (2) clients, has two (2) twin sized beds and comfortable mattresses, linen, blankets and pillows; adequate drawer and closet space. There is one (1) walk in closet. There is adequate lighting and the windows have vertical and horizontal slide locked with vertical shades observed to be in good condition. Bedroom # 2: Occupied by two (2) clients, has two (2) twin sized beds and comfortable mattresses, linen, blankets and pillows; adequate drawer and closet space. There is one (1) walk in closet. There is adequate lighting and the windows have vertical and horizontal slide locked with vertical shades observed to be in good condition. Bedroom # 3: Occupied by two (1) clients, has two (2) twin sized beds and comfortable mattresses, linen, blankets and pillows; adequate drawer and closet space. There is one (1) walk in closet. There is adequate lighting and the windows have vertical and horizontal slide locked with vertical shades observed to be in good condition. All Bathrooms: have toilets, sinks and tub/showers. All are in clean and operating properly. Water temperature measured within safe temperature range, at not less than 105 and did not exceed 120 degrees Fahrenheit. The Facility was inspected, and the following was observed: The home is clean, safe, sanitary, and in good repair. Carbon Monoxide alarms and smoke detectors, located on each floor were observed and functional in the home. All 3 fire extinguishers in the home were fully charged. First Aid kit was complete with all required supplies: scissors, tweezers, thermometer, gauzes, antiseptic and 1st Aid Manual. All posting requirements observed: The facility current License, Mental Health Certification; Ombudsman Grievances and Personal Rights; are posted on the wall. page 2 of Outdoor activity space is free of hazard materials and debris. LPAs observed that the perimeter screens of the house were in good condition. LPAs observed that there is a hot water heater that is enclosed and locked. LPAs confirm that staff were aware of the utility shut-off valves. Children will be accorded personal rights. Children are not restricted to make phones calls based on the court and or authorized representative. The staff room is available for the clients to make phones calls and the Phone Call Log is kept in the clients' file. LPAs conducted 2 confidential staff interviews with staff and 2 confidential interview with clients. There were no deficiencies cited at this time. An exit interview was conducted, and a copy of this report will be emailed to Facility Administrator. page 3 of 3

met_with: Leslie Allen


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Investigation Findings:
13On July 16, 2025, Licensing Program Analyst (LPA) C. White made an unannounced visit to Bourne Inc. - Hill, Facility #198209720, located at N. Hill Ave Pasadena, CA. 91104 for the purpose of delivering findings on the above complaint allegations. LPA met with Administrator, Barbara Waffer and discussed the investigation. During the course of this investigation, LPA conducted confidential interviews with pertinent parties and reviewed records. Confidential interviews and documentary evidence did not produce corroborating proof to support the allegations. Based on information obtained during the investigation, the allegations are found to be unsubstantiated, meaning although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a has violation did or did not occur. There are no deficiencies cited at this time. An exit interview was completed, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Enrique M Hernandez LICENSING EVALUATOR NAME: Charmetha White 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


facility_name: BOURNE INC. - MONTEROSA

summary: Complaint Investigation - Substantiated - 1 allegation

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Narrative:
Information obtained during the investigation, including confidential interviews with facility residents and staff members, review of related records including, but not limited to, facility incident reports, and corresponding medical records concerning C1 revealed enough evidence to support the alleged. Medical records reviewed for C1 confirmed C1 tested positive for "Benzodiazepines" and "Cannabinoids/THC". In addition, C1 experienced respiratory failure requiring "Endotracheal intubation". As a result, C1 was placed on mechanical ventilation. Interviews revealed Client #2 (C2) also consumed Xanax pills with C1 on July 27, 2021, also requiring emergency hospitalization. Statements were obtained admitting to clients obtaining and consumption of illegal drugs while in the facility. Interviews further revealed that facility staff commonly perform room searches and conduct room checks; however, the frequency of room searches and room checks are inconsistent. Based on confidential interviews and medical reports, the preponderance of evidence standard has been met. The Department has determined substantiated findings that residents obtained and consumed illegal drugs while at the facility that resulted in their hospitalization. This poses an immediate health, safety and personal rights risk to children in care. The facility is issued a citation per the California Code of Regulations, Title Division 6, Chapter 1, Article 06 80078 (a) Responsibility for Providing Care and Supervision. An enhanced civil penalty determination is pending currently. An exit interview was conducted, appeal rights were discussed, and a copy of this report, the Confidential Names List and appeal rights were provided to the administrator via email. (Continued on page LIC9099D)

Investigation Findings:
13On March 22, 2022 at 2: PM, Licensing Program Analyst (LPA), Regina Martin conducted a follow-up complaint inspection to deliver findings concerning the above-mentioned allegations. LPA Martin met with Kashmeir Tucker, Facility Administrator at the facility main office to discuss the investigative outcome. The investigation was conducted by Investigator Edward Hector of the Community Care Licensing Division (CCLD) Investigations Bureau. On July 27, 2021, CCLD received complaint allegations concerning neglect/lack of supervision as Client #1 (C1) was brought in via ambulance on July 27, 2021, to the Hospital Emergency Department after the facility staff member observed minor to be high on some type of drug and slurring of speech. At some point a short time later, C1 became lethargic with compromised respiration. Due to critical condition, C1 was intubated due to respiratory distress/failure requiring placement in the Intensive Care Unit (ICU). Medical examination indicated C1 was positive for Benzos, Cannabidiol (CBD), and Tetrahydrocannabinol (THC). SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Regina Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290b El Segundo, CA Facility Name: Bourne INC. - MONTEROSAFACILITY NUMBER: VISIT DATE: 03/22/2022

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

met_with: Facility Representative/Administrator

complaint_status: SUBSTANTIATED


summary: Facility Evaluation

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Narrative:
On October 5, 2021 at 10AM Licensing Program Analysts (LPA) Donald Martin arrived at the facility for the purpose of conducting an unannounced Random Annual Inspection. LPA met with Bridgette Nelson, Facility Manager who granted access to the facility and a tour was conducted. The facility is licensed to care for 6 children, males only ages 12 -17 years, ambulatory only. The census this day is 0. The home is set up as follows: This is a two-story family home with 3 bedrooms, 3 bathrooms, Living Room, Dining area and kitchen. There are no security bars on the windows. Carbon monoxide and smoke detectors are working properly. The fire extinguisher is fully charged. First Aid kit complete with First Aid Manual, tweezers, scissors and thermometer. Licensee states there are no guns/weapons in the home. Medications are locked in cabinet located near the staff bathroom. Sharp knives are stored in a locked cabinet located outside of the kitchen. Hot water temperature is 110 and within safe range. Living Room: There is adequate furniture which appears to be in good condition. A fireplace with a secured screen barrier. Dining Area: One table with six chairs. Kitchen: There is a stove/oven with six (6) burners, all working at this time. There is a microwave and refrigerator/freezer. The food service in the home is adequate with perishable/nonperishable food supplies and nutritious snacks. There are no wall heaters in the facility. Bedroom # Occupied by 2 clients. There are 2 twin sized beds, adequate drawers, closet space, and lighting in this room. Bedroom # Occupied by 2 clients. There are 2 twin sized beds, adequate drawers, closet space, and lighting in this room. Bedroom # Occupied by 1 client. There are 2 twin sized beds, adequate drawers, closet space, and lighting in this room. Bedroom # 3-Occupied by 2 clients. There are 2 twin sized beds, adequate, closet space, and lighting in this room. Note: There is only one dresser for the clients. This deficiency was dictated to the Facility Manager and Administrator. Bathrooms: have toilets, sinks and tub/showers. All are in clean and operating properly. The home was inspected, and the following was observed: Facility is clean, safe, sanitary, and in good repair. There is a swimming pools, however pool is empty, but covered with a net. Pool is also surrounded by a gate with proper latching device. NOTE: The gate is in bad repair. LPA will discuss this issue with LPM JoAunne Griffiin due to the safety net being over the pool. There are no Jacuzzis or ponds on the premises. All outdoor passageways and open porches are free from obstruction. Disinfectants, cleaning solutions, and poisons are inaccessible to clients and locked in the cabinet outside of the kitchen. Facility provides nutritious between meal snacks. The downstairs area is only used for Therapy and personal meetings for clients, otherwise inaccessible to clients Clients can contact the licensing agency or Foster Care Ombudsman person in confidence without threats or punishment for making complaints. Clients attend school, extracurricular, cultural, and personal enrichment activities. LPA reviewed 2 client files. LPA will review a third file upon return at the main office. Facility records client cash resources, personal property, and valuables. Client's records contain authorization for emergency medical care signed by each child's authorized representative. Client's records contain original needs and services plan signed by each child and their authorized representative. All posting requirements were met. Exit Interview was conducted with Bridgette Nelson, and a copy of this report was left with licensee.

met_with: Brigette Nelson-Facility Manager


summary: Facility Evaluation

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Narrative:
On October 7, 2021 at 11am Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for the purpose of an Annual Inspection Continuation. LPA was met by Barbara Waffer, and allowed into the facility. LPA reviewed 3 staff files. All staff files were in fantastic order and all documents were accounted for. LPA also interviewed two staff and one client who arrived from school during the time LPA was present. LPA expressed to the Facility Manager and Administrator that although a deficiency was not assessed, the gate surrounding the pool needs to be repaired. The pool has a safety net covering the pool along with the safety gate. The gate has a couple openings that a client may be able to climb through. Room 3 only has one dresser in the room for two clients, however the dresser has ample space for two clients to share. A work order has been provided to LPA for the replacement of the broken dresser. Administrator will send a picture of the new dresser to LPA upon arrival. There were no deficiencies to report at this time.

met_with: Barbara Waffer-Administrator26


summary: Facility Evaluation

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Narrative:
On March 22, 2022 at 11:26am, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Bourne Inc. (Monterosa) for the purpose of conducting an Annual Random Inspection. LPA met with Brigette Nelson, Facility Manager who granted access into the facility and together a tour was conducted. The facility is licensed to provide care and supervision for six (6) male children ages 12 -17 years, ambulatory only. The facility is also licensed to provide services to non-minor dependents pursuant to W & I code 16501(C)(1). There is a swimming pool, however pool is empty and covered with a net. Pool is also surrounded by a gate with proper latching device. NOTE: The gate is in bad repair. There are no other bodies of water on the premises. The census on the day of this visit is five (5). The home is set up as follows: This is a two story family home with three (3) bedrooms, three (3) bathrooms, living Room, dining area and kitchen. There are no security bars on the windows. The staff office is located downstairs and also used for therapy, personal meetings for clients and is otherwise inaccessible to clients. Living Room: Equipped with a couch and a secured screened fireplace. The furniture is in good repair. Dining Area: Equipped with a table with six (6) chairs. Dining furniture is in good repair. Kitchen: Equipped with a stove/oven with six (6) working burners. There is a microwave and refrigerator/freezer. The food service in the home is adequate with enough perishable/nonperishable food supplies and nutritious snacks for one (1) week. There are no wall heaters in the facility. Laundry Area: Located in an area outside of the kitchen. Equipped with a washer and dryer. Continued on LIC 809-C Bedroom #1: Occupied with two (2) clients. Equipped with two (2) twin sized beds with adequate drawers, closet space, and lighting in this room. Bedroom #2: Occupied with one (1) client. Equipped with two (2) twin sized beds with adequate drawers, closet space, and lighting in this room. Bedroom # 3: - Occupied with one (1) client. Equipped with two (2) twin sized beds with adequate drawers, closet space, and lighting in this room. Bathroom #1: Equipped with toilet, sink and tub/showers. Clean and in good operating condition. Bathroom #2: Equipped with toilet, sink and tub/showers. Clean and in good operating condition. Bathroom #3: Equipped with toilet, sink and tub/showers. Clean and in good operating condition. The home was inspected, and the following was observed: Facility is clean, safe, sanitary, and in good repair. All outdoor passageways and open porches are free from obstruction. Disinfectants, cleaning solutions, and poisons are inaccessible to clients and locked in the cabinet outside of the kitchen. Carbon monoxide and smoke detectors are working properly. All fire extinguishers are fully charged. First Aid kits are complete with First Aid Manual, tweezers, scissors, and thermometer. Licensee states there are no guns/weapons in the home. Medications are locked in cabinet located near the staff bathroom. Sharp knives are stored in a locked cabinet located outside of the kitchen. Hot water temperature is within a safe range. During this visit, LPA reviewed three (3) client records which contained copies of Needs and Service Plans and Medical Authorizations signed by each child and their authorized representative. Children in care are supervised and protected at all times. Children are accorded dignity in personal relationships with staff and others. Children can contact the licensing agency or Foster Care Ombudsperson in confidence without threats or punishment for making complaints. It was reported that children attend school, extracurricular, cultural and personal enrichment activities. LPA will conduct client interviews on a later date. Continued on LIC 809-C Caregiver(s)/adults working/residing in the home have DOJ/FBI criminal record clearances and Child Abuse Index Checks. Emergency Mass Disaster Casualty Plan was available for review. LPA reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. The home is operating within the capacity and limitations of the license. LPA will review staff records and conduct staff interviews on a later date. Facility cited on the attached LIC 809-D for violation of California Code of Regulations, Title 22, Division 6, regulation 80087(e)(1) Buildings and Grounds. The gate surrounding the pool needs to be repaired. The pool has a safety net covering the pool along with the safety gate. The pool cover does not support the weight of an adult. The gate has a couple openings that a client may be able to climb through. Exit Interview was conducted, and a copy of this report will be emailed to the Facility Manager and Administrator.


summary: Facility Evaluation

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Narrative:
Kaleal Jackson DOB: 10/15/ Client On March 22, 2022 at 12:45pm, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Bourne Inc (Monterosa) for the purpose of conducting an interview with client for a complaint investigation which took place at Five Acres TSCF when client was in placement there. LPA spoke with Kashmeir Tucker, Administrator who allowed LPA access to interview client.


summary: Facility Evaluation

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Narrative:
On April 14, 2022 at 9:52am, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Bourne Inc. (Monterosa) for the purpose of conducting a Case Management for an Annual Random Inspection which took place on March 22, 2022. . LPA met with Martin Gonzalez, Facility Manager who granted access to the facility. The facility is licensed to provide care and supervision for six (6) male children ages 12 -17 years, ambulatory only. The facility is also licensed to provide services to non-minor dependents pursuant to W & I code 16501(C)(1). There is a swimming pool, however pool is empty and covered with a net cover which supports the weight of an adult. Pool also surrounded by a gate with proper latching device. There are no other bodies of water on the premises. The census on the day of this visit is five (5). The home is set up as follows: This is a two-story family home with 3 bedrooms, 3 bathrooms, Living Room, Dining area and kitchen. There are no security bars on the windows. The downstairs area is only used for Therapy and personal meetings for clients, otherwise inaccessible to clients. The home was inspected, and the following was observed: Facility is clean, safe, sanitary, and in good repair. All outdoor passageways and open porches are free from obstruction. Disinfectants, cleaning solutions, and poisons are inaccessible to clients and locked in the cabinet outside of the kitchen. Carbon monoxide and smoke detectors are working properly. The fire extinguisher is fully charged. First Aid kit complete with First Aid Manual, tweezers, scissors, and thermometer. Licensee states there are no guns/weapons in the home. Medications are locked in cabinet located near the staff bathroom. Sharp knives are stored in a locked cabinet located outside of the kitchen. Hot water temperature is 110 and within safe range. Continued on LIC 809-C During this visit, LPA conducted one (1) client interview. Children in care are supervised and protected at all times. Children are accorded dignity in personal relationships with staff and others. Children can contact the licensing agency or Foster Care Ombudsperson in confidence without threats or punishment for making complaints. It was reported that children attend school, extracurricular, cultural and personal enrichment activities LPA conducted three (3) staff interviews and reviewed five (5) staff records and found facility personnel meet staff qualifications. Caregiver(s)/adults working/residing in the home have DOJ/FBI criminal record clearances and Child Abuse Index Checks. Emergency Mass Disaster Casualty Plan was available for review. LPA reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. The home is operating within the capacity and limitations of the license. Based on the observations made during today's inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. Exit Interview was conducted, and a copy of this report will be emailed to the Administrator.

met_with: Martin Gonzalez-Facility Manager